Introduction

The modern anesthesia machine is a complex operating room instrument that

incorporates a ventilator to optimize the delivery of inhaled anesthetics. The
anesthesia machine has gradually evolved from simply a means to anesthetize and
oxygenate a patient to an anesthesia workstation incorporating increasingly
complex ventilator modes, end-tidal CO2 monitors, end-tidal anesthetic
concentrations, minimal alveolar concentration estimators, and a means of
monitoring vital signs. Despite all these innovations and new instruments added to
the anesthesia machine, an understanding of the anesthesia machine is still a core
.component of the practice of anesthesiology

Function
The modern anesthesia machine seamlessly incorporates a ventilator to allow for
optimal anesthetic delivery.  

There are four main functions of the modern anesthesia machine: 

1. Oxygenation
2. The accurate mixture of anesthetic vapors
3. Appropriate ventilation
4. Reduce exposure of anesthetic vapors to personelle

Important Components of the Anesthesia Machine

Vaporizer

There are essentially two broad categories of anesthesia machine vaporizers:

 .variable bypass vaporizers and measured flow vaporizers

Variable bypass vaporizers work by setting a "splitting ratio" on a dial controlling

the vaporizer.  The splitting ratio describes the ratio of fresh gas flow that enters the
vaporizing chamber compared to the fresh gas flow that bypasses the vapor
chamber. The gas that enters the vapor chamber becomes saturated with anesthetic
and then reunites with the fresh gas flow to deliver a carefully calculated dose of
volatile anesthetic. The variable bypass vaporizer automatically compensates for a
wide range of temperatures in the operating room to ensure a steady output of
anesthetic at a given atmospheric pressure.  Each vaporizer is specific for a certain
.volatile anesthetic such as halothane, isoflurane, enflurane, and sevoflurane

Measured flow vaporizers function differently. The most common example of a

measured flow vaporized is the desflurane vaporizer. Due to desflurane's low
boiling point and proclivity to volatility, it is heated to a constant temperature of 39
degrees Celsius, and the vaporizer's circuit begins in the vaporizer itself as opposed
to fresh gas flowing over the volatile anesthetic

Adjustable Pressure Limiting Valve (APL Valve)

As expired gases travel back to the anesthesia machine from the patient, the APL
Valve, otherwise known as the "pop-off valve," sits between the expiratory
unidirectional valve and the carbon dioxide absorber. The APL valve serves as a
pressure relief valve to prevent excessive pressures in the breathing circuit when
tubing may become obstructed.  Excessive pressures may result in barotrauma to
the patient or damage to flowmeters or vaporizers. As the name suggests, the APL
valve can be adjusted during different phases of anesthesia to best suit the patient.
During spontaneous ventilation, the valve remains open to facilitate easier
breathing. After induction, when positive pressure ventilation is required, the valve
can be closed partially (typically to less than 20 cm H20) to allow for positive
pressure ventilation by squeezing the reservoir bag. Any gas released from the APL
valve to limit pressure is routed to the scavenger system to minimize operating
room pollution

Oxygen Flush Button

The intermediate pressure system has a button referred to as the "oxygen flush"
button, which, when pressed, allows for the opening of a direct connection between
the pipeline oxygen and the oxygen pressure regulator to deliver 35 to 70 liters per
minute of pure oxygen at a pressure of 45 to 60 psi to the patient. Its most common
use is during mask ventilation when an inadequate mask seal cannot be obtained
due to various reasons such as a patient's beard, operator error, and patients with
difficult airways. The anesthesia provider needs to be cognizant that while pushing
the oxygen flush button, only oxygen and not any volatile anesthetic or nitrous
oxide is being administered to the patient even if the volatile anesthetic or nitrous
oxide is turned on. Use of the oxygen flush can result in periods of awareness during
anesthesia and barotrauma to the patient's lungs due to the flow of gas at higher
pressures (45 to 60 psi) than the typical low-pressure system of the anesthesia
.machine

