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GAS MAN

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by James H. Philip, ME(E), MD
Associate Professor of Anaesthesia
Harvard Medical School
Anesthesiologist & Director of Bioengineering in Anesthesia
Brigham and Women's Hospital
Boston, Massachusetts

A product of
Med Man Simulations,lnc. P.O. Box 67-160 Chestnut Hill, MA 02467

© Copyright 1995-2002 by Med Man Simulations, Inc.

Gas Man® is a registered trademark and Med Man'" is a trademark of
Med Man Simulations, Inc.
Microsoft® and Windows"\! are trademarks of Microsoft Corporation.
Macintosh@ is a registered trademark of Apple Computer Inc.

Gas Man is a simulation and teaching tool. Med Man Simulations, Inc.
disclaims any warranty for planning of actual medical treatment for patients.

Credits
Author James H. Philip, ME(E). MD

Editing, Design and Logo Ronald S. Waite, IV! r II
Gas Man Screen Icon Ben Philip
Gas Man Program for Windows Hal Franklin
Gas Man Program for the Macintosh Hal Franklin
IntelliMetrics Instrument Corp.
Peter Martin, ME
Daniel Litvack
Edwin Trautman, PHD

Gas Man® Preface

reface

There are many uses for computer technology within the practice of
anesthesia. Usually, computers are used to automate practices which are
already well-established. Using the computer to help teach difficult con-
cepts is another matter, however, that goes far beyond the automation of
procedure. Computer-aided learning is difficult to develop, but very
rewarding in its effectiveness. This program, Gas Man®, exploits the
potential of the computer to help students understand anesthesia uptake
and distribution.

The fundamental principles underlying anesthetic pharmacokinetics are
simple. The important rules are: a) conservation of mass, and b) physio-
logic maintenance of lung volume. Unfortunately, the dynamic implications
of these principles are not easy to comprehend. Indeed, it is the need for
explanation and demonstration of the dynamic changes in anesthetic
tension equilibration which led me to design and implement this
educational tool.

The Gas Man program is a powerful marriage of computer simulation and
image production with the printed word. In place of the instructor in a
simulation laboratory, we have the instructor's voice (in print) and a labora-
tory inside a personal computer (Gas Man). By using the set of Exercises in
this Manual, and by learning how to use Gas Man as a tool for further
exploration, users can study the simplicities and subtleties of the dynamic
properties of anesthesia uptake and distribution regardless of where they
are or what other resources are available to them.

I first began investigating the use of computers to help teach the concepts
of anesthesia uptake and distribution in 1980, when I received a grant from
the Apple Educational Foundation to explore the use of Apple II comput-
ers. In 1982 the first version of Gas Man for the Apple II was shown at the
American Society of Anesthesiologists meeting. The program was immedi-
ately well-received. The program and a set of exercises similar to this
Manual was published and distributed by Addison-Wesley in 1984. Mter
many colleagues clamored for an updated version of the program suitable
for microcomputers, we demonstrated in 1989 a version of Gas Man for the

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Gas Man® Pllface

Macintosh. In 1994 we released Gas Man forWindows™, and Version 2.1,
with many new features, was released in cor~junction with this manual in
October 1995.

Gas Man's new features significantly broaden the base of users and uses.
The ability to compare and contrast anesthetic techniques and agent
choices should attract a solid follovving by hospital administrators, pharma-
cists, and anyone concerned with the cost of health care.

The ability of the Gas Man Overlay to normalize tensions to agent MAC and
then explore the effects of blood/ gas solubility provides drug and equip-
ment manufacturers with insights not previously available. Vaporizers for
the new agents sevoflurane and desflurane have maximum dial settings that
account for both ]'viAC and solubility, allowing the same relative alveolar
overpressure found with halothane and desflurane vaporizers. Meanwhile,
clinicians can use the same displays to compare and contrast administra-
tions with different drugs and different techniques.

Finally, with Gas Man's wider weight range - from 50 g to 1500 Kg - ani-
mals of interest to veterinarians can now be simulated with ease.

Gas Man has been reviewed favorably in numerous publicationsl.~,3,-t5.l().
Several studies have demonstrated the effectiveness of Gas Man as an edu-
cational tool in centers other than where it was written(i" and when com-
pared to lecture presentation". Ongoing study of its efficacy as a
simulation program has endorsed its accuracy'!. I am committed to the
wide-ranging audience of Gas Man users to continue to refine and enhance
the program and its applications.

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my trusted administrative assistant. Ronald Waife has served as the creative editor and designer for both edi- tions of the book. MD pro- vided information on scaling over wide weight ranges. he added numer- ous new features and ideas that only an insightful mathematician-engineer- physiologist could envision and implement. assistants. James H.). DVM and other veterinary anesthesiologists encouraged me to actually add the wide range of weight capability. Iggy Calalang tested varous components of the simulation for consistency. Daniel Raemer. friends. and Ben) for allowing me the time required to prepare both the computer program and this textbook. MD each tested various portions of the mathematics using analytic and simulation techniques.Gas Man® o ACKNOWLEDGEMENTS I gratefully acknowledge the help and support of family members. (E. PhD provided insight and assistance in the initial system model. ~LD. Massachusetts October 1995 v .E. In doing so. Xin Bao Ji. supported me in all my tasks related and unrelated to this endeavor. students.0 and 2. Chestnut Hill. Pauline Wong.l. and teachers. M. Philip. I thank the staff and especially the residents of Brigham and Women's Hospital who afforded me the opportunity to de- velop and test both the program and text. enhancing its content and clarity. David Leith. I thank my family (Beverly. Noah. Anne Kamara. Hal Franklin imple- mented Gas Man for Windows 2. kid I thank the enthusiastic Gas Man users and teachers who continue to encourage me to develop and release new versions. PhD and Jeff Mandel. Khaled Khodr tested the implemention of some of Gas Man's new features including the second gas effect and weight scaling. allowing a wider audi- ence of users to draw benefit from this work.

4. Gage. DeanJM: GasMan. Anesthesiology 73: A1025. 5.JS: Mathematics andjudgement: A review of the computer simulation Gas Man. Torda TA: Gas Man. JAMA 255: 268. 1984.1985. Philip JH: An evaluation of the effectiveness of a computer simulation of anesthetic uptake and distribution as a teaching tool. Book Reviews. 10. 1992. 2. Audio-Visual Review. Raemer. Paskin. vz . Philip JH: Gas Man simulation of overpressure is verified by correct alveolar plateaus. Brandom BW: GAS NIAN. Philip JH. 7. Educational Resources Review.1986.1989. Anes Analg 65: 106. 6. Lema J\llL Raemer DB.1986.1985. MD Computing 3: 53. 1985. Software Review. 1986. 3. Garfield JM. Anaes Intens Care 13: Ill. Books. Garfield JM. News Soc Ed Anes 2: 2. Crocker D: Is computer simulation as effective as lecture for teaching residents anesthetic uptake and distribution? Anesthesiology 63: A503. 9. Schneider AJ: GAS J\lIAN. Philip JH: Is computer simulation of anesthetic uptake and distribution an effective teaching tool for anesthesia residents? J Clin Mon 1: 87. DB. 8.Gas Man® Prej(lce October 1995 1. 1990. Shanks CA: Gas Man. S. Med Educ 23: 457. MD Computing 9:54. Paskin S.

........................................ 2-20 Running a Gas Man Simulation .................................................. 1-8 o 2: GETTING STARTED WITH Gas Man® Introduction ......................... 4-12 Vll ...................................................................... 2-3 The Gas Man Picture & Graph ......................................... 2-1 Your Software License .............................................................. 4-10 Summary ............................................................................. 3-14 Summary .......................................................... 3-3 Exercise 3-2: The time constant for wash-in .......................................................................................................... iii o 1: OVERVIEW OF Gas Man® AND ITS USES Introduction ....................................................................................................................................................................................................................................................................... 2-10 Installing & Using Gas Man on the Macintosh™ ............................ 2-24 SUlnrnary ....................................... 4-1 Exercise 4-1: The step response ........ able of Contents o Preface Preface ......................................................................... 2-6 The Gas Man Menus & Toolbar .................................................................. 1-3 Uses for Gas ]\Iran ............................................................. 3-1 Exercise 3-1: Wash-in of a single compartment ..................................................................................... 1-1 The Gas Man Approach .............. 1-7 Summary .............. 1-4 Other Users of Gas Man ............. 4-7 Exercise 4-4: Overpressure ...................................................................................... 4-4 Exercise 4-3: Wash-in delays are additive ......................................................................................................................................................................................................... 4-2 Exercise 4-2: The alveolar step response ......................................................... 3-16 o 4: TWO SEQUENTIAL COMPARTMENTS Theory .............. 2-2 Installing Gas Man on Windows™ Computers .......................................... 3-11 Exercise 3-3: Exponential curves ................................................................ 2-28 o 3: A ONE COMPARTMENT MODEL Theory ........

....................................................................... 6-1 Exercise 6-1: Knee height varies with blood/ gas solubility ............................. 7-22 o 8: THE HIGH INSPIRED CONCENTRATION EFFECT Theory ....................... 6-18 o 7: OVERPRESSURE & OPTIMUM ANESTHESIA Theory . 7-9 Exercise 7-3: Optimum anesthesia and vaporizer adjustment ....................................................................... 6-13 Exercise 6-4: Overpressure-induced 1 MAC in the alveoli .................................... 5-2 Exercise 5-2: The initial rise .................................................................................................................................................... 5-2Ll o 6: PLATEAU HEIGHT & BLOOD/GAS SOLUBILITY Theory .............................................................................................................................................................. 6-3 Exercise 6-2: High blood/gas solubility and low knee ................Gas Man® Toble 0/ Con tents o 5: THE ALVEOLAR TENSION CURVE Theory ............ 5-14 Exercise 5-7: The ratio of alveolar ventilation to cardiac output .............. 8-14 VlZZ ............................... 7-1 Exercise 7-1: Overpressure-induced 1 MAC in the alveolar compartment ..... 6-15 Summary ................ 5-1 Exercise 5-1: Patient wash-in: the alveolar tension curve .......................................... 8-8 Exercise 8-4: Removing the concentration effect ........ 5-5 Exercise 5-3: The initial rise and alveolar ventilation ......................................................... MAC and overpressure ........................................................................................ 7-16 SUlnmary .................................................. 8-3 Exercise 8-2: The concentration effect varies with inspired concentration .......... 8-1 Exercise 8-1: The concentration effect ......................................................................... 5-20 Summary ................................................. 8-12 Summary ...... 8-6 Exercise 8-3: Cardiac output and 100% inspired .................................................................................................................................................................................................. 5-12 Exercise 5-6: Increasing cardiac ouput ........... 5-7 Exercise 5-4: The knee and the plateau ...... 7-3 Exercise 7-2: Optimum anesthesia and constant brain tension .............. 6-11 Exercise 6-3: The A/I ratio............... 5-10 Exercise 5-5: Increasing alveolar ventilation .... 5-16 Exercise 5-8: The tail: anesthetic returned to the lungs ....................

....................................... 10-5 ........................ 10-3 Exercise 10-2: Closed-circuit optimal anesthesia ............................................................................ 12-5 Sun1n1ary .................................................. 11-11 Sun1n1ary ............. 13-4 Summary .................. 13-1 Exercise 13-1: Kinetics is faster with patients of smaller size ..................................................... 9-12 o 10: CLOSED-CIRCUIT ANESTHESIA Theory . <) I II ")11 10....................................................... ]............................................................................. 12-8 o 13: PATIENT SIZE Theory ..... 10-1 Exercise 10-1: A closed-circuit liquid anesthetic injection ........... 9-5 Exercise 9-3: The ideal circuit .................. 11-3 Exercise 11-2: High concentration of first gas .............................................................. ............... 9-1 Exercise 9-1: Reducing fresh gas flow ............................. 12-2 Exercise 12-2: Alveolar tension during wake up is lower with a low solubility drug .. 11-5 Exercise 11-3: 70% nitrous enhances alveolar rise of isoflurane ......................................................... 9-2 Exercise 9-2: Circuit flush reduces anesthetic tension faster ........................................................................................ 10-14 o 11: THE SECOND GAS EFFECT Theory .......................................................................... ~ ose -orcUlt ll1JectlOn USll1g t"............................................................................. 13-2 Exercise 13-2: Kinetics is faster with small animals .................................................. 11-1 Exercise 11-1: Low concentration of first gas ....................... 12-1 Exercise 12-1: Wake up is the inverse of induction .......................................................................0-~): CI E< xerose d' .............................. .......Gas Man® Table oj Conlnlls o 9: lOW FRESH GAS FLOW ANESTHESIA Theory ..... 11-9 Exercise 11-4: Second gas effect less with low solubility drug ........................... 11-13 o 12: PATIENT WAKE UP Theory ...................................... 9-10 SlllTIrnary .....................................................10 SlllTIrnary ........................................................................ 13-6 zx .. .................................................................................................

..... Modeling and Simulation of Anesthesia Uptake and Distribution ...................................................... A-I Further Considerations on Use of Gas Man ............................... 15-1 Setting Program Defaults ................................................................................... 15-12 o Appendix Evolution of the Understanding........................................................................................... 14-1 Exercise 14-1: Cost can be determined with Gas Man ...................................................................... 15-9 Printing & Export Options ............................................. A-4 Gas Man System Defaults .. 14-2 Exercise 14-2: Cost is lower with lower FGF ...................................................................................................................... B-1 o Index Index .................................................................. 15-5 Using Overlays .............................................................................................................................................................. 14-10 o 15: ADVANCED FEATURES OF Gas Man® Introduction .................................................................................................................................... 14-5 Summary ..........Gas Man® Table of Contents o 14: ANALYZING COST Theory ....... I-I o license Agreement x .. A-6 o Bibliography Bibliography ...

(-\ Chapter 1 \\ ) Overvie~f'Gas Man® and its Uses ~ o ntroduction Welcome to Gas Man® 2. by displaying compartment ratios. The key component of the program is an interactive schematic Picture which shows dynamically what the clinician controls and how the patient's lungs and tissues equilibrate with inspired anesthetic. The computer simulation depicts anesthetic tension (partial pressure) in the anesthesia machine. The Gas Man Overlay allows you to analyze your simulations graphically. and enhance your appreciation and enjoyment of the subject. The Gas Man Graph shows the evolving time course of gas tensions in the locations and tissues of interest. the innovative computer-based teach- ing and simulation program.0. 1-1 . breathing circuit. Gas Man is a computer simulation tool that teaches about anes- thesia. The program was designed to be used in close conjunction with this Manual. a text which guides the learner through a set of Exercises that demonstrate the important concepts and features of the administration of inhalation anesthetics. speed your learning time. Specifically. You are about to explore the con- cepts of inhalation anesthesia pharmacokinetics in a way that has proven to: increase the clarity and retention of the material. Gas Man also enables you to study the cost of different anesthetic agents and administration techniques. and patient. and the time course of anesthetic tension change. and by comparing one simulation to another. Gas Man focuses on anesthesia uptake and distribution.

.. The Knee: Equilibration with Blood Deterlninants: .. 1-2 .. 4. by Chapter 3. Two Sequential Compartmenls. The Tail: Augmentation by Venous Return Determinants: • Tissue blood flows . 5. Blood/gas solubility C. Tissue blood solubilities .Gas Man® Overview 0/ Gas J\.[an'!9 Concepts Covered in the Gas Man Tutorial. Closed-Circuit Anesthesia with Liquid Injection 11. The Concentration Effect 9. A. The Initial Rise: Alveolar Wash-In Detenninants: ... Low Flow Anesthesia 10. The Alveolar Tension Curve. Return of mixed venous blood 6. Alveolar (lung) ventilation . Alveolar volume (FRC) B. The One Compartment Model & its Step Response or Wash-in. Overpressure & Optimal Anesthesia Course for Clinical Anesthesia 8. Tissue volumes . Cardiac output . The Second Gas Effect Table 1-1.. Inspired tension . Alveolar ventilation . Concepts taught by Gas Man and the Exercises in the LVIanual. Plateau Height is Determined by Blood/Gas Solubilit)' 7.

\Then the Exercises are completed in order. the student will have constructed the breathing circuit and the patient components in step-by-step fashion to form a coherent. \. understandable model. In the end. An outline of these Chapters is presen ted in Table 1-1. The tutorial introduces simple systems first. and then combines them while maintaining their piece-by-piece simplicity. Each tutorial chapter introduces an important concept and follows it with Exercises to demonstrate and reinforce the con- cept using Gas Man. With this clinical system. Along this path from vaporizer to brain. the path of the anesthetic is depicted as beginning with the anesthesiologist's hand adjusting the vaporizer setting.\Tindowsr'l and Macintosh® computers.Gas Man® OVI'J1!i('w 0/ Gas JVlan® This manual is organized as follows: Chapter 1 The many uses aJGas Man Chapter 2 How to install and use the program on \. various administration tech- niques can be demonstrated and their implications explored. Chapters 3-14 These chapters are the tutorial portion of this manual. and culminates with the anesthetic effect achieved in the patient's brain. The Gas Man program is designed to be used hand-in-hand with the Exercises in this manual. physical and physiologic interactions affect anesthetic levels achieved and the rapidity of change. he Gas Man® Approach In Gas Man.0. Chapter 15 How to use the advanced features of Gas Man 2. 1-3 . the student will have achieved a system of sufficient complexity to explain clinical events. These Exercises can serve as a standalone curriculum on anesthesia uptake and distribution.

No claim is made that Gas Man can or should be used to determine the actual medical treatment of any patient. pub- lished in 1950. Eger IJII to validate the model. it is not a substitute for the clinician's judg- ment during the actual course of anesthesia administration in the operating room. • to teach anesthesia principles and kinetics in the classroom. ses for Gas Man® Gas Man can be used in several ways: • to learn the concepts..Gas Man® Overview 0/ Gas Alan") The o~jective of this approach is to provide a high level of knowl- edge. satisfaction. • to experiment with various anesthetic administration possibilities. Throughout. understanding and insight that can then be applied in every- day clinical practice to provide both better patient care and greater understanding. We also incorporated additional concepts and clinical techniques offered by others. and discover and elucidate its subtleties.. The overall approach follows that presented by Ketl9 in the origi- nal explanation of inhalation anesthesia pharmacokinetics. and enjoyment for the medical profes- sional. • to plan your administration in accordance with different clinical or cost objectives. designers. we used the data obtained by Edmund 1. 1-4 . quantify its parameters. Note: It is important to stress that although one can plan a clinical strategy with the Gas Man tool.. The equilibration of anesthetic partial pressure from compartment to compartment is the seminal concept that underlies the entire approach. • to better interpret your anesthetic monitors. and • by the many people who serve the anesthesia clinicians (manufacturers. sales representatives) who need to understand inhalation kinetics and administration • to design clinical research experiments. . features and technical subtleties of inhalation anesthesia by following the tutorial Exercises.

o TO PLAN A clinician can plan an anesthetic administration to optimize for specific objectives. Under some circumstances. For instance. Or a clinician can analyze a recent anesthetic administration to understand why the observed clinical events occurred or why the desired course was not achieved. In this circumstance. one may want to maintain a constant depth of anesthesia. For instance. accelerated time) simulations which can be viewed interactively by a group. where the goal is to minimize the time to perfect anesthesia depth. without following the Exercises. the program can be used to simply experiment with anesthetic administrations. The program and the Exercises can be incorporated into an educational curriculum either as a primary educational tool to teach inhalation anesthetic pharmacokinetics or as an educa- tional adjunct . the resident or the experienced clinician can simulate various anes- thetic administration possibilities. up to a desired endpoint.reinforcing. and deepening the students' understanding of the subject. and dura- tion of anesthetization is often more complex than it seems. For instance. Gas Man can also be projected in the classroom quite effectively with a computer projector or overhead LCD panel to provide real-time (actually.Gas Man® Overview of Gas iVlml® o TO TEACH Gas Man can be used by the teacher/educator in several ways. The student. 1-5 . expanding. where anesthetic depth is increased at a constant rate. a lecturer on inhalation anesthesia pharmacokinetics can easily produce the artwork for a sequence of overheads or slides which explain the points covered in the lecture by printing out the Gas Man Picture and Graph of a particular simulation. and Gas Man can help the clinician simulate the interrelationships. the relationship between fresh gas flow. one possible objective is speed of induction. Another objective is gentleness of induction. o TO EXPERIMENT Gas Man can be used several other ways. vaporizer setting.

and even experienced llsers. drug and patient. In such situations. alteration of anes- thetic depth at various times during the course of anesthesia. but usually. controlled. First-time users. either the vaporizer or the monitor may not be functioning properly. the observed differences can be explained by the physics and physiol- ogy of the machine. One can practice and analyze the use of low/low and closed circuit anesthesia to minimize the quantity of drug used. Occasionally. facilitating the analysis of new agents and tech- niques. -----------------~---"----~-------------- 1-6 . In this situation. of agent monitors are often perplexed or disturbed by the difference between what is set on the vaporizer and what inspired and end- tidal measurements are displayed and recorded. Gas Man can be used to produce a good approximation of what is ob- served on the monitor. Another clinical goal can be rapid. and helps the clinician formulate a more correct explanation for what is observed as well as a more correct expectation for the future. o TO INTERPRET MONITORS Anesthetic agent monitors are common in clinical anesthesia practice. both are correct.Gas Man® o TO REDUCE COSTS Gas Man calculates and displays the cost of anesthesia adminstration.

Pharmacists can better understand drug delivery system-patient interactions. In hospitals. in any of the ways described above. and patient.Gas Man® ther Users of Gas Man Gas Man can be used by many professions: all medical personnel. Clinical Engineers and Biomedical Equipment Technicians can use Gas Man to better understand the technical and clinical complexities inherent in their equipment. delivery system. and the interactions of drug. By preparing answers to these questions in advance. hospital and managed care administrators. manufacturers and marketers of agent monitors and anesthesia delivery systems. 1-7 . Biomedical Equipment Technicians and pharmacists. hospital Clinical Engineers. Manufacturers of agent monitors . residents. manufacturers and marketers of inhalation anesthetic drugs. the introduction and continued use of the monitor will be facilitated. and to calculate cost and price objectives. including students. Administrators of hospitals and managed care organizations can use Gas Man to analyze the cost of new agents or techniques. and administrators can better appreciate the trade-offs clinicians make between quantity of drug used and clinical care provided for the patient.can better appreciate the ques- tions that will be asked and the confusion that will initially be engendered when their products are introduced in the operating room. sales and user education staffs . and practicing physicians. and educators in other fields interested in the applicability of simulation software for training and communication. CRL'JAs.particularly their marketing.

unencumbered by limitations inherent in machine and patient that were previously difficult to overcome. even when the vaporizer is performing perfectly. since it demonstrates how the simulation of a complex process. can effectively improve the user's understanding of his environ- ment and enhance performance on the job. Manufacturers of the anesthetic agents can better understand and explain the pharmacokinetics of the drugs they market. sell. 1-8 . In addition. vaporizer specifi- cations can be better determined by carefully considering breath- ing circuit kinetics and solubility of the drug in blood and other tissues. technician or product developer to simulate the interactions of physiological. the implications of drug attributes such as solubility in blood and various tissues can be understood through Gas Man's computer modeling and simulation. Educators in other fields might also be interested in Gas Man. It can also be used as a general tool for the practicing anesthesiologist. The drug manufacturer can enhance patient care by helping clinicians learn to use the drugs effectively. Understanding the clinical goals and administrative objectives taught by Gas Man should in fact assist in the design of new anesthesia machines. accompanied by direct.Gas Man® Overview of Gas IHan® Manufacturers of gas delivery systems (anesthesia gas machines) can use Gas Man to understand and explain why the concentra- tion the patient inspires from the breathing circuit is not what the clinician set on his vaporizer. ummary The Gas Man program is a unique tool for teaching and simulat- ing anesthesia uptake and distribution. pharmacological and physical components. interactive simulations to demonstrate these concepts and reinforce learning. combined with straightforward user interaction with the model. Also. It can be used with the Exercises in this Manual for a clear. or manufacture. detailed presentation of concepts.

please refer to Chapter 15.0. /~~ Chapter 2 ( ) Getting ~a)t-ed/ with Gas Man® ( ') ~ o ntroduction In this chapter. When you finish this chapter. you will find: your software license agreement how to install Gas Man® on Windows™ and Macintosh nr computers an introduction to the Gas Man Pictw'e and Graph an explanation of Gas Man's Menu Bar and Toolbar on Windows and Macintosh computers your first exercise in Gas Man. and can begin the tutorial section of this manual by going on to Chapter 3. 2-1 . you will be ready to run Gas Man simulations on your own. showing you how to run a simple simulation an introduction to some of Gas Man 2. If you are not comfortable with how your computer works. such as Rewind and Bookmarks. '-Note: This chapter assumes that you are already familiar with the Windows or Macintosh computer on which you plan to run Gas Man.0's newfeatures. To learn more about the advanced features of Gas Man 2. please complete an introductory tutorial on your computer's operating system before starting to use Gas Man.

In addition. Salespersons representing drug or device manu- facturers are required to own individual licenses. you may not install the Gas Man software on more than one computer. o THE SITE LICENSE Site Licenses are designed for single departments of universities. monitors. hospitals. and gas ma- chines. but not the Manual. Inc. Additional copies may be purchased only by Site License holders. you may not make copies of the software or this Manual to distribute to others. under the Single User License. The exact organization must be defined in the Site Li- cense Agreement. o THE SINGLE USER LICENSE The Single User License includes one copy of this Manual and is intended for a single user on one computer such as a desktop or portable. and to install it on computers within their organization. The Site License authorizes users to copy the Gas Man software. Under the Single User License. and are not authorized to make and distribute copies of the software or the Manual.Gas Man@ Gelling Started our Software License Gas Man® is licensed for use in two ways. Please contact Med Man Simulations. vou must remove it from the original / / machine. If you wish to put Gas Man on a different machine of yours other than the one where vou first installed it. 2-2 . and manufacturers of drugs. The Single User Li- cense and the Site License are fully described in the License Agreement that accompanies this software and is printed in the back of this Manual. The Site License includes a specified number of copies of the Manual.

2-3 . Have Windows running on your computer and the Program Manager open. 3 Make a backup copy of the Gas Man installation disk for your protection. Windows for WorkgroupsTtvl 3.0 or later. the speed of the processor is not important. preferably color SVGA or better " a hard drive with at least 2 mB available ell a floppy drive (for installation only. !ling Gas Man on Windows™ Comp_u_te_r_s_ _ _ _ _ _ _ __ o HARDWARE REQUIREMENTS ell a personal computer using an Intel® processor (486 or higher preferred. can be external) • 4mB RAM or more (2mB is OK but not desirable) o INSTALLING THE SOFTWARE 1 Read the Software License Agreement. although faster is always better) or a PowerMac processor run- ning SoftWindows 2. Under both the Single User License and the Site License.Gas Man® Gelling S'/(Irled o COPYING & DISTRIBUTING THE MANUAL & SOFTWARE This Manual is protected under applicable Copyright law and may not be copied for redistribution under either the Single User License or the Site License. 386 OK. 2 Make sure you have enough space on your hard disk.1.1 or Windows/NTTtvl " a VGA monitor. 4 Install like any other Windows program. the user may make a backup copy of the software on a diskette to protect against damage to the original disk. Microsoft® Windows™ 95 or Windows 3.

Compete the information and continue. This allows you to decide in which window on your desktop you wish the icon to appear.Gas Man® Cell illg SI (frted 5 Insert the Gas Man installation disk into the floppy disk drive. Then a dialog box will appear with a suggested location for the Gas Man jJrograrn icon. type A:\INSTALL Select "OK" or press ENTER. You can change this if you wish by typing over it. where (if you didn't skip the icon step) you will find the nevv Gas Man icon in the Group where you placed it. 10 A progress dialog will show how the installation is progressing. 8 After a few moments. You may either accept the sug- gestion or select a different location from the drop-down listbox. to register your copy of Gas Man. choose Run . 7 In the Command Line space. 9 The next window shows the directory on your hard drive where the Gas Man prograrn will be installed. 2-4 . and a README. Either press CREATE to complete the install.FULL and CUSTOM install. 12 A dialog box will inform you that your installation was successful. There are also two buttons .TXT file that contains important infor- mation and reminders. 6 Under File in the Program Manager menu bar. Press OK to end the installation process and return to the Pro- gram Manager.. Press CONTINUE. or press SKIP to prevent the addition of a program icon. Press the FULL install button to have Gas Man install automatically. You will be able to launch Gas Man from this icon.. 11 A dialog box will ask you for your name and organization. you will see the Gas Man installation screen.

If the system complains about being short of memory. and the file's menu bar. 5 Ask someone who works with you. Inc. Floppy media and drives can make mistakes. or with run- ning Gas Man once the installation is complete. and by select- ing FULL install even you wish a Custom installation. try shutting down all non-essential applications. in order to have the Gas Man Picture fill your screen. You close Gas Man as you would any Windows program. Then try these remedies: 1 Respond to any messages appropriately.TXT file in the Gas Man directory for other instructions. and the program open on your computer. 3 Try it again without changing any default responses. You should see the Gas Man start-up screen and then the Gas Man Picture. 2-5 . The file name will be "Untitled". o IF YOU HAVE AN INSTALLATION PROBLEM Should you have any problem with the installation. for example. 4 Look for the README. You may want to click on the expand button in the upper right corner of the Gas Man menu bar. by choosing Exit from the File menu or typing ALT +F4.Gas Man® Gelling Started 13 Try opening Gas Man by double clicking on its icon. such as Microsoft Office™ or Lotus® SmartSuite™. If none of these work. 14 If you frequently use a suite of applications. you may want to add the Gas Man program icon to the suite's toolbar. 2 Try it again. call or fax Med Man Simulations. Have the details of the failure handy. record the cir- cumstances and any messages that appear on the screen before attempting to recover.

52 I Uptake (ll agent in '-----' ~ tissues & in 3. each compartment is filled during the simulation Alenll Bar Toolbar Agent: II soflur ane Circuit: ISemi-Closedl~1 . annotated with descriptions of its components. 70 1 10 .\3 1 LIm ~ I 60x .wl rich groll/J = agmt tensioll in % I aIm o (inc.48 1 Delivered (ll circuit (toggles '-----' with Cost) Flows in liters /Jer ____ FGF rR! VA CO Speed: minnie lIm ~ LIm 4 1 . 78 1 11. 32 1 %at/~ ART VRG MUS FAT VEN Deli< l eredfroll1 f1iil f1iil ~ Simulation Time Iheva/!Orizer ~ ~ I 0:15:00 1 Time (h:mm:ssJ I Volume of 0. press F1 ! Slatus Bar Figure 2-1 shows the Gas Man Picture after a simulation has been run.11017 = alveoli (lullgs) II FiT = arteriat blood Height = Flush I'HG 'Ie. One of the convenient features of Gas Man is that several of the key program controls are located on both windows. Getting Started he Gas Man Picture & The Gas Man program uses interactive graphics to depict anes- thetic tension in various locations from vaporizer to patient.+!I Fresh Gas Flow Alveolar (lung) Ventilation Cardiac OlltjJllt (blood flow) Simulation SIJeed I For Help. brain) MUS = muscle FAT=f{ll \fEN = venous blood Breathing circuil DE: 0 CK~2.the Gas Man Picture and the Gas Man Graph - are used.521 AlVll. The Gas Man Picture shows a schematic compartmental diagram of the patient. 01 1 11 . 2-6 . 15 1 10.781 11 . in order to minimize toggling back and forth between windows. Two main windows .

