Anesthesia HQ!

Anesthesia HQ

Anesthesia Review
for board preparation
6th Edition

ANESTHESIA HQ 2009 ! 1
" Anesthesia HQ

Copyright 2003-2009 by The Sock Lake Group, LLC

Notice of Rights
All rights reserved. No part of this publication may be reproduced in any form or by any
electronic or mechanical means, including photocopying, recording, information storage and
retrieval systems and otherwise, without permission in writing from the publisher. For
information on obtaining permission for reprints and excerpts, contact the Sock Lake Group,
LLC.

Trademark Notice
Anesthesia HQ, AHQ Bank, and the Anesthesia HQ logo are the trademarks of the Sock Lake
Group, LLC

Find us on the World Wide Web at: http://www.anesthesiahq.com

2! ANESTHESIA HQ 2009
Anesthesia HQ!

Preface to the 6th Edition

My motivation in creating Anesthesia HQ was to create a concise and comprehensive

anesthesia study guide and an interactive, online exam web site for those preparing for the
anesthesia board exams. During the past several years, I!ve had the opportunity to assist
many examinees prepare and pass their anesthesia board exams. It is with feedback and
critical input from many that I am able to continue to improve the board preparation materials
and the web site. This sixth edition of the study guide maintains my initial goal and with the
combination of the website, www.anesthesiahq.com, offers a unique learning experience for
those preparing for the anesthesia board exams.

The study guide is still organized by topics and chapters in an easy to read outline format,
which also will provide you with the opportunity to add your own knowledge, thoughts, and
comments throughout the review process. The study guide is intended as a supplement and
an aid to your previous years of study, diligence, and hard work. From the moment you begin
preparing for the anesthesia board exam, you should read, reread, and review again, all of the
topics and information contained in the study guide, web site, and additional textbooks.

My goal is to provide you with the tools to prepare, organize, and ultimately pass the
anesthesia board exams. I wish you good luck and success in your studies and career.

Michael K Loushin, MD
Founder
Anesthesia HQ

ANESTHESIA HQ 2009 ! 3
" Anesthesia HQ

4! ANESTHESIA HQ 2009
Anesthesia HQ!

Dedication

To my loving family and friends for their patience and understanding.

ANESTHESIA HQ 2009 ! 5
" Anesthesia HQ

Notice of Liability

The information contained herein is only to be used as a study aide in preparation for the
anesthesia board exams. Such information is not to replace any medical education, clinical
experiences, or the study of textbooks and medical journals. The actual use of this
information, including any medical concepts, facts, drug dosages, and methods, therefore is
at the reader!s own risk. We assume NO responsibility for any injury or damages to any
person or property that may result from such reliance on or use of any of this information.

We have taken all reasonable precautions to confirm the accuracy of the information
presented herein and to describe generally accepted practices. However, we are not
responsible for any inaccuracies, errors, and/or omissions or for any consequences from the
use or application of any of the information contained herein and make no promise or
warranty, express or implied, with respect thereto.

We have taken all reasonable precautions to ensure that the drug selection and dosages set
forth in this text are in accordance with recommendations and practice current at the time of
writing. However, in view of ongoing research, changes in government regulations, and the
constant flow of information relating to drug therapy and drug reactions, the reader is solely
responsible for reviewing and following the package insert for each drug for any change in
indications and dosage and for any warnings and precautions. This is particularly important
when the recommended agent is a new or infrequently employed drug.

Some drugs and medical devices presented in this publication have Food and Drug
Administration (FDA) clearance for limited use in restricted research settings. It therefore is
the sole responsibility of the reader to ensure that the applicable health care provider has
ascertained the FDA status of each drug or device planned for use in their clinical practice.

THE READER ASSUMES ANY AND ALL RISKS ASSOCIATED WITH THE ACTUAL USE
AND/OR RELIANCE ON ANY OF THE INFORMATION CONTAINED HEREIN THAT
DEVIATES IN ANY WAY FROM THE INTENDED PURPOSE OF SUCH INFORMATION AS
ONLY A STUDY AIDE IN PREPARATION OF THE ANESTHESIA BOARD EXAMS. TO THE
EXTENT THE READER ULTIMATELY RELIES ON AND/OR OTHERWISE USES ANY SUCH
INFORMATION FOR ANY OTHER PURPOSE, WHETHER INTENDED OR OTHERWISE,
THE READER AGREES TO INDEMNIFY AND HOLD US HARMLESS FROM ANY AND ALL
INJURIES, DAMAGES, COSTS, FEES AND EXPENSES (INCLUDING ATTORNEYS! FEES
AND EXPENSES) THAT MAY OR DOES IN ANY WAY RESULT FROM SUCH ACTUAL USE
AND/OR RELIANCE.

