UNDERSTANDING THE GA MACHINE

MODULE FOR HOUSE OFFICER ROTATION IN ANAESTHESIA

Dr Aktar bin Abdul Rahman Dato Dr Subrahmanyam Balan Anaesthesia Department HOSPITAL SULTANAH AMINAH JOHOR BAHRU 2009

What is a GA machine?
An electronic mechanical device for:
1. Administration of inhalation anesthetic gases and volatile anesthetic agents. 2. Controlling ventilation

A typical modern anaesthetic machine

a Physiological monitor, b ventilator controls, c dual flowmeter tubes, d vaporizer locks, e multiple vaporizers, f master gas on/off switch, g Bourdon gauges, h ventilator bellows, i APL valve, j emergency oxygen, k patient monitor connection, l CO2 absorber, m reservoir bag.

Components of a GA machine
1. A delivery system for medical gases, 2. A flowmeter to measure gas flow, 3. Vaporizers for volatilizing and combining the anesthetic agents with oxygen and carrier gases, 4. A circuit for delivering the gas to the patient, 5. Monitoring equipment or gauges, 6. A ventilator, and 7. A scavenging system to collect and discharge excess gas

Delivery system for medical gases

1. Hospital pipe lines.

From the hospital medical gas system (wall outlet). Pressure should be around 400 kPa (60 psi; 4 atmospheres). Colour coded fitted with a Schrader connector or Noninterchangeable screw-threaded (NIST).
Oxygen, air, and nitrous oxide attached via a specific yoke with a Bodok seal. The regulators for the cylinders are set at 300 kPa (45 psi; 3 atmospheres).

2. Reserve gas cylinders

Note: If the cylinders are left on and the machine is plugged into the wall outlet, gas from the wall supply will be used preferentially, since it is at a higher pressure.

Medical gases colour coding

Noninterchangeable screw threaded (NIST)

Noninterchangeable screw-threaded (NIST) connectors showing

a pipeline end and b corresponding machine connection.

Medical gas terminal outlets

Schrader probes

Gas cylinders

The cylinders are fixed to the anaesthetic machine using a gas specific pin indexed yoke. The pins on the yoke match holes drilled on the face of the cylinder valve to prevent connection with a cylinder of the wrong gas. All valve yokes are indelibly marked with the gas they have been designed to carry. Between the face of the cylinder and the face of the yoke lies a thin aluminium and neoprene washer, the Bodok seal. Once the gas has entered the yoke, it passes through a filter, and then a one-way check valve. The function of the check valve is to prevent egress of gas, in the event that there is more than one cylinder yoke for a given gas and a cylinder is missing. When new, the check valve is highly efficient, allowing a maximum leak rate of 15 ml/min. However, with use, the check valve becomes inefficient, and if a cylinder is not present a blanking plug should be fitted. From the cylinder yoke, the gas flows through the reducing valves into the machine.

Cylinder Yoke
A nitrous oxide cylinder yoke.
a The two pins of the pin index safety system, b the metal-rimmed Bodok seal, c on the right of the yoke is the noninterchangeable screw thread (NIST) pipeline attachment.

A nitrous oxide cylinder yoke with a blanking plug installed

Pin Index Safety System (PISS)

A safety system to ensure that pneumatic connections between a gas cylinder and a machine that uses pressurized gases are not connected to the wrong gas yoke

O2: 2-5 N2O: 3-5 Air: 1-5 CO2: 1-6 Heliox: 2-4

Pin Index Safety System (PISS)

Flowmeters

Made of tempered glass and are individually calibrated for the gas. Gas flow rate should be read at the top of the plumb bob and skirted floats, or at the widest point of the ball. A safety feature of the flow meter block is that the oxygen flow control is always on the lefthand side of the block, and uses a different type of knob so that it can instantly be distinguished from the other gases. O2 is the last gas to enter the manifold to minimizes the possibility of O2 leakage from cracks in the other flow meter tubes causing inadvertent delivery of a hypoxic mixture. Most manufacturers now fit anti-hypoxia devices to their machines so that it is impossible to deliver less than 2530% oxygen when nitrous oxide is used.