The fresh gas flow is the total gas flow from the anesthesia machine common outlet into the breathing circuit. .Gas Man® Gelling Slarted according to its partial pressure. I = CKT = Inspired Ddi1l('mi anl'sliteslic ({.. Fresh Gas How ill lilen/mimlle LIM -- o--~------------------------------------------------------~ 3--~------------------------~----------------------_. 2-7 . Agent: Iisoflurane Circuit: 1Semi-Closed I 10--.... The heights of the fill represent anesthetic tension. The Gas Man Graph shmvs the time course of anesthetic tension in the tissues of interest. FGF .1'011 10 sec graphical re({mi beyond the li)))e liwl.. . ..R = VRG = vessel rich grolljJ ________________________________.pone11ls. The bottom half of the Picture depicts the rates of flow between compartments.. The delivered tension is the anesthetic partial pressure (% of one atmosphere) of the fresh gas.p(ess Fl Figure 2-2 shows the Gas Man Graph.Jlsion/iYJ))! Ihl' %atm .J 3 M = MUS = JllllScie en F=FAT=Jat Desired M'-\ C level ALV (minimuJJl alveo/ar VRG (oncentration) MUS %atm o 0:00 0:10 0:20 0:30 View: Length o/lime displayed in GrajJh window 130 MinI~f I+LJ· . annotated with descriptions of its com. DEL .. after a simulation has been run. the top two panels show the trends of the values of delivered anesthetic tension (DEL) and Fresh Gas Flow (FGF).. The bottom panel shows anes- thetic tension in inspired gas (I). When a Semi-closed. A=/iLI'=E:dzaled vajJorizer in S1a I aIm 0--'--------. alveolar or expired gas (A).. Closed or Ideal circuit has been selected....-----------------------------------------------------.. ) I L~d ~{)rltinlJ~J SO'oll bar enables ./ils in Ihe window For Help..

Gas Man® Gelling Started vessel-rich tissue group (R). therefore. 2-8 . by changing the upper limit of the DEL scale. in this situa- tion. muscle (M) and fat (F). or type a new numeric value in the appropriate box. When an Open circuit is selected. The height of the vertical scale of compartment tension (the lower half of the Graph) is automatically determined by the height of the DEL scale at the upper left of the Picture. Values are expressed in percent of one standard atmosphere of the anes- thetic chosen. o SETTING PARAMETERS The parameters and variables used by the Gas Man program can be adjusted or controlled prior to and during a simulation in three wavs: j click on the upl down buttons next to the control bars. This is useful in certain simulations to better see the anesthetic time course. delivered tension equals inspired tension. grab (click and drag) the control bar itself and move it up or down (the fastest but crudest method). The numeric values you enter can be expressed in hundredths of percent or Llmin for precise control. You can adjust your view of the compartment tension graph. the top 1:\'\10 panels display alveolar ventilation (VA) and cardiac output (CO).

The actual speed of these settings will vary depending on the speed of your computer. Closed or Ideal. You can choose from lx. Weight Acljust from 0. CO Aqjust the cardiac output (L/min). Circuit Choose from Open. enflurane. Choose the simulated speed (compared to real time) at which you wish the simulation to run. Semi-Closed. Choose the duration of time shown on the Gas Man Graph.05 to 1500 kg. Gas Man's advanced features employ additional param- eters described in Chapter 15. 60x. VA A(~just the alveolar ventilation (L/min).Gas Man® Gelling Started Gas Man Basic Parameter Choices Agent Choose from desflurane. lOx. 5x. halothane. The basic Gas Man parameters and the available choices used to define each simulation. FGF Adjust the fresh gas flow (L/min). 20x. Table 2-1. isoflurane. nitrogen. The choices range from 5 minutes to 10 hours. or sevoflurane. 120x and AFAP (as fast as possible). DEL (%) Acljust the anesthetic tension (% of one atmosphere) from the vaporizer. 2-9 . nitrous oxide. 2x.

elect All Unit Qose . in its Windows version. Circuit.. 2-10 .CO . . Y:iew New View Qraph CTRL+G . Agent 8. . file Edit Anesthesia Qesktop Yiew ~pecial Edit Re~ind East Fwd Zero Timer Ctrl+Z Anesthesia Clear All Liquid Inject Ctrl+L ..pecial ~ascade Disable !1ptake Ctrl+U lile Disable Return Ctrl+R Arrange Icons Enable Y:apor Ctrl+V v 1 Untitled7 Change Eatient Set .... ~opy Data Ctrl+C EGF.s.crolling tiide Numerics Show ~ost Figure 2-3 shows four of the drop-down menus from the Gas Man application menu bar.DELVA.6. Ctrl+D Copy Selec!ion Ctrl+X Set ~ost.s.s..Qverlay .ookmark Enable .Gas Man® Gelling Started he Gas Man Menus & Toolbar This section describes each of the commands available to you under the menu bar of the Gas Man application.

The Print and Set Default commands are more fully explained in Chapter 15. such as word processing or presentation software files. without saving it. creates a snapshot of the current Gas Man screen that can be copied to the Windows Clipboard. allows you to begin again the simulation you have just paused or completed. erases the simulation you have just paused or just completed. From the Clipboard.. holding down the right mouse button. keeping all the setting5 as they were throughout the simulation. 2-11 . . Many of these commands are also available in the Toolbar (see fJage 2-16). heefJing all the settings as they were throughout the simulation. Rewind . DEDIT At the left of Figure 2-3 is the Edit menu. including a list of recently saved or used files. including any changes or manual adjustments you made . and restores the settings to the current defaults. Fast Fwd .. Select All .. . takes you immediately forward to the next Bookmark or the end of the simulation you have just completed. allows you to rewind in preparation for replaying the simula- tion you have just paused or completed. creating and saving files.. closing. .Gas Man® Getting S'/arter! o FilE At the left of the menu bar is the File menu (not shown above). . but retains the settings as you had when you choose this command . and dragging to surround your selection.. Under this menu are two kinds of commands . including any changes or manual adjustments you made . Zero Timer . Here you find the usual commands for opening. A portion of the current display can be selected by positioning the mouse where desired on the screen.those for resetting or replaying the simulation. and those for using the simulation data in other applications . the screen image can be pasted into many other Windows applica- tions. Clear All .. You can also Run simulations (or Run All if there are more than one simulation open) from this menu.

allowing you to hide the Toolbar (shown later in this chapter) or the Status Bar. which is at the very bottom of the Gas Man application window. You can also do this by clicking on the syringe icon in the Gas Man Picture . Unit Dose . copies the current data from the active simulation to the Clipboard.. in US dollars..VA.. and to make simulation parameter adjustments more quickly than typing them in at their individual screen boxes . . allows you to set the volume in ml of the liquid injection. Once you are confident with the program.introduces a unit dose of liquid anesthetic into the breathing circuit. allowing you to paste it into a spreadsheet or word processing application for analysis and presentation. FGF.. These can also be set directly on the Picture. allows you to set each or all of these parameters in one dialog box.. o ANESTHESIA The next menu to the right is the Anesthesia menu.. copies your display selection to the Clipboard . allows you to type in the bottle volume and bottle cost of the anesthetic agent you have selected. Agent&Circuit . . The Status Bar shows a message for each action that you take. Set Cost ..Gas Man® Getting Started Copy Selection ... sometimes this can help explain a command. you might want to hide either or both of these items to give Gas Man more room to display on your monitor. Here you will find commands that enable you to use the unique liquid injection feature..DEl. These can also be set directly on the Picture. . allows you to set each or all of these parameters in one dialog box. 2-12 .CO . to enter your costs for anesthetic agents. o DESKTOP The Desktop menu (not shown) has two choices. Copy Data . liquid Inject ..

. can be open simultaneously on your screen. changes the current active view to the Gas Man Graph. arranges the open windows to fill the screen. 2-13 . arranges the open windows in an overlapping display.. or to administer an additional agent during the simulation.. Graph . you can study that same quotient across multiple simulations.. Overlay can also be invoked from the Toolbar. These tvvo views. v\Then you have a number of simulations or views of one simula- tion open at a time. whether at full size or iconized. You will also find at the bottom of the View menu a listing of any open simulations and views.. The new window will be labeled" [File Name] :2". Cascade . which is used in some of the exercises in the tutorial chapters of this Manual and fully ex- plained in Chapter 15. Arrange Icons ... invokes the Overlay dialog box. The Overlay feature of Gas Man allows you to graph a curve showing the relationship between any two of of the program's variables (such as alveolar concentration versus circuit concentration).Gas Man® Getting Started o VIEW The View menu allows you to create and manipulate multiple views of the same simulation. changes the current active view to the Gas Man Picture. You can use this feature to view a Picture and Graph simultaneously. Tile . creates a new window of the same simulation you are running... arranges the icons representing open simulations and views on your desktop (usually into the lower left portion of your screen).... and have the resulting curves all shown on one graph. and indeed multiple versions of these views. the Gas Man program uses both a Picture (showing the compartments of the anesthesia circuit) and a Graph (showing the time course of the value of each variable during the simula- tion). New View . Overlay . Picture . it is often helpful to "iconize" or reduce some of the windows to avoid visual clutter... As described in the previous sec- tion. In addition.

. set that time as the "View" time on the 2-14 .Gas Man® Gelling Slaried o SPECIAL The Special menu allows you to use some of the advanced fea- tures of Gas Man... ''''ith these commands. removes the effect of anesthesia uptake on alveolar ventilation.. and the / t. If you wish your simulation to run only for a specific length of time. t.. Disable Return . you can change the way some aspects of the simulations run.. allows you to set or change a number of parameters for the current patient. Enable Vapor . ensures that the simulation will keep running even if the screen display of the Gas Man Graph is fully filled (othenvise. compartment volumes and flow percentages.. Note that Gas Man will change c the values for VA and CO automaticallv/ according to the weight you choose... Change Patient ... Some of these can be set directly on the Picture. which is the sum of the FGF you set and the flow of agent added by the vapor- izer (see Chapter 15). including Weight (in either kilograms or pounds).. it is marked by a checkmark in the drop-down menu. and all of them have defaults which can be changed under the File menu (see Chapter 15). the simulation will pause automatically when it reaches the time set in the "View" box of the Gas Man Graph).. removes the effect on alveolar tension caused by anesthetic agent in the venous blood. causes the simulation to use iffective fresh gas flow. Enable Scrolling .. you would use this command if you wanted the simulation to run for 2 hours but like to see its progress displayed in the Graph in 15- minute segments. and how information is displayed on the screen. Set Bookmark .. allows you to set times when you 'wish the simulation to pause. checkmark disappears. and metabolic parameters (VA and CO). Each of these commands toggle: when you select one. This is explained further later in this chapter.. For instance. de-select it bv clicking· on the command again. but you can also changes those values manually through this command... Disable Uptake .

You may find the display more intuitive in this manner. changes the values in the "Uptake" and "Delivered" windows in the Gas Man Picture from volume in liters to cost in US dollars... If this command is enabled. Hide Numerics . ART. To return to liters. The Help function in Gas Man works identi- cally to other Microsoft® Help resources. and do not enable this command. FAT and YEN. o HELP The Help menu is found on the far right side of the program's menu bar. a checkmark will appear next to it in the menu's drop- down window.Gas Man® Getting Slarted Graph. Under this menu. and also find out which version number of Gas Man you are using. click on this command again. eliminates from the display the numbers under the compart- ments for ALV.. You can also control this through the Toolbar. VRG. Show Cost .. you can find out more about using the Help feature. MUS. Note that using scrolling will likely slow down the simulation considerably. 2-15 .

Gas Man® Getting Started o THE TOOLBAR The Gas Man Toolbar contains an iconographic set of commonly used commands. Pressing Print will bring up the printing dialog. Starting from the left. the first icon will create a New simulation. About Gas Man will tell you the current application version num- ber. One click on this icon will open a new window and a new file (not a new window of the current simulation. Point that question mark at the section of your screen you want more information about. 2-16 . Copy Data Picture/Graph Rewind Copy Selection Print Fast Forward \ About Gas Man Run/Stop New Save Overlay I Gas N[an Help Run All/ Stop All Figure 24 identifies the icons on the Gas Man Toolbar. if one is already run- ning. Save will enable you to save the simulation running in the active window. If you select a portion of the display for copying to the Clipboard (by clicking on the right mouse button and surrounding the selected area). You may find it helpful to use these icons in addition to the drop-down menus and keyboard shortcuts. then pressing Copy Selection will do the copying. Copy Data will copy the current simulation data values to the Clipboard.) A click on Open will bring up a dialog asking you to select a simulation that has been previously saved. The Gas NIan Help icon is a context-sensitive tool: pressing on this icon will turn your mouse pointer into a question mark.

because only one simulation is open. as is Run All and Stop All. a simulation has been run and stopped. 2-17 . described briefly above and in more detail in this Manual's exercises and in Chapter 15. Show Cost will replace the volume of Delivered and Uptake in liters with the cost of anesthetic Delivered and Uptake in US dollars. Gas Man determines Cost by the bottle size and bottle costs listed in the Set Cost command of the Anesthesia menu. Bookmarks are described later in this chapter. This command is also available from the Special menu.Gas Man® Getting Started Wilen you want to switch between the Gas Man Picture and GmjJh in the active window. These commands are also found under the File menu. Fast forward is grayed out because we are at the end of the simulation. Pressing the Overlay icon will immediately open the Overlay display. Set Bookmark allows Pause times to be set. In Figure 2-1. Similarly. Run and Stop is a toggle button. click back and forth on whichever icon is showing (it will be the opposite of what is being displayed). the Run All button (racing cars) is grayed out. so the Run/Stop toggle is showing Run (the traffic light). These commands are described later in this chapter. Rewind and Past Forward are also found under the Edit menu.

you can determine which portion of the Picture or Graph appears in the space you have for it on the screen. you are getting multiple views of the same simulation. it offers the Gas Man user some advantages in being able to display a wide range of information as densely as possible on the screen. In Untitled:l. Grab this bar at the bottom of the Gas Man Picture with your mouse pointer. By moving the scroll button. two views of the simulation "Untitled" are open. The Pic- ture ofUntitled:2 (on top) shows the compartments. while only the FGF section of the Graph is showing. By opening multiple windows. Each view in turn is split between Picture and Graph. Also note now that both the Picture and Graph have scroll bars along their right edges. that would not otherwise be possible. In this example. in which the Picture and Graph are in separate windows and must be toggled be- tween. 2-18 . an operating system feature which Gas Man fully utilizes. You will see the Gas Man Graph unfold as you raise the bar. Although this may be confusing at first. Gefling Started o WORKING WITH MULTIPLE VIEWS The multiple document interface (MDI). You can also have more than one file (simulation) open at a time. This is demonstrated in Figure 2-5. such as that with a laptop computer. Unlike the Macintosh version of Gas Man. Any view of the simulation can show anything any other view can show. enables you to open more than one window of the same file or document. while the Graph shows the time course of compartment tensions. or clicking on the up and down arrows. They are separated by a three-dimen- sional gray bar called the "splitter bar". and drag it upward. Therefore. you can use this feature to see different components of the simulation dis- play. side-by-side. both the Picture and Graph are in a single Windows view of a Gas Man simulation. Cost is shown on the right hand side of the window. if you have a small screen.

Also remember that certain menu commands will only work on the active window. and each view is split between Picture and Graph.51 Uptake {$} 2. Similarly. and all the Edit menu commands. apply to all open views of the simulation. This is also true of the bottom half of the Special menu (scrolling. numerics. This enables you to show cost in one view while keeping volume displayed in another view. or by the keyboard shortcuts. 2-19 . Other Gas Man commands. This includes Close. Note that the Graph Paper is being used in the top view for added contrast. but not in the bottom view. you would find that volume is being shown instead of cost. and all the numeric parameter settings. cost). such as Disable Up- take and Disable Return. Save and Print. Keep in mind that you can still toggle between full screen views of the Picture and Graph by pressing on the respective icons in the Toolbar. if you scrolled through the Picture in the top view. graph paper.Srro!! /Jars SjJlilll'f /Jars 0.89 Delivered ($) View: 0:00 0:05 0:10 0:15 Figure 2-5 shows two views of a simulation. Gas Man® Getting Started Flush o .

insert the Gas Man disk into the floppy drive of your Macintosh computer. the better. o INSTALLATION ON THE MACINTOSH To install Gas Man on a hard disk. The installation instructions assume you have a hard disk. To open Gas Man.Gas Man® Getting S'{arled nstalling & Using Gas Man on the Macintosh ™ -------- Gas Man runs on nearly any Macintosh computer. Move the pointer to the OK button and click the mouse. Once you select OK. a Title and Copyright statement appears on the screen. Pick the icon with the mouse pointer so that the icon is high- lighted and drag the icon to your hard disk. or press the Return key on your keyboard. The program will be copied. Figure 2-6 shows the Gas Man icon. When the program begins. and the more RAM you have. Then drag the Gas Man disk to the Trash to eject it. As with any software. Double-click on the disk icon and a window will appear with the Gas Man icon inside. the Gas Man Picture is displayed 2-20 . The disk icon will appear on your desktop. double click on the program icon. the faster your machine.

. in order to execute the command without first opening the menu. 2-21 . and others have key combinations listed to their right. .. some have ellipses ( ..... you will be referring to both windows - Picture and Graph ........ CO ...... ········t Agent {} Circuit ........ or you will toggle between the two by selecting one window and then the other.. New :3€N Liquid Inject :3€L Normal Unit Dose. .. If you look again at the File menu.. Usually this involves pressing the Macintosh command key ( ) in conjunction with another key. All Macintosh applications follow certain menu conventions. you will notice that some items appear dimmed......... .... Depending on the size of your monitor screen. These conventions communicate additional information about the menu commands............ ) after their names... LIA...... as shown in Table 2-2. Some commands have a "shortcut" key combination shown to the right of the menu command. 1 ..Gas Man® Getting Slarted o USING THE MACINTOSH WINDOWS & MENUS When using Gas Man. Enable Scrolling ····················································1 Hide Numerics Page Setup . Print:3€p ~ Both ··············································11 Graph Only Quit :3€Q Picture Onl Figure 2-7 shows all the menu choices available from the Gas Man menu bar on the Macintosh. ..... :3€D Disable Uptake :3€U f··········································· :3€G Disable Return :3€U DEL..frequently. you will either be able to place the Picture and Graph beside or on top of each other...... FGF..

A checkmark to the left of the The command or selection choice is active. A key combination after the The listed combination of keys is a conllnand name. Macintosh menu conventions that apply to Gas Man and most other Macintosh software programs. This convention is used [or selections or commands that toggle. A triangle (t) to the right of the The command leads to a cascading menu. is chosen. asking for additional information or confirmation before carrying out the command.. command (or selection choice). You might have to select something else before you use this command. or else it may be that the command is not available with your application or hardware. An ellipsis ( . Table 2-2. command name." The command can be chosen within Gas Man and without opening the menu by pressing this key combination. which lists additional commands that are available.Gas Man® Getting Stalter! MACINTOSH MENU CONVENTIONS Menu Convention Meaning Dimmed command name The command is not available at this time. "shortcut. 2-22 .. ) after the A dialog box will appear when the command the command name.

. find the Pop-up Menu for the anesthetic Agent and change the selection to halothane..-:::: --. -./ \..00 I V~~G 10....-- 15. ''-----.'tarled There are also several Pop-up Menus on the Gas Man Picture and Graph. ...Gas Man® Getting ". SeLlofim-ane .. Nitrogen 0 - ffiI"' ~// :~.0 I T 1~·lE ([11 N) 10 Min L. ..-. 2-23 ..00 I 5 H ( Elegin J Speed: FGF Viev'i: 2 Hr 5 Hr v' 10 Hr CO Speed: 10 H v'AFAP _f I: IntetTupt Continue ] 1 - I Figure 2-8 shows the Pop-up Menus and Buttons of the Gas Man Picture.1 r+. c: 1H 2 H DEL 1'v'ERED (L) I 8.00 1 Hr 15....00 I AL\l' AIH I 0.'1'"1' ) 15 Min I 0.) Ilesflurane . ILL !::L Closed Isoflurane ~-1:L- .00 FAT I oi%o -'lEN '~rn 5 Min I 0. They can be opened and commands can be selected in the same manner as menus on the Menu Bar Nitrous OHide Gas Man(EiI Picture Open Agent: Halothane Enflurane I Ci rcui t: Semi-Closed c . For practice./ ....00 I r·1US 10...00 DEL 10.J r-+ .~- (...0 I UPTAKE (L) o ffiI 30 Min 45 Min o .00 CKT I []i]"jL 10. The functions of most of them are obvious from their name...

00 I Delivered ($) Speed: FGF [QI VA co lim U lim 14.ool 10.:.:.ool AlVlo.00 I Uptake ($) 0.:.:. you will actually run your first Gas Man simula- tion. 00 1 ART VRG MUS FAT VEN I 0:00:00 I Time (h:mm:ss) 0.:.00 1 lim 15. 00 1 10 . 00 1 10.Gas Man® Gelling Started unning a Gas Man Simulation In this section.:..:..:. Open the application and follow the steps outlined below: DEL %atm CKTlo.:. 2-24 . 00 1 10 .001 10 .:.:. 05 1 I 60x I~:I Agent: Iisoflurane Circuit: ISemi.:.:.: - %atm 0 ! ! 0:00 0:05 0:10 0:15 View: 11IIifII1:t) Figure 2-9 shows the Gas Man Picture and Graph before a simulation begins.Closed I 10 FGF LIM 0 § 3 ~ DEL %atm 0 cn 3 AlV VRG - MUS ...:.

A fresh Gas Man Picture will appear. equilibrating with inspired tension: the lung alveoli (ALV) and arterial blood (ART). the vessel-rich group (VRG) con taining the brain. The other compartments follow in succession. To save this simulation. if it is not there already. see Chapter 15. and finally fat (FAT). or press the Save icon in the Toolbar. 5 The simulation will stop at the time set in the View field in the Graph. choose Save from the File menu. As the simulation evolves. anesthetic tension rises in the breathing circuit (CKT). and other well-perfused organs. muscle (MUS). 2 Click Begin to begin simulating administering an isoflurane anesthetic with a Semi-closed breathing circuit. heart. 2-25 . 3 Grab the control bar for the vaporizer (DEL) and drag it to the top of the scale. type Ctrl+S. To print. 4 Grab the splitter bar or click on the Graph icon in the Toolbar to bring up the Gas Man Graph and observe the time course of anesthetic tension equilibration. each weighted by relative blood now to (and from) the compartment.Gas Man® Gelting Started 1 Choose New from the File menu or use the keyboard short cut Ctrl+N (holding down the control key and "N" at the same time). Venous blood anesthetic tension (YEN) lies somewhere between the vessel rich group and muscle since it contains an anesthetic tension equal to the average of those leaving the various body compartments.

This is particularly useful if you make manual acUustments during a simulation. the default directory for saving simulations is the GAS MAN directory with the ". perhaps at a different speed. or press the traffic light in the Toolbar. it will play out exactly as you ran it before you saved it. and then Begin. and choose OK in response to the dialog box. Try run- ning a new simulation. you can either choose New again. You can adjust the parameters either before or after selecting this command. If you run this simulation. The simulation will replay itself exactly as it ran before.GAS" extension. choose Clear All and then Begin. You will see the standard File Manager dialog box.0 allows you several options for replaying and revising your simulations. and make some manual adjustments during its course. 3 To run a simulation using the default settings for all parameters. which will create a new simula- tion with a new name. Try the following steps to become familiar with these features: 1 Return to the simulation you ran on the previous page. Choose Rewind. or you can simply choose Zero Timer (Ctrl+Z) from the Edit menu. 4 Save this simulation by choosing Save from the Edit menu or click the Save icon in the Toolbar. You will see the Gas Man Picture at its time-zero state.Gas Man® Getting Started o REPLAYING & REVISING THE SIMULATION Gas Man 2. 2 If you want to run a simulation with a different set of parameters. Now click on Begin. including saving and replaying simulations from a previous session. 2-26 . and want to watch the Picture or Graph again. Choose Rewind from the Edit menu or Toolbar. Open the simulation by choosing Open (Ctrl+O) from the File menu. and watch the changes occur again. when you choose Begin the simulation will run using the new parameters.

delete or change multiple bookmarks for each simulation. Then press "Add". The command Set Bookmark is found under the Special menu. minutes and/or seconds. The bookmarks are saved with the experiment. Note: if you choose this command in mid-experiment. highlight it with the mouse pointer and click delete. You can add. no bookmark will be set. (If you set the time and click OK without pressing Add. pausing the experiment.Gas Man® Gettillg Star/cd o USING THE BOOKMARK A useful feature of Gas Man 2. To delete a bookmark. or select a new time.0 is the ability to set bookmarks during the simulation.) The time of the book- mark will now appear in the white space on the left of the dialog box. the simulation will automatically pause at those times whenever the simulation is run. type in the hours. Press Add to use that time for a bookmark. the de- fault time for the bookmark will be that moment in the simula- tion minus one second. To add a bookmark. 0:03:00 0:15:00 Figure 2-10 shows the dialog box of the Set Bookmark command. You can pick any time earlier or later than the moment of the simulation you have paused. 2-27 .add. making this a useful feature for lectures and presentations. It is also useful for setting precise timings when comparing simulations. Once the book- marks have been set. The dialog box has three choices . delete and clear all.

Gas Man® Getting Started ummary ---=------ You now know enough about using Gas Man to go on to Chapter 3 and begin the Exercises which teach anesthesia uptake and distribution. you will learn the use of all of the program options available.0/2. reviewed the basic features and commands of the Gas Man program. Remem- ber to look at Chapter 15 for a description of the more advanced features of Gas Man 2. You have set up the correct hardware. and run an actual Gas Man simulation.1. 2-28 . installed the software. As you work your way through the Exercises in this Manual.

which could be measured with a ruler. less than I ml (0. depending on the organ. For nitrous oxide the blood/ gas solubility is equal to 0.42 ml) of these gases will be con- tained in I ml of blood. If the compartment contains body tissues rather than air.47 or 0. the blood/gas solubility is 3-1 . For non-gas filled compartments. for desflurane it is 0. For a gas-filled compartment (breathing circuit or alveolar space) : AT/G =1 ml gas/1 ml volume = 1.42. Thus.47. one milliliter of tissue or blood may be able to absorb more or less than I milliliter of anesthetic gas or vapor.Chapter 3 (-~ A One cU'!m~ent Model o Compartments are real or theoretical containers which initially contain no anesthetic. capacity or effective volume equals volume times solubility: c = V X AT/G. the capacity or effective volume of the compartment will be different from the actual volume. Thus. For halothane. A compartment has an actual volume. For example: AH/G = heart/gas solubility AB/G = blood/gas solubility. The ratio of effective volume to actual volume is the tissue/gas solubility or tissue/gas partition coefficient: AT/G = tissue/gas solubility with the tissue specified by name.

"Vhen compartments are in equilibrium.47. anesthetic tension within the compartment approaches and finally equals anesthetic tension in the inflow. either in containers or on graphs. It is the direct result of the law of concentration of mass. It is the flow of this carrier fluid. anesthetic tensions are expressed as percent of one atmosphere. Less for- mally. 2. this is the fundamental rule upon which all of the Gas Man simulation is based. Anesthetic arrives in the compartment in some carrier gas or liquid. The terms anesthetic tension and anesthetic partial pressure will be used interchangeably in this book. compared to the capacity of the com- partment.47 ml of vapor will be contained in 1 ml of blood.30. which determines the time course of anesthetic tension change. Anesthetic tension difference is the drivingforce which causes gas molecules to move from an area of high partial pressure to one of lower partial pressure. The interaction of a compartment with an inflow of anesthetic- laden or anesthetic-devoid flow determines how the anesthetic tension in the compartment changes with time. The response of a compartment to a sudden or step change in inflow tension is termed the step response. For isoflurane. Tissue/gas solubilities are tabulated in the Appendix.Gas Man® il (Jne ComjJ(lrtmml Alude! 2. The venous anesthetic tension leaving the tissue is assumed to equal average tissue tension. the value is 1. 1. This term evokes the way the sudden change in inflow tension "washes in" to the compartment. they are shown as vertical heights. 3-2 . With time. the step response is called the wash-in of the compartment. In fact. Partial pressure is the pressure of the anesthetic if it were present by itself. their anesthetic tensions are equal. that is.3 ml of vapor will be contained in 1 ml of blood. In this program. This assumes perfect mixing and no shunting within the compart- ment. With each inflow there must be an equal outflow of carrier (venous blood) from the tissues.

.......................... This circuit type is called semi-closed... which is adjustable with the DEL display and control bar at the left edge of the top of the Gas Man Picture.Gas Man® A One ComjJartment Model xercise 3-1 Wash-in of a single compartment produces an exponential curve.................. DEL (%) .. The anesthetic tension in the fresh gas flow is that delivered from the vaporizer..... 100 Use of the display and control bar is FGF (Ljmin) ...............and watch the changes in the Gas Man Picture and Graph............. or click on the numerical value VIEW (min) ... The parameters Circuit ..... o SETUP Parameter For each exercise in this book.................. ... Nitrous Oxide program as shown in the summary box.. Semi-Closed are explained on the following page................. lOx Special ........... VA (Ljmin) ...... In this first exercise you will simulate the step response of a single compartment .......the breathing circuit .. 3-3 . seen to the left here........ The inf10vv carrier gas is the fresh gas flow (FGF) ........ The circuit volume is 8 liters and the gas/gas partition coefTicient is 1......... 10 displayed and enter a new value through the Dialog Box............ SPEED ........... 0 arrow....... The circuit capacity is therefore 8 liters...... adjustable with the FGF display and control bar (FGF control) at the left edge of the bottom of the Gas Man Picture.. As a reminder.............. and is termed the delivered tension. to raise or lower the displayed value.... drag anywhere on the indicator bar....... 8 described in Chapter 2..... 0 either: click and hold the up or clown CO (Ljmin) ... you will Selection adjust the parameters of the Gas Man Agent ......

Gas Man® A Ollt ComjJar/lI1en { Model 1 Choose New from the File menu in the Menu Bar at the top of the screen. 6 Set alveolar ventilation (VA) to 0 (zero) L/min. Setting both VA and CO to zero will simulate a breathing circuit without a patient connected. You can do this from either the Picture or the Graph. 5 Adjust Fresh Gas Flow (FGF) to 8 L/min (bottom left corner). The settings that appear are the defaults set for the program. 9 Move the cursor to the Toolbar and click on the Graph icon. 7 Set cardiac output (CO) to 0 (zero) L/min. typing in the value is the safest way to enter parameters. select Begin. 3 Select Semi-Closed for the breathing circuit (upper -right cor- ner) . See Chapter 14 to find out how to change these de- faults. 4 Adjust the tension of nitrous oxide delivered (DEL) to 100% using the control bar. This will bring the Graph forward as the active window. 2 Select Nitrous Oxide as the anesthetic. 3-4 . 10 When you are ready to run the simulation exercise. At the bottom of the Gas Man Graph. 8 Set the Speed to 10X by using the popup menu in the bottom right corner. using the Agent popup menu in the upper left corner of the Gas Man Picture. For values not at the top or bottom of the adjustment range. select a View of 5 minutes in the popup menu.

3-5 . Press Pause after one minute. Because alveolar ventilation (VA) is zero.Gas Man® A One Comj.artment iVlodel o OBSERVATION Agent: 1Nitrous Oxide I±j ~Weight [Kg) Circuit: 1Semi-Closed!±! DEL %atm 1 100 1 CKT~ ALV~ ~ ~ ~ ~ ~ ART VRG MUS FAT VEN 1 0:00:00 I Time [h:mm:ssl ~UPtake[Ll ~ Deliyered (LI Speed: FGF f8I VA CO lim ~ lim 10 _00 1 lim 10 _00 1 110x I±j Agent: INitrous 0 xide I Circuit: 1Semi-Closed 1 FGF LIM 1: ~ I DEL 10: ~ %atm I en ALV VRG MUS %atm '] 0:00 I 0:01 I 0:02 I 0:03 0:04 I i 0:05 Figure 3-1 a shows the Picture and Graph displayed at the completion of parameter adjustment for Exercise 3-1. change the parameters now. only the breathing circuit (CKT) need be considered. start the simulation and watch the Time window in the Picture. VVhen you are ready. If you have not already done so while reading the text above. which will show a single compartment step response or wash-in.

To view the Graph. You can toggle back and forth between Picture and Graph in this manner.l CO Speed: 110x I:!:j I Conti.nue LlmU lim ~ lim 10 .Gas Man® A OTIC ComjJartJllent jHode1 INitrous Oxide L±j ~Weight (Kg) Flush ~ 0 :i'I f100l AlV~ ~ ~ ~ ~ ~ DEL <:atm ~ CKT@J ART VRG MUS FAT VEN I 0:01:00 I Time (h:mm:ss) ~ Uptake(l) ~ Defivered (ll FGF 101 VA InOi. to return to the Picture. click on the Picture icon. 00 1 Agent: !Nitrous Oxide I Circuit: ISemi~Closed I FGF LIM DEL %atm 10: ~ en 100 J/~ ALV VHG MUS 7:.0 minute of simulated time in Exercise 3-1.atm I I I 0:00 0:01 0:02 0:03 0:04 0:05 Figure 3-1b shows the Picture and Graph displayed after 1. click on its Toolbar icon to bring it forward on the screen. 3-6 . Note in the Picture and the Graph that circuit (CKT) has reached about 63% of the 100% delivered at the end of the one minute simulated so far.

