1. Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002, James H Philip, all rights reserved

2. Ready

3. Clinical Conference – Anesthesia Machines don ’ t fail, do they?

4. Case 1 57 yo F for Laparoscopy PMH Hypertension on Atenalol, GERD successfully Tx’s w Prilosec, Mild COPD. Otherwise healthy 5’2” 165# + COPD Elect GETA Plan Propofol, Succinylcholine, Tube, Desflurane, Vecuronium if necessary

5. Preparation Resident starts IV I check the Anesthesia Machine Desflurane vaporizer is missing I page Anes Tech Tech and Vaporizer arrive He attaches vaporizer

7. What do I do next? I have added a vaporizer

8. Negative Pressure Leak Test Where do I find the bulb?

9. Bottom Drawer of Anesthesia Machine

10. Is there anything wrong here?

11. Cable does better here

12. Negative Pressure Leak Test OK

13. And, the Exclusion Interlock now works.

14. Remainder of Check out What am I doing here? What is my FGF set to? What pressure am I trying to hold? What pressure do I not want to exceed? How big can the bag get?

15. 250 Liters

16. Pressure = 30 cmH2O

17. Actually find minor leak

18. Tighten Expiratory Valve Cover

19. Resident brings patient to OR Apply Monitors, Apply Bair Hugger Prepare to denitrogenate

20. What Fresh Gas Flow?

21. Oxygen only F I O 2 > 80 Flow keeps bag mostly full

22. Apply mask

23. Denitrogenate Mask - Tight or Loose? FGF - High or Low? Pop-off valve - Open or Closed? Selector Switch - Bag or Vent?

24. Select Bag, Pop off open

25. Patient feels smothered. Why?

26. Airway pressure What does it mean?

27. Select Bag, Pop off open

28. What is good about the bellows? What is bad about the bellows?

29. What is good about the bellows? Low opening pressure

30. What is good about the bellows? What is bad about the bellows? Low opening pressure Tachycardia and Hypertension

31. What is good about the bellows? What is bad about the bellows? Low opening pressure Tachycardia and Hypertension In the anesthesiologist Who feels total obstruction

32. Select Bag, Pop off open Smothered again!

33. What can I do? Remove Reservoir Bag

34. IV Induction

35. Difficult to ventilate Slow Exhalation

36. What should I do?

37. Decide to Intubate

39. Airway Pressure normal?

40. What should I do

41. “Ambu Bag”

42. Ventilate and Monitor gases

43. What was wrong?

44. Expiratory Valve - Missing O Ring How did this happen? PEEP Valve incorrectly removed Note that Cage and Valve are depressed !

45. Valve and cage

46. Replace valve, cage, o-ring

47. Replace Cover

48. Normal airway pressure curve

49. Normal ventilation Unremarkable case Patient went home in time for Lunch !

50. Who ya’ gonna call OR Biomedical Engineering Page 3-1055 Call 3-1291

51. Thank You