Anti-hypoxic device
A mechanical interface that physically tethers the oxygen flow control valve itself to the nitrous oxide flow control valve, producing a certain minimal ratio of O2 to NO2.
Both the ratio of sprocket teeth and the individual gas supply pressures to the flow meters determine the final 3:1 minimal ratio of NO2 to O2 flow so that a minimum 25% of O2 will be delivered if attempts are made to increase the NO2 flow greater than the 3:1.

Back bar (Selectatec system)

Part of the anaesthetic machine to which the vaporizers are attached. Many manufacturers use the Selectatec system, which allows the user the freedom to add or remove specific anaesthetic agent vaporizers.

Diagram of a generic two-gas anesthesia machine

Common gas outlet

Medical gases and vapours exit the anaesthetic machine via a 22 mm male/15 mm female conically tapered connector. This connector is sometimes fixed, other manufacturers supply a swivel connector. Historically an emergency oxygen flush has been located close to the common gas outlet, though with integrated machines this is less common. It is required to provide a minimum of 30 litre/min oxygen, though some machines produce flow rates of up to 70 litre/min. In addition to the common gas outlet, many manufacturers provide one or more 400 kPa auxiliary gas drive points. These points are fitted with mini-Schrader sockets and supply either air or oxygen.

Vaporizers
A mechanical devices attached to the GA machine back bar to produce a controlled and predictable concentration of anesthetic vapor in the carrier gas passing through the vaporizer. Vaporizer design has been influenced by the physical properties of the different agents and techniques to ensure their safe and accurate delivery.

Vaporizers
Colour coded:
Isoflurane: purple Sevoflurane: Yellow Desflurane: Blue Halotane: Red

Vaporizers
Common vaporizers:
Tec (Temperature compensated) 4,5 (Isoflurane, sevoflurane) Tec 6 (desflurane)

Sevoflurane and halotane can be used for inhalational induction Desflurane and Isofurane can not be used for inhalational induction

Vaporizers

Vaporizers (TEC 5)
Important safety features include:
Keyed fillers Low filling port Secured vaporizers (less ability to move them about minimizes tipping) Interlocks (selectatec) Concentration dial increases output in all when rotated counterclockwise Agents level

Plenum vaporizers
Designed for use with gas flowing under positive pressure through the vaporization chamber.

Plenum vaporizers

Vaporizers (TEC 6)
Specific only for desflurane The volatile agents sum electrically heated to 390C, thus takes time to warm up ~ 5 minutes Can be refill while in used Knob to be dialed up gradually to the desired concentration as can cause tachycardia if suddenly turn up to a high concentration. Can cause bradycardia. Can cause increase in secretions Can not be used for inhalational induction agent Suitable for day surgery (ambulatory) anaesthesia, fast onset and off set. Volatile agent level by LED displayed

Vaporizers (TEC 6)

The TEC 6 is electrically powered to heat the desflurane to 39C, producing a stable SVP of about 1500 mm Hg. The desflurane concentration is set by a dial controlling a variable restrictor downstream from the vaporizing chamber. A differential pressure transducer continually senses the pressure in the vapour upstream of the variable restrictor as well as backpressure from the fresh gas flow. An additional stop point on the control dial at 12% before accessing higher concentrations (the airway irritability of desflurane can provoke coughing in the spontaneously breathing patient at high inspired concentrations). Two further heating elements in the upper structure prevent vapour condensation and a reduction in delivered concentration. A tilt detector shuts off the vaporizer if it senses a tilt greater than 15 from the vertical. A filler port that accepts only the desflurane bottle nozzle to prevent accidental filling with other volatile agents.

Inhalational agents
The ideal characteristics of an inhalational agent are:
quick onset and offset low airway irritability cardiovascular stability low incidence of side-effects.