Note that after five minutes.Gas Man® A One ComjJartll1ent Model Agent: 'Nitrous Oxide' ±j IECJWeighl (Kg) Circuit: 'Semi.Closedl±' I I Flush ±J 0 :id DEL f100l CKT~ ALV@] @] @] @] @] @] %alm ~ ART VRG MUS FAT VEN I 0:05:00 I Time (h:mm:ss) ~ Uptake(L) ~ Delivered (L) FUF fBI VA CO Speed: 1. along with muscle (MUS) and fat (FAT). 00 1 1 10x I±j Agent: 'Nitrous Oxide I Circuit: ISemi*Closed I 10 ~ FUF LIM o OEL %atm CKT ALV VRG MUS %atm Figure 3-1 c shows the Picture and Graph displayed at the end of the full five minutes of Exercise 3-1. inspired tension has reach> 99% of DELivered.1 lim L-J LIm 10. alveolar (ALV) and vessel rich (VRG) group tensions remain zero. 3-7 .001 LIm 110 . Since alveolar ventilation is zero.Continue .

is used.and hence the rate of rise . this difference . 2. which is the time required for the curve to reach 50% of its final value. 3-8 . It is convenient to measure the time delay associated with this curve using a defined time measure.718 . breathing circuit (CKT) and delivered (DEL) gas.decreases. As the breathing circuit "fills" with anesthetic. As these tensions become closer. a smaller deliv- ered quantity (8 L rather than 40 L) would have been required to change its composition.Gas Man® .l One ComjJartment i\1odel o DISCUSSION Observe the anesthetic tension height within the semi-closed breathing circuit. Had the circuit been emptied and refilled with fresh gas. Then the filling process progressively slows (Figure 3-1c). Sometimes a half-time. explained below. The curve shape you have just seen is an exponential curve and is described by the equation The "P" represents partial pressures in inspired (I). Remember that there is a constant carrier flow from the breath- ing circuit out the pop off valve. t1/2. the circuit tension changes more slowly.. The circuit fills rapidly during the first minute (Figure 3-1b). "t" is time and "'"[" (tau) is the time constant... exactly equal to the inflow of fresh gas. This is because there is initially a large gradient between the 100% anesthetic tension in the delivered gas (PDELJ and the 0% anesthetic tension in the breathing circuit (PI or Pcrcr). "e" is the base of natural logarithms. . It is interesting to realize that the anesthetic leaving the circuit is essentially wasted. The anesthetic tension in the outflow is equal to the anesthetic tension in the circuit.

or 63% of its final value. When t 1: in the equation above: PI =P OEL (:1. 3-9 .63.0. 00 1 1 1 10• !±! Agent: INitrous Oxide I Circuit: ISemi-Closed I FGF LIM 1:1 DEL %atm 10: 1 '" 1/~ CKT ALV VflG MUS %atm Or I I I I 0:00 0:01 0:02 0:03 0:04 0:05 Figure 3-1d shows that under the settings for this Exercise.4 seconds). t1/2 (half time) = 0.e. the time constant 1:. Thus 1: is the time required for the curve to reach 1 .) =P OEL X (:1. 1: = to.-e-1.()3 .1. .69 minute (41. Mathematicians prefer to use a different measure.-2.8-1.) =P OEL X (:1.7:1.Gas Man® A One ComjJartment Alodel ~Weight (Kg) Circuit: !Semi-Closed!:!:1 Flush o DEL 1100.37) =P OEL X 0.1 CKT~ ALV~ ~ ~ ~ ~ ~ %atm ART VRG MUS FAT VEN I 0:00:41 I Time (h:mm:ssJ ~UPtake(LJ ~ Delivered (L) Speed: FGF VA CO LIm EJ lim 10. 00 1 lim 0 .

P OEL. the rate coefficient. There is a specific relationship between the rate coefficient and the time constant: they are reciprocals.63 . is often computed. Because Gas Man separates the process into individual breaths.. the simulated values are slightly different. and 98% of that delivered from the vaporizer. 86%. respectively.86 . Thus we might say at the end of 1. P OEL .Gas Man® A One ComjJartment iVIodel In this experiment. or asymptote. Values for inspired tension expressed as a fraction of delivered tension are tabulated below: o 2 3 4 o . The units for 1: and K are sec and sec-I. K = 1/1:. but is approached closely. is never actually reached. the circuit tension equals 63%. and 4 time constants. 2.98 We often measure time in units of time constant.95 . is the delivered tension. The final value. In explaining first order kinetics. 3-10 . the final value. That is. K. 3. 95%. The time constant measures time while the rate coefficient measures rate or speed.

.... Agent ................ In Exercise 3-1.......... This exemplifies the extremely simple quantification of the relationship between volume....... Look back at Figures 3-lb and 3-1c........... To test this hypothesis...Gas Man® A One ComjJartment Model xercise 3-2 The time constant for wash in of a single compartment equals effective volume divided by effective inflow rate 1: =V IF. 0 co (Ljmin) ............................... lOx 3-11 ............ we'll change the fresh gas flow in the next exerCIse......... Nitrous Oxide adjust parameters as shown...... 100 FGF (Ljmin) . Circuit ........... Semi-Closed DEL (%) ........ and time constant: 1: = VjF.. 5 SPEED ..................... volume equaled 8 L and flow equaled 8 LI min............ 4 VA (Ljmin) ... 0 VIEW (min) .. flow. o SETUP To demonstrate the relationship be- Parameter Selection tween inflow rate and time constant................................................ Stated in words: The time constant for a compartment is equal to the ratio of the capacity of the compartment to the flow through that compartment... and note that circuit tension reaches 63% at a time of 1 minute....

}J ~ LIm 10. 'I =VjF =8 lj(4 ljmin) =2 min.Gas Man® it One Compartment JVIodel o OBSERVATION Agent: INitrous Oxide 1:!:j ~Weight (Kg) Circuit: 1Semi-ClosedL±j DEL 1100. 00 1 110K I±j Agent: INitrous Oxide I Circuit: ISemi-Closed I FGF LIM 1:1___________________________________________ ~ DEL %atm CKf "LV VHG MUS %atm Figure 3-2 shows the Picture and Graph of Exercise 3-2. 3-12 .1 CKT~ ALV~ ~ ~ ~ ~ ~ %atm ART VRG MUS FAT VEN 1 0:05:00 I Time (h:mm:ss) ~ Uptake(l) ~ Delivered (L) Speed: FGF r:. Watch the Gas Man Picture briefly and note that progress seems to be going about half as fast as before. This time..ru}] VA CO L1m~ LIm ro. Bring the Graph forward and visually determine the half-time and time constant.. Notice that the time constant is again equal to the ratio of volume to flow.

. The exact value for the constant relating. inspired tension has reached 63% of delivered.69.. 3-13 .6931. In Exercises 3-1 and 3-2. when time reaches two minutes.69 . This is twice the time required with FGF = 8 L/min in Exercise 3-1. or tIn/' = 0. the relationship between half-time and time constant was tl/2 = 0.Gas Man® it One ComjJartment Model o DISCUSSION In this exercise.). to tl/2 is the natural log of 2 (In 2 = loge 2 = 0.

..[oriel xercise 3-3 Time scale compression shows that all exponential curves have the same shape.. adjust the parameters as DEL (%) ................ Nitrous Oxide but you will set View to 10 minutes to compress the time scale.................................................... 4 VA (L/min) ...... FGF (L/min) .................... o SETUP Selection This next exercise repeats Exercise 3-2..................... 10 SPEED ............... 100 shown.. To compress Circuit ................. 3-14 ....... n.... 0 CO (L/min) ......... Semi-Closed the time scale....................a............Gas Man® A (Jill' COIII/)(lrtment l\.................. lOx Special ...................... Agent .. 0 VIEW (min) ....

is being drawn only half as fast.Gas Man® A One Compartment j\lIodel o OBSERVATION Agent: INitrous Oxide I Circuil: ISemi-Closed 1 10 FGF LIM o . . 3-15 . - DEL %atm en 100 ALV VRG MUS %atm 0:02 0:06 0:08 View: 110 Min !±! .+ .Ctlfltifl~!lJ Figure 3-3 shows the Gas Man Graphfor Exercise 3-3. . This curve. You should see a curve that has the same exponential shape as you saw in Exercise 3-2.g. however. .. .

3-16 . is the reciprocal of the time constant L: K = lh. and simultaneously forces out an equal quan- tity of mixed compartment gas.Gas Man® A One C01nj)(lrlmenl Nlodel ummary In this chapter. you have observed anesthetic tension when a constant flow of anesthetic-laden fresh gas enters a compartment. is represented by an exponential curve that has a time constant L = V IF. mixes completely. The rate coefficient. called the step response or wash in. You have seen that this response to a step change in input. K. and follows the equation Pr(t) = P DEL (l-e-th).

the alveolar vol- ume alone. moves toward equilibrium with the first is determined by two factors. You can determine the effect of 1:\vo sequential compartments with the Gas Man program. 4-1 . the lungs. the lungs' response to a step change in circuit (or inspired) tension is an exponential curve with a time con- stant (1) equal to the ratio of alveolar volume (FRC) to alveolar flow: 1: = FRCjVA. which here is the alveolar volume or functional residual capacity of the patient's lungs (FRC). Considered alone. here the alveolar ventilation (VA). One factor is the effective volume of the second compartment. you will observe wash-in of the breathing circuit alone. The second factor is the flow of gas be- tween the two compartments. you will observe the interaction of two sequential compartments: the breathing circuit and the patient's lungs. In the following exercises. You will also observe that increasing delivered and inspired tensions above that de- sired in the alveoli (overpressure) speeds achieving the desired alveolar tension. /-~ ( \ Chapter4 \ ) Two Sequ-E\rtti-af/ ( . Compartments U o In this chapter. and the two in combination. The rate at which the second compartment. You have already experimented with a single compartment (the breathing circuit) and its equilibration with gas inflow.

...... DEL (%) .............................)'cqllcntial C:om!)(/rlmenls xercise 4-1 The step response of a perfectly mixed breathing circuit is an exponential curve with height equal to the tension delivered from the vaporizer.... Semi-Closed = AFAP)............. and the time constant equal to circuit volume divided by fresh gas flow: 1: = VCKT/ FGF.....................Gas Man® Two .... 100 FGF (Ljmin) ... 4 VA (Ljmin) ................... AFAP Special ...................................................................... o SETUP Repeat Exercise 3-2 demonstrating wash- in of a single 8 L compartment with a fresh gas flow of 4 L/min.. 0 CO (Ljmin) ............ but let the simulation run as fast as possible (Speed Circuit ..a........................ 0 VIEW (min) ......... 4-2 .... The other parameters to be set are shown below... n... 10 SPEED .

Make a note of the half-time and time con- stant. showing wash-in of th e 8 L circuit volume with a fresh gas flow of 4 L/min. as we observed in Chapter 3. 4-3 . 'Watch the picture for a simulated minute and then observe the shape of the graph. with a time constant equal to the circuit volume di- vided by fresh gas flow. The circuit tension rises toward that delivered from the vaporizer.Gas Man® Tzuo Sequential Comj}(trtllleJlls Agent: INitrous Oxide I±! ~Weight (Kg] Circuit: ISemi-Closedl ±j Flush o CKT~ ALVQJ QJ QJ QJ QJ QJ ART VRG MUS FAT VEN I 0:10:00 I Time {h:mm:ss] ~ Uptake(L] ~ Delivered (l] FGFrAI VA 101 CO Speed: 160 x I±j lIm~ lImU lIm[] Agent: INitrous Oxide I Circuit: Is emi-Cfosed I FGF LIM 1: q DEL %atm 10: q CKl AlV VRG MUS %atm Figure 4-1 displays the Picture and Graph displayed at the end of Exercise 4-1.

.....a..... Open DEL (%) .......... The step response of the alveolar compartment (FRC) is an exponential curve with height equal to inspired tension............................... ~-~~--~--~--~~-~--~~-~----~ An open or non-rebreathing circuit demonstrates the alveolar step response........Gas Man® Two Sequential Comj){{rl men!:. 10 VA (Ljmin) .. and time constant equal to FRC divided by alveolar ventilation: 1: = FRC/VA... in which inspired anesthetic equals that delivered from the vaporizer.. n.. 4-4 .... Circuit ..... 0 VIEW (min) .. o SETUP Parameter Selection Set the parameters as shown... 10 SPEED ....5 CO (Ljmin) ......... AFAP Special . 2................... Note that fresh gas now (FGF) is automatically Agent ................................... Nitrous Oxide shown as 10 L/min when Open circuit is chosen...5 L alveolar compartment and 2............ Next.............. xercise 4-2 -----------.............................................. using an open or non-rebreathing circuit..... 100 FGF (Ljmin) .................5 L/min alveolar ventilation.... perform a similar experiment with a single 2.............

Yl DEL 1100.::. Again.:pec.1 CKT~ AlVl 100 1 ~ OJ OJ OJ OJ %atm ART VRG MUS FAT VEN I 0:10:00 I Time (h:mm:ssl ~Up!ake(L) 1100.5 L/min. which looks identical to the inspired tension curve (CKT) achieved with a semi-closed circuit in Exercise 4-1.. and make sure that they are the same as the ones you recorded for the circuit compartment in Exercise 4-1. Flush ~ 0 . Note that the graph displays an alveolar tension curve (ALV) .:. note the half-time and time constant.Gas Man® Two Sequential Compartments o OBSERVATION Agent: INitrous Oxide I~J ~Weight (Kg) n _---'I=~l Circuit: c::. showing wash-in of the patient's 2.C___----' 1: ~~------------------------- VA LIM CO LIM 1: ~ MUS %atm Figure 4-2 displays the Picture and Graph at the end of Exercise 4-2...IO.5 L alveolar volume (FRC) with a flow (alveolar ventilation) of 2..00 I Delivered (Ll Speed: FGF r:1fll VA CO l/m~ LIm ~ lim [J IAFA? I±j Agent: INitrous Oxide I Circuit: L::. 4-5 .

volume equals functional residual capacity (FRC) and flow equals alveolar ventilation (VA). the time constant equals volume divided by flow. 4-6 .Gas Man® Two Sequential COll1jJartments o DISCUSSION For the alveolar compartment. 1: = VjF. just as for the breathing circuit. This time.

...yo compartments in series can now be stud- ied.................... (The words series.... 10 .... 100 ... .............. and cascade will be used inter- changeably... 4 .......... o SETUP Selection Set the program parameters as shown ..........5 ................ 4-7 ... MTT (mean transit time) = '1:1 + '1:2- The interaction of 1:\............................. n. Semi-Closed .................................. 0 (min) ......... AFAP ........Gas Man® Two Sequential COll1jJarlmeJ?ts xercise 4-3 Wash-in of two compartments in series is slowed by each in an additive fashion........................ you will observe the behavior of the breathing circuit and alveolar volume in series... Nitrous Oxide ........................) In this exercise.a. 2....................... sequence.....

observe the Gas Man Graph and watch it evolve.Closedl !:j Flush o DEL 1100. it appears that the delay from the time inspired tension (I) reaches a level. At the end of tvvo minutes of simulation.Gas Man® T'zuo Sequential Comj)({rimellls o OBSERVATION Agent: INitrous Oxide I!:j ~Weight (Kg) Circuit: ISemi. a little longer than 2 minutes. \l\Tash- 4-8 . displaying a completed 10-minute simulation of anesthetic tension equilibration in two sequential compartments. is approximately one minute. Looking at points of equal anesthetic tension (equal height) on the graph. to the time alveolar tension (A) reaches the same level.1 CKT~ AlV~ ~ IT] IT] IT] IT] %atm ART VRG MUS FAT VEN I 0:10:00 I Time (h:mm:ss) ~ Uptake(L) ~ Delivered IL) Speed: FGF iii VA CO LIm ~ LIm [IT] LIm ~ IAFAP I!:j Agent: INitrous Oxide I Circuit: ISemi-Closed I FGF LIM 1 1: DEL %atffi 10: 1 I ALV VRG MUS %atm --------. ---- Figure 4-3 shows the Picture and Graph of the results of Exercise 4-3. Inspired anesthetic tension (I) ap- pears to be an exponential curve with'].

The mean transit time is equal to the sum of the two time constants: MTT total = 't1 + 't2. It is the time. 4-9 . the mean transit time is equal to the time constant (MTT = T). the average delay between the second and first curves is exactly one minute. is approximately one minute. When compartments are in sequence as these are. on the average. For each of our simple. o DISCUSSION Theoretically. for a substance to move from one location (breathing circuit) to another (alveolar com- partment). the total mean transit time through the system is equal to the sum of the mean transit times through the individual compartments: MTT = MTTCKT + MTTALV·= 'tCKT + 'tALV. in an additive manner.Gas Man® Two Se(jllcllti([/ COlI/jJartme11ts (A) reaches the same level. The definition of average delay between two curves is a measure called the mean transit time (MTT). fully mixed compartments. \I\Tash- in of Lhe two compartments in series has been slowed by wash-in of each.

... set the Gas Man parameters as Circuit ...... o SETUP To understand overpressure and the Parameter Selection vaporizer adjustments needed to control Agent . lOx away........ Nitrous Oxide anesthetic tension in the alveolar com- partment............ By acljusting anesthetic delivered to the FGF (L/min) .............. Use of el- evated partial pressure to achieve a rapid change to a lower level is termed overpressure........................................ The next exercise will explore ways to produce a step rise in alveolar anesthetic tension by briefly increasing delivered and inspired tension above that desired in the alveoli..... You will see that it is difficult to control a variable (alveolar tension) VIEW (min) .... 2........................... 4-10 ........ prepare to adjust! to achieve 70% alveolar tension............................ 0 70%............ try to achieve 70% alveolar tension smoothlv and / VA (L/min) .......... Special ............... The o~jective in this exercise is DEL (%) ... n...Gas Man® Two Seq1lClltial Co 1I1jmrlmcn Is xercise 4-4 Overpressure can speed the rise in anesthetic tension two com- partments away....... 10 when you can only control an input (delivered tension) two compartments SPEED ....... Semi-Closed shown.............. 4 breathing circuit (DEL).5 quickly... without allowing it to rise above CO (L/min) ....a.

5 °1 LIm [J 110K I:!:j Agent: 1Nitrous Oxide I Circuit: ISemi~Closed I FGF LIM l: q~------------------------------------------- DEL %atm CKT ALV VHG MUS %atm Figure 44 displays the Picture and Graph as a result of Exercise 44. showing how overpressure can speed the rise in anesthetic tension two compartments away from the location controlled. 4-11 . Alveolar tension fluctuates as you try to keep it at 70% byadjust- ing delivered tension (DEL).Gas Man® Two Sequential Com. Your results may differ depending on how you adjusted DEL during the course of this experiment.Closedl :!:I Flush ~ 0 yj DEL %atm CKT~ ALV~ ~ QJ QJ QJQJ ART VRG MUS FAT 'lEN 1 0:10:00 1 Time {h:mm:ss] ~ Uptake(L] ~ Delivered (LJ Speed: FGF fA! VA CO Llm~ LIm 12 .j)artmenls o OBSERVATION Agent: INitrous Oxide I!oj §C]Weight (Kg) Circuil: ISemi.

MTT = 'to The effects of the two compartments are additive in delaying the response to a step input. For each simple. delivered tension can be adjusted to optimize the response in the alveolar compartment.Gas Man® Two Sequential Compartments In this chapter. 4-12 . This is done by the use of overpressure. MTT. The measure of the delay of each compartment is the mean transit time. fully-mixed compartment. With some difficulty. the mean transit time is the sum of the individual mean transit times. the response of two sequential compartments to a step input to the first compartment has been investigated.

patient wash- in. To demonstrate and dissect the alveolar tension curve into its component parts. blood/gas solubility. it is the key to understanding inhalation anesthesia uptake and distribution and the process of anesthetic tension equilibration from the vaporizer to the patient's brain and anesthesia depth. effects of alveolar ventilation. cardiac output. 5-1 . Analogous to the one compartment example. The alveolar tension curve shape has several important compo- nents. But it is far from a simple exponential. use the Gas Man Program to simulate anes- thetic administration at constant inspired concentration (ten- sion) through an open circuit. The resulting curve is termed the alveolar tension curve. The terms open and non-rebreathing are used interchangeably. In this chapter. The alveolar tension curve is extremely important. and venous return of anesthetic will be demonstrated and explained. this could be termed the wash-in of the patient including lungs and tissues. or simply. tissue uptake. each of which must be understood.In this chapter you will study the response of the alveolar com- partnlent to a step change in inspired anesthetic tension. Open circuit is the term used to signify that the clinician has perfect control over inspired tension without the patient rebreathing exhaled gases and diluting inspired tension.

.......................................................................... n...............a.... o SETUP To observe the response of the alveolar Parameter Selection compartment to a step change in in- Agent .............. 5-2 . 5 VIEW (min) .................... 5 FGF (L/min) ...... adjust the parameters as shown.............................. 60x Special ....... 15 SPEED ...............Gas Man® The Itl1lm/of Tension Curof' xercise 5-1 The open circuit alveolar tension curve is the alveolar response to a step change in inspired tension....................... 10 VA (L/min) ........ Open DEL (%) ... Isoflurane spired tension.... Circuit ........ representing patient wash-in....... 4 CO (L/min) ............................

observe the Gas Man Graph.021 12.t.-e_n_--. 5-3 .-pe_n_-"i.001 ALV13. 62 1 13. VVhile watching the Gas Man Picture... note the initial rapid rise in ALV (alveolar anesthetic tension). 00 1 CKT15. After about 2 minutes of simu- lated time.341 10. displaying anesthetic tension in response to 5% delivered and inspired isojlurane.atm Figure 5-1 shows the Picture and Graph of the results of Exercise 5-1 after 15 minutes.l LIm ~ LIm ~ LIm ~ iAFAP I±j Agent: II soffurane Circuit: I. Note also the more sluggish rise in VRG (vessel-rich group) and barely discernable rise in MUS (muscle) and FAT (fat).621 13.731 %atm ART VRG MUS FAT VEN I 0:15:00 I Time (h:rnm:ssJ ~UPtake(lJ ~ Delivered (lJ Speed: FGF f10iil VA ~ co r. VA LIM 1: ~ CO LIM 1: ~ en ALV VBG MUS 7.Gas Man® The Alveolar Tension Curve o OBSERVATION Agent: II sollurane I~ j §]Weight (Kg) Circuit: I.-O.=l±j Flush :tJ 0 :tJ DEL 15 ..511 10.-Op. Observe especially the Gas Man Graph and focus on the alveolar curve.

11)(1(. The initial rise occurs rapidly. approaching (asymptotically) inspired tension. They will be explained in the remainder of this chapter. A knee terminates this rise in a plateau that instantly merges into an ascending tail. which continues indefinitely. o DISCUSSION Descriptive names are used to designate segments of the alveolar tension curve. 5-4 . The causes of the initial rise.Gas Man® The Alv('olar Tl'lIsioll (. and tail of the alveolar tension curve are important in understanding up- take and distribution of anesthetics and equilibration and equal- ization of anesthetic tension from location to location. knee.

. putting CO Parameter Selection at zero............... we do this by eliminating cardiac output (CO=O) in the Gas Man model.......... 0 VIEW (min) ...... and alveolar volume (FRC).. Agent ........... Open DEL (%) ...... To observe the initial rise in its purest form.. 10 VA (L/min) ....... Set a bookmark for 3 minutes........ 7....................................... the effect of body uptake will be eliminated................ Isoflurane Circuit . alveolar ventilation.......... The shape of the initial rise is determined by the interac- tion of inspired tension..... 5-5 ............. 5 FGF (L/min) ..Gas Man® The Alveolar Tension CU'rUI? xercise 5-2 The initial rise in the alveolar tension curve results from alveolar wash-in responsive to a step change in inspired tension.. o SETUP Set the parameters as shown.. The initial rise of the alveolar tension curve is caused by wash-in of the alveolar space with inspired gas................... carried by alveolar ventila- tion..... Set Bookmark @ 3 min.......................... 15 SPEED .......... AFAP Special ................5 CO (L/min) .........

50 1 LIm 10 .. 5-6 .001 ART VRG MUS FAT VEN I 0:15:00 I Time {h:mm:ssJ ~UPtake{LI ~ Delivered (L) Speed: FGF f10l VA CO Llm~ LIm 17.Gas Man® The Alveolar Tension Curve Agent II.001 15.001 10. T.33 minute. appears to be about 0.001 ALV15. and can be calculated to be: T = VjF = FRC j VA = [2.-pe_n_-11="'1 Flush ~ 0 :tl DEL "" %atm ~ CKT15.J VA LIM 1: ~ CO LIM 1: ~ CKT ALV VRG MUS %atm Figure 5-2 shows the Picture and Graph of the results of Exercise 5-2..001 10.5 ljmin] = 0.001 10. Note the rapid rise in alveolar tension as it approaches and equals inspired tension..3 minutes. The time constant. displaying alveolar anesthetic tension in response to 5 % inspired isoflurane with cardiac output (CO) = 0 and alveolar ventilation (VA) = 7. 00 1 IAFAP 1"'1 Agent: Iisoflurane Circuit <-IO.anurane 1"'1 ~\>Ieight (Kg) Circuit IL0.5 l] j [7...001 10.5 L/min.-pe_n_.

........................................... 15 SPEED ........................... 5 VIEW (min) ....... o SETUP Set the parameters shown.........................25........................ 1.... Open DEL (%) . Isoflurane Circuit .25 CO (L/min) .....................Gas Man® nw Alveolar Tensioll Curve xercise 5-3 The initial rise in alveolar tension is slower with lower alveolar ventilation but alveolar tension asymptotically approaches in- spired......... n............ 60x Special ................... 5-7 ... 5 FGF (L/min) ............. lowering Parameter Selection alveolar ventilation to 1...a................ Agent ............................. 10 VA (L/min) ...........

25 L/min.ool AlV15. 00 1 IAFAP L~l Agent: !Isoflutane Circuit: IOpen '--'----' VA LIM 1: ~ CO LIM 1: ~ en ALV VRG MUS %atm 0:05 Figure 5-3 displays the Picture and Graph of the results of Exercise 5-3. Observe how much slower alveolar tension rises.25 L/min) with CO= o.:tl CO ] ~ Uptake{ll ~ Delivered (l) Speed: lim 10.1 ~Weight (Kg) Circuit: I.001 15.25 L/min] =2 minutes.001 ART VRG MUS FAT VEN ~J ~~ ~ I 0:15:00 I Time (h:mm:ssl ±l .--O.001 10. 5-8 . showing the iffect of low alveolar ventilation (VA = 1.-pe_n_-.I-.0 LIm 11 .Gas Man® 17ze AlveolaT Tension Curve Agent: !Isoflurane I~. The only change you have made is to change alveolar ventilation (VA) from 7.~I Flush ±l [] .001 10.:tl DEL %atm 15. The time constant is observed to be 2 minutes and is calculated to be: 'r =V/F =FRC / VA =[2.. 25 1 lim 10 .:tl FGF ~ . 00 1 CKTls.001 10.:tl VA ±l .5 L/min to 1.001 10.-.5 L] / [1.

as cardiac output removes anesthetic from the alveolar volume. and alveolar tension is held at a lower value. 5-9 . alveolar tension reached a final value equal to inspired tension. Instead. This complete equalization between inspired and alveolar gas is not possible when there is uptake by blood. less anesthetic remains.Gas Man® The Alveolar '['ension Curve o DISCUSSION In this and the previous exercise. This will be shown in the next exerCise.

..... the simulation will show the effect of cardiac output removing anesthetic from the alveoli........ press ... Isoflurane output and adjust the other parameters as shown............................... This knee would continue as a flat plateau if anesthetic-contain- ing venous blood did not later return to the lungs................. This is indicated by the empty venous anesthetic tension bar (YEN) on the right edge of the top half of the screen. 5 interrupt the simulation................ That is. anesthetic is "removed" from venous blood before it returns to the heart and lungs.......... the previous complete wash-in of the alveolar space is interrupted by uptake into blood.......... vVhen alveolar tension is viewed graphically.... Open the Pause button on the Picture or Graph to (%) ........ lOx .... In essence. In the Menu Bar at the top of the Gas Man screen is a drop-down menu labeled Special............... If you choose Disable Return from this menu.. but without the effect of venous blood returning some of it later. o SETUP Selection To observe the knee and plateau of the alveolar tension curve........ 10 (min) .Gas Man® The Alveolar Tension Curer! xercise 5-4 Uptake of anesthetic by cardiac output produces a knee and plateau in the alveolar tension curve...................... add cardiac ..... 15 .. (L/min) .......... Disable Return 5-10 ..... After 3 simulated minutes..... Gas Man has a special feature to demonstrate this......... a knee interrupts the rise in alveolar tension when (nonzero) cardiac output re- moves anesthetic from the alveoli.

and in the Picture.1 % isoflurane.Gas Man® The Alveolar T'emion Curve o OBSERVATION Agent: Iisoflurane Circuit: I'- O -'-pe_n_---' VA LIM ] 10 ~ CO LIM o ALV - vnG - MUS -~ %atm View: 115Minl±j Ij. In the upper panels of the Graph. Tissue anes- thetic tensions rise but have no effect on alveolar tension because anesthetic has been removed from venous blood before it returns to the lungs using the Special/Disable Return feature. a small cardiac output is carry- ing blood and anesthetic away to the body tissues. Note the knee continuing to a plateau in the alveolar tension curve at approximately 2. you see that a small alveolar venti- lation is bringing 5% iso-flurane from the breathing circuit to the patient's lungs.l i Figure 54 shows the Graph of Exercise 54 at the end of 3 minutes of simulation. Simultaneously. 5-11 .

... AB/G........................ Isoflurane venous blood since venous return is Circuit ................................................... die!? Pause and obseroe CO (Ljmin) .. We will show that plateau height is elevated by alveolar ventilation and de- pressed by effective cardiac output............. No anesthetic is returning to the lungs in Agent ...................... Effective cardiac output is equal to actual cardiac output multiplied by the blood/gas solu- bility.........5 parameters as shown... JiJ'hen the clock reads 6 minutes.. Open disabled.............................. 1...... Disable Return 5-12 ..25 the Graph again... 15 SPEED ... 10 the simulation-in-progress by setting the VA (Ljmin) ... vVhile anesthesia administration is still interrupted............. 5 out starting a new simulation...................... VIEW (min) ............... o SETUP You should already have completed 3 Parameter Selection minutes of anesthesia administration and (Time elapsed = 3 minutes) the simulation should be paused........ 7............Gas Man® The Alveolar Tension Cume xercise 5-5 Increasing alveolar ventilation raises the knee and plateau of the alveolar tension curve.. the param- eters can be adjusted to explore the effects of alveolar ventilation and cardiac output on the knee or plateau height... increase alveolar ventilation and then continue FGF (L/min) .. To observe the effect of alveo- lar ventilation on alveolar tension with- DEL (%) .. lOx Special ...

5-13 .5 L/min vs 1. faster) time constant as well as a higher plateau. Note that alveolar tension has reached a new.25 L/min) has resulted in a smaller (shorter.Gas Man® The Alv('olar Tension Curve o OBSERVATION Agent: Iisoflurane Circuit: '-'-_ _-' 10 ~ I VA LIM 0 CO LIM '] 5 en ALV VRG MUS %atm 0 0:00 View: 115 Min I!I Figure 5-5 shows the Graph of Exercise 5-5 at the end of 6 minutes of simulation.1 % because of increased alveolar ventilation. The higher alveolar ventilation (7. higher plateau of approximately 4. Note also that the time course of this new change is much more rapid than for the first change.