6! ANESTHESIA HQ 2009
Anesthesia HQ!

Table of Contents
Anesthesia Circuits and Machines" 13
Bellows" 25
Vaporizers" 29
Scavenger System" 37
E Cylinders" 43
Carbon Dioxide Absorbers" 47
Electricity " 51
Capnography " 57
Blood Pressure Monitoring" 69
Central Venous Pressure Monitoring" 77
Pulmonary Artery Catheter" 85
Cardiac Output & Cardiac Index Monitoring" 95
Pulse Oximetry " 101
Mixed Venous Saturation Monitoring" 105
Cardiac Pressure-Volume Curves" 109
Inhalational Anesthetics" 117
Neuromuscular Blockers" 133
Local Anesthetics" 145
Obstetric Anesthesia: An Overview " 153
Obstetric Emergencies" 163
Pre-eclampsia" 171
Fetal Heart Tracing" 175
Myocardial Ischemia & Myocardial Infarction" 185
Valvular Diseases" 195
Pacemakers & Automated Implantable Cardiovertor Defibrillators" 209
Anesthetic Management of Pacemakers & AICDs" 215
Cardiac Reflexes" 219
Heart Transplant" 221
Abdominal Aortic Aneurysm" 223
Thoracic Aortic Aneurysm" 229
Intra-aortic Balloon Pump" 235
Cardiopulmonary Bypass Circuit" 239
Respiratory: An Overview" 245

ANESTHESIA HQ 2009 ! 7
" Anesthesia HQ

Hypoxemia" 259
Pulmonary Embolism" 263
Thoracic Anesthesia" 265
Mediastinoscopy" 275
Cystic Fibrosis" 277
Obstructive & Restrictive" 279
Lung Diseases" 279
Aspiration" 289
Acid-Base: An Overview" 293
Metabolic Acidosis" 301
Metabolic Alkalosis" 307
Respiratory Acidosis" 311
Respiratory Alkalosis" 317
Alpha-stat & pH-stat" 319
Blood Gas Management" 319
Neuroanesthesia" 321
Evoked Potentials" 333
Carotid Endarterectomy " 337
Arnold-Chiari Malformation" 341
Venous Air Embolism" 343
Spine Anatomy" 347
Spinal Cord Injury & Spinal Shock" 355
Tourniquet Pain" 359
Pediatric Anesthesia & Physiology " 361
Congenital Heart Disease" 371
Congenital Diaphragmatic Hernia" 377
Necrotizing Enterocolitis" 379
Ligation of a Patent Ductus Arteriosus" 381
Pyloric Stenosis" 385
Retinopathy of Prematurity " 389
Tracheo-esophageal Fistula" 391
Gastroschisis & Omphalocele" 395
Extracorporeal Membrane Oxygenation" 397
Ophthalmology & Eye Physiology " 399
Retrobulbar Block" 405

8! ANESTHESIA HQ 2009
Anesthesia HQ!

Perioperative Eye Injury " 407

Endocrine" 411
Thyroid Hormone" 415
Parathyroid Hormone" 423
Pheochromocytoma" 427
Obesity " 433
Liver Physiology " 437
Geriatrics" 441
Temperature Regulation during Anesthesia" 443
Malignant Hyperthermia" 449
Neuroleptic Malignant Syndrome" 453
TURP Syndrome" 455
Extracorporeal Shock Wave Lithotripsy " 459
Coagulopathies" 461
Hemoglobinopathies" 467
Porphyrias" 473
Scleroderma" 477
Scoliosis" 479
Parkinson!s Disease" 483
Systemic Lupus Erythematosus" 485
Osteogenesis Imperfecta" 489
Myotonic Dystrophy " 491
Muscular Dystrophy " 495
Multiple Sclerosis" 497
Myasthenia Gravis" 499
Myasthenic (Lambert-Eaton) Syndrome" 502
Guillain-Barre Syndrome" 505
Amyotrophic Lateral Sclerosis" 507
Carcinoid Syndrome" 509
Coexisting Diseases" 513
Airway & ENT" 519
Acute Epiglottitis" 525
Blood Transfusion" 527
Transfusion Reaction" 537
Isovolemic Hemodilution" 541

