Medical Gases: Learning Objectives

CLINICAL ANAESTHESIA
Medical gases Learning objectives

William Malein After reading this article, you should be able to:
Christina Beecroft C describe the methods of production, storage, and delivery of
common medical gases
C describe the function of a vacuum-insulated evaporator,
Abstract including a simplified drawing
Understanding the complex process of production, storage and deliv- C give key definitions required for the FRCA examinations
ery of medical gases is vitally important to ensure safe and efficient C describe some of the safety features important in the use and
practice by anaesthetists. This article discusses the medical gases handling of medical gases
commonly used in anaesthesia and intensive care, and details the
journey of the commonly used medical gases from production to pa-
tient delivery. It includes core knowledge for the FRCA.
Keywords Carbon dioxide; cylinder manifold; cylinders; Entonox;
helium; medical gases; nitrous oxide; oxygen; pin index system; vac- Key definitions
uum-insulated evaporator C Vapour: A substance in its gaseous form but below its critical
temperature
Royal College of Anaesthetists CPD Matrix: 1A03 C Critical temperature: The temperature above which a gas
cannot be liquefied by any amount of pressure
C Critical pressure: The pressure required to liquefy a vapour at
its critical temperature
C Saturated vapour pressure (SVP): The pressure exerted by the
Oxygen (O2) vapour when it is equilibrium with its liquid phase. SVP
In 1774 Joseph Priestly produced ‘dephlogisticated air’, now changes with temperature but is independent of pressure and
known as oxygen, by heating mercuric oxide. The Swedish indicates how volatile, and thus how easy to vaporize, a
pharmacist Karl Scheele actually discovered oxygen in 1771, but substance is
his work was not published until 1777, 3 years after Priestly’s C Latent heat of vaporization: The heat energy absorbed when a
discovery was made public. However, after more than a century substance undergoes a change of state from a liquid to a gas
during which the many different uses of oxygen included a without a change in its temperature. Approaches zero as
fashionable inhalation, ‘a cure-all’ tonic, and administration in temperature approaches critical temperature
many an orifice (including the urethra), it was John Scott Hal- C Boiling point (BP): The temperature of a substance at which
dane (1860e1936) who finally published ‘The Therapeutic its SVP is equal to atmospheric pressure. At BP, adding more
Administration of Oxygen’. This paper was well ahead of current heat does not increase the temperature, only provides latent
thinking and outlined principles of respiratory drive, hypoxaemia heat
and even ventilation-perfusion mismatching.1 The key properties Ideal gas laws
of oxygen are shown in Box 1. C Boyle’s law (first): At a constant temperature, the volume of a
fixed mass of a perfect gas varies inversely with pressure
Production
C Charles’ law (second): At a constant pressure, the volume of a
Oxygen can be produced in two ways: by fractional distillation or
fixed mass of gas is proportional to its temperature
with oxygen concentrators.
C Gay-Lussac’s law (third): At a constant volume, the pressure
of a fixed mass of gas is proportional to its temperature
Fractional distillation: this is the main method of industrial
oxygen production. Air is filtered to remove impurities and then
leaving pure oxygen. This oxygen is then compressed either into
compressed and cooled. At 79 C carbon dioxide solidifies and
medical cylinders or larger vessels for delivery to hospitals.2,3
is removed and at 200 C the remaining liquid is passed into a
column of graduated temperature, warmer at the bottom than the
Oxygen concentrators: these are devices which extract oxygen
top (185 C vs 195 C). Nitrogen boils at 195 C and escapes
from atmospheric air. They vary in capacity from personal units
through the top of the column, leaving oxygen and argon. A
further fractional distillation column is required to remove argon,
Key properties of oxygen
C Critical temperature: 118.4 C

