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Principles of Anesthesia Equipment
Yasodananda K Areti, Bhavani Shankar Kodali
CHAPTER 1:
Applied Physics
INTRODUCTION
COMPRESSED GASES
Adiabatic Process
Adiabatic Expansion
Adiabatic Compression
Atmospheric Pressure and Units (Table 1.1)
Critical Temperature and Critical Pressure
Poynting Effect
The Entonox Cylinder
Force (Relation to Pressure)
Gas Laws (see Table 1.2)
Avogadro's Hypothesis
Boyle's Law
Charle's Law
Gay Lussac's Law
The Ideal Gas Law
Universal Gas Constant
Dalton's Law of Partial Pressures
Henry's Law
VAPORS
Boiling Point
Latent Heat of Vaporization
Saturated Vapor Pressure and Vaporization
FLUIDS
Density and Viscosity
Factors Affecting Viscosity
Flow
Laminar Flow/Tubular Flow (Figs. 1.2A and B)
Turbulent Flow/Orificial Flow (Fig. 1.3)
Bernoulli's Principle
Venturi Effect
The Venturi Mask (Fig. 1.6)—An Application of the Venturi Tube
Coanda Effect (Figs. 1.7 and 1.8)
Applications
Surface Tension (Laplace's Law)
DIFFUSION/OSMOSIS
Diffusion
Osmosis
Osmometry
Tonicity
Colloid Osmotic Pressure
HEAT
Specific Heat
Thermal Conductivity
HUMIDITY
Absolute Humidity
Relative Humidity
Measurement of Humidity
Humidification
Heat and Water Loss
Advantages of Humidification
Disadvantages of Humidification
Methods of Humidification
Anesthetic Circuits
Heat and Moisture Exchanger and HME Filter
Water Bath Humidifier
Nebulizers
ELECTROMAGNETIC SPECTRUM
Beer-Lambert Law
Clinical Application in Anesthesia
Light
Infrared Analyzers
Infrared Spectroscopy
LASER (SEE CHAPTER 9)
Ultraviolet Light
ELECTRICITY
Electromagnetism
Electrical Charge and Potential
Units, Laws and Concepts in Electricity
Alternating Current and Direct Current (Figs. 1.15A and B)
Capacitance
Impedance and Resistance
Wavelength and Amplitude
Static Electricity
Wheatstone Bridge (Fig. 1.18)
ULTRASOUND
Basic Physics of Ultrasound (see Chapter 10)
Propagation of Sound
Features of an Ultrasound Image
Typical Appearance of Normal Tissue (Table 1.7):
Components of Ultrasound Imaging
Transducer
Receiver and Processor
Image Display—Modes
Doppler Ultrasound
Uses of Ultrasound in Anesthesia
Regional Anesthesia (see Chapter 10)
Transesophageal Echocardiography
Vascular Access
Other Applications of Ultrasound
CHAPTER 2:
Medical Gas Supply, Vacuum, and Scavenging
INTRODUCTION
MEDICAL GASES AND SUPPLY
Oxygen
Liquid Oxygen
Oxygen Concentrator
Nitrous Oxide
Medical Air
MEDICAL GAS CYLINDERS
Filling the Cylinder
Safety Pressure Release
Devices to Open or Close a Cylinder
Contents of a Cylinder
Valves
MANIFOLD AND PIPELINE NETWORK
Outlets
Quick Connectors (Fig. 2.8)
The Diameter Index Safety System
Safe Use of Cylinders
OTHER MEDICAL GASES OF INTEREST TO ANESTHESIOLOGIST
Entonox
Nitric Oxide
Heliox
Xenon
VACUUM
SCAVENGING SYSTEMS (FIGS. 2.11 AND 2.12)
WEBSITES
CHAPTER 3:
Anesthesia Machine or Workstation