Isoflurane tension....5 CO (L/min) .........5 VIEW (min) ............... FGF (L/min) .................. Obseroe the Graph and DEL (%) ............ Disable Return 5-14 .. o SETUP You should have completed 6 minutes of Parameter Selection anesthesia administration and the simu- (Time elapsed = 6 minutes) lation should be interrupted........... 15 SPEED ............................. To observe the effect of cardiac output on alveolar Agent ............................ continue where Exercise 5-5 left off by increasing cardiac input to 7...... 10 VA (L/min) ... 7....... 7..Gas Man® The AJv(!olar Tension CI/..................................5 L/ Circuit ....................... 5 click Pause at 9 minutes. Open min................. as shown...................... lOx Special .rue xercise 5-6 Increasing cardiac output lowers the knee and plateau of the alveolar tension curve..........

Note that alveolar tension has again fallen to approximately 2.5 L/min each. 5-15 .-----------------~----------------------_.25 L/min each.1 %. Tel/sion Curve o OBSERVATION Agent: II soflurane Circuit: '----'-_ _-' VA LIM I CO LIM ] I en 5-. now)...Gas Man® The Alveolo. compared with 7. This is the same level that was reached when cardiac output and alveolar ventilation were both equal but lower (1. ALV VRG MUS %atm 0:00 0:05 0:10 0:15 View: 115Minl~1 I~ll I~I Figure 5-6 shows the Graph of Exercise 5-6 at the end of 9 minutes of simulation.

......llveol([}" Tension Curve xercise 5-7 The ratio of alveolar ventilation to effective cardiac output determines the height of the knee and plateau of the alveolar tension curve............... 5 CO (L/min) .... 10 VA (L/min) .................. return to Gas Man for yet another simulation..... To verify this........................................... 5 VIEW (min) .............. Reconfirm that the plateau height is unchanged when the ratio of alveolar ventilation to effective cardiac output is constant by selecting new values for VA and CO that are again equal to each other.......... Disable Return 5-16 ............... but different from the previ- ous exerClse............... Agent .............. Isoflurane Circuit ... o SETUP Adjust VA and CO each to 5 L/ min and Parameter Selection continue the simulation at 9 (Time elapsed = 9 minutes) minutes. You have seen that the knee or plateau height of the alveolar tension curve appears to be determined by the ratio of alveolar ventilation to cardiac output.......................................... as shown....... 5 FGF (L/min) ..... Open DEL (%) . lOx Special .........Gas Man® The ....... 15 SPEED ...................

cardiac output (CO) is likewise increased from 1. alveolar ventilation (VA) is increased from 1.pe::. Mter 3 minutes of 5% delivered isoflurane.25 to 7..-pe_n _-"-".:n_---' VA LIM 1: ~ I \ CO LIM 1: ~ I \~------------~ CKf AlV VRG MUS %:atm Figure 5-7a displays the Picture and Graph at the conclusion of Exer- cise 5-7.001 AlV12. 00 1 IAFAP If I Agent: Ifsoflurane Circuit: <-::1D.. restoring the ratio VA/CO to its previous value of 1:1. 24 1 12 .:!oj DEL CKT15.:.5 L/min. 21 1 10.25 to 7. At 6 min- utes. Note that the alveolar tension plateau height is unchanged despite changes you have made in alveolar ventilation and car- diac output. 23 1 10 .Gas Man® The Alveolar Tension Curve o OBSERVATION Agent: Iisoflurane ':!oJ ~Weight (Kg) Circuit: 'L0..::.. 1 lim 15 . 00 1 %atm ART VRG MUS FAT VEN I 0:15:00 I Time (h:mm:ss) ~ Uptake(l) ~ Delivered (ll Speed: FGF VA CO lim ~ 5 15 lim 1 .5 L/min. showing the r1Ject of alveolar ventilation and cardiac output on knee height of the alveolar tension curve. 5-17 .24 1 12 .011 10 .

and the alveolar tension plateau is again unchanged.Gas Man® The Alveolar Tension Curve and the ah'eolar tension plateau to its previous height. Alveolar ventilation has been stepped 1 L/min at a time from 0 to 10 L/min with a constant cardiac output of 5 L/min. At 9 minutes. Figure 5-7b demonstrates the relationship between knee height and alveolar ventilation.+1. Agent: Iisoflurane Circuit: IOpen '--'----' VA LIM CO LIM ': ~~------------------------------------------~ ALV VriG MUS %atm 0:05 0:10 0:15 View: 115 Min I±I 1. alveolar ventilation (VA) and cardiac output (CO) are each ac:ljusted to 5 L/min. 5-18 .

o DISCUSSION You have seen that the knee and plateau height of the alveolar tension curve is determined by the ratio of alveolar ventilation Lo effective cardiac output.Gas Man® The Alveolar Tension Cnrlle Agent: Iisoflurane Circuit: .--pe_n_---. You may also want to use Gas Man's Overlay feature for comparisons (see Chapter 15). LIM ': g~------------------------------------------4 ':~~ CO LIM ALV VRG MUS %atm 0:05 0:10 0:15 View: \15 Min \±j I!:j Figure 5-7c shows the rise in knee height as cardiac output is decreased in a stepwise manner from 10 to 0 L/min with an alveolar ventilation 0/5 L/min. 5-19 . AB/C. Remember that effective cardiac output is equal to the product of cardiac output and blood/gas solubil- ity. Anesthetics with different solubilities will have differ- ent plateau heights for the same alveolar ventilation and cardiac output. You may want to reproduce these figures yourself but diligence is required to produce perfect Graphs. This will be explored in Chapter 6.-IO-.

......... o SETUP Parameter Selection To understand the tail of the alveolar Agent ........ CO (L/min) .... 5 minutes. 5 exercises you selected Special/Disable Return. To demonstrate this.. and this is still preventing anes- FGF (L/min) .......... This will augment the total quantity of anesthetic delivered to the lungs and hence increase alveolar tension. proceed as Circuit ..... in this next exercise you will suddenly allow the anesthetic in venous blood to reach the lungs normally. Venous delivery increases as tissue anesthetic tensions increase....................................... Isoflurane tension curve created by anesthetic returning from the lungs................... Set a bookmark at 2 VA (L/min) ..... 5 VIEW (min) . 10 thetic from returning to the lungs in venous blood.................. 15 SPEED ................... This converts the previously-seen plateau in alveolar tension into an ascending tail........ total anesthetic delivery to the alveoli increases...........Gas Man® The Alveolar Tension ell me xercise 5-8 Anesthetic returned to the lungs in venous blood converts the alveolar tension curve plateau into a gently-rising tail...... Open shown.............................. lOx Special ..... When anesthetic-laden venous blood is allowed to return to the lungs................ Remember that in the previous DEL (%) .... Disable Return 5-20 ..................................

00 1 lo..-IO-. As you continue the Exercise. 00 1 IAFAP L±j Agent: Iisoffurane Circuit: 'L0. 15 ! LIm 15. watch the empty venous anesthetic tension display bar on the right edge of the Picture.pe_n_--. 5-21 .:.241 12 .--pe_n_--. Next.oo! AlV12.. VA LIM 1: ~ CO LIM 1: ~ en 5 ALV VRG MUS %atm 0 0:00 0:05 0:10 0:15 Figure 5-8a displays the Picture and Graph of the alveolar tension curve with anesthetic in venous blood removed before it retunzs to the lungs. 24 ! 11.Gas Man® The Alveolar 'Tension Curve o OBSERVATION Agent: Iisoflur ane 1±j ~Weight (Kg) Circuit: .oo! ART VRG MUS FAT VEN I 0:02:00 I Time (h:mm:ssl ~UPtaKe(ll ~ Delivered (ll Speed: FGF VA CO LIm §J LIm 15. Observe the flat plateau on the Graph and view the Picture again. 13 ! 10. then click Continue.03! 10. Use the Special menu in the Menu Bar and deselect Disable Return.-!±""J Flush ~ 0 ±l DEL %atm CKTls. you will allow anesthetic to return to the lungs in venous blood.

pe::.-----. 5-22 .. This is caused by the return of anesthetic to the lungs in the venous blood.J VA LIM 1: ~~---~______--__--__--------------------~ 10 CO LIM o ~1----------I en ALV VRG MUS %atm Figure 5-8b displays the Picture and Graph after the transition from venous return disabled to normal venous retunl. 1 Agent: IlsoflUJane Circuit: LI0-.n.02 1 12 ...91 1 ART VRG MUS FAT VEN ~ ~ ~ j 1 0:15:00 I Time (h:mm:ssl +l ~J +i. :!l ~ Uptake(LI ::tJ ::tJ ±l ~ Delivered (Ll FGF [!IJ VA 5 06 CO 5 00 Speed: IAFAP If I I :~oniin~e lim lim 1 .-pec. Observe that the previous knee and flat plateau has been transformed to a knee leading to an ascending tail.. Notice that anesthetic tension in the alveolar compartment suddenly begins to rise. 74 1 [iill] 10 .Gas Man® The Alveolar Tl'IIsioli CurvE' Agent: II soriurane Ifl ~Weight (Kgl Circuit: t....:n_--LI:::. 1 lim 1 .... 84 1 13 . 84 1 13.:10c:.JfJ Flush 1:1 0 ::tJ DEL %atm [J CKT@J@ ALV13.

5-23 .Gas Man® The Alveolar Tension Cume Circuit: 10pen '--'----' 10 ~ VA LIM 0 CO LIM '] en ALV VRG MUS %atm View: 115 Min I±] Figure 5-8c shows superimposed graphs with and without anesthetic in venous return. Note that in Figure 5-8c the flat plateau caused by the absence of venous return has been transformed to an up-going tail as anes- thetic returning from tissues re-enters the lungs as a second source of anesthetic.

which together comprise effective cardiac output. The knee height is determined by the ratio of alveolar ventilation to the product of cardiac output and blood/gas solubility. In this chapter. the open (or non-rebreathing) circuit alveolar tension curve has been dissected into its component parts. The equations that ex- presses this are: PT (t) == P a X (1-e -t/'T) . the anesthetic tension is determined by the history of arterial blood anesthetic tension and by tissue blood flow and tissue capacity. initial rise. tissue time constant is the ratio of effective tissue volume to the effective flow to the tissue. The actual venous anesthetic tension is the average of the tissue anesthetic tensions. This will be explored in Chapter 6. The !llveolar Tension CUJ(H' o DISCUSSION The slowly ascending tail of the open-circuit alveolar tension curve has been produced by the addition of anesthetic returning in venous blood. If arterial anesthetic tension were constant. The time constant of the initial rise is the ratio of alveolar ventilation (VA) to alveolar volume (FRC). knee. The multi-exponential tail of the curve is pro- duced by anesthetic returning in venous blood augmenting alveolar tension. tissue anesthetic tension would be an exponential with the time constant appro- priate for the tissue and blood flow. The maximum possible height is the inspired anesthetic tension. where 1: == (VT X AT/B) / FT- That is. and tail. For each tissue. 5-24 . its shape is determined by the rate of tissue equilibration. weighted by their re- spective blood flows.

enf1urane. The effect of blood/ gas solubility on the time course of anesthesia can be observed using the Gas Man program. making expired more closely approach inspired.Plateau l) ~. the newer agents sevoflurane and desflurane. ) & Blood/Gas Solubility o Each anesthetic has a different value for the blood/gas partition coefficient. The blood/gas solubili- ties and other values for these exercises are shown in Table 6-1. Cha fer 6 . 6-1 . Nitrogen is also simulated. and low blood/gas solubility raises the knee. and the older insoluble nitrous oxide. We will see that high blood/ gas solubility lowers the knee of the alveolar tension curve. isoflurane. referred to as blood/gas solubility (AB/C). The drugs we will study are halothane.

.93 PLATEAU AND OVERPRESSURE RATIOS 6 Alveolar / Inspired Plateau Ratio 0.0 5.3% 3.24 0.8% 2.76 11.90 1.30 1..8% 9. Table 6-1.0 5. ~--~"~- :1 PATIENT PARAMETERS VA= 4.38 4.7% 0.9% 5. plateau height.0 5.22 2.63 0. Parameters and computations for each agent including blood/ gas solubility ratio.10 1.42 0..00 2 DRUG Iso Enf Hal Sevo Des N2 0 NZ 3 BLOOD/GAS SOLUBILITY 1.-.' Blood/Gas S'olilbility BLOOD/GAS SOLUBILITY & ITS EFFECT ON PLATEAU HEIGHT.66 0.0 18.0% 110%b 7 Atm C 9 Inspired Overpressure for 1 J'v1AC 2. lVIAC value.90 2.55 0.0% 175% a Anesthetic has been removed from venous return to maintain the plateau height.65 0.0 100 4Atm 5 Alveolar plateau height (%) 1. overpressure ratio.8 63 3.Gas Man® Pla/call Height (.59 1.63 3.02 OVERPRESSURE FOR 1 MAC 8 MAC (% arm) 1.00 CO= 5.1% 6.38 0.. and overpressure tension to achieve I lVIAC in the alveoli.98 7 Inspired / Alveolar (OverP Ratio) 2. 6-2 .50 1.8] 1.47 ..014 PL\TEAU HEIGl-IT FOR MAX DEL 4 Inspired setting (%) 5.47 0.1% 1.7% 3.48 1.30 0. A/I RATIO & OVERPRESSURE a .

but we use the maximum VIEW (min) .. 4 tensions in body compartments will CO (L/min) ..as "..... 6-3 ......c. top of the scale isoflurane.......... 5 shows higher values than those used clinically.. 10 tension from the vaporizer (DEL) to the top of its control bar scale...... .................h! & Bfood/(. Anesthetic VA (L/min) .......Gas Man® Pla!mu Heip.the concentration if....... A similar comparison could be made by disabling venous return for all the agents (Disable Return).. adjust parameters as shown..................b. Agent . This will avoid confusion by eliminating the effect of uptake on ventilation ...e................ set delivered FGF (L/min) ..... enflurane....... Each time.... etc.. 15 setting of DEL for graphic demonstra- tion of this effect. sevoflurane.... explained in Chapter 8.. o SETUP To observe the effect of agent choice on the shape of the alveolar tension curve.....f.................. repeat the experiment for ni- trous oxide. Tail shape varies with tissue/gas solubilities....{ect. and clesflurane.. After simu- lating a halothane anesthetic with con- Circuit ..... Knee height of the curve varies with blood/gas solubility....... Finally.oll/bili!)' xercise 6-1 ---------.... SPEED ........... Open stant inspired tension.......... The graphs resulting from these simulations are shown in Figures 6-1 a....................d......... AFAP Special .... but use the Special menu to Disable Uptake this time...... Halothane....... do the same for DEL (%) ..... ----------------- The alveolar tension curves for different anesthetic agents have generally the same shape..

--O-.Gas Man® Plateau Height & Blood/Gas Solubility o OBSERVATION Agent: I Halothane I ±j ~Weight [Kg) Circuit: I. 22 1 10 .' VA LIM 1: f CO LIM 1: ~ en AlV VRG MUS %atm 0:15 Figure 6-1 a shows the Picture and Graph after administering halothane at constant inspired tension of 5 %for 15 minutes.~ntinue FGFI1iiI lim ~ VA LIm 14. 59 1 10.001 I I AlV 2. 01 1 12 . 01 1 ART VRG MUS FAT VEN I 0:15:00 I Time (h:mm:ss) ~UPtakell) ~ Delivered ILJ Speed: I _c.76 12.I=J~.09 1 CO lim ro IAFAP I:!:j Agent: IHalothane Circuit: 10pen _ .j Flush ~ 0 ~ DEL 15 .761 12.--pe_n_--<. 00 1 %atm CKT15. 6-4 .

.id ~ Delivered (L) Speed.:J ~Weight (Kg) Flush ~ 0 ~ DEL %atm 15......14 1 10.. 00 1 CKT15.. 6-5 ...1:l .........mm:ss) +l ~UPtake(L) ..:..241 13 .00 I Time (h... VA LIM ~~~--------------------------------------------_4 O--L-------------------------------------------~ 10 CO LIM ~~--------------------------------------------_4 0--'--------------------------------------------' CKr ALV VflG MUS %atm 0:05 0:10 0:15 Figure 6-1 b shows the Picture and Graph after administering enJlurane at constant inspired tension of 5% for 15 minutes....461 ART VRG MUS FAT VEN L!TI L!TI 1 0.001 ALV13.421 10 ....p_eo'--_-' 10 . FGF VA fAi17l co ~ lim LIm ~ LIm ~ IAFAP I±j Agent: IEnflurane Circuit: LIO....15..241 13.. ..Gas Man® Plateau Height & Blood/Gas Solubility Agent: IEnflurane I. 02 1 12.

pe_n_-----' ..GnUrane I!! ~Weight (Kg) Circuit I.. 00 1 CKT15.:.--O-.73 1 %atm ART VRG MUS FAT VEN I 0:15:00 I Time (h:mm:ss) @::J Uptake (LJ ~ Delivered (LJ Speed: FGF VA 14.-p_en_ _. 34 1 10.001 ALv13.621 13..l Flush ~ 0 :tl DEL 11 5.. 02 1 12 .-I 10 VA LIM ~r------------------------------~ OI~L------------------------------~ 10 L~~ ~r--------------------------------------------~ o =1 eKr AlV VRG MUS %atm Figure 6-1 c shows the Picture and Graph after administering isojlurane at constant inspired tension of 5 %for 15 minutes.L1!. 6-6 ..Gas Man® Plateau Heighl & Blood/Gas Solubility Agent: II . 51 1 10...621 13 .06 1 co " " LIm LIm LIm~ IAFAP I!! Agent: Iisoflurane Circuit O.

00 1 CKT15.20 1 ART VRG MUS FAT VEN I0:15:00 I Time (h:mm:ss) ~UPtake(L] ~ Delivered (L] Speed: FGF r:tnl VA co lIm~ lim 14.. 6-7 .201 ALV 4.flu- rane at constant inspired tension of 5% for 15 minutes.atm Figure 6-1 d shows the Picture and Graph after administering sevq.Gas Man® Plateau Height & Blood/Gas S'OI11bilitv Agent: ISevoflurane I :l:j ~Yleight (Kg] Circuit: '--'-_ _--'=-' DEL %atm 15.-O-.2 0 14. 10 VA LIM ~~---------------------------------------~ O-J-------------------------~ 10 CO LIM ~~-------------------------------------~ O-J-------------------------~ cn ALV VRG MUS !'. 03 1 lim [J IAFAP I±j Agent: ISevoflurane Circuit: I.001 I 1 14. 02 1 13.401 1°.. 12 1 10 .-pe_n_--.

5 1 §l @] @] 112..-pe.51 116.9 1 ART VRG MUS FAT VEN GIl GIl ] 1 0:15:00 1 Time (h:mm:ss) +! __ 1 ~UPtake{LI :otl ~ Delivered (ll Speed: FGF f1ill VA r:.n:. 6-8 .. 0 1 ALV116.l CO LIm ~ LIm ~ LIm IAFAP L~:l Agent: IDesflurane Circuit I'-O.Gas Man® Plateau Height (5 Blood/Gas Solubility Agent: IDesflurane I !j ~W'eight (Kg) Circuit: Ic::0.:cn_--LI!c:J1 DEL %atm CKT118.-'-pe_n_---' 10 VA LIM ~~~------------------------------------------~ O.~~------------------------------------------~ 10 S~ ~~------------------------------------------~ o =! CKf IILV VRG MUS %atm Figure 6-1 e shows the Picture and Graph after administering de~flu­ rane at constant inspired tension of 18% for 15 minutes.

00 I Delivered (ll Speed: ~ VA CO FGF LIm 10.0 IWeight (Kg) Circuit: cIO"-.. . explained in Chapter 8. The concentration effect has been eliminated by disabling the effect of uptake (Special menu.Gas Man® Plateau Height (5 Blood/Gas S'olubilily Agent: INitrous Oxide I!:1 170..-o_--L:I±". Disable Uptake) on alveolar ventilation.00 1 lim @=:J IAFAP !±l Agent: INitrous Oxide) Circuit: I-IO-'-pe_n_----' VA LIM 1: q -+---------!I I CO LIM 1: ~ I en ALV VRG MUS %atm Figure 6-1f shows the Picture and Graph after administering constant inspired tension of 1 00% nitrous oxide for 15 minutes.pe'-. lim 14.J DEL %atm ~ CKT~ AlV~ ~ ~ ~ l:JI] [£] ART VRG MUS FAT VEN ~] GIJ I 0:15:00 I Time (h:mm:ss) ~ ~ Uptake{L) :i-J :i-J I 150.

and then more slowly after what is termed the knee. Knee height differs with agent solubility.hl {5 Blood/Gas Solubility o DISCUSSION Note that the different anesthetic agents have alveolar tension curves that are similar in overall shape. Vessel-rich group (VRG) anesthetic tension follows alveolar soon thereafter (1-3 minutes). In all cases. Muscle and fat do not develop any significant anesthetic partial pressure during the 15 minutes viewed. 6-10 . alveo- lar tension rises rapidly at first. Tail shape varies slightly from agent to agent.Gas Man® PlalNlu Hcip. They all possess an identical initial rise.

etc....... 5 ""'Note: When simulating nitrous oxide VIEW (min) ..... select enflurane. 4 each.. top of the scale the picture and graph... This will produce a well-defined plateau rather than an ill-de- fined knee leading to a rising tail... you will next eliminate the eflect of anesthetic in venous blood returning to the lungs and heart.. After observing alveolar tension reach a plateau after 2 minutes...... Special . sevoflurane... To do so....... o SETUP To demonstrate the plateau height for Parameter Selection each anesthetic........Gas Man® Plateau Height & Blood/Gas Solubility xercise 6-2 Drugs with high blood/gas solubility have low alveolar knee and plateau heights and low A/I (Alveolar/Inspired) or E/I (Expired/Inspired) ratios... 15 administration. To see the effect of blood/gas solubility independent of tissue effects.............................. isoflurane....................... des- FGF (L/min) . adjust parameters as Agent ...... Next....... note its Circuit ... AFAP eliminate the concentration effect....... and nitrous oxide and observe... 10 flurane. shown...... CO (L/min) .... Halothane. or print the plateau height of VA (L/min) .............. It will then be easy to see the effect of blood/ gas solubility on the plateau height..................... you will use the Special menu and select Disable Return.......... use the Special menu to Disable Uptake before clicking Begin............. Disable Return 6-11 ........ Open height or use the File menu and Print DEL (%) ...... as in Chapter 5... to SPEED ................. record..

The alveolar plateau heights for 5% inspired agent are tabulated in Table 6-1.Gas Man® Plateau Height & Blood/Gas Solubilitv o OBSERVATION 1. The effect of venous return of anesthetic to the lungs was removed by using Disable Return. lines #4 and #5.25 Halothane 0:00 1:00 2:00 3:00 4:00 Figure 6-2 shows the Graphs of the alveolar tension plateau for each anesthetic agent plotted on the same axes to allow easy comparison. 6-12 .50 Isojlurane Enflurane .75 Desjlurane Sevojlurane .0--~----------------------------------------------~ A/I Ratio .

alveolar/inspired = expired/inspired or A/I = E/I. the plateau height depends on both alveolar ventilation and cardiac output. line #6). In addition to depending on the blood/gas solubility. Alveolar is what is present in the lungs. combined with MAC. neither of these values can be easily and continuously quantified. Pla/emf Heigh/ & Blood/Gas Solubility xercise 6-3 Alveolar plateau height or A/I ratio. In reality. In this exercise. we take a break from running Gas Man simula- tions and explain the concept of Minimum Alveolar Concentra- tion (MAC). Because expired tension is a reasonable ap- proximation of alveolar tension. the two terms are often used interchangeably. they may be different. deter- mine the initial overpressure value required to produce 1 MAC in the alveoli. Expired is what we mea- sure with an airway gas analyzer. In the clinical setting. If real measurements of plateau height could be made for an agent of known blood/gas solubility. respectively. That is. the ratio of cardiac output to alveolar ventilation could be inferred. anesthetics with low blood/gas partition coefficients produce high alveolar anesthetic plateaus. 6-13 . and the relationship of alveolar to inspired tension. Plateau heights are described in terms of ratios of alveolar to inspired tension. This relationship can be quantified: 1 1 + CO'A/VA where PA and PI are alveolar and inspired anesthetic tensions. The important point here is that relative plateau height is inversely related to blood/ gas solubility. From the results of Exercise 6-2 we can compute the A/I ratios for each drug (see Table 6-1. 'A is the blood/gas partition coefficient. and VA and CO are alveo- lar ventilation and cardiac output. One note of caution is required here.

/zf & Blood/Gas Solubility If the objective here were to control alveolar tension to a certain plateau height. 50% of patients fail to move in response to a surgical incision. Thus. the overpressure ratio (II A) decreases wward 1. if vou / know the overpressure ratio and the MAC value for an anes- thetic. then it is not the A/I ratio that is useful. Thus we see that as blood/gas solubility decreases toward 0. To combine the concepts of MAC and overpressure. The overpressure ratio can be calculated for each of the anesthetic agents (see Table 6-1. A surgical incision is then made. A record is made of whether or not the patient moves. expressed in percent of one sea level atmo- sphere. line #7). End-expired gas is taken to represent alveolar gas. And brain tension is assumed to equal arterial tension after 15 minutes of equilibration. the concentration value should be thought of as partial pressure or tension. but rather the l/A ratio. This is the approach consistently used in Gas Man. The !vIAC values for each gas simulated here are shown in Table 6-1. At the MAC value. you can easily calculate the inspired tension required to 6-14 . blood. The relationship between the two is simple: one is the reciprocal of the otherl The II A ratio can be thought of as the overpressure ratio required to achieve the desired tension in the alveoli. We know that each of the anesthetic agents requires a different brain level to achieve anesthesia: The value of brain. Alveolar gas tension is taken to precisely equal arterial blood tension. defined as the Minimum Alveolar Concentration for anesthetization at 1 atmosphere pressure. This definitive end-point of yes or no makes statistical analysis convenient. !vIAC is often measured by successive ap- proximation in a series of patients. The value is assessed by measuring end-expired anesthetic tension 15 minutes after constant expired tension has been established.Gas Man® Pla/eau Heip. To make the same MAC value applicable at any barometric pressure. and alveolar anesthetic which anesthetizes 50 % of patients is 1WA C. assume that the desired alveolar level is 1 MAC. line #8.

. By leaving venous return dis- ...Gas Man® Plateau Heig:ht & Blood/Cas Solubility produce an alveolar plateau of 1 MAC ........................ Use of appropriate overpressure brings alveolar anesthetic ten- sion to ] YVU\C rapidly.... By FGF (L/min) ... You will explore this in the next exercise...... 5 venous return of anesthetic to the lungs................... 5 eters as shown......MAC = VA ratio x MAC......... Adjust the param- co (L/min) . AFAP 6-15 ......... you can achieve and maintain I MAC in the alveoli.... you will see (%) ................ 10 choosing the solubility-adjusted overpres- sure value........................................ Isoflurane tension to 1 rvlJ\C with each of the anes- thetics............... Remember to use Disable Return to remove the effect of VIEW (min) ............... 4 the 1 MAC you desire. MAC = 11........ iL is the product of the two: Inspired overpressure for 1.... xercise 6-4 -----~------~--~~-~-----~------------------~-----~--~-~--~~-~---~ By choosing the solubility-adjusted overpressure value........................... you will achieve and maintain VA (L/min) .. Open abled in the Gas Man model.. o SETUP In this exercise... you will simulate an Selection overpressure-induced step in alveolar ... 5 a flat plateau in alveolar tension in response to constant inspired tension. SPEED ..................

At the end of 1 minute of simulation.9% overpressure value was calculated based on the blood/gas solubility ratio of iso- flurane and a value for ventilation (VA = 4 L/min) and perfusion (CO = 5 L/min).9 % isoflurane with an open circuit.Gas Man® Pla/mll Height & Blood/Gas Solubility o OBSERVATION Agent: Iisoflurane I.00 1 ~ ART VRG MUS FAT VEN I 0:05:00 I Time (h:mm:ssl ~ Uptake(ll ~ Delivered (Ll Speed: FGF r:1Ol VA CO r.--l LIm ~ LIm 4. 07 1 1 LIm ~ IAFAP It] Agent: /Isoflurane Circuit: I'-O.-=e.' VA LIM 1: ~ CO LIM 1: ~ CKf ALV VRG MUS %atm Figure 6-3 shows the Picture and Graph of the result of Exercise 6-4 after administering 2. 04 1 10 .1.=J:!:1 Flush ~ 0 Yl DEL %atm CKT12.96 1 10 .--pe_n_ . The 2.0 IWeight (Kg I Circuit: I~Op.-n_-. note that vou have J achieved 1 MAC already. The effect of venous return of anesthetic to the lungs was re- moved by using Disable Return.121 10 .:!:! 1170. Note also that the alveolar tension does 6-16 ..121 11.:. 90 1 AlVI1.-.

you may have noticed that some brands and models of enflurane vaporizers deliver up to 7%. would. 6-17 . / '-Clinical Note: If you have seen anesthetic vaporizers. Now you know why 7% is an advan- tage for this drug that has both low potency (high MAC) and relatively high solubility. and nitrous oxide. sevoflurane. Note that for enflurane. and then adjust the control bar to 5. Now that you have produced 1 MAC isoflurane. desflurane. based on the alveolar tension desired and the MAC value for the anesthetic agent you selected. do the same for the other anesthetic agents: enflurane. you have achieved a 1 :MAC plateau.7%. A flat plateau is created in this educa- tional simulation because venous return has been disabled.Gas Man® Plateau Height & Blood/Gas Solubility not change as the simulation continues to 5 minutes. Adjust the scale of the picture display by entering "6" in the box to the left of the scale.7 as vou normally. The plateau height is formed by the balance between anesthetic delivery in ventilation and removal by cardiac output. halothane.1 % isoflurane) because you correctly calcu- lated the inspired tension to use. The pla- teau is at 1 MAC (1. Set DEL according to Table 6-1 (Inspired Overpressure for 1 MAC) or calculate it yourself for each anesthetic. the setting required is 5. others only up to 5%.

You have calculated and simulated the A/I plateau ratio and the 1/A overpressure ratio. You have also noted that the tail of the alveolar tension curve is removed by disabling venous return of anesthetic to the lungs. you have compared various anesthetic agents and seen that blood/gas solubilities (blood/gas partition coefficients) significantly affect the height of the knee of the alveolar tension curve. along with the overpressure for 1 MAC for each agent. 6-18 . Table 6-] tabulates pertinent data and calculations you can consider in clinical practice. By choosing the solubility-adjusted overpressure value. Blood/Gas Solubility ummary In this chapter.Gas Man® Pla/eau Heighl (. you can achieve and main- tain 1 MAC in the alveoli..

//~--------'-. some breathing circuits and anesthesia machines are designed to do this. In Exercise 4-4. we will explore the judicious use of overpressure to achieve a rapid rise and stable maintenance of anesthetic tension somewhere other than where we are controlling it.~\ I . With conventional anesthesia machines commonly available 7-1 . You will reproduce the halothane simulation published by Eger l 4. as well as perform similar simulation experi- ments for the other agents. In Chapter 6 we saw the level of inspired overpressure required to achieve I MAC in the alveoli and exhaled gas during the time before anesthetic returns in venous blood. First we will consider the alveoli (actually the expired gas). That is. Overpressure is the term for using a higher partial pressure in the inflow than is desired in the compartment being controlled. we will eliminate the delay and diffi- culty in prediction introduced by the breathing circuit and use a perfect non-rebreathing. inspired anesthetic tension is continually or frequently adjusted to produce a con- stant tension somewhere else. we adjusted the vaporizer setting to control alveolar anesthetic tension. To make our work easier. Chapter 7 II ) Overpressure-8i / '\ Optimum Anesthesia U () The concept and technique of overpressure has been used for a long time. With proper use of overpressure. circuit. Then we will consider the brain as the location in which anesthetic tension is to be controlled. we saw that overpressure could speed the rise in anesthetic tension two compartments away. or open. In this chapter. In practice. In this chapter we apply the same principle to control alveolar anesthetic tension by adjusting inspired tension in the face of returning anesthetic in venous blood. notably the brain or alveoli.

