27.

If the anesthesia machine is discovered Monday morning to have run with 5 L/min of oxygen
all weekend long, the most reasonable course of action before administering the next anesthetic
would be to
A. Administer 100% oxygen for the first hour of the next case
B. Place humidifier in line with the expiratory limb
C. Avoid use of sevoflurane
D. Change the CO2 absorbent
28. According to NIOSH regulations, the highest concentration of volatile anesthetic
contamination allowed in the OR atmosphere when administered in conjunction with N2O is
A. 0.5ppm
B. 2ppm
C. 5 ppm
D. 25 ppm
29. The device on anesthesia machines that most reliably detects delivery of hypoxic gas
mixtures is the
A. Fail-safe valve
B. O2 analyzer
C. Second-stage O2 pressure regulator
D. Proportion-limiting control system
30. A ventilator pressure-relief valve stuck in the closed position can result in
A. Barotrauma
B. Hypoventilation
C. Hyperventilation
D. Low breathing circuit pressure
31. A mixture of 1% isoflurane, 70% N2O, and 30% O2 is administered to a patient for
30 minutes. The expired isoflurane concentration measured is 1%. N2O is shut off, and a mixture
of 30% O2 and 70% N2 with 1% isoflurane is administered. The expired isoflurane concentration
measured 1 minute after the start of this new mixture is 2.3%. The best explanation for this
observation is
A. Intermittent back pressure (pumping effect)
B. Diffusion hypoxia
C. Concentration effect
D. Effect of N2O solubility in isoflurane

27. (D)
CO can be generated when volatile anesthetics are exposed to CO2 absorbers that contain NaOH
or KOH (e.g., soda lime). Factors that can influence CO formation:
(1) The volatile anesthetic used (desflurane isoflurane sevoflurane)
(2) Concentration of volatile (more CO is generated at higher concentrations)
(3) High Temp (more CO is generated at higher temperatures)
(4) Low fresh gas flows
(5) Dry soda lime (dry granules produce more CO than do hydrated granules). Soda lime
contains 15% water by weight, and only when it gets dehydrated to below 1.4% will appreciable
amounts of CO be formed.
Many of the reported cases of patients experiencing elevated carboxyhemoglobin levels occurred
on Monday mornings, when the fresh gas flow on the anesthesia circuit was not turned off and
high anesthetic fresh gas flows (>5 L/min) for prolonged periods of time (e.g., >48 hours)
occurred. Because of some resistance of the inspiratory valve, retrograde flow through the CO2
absorber (which hastens the drying of the soda lime) will develop, especially if the breathing bag
is absent, the Y-piece of the circuit is occluded, and the adjustable pressure-limiting valve is
open. Whenever you are uncertain as to the dryness of the CO2 absorber, especially when the
fresh gas flow was not turned off the anesthesia machine for an extended or indeterminate period
of time, the CO2 absorber should be changed. This CO production occurs with soda lime, but it
does not occur with Amsorb Plus or DrgerSorb Free (which contains calcium chloride and
calcium hydroxide and no NaOH or KOH) (Barash: Clinical Anesthesia, ed 7, p 676; Miller:
Basics of Anesthesia, ed 6, pp 212215; Miller: Millers Anesthesia, ed 8, pp 789792).
Hillcrest = Sodasorb by W.R. Grace & Co.
Primarily Calcium Hydroxide (Ca(OH)2), blended with a small quantity of
NaOH and KOH
28. (A)
NIOSH (National Institute for Occupational Safety and Health) mandates that the highest trace
concentration of volatile anesthetic contamination of the OR atmosphere when administered in
conjunction with N2O is 0.5 ppm (Butterworth: Morgan & Mikhails Clinical Anesthesiology, ed
5, p 81).
Volatile Anesthetics alone = 2ppm
N2O alone = 25ppm
29. (B)
The O2 analyzer is the last line of defense against the inadvertent delivery of hypoxic gas
mixtures. It should be located in the inspiratory (not expiratory) limb of the patients breathing
circuit to provide maximum safety. Because the O2 concentration in the fresh-gas supply line
may be different from that of the patients breathing circuit, the O2 analyzer should not be located
in the fresh-gas supply line (Ehrenwerth: Anesthesia Equipment: Principles and Applications, ed
2, pp 209210).
The fail-safe valve/device shuts off the N2O supply if there is a loss of O2 supply pressure. It
senses only pressure and does not check whether the supplied gas is actually oxygen. Because of

the fail-safe device, a decrease in N2O flow (with the N2O flowmeter bobbins dropping to zero)
may actually be the first sign of loss of oxygen supply pressure.
30. (A)
The ventilator pressure-relief valve (also called the spill valve) is pressure controlled via pilot
tubing that communicates with the ventilator bellows chamber. As pressure within the bellows
chamber increases during the inspiratory phase of the ventilator cycle, the pressure is transmitted
via the pilot tubing to close the pressure-relief valve, thus making the patients breathing circuit
gas tight. This valve should open during the expiratory phase of the ventilator cycle to allow
the release of excess gas from the patients breathing circuit into the waste-gas scavenging circuit
after the bellows has fully expanded. If the ventilator pressure-relief valve were to stick in the
closed position, there would be a rapid buildup of pressure within the circle system that would be
readily transmitted to the patient. Barotrauma to the patients lungs would result if this situation
were to continue unrecognized (Butterworth: Morgan & Mikhails Clinical Anesthesiology, ed 5,
pp 34, 7980).

1.

31. (D)
Vaporizer output can be affected by the composition of the carrier gas used to vaporize the
volatile agent in the vaporizing chamber, especially when N2O is either initiated or discontinued.
This observation can be explained by the solubility of N2O in the volatile agent. When N2O and
oxygen enter the vaporizing chamber, a portion of the N2O dissolves in the liquid agent. Thus,
the vaporizer output transiently decreases. Conversely, when N2O is withdrawn as part of the
carrier gas, the N2O dissolved in the volatile agent comes out of solution, thereby transiently
increasing the vaporizer output (Miller: Millers Anesthesia, ed 8, pp 769771).