ANESTHESIA HQ 2009 ! 9
" Anesthesia HQ

Heparin-Induced Thrombocytopenia" 545

Chemotherapeutic" 547
& Immunosuppressant Drugs" 547
Electroconvulsive Therapy " 551
Burns" 555
Pain and Regional Anesthesia" 561
Intraoperative Awareness and Depth of Anesthesia" 583
Statistics" 585
Equations" 589
Anticholinergics" 599
Antiplatelets" 601
Barbiturates" 602
Benzodiazepines" 604
Beta Blockers" 606
Cholinesterase Inhibitors" 608
Clonidine" 610
Digoxin" 611
Dobutamine" 613
Dopamine" 614
Droperidol" 615
Ephedrine" 616
Epinephrine" 617
Etomidate" 618
Fenoldopam" 619
Fentanyl" 620
Glucagon" 621
H-2 Receptor Blockers" 622
Heparin" 623
Hydralazine" 624
Isoproterenol" 625
Ketamine" 626
Meperidine" 628
Metoclopramide" 629
Milrinone" 630
Morphine" 631

10! ANESTHESIA HQ 2009

Anesthesia HQ!

Naloxone" 632
Nicardipine" 633
Nitric Oxide" 634
Nitroglycerin" 635
Nitroprusside" 636
Norepinephrine" 638
Phentolamine" 639
Phenylephrine" 640
Prazosin" 641
Propofol" 642
Succinylcholine" 644
Sufentanil & Remifentanil" 646
Sympathomimetics" 647
Trimethaphan" 648
Vasopressin" 649
Index" 653

ANESTHESIA HQ 2009 ! 11
" Anesthesia HQ

12! ANESTHESIA HQ 2009

! Chapter: Anesthesia Circuits and Machines

! Anesthesia Circuits and Machines

A. Circle systems are complex anesthesia circuits where the components are arranged in a
circle. Circle systems are utilized to prevent rebreathing of carbon dioxide (CO2) during
low fresh gas flow. They also allow good conservation of respiratory heat and humidity.

B. Circle systems prevent rebreathing of carbon dioxide by means of a CO2 absorber. They
allow rebreathing of exhaled gases (oxygen and anesthetic gases). A scavenger system
removes any waste gases from the circle system.

C. A circle system can be semi-closed, semi-open, or closed.

1. Semi-open system does not allow rebreathing of gases and requires very high fresh
gas flow rates.
2. Semi-closed system allows rebreathing of gases and can be used with low fresh gas
flow rates.
3. Closed system allows rebreathing of gases, and the inspiratory and expiratory volumes
are essentially matched. A semi-closed system can be converted into a closed system
by closing the adjustable pressure limiting (APL) or pop-off valve.

D. A semi-closed system allows rebreathing of gases.

1. It is the most common anesthesia system used in the United States.
2. Due to circuit and multiple valves, a semi-closed system has more resistance to
breathing during spontaneous ventilation.
3. Multiple valves are present in the breathing circuit of a semi-closed system.
4. Reservoir (breathing) bag is part of the breathing circuit.
5. With a semi-closed system, it is still possible to rebreathe CO2.
6. Administration of low fresh gas flow rate can be utilized with a semi-closed system.

E. A semi-open system does not allow rebreathing of gases and requires high fresh gas flow.
1. Mapleson systems are semi-open systems.
2. Semi-open systems are associated with increased loss of heat and humidity due to
high fresh gas flow rates and absence of rebreathing.
3. It is difficult to scavenge waste gases with a semi-open system.
4. Since they do not contain valves, semi-open systems have less resistance to
spontaneous breathing.

ANESTHESIA HQ 2009 ! 13
Chapter: Anesthesia Circuits and Machines "

F. A closed system has fresh inflow gas which nearly equals the amount of gas taken up by
the patient.
1. The amount of inflow gas that needs to be replaced is the amount of oxygen
consumed by the patient and the amount of anesthetic gas absorbed by the patient!s
body and the anesthesia circuit.
2. There is complete rebreathing of gases (oxygen and inhalational anesthetic) after
removal of CO2 by the carbon dioxide absorber.
3. There is no gas exiting through the scavenger.
4. The APL valve is also closed, preventing overflow of gases.
5. Some of the semi-closed systems may be turned into closed systems by turning the
APL valve to the off/closed position.
6. Since there is nearly complete rebreathing of gases, a closed system offers maximum
conservation of heat and humidity.
7. A change in gas concentration occurs very slowly, due to low fresh gas flows.