C level. Your goal in each exercise will be to bring either alveolar or vessel-rich group tension up to 1 MAC and maintain that level. Select Pause and type in new values as needed or desired . but it is still not perfect. line 9. Vve will use 1 J\!IAC as our target level. 7-2 . move the mouse pointer onto the control bar and click the mouse button. a fresh gas flow of 10 L/ min will do an adequate job. When you do this. at which time the simulation automatically resumes. First.Gas Man® OVeJjJrCSSlIlP & OjJlimum Anesthesia in the US. A logical vaporizer starting value for each agent is found in Table 6-1. You may find that dragging the control bar is the most enjoyable method. You may have to continuously adjust the vaporizer setting (DEL) to do this perfectly. With the simulation running. The inspired tension shown there will raise ALV to 1 MAC immediately. These numbers are the starting values in the Exercises. the simulation automatically pauses until you release the button. The dotted line in the alveolar (ALV) and vessel rich group (VRG) compartments represents the MA. slow the Speed to 5X or lOX. You can use any of three ways to adjust the vaporizer: Drag the DEL control bar by clicking and holding the mouse button . Click the down arrow next the the DEL scale ..

......... o SETUP To achieve 1 MAC in the alveolar com- Parameter partment........... producing graphs like Figures 7-1 b.. you should have produced a graph something like Figure 7-1a... that level. tion............ .......... .a.......... your goal in each exercise is to bring alveolar tension up to VA (L/min) .... n.............. 15 ting... the dotted line (l MAC) and maintain CO (L/min) .SSUFI' & OjJli mum A nest liesia xercise 7-1 Carefully adjusted inspired overpressure can achieve and main- tain 1 MAC in the alveolar compartment and exhaled gas............ ......... Remember....... start reducing DEL in one of the three ways described on the previous FGF (L/min) . a~just the parameters as shown.....e.......Gas Man® OVCljJr(...................... ........ 7-3 .......... page. You can repeat this exercise with each of the anesthetic agents............. Keep your eye on the alveolar tension as you a~just the vaporizer set- VIEW (min) .....d........ ......c... Agent ... Special ................. SPEED ........ ....... measured as exhaled gas. Circuit ..... Immediately after beginning the simula- DEL (%) .. 5x At the end of the 15 minute simulation.....

83 1 ART VRG MUS FAT VEN I 0:15:00 I Time (h:mm:ss) ~ Uptake(L) ~ Delivered (Ll FGF r1ilill VA CO Speed: I. 07 1 10 . Continue Llm~ LIm 14.07 I 11. achieved by continuolls manual adjustment ofinspired tension.441 CKII1.Gas Man® OvmjJ)"essure & OjJtimum Anesthesia o OBSERVATION Iisoflurane L±j ~Weight (Kg) Circuit: LI O-.-pe_n_--LI:!:::JJ Flush o DEL %atm 11. 12 1 10.071 11.-pe""n_-----. 00 1 ~ Agent: Iisoflurane Circuit: LI0-. 02 1 LIm 15 . VA LIM 1: g CO LIM 1: g eu ALV VRG MUS %atm --------- Figure 7-1a shows the Picture and Graph resultingfrom keeping anesthesia administration at a constant alveolar tension with is'?/1urane. 01 1 1°. 7-4 .HI ALvl 1.

:IO. 33 1 ART VRG MUS FAT VEN ~ ~ ] I 0:15:00 1 Time (h:mm:ss) ~ :tl ~UPtake(LJ ~ ~ ~ Delivered (LJ Speed: FGF VA CO ~ lim §] lim 14 . 01 1 11 . 7-5 .:n_----' VA LIM 10 t~--------------------------------------------~ O·~~------------------------------------------~ 10 CO LIM ~~--------------------------------------------~ O·~~------------------------------------------~ cn ALV VRG MUS %atm Figure 7-1b shows the Picture and Graph resultingfrom keeping anes- thesia administration at a constant alveolar tension with enflurane.:.::. I±j Agent: !Enflurane Circuit: c.0 IWeight (Kg) Circuit: 10pen '-'----"'--' I±J 12 . achieved by continuous manual adJustment of inspired tension.Gas Man® OveljJressure & OJ!til71u1I1 Anesthesia Agent: !Enflurane ! ±J 170.69 ALV 1. 52 1 CKT12.521 I 1 11. 03 1 LIm U I 5.pe:.69 1 M 1°.691 11.

051 10. 39 1 %atm ART VRG MUS FAT VEN 1 0:10:00 I Time {h:mm:ssl ~UPtake{lJ ~ Delivered {Ll FGF f3I VA CO Speed: I:!:j I.331 10.001 CKTlo.Gas Man® OverjJrCSSllTC & OjJtimlUlI Ancsthesia Agent: Ilsoflurane I:!:j ~Weight (Kg) Circuit: ISemi-Closedl ~l Flush o DEL 10.501 1°.001 1°.331 10.. 7-6 . achieved by continuous manual adjustment of inspired tension.Cont.221 ALV10.inue. 00 1 lim [ ] 160x Agent: Iisotrurane Circuit ISemi-Closed I FGF LIM :~ 4-----------------~A~ __________________ 1 DEL %atm :§ \ CKl AlV VRG MUS %atm Figure 7-lc shows the Picture and Graph resultingfrom keeping anes- thesia administration at a constant alveolar tension with halothane. 1 LIm L-J LIm 14 .

-pe:.-I DEl %atm CKT!Z.Gas Man® ()ZJe1jJressure & ()jJtim.9 9 1 11.3S! AlV!1.:.:)l CO lIm ~ lim EJ Eill Agent: ISevoflurane Circuit: Ic0-. 7-7 . 53 1 ART VRG MUS FAT VEN I 0:15:00 I Time (h:mm:. .--_.0 IWeight (Kg) O-=-pe_n_--LI±..~ en ALV VHG MUS %atm 0:05 0:10 0. 01 1 11.n. achieved by continuous manual adjustment of inspired tension.97 1 10..~.======1'.991 11. VA LIM 1: ~+--_ _ _ _----II CO LIM 1: ~l-----------ll :~===-~~.wn Anesthesia Agent: 1Sevoflurane L±j 170.15 Figure 7-ld shows the Picture and Graph resultingfrom keeping anesthesia administration at a constant alveolar tension with sevoflu- " rane.. 21 1 10 .-.s) ~UPtake(l) ~ Delivered (l) Speed: VA r::.Jj Circuit: ..

DEL %atm @] CKT@] ALV~ ~ ~ @] @]@] ART VRG MUS FAT VEN ~ ~] 1 0:15:00 I Time (h:mm:ssl ~ ~UPtake(L) ~ ~ Delivered (Ll Speed: §J VA co FGF LIm 10.-O"-. you need less overpressure to achieve and maintain 1 MAC. 7-8 .Gas Man® Ouel!Jressure & Ojitilll1l1n Anesthesia Agent: IDesflurane I:tJ ~Weight (Kg) Circuit: I..pe_n_--1-1:tl .. such as desf1urane and sevof1urane.. Note that when using drugs of lower solubility. L:tl Agent: !Desflurane Circuit: LIO"-pe_n_---' VA LIM 1: ~~----------------------------------------~ CO LIM 1: ~r--------------------------------~ CKI ALV VRG MUS %atm Figure 7-1e shows the Picture and Graph resultingfrom keeping anes- thesia administration at a constant alveolar tension with desflurane. J achieved by continuous manual adjustment of inspired tension.03 1 LIm ~ I 5.. lim 14.

...... Open DEL (%) .. 5 Adjust the vaporizer to achieve constant brain (VRG) tension at 1 MAC = 1....................................... 15 is achieved in the blood which perfuses the brain................... 4 tension carefully.............. alveolar or VRG tension may not be desirable on clinical grounds..... 10 overlying the dotted line. It must be recognized. Isoflurane pressure perfectly controlled.....Gas Man® OVCljJr('SSlirc & Optimum Anesthesia xercise 7-2 Optimum anesthesia uses inspired and alveolar overpressure to achieve and maintain constant brain anesthetic tension...............1 %......... ................. 7-9 ............... with some drugs and with some patients.... adjust the parameters as shown... The overpressure you use in the alveolar compartment should be transient. 5 the 1 MAC line a bit.............. higher level than its final value... temporarily driving it toward a SPEED . Observe alveolar VA (L/min) .......... there should be no overpressure achieved in the brain... The alveolar over- shoot is the alveolar overpressure which VIEW (min) .. Circuit ........ allow it to overshoot CO (L/min) .. o SETUP Parameter To attempt optimum administration of Selection anesthesia which maintains brain partial Agent ....... FGF (L/min) .. As you adjust inspired tension.................. that the high and rapid rise in inspired.

-pe_n_--l..031 10. For each volatile anesthetic agent (isoflurane. sevoflurane..flurane.J LIm 14.-e_n_--.021 11. 00 1 1 10x I:!:l Agent: Itsoflurane Circuit: !.131 10. showing an optimum anesthetic course (1 . Many variations are possible. 01 1 LIm 15 . In each case. halothane.36 1 CKTI1.--Op. desflurane). trying to achieve vessel- rich group tensions that overlay the dotted line at 1 MAC as quichly as possible.MAC in VRG) with isq.021 11.011 10..3 6 1 AlVll. enflurane. the dotted line on the picture and graph represen ts 1 :MAC (see Table 6-1). 10 ~ VA LIM 0 10 ~ CO LIM 0 CK! ALV VflG MUS %atm ------~-- Figure 7-2a shows the Picture and Graph of Exercise 7-2.I:!:o-Ji DEL 11.. Repeat this exercise with the other anesthetic agents. start with the vaporizer set to the top of the control bar. 7-10 .811 %"atm AAT VAG MUS FAT VEN I 0:15:00 I Time (h:mm:ssl ~UPtake(Ll ~ Delivered (Ll Speed: FGF f1ill VA CO LIm t.:.Gas Man® OVeljJreSSllre & Optimum Anesthesia o OBSERVATION Agent: Iisoflurane I :!:1 §:]Weighl (Kg) Circuit: LIO-.::::.

:!:i ~Weight (Kg) Flush o DEL 12.d.641 10.-pe__n_--. 36 1 ALVI1.271 10.n:. depending on the frequency of the adjustments you made and your facility with using the mouse.c. 62 1 11.e show examples of the Picture and Graph for each anesthetic. Figures 7-2 b. <-I VA LIM 1: f CO LIM 1: ~ en ALV VRG MUS %atm Figure 7-2b shows the Picture and Graph of Exercise 7-2.291 ART VRG MUS FAT VEN I 0:15:00 I Time (h:mm:ss) ~ Uptake(l) ~ Delivered Il) Speed: VA r:.021 11. showing an optimum anesthetic course (l MAC in VRG) with enflurane.Gas Man® Ollfllm'SSlIlP (5' OjJtimum Anesthesia Agent: IEnflurane l. 36 1 %atm CKT12.621 11. 7-11 .] FGF lIm~ "'" lim ~ co " lim~ " 110x I:!:j Agent: IEnflUfane Circuit: O-. Yours may look different.

~-~~ I!I .811 10.-O-. 7-12 . showing an optimum anesthetic course (1 MAC in VRG) with halothane.791 10. 02 1 lim 110x I!l Agent: IHalothane I Circuit .Gas Man® 01Je1jJressure (5 OjJtimw71 Anesthesia / Halothane L!l ~Weight (Kg) Circuit: IOpen ~.001 10.631 ART VRG MUS FAT VEN I 0:15:00 I Time [h:mm:ssl ~Uptake(LI Delivered [Ll Speed: FGF r:1ill VA CO LIm ~ LIm 14 .791 10. DEL %atm IUS/ 'O'~ DOD ~ cn/usl ALVI0..-pe_n_-" VA LIM 1: ~~_________________________________________ CO 1: ~~__________________________________________ LIM ALV VRG MUS %atm Figure 7-2c shows the Picture and Graph of Exercise 7-2.091 10.

521 %atm ART VRG MUS FAT VEN I 0:15:00 I Time (h:mm:ss) @=:J Uptake (Ll @:=J Delivered (Ll Speed: FGF fliJl VA CO LIm L:. 28 1 CKT12.. 7-13 .941 11.Gas Man® Ovel1m~SS1lre & Optimum Anesthesia Agent: !Sevoflurane L~:1 ~Weight (Kg) Circuit: <. 28 1 AlV\1... 01 1 lIm EI 110K Ifj Agent: !Sevoflurane Circuit: O. 94 1 \1.:IO-'-pe. showing an optimum anesthetic course (1 .=."_------il""'f! Flush o OEl \2.MAC in VRG) with sevoflurane.. CKT ALV VHG MUS %:atm ==1..J LIm 14. I 0:05 0:10 0:15 Figure 7-2d shows the Picture and Graph of Exercise 7-2..!::pe::::n~---.:l VA LIM CO LIM e~"====.23\ 1°.951 1°.J t.:.011 11..

I""'±j Flush o DEL CKT~ ALV~ ~ ~ ~ ~ ~ %atm ART VRG MUS FAT VEN 1 0:15:00 1 Time (h:mm:ss) ~UPtake(L} ~ Delivered (L) Speed: FGF ~ VA CO ~ LIm ~ LIm /4. 7-14 . showing an optimum anesthetic course (1 . d ALV VRG MUS %atm I 0:05 0:10 0:15 Figure 7-2e shows the Picture and Graph as a result of Exercise 7-2. _ _ -----jl CKT ]as: .=.Gas Man® OVl'ljJr!'SSlIIP & Oplimwn Anesthesia . 03 1 LIm ~ 1 1 0x !±j Agent: 1Desflurane Circuit: LIO-'--pe_n_---' VA LIM 1: -+--~ ---------ll CO LIM 1: ~I----.------------------------------------------------- Agent: \Desflurane \±l ~Weight (Kg) Circuit IL0-'-pe=-:n_---<.MAC in VRG) with desflumne.

These techniques have not yet been shown to be reliable. End-expiratory tension is a good approximation to alveolar tension and arterial anesthetic tension. This is not practical. so the brain is usually monitored by observing the clinical signs of anesthesia (pupil size. 7-15 . Monitoring inspired and end-expired tensions has proven useful in clinical management.Gas Man® OveJjJressure & OJ)/i Inurn Anesthesia o DISCUSSION Ideally. pulse. Inspiratory and expiratory anesthetic tensions can be measured easily with commercial monitors using anyone of several tech- nologies. respiration.). etc. one would like to monitor anesthetic tension in the brain to precisely predict anesthesia depth. reflex responses to surgical stimulation. the electroencephalogram (EEG) or evoked potential (EP) are used. Occasionally. blood pressure.

........................ alveolar or VRG tension may not be desirable on clinical grounds. decrease the delivered VA (L/min) ........... You should observe that ALV and VRG anesthetic CO (L/min) ............ adjust the vaporizer to achieve FGF (L/min) ... semi-closed Parameter Selection circuit to attempt optimum clinical Agent ... Isoflurane...... Semi-closed With the delivered isoflurane tension set DEL(%) ...sthesia xercise 7-3 Optimum clinical anesthesia uses vaporizer adjustment for inspired overpressure and alveolar overpressure to achieve and maintain constant brain anesthetic tension... and rapid rise in inspired..Gas Man® OVe!preSS?lre & OJ)timw/l Anp.. 5 tensions are approximately 1. 4 isoflurane tension to 3.......1 %........................ 10 constant brain tension.. that the high Special ...a.....................5%.......................... o SETUP You will now use a high-flow...... overly- VIEW (min) .... SPEED ............ lOx It must be recognized... At the end of 2 minutes...... with some drugs and with some patients..... administration of anesthesia................. Circuit ........... etc.. 5 to 5%.............. 15 ing the dotted line.. Adjust the parameters as shown....... 7-16 ....... n...............

OS I 11.52 ! %atm CKT!1.) ~UPtake(L) ~ Delivered IL) FGF r:.OS! Il.d. trying to achieve vessel-rich group tensions that overlay the dotted line at 1 MAC as quickl)) as possible. Figures 7-3 b.13! 1°.. 01 1 lim [ ] 120K l:!oj Agent: Iisoflurane Circuit: ISemi-Closed I FGF LIM DEL %atm en ALV VRG MUS %atm 0:05 0:10 0:15 Figure 7-3a shows the Picture and Graph of clinical optimum anesthe- sia administration (1 MAC in VRG) with isoflurane.3S! ALVll.OS! 10. Yours may look different.c. 7-17 .Gas Man® OverjJressure & OjJtimum illlesthesia o OBSERVATION Agent: Ilsoflurane til ~\IIeight (Kg) Circuit: ~~:5~ DEL 11 .851 ART VRG MUS FAT VEN I 0:15:00 I Time (h:mm:.011 1°. depending on the frequency of the adjustments you made and your facility with using the mouse.e show examples of the Gas Man Picture and Graph for each anesthetic.(ll VA co Speed: lIm~ lim 14 . achieved by continuous manual adjustment of the vaporizer with FGF = 10 L/min. Many variations are possible. Repeat this exercise with the other anesthetic agents.

96 1 cnl2.731 11. 7-18 .1/ LIm [J 1 20x I:!:I Agent: IEnflurane Circuit: ISemi·Closed I FGF LIM DEL %atm :~ ~'-----l :1G:2:-~.721 10.0.Gas Man® OveljJrr'sslIJ'e & OjJtimum Anesthesia Agent: IEnflurane 1:!:1 ~Weight (Kg) Circuit: ISemi~Closedl :!1 Flush ~ 0 :t:l DEL 112.361 %atm ART VRG MUS FAT VEN I 0:15:00 I Time (h:mm:ss) ~ Uptake(L) ~ Delivered (ll Speed: FGF r::.251 10.n-] VA CO lim ~ LIm 14...MAC in VRG) with enjlurane. achieved by continuous manual adjustment of the vaporizer with FGE equal to 10 L/min and an initial vaporizer setting equal to 7%. 73 1 11.6ll AlVI1.021 11.~I en ALV VRG MUS %atm 0:05 0:10 0:15 Figure 7-3b shows the Picture and Graph of clinical optimum anesthe- sia administration (1 .

8s l 10. 7-19 .Closedl:!:l DEL 11.091 1°.Gas Man® OverjJressure & OjJtimulIlllneslhesia --~-----~------------------~ Agent: IHalothane I:!:j ~Weight{KgJ Circuit: ISemi.MAC in VRG) with halothane.°°1 10.871 1°.681 ART VRG MUS FAT VEN I 0:15:00 I Time {h:mm:ssJ ~ Uptake{lJ @=:J Delivered {ll Speed: VA CO lim 14.48 I AlVlo. achieved by continuous manual adjustment of vaporizer with FGF = 10 L/min.721 %atm CKTI 1.02 1 lim ~ 120K I:!:j Agent: IHalolhane Circuit: ISemi-Closed I FGF LIM 1: ~ DEL %atm en AlV :~ VRG MUS %atm Figure 7-3c shows the Picture and Graph of clinical optimum anesthe- sia administration (1 .ssl 10.

36 1 %atm CKT12. 01 1 LIm L. 01 1 11 .MAC in VRG) with sevq.flurane. 51 1 ART VRG MUS FAT VEN I 0:15:00 1 Time (h:mm:ss) @J Uptake (L) ~ Delivered {L} Speed: FGF 1101 VA co r<:! Llm~ LIm 14.J 120• I±l Agent: !Sevoflurane Circuit: ISemi~Closed I FGF LIM 1: ~ I DEL %atm 5 ~ L1'--_~_ _ 1 en J~ I I ALV VRG MUS %alm 0:05 0:10 0:15 Figure 7-3d shows the Picture and Graph of clinical optimum anesthe- sia administration (1 .Gas Man® Ov(!1jJTessure & Optimum ilnesthesia Agent: ISevonurane I~J ~\y'eighl (Kg) Circuit: ISemi~Closedt:tl Flush o DEL 12 . 94 1 10. 7-20 . 22 1 10. achieved by continuolls manual adjustment of vaporizer with FGF = 10 L/min. 23 1 ALV~ ~ 11 .

7-21 . 02 1 LIm U \20.MAC in VRG) with desjlurane.resslIre & Optimum Anesthesia Agent: IOesflurane 1#:1 ~Weight (Kg) Circuit: ISemi~Closedl. achieved by continuous manual adjustment of vaporizer with FGF = 10 L/min.i Flush o DEL 4:atm CKT@] ALV~ ~ ~ @] ~ @] ART VRG MUS FAT VEN I 0:15:00 I Time (h:mm:.s) ~UPtake(LI ~ Delivered (Ll Speed: VA co ~ LIm 14 . L~I Agent: IOesflurane Circuit: Isemi~Clo$ed I FGF LIM OEl %atm en AlV VBG MUS %atm Figure 7-3e shows the Picture and Graph of clinical optimum anesthe- sia administration (1 .Gas Man® OVClj.

alveolar overpressure will be required only transiently. Since arterial blood anesthetic tension is considered to equal alveolar. inspired overpressure achieves the alveolar overpressure required. In an open cir- cuit. with some drugs and with sorne patients. you have reproduced the classic simulations of anesthesia administration at constant alveolar concentration with an open (non-rebreathing) circuit". this overpres- sure can be controlled by controlling alveolar or expired tension. alveolar or VRG tension may not be desirable on clinical grounds.anesthetic agents on your own. an additional level of vaporizer overpressure is required to bring inspired up to the levels required. In turn. An optimum anesthetic course provides constant brain anes- thetic tension. 7-22 . This is achieved by briefly providing the correct level of arterial overpressure to the brain. notably muscle and fat. In this chapter. Because the brain comes to perfect equilibrium with blood in only a short time. frequent or continuous adjustments of delivered anesthetic tension are required to maintain the desired level. that the high and rapid rise in inspired. unlike inspired overpressure which must be maintained as long as anesthetic is being taken up by other tissues. and have designed optimum administration of othel. Initial in- spired tension should be the target alveolar tension multiplied by the solubility-acUusted overpressure ratio. Il must be recognized. because of the limitations of today's breathing circuits. Finally.Gas Man® OVI'JjJrl'ssure & OjJtimum Anesthesia ummary ---~- Overpressure can be used to bring alveolar or exhaled anesthetic tension to any desired level quickly and easily.

This volume reduction. When a gas is administered to a patient's lungs. In the extreme case when the inspired concentration is 100%. lung volume is replaced with a nitrous oxide-plus-oxygen mixture that does not fully compensate for nitrous oxide uptake. Thus. additional gas is drawn into the lungs with each breath. If inspired nitrous oxide concentration is less than 100%. and inspired alveolar ventilation is elevated. uptake of that gas into the bloodstream attempts to decrease lung volume below normal. This is sometimes practiced clinically with nitrous oxide 17 • The end result is that uptake does not delay the rise in alveolar anesthetic tension as is the case with lower in- spired tensions. In other words. Anesthetic uptake into the blood is governed by inspired tension. Hence. and blood/gas solubility. the rise in alveolar tension is not accelerated as much as with a 8-1 . This is explained in the following manner. would be equal to anesthetic uptake into the blood. cardiac output. were it to occur.Chapter 8 \ 11\\ ) The Higl}J~Spir~d Concentration Effect U o The concentration rjJect explains the observation that alveolar tension approaches inspired tension more rapidly with high inspired concentration than with low. To maintain constant lung volume. inspired alveolar ventilation is augmented to bring 100% nitrous oxide into the lungs as fast as nitrous oxide is removed from the lungs by cardiac output. the increased inspired ventilation exactiy compensates for gas uptake into blood. alteration of cardiac output should not affect the alveolar tension curve.

8-2 .. An oxygen monitor (with alarms) must be used. The Gas Man program allows you to try this and other hazardous anesthetic administrations in simulation so that you can learn basic prin- ciples without risking patient harm. Finally.WARNING: Administering 100% nitrous oxide to patients is potentially hazardous.Gas Man® High insjJireri Concentration EJIect higher concentration. or pre-oxygenation). and only after previous administra- tion of oxygen (de-nitrogenation. There is a continuum in compensation for uptake between the extremes of 100% anesthetic and trace concentrations. To study the concentration effect. you will observe the slowed alveolar tension curve when the augmentation of inspired alveolar ventilation is totally eliminated in the simula- tion. you will first observe the rapid rise in alveolar tension with 100% nitrous oxide and the slower rise with 40% nitrous oxide inspired. It should rarely be used except for short periods (typically less than 1 minute). (. Next you will demonstrate that cardiac output does not affect the alveolar tension curve when 100% nitrous oxide is inspired.

...... To observe the concentration effect most Agent ...................Gas Man® High InsjliFed COTu:entmtio1/ FJpct xercise 8-1 The concentration effect is demonstrated by administering 100% inspired nitrous oxide followed by administering a lower concen- tration.... 5 VIEW (min) ............. 10 SPEED .. simulate administering 100% inspired nitrous oxide.................. o SETUP Parameter Selection Set the program parameters as shown................................... Circuit ............ Open DEL (%) ...... 10 anesthetic in clinical practice...... n...a.................... VA (Ljmin) ..... Nitrous Oxide dramatically.............. 70-75% is a more reasonable maximum.................................... 4 CO (Ljmin) .. and observing the alveolar tension curve in response to each.................. 8-3 ..... 100 ~Note: This is not meant to suggest using 100% FGF (Ljmin) ... 60x Special ..................................

..-O-. 8-4 .pe"..-pe_n_--LI±.1 CKTI 100 1 AlVIJ!] IJ!] ~ Q2J QJ ~ ART VRG MUS FAT VEN I 0:10:00 I Time {h:mm:ssl ~ Uptake(ll 1100.Jl DEL %atm 1100. demonstrat- ing anesthetic tensions after administering 100 % nitrous oxide for 10 minutes.Conlinue lIm ~ lim 14. The concentration effect has augmented inspired alveolar venti- lation (VA) and sped equilibration betw·een inspired and alveolar tensions.::.00 I Delivered III Speed: FGF f1fll VA CO '·. This should never be attempted in clinical practice.-O. 00 1 LIm [::::J IAFAP I±j Agent: INitrous ORide I Circuit: I.n_--.-.Gas Man® High fnsjJired CO}7centration Lffect o OBSERVATION INitrous Oxide I :!:1 BC]Weignt (Kg) Circuit: I.. VA LIM l: q~-----------------------------------------~ CO LIM 1: q~ ________________________________ ~ en ALV VRG MUS %atm Figure 8-1 shows the Picture and Graphfrom Exercise 8-1.

and then returns slowly toward its original value. Total body uptake of nitrous oxide is 7. The value shown represents inspired alveolar ventilation. The time constant appears to be 0.Gas Man® High ImjJired Concentration Effect o DISCUSSION Observe how rapidly the alveolar anesthetic tension rises toward 100%. Notice also that alveolar ventilation increases from 4.0 to 5. in the Graph alveolar tension reaches inspired tension in about 2. Inspired alveolar ventilation is the alveolar ventilation you selected plus the addi- tional inspired ventilation necessary to maintain constant lung volume (FRC) on a breath-by-breath basis.3 L after 10 minutes.6 L/ min. 8-5 .6 minutes.7 minutes.

... 4 CO (Ljmin) .... 8-6 ...... 60x Special .Gas Man® High insjJired Concentration Effect xercise 8-2 ----~~............. n. and Agent .... 5 VIEW (min) .............................. o SETUP Parameter Selection Set delivered tension (DEL) to 40% while maintaining the other settings..a..... 10 VA (Ljmin) ......... Circuit ................................ Open DEL (%) ........... Nitrous Oxide observe the alveolar tension curve.........................................--~ The concentration effect is smaller with 40% nitrous oxide inspired than with 100%.......... 10 SPEED ................................................................... 40 FGF (Ljmin) .....................

even after 10 minutes. enflurane. and isoflurane is produced. Alveolar tension does not quite equal inspired. a curve similar to those observed with halothane.--] lim ~ lim ~ lim ~ 160x I:!:I Agent: INitrous OKide I Circuit: ~-~ VA LIM ': ~~~------------------------------------~ CO LIM AlV VRG MUS %atm Figure 8-2 displays the Picture and Graph from Exercise 8-2. since alveolar ventilation is seen to rise slightly. showing a small concentration effect when 40 % nitrous oxide is inspired.:::J ART VAG MUS FAT VEN I 0:10:00 I Time (h:mm:ss) ~ Uptake(l) ~ Delivered (lJ Speed: FGF f1rll VA ~ CO r. Rather. Here. Note that alveolar tension no longer reaches inspired tension in the first 3 minutes.. the concentration effect plays some role..Gas Man® High ImjJired Concentration E[(ect o OBSERVATION Agent: INitrous Oxide I:!:j ~Weight (Kg) Flush ~ 0 :tJ DEL f4iil en[§] AlVCE] CE] CE] QJ QJ ~ %atm L. 8-7 .

...... then 10 L/min.......... 10 SPEED ....... n..... 4 CO (L/min) ........ vary car- Parameter Selection diac output as follows: first set co at 1 L/ Agent ................ the param- Circuit .............. 1... o SETUP In the next three simulations........ For each simulation... The concentration effect brings inspired gas into the lungs as cardiac output takes it away..............!1 InsjJired Concentration £jJect xercise 8-3 Cardiac output has no effect on alveolar tension when 100% anesthetic is inspired..a... DEL (%) .. You will next test whether this works in the limiting cases when cardiac output is taken to extremes............... then 10............ 8-8 ................. Nitrous Oxide min............................. then 0 VIEW (min) . 100 FGF (L/min) .............................. AFAP Special .....Gas Man® Hip....... Open eters should be set as shown.............. 10 VA (L/min) ...... and finally 0 L/ min.

Total body nitrous oxide uptake is 2. :!o O-. 8-9 . Alveolar reaches inspired tension in about 2.-pe_n_--.ed III FGF f1ill VA CO lim ~ lim ~ lim 11.Gas Man® High fllsjlired COllcentration E1!ect o OBSERVATION Agent: INitrous O...00 I Delive.7 minutes.9 L after 10 minutes.. Alveolar ventilation rises slightly. I Flush o f100l DEL %atm ~ CKT~ AlV~ 1 100 1 ~ QJ OJ ~ ART VRG MUS FAT VEN 1 0:10:00 I Time (h:mm:ss) ~UPtakelll 1100.00 1 Agent: INitrous Oxide I Circuit: LeiO-'-pe_n_---' VA LIM l:f I CO LIM 1: ~ I '~~ CK1 AlV VRG MUS %atm 0:02 0:04 0:06 0:08 0:10 Figure 8-3a shows the Picture and Graph of anesthetic tensions after administering 100 % nitrous oxide for 10 minutes with cardiac output ofl L/min.cuit:1'.ide 1:!oj §:]weight (Kg) Ci.-I.

Gas Man® High InsjJirrd Concentratiol7 Effect

Agent: INitrous OHide I.~l ~Weight (Kg)

Flush
~ 0
:t:l

DEL 1100_1
%atm
CKlllOol ALVllool ~ 1 100 1 ~ ~ [£J
ARl VRG MUS FAl VEN

1 0:10:00 1 lime (h:mm:s.l

~UPtake(LI

1100_00 1 Delivered (Ll

Speed:
FGF f1(i"I VA CO
Llm~ LIm
U8
I 1 LIm Imol IAFAP If)

Agent: INitrous Oxide I Circuit: LI0-'--pe_n_---'

VA
LIM 1: ~_.__--__--------------------------------~
CO
LIM

en
ALV
VRG
MUS

%atm

Figure 8-3b shows the Picture and Graph of anesthetic tensions after
administering 100 % nitrous oxide for 10 minutes with cardiac output
of 10 L/min.

Alveolar tension again reaches inspired tension in about 2.7
minutes, and the alveolar tension curve is again unchanged
despite the increase in tissue uptake. Total body nitrous oxide
uptake is l1A L after 10 minutes of simulation. Alveolar ventila-
tion rises slightly.

8-10

Gas Man® H(gh Inspired Concentration j,jj(xi

Agent: !Hitrous Oxidili ~Weight (Kg) Circuit: ' - ' - _ - - - ' - '

~ ]~----O'"fr
:]'0'
Il [l [l
rJ J J J
[l
DEL
%atm
CKT~ ALVl 100i
~ OJ OJ OJ OJ
ART VRG MUS FAT VEN

I 0:10:00 I Time (h:mm:ssl
~ Uptake(Ll

1100.00 I Delivered (Ll
FGF VA CO Speed:
I Continue
LIm §] lIm 14. 00 1 lim 000
1 1 IAFAP I±I

Agent: INitrous Oxide I Circuit: lL:.op::..::e~n_--,

VA
LIM

CO
LIM 1: ~

%atm

Figure 8-3c shows the Picture and Graph of alveolar anesthetic tension
if there were no uptake into blood (CO=O).