INTRODUCTION
STRUCTURE OF ANESTHETIC MACHINE
COMPONENTS OF THE MACHINE
Power Supply (Figs. 3.3A and B)
Medical Gas Inlets (Fig. 3.4)
Pressure Gauge
Pressure Regulator
Check Valves
Oxygen Fail-Safe Device
Oxygen Failure Protection Device
Proportioning Systems
Datex-Ohmeda Link 25 (Figs. 3.8A and B)
Dräger® Oxygen Ratio Monitor Controller (Fig. 3.9)
Oxygen Low-Pressure Alarm
FLOW METERS
Traditional (Fig. 3.10)
Hybrid
Electronic
The “Back Bar” (Fig. 3.13)
High-Pressure-Relief Valves
VAPORIZERS
Functional Analysis of Vaporizers
Plenum Vaporizers
Electronic Vaporizers
Direct Injection of Volatile Agents
Oxygen Flush (see Fig. 3.3A)
Common Gas Outlet (see Fig. 3.3A)
ANESTHESIA INFORMATION MANAGEMENT SYSTEM
Software
Hardware
SUMMARY OF SAFETY MECHANISMS TO PREVENT ADMINISTRATION OF HYPOXIC GAS MIXTURE
OPERATING ROOM PROTOCOL IN THE EVENT OF FAILURE OF PIPELINE OXYGEN SUPPLY
WEBSITES
CHAPTER 4:
Anesthesia Breathing Systems
INTRODUCTION
COMPONENTS
APPARATUS DEAD SPACE
CLASSIFICATION OF BREATHING SYSTEMS
SYSTEMS WITH UNIDIRECTIONAL FLOW USING ABSORBENTS TO REMOVE CO2 (CIRCLE SYSTEM)
Inhaled Anesthetic Agents and CO2 Absorbents
Compound A
Carbon Monoxide
Indication of Absorbent Exhaustion
Circle System (Fig. 4.2B)
Structure
Certain Positions of APL Valve, RB and FGF That Can Lead to Accumulation of CO2:
Functional Analysis
Advantages and Disadvantages of Circle System
SYSTEMS WITH BIDIRECTIONAL FLOW USING CO2 ABSORBENT
Waters To-and-Fro System (Fig. 4.3)
UNIDIRECTIONAL SYSTEMS USING NONREBREATHING VALVES FOR CO2 ELIMINATION
CO2 ELIMINATION SYSTEMS WITH BIDIRECTIONAL FLOW (NO CO2 ABSORBENT)
Mapleson Systems (Fig. 4.5)
Bain Circuit (Fig. 4.7)
T-piece Systems
Enclosed Afferent Reserve System
Functional Analysis
T-piece Systems
MONITORING
Inspired Oxygen Concentration
Airway Pressure
Spirometry
Capnography
WEBSITES
CHAPTER 5:
Anesthesia Ventilators
INTRODUCTION
MODES OF VENTILATION IN THE ANESTHESIA VENTILATORS
Volume Control Ventilation
Disadvantages of Volume-Controlled Ventilation
Pressure Control Ventilation
Disadvantages of Pressure-Controlled Ventilation
Pressure-Controlled Ventilation with Volume Guarantee (Fig. 5.3)
Synchronized Intermittent Mandatory Ventilation
Pressure Support Ventilation
Positive End-Expiratory Pressure
CLASSIFICATION OF ANESTHESIA VENTILATORS
CHALLENGES SPECIFIC TO ANESTHESIA VENTILATORS
Low-Flow Inhalational Anesthesia
Driving the Ventilator
Gas-Driven
Piston Ventilators
TurboVent
Volume Reflector Technology
Effect of Fresh Gas Flow on the Delivered Tidal Volume
Fresh Gas Decoupling or Fresh Gas Compensation
Effect of Compliance and Leaks on Delivered Tidal Volume
Ability to Switch from Mechanical to Manual Ventilation
Use of Oxygen Flush
Pediatric Ventilation
Waste Anesthetic Gas Scavenging (see Fig. 5.7)
Application of Positive End-Expiratory Pressure
COMMONLY USED CURRENT MODELS OF ANESTHESIA VENTILATORS