Inhalational agents

Anesthetic Breathing Circuit

Breathing circuit
1. Most commonly a circle attachment, or a Bain's breathing system, which are breathing hoses connected to a anaesthesia face mask 2. A heat and moisture exchanger (HME) with or without bacteria-viral filter (HMEF).

Circle breathing system

Se7en components:
1. a fresh gas source; 2. Inspiratory and expiratory unidirectional valves; 3. inspiratory and expiratory limbs of the breathing circuit; 4. a Y-type connector; 5. a pop-off valve; 6. a reservoir bag; and 7. a carbon dioxide absorbent canister

Other breathing systems

Ventilators
Usually Volume and Pressure control mode. In some ventilator: SIMV, PSVpro mode Volume control: set VT~ 7-10mls/kg Pressure control: set IP~ 10-15mmHg Respiratory rate I:E ratio PEEP Alarms setting

Monitors
Physiological monitors to monitor the patient's:
1. 2. 3. 4. 5. 6. 7. 8. 9. Heart rate, ECG, Non-invasive blood pressure and Plethysmography with Oxygen saturation End-tidal CO2, Temperature, Arterial blood pressure Central venous pressure The gases compositions delivered to the patient (and breathed out) is monitored continuously.

Scavenging system

To remove expired anaesthetic gases from the operating room. Scavenged gases are usually vented to the atmosphere. Common sources for waste gas contamination of the operating room:
1. anesthetics given with uncuffed endotracheal tubes or poorly fitting face masks, 2. spilled agent from refilling vaporizers, 3. excessive use of the oxygen flush valve, 4. failure to turn off the flowmeters at the end of the case, and 5. poorly adjusted closed scavenging interfaces. 6. Other sources of contamination may come from leaks at connection sites of the pipeline supplies to the anesthesia machine, 7. from internal leaks in the anesthesia machine, and 8. from patient gas sampled from the breathing circuit for airway gas analysis (capnography and anesthetic agent detection).

Scavenging system

Safety features
The most important safety feature is the machine check. The operators manual for a specific machine should always be consulted when using a new machine for the first time. The second most important safety feature is the oxygen supply failure alarm. Once sounding, the only way to silence the alarm is to restore the oxygen supply. The anaesthetic machine is fitted with a pressure relief valve. It is set to open at 3042 kPa and is designed to protect the machine not the patient. Subjecting the lungs to this pressure would cause severe barotrauma.

MCQ
1. Regarding medical gases:

NO2 is odourless Oxygen in cylinder is stored in liquid form. NO2s cylinder has a white shoulder with a blue body. Air for GA machine is supplied at 450kPa from the wall outlet. Colour-coded for Oxygens cylinder is white sholuder with a black body.

MCQ
2. Regarding Vaporizers:
Vaporizers are agent nonspecific Both vaporizers can be turn on simultaneously if the are attached together at the back bar Sevoflurane vaporizer (TEC 5) can be refill during operation It is ok to to refill desflurane vaporizer (TEC 6) without turn it off. All vaporizers are electrically heated.

MCQ
3. The following statements are true:
The GA machine can deliver 100% NO2 It is OK to press the O2 flush during Inspiration phase of ventilation It is OK to press the O2 flush during Expiratory phase of ventilation The PISS for O2 is 2-5 The PISS for NO2 is 2-5

MCQ
4. Regarding inhalational agents:
Sevoflurane can be used as an induction agent Desflurance can be used as an inhalational induction agent Sevoflurane causes hypotention in dose dependent manner Isoflurane can cause uterine atony Isoflurane can cause bronchospasm

MCQ
5. Safety features of a GA machine:
Selectec system to avoid accidential delivery of 2 inhalational agents. The oxygen will flow if the NO2 knob is accidentally turned on It is possible to connect the Oxygen cable to the air wall outlet The bodok seal is not necessary to connect the Cylinder to the GA yoke The Oxygen knob is bigger than the NO2 and Air.