William Malein MBChB is an ACCS Trainee in Anaesthesia at C Molecular weight: 32
Ninewells Hospital, Dundee, Scotland, UK. Conflicts of interest: none C Boiling point: 183 C
declared.
C Pin index, 2 and 5
Christina Beecroft FRCA FDSRCS is a Consultant Anaesthetist at C Supports combustion
Ninewells Hospital, Dundee, Scotland, UK. Conflicts of interest: none
declared. Box 1
ANAESTHESIA AND INTENSIVE CARE MEDICINE 19:11 595 Ó 2018 Elsevier Ltd. All rights reserved.
Descargado para Anonymous User (n/a) en New Granada Military University de ClinicalKey.es por Elsevier en septiembre 08, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
used at home to those capable of supplying a whole hospital. The Nitrous oxide (N2O)
oxygen concentrator consists of two columns of zeolite, which
Nitrous oxide is a clear, colourless and odourless gas. Discovered
can be thought of as a ‘molecular sieve’, connected to a
in 1772 by Joseph Priestly, it was Humphrey Davy in 1800 who
compressor. Air is fed into one column, removing the nitrogen
realised its potential, writing ‘As nitrous oxide appears capable of
and water vapour. Once the zeolite is saturated, flow is directed
destroying physical pain, it may probably be used with advan-
into the second column while oxygen escapes from the first
tage during surgical operations in which no great effusion of
column; this alternating process is continuous.
Storage
The two main methods of oxygen storage at hospitals are cylin- Cylinder manifold
ders and the vacuum insulated evaporator (VIE).
Oxygen cylinders: the most commonly used oxygen cylinders

are made from molybdenum steel and contain compressed ox-
ygen in its gaseous form at 137 bar at 15 C when full. Oxygen
cylinders will always have white shoulders and usually a black
body; an exception is the CD size oxygen cylinder which is
made from lighter Kevlar wrapped aluminium, has a flat bottom
and is all white. The pressure inside a CD cylinder is 230 bar
when full and it holds 460 litres of oxygen.4 Table 1 shows the
common sizes of oxygen cylinders and their corresponding
capacity.
Oxygen cylinders can be singular and attached to their own
flow regulators for direct clinical use, or part of a cylinder
manifold with multiple cylinders providing a large reservoir of
oxygen. These cylinder ‘banks’ can be used as a back-up system
for wall oxygen outlets in case of VIE failure, or as the main
source of piped gas for smaller hospitals. The manifolds are
usually arranged in two banks with an automatic pneumatic
switch between the two to maintain supply during cylinder
change or maintenance (Figure 1).
• Two banks of cylinders
Vacuum insulated evaporators: VIEs form the main reservoir of • Manifold automatically changes over between each bank
oxygen for larger hospitals. Kept outside, they consist of a large of cylinders in the primary supply system
• Secondary system present in the same room provides 4
dual walled tank with inner stainless steel and outer carbon steel hours of oxygen supply during damage or repair
shells separated by a vacuum (Figure 2). The tank stores liquid
oxygen at 180 C and 10 bar, with its vapour above. It has a safety
pressure blow-off valve set at 17 bar. In normal conditions, oxygen
is piped from the top of the tank through a superheater coil. It then
passes through a series of pressure reducing valves that sequen-
tially reduce the pressure to pipeline pressure (4.1 bar). At times of
high demand, cooling of the system occurs due to latent heat of
vaporization; this reduces the SVP. When this occurs, the pressure
raising valve opens and liquid oxygen is piped from the bottom of
the container through a pressure raising vaporizer before being
allowed to re-join the conventional stream. At times of low de-
mand, the temperature and pressure increase, thus obeying the
third perfect gas law which states that at a constant volume, the
pressure of a fixed mass of gas is proportional to its temperature.
This may open the blow-off valve leading to evaporation, and thus
cooling, re-instating normal working temperature.
Common sizes and capacities of oxygen cylinders

Size C D E J CD
Volume when full (litres) 170 340 680 6800 460
Table 1 Figure 1
Simplified diagram of a vacuum insulated evaporator (VIE)
10 Bar Pressure reducing valve