G. A circle system requires the following components.

1. Fresh gas inlet
2. Tubing for expiratory and inspiratory limbs
3. Reservoir (ventilating) bag
4. Adjustable pressure limiting (APL) valve
5. Unidirectional valves on expiratory and inspiratory limbs
6. Carbon dioxide absorber
7. Y-piece that connects the inspiratory and expiratory limbs of the circuit

14! ANESTHESIA HQ 2009

! Chapter: Anesthesia Circuits and Machines

H. The components of the circle system may be arranged in multiple ways, but certain criteria
must be met in order to prevent rebreathing of carbon dioxide.
1. The fresh gas inlet must be between the CO2 absorber and inspiratory valve. It cannot
be on the expiratory limb.
2. The adjustable pressure limiting valve (APL) must be between the CO2 absorber and
expiratory valve. It cannot be in the inspiratory limb.
3. The unidirectional valves must be present between the reservoir bag/bellows and the
patient (Y-piece).
4. Other components of the circle system may have varying configurations.

I. Advantages of a circle system include the following:

1. Conservation of respiratory heat and humidity
2. Ability to scavenge waste gases
3. More constant concentration of inspired anesthetic gases
4. Allows administration of very low fresh gas flow without causing rebreathing CO2
5. Economical since it allows rebreathing of exhaled oxygen and volatile anesthetics

ANESTHESIA HQ 2009 ! 15
Chapter: Anesthesia Circuits and Machines "

J. Disadvantages of a circle system include the following:

1. Greater potential for system leaks and disconnections
2. Risk of malfunctioning unidirectional valves (stuck open or closed)
3. Due to multiple valves and components of the anesthesia circuit, there is increased
resistance and work of breathing during spontaneous ventilation.

K. During spontaneous ventilation with a circle system, the APL valve is fully open.

L. In a circle system, the ventilation dead space is distal to the Ypiece of the breathing
circuit.
1. The length of the separate inspiratory and expiratory limbs of the tubing does not affect
dead space caused by the anesthesia circuit.
2. For example, increasing the length of the inspiratory and expiratory limbs does not
increase the dead space distal to the Y-piece.

M. The compliance of the circuit tubing will affect the tidal volume that is delivered to the
patient. A portion of a set tidal volume can be lost to distending the circuit tubing.
1. A less compliant tubing results in smaller distention of the circuit tubing with each
inspiratory volume.
a. Pediatric and neonatal circuit tubing are less compliant. This minimizes the
amount of tidal volume lost to distending the tubing with each delivered ventilation.
b. Anesthesia circuit tubing with low compliance should be used for neonates and
infants.
2. For example, if the circuit tubing has a compliance of 5 mL/cm H2O, and the inspiratory
pressure is 20 cm H2O, the amount of volume lost to distending the tubing is 100 mL (5
mL/cm H2O multiplied by 20 cm H2O).
a. One can see from the above example how tubing compliance can cause
hypoventilation issues in small children and neonates. Depending on the
compliance of the lungs, majority of the set tidal volume may be used to just
distend the tubing.
b. Using the above example, let!s say a neonate required a tidal volume of 80 mL.
Since 100 mL is lost to distending the tubing, the neonate may not receive any lung
ventilation. Instead, the set tidal volume would only distend the circuit tubing.
3. Some of the newer anesthesia machines compensate for tubing compliance. The
compensatory mechanism allows better matching of set tidal volume to actual
delivered tidal volume.

N. Oxygen flush valve is connected inline with the inspiratory limb of the breathing circuit.
1. When the oxygen flush valve is open, fresh gas (oxygen) flows at approximately 50 psi
and greater than 30 L/min.
2. Opening the oxygen flush valve can result in the following:

16! ANESTHESIA HQ 2009

! Chapter: Anesthesia Circuits and Machines

a. Dilute the concentration of an anesthetic gas delivered to the patient.

b. Acutely increase the fraction inspired oxygen (FIO2).
c. When the inspiratory valve is open, activating the oxygen flush valve can increase
the risk of barotrauma and pneumothorax.

