© 2002-2003, James H Philip, all rights reserved New Anesthesia Delivery Systems at BWH Ohmeda Aestiva Draeger Fabius GS Draft C © 2002-2003, James H Philip, all rights reserved

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James H Philip MD CCE Draft C New Anesthesia Delivery Systems at BWH Ohmeda Aestiva Draeger Fabius GS James H Philip MD CCE Draft C

Short Clinical Conference first Surprise !!

Case 1 Ohmeda Aestiva 65 yo M for CABG on a Tuesday morning. You induce anesthesia, intubate the trachea and confirm correct tube placement. You turn on the ventilator on your Ohmeda Aestiva Anesthesia Machine Ventilator alarms “Cannot Deliver Correct Volume” Soon, it alarms “Cannot Ventilate” If you know what is wrong and how to correct it Raise your hand now If you do not know what is wrong and how to correct it Raise your hand now

Case 2 Draeger Fabius GS 45 yo M for Thoracotomy on a Saturday You intubate trachea and confirm tube placement. You turn on the ventilator on your Draeger Fabius GS Anesthesia Machine Vent Monitor shows alarm “Vent Fail” There is no mechanical ventilation If you know what is wrong and how to correct it Raise your hand now If you do not know what is wrong and how to correct it Raise your hand now Draeger Fabius GS

Ventilators do fail 1) Use reservoir bag and manually ventilate 2) If all else fails, use the Manual Resuscitator (Ambu Bag) on the back of the Anes Mach. 3) Determine ventilator problem and eliminate it Get help Repair your self

Ohmeda SmartVent Design SmartVent is used in these Ohmeda ADSs SmartVent 7900 Aestiva Compare expired volume to set volume Adjust the next breath to correct this by adjusting movement of the bellows Flow sensors are the key element They are required for ventilation Measurement is more difficult than Control

Key Element = Flow Sensors

Differential Pressure Flow Sensors DP Differential Pressure Flow Sensors DP

Differential Pressure Flow Sensor Pressure Transducer Variable Orifice Flow

When Aestiva or any Ohmeda SmartVent fails Usually a wet flow sensor User Action Ventilate by hand Change or shake dry the flow sensors Call for help if required

Fabius GS Introduction We will soon have > 15 of these machines We all must learn about them We each must document that we have learned Dept could not buy “old machines” They are no longer for sale Dept did not buy more Ohmeda Aestivas Early failures led some clinicians to be wary

Gas flow interface Mechanical Needle Valves and Electronic Flow Measurement and Display Pipeline pressures Total flow Mechanical rotameter Digital flow display O2 supply low LED Flow control valves Wall pressure gauge

High-resolution display at BWH Pipeline pressures Total flow Mechanical rotameter Finer needle Valves Are coming Digital flow display O2 supply low LED Flow control valves Wall pressure gauge

User Control Many Keys, One Knob Alarm Lamps Warn Caution Advisory Alarm limits Ventilation mode Alarm Silence Volume Setup menu Pressure Future 1 Future 2 AC power LED Standby Reading lamp Home screen Function Rotary Control Knob And, Press to Confirm

Ventilation Monitor Screen Alarm Thresholds Time Alarm messages Status Inspired Oxygen Fresh Gas Virtual flowmeters Ventilation Volume Ventilation Pressure Pressure threshold Pressure waveform Function key descriptions

COSY COmpact SYstem for CO2 Absorption

COSY Breathing System – Top Expiratory valve Expiratory port APL valve Manual breathing bag connection PEEP / Pmax valve Inspiratory port APL bypass valve Inspiratory valve

COSY Breathing Circuit - Bottom Flow sensor Scavenging connection Fresh gas hose connection Pressure sensor connection Ventilator hose connection Absorber canister

Ventilator (eVent) Electrically driven = consumes no drive gas Ventilation Modes Volume controlled Pressure controlled + future options Easy access to ventilator by opening ventilator door but, can’t see much Ventilator movement visible through window Ventilation Monitor displays all information

Ventilator Piston

Flow sensor

Hot wire is cooled by flow Anemometer

Cause of Ventilation Failure Piston and its membrane are mis-aligned because Membrane has been drawn off piston surface This occurs from negative pressure in circuit Immediate Solution Cycle ventilator off and on 1 - 2 times Vacuum draws membrane to piston. Problem is solved. Ventilator ventilates. Long term Solution Draeger believes that this no longer occurs. Piston software prevents this.