Dräger Divan Ventilator (Piston and Bellows)
E-Vent plus Piston Ventilator (Primus IE, Fabius GS; Figs. 5.8 and 5.9)
Zeus TurboVent®
Maquet FLOW-i Machine (Fig. 5.10)
Ohmeda 7000 Bellows Ventilator (Fig. 5.11; Ohmeda Excel)
Datex-Ohmeda 7100 Bellows Ventilator (Aespire, Aestiva Machines)
Ohmeda 7900 “SmartVent” Bellows Ventilator (Fig. 5.12)
Datex-Ohmeda S/5 ADU Bellows Ventilator
TYPICAL VENTILATOR ALARMS
Low Inspired Oxygen
WEBSITES
CHAPTER 6:
Equipment for Airway Maintenance
ENDOTRACHEAL EQUIPMENT
FACE MASK
Parts of the Face Mask
Body
Seal (Edge)
Connector (Mount)
Types of Face Masks
Sizes Available
Dead Space
Technique of Use
Advantages of Face Mask
Disadvantages of Face Mask
ARTIFICIAL AIRWAYS
Oropharyngeal Airways
Description
Sizes
Technique of Insertion
Complications
Nasopharyngeal Airways
Description
Size
Insertion Technique
Complications
LARYNGOSCOPES
History
Parts of a Rigid Laryngoscope
Blade
Light Source
Sizes of Laryngoscopes
Types of Blades
Macintosh
Miller
McCoy
Polio
Flexiblade
Single-Use Blades
Technique of Laryngoscopy
Complications
TRACHEAL TUBES
History
Design
Cuff System
Cuff
Inflation Lumen
Inflation Tube
Pilot Balloon
Cuff Pressure
Markings on the Tube
Construction Material
Size
Formula for Uncuffed Tubes
Formula for Cuffed Tubes
Technique of Intubation
Oral Insertion by Direct Laryngoscopy
Nasal Intubation by Direct Laryngoscopy
Confirmation of Tube Placement in the Trachea
Depth of Insertion
Problems and Complications
RAE Tubes
Flexometallic Tubes
Laser Tubes
Microlaryngeal Tubes
Laryngectomy Tube
LITA Tube
Tubes with Subglottic Suction
Intubating Laryngeal Mask Airway Tube
Tubes for Lung Isolation
Double-Lumen Tubes
Tubes with Bronchial Blockers
Bronchial Blockers
Arndt Blocker
Cohen Flexitip Blocker
Fuji Uniblocker
EZ-Blocker
AIDS FOR INTUBATION
Bougies
Description
Uses
Technique of Use
Complications
STYLETS
Lighted Stylets
Optical Stylets
Shikani Optical Stylet
Bonfils Optical Stylet (Bonfils Retromolar Fiberscope)
MAGILL'S FORCEPS
FIBEROPTIC BRONCHOSCOPIC INTUBATION
History
Physics
Parts of a Fiberoptic Bronchoscope
Handle (Body)
Insertion Cord
Universal Cord
Power Source
Steps in Planning and Execution
Types of FOB Intubation
Advantages of Awake Intubation
Disadvantages of Awake Intubation
Awake Oral
Awake Nasal
Anesthetized
Points to Remember for a Successful Fiberoptic Intubation
Choice of Fiberoptic Bronchoscopes
Flexible Intubating Video Endoscope (Karl Storz)
Ambu aScope
Adjuncts to Fiberoptic Intubation
Conduit Oropharyngeal Airways
Masks for Ventilation/Intubation
Aintree Intubation Catheter (Cook Medical)
SUPRAGLOTTIC DEVICES
Classification
CUFFED PERILARYNGEAL SEALERS
Classic LMA
Design
Sizes
Insertion Technique
Benefits
Uses
Contraindications
Problems
LMA Flexible
Design
Sizes
Insertion
Indications
Problems
LMA Fastrach
Design
Sizes