As before, alveolar reaches inspired tension in about 2.7 minutes
and the alveolar tension curve is unchanged. With no cardiac
output, tissue uptake is of course zero. Alveolar ventilation rises
slightly.

8-11

Gas Man® High InsjJired Concentration E,ffi:ct

xercise 8-4

The concentration effect is removed by eliminating uptake's
augmentation of inspired alveolar ventilation.

Next, you will use a special feature of the Gas Man program that
eliminates the effect of uptake on alveolar ventilation. This is not
possible physiologically, of course, but it serves to emphasize that
the concentration effect is caused by increased inspired alveolar
ventilation secondary to anesthetic uptake into blood. By using
the Special menu and selecting Disable Uptake, you can totally
eliminate the concentration effect. When you do, you will see a
curve shape representative of the response to trace or low anes-
thetic tension administration, no matter how high the actual
concentration.

o SETUP
Parameter Selection
Set the parameters for this exercise as
Agent ................... Nitrous Oxide shown, using the Special menu to
Disable Uptake.
Circuit .............................. Open

DEL (%) ............................. 100

FGF (L/min) ......................... 10

VA (L/min) ............................. 4

CO (L/min) ............................ 5

VIEW (min) ........................... 10

SPEED ............................. AFAP

Special ............. Disable Uptake

8-12

Gas Man® High InsjJired Concenlralion hfJect

o OBSERVATION
Agent: INitrous Oxide I:!:J ~Weight (Kg) Circuit: t.::IO-'=-pe::.:.:n_---LI-::.J+!

Flush
±l [J
:tl

DEL
%atm
1100.1 CKT~ ALV~ ~ ~ Q!] IT] ~
ART VRG MUS FAT VEN

I 0:10:00 I Time (h:mm:ssl
~ Uplake{LI

1100.00 I Delivered (Ll
Speed:
FGF f1nl VA CD ~ IC(lOli.nue .
10
LIm ~ LIm 14. 00 1 LIm L IAFAP If I

Agent: INitrous Oxide I Circuit: IL-Dp=-e_o_-,

VA
LIM
1: + - q_ _ _ _ ---II
CO
LIM 1: ~f--------il

'~~I'I I
CKT
ALV
VRG
MUS

%atm

0:02 0:04 0:06 0:08 0:10

Figure 84 shows the Picture and Graph of Exercise 84, demonstrating
anesthetic tensions with 100 % nitrous oxide inspired with the concen-
tration iffect removed.

Notice that although alveolar tension rises rapidly at first, a knee
occurs at about 1 minute, when alveolar tension reaches about
60% of inspired. The curve is qualitatively similar to the open
circuit alveolar tension curves observed earlier for halothane,
enflurane, and isoflurane administered in low concentrations.
The initial rise, knee, and tail are clearly seen.

8-13

simultaneously admin- istered. you have seen that the concentration effect describes the accelerated alveolar tension rise that occurs at high inspired concentration. this effect is maximized. the alveolar tension of the second gas rises higher and faster than it would have if it were present alone. 8-14 . This is termed the second gas effect. and alveolar tension rise becomes independent of cardiac output. you will see that if a second gas is administered simultaneously. In this chapter.Vhen inspired con- centration is 100%. This is discussed in detail in Chapter 11. It is due to the increased inspired alveo- lar ventilation and increased alveolar anesthetic delivery that accompanies uptake into the bloodstream.Gas Man® High IusjJired Conrel1lmlioll Efji:c/ The second gas 1fect is the result of rapid uptake of one gas in- creasing the alveolar tension of a second. . gas. In Chapter 11.

~\
Chapter 9 ( )
low Fre~\Ga~FIOW Anesthesia
! )
\~
o

heory

In a semi-closed breathing circuit, high fresh gas flow allows the
inspired anesthetic tension to closely approximate that delivered
from the anesthesia machine, even during induction. This
relationship is important, since it is the delivered tension that the
anesthetist controls. As anesthesia proceeds, expired anesthetic
tension rises toward inspired tension. The fresh gas flow may
now be lowered, since the only consequence is rebreathing the
warm, humidified, anesthetic-containing expired gas. For this
reason, low flow anesthesia is used by some clinicians for mainte-
nance of anesthesia after induction is completed. Reducing flows
from 8 to 2 L/min, for instance, reduces anesthesia cost by about
75%3U'l,41,42 while simultaneously providing heat and humidity to
inspired gas8 .

When real breathing circuits are used with low fresh gas flow,
agents can be removed by flushing with oxygen. The Flush but-
ton in the Gas Man Picture allows you to simulate this action.

Gas Man also provides the user an ideal circuit for experimenta-
tion. Real breathing circuits behave in a manner somewhere
between Gas Man's fully mixed semi-closed circuit and the un-
mixed, first-in first-out ideal circuit. The ideal circuit has all of
the properties of the non-rebreathing or open circuit whenever
FGF exceeds ventilation. W11en FGF is less than ventilation, fresh
gas is breathed in preference to exhaled gas. Thus, inspired gas is
dominated by fresh gas as long as FGF is high.

9-1

Gas Man® Low Fresh Gas Flow Anl!sthesia

xercise 9-1

Fresh gas flow can be reduced without changing clinical course.

o SETUP
To demonstrate the effect of reducing
Parameter Selection
fresh gas flow during anesthesia, adjust
Agent ........................ Isoflurane the Gas Man parameters as shown. Set
Bookmarks at 1 minute and 4 minutes
Circuit ................... Semi-Closed
for convenience. Start with DEL set to
DEL (%) ..................... 5% - See Text 5 %. After 1 minute, instead of decreasing
the vaporizer setting as most do clinically,
FGF (L/min) ................. 8 - See Text decrease the fresh gas flow to 2 L/min. At 4
minutes, decrease DEL to 2%.
VA (L/min) ............................. 4

CO (L/min) ............................ 5

VIEW (min) ........................... 15

SPEED ................................ 20x

Special ................................ n.a.

9-2

Gas Man® Low Fresh Gas Flow A1?I'sthesia

o OBSERVATION
Agent: Iisoflurane L~l ~Weight [Kg)

DEL
%atm
12.°°1 CKT\1.37\ AlV\l.04\ \1.041 11.071 \°.121 \0.01\ \0.83\
ART VRG MUS FAT VEN

I 0:15:00 I Time [h:mm:ss)
~ Uptake[l)

~ Delivered IL)

Speed:
FG F r;-;;;)l VA ~ CO
LIm ~ LIm ~ lim [ ] IAFAP L±\

Agent: Iisoflurane Circuit: ISemi-Closed I

FGF
LIM
':0
DEL
%atm

CKT
AlV
:~ \

VRG
MUS

%atm

Figure 9-1 shows the Picture and Graph of Exercise 9-1, demonstrating
the response to high jlow induction with isojlurane for 1 minute, fol-
lowed by a reduction of FGF and, later, delivered tension (DEL).

Note in Figure 9-1 that the patient's VRG tension rises to and
remains constant at 1 MAC despite the changes in FGF and DEL.
You can perform additional experiments, adjusting fresh gas flow
and delivered tension while trying to produce the same alveolar
anesthetic tension curve.

9-3

Gas Man® Low i'Jes/z Gas Flow Anesthesia

o DISCUSSION
After each simulation you run in this Exercise, observe the Pic-
ture and note the volume of anesthetic delivered to the circuit
(Delivered) and the volume taken up by the patient (Uptake).
You can infer the efficiency of anesthesia administration by
computing the ratio of uptake to delivered quantity. The poten-
tial for monetary savings can be seen from the difference be-
tween delivered and uptake. This is discussed in more detail in
Chapter 14, Analyzing Cost. For now, select the Show Cost icon
from the toolbar and note how the differences in volume with
different techniques translate to dollars

9-4

.. 9-5 ............................. Set Bookmarks at 5 minutes Agent ................... o SETUP Parameter Selection Set the parameters as shown to start this Exercise..a... 5% ............................... 4 CO (L/min) ....... 60x Special ...................... and continue the Circuit ............................. DEL (%) ........ 3 VA (L/min) .......... Semi-Closed simulation to its end... 10 SPEED ........ n................. 5 VIEW (min) .........See Text FGF (L/min) .... At the end of 5 minutes...............Gas Man® IJJW Fresh Cas Flow A nes[//{~sia xercise 9-2 Circuit Flush reduces anesthetic tension faster than turning off the vaporizer............. reduce DEL to 0%..... Isoflurane and 10 minutes.............

071 10. 00 1 %atm CKTI 0.581 10.S31 10. Save this simulation (you will need to name it) and reduce it to an icon on your desktop by clicking on the down arrow in the upper right corner of the simulation's window.Gas Man® Low Fresh Gas Flow Anesthesia o OBSERVATION Agent: !Isollurane ! :!1:j ~Weight [Kg} Circuit: DEL 10 .001 10. 9-6 .58% for ALV.641 ART VRG MUS FAT VEN I 0:10:00 I Time {h:mm:ssl ~ Uptake(l} ~ Delivered ILl Speed: FGF r:>i VA co ~ LIm ~ LIm 4. 00 1 1 lim ~ 160x Ifj Agent: II sollur ane Circuit: ISemi-Closed I FGF LIM :j DEL %atm :j CKT Figure 9-2a shows the first Picture and Graph of Exercise 9-2. and 0.42 I AlV10. wherein DEL is reduced to 0 % halfway through a 10 minute anesthetic.83% for VRG. 58 1 1°.42% for CKT. 0. Reducing DEL from 5% to zero after 5 minutes results in 10- minute values of 0.

Gas Man® Low Fresh Gas Flow Anesthesia Agent: IlsoHwane I:!:] ~\IIeight (Kg] EJ ~ :!:l IT Flu. wherein the circuit is flushed halfway through a 10 minute anesthetic. The results are shown in Figure 9-2.h 0 DEL %atm 10. located between the DEL control bar and the CKT com- partment. 9-7 .331 10. and 0. you see 10- minute values of 0.001 cnlo.50% for VRG. Then. anesthetic again returns to the circuit in exhaled gas and circuit tension rises slightly.221 AlV10. Open a New simulation and run it using the same parameters.331 10. 0. Once the circuit is flushed. at 5 minutes. reduce DEL to 0% and press the Flush button. but this time. With this technique.33% for ALV.001 1°.391 ART VRG MUS FAT VEN I 0:10:00 I Time (h:mm:ssl ~ Uptake(L) ~ Delivered (L] FGF r:>I VA rAnnl co ~ Speed: I. S. Press Continue.22% for CKT. CKT tension immediately falls to zero.5°1 10051 10. Continue . I±! Agent: Iisoflurane Circuit: ISemi~Closed I 4-__________________-JA~ ___________________ FGF LIM :j DEL Zatm :j en ALV VRG MUS Figure 9-2b shows the second Picture and Graph of Exercise 9-2.J l/m~ lim ~ lim ~ ISO.

a flush is needed if the clinician wants the circuit.Gas Man® Low Fresh Gas Flow A lIes/ hesia o DISCUSSION vVith a low fresh gas flow (3 L/min). As you move through these overlays. CKT. note the following: DEL is the same for both. circuit tension fell to zero immediately and rose only to 0. 9-8 . \vhen you flushed the circuit after setting DEL to zero. CKT falls to zero and then rises slightly in the flush technique. You can further analyze these two techniques by using Gas Man's Overlay feature. alveolar tension and vessel rich group tension were much lower after the circuit was flushed than when it was not. and VRG tensions to fall to a wake up level quickly. Because of this. Select Overlay from the View menu or click on the Overlay icon in the Toolbar. Keeping the second simulation open. However. ALV falls rapidly in the flushed circuit. alveolar. you see that despite the vaporizer being switched off. you will see that wake up occurs when the VRG falls to some threshold value. find the icon of the first simulation on your desktop and double-click to open it. In Chapter 13. ALV and VRG. inspired tension slowly fell to 0.22%. and VRG falls more rapidly with the flush technique. Then observe each compartment's tension over MAC by selecting in sequence in the left ("Show") column DEL. Select MAC in the right ("Over") column by clicking the radio button to its right. It is clear that with low FGF.35% by the end of 10 minutes.

O OVRGO OMUSO OFA.. ~.tO OVEr-tO 0:00 0:02 0:04 0:06 0:08 0:10 MAC® Time {HH:MMI One> 0 legend: o Cos! t ... £~()!~ .. .. J I. Show Over 2--~----------------------------~ o DEl 0 OCKT 0 ®ALV. JJ Figure 9-2d shows the Overlay View comparing the ALVjMAC curves with and without a flushed circuit.~!~.. Low Fresh Gos Flow Anesthesia Show Over o DEL 0 ®CKT 0 ALV 0 OVRGO o MUSO o FAT 0 OVEN 0 0:00 0:02 0:04 0:06 0:08 0:10 MAC ® Time (HH:MM) One 0 legend: o Cost Figure 9-2c shows the Overlay View comparing the CKTjMAC CU17JeS with and without a flushed circuit.. 9·9 .. .. .

.... In that case....... 10 SPEED .... Isoflurane shown at left .............. 9-10 ................... Semi-Closed..Gas Man® Low Fresh Gas Flow Ii nesthesia xercise 9-3 In an Ideal circuit... 3% FGF (L/min) ............. n. The ideal circuit represents what would happen if there were no gas mixing in the semi-closed circuit..a................... o SETUP ------------- For this Exercise.......................... 5 VIEW (min) ......... you will run two simu- Parameter Selection lations according to the parameters Agent ....... At very low fresh gas flows............ the ideal circuit behaves more and more like an ideal circuit..... 3 VA (L/min) .......................... Ideal DEL (%) ...... inspired ten- sion would approach delivered tension more closely.................. The behavior of clinical circuits lies somewhere in between that of the semi-closed and ideal circuit...first using a semi-closed circuit and then using an ideal circuit......... both circuits would behave similarly...... 60x Special ....................... As fresh gas flow approaches minute ventilation...... fresh gas fills the circuit first and then mixes with exhaled gas....... Circuit .. 4 CO (L/min) ......

:. In an ideal circuit. inspired rises to near 4% very quickly and then begins to level off. inspired rises exponentially toward the 5% set on the vaporizer.r-- %atm 0 / .-- VRG MUS - . This augments circuit concentration. because in an ideal circuit. This is expected...-I_-l FGF LIM :j DEL %atm :j en AlV .:. 9-11 ..:11d::.Gas Man® Low Fresh Gas Flow Anesthesia o OBSERVATION Agent: II soflur ane Circuit: ISemi·Closed I FGF LIM :j DEL %atm :j en ALV VRG MUS %atm Agent: !Isoflurane Circuit: t.:ea:.---- I I I I 0:02 0:04 0:06 0:08 0:10 View: 110 Min I!l Figure 9-3 shows the Graphs of Exercise 9-3. The Graphs from these two simulations (Figure 9-3) show that with a semi-closed circuit. simulating low jlow administration ofisojlurane in a semi-closed (toP) and ideal (bottom) circuit. augmented by the requisite exhaled gas to provide minute ventilation. inspired gas is comprised preferen- tially of fresh gas.

at least transiently. fresh gas flow can be decreased after the initial period of rapid anesthesia uptake without sacrificing control of inspired tension.as Flow lll1esl/zesia In low flow anesthesia. in which the patient breathes fresh gas in preference to exhaled gas. pushing the oxy- gen flush button clears the breathing circuit of anesthetic agent. If actual breathing circuits were not well mixed. as with high flow technique.Gas Man® Low Fresh (. 9-12 . Cost savings can be achieved while maintaining the same inspired anesthetic tension. To allow rapid lightening of anesthetic depth. and hence the same clinical anesthesia course. they could perform more like the Ideal circuit.

Unlike other anesthesia techniques. delivered or inspired tension is usually not adjusted directly. To achieve the same anesthesia time course with a closed system. no gases are allowed to leave the system other than carbon dioxide which is absorbed chemically. In a closed system. the rate of anes- thetic added to the breathing circuit is controlled. the desired anesthesia level will not be attained and the rate of administration will require modification. \t\Tith the closed-circuit technique. /~-~ I "\ Chapter 1 0 ( ) Closed-(. A prediction of anesthetic uptake based upon patient size allows the amount and timing of anesthesia administration to be de- cided before the patient's actual response is observed. anesthetic drug administration can be tailored to achieve the inspired. If the prediction is wrong. and uptake is observed by monitoring the required quantity adminis- tered. Rather. "With semi-closed and open breathing circuits. To understand a closed-circuit liquid-injection anesthetic induc- tion. inspired and expired tensions can be measured.I \ I \ / "---" o Closed-circuit anesthesia is a drug administration technique in which quantities of anesthetic are administered to the patient- breathing circuit combination in an effort to produce a constant level of anesthesia. inspired anesthetic tension can be controlled indirectly or di- rectly. uptake cannot easily be measured.Jr~~Anesthesia . alveolar or brain tension desired. Using these monitors. remember that the time course of inspired anesthetic 10-1 . The use of a moni tor for end-expired (or approximately alveo- lar) anesthetic tension allows this modification to be made easily. the inspired anesthetic tension should be the same as with any other system.

10-2 . For each of the volatile liquid anesthetics. 23. during both induction and mainte- nance. you can iruect liquid anes- thetic into the breathing circuit and allow it to vaporize there. you should expect the same time course of exhaled or alveolar anesthetic tension you observed before. The red-and-black syringe icon is located on the Gas Man Screen. One of the unique features of Gas Man is the ability to represent liquid anesthetic administration. A single click on the syringe will simulate liquid injection into the breathing circuit. Using the Gas Man computer simulation. The default unit dose of the liquid injected is 1.0 mL for desflu- rane.5 mL for halothane and isoflurane. Figures 7-1 through 7-3 in Chapter 7 provide guidelines for a desirable time course of inspired anesthetic tension. If you properly control the inspired tension. This "unit dose" should not be confused with the Standard Unit Dose. 24. You can administer these injections so that the inspired anes- thetic tension curve is similar to that produced with the semi- closed or open circuit. I mL of liquid will vaporize the following amounts: desflurane 1 mL liquid = 209 mL vapor enflurane 1 mL liquid = 198 mL vapor halothane 1 mL liquid = 228 mL vapor isoflurane 1 mL liquid = 196 mL vapor sevoflurane 1 mL liquid = 183 mL vapor. and 0. selecting Unit Dose. calcu- lated using formulas found in the closed-circuit anesthesia litera- ture22. and the circuit and inspired tensions rise as if liquid was instanta- neously mixed in the single breathing circuit compartment. attached to the breathing circuit. the plunger in the syringe moves. enflurane and sevoflurane. This can be adjusted by using the Anesthesia menu. and typing in the desired value.Gas Man® Closeri-Cirwil A 17esl hesia should be similar to that required for a conventional semi-closed or open-circuit anesthetic. vVhen liquid is irUected. The same holds true for the anesthetic tension in the brain.

.Gas Man® Closed-Circuit Anesthesia xercise 10-1 A closed-circuit liquid anesthetic injection induction can be simulated with Gas Man.................... Isoflurane Gas Man parameters as shown................... move the cursor DEL (%) ................ 5 menu................... n................... 0.25 two......... by selecting Unit Dose.....5 mL of liquid isoflurane................................................. 10-3 ...... liquid- Parameter Selection injection anesthetic induction....a. 4 can be changed with the Anesthesia CO (L/min) ............. 15 SPEED .... adjust the Agent .......... 5x Special .......... VIEW (min) ............ o SETUP To simulate a closed-circuit. To demonstrate a closed-circuit induction... The unit dose injected VA (L/min) ................. Closed click the Begin button... Each click will inject 0........................... Circuit ..... 0 an d click on the anesthetic syringe icon four times over a period of a simulated minute or FGF (L/min) ..

10-4 . demonstrat- ing four injections of 0.Id ~ Delivered {ll FGF VA CO Speed: I Continue LIm M LIm 1400 1 LIm ~ ~ Agent: !fsoffurane Circuit: IClosed FGF LIM DEL %atm i\l V MUS Zatm Figure 10-1 shows the Picture and Graph of Exercise 10-1.5 mlliquid isoflurane into the breathing circuit. Note in the Graph that inspired anesthetic tension reaches approximately 4% and then trails off to 1% near 7 minutes. Closed-Circllit A nesl hesi({ o OBSERVATION Agent: !Isoflurane =w I2!CJWeight (Kg) Circuit: '--_ _-'---' DEL 10 _00 1 CKT10_ 59 1 Zatm ~~I] ~ I 0:15:00 I Time (h:mm:ss) ±l ~UPtake{ll :i:J :.

Closed ing on the syringe icon at appropriate DEL(%) ........25 2a.................. 5x Special ....... Isoflurane injection....... n..... o SETUP To simulate closed-circuit induction and Selection Inaintenance at 1 MAC using liquid Agent ..................... CO (Ljmin) ..... click on the ....................... achieving and maintaining 1 MAC in the brain..0-2 Closed-circuit liquid injection can produce optimum anesthesia......... 5 times to produce anesthetic induction and maintenance similar to Exercise 7- FGF (Ljmin) ......... acljust the parameters as shown.... which demonstrated constant brain tension............. 10-5 .... Mahe liquid iTifectiol1s by click- Circuit ..... ...... 4 falls below the desired level......... 15 SPEED . Each time the inspired tension VA (Ljmin) .................................... VIEW (min) ....................... 0................a....... 5 synnge Icon agam....... C{osfd-Ci rru it A nesl/zesia xercise 1................................

10-6 .t. of liquid anes- thetic is required to elevate inspired tension and that 0.131 /0. Note the volumes delivered and taken up.oflurane Circuit: IClosed FGF 10 ~ LIM O--~--------------------------------------~ DEL %atm :~ A I :J~.-o-] %atm ~ CKTI U9 1 ALV~ ~ /1.01/ /0. and consider the potential monetary savings as well as the elegance of the technique. " You will note that about four injections.91/ ART VRG MUS FAT VEN / 0:15:00 I Time (h:mm:ssJ ~UPtake(L) ~ Delivered (L) Speed: FGF 1025 1 VA CO LIm .:.Gas Man® Closed-Circuit Anesthesia o OBSERVATION Agent: Iisoflurane L~l ~Weight (Kg) Circuit: IClosed L!oi Flush o DEL r:. showing a simulated closed-circuit anesthetic with isoflurane.5 mL increments are then required with decreasing frequency.d CKT ALV VRG MUS %atm 005 010 015 Figure 10-2a displays the Picture and Graph of Exercise 10-2. 01 1 LIm [J 110x Letl Agent: II. LIm /4. or 2 mL. Try similar inductions for enjlurane and halothane and observe results analogous to those shown in Figure 10-2a.17/ /°.

°°1 LIm ~ ~ Agent: IE nflur ane Circuit: IClosed FGF LIM DEL %atm en ALV VRG MUS %atm Figure 10-2b displays the Picture and Graph of Exercise 10-2.241 1°.60 I 11.601 11.701 10.341 ART VRG MUS FAT VEN I 0:15:00 I Time (h:mm:ss] ~UPtake(L] ~ Delivered (Ll VA CD ~ Speed: I. showing a simulated closed-circuit anesthetic with enflurane. 15 1 ALVI 1.011 11.! LIm 4 1 .Gas Man® Closed-Circuit Anesthesia Agent: IEnflurane I:!:! ~Weight (Kg] Circuit: IClosed L:!:j Flush o DEL %atm IHOI CKT12. Continue . " 10-7 .

Closed-Circuit Anesthesia

Agent: IHalothane I !l ~Weight (Kg) _J..l!->!
Circuit: I,-C_los_e_d

Flush
:tl 0
~

DEL
%atm 13. 3°1 CKTI1.011 ALVlo. 74 1 1°.741 1°. 83 1 1°. 09 1 10.°°1 1°. 65 1
ART VRG MUS FAT VEN

~]
~ 10:15:00 I Time (h:mm:ss)
f:l f:l ~ Uptake(Lj
!!d ±J ~ Deliyered (L)

FGF ~ VA CO
[J
Speed:
! Cont~n~e
lim 0.25 LIm 14.0 0 1 lim ~

Agent: IHalothane Circuit: IClosed

FGF
LIM

DEL
%atm

ALV
VnG
MllS

Figure 10-2c displays the Picture and Graph of Exercise 10-2, showing
a simulated closed-circuit anesthetic with halothane.

10-8

Gas Man® Closer/-Circuit AllCstizesia

o DISCUSSION
The closed-circuit anesthetic inductions you have just performed
are similar to those described by Lowe~~, and Lowe and Ernst2\
but use smaller, more frequent injections. Lowe's technique
requires standard unit dose liquid injection at predetermined
times based upon a model of the closed system, and on the
observation that nitrous oxide requirement decreases approxi-
mately in proportion to the square root of time 3li :

(1/~ t = 1/f1./2 = t -:1/2).

In the next exercise, you will administer closed-circuit anesthesia
"by the book".

10-9

Gas Man® Closed-Circnit it nesthesia

xercise 10-3

Liquid injection following the "t- 1/2" regimen is a classic closed-
circuit approach.

o SETUP
To simulate closed-circuit liquid injec-
Parameter Selection
tion anesthesia following the t- 1/ 2 model
Agent ....................... . with isoflurane, adjust the parameters as
shown. Immediately after clicking the
Circuit .......................... .
Begin button, administer a priming dose
DEL (%) ............................... . of 0.5 mL isoflurane by clicking on the
syringe icon. Interrupt the simulation by
FGF (L/min) ......................... . clicking Pause and adjust Unit Dose to
0.7 mL and click Continue. Next, click on
VA (L/min) ........................... .
the liquid syringe at 1 minute, 4 minutes, and
CO (L/min) .......................... . 9 minutes. You can use Special/Set
Bookmark to stop the Exercise at these
VIEW (min) .......................... . precise time intervals.
SPEED .................................. 5x

Special ................................ n.a.

10-10

Gas Man® C;losed-Circuit Anesthesia

o OBSERVATION
Agent: /Isoflurane L~J ~Weight (Kg) I
Circuit: Closed I±!

Flush
~ 0
.id

DEL rill
%atm ~ ALVlo. 90 1 10.901 11.031 ~ 10.011 10.801
ART VRG MUS FAT VEN

I 0:15:00 I Time (h:mm:ssl
~ Uptake(L)

~ Delivered (Ll

Speed:
1025 1 VA co
FGF
LIm . LIm l·tOOI LIm [::J I I±l

Agent: !Isoflurane Circuit: IClosed

FGF
LIM

DEL
%atm

CKT
ALV
VRG
MUS

%atm

Figure 10-3a displays the Picture and Graph of Exercise 10-3, showing
a completed 15-minute course of closed-circuit anesthesia with liquid
isojlurane, using predetermined times of administration following the
t-1/ 2 regimen.

Repeat the closed-circuit liquid injection technique with desflu-
rane and halothane. For deflurane, chose a priming dose of 2.0
mL and a unit dose of 0.9 mL. For halothane, chose a priming
dose of 0.5 mL and a unit dose of 0.7 mL. Again, make injec-
tions at 1, 4, and 9 minutes. These are examples of the classic
closed-circuit approach introduced by Lowe 22 and refined by
Ernst23 . Priming doses used here are smaller.

10-11

Gas Man® Uosl'd-Cirrll i/ AlIl's/ Iztsia

Agent: IDesflurane I~i ~Weight (Kg) Circuit: IClosed I:!: I

Flush
±l 0
:t{

DEL
%atm
CKT16.59 I ALVI6. 12 1 16 . 12 1 16 . 33 1 10 . 94 1 10.061 14.98 1
ART VRG MUS FAT VEN

I 0:15:00 I Time (h:mm:ss)
~ Uplake{L)

~ Delivered (L)

Speed:
FGF ~ VA co
lim ~ lim 14 . 02 1 LIm ~ ~

Agent: IDesflurane Circuit: 1Closed

FGF
LIM

DEL
%atm

AlV
VRG
MUS

%atm

Figure 10-3b displays the Picture and Graph of Exercise 10-3, showing
a completed 15-minute course of closed-circuit anesthesia with liquid
desjlurane using predetermined times of administration following the
t- I / 2 regimen.

Note that when using desflurane, the volume of the priming dose
exceeded the volume of the subsequent unit doses, while in
isoflurane and halothane, the opposite is true. This is because
desflurane's low blood/ gas solubility decreases uptake into blood
and tissues, but not into the breathing circuit.

10-12

Gas Man® Closeri-CirCllit Anesthesia

Agent: IHalothane L~l ~"'eight [Kg] Circuit: IClosed I!j

DEL 10. 00 1
%atm
CKTI 0.69 I ALV~ 1°.561 10.66! 10.06! [ilOO] !0.51 I
ART VRG MUS FAT VEN

I 0:15:00 ! Time {h:mm:ss]
~ Uptake(Ll

~ Delivered {Ll

FGF r;;-:;;;J VA CO
LIm ~ LIm [Ulii] LIm EJ
Agent: IHalothane Circuit: IClosed

FGF
LIM

DEL
%atm

CKT
AlV
VflG
MUS

%atm

Figure 10-3c displays the Picture and Graph of Exercise 10-3, showing
a completed 15-minute course of closed-circuit anesthesia with liquid
halothane using predetennined times of administration following the
t-1/ 2 regimen.

10-13

Gas Man® Closcr/-Cirruil Anesthesia

o DISCUSSION
The simulations in Exercises 10-2 and 10-3 have shown that liquid
anesthetic injection into the breathing-circuit can produce satis-
factory anesthesia. Viewing the vessel-rich group has shown that
anesthetic tension in the location of interest (the brain) follows a
relatively smooth time course. This is evident even when alveolar
and especially inspired tension changes dramatically between
injections.

ummary

Closed-circuit anesthesia with liquid injection into the breathing
circuit can produce the same time course of inspired anesthetic
tension, alveolar anesthetic tension, and brain anesthetic tension
that conventional high-flow techniques allow. The Gas Man
program allows various drug administration techniques to be
tested and visualized in simulation.

10-14

In Chapter 8 we learned that the concentration effect increases the alveolar concentration achieved by a gas of high concentra- tion as a result of its own uptake. 16 and reviewed well by Eger ll . This is called the second gas iffect. In order to study the second gas effect using Gas Man. w --~ Chapter 11 The see · 1 s Effect Uo If a second gas is administered along with a first gas of high concentration. and alveolar tension rise is unaltered by cardiac output. This effect causes alveolar tension to rise relatively higher when inspired concentration is high than when it is low. The second gas effect is composed of two parts. The concentration effect is most no- table with inspired concentrations above 70%. the ventilation iffect describes the increased inspired ventilation which restores lung volume after the large quantity of the first (high concentration) gas is removed. one for each agent: 11-1 . you will look at two simultaneous Views of the same simulation. no matter how high its value. When inspired concentration is 100%. the alveolar tension of the second gas achieves a greater height than if the first gas weren't present. First. the concen- tration iffect describes the higher concentration of the second gas after a large amount of the first (high concentration) gas is removed. This phenomenon was described by Epstein et al. Second. this effect is maximized.

Change the agent shown to nitrous oxide. A dialog box asks if you want to add an additional agent or change the primary anesthetic. In the new View. 2 Use the View menu and select New. Gas Man calls this the "primary" anesthetic. The uptake of one gas will correctly affect the other gas . change the Agent to isoflurane.Gas Man® The Second Gus EjJfY/ 1 Open a new simulation by opening the File menu and selecting New. You have now created two linked simulations. not a nevv simulation. Click on Add. This is a new view of the same simulation.the second gas effect. 11-2 .

o SETUP Select the first or "primary" view (by clicking in it or using the View menu) Agents.Gas Man® The ....... 5 "additional" view... To make the isoflurane VIEW (min) ...... In this way.. the top of the scale should also be set to this value (type "1" in the box aL FGF (L/min) ...... To best visualize the Exer- DEL (%) ...... set the isoflurane control to 1 %......................... Make sure the SPEED ...... 10 the top left of the DEL scale).... (non-rebreathing) circuit...... isoflurane and set the nitrous oxide concentration to 1 % (type" 1" in the box below the Circuit ......... Click Begin.......... 4 available vertical height......... there is little effect on the uptake of a second gas.. n.... Open DEL scale)................... 5 concentration more visible.......... the 1 % dial setting fills the entire VA (L/min) . In the second or CO (L/min) ............. Nitrous oxide. each 1% cise............. 11-3 ....a..............c..... AFAP breathing circuit selected is an Open Special .... set the top of the DEL scale to 1 %....................................................ccond Gas Effect xercise 11-1 --------------------------- With the concentration of the first gas 1 %.....