ANESTHESIA HQ 2009 ! 17
Chapter: Anesthesia Circuits and Machines "

Mechanical Ventilation: Inspiration

During mechanical inspiration, the bag/bellows switch is closed to the
ventilator bag.
The scavenger valve is closed during inspiration.
The inspiratory valve is open.
The expiratory valve is closed during inspiration.
Gases from the bellows flows through the CO2 absorber prior to going to
the patient.
The fresh gas inlet also provides fresh oxygen and volatile anesthetics.

18! ANESTHESIA HQ 2009

! Chapter: Anesthesia Circuits and Machines

Mechanical Ventilation: Expiration

During mechanical expiration, the bag/bellows switch is closed to the
ventilator bag.
The expiratory valve is open.
The inspiratory valve is closed during expiration.
Gases from the patient flow into the bellows.
The fresh gas also provides the bellows with oxygen and volatile
anesthetics.
Once the ventilation bellows is filled, excess gases are vented to the
scavenger.

ANESTHESIA HQ 2009 ! 19
Chapter: Anesthesia Circuits and Machines "

Manual (Bag) Ventilation: Inspiration

During manual (bag) ventilation, the bag/bellows switch is open to the
ventilator bag and closed to the bellows.
Once the ventilator bag fills with gases, the excess gases are vented to
the scavenger by adjusting the APL valve.
When the ventilator bag is squeezed, the gases flow through the CO2
absorber and to the patient.
The fresh gas inlet provides additional oxygen and volatile anesthetics.
Expiratory valve is closed during inspiration.

20! ANESTHESIA HQ 2009

! Chapter: Anesthesia Circuits and Machines

Manual (Bag) Ventilation: Expiration

During manual (bag) ventilation, the bag/bellows switch is open to the
ventilator bag and closed to the bellows.
The exhaled gases from the patient fill the ventilator bag.
The fresh gas inlet provides additional oxygen and volatile anesthetics to
the ventilator bag.
Once the ventilator bag is completely filled, excess gases are vented to
the scavenger by adjusting the APL valve.
Inspiratory valve is closed during expiration.

ANESTHESIA HQ 2009 ! 21
Chapter: Anesthesia Circuits and Machines "

O. Currently used anesthesia machines have evolved from simple anesthesia delivery
machines into complex ventilators with specialized anesthetic delivery mechanisms that
are controlled by powerful computers.

1. Even with the evolution of the complex anesthesia machine, the basic components of
an anesthesia machine have not significantly changed. The basic components include
the following:

a. Gas supply (oxygen, nitrous oxide, air) is provided by central and E-cylinder
sources.

b. Pressure regulators to control the supply of gases from the central and E-cylinder
gas sources.

c. Multiple alarms and monitors

d. Gas flow meters

e. Anesthetic agent vaporizers

2. The central gas supply has a safety device called a diameter index safety system
(DISS) that helps prevent connection of improper gas lines to the central gas supply
source.

a. For example, the DISS helps prevent connection of the oxygen gas line to the
nitrous oxide central gas supply. Connection of the nitrous oxide line to the oxygen
central supply is also prohibited.

b. The central gas supply has a pressure around 45-55 psi.

3. All E-cylinders also have a safety system that helps prevent connection of the incorrect
gas cylinder to the anesthesia machine. This is called the pin index safety system
(PISS).

4. The pressure regulators in the anesthesia machine lower the pressure of the delivered
gases prior to administration to the patient.

a. Low pressure system includes the components of the flow meters, control valves,
and vaporizer to the common gas outlet to the patient.

b. Intermediate pressure system includes the down-regulated E-cylinders pressure

(~45-50 psi) to the flow meters and control valves.

(1) Recall, the normal pressure from the oxygen E-cylinders is approximately 2200
psi and the nitrous oxide pressure is about 740 psi.

(2) The oxygen line from the high pressure wall supply is about 50 psi.