Technique of Fastrach-Guided Intubation
Chandy's Maneuver
Indications for Fastrach Intubation
Problems
CTrach LMA
Design
Insertion
Benefits
Laryngeal Tube, Laryngeal Tube Suction, Gastrolaryngeal Tube
Design
Size
Benefits
Problems
Laryngeal Tube Suction
Cobra PLA
Design
Insertion
Size
Benefits
Problems
Ambu Laryngeal Masks
Design
Sizes and Types
Benefits
Proseal LMA
Design
Technique of Insertion
Indications
Problems
LMA Supreme
Design
Sizes
Merits
i-gel Airway
Design
Demerits
VIDEOLARYNGOSCOPES
Principles of Videolaryngoscopy
Classification
Angulated Blades
Glidescope
Technique of Intubation with Glidescope
Merits
Limitations
King Vision Scope
McGrath Series 5 Scope
ANATOMICALLY SHAPED BLADES WITH CHANNELS FOR ENDOTRACHEAL TUBE
Airtraq Laryngoscope
Design
Technique
Merits
Demerits
Airway Scope
MACINTOSH TYPE BLADES
C-MAC Videolaryngoscope
Design
Merits
Truview Picture Capture Device
Design
Pitfalls with Videolaryngoscopy
Pearls for Successful Use of Videolaryngoscopes
RETROGRADE INTUBATION (TRANSLARYNGEAL GUIDED INTUBATION)
History
Indications
Coagulopathy
Technique
Classical Technique
Guidewire Technique
Fiberoptic Technique
TRANSTRACHEAL VENTILATION
Indications
Equipment
Complications
CRICOTHYROTOMY
Relevant Anatomy
Classification
Direct Needle Puncture Cricothyrotomy
Percutaneous Dilational Cricothyrotomy
Melker's Cricothyrotomy Kit
Technique
Surgical Cricothyrotomy
Indications
Contraindications
Complications
TRACHEOSTOMY TUBES
Cuffed or Cuffless
Single or Dual Cannula
Fenestrated or Nonfenestrated
PERCUTANEOUS DILATIONAL TRACHEOSTOMY
Technique
Ciaglia Multiple Dilation Technique (Named after Dr Pasquale Pat Ciaglia Who Developed It—1985)
Ciaglia Blue Rhino Single Dilation Technique (1999)
Rapitrach Technique
Griggs Technique (1990)
Fanconi (Translaryngeal Tracheostomy)
Percutwist Technique or Rotational Dilatational Tracheostomy (2002)
Ciaglia Blue Dolphin Balloon-Assisted Tracheostomy (2005)
Indications
Contraindications
Complications
ADJUNCT FOR GUIDED EXTUBATION
Airway Exchange Catheter
DIFFICULT INTUBATION TROLLEY
WEBSITES
CHAPTER 7:
Monitoring Technology
INTRODUCTION
INSPIRED OXYGEN
Galvanic Oxygen Analyzer (Fuel Cell)
Polarographic Analyzer (Clark Electrode)
Paramagnetic Analyzer
CAPNOGRAPHY
Principles of Capnography
Types of Capnographs
Calibration
Normal Capnogram
Abnormal Capnograms and Clinical Considerations (Figs. 7.7A to F)
INHALATIONAL AGENT MEASUREMENT
SPIROMETRY AND GAS FLOW SENSORS
Flow-Volume Loops/Flow-Time Loops
Obstructive Lung Disease
Restrictive Lung Disease
Mixed Lung Disease
Variable Larger Airway Obstruction
Fixed Large Airway Obstruction
PULSE OXIMETRY
Principles of Pulse Oximetry
Pulse Oximetry Sensor
Functional versus Fractional Hemoglobin Saturations
Calibration and Practical Limitations
NONINVASIVE ARTERIAL BLOOD PRESSURE MONITORING
INVASIVE ARTERIAL PRESSURE MONITORING
Zeroing