Let’s look at Fabius GS Breathing Circuit

Constant Volume FGF Decoupling COSY-1

Puff Leak from high flow through CO2 Absorber caused re-design

Constant Volume FGF Decoupling COSY-2 Prev Bag location Moved

Constant Volume FGF Decoupling Fresh Gas is Stored until the next breath

Virtual Anesthesia Machine Operation Simulation Virtual Anesthesia Machine Virtual Fabius GS http:www.simanest.org University of Florida Sem Lampotang

VAS

Check Out and Use

Power Switch ON Hidden on Back of Machine OFF

Fabius GS Startup Standby when not in use No need to power off Startup simple and straightforward No automatic self test Manual leak test Manual calibration of sensors

Gases Connect pipeline gas supplies Connect reserve cylinders Check that the supply pressures are in the specified range (green zone) Connect reserve cylinders Check cylinder pressure (open and re-close cylinder valve Verify pressure (O2 > 725PSI, N2O > 435 PSI)

Electric Verify electrical connection Verify Power Switch is on The green LED on the user interface illuminates whenever AC power is connected Verify Power Switch is on Power switch is located on the rear next to the AC power cord

Internal Diagnostics are automatic Result FUNCTIONAL CONDITIONALLY FUNCTIONAL - Use Non-critical fault Use machine now - Press Rotary Knob Call for repair - 3-1291 BB 3-1055 to continue operation. NON-FUNCTIONAL - Don’t use Serious fault was detected Can’t use it

1 2 3 User Tests Defaults to Standby User Tests components Simply follow directions System Test (done) Calibrate Flow Sensor Calibrate O2 Sensor Run Leak Test Access alarm log Restore site defaults Done 1 2 3 Show all

Calibrate Flow Sensor Hot-wire flow sensor (Spirolog®) Julian and Evita products. Calibration time <15 seconds

Standby Mode Run Leak Test The leak test function key opens the support page for the leak test Leak test instructions Airway pressure numeric Oxygen flow numeric For machines equipped with the auxiliary pressure gauge, the leak test can be performed by building up a pressure of 30 cmH2O and observing the pressure drop on the gauge. The leak test includes the vaporizers. There is no need for a negative pressure test.

Calibrate Oxygen Sensor Defaults to Standby User Tests components System Test (done) Calibrate flow sensor Calibrate O2 sensor Run leak test Access alarm log Restore site defaults

Calibrate Oxygen Sensor Calibration time is < 15 seconds Room air 2 minutes first !

[Access Alarm Log] Access Alarm Log Alarm History up to 99 messages The site defaults volume control settings, pressure control settings, alarm limits and alarm volume can be restored by pressing the “Restore Site Defaults” function key.

Sleep Mode Do not power off, put to sleep Happens after 5 minutes No Buttons pressed No Fresh Gas Flow Pressing any button for Standby. Emergency wakeup Turn of FGF and awakens Man/Spont mode No confirmation required

Common Errors

Everything requires confirmation with Control Knob Rotary Control and Push to Accept Knob

Flow Sensor can get wet Remove it, shake it dry, re-insert it If replaced, calibrate before next case Reported expired volume will be wrong Delivered volume measured will be right

Compensate for Desflurane high conc High concentration of desflurane increases specific heat of the gas combo cools hot wire anemometer more than right Des Compensation On corrects this Fabius GS does not measure agent so does not know when to correct

Leak and Functionality Check You have done them, automatically And, the ADS knows it was checked compensates for compliance

Further Fabius GS Education Duty Room today Patrick Parisi, Draeger representative Mike Bradish Anes Engineering Elective Res Support Info ftp://jphilip.bwh.harvard.edu/technologyblock Philip Grand Rounds Lecture Bradish Check Out Directions for Use PDF file BWH Check Out for older machines Anesthesia Written Board Exam Questions Simulation at http:www.simanest.org [University of Florida]

Thank you End

Anesthesia Machines November 5, 2003 Study Guide Anesthesia Written Board Exam Questions ftp://jphilip.bwh.harvard.edu/technologyblock My answers available to all who answer the questions Grand Rounds New Anesthesia Delivery Systems at BWH Ohmeda Aestiva Draeger Fabius GS Clinical Conference Anesthesia Ventilator Failures Support Info ftp://jphilip.bwh.harvard.edu/technologyblock Simulation at http:www.simanest.org [University of Florida]

Clinical Conference

Case 1 Ohmeda Aestiva 65 yo M for CABG on a Tuesday morning. You induce anesthesia, intubate the trachea and confirm correct tube placement. You turn on the ventilator on your Ohmeda Aestiva Anesthesia Machine Ventilator alarms “Cannot Deliver Correct Volume” Soon, it alarms “Cannot Ventilate” If you know what is wrong and how to correct it Raise your hand now If you do not know what is wrong and how to correct it Raise your hand now Answer Dry the flow sensor tubes Use an HME to keep circuit dry

Case 2 Draeger Fabius GS 45 yo M for Thoracotomy on a Saturday You intubate trachea and confirm tube placement. You turn on the ventilator on your Draeger Fabius GS Anesthesia Machine Vent Monitor shows alarm “Vent Fail” There is no mechanical ventilation If you know what is wrong and how to correct it Raise your hand now If you do not know what is wrong and how to correct it Raise your hand now Answer Cycle between Vent and Bag/Man Ask why software not upgraded Draeger Fabius GS