5. The fail-safe valve is one of the key safety components of an anesthesia machine.
The purpose of the fail-safe valve is to help detect and protect from the delivery of
hypoxic mixtures of gases. The 2000 ASTM F1850-00 standard requires the following

22! ANESTHESIA HQ 2009

! Chapter: Anesthesia Circuits and Machines

for all anesthesia machines: the delivered oxygen concentration shall not decrease
below 19% at the common gas outlet; an alarm shall activate within five seconds when
pressure decreases below manufacturers specified threshold. Current anesthesia
machines have alarms that activate when the pressure falls below 30 psi. There are
two types of fail-safe valves, depending on the manufacturer of the anesthesia
machine.

a. The Datex Ohmeda anesthesia machines utilizes a pressure sensor shut off valve.
With this system, the fail-safe valve is either open or closed. When the pressure of
oxygen falls to a set threshold (20 psi), the valve closes and shuts off flow of all
gases except oxygen to help detect and protect from the delivery of hypoxic
mixture of gases.

(1) The Datex Ohmeda machines also have a second-stage oxygen regulator that
allows flow of oxygen from the flow valve control to be constant when the
pressure is greater than 12-14 psi.

b. The Drager anesthesia machines use a proportioning system called an oxygen

failure protection device (OFPD).

(1) The proportioning system decreases the supply of nitrous oxide as the
pressure of oxygen supply decreases. At a critical level, the nitrous oxide
supply is shut off.

c. The fail-safe valve does not prevent the delivery of an hypoxic mixture of gases.
The oxygen analyzer on the distal end of the anesthesia circuit is the last line of
defense in detecting the delivery of hypoxic mixture of gases.

d. Recall that the fail-safe monitor is pressure sensitive and not flow sensitive.

ANESTHESIA HQ 2009 ! 23
Chapter: Anesthesia Circuits and Machines "

Recommended Reading & Reference:

Andrews, JJ, Inhaled Anesthetic Delivery Systems, Anesthesia 5th Edition (Miller R, ed),
Churchill Livingstone, Philadelphia, PA, p.174-206
Clinical Anesthesia 3rd Edition (Barash P, Cullen B, Stoelting R, ed), Lippincott Williams &
Wilkins, Philadelphia, PA, p.551-554
Miller!s Anesthesia 6th Edition (Miller R, ed), Churchill Livingstone, Philadelphia, PA, p.
273-316.

24! ANESTHESIA HQ 2009

! Chapter: E Cylinders

! E Cylinders

A. Anesthesia machines have backup gas cylinders (E cylinders). The E cylinders connect
directly to an anesthesia machine and are available in the event of a central gas supply
failure.

B. The intrinsic pressures of the E cylinders (oxygen ~2200 psi; nitrous oxide ~745 psi) are
regulated down to approximately 45 psi by pressure regulators on the E cylinders and
anesthesia machine.
1. The down-regulated E cylinder pressure is less than the central gas pressure, which
allows preferential gas flow from the central gas source.
2. When the central gas pressure falls below 45 psi, the E cylinder gas becomes
available to the anesthesia machine.
3. All E cylinders must be checked prior to each anesthetic.

C. The Pin Index Safety System (PISS) was developed to safeguard against connecting
incorrect E cylinders to the anesthesia machine.
1. For example, an oxygen E cylinder cannot be easily connected to the E cylinder yolk
for nitrous oxide on the anesthesia machine.

E cylinder Form Capacit Pressure Color Color (Intl) Critical

y (L) (psi) (USA) Temp (C)
~2000-220
Oxygen Gas ~625 Green White -119
0
Nitrous
Liquid/Gas ~1600 ~745 Blue Blue 36
Oxide
Air Gas ~625 ~2000 Yellow White + Black -140
Nitrogen Gas ~625 ~2000 Black Black -149
Carbon
Liquid/Gas ~845 ~1600 Gray Gray 31
Dioxide
~1600-200
Helium Gas ~500 Brown Brown -268
0

D. Critical temperature for a gas is the temperature at which a gas can be liquefied under
pressure. Above the critical temperature, a gas cannot be liquefied regardless of
pressure; distinct gas and liquid states do not exist.
1. For example, the critical temperature for oxygen is 119o C. This means that oxygen
can be liquefied under pressure if the temperature is colder than -119o. Above this
temperature, it exists only as a gas.

ANESTHESIA HQ 2009 ! 43
Chapter: E Cylinders"

2. The critical temperature for nitrous oxide is 36o C. This explains why nitrous oxide
exists as a liquid at room temperature.