Leveling
Resonance and Damping (Fig. 7.23)
MONITORING CARDIAC OUTPUT
Minimal and Noninvasive Methods
Introduction
Minimally Invasive Methods (Via Endotracheal Intubation)
NICO System: Partial CO2 Rebreathing Monitor
Endotracheal Cardiac Output Monitor
Minimally Invasive Methods (Via Esophagus)
Transesophageal Echocardiography
Esophageal Doppler
Minimally Invasive Methods (Via Arterial Line)
Pulse Contour Analysis
The PiCCO System
The LiDCO System: Pulse Power Analysis
The FloTrac System and Vigileo Monitor
Pressure Recording Analytic Method
Truly Noninvasive Methods
Thoracic Bioimpedance
Thoracic Bioreactance: NICOM System
Summary of Cardiac Output Measurements
TEMPERATURE DEVICES
Resistance Thermometers
Thermistors
Thermocouple
WEBSITES
CHAPTER 8:
Preuse Check of Anesthesia Equipment
AUTOMATED CHECKOUT
CHECKING VARIOUS COMPONENTS
Gas Supply
Cylinders
Pipelines
Ensuring Hypoxic Gas Mixture is Not Delivered
Vaporizers
CIRCLE BREATHING SYSTEM
Two-Bag Test
Testing the Competence of Unidirectional Valves (Three-Bag Test)
Checking the Ventilator
Alternate Breathing Systems
Leaks
High-Pressure System
Intermediate-Pressure System and Low-Pressure System
Breathing Systems
Scavenging System
Suction
Monitors
Airway Management
Equipment for Total Intravenous Anesthesia
CHECK FINAL STATUS OF MACHINE
WEBSITES
CHAPTER 9:
Electrical Safety, Cautery and Lasers
ELECTRICAL SAFETY
Electrical Hazards in the Operating Theater Environment
What is “Earthing” or “Grounding”?
Electric Shock
SURGICAL DIATHERMY
Principles
Electrical Hazards from Surgical Diathermy
LASERS
How are Lasers Generated?
Surgical Lasers
General Safety in Operating Theaters
Lasers and Anesthesia
Endotracheal Tubes for Airway Surgery
Skin and Eyes for Ophthalmic Surgery
Choice of Anesthetic Gases
Management of Airway Fire
CHAPTER 10:
Equipment for Regional Anesthesia
INTRODUCTION
PERIPHERAL NERVE STIMULATION
History
Electrophysiology
Strength and Duration of Electrical Stimulus
Frequency
Pattern of Stimulus
Electrical Polarity
Needle-to-Nerve Distance
Current Density
PERIPHERAL NERVE STIMULATOR
Desirable Features of the Peripheral Nerve Stimulator
Recommended Practice
ULTRASOUND GUIDED REGIONAL ANESTHESIA
History
Basic Physics of Ultrasound
CHAPTER 11:
Central Neuraxial Block (Anesthesia)
HISTORY
DEFINITION
ANATOMY
Subarachnoid Space
Epidural Space
Blood Supply
Arterial
Venous Drainage
INDICATIONS FOR NEURAXIAL BLOCKS
CONTRAINDICATIONS
Absolute
Relative
TECHNIQUE OF PERFORMING NEURAXIAL BLOCKS
Preparation
Patient
Performer
Position
Patient
Lateral Decubitus Position (Fig. 11.2)
Sitting Position (Fig. 11.3)
Prone Position (Fig. 11.4)
Performer
Projection
Puncture
Identification of the Puncture Site and Preparation
SUBARACHNOID BLOCK
Equipment Specific for Subarachnoid Block
Advantage of Different Needles
Disadvantages of Different Needles
TECHNIQUE FOR SPINAL