Note that in both views. 4.00 to approx. reduce both views to an icon by clicking in the down-arrow box in the upper right corner of each view.Gas Man® The Secolld Gas E/j(!c/ o OBSERVATION INitrous Oxide I±\ ~Wei9ht (Kg) Circuit: Flush 1:1 0 i:l iii DEL %:atm ~ AlVQJ QJ QJ QJ QJ QJ AAT VAG MUS FAT VEN I 0:15:00 I Time (h:mm: . Save this simulation (you will need to name it something).. 11-4 .I Flush 1:1 0 :i:l DEl f1. in which 1 % of both nitrous oxide and isoflurane were administered.) ~Uptake(l} ~ Deliyered (l) Speed: FGF IffiOl VA r.OO1 CKT~ AlV~ ~ §] ~ ~ ~ %atm L. Next.02 Lim.:. This increase occurred because the small uptake of both nitrous oxide and isoflurane enhanced inspired alveolar ventilation. albeit slightly.n:.:::::l AAT VAG MUS FAT VEN I 0:15:00 I Time (h:mm:ss) ~ Uptake(l} ~ Delivered (l) Speed: FGF IffiOl VA CO lim ~ lim ~ lim [ ] IAFAP I±j Figure 11-1 shows both Views of the Picture for Exercise 11-1.] CO lim ~ lim ~ lim [ ] IAFAP I±j Agent: !Isoffurane I~t ~Wei9ht (Kg) Circuit: IOpen I:!: '---'------" ... You will view these again later in Overlay mode... alveolar ventilation (VA) has increased from 4..

.....Gas Man® The Second Gas Effect xercise 1. Set the isoflurane control to 1 %.... Special .............. This time..just Parameter as you did in exercise 11-1.......... and nitrous oxide is the second gas.... Now... 11-5 .. This will be a reminder that isoflurane is the first gas FGF (L/min) ...... Mter you open Circuit ... change the agent in that DEL (%) .. the nitrous oxide control to 100% ni- trous oxide..... ... view to nitrous oxide.... .. Isoflurane.. the uptake of a second gas is enhanced dramatically. ............ Begin. ....... . whose uptake is augmented by the high VA (L/min) ............. ........................................ a second view.. set CO (L/min) ........... .1-2 When the concentration of the first gas is almost 100%..... concentration of the first gas.. ............ You will want the top of the VIEW (min) ...... Click SPEED . o SETUP Open a new simulation of two gases.. Agents..... for logic's sake. change the name of the first agent to isoflurane.... nitrous oxide scale to read 100% also..

a~-e-I---~-.-cu.J..I~'::. f Agent: INitrous Oxide I Circuit: LC--_---' IOpen VA LIM 1: t: CO LIM 1: 100 1 CKT AlV VRG MUS %atm 0:00 0:01 I 0:04 I 0:05 View: I 5 M..-.nuel Figure 11-2a shows the Graphs of both Views of Exercise 11-2. I:p-en---I~ I _~ ___ n 1~ 0t 0 ~-------------------------------------4 CO LIM 1: ~r--------------------------------------~ en ALV VflG MUS %atm View: I 5MinJ!i I Continue.-------------C. Observe the alveolar tension curves for isoflurane and nitrous oxide when 100% nitrous oxide is used as the second gas (Figure 11-2a) .-ofl-u.l I Cont.cl__-'--_______----1=lL!.Gas Man® The Second Gas F!j(!ct o OBSERVATION ~.n L~! ""Lt"". 11-6 . using 1 % isoflurane and 100 % nitrous oxide.

4 Observe alveolar over inspired by clicking on the ALV radio button in the left ("Show") column and the CKT radio button in the right ("Over") column. if you did not already do so when you ran the simulations). Reduce the isoflurane graph. 11-7 .5 minutes in your primary view. however.Gas Man® The Second Gas E1I.1C/ In order to compare the two simulations you have run in Exer- cise 11-1 and 11-2. With 1 % inspired nitrous oxide. First. leg~nd: Figure 11-2b shows the Overlay View comparing the A/I ratios for nitrous oxide in Exercises 11-1 and 11-2. Note in the resulting Overlay graph (Figure 11-2b) that the high concentration of nitrous oxide (100%) caused alveolar to closely approach inspired in the first few minutes. alveolar tension rises in a manner similar to other agents in low concentration. use the Overlay feature of Gas Man. 3 Choose Overlay from the View menu (remember to set the View time to . 2 Open the nitrous oxide icon from the previous Exercise. analyze nitrous oxide: 1.

administered in 1 % concentration. iconize the nitrous oxide windows and open both the isoflurane windows. This overlav is / shown in Figure 11-2c. isoflurane.t Once you have verified the concentration effect for the first gas (nitrous oxide). This is the second gas effect. The rapid uptake of the first gas (nitrous oxide in I % and 100% concentrations) has minimally and maximally affected the uptake of the second gas. you will notice that their graphs are quite different. 11-8 . The graph obtained in the presence of 1 % nitrous oxide (Exercise II-I) looks like any other 1% isoflurane graph. The graph of isoflurane in the presence of 100% nitrous oxide (Exercise 11-2) shows alveolar tension ap- proaching inspired tension a little more closely in the first few minutes. vVhen you do this. Figure 11-2c shows the Overlay View comparing the A/I ratios for isojlurane in Exercises 11-1 and 11-2.Gas Man® The Second Gas L'fjix.

........ This effect is ever more prominent as inspired nitrous oxide concentration approaches 100%."".. Open oxide plus isoflurane anesthetic at clini- cally relevant concentrations.. " " " " " " " " " .. n ...."""""". click Begin.. AFAP Spec i a I ." 5 SPEED """"""""". as FGF (L/min) "... Nitrous oxide......'erond Gas Effect xercise 11-3 The addition of 70% nitrous oxide enhances the rise of alveolar isoflurane toward inspired isoflurane concentration. Notice that the alveolar tension for isoflurane rises higher with 70% than with 1 % nitrous oxide.5 VI EW (m in) """.. isoflurane administered.....Gas Man® The ". " .a... CO (L/min) ". " ..... 10 before..... o SETUP Because 100% nitrous oxide is not com- Parameter Selection patible with life and should never be Agents.. " ."""""".".4 circuit. 1% new simulation and add a second gas. 11-9 . Use nitrous oxide 70% com- bined with isoflurane 1 %.. o OBSERVATION Overlay the isoflurane curve from Exercise 11-3 with the isoflurane curves from Exercises 11-1 and 11-2... Open a DEL (%) """".. " " " " ...""".""""".."..".. ..70%. and lower than with 100% nitrous oxide (Fig- ure 11-3).......""....... in this Exercise you will see the impact of administering nitrous Circuit. Using an open VA (L/min) """""""""...

GAS L.04 0:05 MAC 0 Time (HH:MM) One 0 Legend: o Cost EX111.-------------------------------. In this chapter. 11·10 . and 100% nitrous oxide a great eflect..H.5 OVRGO OMUSO o FAT 0 OVEN 0 0:01 0:02 0:03 0. 70 % and 100 % nitrous oxide. Show Over o DEL 0 OCta ® ®ALV 0 0. 70% nitrous oxide a moderate effect.~lph~J L{~:!9i~Lh_. One percent of nitrous oxide exerts almost no effect. in which the simultaneous administration of a second gas with a first gas in high concentration causes the alveolar tension of the second gas to rise higher than it would if it were present alone.Gas Man® 1--. you have studied the second gas effect. JI Figure 11-3 shows the Overlay of the isojlurane A/I cllroes from each of Exercises 11-1 through 11-3.. comparing the second gas effect of 1 %.

fast compartments drop to zero quickly while slow compartments take longer. Chapter 12 \ \) Patient yv:~k~--up ! ') \. At the end of a theoretical "infinite length" anesthetic. the vaporizer is set to zero and tissue tensions fall toward this zero value. or as inverted images of each other. while "slow" compartments (muscle. Dur- ing induction. v heory Wake up from a long anesthetic is analogous to induction. ~. For ernergence.zero. all tissue tensions would equal that set on the vaporizer.~~/ (-. vessel-rich group) arrive there quickly. 12-1 . Again. or wake up. "Fast" compartments (alveolar. This will be shown in this chapter's simulations. all tissue tensions again equal that set on the vaporizer . anesthetic tension in all compartments begins at zero. the course of anesthetic tensions during induction and wake up appear flipped horizontally. fat) take longer. At the end of wake up. Tissue tensions then rise toward the value set on the vapor- izer. When looked at graphically.

.......... Acljust the parameters as shown Circuit ............ and run the simulation for 10 DEL (%) ................... At the end of 10 hours........ 5 Run the simulation for 5 more minutes while observing the Graph...................... lOx Special .................................a.......................... VIEW min) . this Exercise simu- Agent ..Gas Man® Patient Wake UjJ xercise 12-1 Wake up is the inverse of induction........... Open at left..................... 10 hours... 9 hours (the fastest way to do this is to set View in the Gas Man Graph to 10 hours FGF (L/min) ....... 8 and run the simulation at AFAP speed)................. o SETUP To demonstrate that wake up is the Parameter Selection inverse of induction...................... 4 vaporizer (reduce DEL to 0 in the Gas CO (L/min) ........ SPEED ... AFAP.. s..vitch off the VA (L/min) ..... Desflurane lates a long anesthetic using an open circuit........... 12-2 ... 5 Man Picture) and change the simulation speed to lOx and View to 5 minutes.. n...

"-~--. Observe in the bottom graph of Figure 12-1 the effect of sud- denly switching off the vaporizer using an open circuit. .!:J LtU l!tl I . simulating patient wake up after a 10-hour anesthetic with desjlurane. Push the slider bar at the bottom of the Graph in the new view all the way to the left to see the first 5 minutes of the simulation.. You can view both Graphs on your screen by opening a second view using New View. Compare the two graphs and note their inverse relation- ship. Note that alveolar tension falls 66% of the way to zero in the first few breaths.Gas Man® Patient Wake [/1) o OBSERVATION .ue: I Figure 12-1 shows the Graphs of the first and last 5 minutes of Exercise 12-1. Agent: IOesflurane Circuit: 10pen 10 ~ VA LIM 0 10 ~ CO LIM 0 CKT AlV VRG MUS %atrn I I I 0:00 0:01 0:02 0:03 0:04 0:05 View: I 5 Minl.~nt~~~. 12-3 . ~-------.~ ~ I Agent: IOesflUJane Circuit: 10pen 10 ~ VA LIM 0 10 ~ CO LIM (I CKr AlV VRG MUS %atm 10:00 10:01 10:02 10:03 10:04 10:05 View: I 5 Mini:!:) IConti..t.

tension in fat would equal 100% of that in all other areas. 12-4 . fat ten- sion was approximately 33% of that in the other compartments. For this reason.Gas Man® Patient Wake Up o DISCUSSION Although these two graphs of induction and wake up are nearly identical inverted images. they vary slightly because the anes- thetic administration was not "infinite". alveolar tension was slightly closer to inspired than during induction (or after an infinite length anesthetic). that it is not visible on the computer screen or in the Figure. The difference between these two situations is that after the 10-hour anesthetic. The difference is so small. however. During wake up from the 10-hour anesthetic. the wake up curve here is actually slightly different from the induction curve. whereas after an infinite duration anesthetic.

. alveolar tension is relatively lower at all times with less soluble agents......& Desflurane three different agents at their clinically relevant concentrations............ 1..................a. 10 hrs.... At VIEW .......... 2...... and desflurane in the FGF (L/min) .......... sevoflurane in the second. change View to SPEED . but with Agents.. In this way you are using the agents in their order of solubility............ n...Gas Man® Patient Wake UfJ xercise 1...... 8 third.. DEL (%) . 10 hours 10 minutes.. you can see all three at once using Tile from the View menu)..... Sevo.05%... Run VA (L/min) ... 6% using isoflurane in the first.2-2 During wake up. AFAP...... 4 each simulation for 10 hours (you can CO (L/min) ......... Iso-.... 5 use Run All command from the File menu or click on the Run All icon)..... in each simulation. Run the simula- tions for 10 more minutes and then observe their Graphs (if you have a large screen............... Open three Circuit .... run the same simulation Parameter Selection as in the previous Exercise.. switch off the vaporizer. and set a Bookmark for Special .............2%..... 12-5 ... Semi-Closed simulations (and keep them open).......... 10 mins the end of 10 hours.... o SETUP In this Exercise................. lOx 10 minutes................

Gas Man® Patient Wake UtJ o OBSERVATION Keeping all three simulations open. simulating patient wake up after a 10-hour anesthetic with isoflurane. Figure 12-2a shows the Overlay ofALV/1\1ACfr0m the simulations run in Exercise 12-2. sevoflurane and desjlurane. 12-6 . use the Overlay feature to view anesthetic tension in the alveoli and the vessel-rich group normalized to MAG You will see that as solubility of the anes- thetic decreases. alveolar and VRG tension is relatively lower at all times during wake up (Figures 12-2a and 12-2b).

• ~_J~!i!~~~~. there will be more of a distinctive difference between wake up times of agents of different solubilities. simulating patient wake up after a 10-hour anesthetic with isoflumne. Although this is often 0. 0 o FAT 0 OVENO 10:00 MAC@) One 0 legend: O>Cost WAKEOES. 12-7 .5 @VBGO '0 MUS. sevoflumne and desflurane. wake up will always be faster. "Vhen MAC awake is lower.Gas Man® Patient H'alw UI) Because anesthetic tension is lower at all times with the less soluble agent."JI Figure 12-2b shows the Overlay ofVRG/MACfrom the simulations run in Exercise 12-2. Show ()OElO Oc:KTO OAlVO 0.GAS (Oesfluranel J Lc~~~ f-Ielp~_~~_ 1. The actual difference in wake up times will depend on the MAC level required for wake up. this factor can sometimes be lower.33 MAC in the VRG.

33 MAC in the ALV and VRG for each agent.5 9. These numbers are tabulated below (keep in mind these numbers are based on the parameters set in the simulations and actual clinical results will vary slightly): Time to Reach 0. the plateau heights seen in the first few minutes of anesthesia in Chapter 6 will provide plateaus during emergence. In each case. ummary In this chapter.33 MAC (minutes) ALV VRG Isoflurane 6. it can be inferred that kinetic comparisons among agents during induction will apply similarly during wake up. overpressure can be used to compensate for solubility. Wake up from less soluble agents occurs earlier than after more soluble agents. 12-8 . there is no way to use "underpressure" to compensate (the vaporizer cannot be set below zero) .9 Sevoflurane 2.1 Because wake up from a very long anesthetic is the approximate inverse of induction. you saw that wake up from a very long anesthetic is the inverse of induction. During wake up. Measure the time required to reach 0. however. Keep in mind that during induction.0 "1.Gas Man® P([lll'nl Wake Up o DISCUSSION Look at each of the Graphs in the simulations you ran in Exercise 12-2.4 6. Thus. comparing alveolar or brain tension curves during induction provides great insight into tensions expected during wake up.3 Desflurane 1. Because of this similarity. the fall in agent tension during wake up will mimic the rise during induction.

. cardiac output) which link these compart- ments. In addition. carbon dioxide production. However. That is. Gas Man scales alveolar ventilation and cardiac output as Kg 3/1. spontaneous alveolar ventilation. the flows that link the compartments are generally not linear4 • The effect of weight on many body processes (eg. By using the simulation capabilities of Gas Man. oxy- gen consumption. and oxygen consumption = 250 mL/min. the variation is surprisingly small. CO = 5 L/min. you can simulate inhalant anesthetic adminstration in animals. because you can vary weights in Gas Man to the extremes of very low or very high weight. volumes scale linearly with patient weight. while it changes compartment volumes linearly with weight (KgI). In general. For these reasons. Values for volumes and flows for a 70 kg patient are those found often in the literature: VA 4 L/min. cardiac output.Chapter 13 C) Patient Size / "- ! \ ~~ o Patient size affects the volumes of body compartments as well as the flows (ventilation. and fluid requirements) has been shown to be proportional to body weight raised to the 3/4 power. Within the normal range of human size. metabolic processes are proportional to Kg 3/4. you can experiment with the effect of different agents and ad- ministrations in patients of varying size. The fact that inter-compartment flows scale up less than compart- ment volumes as weight increases means that kinetic processes speed up in patients of lower weight and slow down in patients of higher weight. This is because most tissues are of reasonably uniform density. 13-1 .

..... simulate administering Parameter Selection 1 % isoflurane to patients of weights 10 Agent ............ Choose Run All from the File menu... CO (L/min) . Leave these simula- tions open in order to use them in the ..... 60........ 4 click on the Run All icon in the tool bar.... choose Overlay to observe their ......... 15 respective A/I ratios...... open a new simulation with isoflurane 1 %.. ....Gas Man® Patient S'izl' xercise 13-1 Kinetics is faster with patients of smaller size........... or VA (L/min) ......... o SETUP To see this effect......... 60 kg........... Open Open circuit...... 5 Now. 1 kg............................. and set body weight to 10 DEL (%) ........ 10.............. using an Circuit .. 10 60 kg and 120 kg patient respectively....................... 120 13-2 ....... "" . open two new simulations (not new Views) and set 1 % isoflurane with a FGF (L/min) ....... AFAP next Exercise .. First..... and 120 Kg...... " ..... Isoflurane kg.................. Next...... with the three simulations com- pleted.......

13-3 . Note in Figure 13-1 the progressive lowering (and secondary slowing) as weight is increases. Also note how small the differ- ence is within normal adult sizes. even when varying the weight as much as 60kg.Gas Man® Patient Size o OBSERVATION Figure 13-1 shows the Overlay of the A/I ratios achieved through administration of 1 % isoflurane to patients of 10. 60 and 120 kg in weight.

....... Run one simulation using Agent . 0.... Then choose Overlay DEL (%) .....1 Kg......................................... 1500 kg................ 15 SPEED ..................... lsoflurane the weight ofa large mouse............. 1 to view the results......................... o SETUP Add two more simulations to those from Parameter Selection Exercise 13-1... AFAP Weight (kg) ..... Open elephant.............1........ 0. 4 CO (L/min) ...... FGF (L/min) .............................. and another using the weight of a small Circuit ....... 10 VA (L/min) ...................Gas Man@ Patient Size xercise 13-2 Kinetics is faster with small animals than with large animals........... 1500 13-4 ...... 5 VIEW (min) ..............

\I\lhile the curve of a very small animal is quite different from human weights. as size increases. In a semi-closed circuit with limited fresh gas flow. 13-5 . Circuit volume in Gas Man can be adjusted in the Simulation Settings window of the Set Defaults command found under the File menu. larger circuit volumes are needed for larger animals. the effect can be dramatic. 10. 120 and 1500 hgin weight.5 OVRGO o MUSO o FAT 0 OVENO 0:00 0:05 0:10 0:15 MAC 0 Time (HH:MMJ One 0 legend: o Cost UntiUed3 (60 Kg} Untitled4 (120 Kg) Figure 13-2 shows the Overlay of the A/I ratios achieved through administration of 1 % isoflurane to patients of 0.Gas Man® Palienl Size o OBSERVATION Show Over ODElO OCKT @ . In addition to a high FGF. Figure 13-2 shows the curves of alveolar tension one would ex- pect in very small and very large animals.1.® AlV 0 0. These simulations all used an open circuit. 60. so the effect of anes- thetic uptake did not diminish inspired tension in the larger animals. the change in the curve lessens.

while flows are modelled as propor- tional to weight to the 3/4 power. vVhen this is done.Gas Man® Patient Size ummary In this chapter. Very large variations in weight are necessary to demon- strate significant changes in the time course of anesthetic ten- SIon. 13-6 . the alveo- lar tension curves for animals and patients slow as body weight increases. you have seen that volumes can be modelled as linear with patient weight.

Bottle size and Bottle cost can be set and changed using the Set Cost command under the Anesthesia menu. or simulate the effect of price changes. so that you can adjust these figures depending on your institution's actual costs. and choosing the Cost versus time curve for different agents or techniques. Gas Man enables you to analyze the cost of administration in two ways. You can also analyze cost by using the Overlay feature. Both FGF and DEL can be adjusted continually throughout a simulation as with an actual anesthetic. you can choose to view Cost instead of Volume in the Uptake and Delivered boxes located in the lower right portion of the Gas Man Picture. First. Delivered Volume in turn is the product of fresh gas flow (FGF) and the vaporizer setting (DEL). It is interesting to compare the "efficiency" of different agents by comparing Delivered and Uptake costs. Cost is affected directly by the anesthetic agent chosen but also by the adminis- tration technique used.Chapter 14 (j AnalYZi"ejbsY o Awareness of the cost of the anesthetic used in surgical proce- dures is increasingly critical to hospital practice. You can modify these values as prices change. The Exercises in this chapter demonstrate these features. The pharmacokinetics of an anesthetic agent and the resulting impact on the patient can lead to the actual cost of a particular anesthetic being quite different from the expectation based solely on price per volume. You can toggle the display of Cost or Volume by using the "$" icon in the Toolbar or choosing Show Cost in the View menu. Cost computations are done automatically in Gas Man by com- puting the product of Delivered Volume and Unit Cost of the Agent selected. 14-1 .

........ Semi-Closed serving the Cost data in the Picture................. reduce DEL to 1..Gas Man® tinalw:.. 60x ..................... 4 CO (Ljmin) ......... Isoflurane and watch the anesthetic tensions ap- proach 1 MAC in the Graph while ob- Circuit ........ Click Begin Agent ...... 5 VIEW (min) ... and continue the simulation through to 60 FGF (Ljmin) ..................5%.............. Keep this simulation open for later use.......... 2% .................... VA (Ljmin) . o SETUP Parameter Selection Set the parameters as shown at left...................................... Set a Bookmark at 13 minutes.......................ing Cost xercise 14-1 The cost to achieve and maintain 1 MAC of isoflurane in the vessel-rich group can be determined with Gas Man........... 8 minutes......... 60 SPEED .. At DEL (%) .......... Show Cost 14-2 .See Text 13 minutes......

tOlI lim [. 02 1 10 . which determined the cost of maintaining 1 l\-1AC of isoflurane for 1 hour. 05 1 10. 37 1 ART VRG MUS FAT VEN 11:00:00 I Time (h:mm:ssJ ~Uptake($) ~ Deliyered ($) Speed: ro-J VA co FGF lIm~ lim l. 33 1 10. Cos! o OBSERVATION Agent: I'soflurane I:!:) ~Weight (Kg) Circuit !Semi.Closed! ~ I Flush ~ 0 ±l DEL IL501 %atm cnl 1.35 I ALV11.J IAFAP \±1 Agent: Jisotlufane Circuit: ISemi-Closed I FGF LIM 1: ~ DEL %atm CKT AlV :~ VRG MUS %atm Figure 14-1 shows the Picture and Graphfor Exercise 14-1. 14-3 .Gas Man® A 11 {[[yzi liP.051 IL051 11.

you will note that ALV has reached 1 NlAC (the dotted line) at the end of 9 minutes 20 seconds.88 of isoflurane.70.00 per 100 ml. VRG has rcached 1 MAC and induction is considered complete. These adminis- tration costs are based on a bottle cost of US$78. After you reduced DEL to 1. 14-4 .5% and completed the 1 hour anesthetization.32 and Uptake cost (anesthetic uptake in patient tissues) was $1. you observed a Delivered cost of $30. which provided tissue uptake of $3.zing Cost o DISCUSSION By observing the Graph in Figure 14-1. you should have observed that the Delivered cost (anesthetic delivered to the breathing circuit) so far was $8.Gas Man® :i l7(1). vVhen you paused the simula- tion at 13 minutes. At the end of 13 minutes.26.

........... you will again simulate a 1 hour anesthetic with isoflurane... Semi-Closed eters as shown..... VA (L/min) ... 1 simulation through to 60 minutes..7%............... 5 VIEW (min) .... 5% ........... Show Cost 14-5 ........... and continue the FGF (L/min) ............See Text minutes. Set the param- Circuit ................................. Click Begin..... 60 SPEED ......... but Agent ............ At 13 minutes....... Set a Bookmark at 13 DEL (%) ......... 4 CO (L/min) ..... reduce DEL to 2.......................... 60x Special . Isoflurane with a higher vaporizer setting combined with a much lower FGF............................................ o SETUP Parameter Selection In this Exercise...Gas Man® Analyzing Cost xercise 14-2 Cost to achieve and maintain 1 MAC in the VRG is lower with lowerFGF........

32) and Uptake cost was $1. At this point.68. 39 1 10. compared with $30.nti~u~ 1 LIm 14.41 I ALVIl. At the end of 1 hour. 09 1 10.l ::t! ~ Delivered ($) VA CO Speed: I t.Gas Man® A /I(l/yzing Cost o OBSERVATION Agent: Iisoflurane I :!:J ~Weight (Kg) Circuit ISemi-Closedl ~l DEL %atm 12. 90 1 ART VRG MUS FAT VEN ~] ~ ~ 11 :00:00 I Time (h:mm:ss) Uptake ($) !:1 1:] Vi -~! +1 ~'. Delivered cost was $7.70 1 CKTI1.l01 §] 11. using a FGF of 1 L/min to achieve 1 MAC of isoflurane.!VlAC only slightly later (10 minutes) than in Exercise 14-1. resulted in ALV reaching 1 . 14-6 .88 in Exercise 14-1. 'while 1 Iv1AC in 'lRGwas again achieved by 13 minutes.17.62 (compared with $8. Reducing the FGF from 8 L/ min to 1 L/ min.o. the 8 L/ min administration was four times more costly than the 1 L/ min anesthetic while achieving the same effect.011 LIm ~ IAFAP I:!:l Circuit: !Semi-Closed I Figure 14-2a shows the Picture and Graph of Exercise 14-2. 02 1 10 . and increasing DEL to 5%. Delivered cost so far was $2. Therefore.

Gas Man® Analyzing Cost The cost advantage of low flow technique can also be discussed in terms of efficiency. the ratio of Delivered cost to Uptake cost after one hour was 8. first overlay ALV over MAC (Figure 14-2c). Select Cost from the left ("Show") column and One from the right ("Over") column. o DISCUSSION You can also compare Exercises 14-1 and 14-2 by using Gas Man's Overlay feature. Using a flow of 8 L/min at 2%.0 (twice as much anesthetic was used as was taken up in the tissues). 14-7 . Note that in the two simulations. ALVreached 1 MAC at the same time. overlay VRG over MAC and see that VRG tension reached 1 MAC at the same time in the two simula- tions as well (Figure 14-2d). To confirm that the anesthetic administrations in Exercises 14-1 and 14-2 were clinically similar. Note the difference in the slopes of the two curves (Figure 14-2b). Next. With both simulations open. Figure 14-2b shows the Overlay View comparing the Cost mrves in Exercises 14-1 and 14-2. while using a flow of 1 L/min at 5% results in a ratio of2.3 (eight times as much anesthetic was used as was taken up in the tissues). select Overlay from the View menu or click on the Overlay icon in the Toolbar.

14-8 .MAC curves In Exercises 14-1 (high flow) and 14-2 (low flow). Figure 14-2d shows the Overlay View of the VRG/.Gas Man® Analyzing Cost Figure 14-2c shows the Overlay View of the ALV/.MAC curves In Exercises 14-1 (high flow) and 14-2 (low flow).

............Gas Man® An({lyzing Cost xercise 14-3 Low flow techniques also decrease the anesthetic cost of new agents..... o SETUP Run two simulations similar to Exercises Selection 14-1 and 14-2...... 1 In the second simulation..............a................. Semi-closed the first eight minutes. n... 60 SPEED .. 60x Special ..... Desflurane mne.. ...... 4 first ten minutes and reduce it to 8% co (L/min) .............. set FGF to 1 L/ min and set the vaporizer at 18% for the ...... VIEW (min) ............ 4.... see text 7% for the rest of the hour................ In the first simulation set FGF to 4 L/min and set the vaporizer at 10% for ................................................ then reduce it to ............... but this time use desflu- ....... 14-9 . 5 thereafter................................

Cost o OBSERVATION >Show ··Over OOElO OCKTO OAtVO OVRG·O o MUs 0 OFA(O O'VENO .Cost Figure 14-3 shows the Overlay comparing the Cost curves of administer- ing desflurane with regular and Zowflow techniques.~AtYO One@ @.Gas Man® Ii nalyzing. 14-10 .

00 per 240 mL bottle of desflurane.68 These simulations show that the cost of anesthesia administration is more sensitive to FGF than to the agent chosen. Cost of One Hour Anesthetic FGF Cost Isoflurane 8 $30.. $78.10 Isoflurane 1 7.88 Desflurane 4 25. i.00 or less. quantitative and qualitative results may change.00 per 100 mL bottle of isoflurane and $70. assuming prices remain at these levels or lower. you will have documented comparative costs as shown in the table below. Of course. bottle prices in the marketplace can change. the maximum cost of one hour of anesthesia with FGF = 1 L/min is around $8. The prices used here are the prices of isoflurane and desflurane when desflurane was first sold in the USA. 14-11 .Gas Man® Alwlyzing Cnst o DISCUSSION When you have completed all four of the simulations in this Chapter. you would discover that desflurane is actually less expensive than isoflurane at these bottle prices. Nonetheless.e. if you compare the costs of closed circuit anesthesia with isoflurane and desflurane. Indeed. As prices change.02 Desflurane 1 8.

cost is more sensitive to fresh gas flow than to agent chosen. All the variables necessary to compare costs can be adjusted in the program . length of induction. Questions and answers are limitless.vaporizer settings. agent supply costs.Gas Man® Analyzing Cost ummary Gas Man allows cost comparison between agents and among techniques. gas flow. 14-12 . In general.

Most of the features listed in Table 15-1 have been described in other chapters of this Manual.0 was first written. For instance.1.0/2. and will continue to be the focus of future releases. In this first section.. Many of these fea- tures were a natural benefit of the Windows™ platform for which Version 2.0. But additionally. ----~- Numerous features have been added to Gas Man since Version 1. The Flush function and the Ideal circuit are demonstrated in Chapter 9.0 for the Macintosh was released in 1989. Table 15-1 lists those features which are new in Version 2. using multiple windows and setting bookmarks are explained in Chapter 2. .0 was to provide a broader and deeper set of analytical tools which would make the Gas Man model even more useful to students. the goal in Version 2. teachers.1 compared to Version 1. you will explore the following in more detail: • Setting program defaults e Overlays • Printing options " Data export. and practicing anesthesiologists. This goal was further served in Version 2. some of these features are reviewed quickly. The use of multiple agents is introduced in Chapter 11. Patient Weight is the subject of Chapter 13 and analyzing Cost is covered in Chapter 14. 15-1 .-----------------------.roduction. In the rest of this chapter.

0/2.0/2.l. and save and replay ED Multiple Views of same simulation ED Multiple simulations run concurrently • Multiple agents can be used in same simulation '" Adjustable scale heights '" Compare and contrast through Overlays • Analyze Cost of agents and techniques '" Adjust Patient Weight from O. 15-2 ./'fes Gas Man Features New to Versions 2.1 ED Windows™ platform '" Color Picture & Graph ED Context-sensitive Help • Split Window for simultaneous display of Picture & Graph '" Replay simulations o Save simulations '" Bookmarks o Adjust parameters during simulation. New features found in Gas Man 2.Gas Man® Advanced Feal1.05kg to 1500kg e User controls over program defaults for all settings '" Expanded Print output options '" Ideal circuit option '" Flush agent from breathing circuit '" Liquid injection in semi-closed circuit '" effect Table 15-1.