E. Nitrous oxide exists as a liquid at room temperature and the volume of gas remaining in
the cylinder is not proportional to the cylinder pressure.
1. The nitrous oxide tank pressure usually does not begin to decrease until the liquid is
exhausted and only gas remains in the tank.
2. When only N2O gas exists in the tank, there is usually less than 400 L of gas
remaining.
3. The most accurate way to determine remaining N2O volume is to weigh the E cylinder.
a. The tare weight (empty weight) is stamped on the cylinder.
b. The volume of nitrous oxide can be calculated by knowing the three components:
(1) the mass (g) of nitrous oxide in the cylinder,
(2) molecular weight of nitrous oxide (44 g/mol), and
(3) one mole of gas at standard temperature and pressure is 22.4L.
c. A simple estimate is that 1000g (1kg) of nitrous oxide is about 550 L of free gas at
20oC. (At STP, the volume would be about 512 L)

Nitrous Oxide E Cylinder Sample Calculation

A nitrous oxide E cylinder has a tare weight of 7 kg. The pressure gauge reads 740
psi and now weighs 8.8 kg. How many liters of nitrous oxide are remaining in the
cylinder at standard temperature and pressure (STP)?

Three known components:

- Mass of nitrous oxide = 1800 g (1.8 kg)
- Molecular weight of nitrous oxide = 44 g/mol
- One mole of nitrous oxide at STP = 22.4 L

Volume = (1800g/44g/mol) x 22.4 L/mol

= 40.9 mol x 22.4 L/mol
= 916 L at STP (standard temperature and pressure)

F. Boyle!s Law describes the relationship between pressure (P) and volume (V) of a gas.
1. At a constant mass of gas and temperature, the product of pressure and volume is
constant (P1V1 = k).
2. As the volume of gas decreases, the pressure inside the E cylinder also decreases in
proportion to the volume of gas.

44! ANESTHESIA HQ 2009

! Chapter: E Cylinders

a. The exception is nitrous oxide, since it is both liquid and gas inside an E cylinder.

G. Charles! Law describes the relationship between volume and temperature. Charles! Law
states that V/T = k at a constant pressure and quantity.
1. Under constant pressure and quantity, the volume of a gas varies directly with
temperature (degrees Kelvin).
2. As the temperature of a gas increases, the volume also increases.

H. The Boyle!s and Charles! laws can be combined. The combined gas law is as follows:
(P1V1)/T1 = (P2V2)/T2

I. Dalton!s Law states that total pressure is equal to the sum of the partial pressures.

J. Recall that standard temperature and pressure (STP) are assumed for these equations.
The standard temperature is 273oK (0oC) and pressure is 14.7 psi. Normal room
temperature is around 20oC or 293oK.

Gas Laws

Boyle!s Law P1V1 = k

Charles! Law V1/T1 = k

Combined Gas Law P1V1/T1 = P2V2/T2

Ideal Gas Law PV = nRT

Dalton!s Law Ptotal = P1 + P2 + P3...+Pn

where P = pressure (atm), V = volume (liters), T =

temperature (Kelvin), n = mol, R = gas constant

Pressure Conversions

1 atm = 14.7 psi

14.7 psi = 760 mmHg

1 mmHg = 1.36 cm H2O

1 mole of gas = 22.4 L

(at standard temperature and pressure)

ANESTHESIA HQ 2009 ! 45
Chapter: E Cylinders"

One can calculate the availability of a gas from an E cylinder by utilizing the the gas laws.

Oxygen E Cylinder Sample Calculation

A previously full oxygen E cylinder with an initial pressure of 2000 psi now reads
1000 psi. How long will the oxygen last when the patient is receiving 6 L/minute via
a face mask?

P1V1 = P2V2

P1 = 1000 psi
V1 = 5 L (approximate internal volume of an E cylinder)
P2 = 14.7 psi (atmospheric pressure)
V2 = needs to be solved with the above equation

V2 = (1000 psi x 5 L) / 14.7 psi

= 340 L

Therefore, approximately 340 L of oxygen is remaining in the tank.

The E cylinder oxygen source will last about 57 minutes (340 L divided by the
flow rate, 6 L/min).

Recommended Reading & Reference:

Andrews JJ, Delivery Systems for Inhaled Anesthetics, Clinical Anesthesia 3rd Edition (Barash
P, Cullen B, Stoelting R, ed), Lippincott Williams & Wilkins, Philadelphia, PA, p.535-537
Clinical Anesthesiology 3rd Edition (Morgan G, Mikhail M, Murray M, ed), Lange Medical
Books/McGraw-Hill, New York, NY, p.16-19

46! ANESTHESIA HQ 2009