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Anesthesia Gas Machine Checkout Procedure Initial Steps High-Pressure System Low-Pressure System Breathing System Ventilator System Final Status Check

AGM Check: Initial Steps 1.1 Quick visual check 1.2 Back-up ventilation equipment

AGM Check: Initial Steps 1 1.1 Quick visual check for: Obvious damage / Missing components BioMed notice of Return-to-Service Electrical power cord plugged into receptacle with generator backup System master switch OFF Red receptacle

AGM Check: Initial Steps 2 1.2 Back-up ventilation equipment Self-inflating resus bag & O2 source Check for incorrect assembly / damaged parts Back to Menu

AGM Check: High Pressure System 2.1 Check central pipeline supplies 2.2 Check O2 reserve cylinder supply

AGM Check: High Pressure System 1 2.1 Check central pipeline supplies Hoses are connected correctly (colours, DISS) Pipeline gauges read 50-55 psig Disconnect O2 pipeline Misconnections Line pressure fluctuations Failure of central O2 supply

AGM Check: High Pressure System 2 2.2 Check O2 reserve cylinder supply Bleed O2 cylinder pressure to zero with O2 flush (O2 pipeline disconnected) Open O2 cylinder and verify at least half full (approx. 1000 psig) Avoid reading “old” cylinder pressure Check for wrong cylinder - double gasket defeats pin index system or pins are broken Dust protection cap still in place

AGM Check: High Pressure System 2 (cont’d) Missing gasket; cylinder not seated in yoke properly Cylinder valve stem loose Unused yoke vacant with no yoke plug Machine master switch allows leak Cylinder control valve leaks Leaking pipeline check valve 2.2 Check O2 reserve cylinder supply (cont’d) Listen - no audible leak Open and close O2 flowmeter - no flow seen Close cylinder - pressure gauge drops less than 100 psig in five min Back to Menu

AGM Check: Low-Pressure System 3.1 Check vaporizer installation 3.2 Perform low-pressure leak test 3.3 Turn ON gas machine master switch 3.4 Test flowmeters

AGM Check: Low Pressure System 1 3.1 Check vaporizer installation Tops of vaporizers are parallel to manifold - cannot be lifted off manifold Vaporizers are full and fill ports closed Verify all vaporizers OFF Vaporizer not locked on to manifold properly Overfilling of vaporizer

AGM Check: Low Pressure System 2 3.2 Perform low-pressure leak test Do leak test with "suction bulb" device on auxiliary (fresh) gas outlet Verify bulb stays collapsed for > 10 secs Repeat leak test for each flowmeter Defective suction bulb Leak somewhere between flow control valves and common gas outlet Cracked, loose, misaligned flow tubes Loose connections – internal piping, components

AGM Check: Low Pressure System 2 (cont’d) 3.2 Perform low-pressure leak test Repeat leak test for each vaporizer, one at a time - setting dial to 1% conc. Verify with each vaporizer that the other vaporizer(s) cannot be turned ON Verify all vaporizers OFF, aux. gas outlet closed, and flush system with O2 Partially open filler/drain port Missing vaporizer port O-ring on manifold Faulty interlock mechanism - can turn on two vaporizers simultaneously Vaporizer will not turn ON - interlock obstructed by ECG lead, etc

AGM Check: Low Pressure System 3 3.3 Verify Electrical Power and Oxygen Supply Failure Alarm Unplug machine power from electrical receptacle Turn ON master switch Verify “Battery Power OK” message, plug in power cord and message disappears Turn ON vital signs monitor Battery discharged because machine previously left ON and unplugged from AC outlet Allows gas analyzer to “warm up”

AGM Check: Low Pressure System 3 (cont’d) 3.3 Verify Electrical Power and Oxygen Supply Failure Alarm (cont’d) Verify O2 supply failure alarm Drain O2 – press O2 Flush Distinctive auditory pattern Visual message on Vent Turn ON O2 cylinder to silence alarm Remove O2 sensor from circuit Alarm mechanism malfunction Exposes O2 sensor to room Air for later calibration

AGM Check: Low Pressure System 4 3.4 Test flowmeters Minimum flows are 25 ml/min for O2 and zero ml/min for other gases Flowtubes are undamaged; floats move smoothly throughout their full range No flow - broken tip of needle valve Floats sticking - dirt, grease, static Float stuck at top of flow tube Stop broken off from top of flow tube and resting on float

AGM Check: Low Pressure System 4 (cont’d) 3.4 Test flowmeters (cont’d) O2 and N2O flow controls cannot supply hypoxic flowrates Turning vaporizer ON does not lower gas flow (Then verify vaporizer OFF) N2O/O2 3:1 proportioner - linkage broken or gear stop misaligned Obstruction in vaporizer or manifold

AGM Check: Low Pressure System 4 (cont’d) 3.4 Test flowmeters (cont’d) Low O2 pressure stops N2O gas flow but NOT Air Set all 3 floats to mid-range - close O2 cylinder - push O2 flush O2 supply failure alarm sounds and N2O float drops while Air continues Close all 3 gas flow controls and reconnect O2 pipeline - verify pipeline pressure No low O2 supply alarm when O2 supply pressure@ 30 psig Shutoff valve for N2O fails to close when O2 @ 20 psig Back to Menu

AGM Check: Breathing System 4.1 Calibrate O2 monitor 4.2 Check initial status of breathing system 4.3 Check function of unidirectional valves 4.4 Perform leak test - Bag / APL valve circuit 4.5 Check APL valve and scavenging system