VA and CO scales in the Picture will change the height of their graphs in the Graph window. For instance. 15-3 . VRG. The Exercises in this Manual all assume that the total flow into the circuit is determined by the FGF setting. VA and CO) . ALV. When you change the height of the DEL scale. For a particular simulation. The default height for each scale is set in the system and adjustable using the Set Defaults command from the File menu (see p. FGF . VAPORIZATION EFFECT The Enable Vapor command found under the Special menu allows you to simulate effective gas flow. Similarly. This feature allows you to make the Graph more useful by choos- ing a y-axis height that maximizes the visibility of the tension traces. You can design experiments with Gas Man to study this more closely.Gas Man® !\r/1J{{llced Fmtllres ADJUSTABLE SCALES The heights of each of the scales in the Gas Man Picture can be adjusted. Actually. 15-5). without including the additional volume of gas provided by the anesthetic agent added to the fresh gas flcnv. the anesthesiologist will naturally adjust the vaporizer downward to main tain desired tension. the height of the DEL scale set in the Picture determines the height of the y-axis of the compartment tension and DEL portions of the Gas Man Graph. adjusting the height of the FGF. The result is that anesthetic cost changes little. it seems logical that enabling agent vaporization would make an anesthetic administration more expensive. ART. the height of each of the body compartments changes accordingly (CKT. and thereby the level of anesthesia received by the patient. FAT and VEN). because the addition of vapor to the breathing circuit increases inspired tension. you can change the scale heights by typing in a value in the box at the upper left of each scale (DEL. Gas Man is used without this effect. Generally. MUS. In addition. This new feature in Gas Man allows you to study the effects of agent vaporization.

Open the Gasman. To do so. In the Appendix of this Manual.. To add an agent. it will probably open automatically). Menu Bar commands are used for individual simulation settings. Adjusting the INI file should be reserved for changing system-level defaults because of new information. you will find a record of the Gas Man System Defaults as they are set when the software is shipped. or to set and save your personal settings in the way you like to use Gas Man. a standard accessory included in Windows™ (if you double-click on the INI file from the Windows File Manager. If you make changes to your INI file and later want to restore its original settings. or even user-invented agents can be added to the Gas Man program by editing or adding to the Gasman.INI file and study the format and syntax carefully. halothane. nitrous oxide and sevoflurane. 15-4 . In examining the INI file you will notice many of the values which can be adjusted through various Menu Bar commands.INI file in the Gas Man directory. use a text editor such as Notepad. refer to this section. isoflurane. other existing agents. the following guide may be helpful: . enflurane. Because Gas Man offers several different ways of adjusting these values. simply type in the name in the anes- thetic list under [Agents]. nitrogen. The Set Defaults commands are used for a long session of multiple simulations. New agents. and list its attributes in the same form as the other agents' attributes are listed.Gas Man® Advanced Features ADJUSTABLE AGENTS & VALUES Gas Man comes with the following anesthetic agents identified and programmed: desflurane.

Print Select.GAS Simulation Settings ... Ctrl+O ~Iose . The first option is Program Settings. Print Preyiew Print Setup . A dialog box will appear when you choose this option enabling you to: • pick whether or not you wish an audible signal to sound with each passing minute of a simulation (assuming you bave a sound card in your computer).. GAS I E~it I Figure 15-1a shows the options available for the Set Defaults command...f.Gas Man® Advanced FMturcs etting Program Defaults An important feature of Gas Man 2...ave Ctrl+S Save As . as described below. 15-5 . Run Run All erint.Edit Anesthesia Qel New Ctrl+N Qpen .. Set Qefaults Program Settings View Settings 1 WAKEDES.GAS Patient Settings J WAKE ISO. WAKESEVO.s.1 is that it enables the user to make adjustments to the default settings and values the program uses to run simulations.. You can choose which of your system sounds to use for this effect.tile . The Set Defaults command under the File menu has four dialog boxes. --..

. etc.abels . set the th ickness of the Graph lines (the Figures in this Manual are all done with a thickness of two).. .!'f! o System 1 o System 3 o Beep o System 2 o System 4 ["...~.J}. turn Graph Paper on.tS.. A setting of 67% means that in a 15-minute view. set \vhether line labels OIl the Graph (1 for inspired.. This may be helpful to viewing the graphs on certain monitors or projectors.Q.1 Figure 15-1b shows the Program Settings dialog box. which puts a gray shading behind the Graph display... .ldvallced Fpa/ures @l. The View Settings dialog enables you to set defaults for how the Picture and Graph will appear in each new simulation you open.ThiCkness One @Two o Three I GraPh Jump Eercent· Use o .aph (jne _.~I. £il~~._---'I=""-J_~Lt~ ·67 Paper L. determine how far to the left the Graph will 'Jump" when you are scrolling through a simulation whose View setting is shorter than the total simulation length.Gas Man® .) never appear (Off)._. always appear (On) or automatically appear (Auto) when there is room or when you are using a monochrome monitor. . You can set defaults for: 15-6 .--·. I rL=!'~. A for alveolar.raPh line 1.!iraph I .. @Off OOn o Auto I ro". each movement of the scroll bar will jump the view 10 minutes (67% of 15 minutes) to the left.

Figure 15-1d shows the Simulation Settings dialog box. VA and CO e the length of the simulation View e whether Show Cost or Show Volume is enabled • whether Graph scrolling is enabled (this command is also available under the Special menu). e the height of the scales for FGF. The Simulation Settings dialog box enables you to set the de- faults which will be active each time a new simulation file is opened: the fresh gas flow for a semi-closed circuit the circuit volume the simulation speed the circuit type the anesthetic agent. 15-7 .Gas Man® Adv(mccd Features Figure 15-1c shows the View Settings dialog box.

The Patient Settings dialog box enables you to make detailed adjustments in key characteristics of the patient: e patient weight (and whether the display will be in kilo- grams or pounds) compartment volumes for each compartment (to change the values which are set automatically by the program according to weight) flow percentages (distribution of vapor absorption by the vessel-rich group. muscle and fat) • patient metabolism (alveolar ventilation and cardiac output .again giving you the option to alter automatic settings) . 15-8 .Gas Man® Advanad Fm/ures Figure 15-1 e shows the Patient Settings dialog box.

The Gas Man Overlay allows you to instantly compare single variables across multiple simulations. Several of the Exer- cises in earlier chapters of this Manual used Overlays to analyze the results. but they are easily repeated and instantly displayed. That is. To save an Over- lay image. The legend underneath tells you which line corresponds to which simulation. to show alveolar over inspired (the A/I ratio). and ratios of any two simulation parameters for one or multiple simula- tions. and time as its x-axis. graphical interface. The two columns of radio buttons construct display commands in the "show X over Y' syntax. Overlays cannot be saved or printed from ·within Gas Man. For overlaying multiple simulations or views. Overlay will assign different colors to each simulation's trace. using an intuitive. This is important to remember to ensure you achieve the visual display you seek. The graphical display uses the value or the ratio as its y-axis. you select the radio button to the left of ALV (in the Show column) and the button to the right of CKT (in the Over column). adjust the View time of the active simulation accordingly. use the Print Screen command from your PC keyboard and paste the image into a presentation or graphics program.Gas Man® Advanced Features sing Overlays The most powerful and useful new feature of Gas Man 2. If that is not the time view you want in the Overlay. 15-9 . The View time view in the Overlay window matches that set in the Graph of the active simulation. Overlay will use the View time from the simulation currently selected. If you are com- paring two simulations with different View times. The Overlay window consists of a graphical display area and two columns of radio buttons.0 is the Overlay function.

You \Nill see a straight line running across the full 15 minutes at the level of DEL=2. run a standard simula- tion (such as 2% isoflurane for 15 minutes). and 2 divided by 1. function. CKT 0 OALV 0 OVRGO o MUSO ····0 FAT 0 OVEN 0 MAC@ One. .J~9~~~~~.~~J 1.~~. choose "DEL over MAC". As you move from "CKT over MAC" down to "FAT over MAC". you will note similar curves.15 equals 1.73. You will see the time course of anesthetic tension in each compart- ment as it approached 1 NlAC in the simulation.73. First. You will see the straight line running at a value just below 2. Click on the Overlay icon in the Toolbar or select Overlay from the View menu.Gas Man® Advanced Features To get c familiar \'\Iith the Overlav.15. 15-10 . It is in fact at 1. one by one. Next. J Figure 15-2a shows the Overlay of CKr/MAC in a simulation of 2 % isojlurane for 15 minutes. select "DEL over One". but the vertical axis scales get lower in heigh t as you go through the compartments. since the MAC ofisoflurane is 1. 0 o Cost H!IE". Now show each of the compartments over MAC. Show Over ODEL 0 <!>.

look at the relationship between compartments.Gas Man® Advanced Features Choosing "Cost over One" will show you the progress of anes- thetic cost through the simulation. Figure 15-2b shows the Overlay comparing ALV/DELfor 5% halothane and 8% sevoflurane in open circuits. see Chapters 5 and 6). Selecting "ALV over CKT" will produce the A/I ratio. Run two simulations in open circuit. one with 5% halothane and the other with 8% sevoflurane. Many of the Exercises in this book have used this feature. Create an Overlay of "ALV over DEL". "CKT over ALV" displays the overpressure ratio. 15-11 . "VRG over CKT" shows the slower rise in the vessel-rich group. You will see from the display that sevoflurane is a much less soluble drug than halothane (for more information. A simple ex- ample would be as follows. Next. Overlays are particularly useful for comparing agents.

The data from Gas Man simulations can be output to a spread- sheet program. set paper size and orientation. The printout lists all changes made to these settings during the course of the simulation. and translate well across the PC and Macintosh platforms. sharing and presenting your findings developed . patient weight. and when the changes were made. date and time of the printout. The Print Select command allows you to choose which tables and figures you wish to print: e Printout. which brings up the usual vVindows dialog box that allows you to set your default printer. re-colored) in most presentation and graphics software. The table includes the name of the siumulation file. which produces a tabular record of the currently active simulation. and the values for the parameters DEL. These images can be edited (cropped. VA. Start with Print Setup. annotated. Any screen image can be copied using the Copy Selection com- mand (Ctrl+X) and pasted into your presentation or word pro- cessing files. There are four commands under the File menu related to printing. agent and circuit used. FGF. Graphs. which records on a full page the time course of all 15-12 .Gas Man® Advanced Features rinting & Export Options Gas Man has a number of printing and output options that are particularly useful in recording. as described in the next section.vith the program. o PRINTING A full record of a Gas Man simulation can be printed on your laser printer. and other options. CO. amount of liquid injected (if any). choose a new one.

Whatever you select through this dialog box will remain selected for all subsequent simulations until you close the program. select which pages you wish to print. 15-13 . You can zoom in and out. VA. Note that the view time of this printout will match the current Vie'IV of the open simula- tion when the Print command is invoked. and a graph with all five compart- ment tensions (thus displaying more than the Gas Man Graph screen display). o DATA EXPORT Another important feature of Gas Man that assists you in analyz- ing your experiments is the ability to export data into other software programs. If you know what you want to print without needing to usc Print Select or Preview. and go directly to the Print dialog box from Preview mode. like Microsoft® ExceFM or Lotus 1-2-3®. Graphs and/ or Screen Image).Gas Man® Ar/r l (lIIccd Fm/ures four parameters (DEL. Once the data is in a spreadsheet. go directly to the Print command. The data contained in a Gas Man simulation can be exported to a spreadsheet program. Note that some printers may not be able to handle the complex data in this image. which prints out a bitmapped image of both the Gas Man Picture and Graph on one page. Check to see if the correct printer is identified. Print Preview will display on the screen the pages you have selected to prin t (Printout. you can create your own custom tables. ALV and VRG. Screen Image. reports and graphs that may meet your needs better than the Overlay and Print functions which Gas Man provides. by using the Copy Data (Ctrl+C) com- mand from the Edit menu. a graph withjust CKT. in which case you can use the keyboard Print Screen function to paste an image on your screen into a presentation or graphics package. FGF. Note that you can reach the Print Setup window through this dialog box if you need to make setup changes. CO). view them one page at a time. and the number of copies.

512 12. highlight the leftmost cell where you want the data from Gas Man to begin.800 3.004 0. switch to the spreadsheet. or use the Copy Data command. A line of data will appear in a single row running to the right.718 1.008 1. A second row of data will appear.803 5.519 3. time.316 0.900 2.900 2.30 41. Your spread- sheet 'williook similar to that pictured in Figure 15-3.603 2. Delivered in dollars. 15-14 .971 0. select the row underneath the first row. DEL. You should note what the headers are and save them in a spreadsheet file for future use. Repeat this a few more times. Delivered in liters. copy the data.030 1.592 1. 2 Open a Gas Man simulation and run it for 15 minutes.635 0.695 0.594 1.281 0.893 1.Gas Man® Adv([lIr:ed Features To practice data export. A 1 Minutes IILV MUS FAT Y£M Uptake L 2 0:15:00 2.152 0. FAT.900 2. Pause.21 23.015 1. MUS. and type Ctrl+V or use the program's Paste command or toolbar icon.523 0.29 51. F""i"Note: Gas Man does not export the header information along with the data.16 5 0:55:00 2. or plot new data relationships using the spreadsheet's graphics tools. Now that the data is in the spreadsheet.871 0. ALV. Uptake in dollars. VRG.92 3 0:25:00 2.012 2.20 4 0:45:00 2. follow these steps: 1 Open a spreadsheet program with a blank file.76 6.480 2.44 5.900 2. From left to right.325 10. 3 Type Ctrl+C. 4 Switch to the spreadsheet. and paste again.04 6 Figure 15-3 shows a spreadsheet constructed from a series of data readings exported from a Gas Man simulation using Copy Data.031 1.639 1. CKT. and Uptake $). DEL. YEN.473 0.521 1.56"3 1. the headers are: Minutes. 5 Switch back to Gas Man and run the simulation for a few more minutes. Uptake in liters.919 1.08 13. you can select subsets of the data (for instance.

Smith. Ashman. and Mapleson 2G . and Beneken 44 used a multiple model approach to study the interaction of circulation effects and anesthetic uptake in 1972. In 1967. et a1. and Brandstater 15 established minimum alveolar concentra- tion (NIAC) as the standard of anesthetic potency. In 1963. 16 described the second gas effect. anesthetic solubilities. This section describes this development and annotates the bibliography included in this book. In 1950 19 and 19512°. and has paralleled the development of our understanding of the subject as well as the capabilities of computer hard- ware and software. In the same year. and flows between compartments were clearly explained. Munson. whose anes- thetic partial pressures tended toward equality. In 1963. Blesser and Epstein I used a nonlinear model for halothane uptake in humans. Eger and Guadagnil4 developed a model for anesthesia administration at constant alveolar concentration. Munson. He I . Munson and Bowers28 simulated the effect of hyperventilation on the rate of cerebral anesthetic equilibration. MacKrelJ25. The effects of volumes. Modeling & Simulation of Anesthesia Uptake & Distribution --------"---. Zwart. Eger. Eger9 . In 1968. Eger A-I . Numerous investigators have added further sophistication to computer simulations by considering various physiologic effects.--"-----. Eger described the concentration effect lO • In 1964. each wrote descrip- tive computer simulations of anesthetic uptake and distribution at constant inspired concentration. The simulation of anesthesia uptake and distribution has been developed over the last forty-five years. In 1973. Epstein. Kety presented a physical and mathematical represen- tation of the dvnamics of anesthetic tension equilibration in the body. In 1970. In 1965. using large computers. and Bowers29 simulated the effects of changes in cardiac output and distribution on the rate of cerebral anesthetic equilibration.---. /~~ I \ Appendix \~'----~ /\ U o volution of the Understanding. Eger. suggested that the body be modeled as several compartments. Saidman.-.

allow- ing the simulation's graphs to be smooth. and regional blood flows. Borgsteclt and Gillies 7 reassessed the evolution of computer simulations in anesthesia and simplified the model to four patient compart- ments. since it is easily transported in the form of a computer disk. In actuality. Cowles. et al. the patient is modeled as four compartments: the lung. a Jarge computer is not required.". The ability to maintain anesthesia depth with automated anesthetic vaporizer control has been demonstrated. It has an advantage over physical hydraulic models. and in- versely proportional to compartment capacity. The Gas Man program was specifically written as an educational tool to teach the fundamentals of anesthesia uptake and distribution:. In Gas Man. It is more versatile since it graphs results and has special educational features (optional removal of anesthetic from venous blood. the breathing circuit is a fifth.Gas Man® AjJjmld ix and Bowers:\(} studied and simulated the effects of anesthesia-depressed ventilation and cardiac output on anesthetic uptake. o THE Gas Man® APPROACH In 1973. The uptake and distribution of inhalation anesthetics depends upon nu- merous parameters and variables. vessel- rich group. The mathematics of the Gas Man program follow an approach similar to that of Cowles. the change in anesthetic tension is proportional to the difference between entering and exiting anesthetic quantity. The simulation uses Euler's method of solution for the simultaneous differential equa- tions 37 . Mapleson~7 integrated circulation time into his digital computer simulation. Closed-circuit simulations have been performed. the interval time is split in half. For each compartment. The model embodied in the Gas Man program utilizes standard values for organ volumes. muscle. that is. the value of A-2 . optional concentration effect. Unlike most other simulation programs. The volume of the functional residual capacity of the lung is held constant by increasing inspired or expired alveolar ventilation. anesthetic solubilities. as shown in Table A-I. mass is conserved. and optional vaporization effect). and fat. Nonlinear models con- tinue to be used. In that seune year. If anesthetic tension in any compartment were to change more than 20% during a single time slice at which tensions are computed. It stresses partial pressure difference as the driving force for equilibration.38 . with linear coefficients that govern the five-compartment system.

1 Tissue/Gas partition co£jjicients MAC 110 1. Values for isoflurane. 1981 2:1• Values for nitrous oxide and enflurane are taken from Eger.5 Blood 5. Table A-I.01 2. - co£jjicients (calculated) Blood/Gas 0.30 1. 1980.76 0.42 4.0 2.80 0.0 3.5 0.69 1.070 Tissue/Blood partition .90 2.29 1.65 0. A-3 .54 1.42 0.00 150.000 Notes: Values for volume.10 0.40 0.15 2. Values for nitrogen al-e taken from Weathersby and Homer.94 1.014 Fat 14.95 53.89 1.47 1.00 34. Gas Man® each of these parameters is at best an estimate for any patient.65 0.1 200.80 4.37 2.00 0.69 0. Targ and Eger 45 .97 2.73 30. Model Parameters in Gas Man 2.47 0.00 13.90 2.014 VRG 6.010 Muscle 33.714 Muscle/Blood 1. halothane.47 1.42 0.30 36.0 Delivered Circuit 8.18 0.7 0.30 1.14 • Values for sevoflurane are taken from the package insert and Abbott data.8 6.1.16 60. flow and relative flow are taken from Lowe and Ernst.10 2.08 70.90 0.50 4. 198112.014 Brain/Blood 0.11 1.47 0.60 9.000 Fat/Blood 2.06 1.0 Alveoli 2.80 0.90 0.31 3.1 1. Model Parameters for Gas Man as set in Version 2.00 63. Users of earlier ver- sions of Gas Man should note that the values of some of these parameters are slightly different.47 1.54 4.84 33.30 0.42 2. desflurane and sevoflurane are taken from Yasuda.0 0.00 0. but they are representative enough for teaching and exploring anesthesia concepts.21 5.

These can be simulated in Version 2. ORGAN BLOOD FLOWS Blood flow to organs is known to change in certain clinical situations.0 and 2. tissue and blood solubility variations are possible. and the depressed cardiac output and alveolar ventilation secondary to deep anesthesia.Gas Man® AjJjJelulix urther Considerations on the Use of Gas Man® Some advanced features of anesthesia uptake and distribution have been added in Versions 2. drug metabolism. and muscularity obviously affect compartment volumes. hyperventilation causes cerebral vasoconstriction and hence slowed anesthetic transfer from blood to brain. Similarly. Obesity.1 of Gas Man. The ability to change tissue volumes and their relative flows allows the user to simulate several interesting clinical phenomena. such as: cachexia and its effect on tissue volumes. incomplete tissue mixing. Specifically. intertissue diffusion. tissue volumes can deviate markedly from those in the standard default Gas Man model.limited by computer resources. by the natural variations in clinical settings. Gas Man is necessarily a limited simulation model.1. and by the need to presene Gas Man's educational simplicity. A-4 . or nonpulmonary drug excretion. cachexia. ORGAN VOLUMES In certain chronic conditions. Excitement (stage II anesthesia) increases muscle blood flow and changes the time course of induction as well. Gas Man does not include the effects of shunts and dead space. the altered perfusion which accompanies hyperventilation and excitement.

dead space has been taken into account by allowing selection of alveolar ventilation rather than total lung minute ventilation.Gas Man® ilfJ pen di x During deep anesthesia. Clinical circuits act as if they fall between the ideal and semi-closed circuits that are simulated with Gas Man. INTER-TISSUE DIFFUSION il-5 . relative blood flows and alveolar ventilation to observe these effects. These shunts slow anesthesia induction with blood-insoluble agents. In a real breathing circuit. In the Gas Man model. When anesthetizing large animals. Dead space affects anesthetic induction. decreasing effective ventilation to the alveolar space. cardiac output decreases with most agents. SHUNTS AND DEAD SPACE Within the lungs. Some of these effects have been programmed to occur auto- matically in other simulation programs. because the fresh gas flow enters near the inspiratory valve. BREATHING CIRCUIT The semiclosed circuit simulated in the Gas Man program assumes perfect gas mixing and instant vaporization of injected anesthetic liquid. Adding a mixing device makes a real breathing circuit function more like the ideal circuit modeled. Anesthetic depth also changes alveolar ventilation during spontaneous breathing. intrapulmonary shunts may allow the delivery of venous blood to the arterial system without equilibrating with alveolar gas. This can be simulated in Gas Man by changing circuit volume by using the Simulation Settings dialog under the Set Defaults command. Gas Man allows the user to adjust cardiac output. Completely unmixed gas in the breathing circuit has been simulated as the Ideal cir- cuit. gases administered to the patient are typically incompletely mixed and contain a preponderance of fresh gas early in each breath. a larger breathing circuit and resevoir bag are often used.

This program should never be used to govern patient care. it is a close approximation.Gas Man® Inter-tissue diffusion may occur between fat and muscle. instead. it is a powerful tool for educational simulation. this effect has been ignored in the Gas Man model. Further. but also has its limitations. Instead. Gas Man does not account for all the phenomena known to affect anesthesia uptake and distribution. A-6 . o SUMMARY The Gas Man theory and program are a natural outgrowth of the work done in the last forty-five years on the computer simulation of anesthesia uptake and distribution. Many physiologic subtleties have been ignored to preserve the simple educational value of the program. L. the quantity of anes- thetic taken up by the arterial blood volume has not been included in Gas Man's calculation of uptake.occurs in each oro-an. It builds on the foundation of earlier models and has important advantages.1 minutes. it is assumed that complete mixing. b and that anesthetic tension evervwhere within I each organ is equal to anesthetic tension in the outt1owing venous blood whose volume is a part of the organ volume. Circulation times between sequential compart- ments are all 0. Although this is not exactly true clinically.

MAN.1 Bo ttleCost= 122 BottleCost=15 BottleCost=72 BottleSize=240 BottleSize=240 BottleSize= 100 i\. found in the Gas Man directory.Gas Man® AjJjJendix as Man System Defaults The following is a listing of the data in the file GAS.7 MAC=0.54 VRG/Gas Parlilion Coefficienl MUS=0. Sevoflurane. Use this listing for reference.Isoflurane.8 MAC=1.8 VRG=4. as it is configured on the Gas Man program disk when you first receive it.Enflurane.INI. Agents=Desflurane.9 MAC=1.5 DefUnitDose=0.-7 .9 Lambda=2A7 Lambda=1./Gas Partition Coefficienl FAT=13 FAT/Gas Partition Coefficient Max=90 A1aximwn value jbr vajJorizer tOj) High=18 High end of vaj)orizer scale Default=9 Default vaj)orizer setting DefU ni tDose= 1 Unit dose of liquid injected Volatility=209 Vapor/Liqu.3 VRG=2.id volume ratio (2(I'C) MAC=6.Halothane.0 ALAC value BottleCost=70 Bottle cosl in $US Bo ttleSize=2 40 Bottle volume in mL [Enflurane] [Halothane] [Iso flurane] Lambda=1.Nitrogen [Desflurane] Lambda=OA2 Blood/Gas Partilion CoeJJicienl VRG=0.Nitrous Oxide.5 Volatility=198 Volatility=240 Volatility= 196 Max=33 Max=25 Max=25 High=7 High=5 High=5 Default=5.7 Default=3.3 Default=2.97 l\IIU'.6 MUS=9.8 VRG=2. The data for the first agent is annotated.5 FAT=63 FAT=150 FAT=70 DefUnitDose=1 DefUnitDose=O.9 MUS=4.1 MUS=4. and for restoring any defaults you may change using the Set Defaults command or directly in the INI file itself.

O seroll=O ALV=2.5 serollpereent=67 MUS=33.l jJjJe n d Lx- [Sevoflurane] [Nitrous Oxide] [Nitrogen] Lambda=0.4 MUS=0.65 Lambda=0.O Volatility=lS3 Volatility=2S7 Ambient=SO Max=33 Max=150 Max=SOO High=S High=lOO High=400 Default=3.l VRG=0.014 VRG=l.42 VRG=O.0 graphminutes=15 VEN=l OverlayShow=Alv OverlayOver=Ckt Showeost=O Weight=70 [Settings] PreviewPages=2 A-8 .1 lIlAC=110 MAC=200 DefU nitDose= 1 DefUnitDose=l.47 Lambda=0.S Default=70 BottleCost=lSO Bottleeost=.070 MAC=2.00 FAT =6 Speed=AFAP Agen t=Isoflurane [Volumes of Compartments] Cireui t=Semi-closed CKT=S.Gas Man® .54 MUS=0.OS FAT=0.00 MUS=lS CO=5.57 Bo ttleSize=250 Bottlesize= 1000 [Ratio of Flows] [Defaults] VRG=76 VA=4.5 linewidth=2 VRG=6 linelabels=2 FAT=14.OlO MUS=2.014 FAT=34 FAT=l.

10. Brown RE: Compartmental system analysis: State of the art. NunnJF: Totally closed circuit nitrous oxide/oxygen anaesthesia. thesis. 8. 9. 1981. eds: Uptake and Distribution of Anesthetic Agents. Ashman MN. 5. In: Papper EM. Gillies AJ: A simplified digital method for prediciting anesthetic uptake and distribution. Barton F.1973. BrJ Anaesth 47: 350. Eger EI II: A mathematical model of uptake and distribution. Eger EI II: Effect of inspired anesthetic concen tration on the rate of rise of alveolar concentration. 4. Blesser vVB. Cowles AL. 72. \l\Telsh National School of Medicine. Ph. 1982. University of Wales. B-1 . 1945. Brandom RB. Anesthesiology 24: 153. 1963. 1963.D. Anesthesiology 54: 258. 1983. New York: McGravv-Hill.Gas Man i' Bibliogmphy 1. 7. p. 1975. Edsall D\I\T: Economy is not a major benefit of closed-system anesthesia. 6. 2. Chilcoat RT: Computer assistance in the control of depth of anaes- thesia. 3. Brody S: Bioenergetics and Growth. Epstein RM: A nonlinear model for the uptake and distribution of halothane in man. 1980. Brandom BvV. Anesthesiology 33: 419. 1970. Anesth Analg 62: 404. Borgsteclt HH. New York: Reinhold. IEEE Trans Biomed Eng 27: I. Cook DR: Uptake and distribution of halothane in infants: In vivo measurements and computer simulations. Com put BioI Med 3: 385. Kitz RJ.

12. Eger EI II. Madison. 1965. 15. 1964. Eger EI II. Guadagni NP: Halothane uptake in man at constant alveolar concentration. 1971. American Society of Anesthesiologists.NI: Airco. Ann Biomed Eng 6: 231. LanzI EF. Kety SS: The theory and applications of the exchange of inert gas at the lungs and tissues. Eger EI II. 1950. 1976. Carpenter SL: The administration of nitrous oxide-oxygen anesthesia in closed systems. UI 14. 1951. Wolf GL: Influence of the concentration effect on the uptake of anesthetic mixtures: The second gas effect. Scientific Exhibits. 13. Annual Meeting. Anesthesiolog-y 26: 756. 18. Latta WE. Lowe HJ: A pharmacokinetic model of closed-circuit inhalation anesthesia. Rackow H. Brandstater B: Minimum alveolar anesthetic concentration: A standard of anesthetic potency. Snider MT: Uptake and distribution: Hydraulic simulation designed for resident teaching. Eger El II: Anesthetic uptake and action. 1981. San Francisco. 17. Goldberg IS. Salanitre E. Pharmacol Rev 3: 1. B-2 . Baltimore: Williams & Wilkins. Saidman q. 1974. Anesthesiology 11: 517. Foldes FF. .1978. Bi/JIiop:mp/iy 11. Bahlman SH: Is the end-tidal anesthetic partial pressure an accurate measure of the arterial anesthetic partial pressure? Anesthesiolog"v 35: 301.Gas Man i. CA. 21. Epstein RM. 16. 20. 19. Eger E1 II: lsoflurane (Forane')<)): A Compendiurn and Reference. Anesthesiology 24: 299. MostertJvV. Kety SS: The physiological and physical factors governing the uptake of anesthetic gases by the body. Annals Surgery 136: 978. Cerayolo AJ. 1952. Anesthesiology 25: 364. 1963.

Bowers DL: The effects of changes in cardiac output and distribution on the rate of cerebral anesthetic equilibration. IVlethoxyf1urane Anesthesia. Eger E1 II. 1. 215. Munson ES. Perl W. Mostert]\"'.Gas Manti Bibliography 22. Lowe HJ. Lowe Hj. J Appl Physiol 20: 621. 3l. B-3 . Abbott Laboratories. 26. Mapleson WVV: Circulation-time models of the uptake of inhaled anaesthetics and data for quantifying them. 30. 1967. New York: McGraw-Hill. 1973. Patel A. 1963. Anesthesiology 28: 377. Eger E1 II. Anesthesiology 29: 533. BrJ Anaesth 45: 319. In: Papper EM. Kitz Rj. MacKrell TN: An electrical teaching model. Rackow H. Bowers DL: Effects of hyperventilation on the rate of cerebral anesthetic equilibration. 1981. Munson ES. 24. Ernst EA: The Quantitative Practice of Anesthesia: Use of Closed Circuit. Baltimore: Williams & \I\rilkins..J: Dose-Regulated Pentlll'ane'. MacKrell TN. Munson ES. 28. 29. 1968. Lowe H. 32. Hagler rq: Quantitative closed circuit anesthesia. 1965. Anesthesiology Review. 1981. J Appl Physiol18: 197. Bowers DL: Effects of anesthetic-depressed ventilation and cardiac output on anesthetic uptake: A computer nonlinear simulation.rolf GL. 25. p. 16. eds: Uptake and Distribution of Anesthetic Agents. Mapleson W'''': An electrical analogue for the uptake and exchange of inert gases and other agents. 1972. Salanitre E. Epstein RM: 1ntertissue diffusion effect for inert fat-soluble gases. p.1963. Milliken RA: Costs of delivery of anesthetic gases re- examined. August 1974. 23. Anesthesiology 55: 710. Anesthesiology 38: 251. 1973. 27. ".

presented at: Low Flow and Closed Circuit Anesthesia Symposium. 1954. Philip ]H. Virtue RW: Low flow anesthesia: Advantage in its clinical applica- tion. IntI] Clin Monitoring & Computing 3: 165. 38. In: Aldrete ]A. Mathematical Biosciences. 37. Cooper]B. 1971. Soong TT: Pharmacokinetics with uncertainties in the rate constants. 1972. 1979. cost. Anesthesiology 55: 711. 1981. Philip ]H: Cas Man'Jc . III.1983.Gas ManE Bibfiop:mjJhv Philip ]H: CAS MAN pictorial and graphical simulation for teaching anesthesia uptake and distribution. Lowe H]. eds: Low flow and closed system anesthesia. B-4 . and ecology. 41. 1986. Virtue RW. 39. 1979. Longnecker DE: The effect of right-to-left shunt on the rate of increase of arterial anesthetic concentration. Anesthesiology 59: A471. 34. 40. Severinghaus ]W: The rate of uptake of nitrous oxide in man. Denver.An example of goal oriented computer- assisted teaching which results in learning. II. Anesthesiology 55: 711. Anesthesiology 36: 352. New York: Academic Press. Spain]A: Cost of delivery of anesthetic gases reexamined. Aldrete]A: Costs of delivery of anesthetic gases re- examined. April 1978. Soong TT: Random Differential Equations in Science and Engineering. New York: Crune and Stratton. CO. Abstract. 35. Virtue R\I\T. 1981. 42. Newbower RS: The Boston Anesthesia System. ] Clin Invest 33: 1183. Stoeling RK. 36.