Safety blow-off valve 17 Bar
4.1 Bar
To pipeline
Superheater coil
–180ºC
Control valve
Pressure-raising vaporizer
Liquid
oxygen
Vacuum
Figure 2
blood takes place’. It took until 1844 for Horace Wells, a US because the pressure gauge is reading the SVP of nitrous oxide.
dentist, to demonstrate its use in general anaesthesia.5 The Once the liquid has evaporated the gauge pressure will start to
properties of nitrous oxide are shown in Box 2. fall rapidly. This is clinically important because a cylinder that is
nearly empty can still read 4400 kPa (Figure 3). Therefore, to
Production reliably measure the contents of a nitrous oxide cylinder you
Nitrous oxide is produced by heating ammonium nitrate to must measure its mass and subtract the tare weight of the cyl-
240 C. This process can produce several impurities including inder, found on the collar.
nitric oxide, nitrogen dioxide, ammonia, nitrogen, and nitric One caveat to the above statements relates to latent heat of
acid. It is therefore passed through scrubbers of caustic soda and vaporization and the application of Charles’ law. If the cylinder is
water to remove them. in constant rapid use, due to latent heat of vaporization the
temperature of the cylinder contents will cool and the SVP will
Storage reduce. Since it is the SVP that is measured by the gauge, the
Nitrous oxide is stored in French blue cylinders as a mixture pressure will fall until the flow is reduced or stopped, allowing
of liquid and vapour. When a cylinder is full, the pressure is the temperature to re-equilibrate with the surroundings.
4400 kPa at 15 C (5200 kPa at 21 C), which represents the SVP of Another key piece of information relating to nitrous oxide
nitrous oxide at that temperature. It is important to understand storage is the filling ratio. This describes the ratio of the mass of
that this pressure remains constant, providing the temperature is liquid nitrous oxide in the cylinder divided by the mass of water
constant, until all the liquid nitrous oxide has evaporated required to fill the whole cylinder. In the UK, the filling ratio for
nitrous oxide is 0.75 but in hotter climates it is 0.67. This is due
to the critical temperature of nitrous oxide; if the ambient tem-
perature exceeds 36.5 C then all the liquid nitrous oxide will
Key properties of nitrous oxide evaporate leading to an explosion with higher filling ratios.6
C Critical temperature: 36.5 C Entonox

C Molecular weight: 44
C Boiling point: 88.5 C Production
C Pin index: 3 and 5 Entonox is a mixture of 50% oxygen and 50% nitrous oxide. Its
C Supports combustion production relies on the Poynting effect which describes the
C MAC: 105% passing of gaseous oxygen through liquid nitrous oxide. This
C Global warming potential (GWP): 310 (310 times CO2) causes vaporization of the liquid, producing a 50:50 gaseous
mixture of oxygen and nitrous oxide.
Box 2
occurs, a high concentration of gaseous oxygen will be supplied

Nitrous oxide cylinders initially but, as the cylinder empties, a potentially dangerous
hypoxic mix approaching 100% nitrous oxide will be delivered.
Medical air
Medical air is stored in cylinders with white and black quartered
shoulders with a grey body. It is also available via pipeline supply
at a pressure of 4.1 bar; this must not be confused with surgical air
used to drive air powered instruments which is supplied at 7 bar.
Heliox
Heliox is a mixture of 21% oxygen and 79% helium. Helium,
despite being the second most abundant element in the universe,
makes up only 0.0005% of the lower atmosphere. When mixed
with oxygen it produces a gas that has a similar viscosity but
approximately six times lower density than air. The lower den-
sity means flow in the airways is more likely to be laminar than
turbulent (Figure 4). Laminar flow lowers resistance, with a
The pressure gauge will read 4400kPa until all liquid nitrous consequent reduction in work of breathing. As a result, Heliox
oxide is used up and cylinder is nearly empty. has applications in patients with airway obstruction.7
Figure 3 Carbon dioxide (CO2)

Carbon dioxide is produced by burning carbon-based compounds
to produce carbon dioxide and water. It is stored in grey cylin-
Reynolds number ders in its liquid form at a pressure of 5000 kPa with a filling ratio
of 0.76.
Re = ρ u L
μ Storage and delivery of medical gases
ρ – density (kg/m3) Cylinders
u – velocity (m/s) Cylinders that store medical gases are manufactured from mo-
L – length (m) lybdenum steel in a range of sizes from A to J; the cylinders
μ – viscosity (kg/m.s) attached to anaesthetic machines are usually size E. The gases
and vapours are stored under pressure and the cylinders are
A Reynolds number <2000 makes laminar flow more likely
manufactured to rigorous standards to avoid malfunction. In
addition, they have numerous safety features and undergo reg-
Figure 4
ular testing:
Storage Cylinders are colour coded to reduce the risk of using the
Entonox is stored in French blue cylinders with a white and blue incorrect gas. They also have a gas-specific pin index
quartered shoulder at a pressure of 13,700 kPa (137 bar). Careful system which prevents incorrect connection (Figure 5).
consideration must be paid to the pseudocritical temperature of They are checked by the manufacturer every 5 years. The
Entonox. This is the temperature at which Entonox splits into its checks include:
constituent parts, gaseous oxygen and liquid nitrous oxide, in a hydraulic pressure testing up to 22,000 kPa
process called lamination. This occurs at 7 C at 137 bar, 30 C tensile and impact tests (at least one cylinder in every
at pipeline pressure (4 bar), and 5.5 C at 117 bar. If splitting one hundred)
Pin index, shoulder and body colours of common medical gases
Oxygen Air Entonox Nitrous Heliox Carbon