AGM Check: Breathing System 1 4.1 Calibrate O2 monitor Ensure monitor reads 21% with sensor in room air Verify low O2 alarm enabled by breathing on to sensor through your surgical mask Reinstall sensor in circuit - flush breathing system with O2 - monitor should read > 95% cannot calibrate - faulty fuel cell crossover between O2 supply and other gas - hospital piping, hoses or in gas machine wrong gas in central supply / cylinder

AGM Check: Breathing System 2 4.2 Check initial status of breathing system Set selector switch to “Bag/APL” Circuit complete, undamaged, unobstructed Verify CO2 absorbent is adequate (colour, quantity) Attach gas sampling line to circuit Set all flows to zero (or minimum) manufacturing defects causing leaks or obstruction foreign object obstructing e.g. sampling port cap inside elbow

AGM Check: Breathing System 3 4.3 Check function of unidirectional valves Attach a spare breathing bag to the inspiratory outlet of the absorber and close APL valve completely Fill both test bag and reservoir bag with O2 flush until pressure gauge reads 35 cm H2O – pressure should hold Open APL valve – pressure holds but only reservoir bag deflates If needed, repeat test on expiratory inlet with inspiratory outlet occluded Missing, incompetent valves or incorrectly seated If pressure holds - both valves are competent If reservoir bag deflates before opening APL valve - expiratory valve is leaking

AGM Check: Breathing System 4 Numerous leak sites possible Auxiliary FGF outlet left open (alarm sounds) CO2 canisters not locked into position Faulty canister seals or granules are preventing a good seal CO2 drain plug partially open Unidirectional valve housing loose O2 sensor not firmly seated in port or sensor housing is cracked Flow sensor housing cracked Pressure sensing tubing from gauge is not tightly connected (internal) Leak in breathing bag, circuit hoses Unused sampling ports not capped Faulty selector switch - allows cross-over of gas into ventilator circuit 4.4 Perform leak test - Bag / APL valve circuit Set selector switch to Bag/APL - close APL valve and attach spare breathing bag to Y-piece Inflate bag with O2 flush to just < 40 cm H2O Circuit pressure holds steady for > 10 secs Sustained pressure alarm sounds Ventilator bellows does not move

AGM Check: Breathing System 5 4.5 Check APL valve and scavenging system With APL valve still closed and circuit occluded, squeeze inflated bag until pressure reaches approx. 70 cm H2O High pressure alarm sounds when limit exceeded (e.g. 40 cm H2O) APL valve partially releases and reservoir bag on scavenger fills Open APL valve slowly until pressure drops below 20 cm H2O, then stop Pressure should stabilize and hold Sustained pressure alarm stops Improperly adjusted APL valve - set to release either too high or too low No alarm - upper limit set too high Cannot adjust pressure - valve sticking (Sustained pressure limit is the high pressure limit or a max of 30 cm H2O)

AGM Check: Breathing System 5 (cont’d) 4.5 Check APL valve and scavenging system (cont’d) Open APL valve fully, flush occluded circuit with O2 Circuit pressure stays < 10 cm H2O Scavenging reservoir bag fills and then positive pressure relief valve releases APL valve fully open, flows set at minimum and circuit still occluded Circuit breathing bag does not deflate Scavenging reservoir bag does deflate opening pressure of APL too high hose from circuit to scavenger blocked faulty positive pressure relief valve on scavenger opening pressure of APL too low too much vacuum and faulty negative pressure relief valve no vacuum; needle valve closed Back to Menu

AGM Check: Ventilation Systems 5.1 Test automatic ventilation system 5.2 Test manual ventilation system

AGM Check: Ventilation System 1 5.1 Test automatic ventilation system Selector switch set to Ventilator - all flows set to minimum, breathing bag on Y-piece Fill bellows with O2 flush between ventilator breaths - pressure does not exceed 15cm H2O - release flush Set appropriate ventilator parameters for next patient - Inspiration - bellows delivers correct tidal volume - Expiration - bellows fills completely - Volume monitor is consistent with ventilator - Proper action of unidirectional valves Defective ventilator relief valve - should release when > 2.5 cm H2O Relief valve does not close to allow bellows to fill completely Bellows housing not fastened tightly Drive gas hose not firmly attached Connection from absorber to bellows is leaking Volume sensor faulty Valves stick or do not seat properly

AGM Check: Ventilation System 1 (cont’d) 5.1 Test automatic ventilation system (cont’d) Remove breathing bag from Y-piece while ventilator is still working Low pressure alarm sounds (“Cannot drive bellows”) until breathing bag is replaced Set selector switch back to Bag/APL (turns ventilator OFF) when bellows fully inflated Ventilator bellows does not drift downward Alarm faulty OR ventilator senses pressure 4 - 9 cm H2O with breathing bag off - obstruction somewhere? Leak somewhere – see previous slide

AGM Check: Ventilation System 2 5.2 Test manual ventilation system Switch in Bag/APL mode Ventilate manually and assure inflation and deflation of artificial lungs and appropriate feel of system resistance and compliance Remove second breathing bag from Y-piece Faulty APL valve - incorrect pressure adjustment Back to Menu

AGM Check: Final Status Checks 6.1 Gas machine and breathing system 6.2 Monitors

AGM Check: Final Status Checks 1 6.1 Gas machine and breathing system Vaporizers OFF Selector switch to Bag/APL and adjust APL valve to MIN Set O2 flow to 3 L/min - other gases to zero Attach face mask to Y-piece and through a surgical mask, breathe in and out through the circuit as final test Set O2 flow to minimum

AGM Check: Final Status Checks 2 6.2 Monitors Check that capnometer registers the CO2 from your breath - and apnea alarm sounds after appropriate interval; check alarm settings Check oximeter on your own finger for function; check alarm settings Make sure manual BP cuff is available Patient suction adequate (“thumb test”) Back to Menu