Carbon Dioxide Absorbent

An essential component of the circle system breathing circuit is the carbon dioxide
(CO2) absorbent. CO2 absorbent contains various mixtures of calcium hydroxide,
sodium hydroxide, potassium hydroxide, and barium hydroxide to prevent the
introduction of carbon dioxide into the inspiratory limb of the anesthesia
machine. Expired gases pass through the filter where carbon dioxide undergoes
chemical reactions with these respective bases to be trapped in the filter to allow for
safer rebreathing of the expired air. The filtered expired air allows expired gases to
be recycled, allowing for low-flow anesthesia (gas flows less than alveolar
ventilation to minimize costs of providing anesthesia). CO2 absorbents used in
anesthesia machines typically have chemical indicators that change color as the
filter becomes saturated. When the filter is two-thirds saturated, the filter should be
changed to prevent the re-breathing of carbon dioxide. Modern anesthesia machine
monitors will often indicate when carbon dioxide is detected in the inspiratory limb,
further alerting the anesthesiologist that the soda lime filter needs to be exchanged.
Carbon dioxide becomes present in the inspiratory limb when the carbon dioxide
absorbent fails to absorb the carbon dioxide in the expired gases present in the
.expiratory limb
The Sequence of Flowmeters

The flowmeters allow for titration of gases from the pipeline or E-Cylinder and
consist of a tapered tube with the smallest diameter at the bottom.  A bobbin sits at
the bottom of the meter and gradually is elevated towards the top of the
flowmeter as the flow of the gas being titrated increases. The sequence of the
flowmeters is of paramount importance to prevent the creation of a hypoxic gas
mixture. The oxygen should always be situated downstream of other gases to
prevent a hypoxic gas mixture. In a scenario where the oxygen is stationed
upstream from other gases, a leak in the system between the entry of the oxygen
and another gas would divert oxygen away from the patient resulting in a hypoxic
gas mixture. With the oxygen situated downstream from other gases, a leak near
the flowmeters may result in a lighter degree of anesthesia but a significantly
.lessened risk of a hypoxic gas mixture

Gas Scavenging System

The long-term effects of exposure to volatile anesthetics are a potential occupational
hazard. Some studies have demonstrated an increased risk of spontaneous
abortions, increased infertility, and having children with congenital anomalies.
Long-term exposure to volatile anesthetics possibly predisposes anesthesiologists to
multiple organ system dysfunctions. The modern anesthesia machine incorporates
a gas scavenging system to capture volatile anesthetics to minimize exposure to
volatile anesthetics. The scavenging system gathers exhaled volatile gases from the
anesthesia equipment. It transports them away from the operating room, likely into
the atmosphere and outside the building, housing the anesthesia machine. Most
anesthesia machines utilize an open system that sits over the exhaust port and
adjustable pressure limiting valve of the anesthesia machine. The scavenging
system gathers gases into a reservoir then utilizes the pipeline suction to transport
the reservoir gases outside of the operating room. Positive and negative pressure
relief valves are utilized to prevent the transmission of scavenged gases into the
.breathing circuit
Instruments commonly used for monitoring during anesthesia
include:
 An inflatable blood pressure cuff. This is usually strapped around your upper
arm.
 A pulse oximeter, a small instrument that is attached to your finger, toe, or
earlobe to measure the level of oxygen in your blood.
 An electrocardiogram (EKG, ECG) to monitor your heart activity. Small wires
(leads) are placed on the skin of your chest and held in place by small
adhesive patches.
 A temperature probe. A monitor connected to your skin by a lead held in
place by a small round adhesive patch may be used to measure skin
temperature. A thermometer that is attached to a small tube inserted through
the mouth into the esophagus after you are unconscious may be used to
measure internal body temperature.
 An oxygen analyzer and carbon dioxide analyzer on the anesthesia machine.
These instruments measure the amount of oxygen and carbon dioxide gases
inhaled and exhaled in your breath.
Other monitoring instruments may also be used, depending on your condition,
the type of surgical procedure you are having, and the type of anesthesia used.
These may be invasive monitors that need to be placed inside the body,
including:

 A urinary catheter. This is a small, flexible tube inserted into the bladder to
collect urine.
 Catheters that are inserted into certain arteries or veins. These can
accurately measure blood pressure or measure heart or lung function. These
larger catheters also are sometimes needed to deliver medicines or blood
transfusions.
 A trans esophageal echocardiograph. This instrument is inserted through the
mouth and down the throat into the esophagus to monitor the heart.