2,6 1,5 Single centre oxide 2,4 dioxide
pin 3,6 1,6
Figure 5
Connections to piped outlets are made via gas-specific, colour-

coded Schraeder female sockets that are only compatible with a
specific size of collar on male probes to prevent incorrect gas
connection (Figure 6). The male probes are connected to flexible
copper pipes which in turn connect to the anaesthetic machines
via non-interchangeable screw threads (NIST). The NIST ensure
that only the correct gas hose can be connected to the correct
inlet on the machine (Figure 7).
Cylinder valves
The cylinder valve block is connected to the top of a gas cylinder
Figure 6 Colour coded gas outlets and hoses. via a threaded brass or chromium plated screw connection. The
cylinder valve block itself attaches to a yoke on the anaesthetic
machine. This has specific pins that correspond to the correct
cylinder valve and each gas has a specific pattern referred to as
the ‘Pin index’ system. The gas exit port on the valve block will
not seal unless the pattern of pins on the yoke corresponds to the
correct holes on the valve block on top of the cylinder (Figure 5).
The washer that seals the connection between the valve and the
yoke is called the Bodok seal; this is a resistant neoprene washer
reinforced by a metal ring. A
REFERENCES
1 Grainge C. Breath of life: the evolution of oxygen therapy. J R Soc
Med 2004; 97: 489e93.
2 Das S, Chattopadhyay S, Bose P. The anaesthesia gas supply
system. Indian J Anaesth 2013; 57: 489e99.
3 Westwood M, Riley W. Medical gases, their storage and delivery.
Figure 7 Non-interchangeable screw threads. Anaesth Intensive Care Med 2012; 13: 533e8.
4 https://www.boconline.co.uk/internet.lg.lg.gbr/en/images/medical-
internal endoscopic inspection. gas-cylinder-data-chart410_39405.pdf?v¼2.0 (accessed 11 May
There is a plastic disc around the neck of the cylinder 2018).
which identifies the year it was last inspected as well as 5 https://eic.rsc.org/feature/nitrous-oxide-are-you-having-a-laugh/
cylinder contents, maximum pressure, size code and di- 2020202.article (accessed 11 May 2018).
rections for storage and handling. 6 Banks A, Hardman JG. Nitrous oxide. Cont Educ Anaesth Crit Care
Full cylinders are stored away from empty ones. Pain 2005; 5: 145e8.
Cylinders should be stored upright to avoid damage to 7 Hashemian SM, Fallahian F. The use of heliox in critical care. Int J
their valves. Crit Illn Inj Sci 2014; 4: 138e42.
They should be stored in a dry, well ventilated room as
FURTHER READING
dampness can lead to corrosion of cylinders and damage to
Yentis Steven M, Hirsch Nicholas P, Ip James K. Anaesthesia and
their valves.
intensive care AeZ: an encyclopaedia of principles and practice.
5th edn. Elsevier Health Sciences, 1 Jan 2013.
Cylinder connections
Davis Paul D, Kenny Gavin NC. Basic physics and measurement in
Pipelines and gas outlets anaesthesia. 5th edn. Butterworth Heinemann, 2003.
Piped medical gases are made available via gas specific outlets Al-Shaikh Baha, Stacey Simon. Essentials of anaesthetic equipment.
either directly on the wall or hanging from suspended hoses. 4th edn. Churchill Livingstone, 19 April 2013.

Medical Gases: Learning Objectives

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Medical Gases: Learning Objectives

Uploaded by

Copyright:

Available Formats

CLINICAL ANAESTHESIA

Medical gases Learning objectives

C Critical temperature: 118.4 C

Oxygen cylinders: the most commonly used oxygen cylinders

Common sizes and capacities of oxygen cylinders

Simplified diagram of a vacuum insulated evaporator (VIE)

10 Bar Pressure reducing valve

C Critical temperature: 36.5 C Entonox

occurs, a high concentration of gaseous oxygen will be supplied

Figure 3 Carbon dioxide (CO2)

Pin index, shoulder and body colours of common medical gases

Oxygen Air Entonox Nitrous Heliox Carbon

Connections to piped outlets are made via gas-specific, colour-

You might also like