Midline Approach (Fig. 11.6)
Paramedian Approach
Taylor or Lumbosacral Approach (Fig. 11.7)
MEDICATIONS USED FOR SUBARACHNOID BLOCK
Local Anesthetics
Additives (Adjuvants)
Mode of Action of Local Anesthetics and Opioids in Subarachnoid Block
Onset Time and Duration of Subarachnoid Block
Factors Affecting the Spread of the Local Anesthetic Solution
Disadvantages of Subarachnoid Anesthesia
EPIDURAL BLOCK
Equipment Specific for Epidural
Technique for Epidural Block
Identification of Epidural Space
Hanging Drop Technique
Confirmation with Mechanical Aids
Ultrasound-Guided Technique
Radiological Technique Using C-Arm
Epidural Catheter Insertion
Fixation of Catheter
TECHNICAL PROBLEMS DURING NEURAXIAL BLOCKS
Technical Problems Specific to Subarachnoid Block
No Cerebrospinal Fluid Flow through the Spinal Needle
Blood Flow from the Spinal Needle
Complaint of Sharp and Stabbing Leg Pain
Technical Problems Specific to Epidural Block
Flow of Fluid through the Needle or Catheter
Pain during Performance
CAUSES OF FAILURE ENCOUNTERED WITH NEURAXIAL BLOCKS
Failed or Patchy Block
Unilateral Block
Segmental Sparing
Visceral Pain
ASSESSMENT OF THE NEURAXIAL BLOCK
EFFECTS OF NEURAXIAL BLOCKS ON DIFFERENT SYSTEMS
Cardiovascular System
Respiratory System
Central Nervous System
Stress Response
Genitourinary
COMPLICATIONS OF NEURAXIAL BLOCKS
Immediate Complications
Delayed Complications
Late Postoperative Complications
POSTOPERATIVE CARE
Monitoring
NEURAXIAL BLOCKS IN PATIENTS ON ANTICOAGULANTS
SUMMARY OF CURRENT RECOMMENDATIONS
Antiplatelets
Oral Anticoagulants
Intravenous Heparin
Patients Receiving Low-Molecular-Weight Heparin
Thrombolytic Therapy
Herbal Therapy
Fondaparinux
Thrombin Inhibitors
Newer Anticoagulants
Dabigartan Etexilate
Rivaroxaban
Prasugrel
WEBSITES
CHAPTER 12:
Disinfection and Sterilization
INTRODUCTION
LEVELS OF DISINFECTION
SPAULDING CLASSIFICATION
CLEANING
METHODS OF DISINFECTION
Physical Methods
Irradiation
Liquid Chemical Agents
Alcohol (Ethyl or Isopropyl)
Glutaraldehyde
Orthophthalaldehyde
Liquid Bleach
Hydrogen Peroxide
Phenols
Iodophors
STERILIZATION
Dry Heat
Mechanism of Action
Steam Sterilization (Autoclaving)
Autoclave
Flash Sterilization
Monitoring Steam Sterilization
CHEMICAL STERILIZATION
Ethylene Oxide
Liquid
Steris System
Physicochemical Methods
CLEANING, DISINFECTION, AND STERILIZATION OF ANESTHESIA EQUIPMENT
WEBSITES
CHAPTER 13:
Simulation in Anesthesia
INTRODUCTION
WHAT MAKES ANESTHESIA UNIQUELY SUITED FOR SIMULATED LEARNING?
WHAT IS REQUIRED TO MAKE A SIMULATION EXERCISE SUCCESSFUL?
AIRWAY MANAGEMENT TRAINERS
VENOUS CANNULATION AND ARTERIAL CANNULATION
Central Venous Cannulation
LIFE SUPPORT TRAINING UNITS
SPINAL AND EPIDURAL ANESTHESIA
SIMULATION OF EMERGENCIES IN ANESTHESIA, TRAUMA AND EMERGENCY MEDICINE
DEBRIEFING
SUMMARY
INDEX
TOC
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