Critical Care Department

Issue number: Version 1

Subject: AnaConDa device (Anaesthetic Conserving Device) in Critical Care

Objective: The AnaConda is an anaesthetic gas delivery system for use in Critical Care
alongside the Dräger ventilator to administer isoflurane in a safe and controlled
manner to mechanically ventilated patients.

Target Level: Departmental

Prepared by: Dr. Sashika Selladurai, Consultant in Critical Care

Dr. Eoghan O’Callaghan, Consultant in Critical Care
Dr. Anand Iyer, Consultant in Critical Care
Kelie Beever, Practice Educator, Critical Care
Sam Hendry, Practice Educator, Critical Care
Dr. Maia Graham, Consultant in Critical Care

Associated Documents: Outline other documents that this document should be read in
conjunction with or may be required for implementation of this clinical guideline (If appropriate).

Information Classification Label Unclassified

Date of Issue: June 2022 Review Date: June 2025
REVIEW HISTORY
Issue No. Page Changes made with rationale and impact on practice Date

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Use of the AnaConDa in Critical Care

Indications

• 2 or more IV agents needed to achieve sedation or resistance to sedation.

• Asthma and Status Asthmaticus.
• Severe Renal and Hepatic impairment.
• Consider in ARDS /COVID-19 (difficult to sedate/ventilate).
• Sedation, especially in the following circumstances:
o High dose IV sedation with associated problems e.g. hypertriglyceridaemia,
o Propofol Infusion Syndrome.
o Risk of accumulation of sedative drugs (especially benzodiazepines) e.g. high dose;
o liver or renal dysfunction.
o History of drug dependency.
o Severe delirium.
o Need for rapid wakening / neurological assessment e.g. post cardiac arrest.

Contraindications
Absolute
• Family history of malignant hyperthermia.

Relative
• Lots of secretions requiring frequent suctioning.
• Raised ICP.
• Pregnancy.
• Profound circulatory shock.
• Thick respiratory secretions.

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Dose and Prescribing

• NOT FOR IV USE

• Consultant Prescribing Only
• Other sedatives may need to be titrated/ discontinued - once established MAC to stop
propofol. Opiate and benzodiazepine should be weaned to RASS and critical care pain
observation tool
• Opiate boluses or low infusion can be still continued for analgesia.
• Isoflurane is a potent vasodilators, the patient may require a fluid bolus +/_ inotropes
• Dose to be titrated to maintain target RASS as specified by Consultant

Critical Incidents

Malignant hyperthermia
• Malignant hyperthermia (MH) is an extremely rare reaction to volatile anaesthetic agents.
It is a medical emergency.
• It manifests as unexplained tachycardia, increased oxygen consumption and CO2
production, fever and rigidity upon exposure to volatile anaesthetic agents.
• Hyperthermia maybe masked. An unexpected and unexplained rise of CO2, or gas sweep
to achieve target CO2, should lead to suspicion of this condition.
• If suspected immediately discontinue the use of sevoflurane, remove the AnaConDa
device, place the patient back on the ICU ventilator on 100% oxygen, start alternate IV
sedation, and refer to the MH guideline (Appendix B).
• MH emergency kit containing Dantrolene is kept in main theatres on the Royal site and in
emergency theatre recovery, as the MH trolley on the Aintree site.

Special Circumstances
Transfers of patients with AnaConDa Device
• AnaConDa can be used with Oxylog Transport Ventilator but at present please use
intravenous sedation (eg. Propofol and opiate) as advised by the Critical Care medical team.

Nebulisation
• Insert high peep/in line nebulisation device between patient and Anaconda device.
• Continuous nebulisation will require more frequent changes of the AnaConDa device.
Change at 12 hours or more before if indication of AnaConDa filter saturation.
• Angle AnaConDa device @ 45 degree (decline towards the patient) to avoid condensation
of frequent nebulisers. Note potential of device saturation due to frequent nebulisers which
may result in increasing circuit resistance (high pressures, low Tidal Volume).

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In line Suctioning
• Suctioned Isoflurane quantities are small and unlikely to leak into the ICU environment in
any significant quantity and therefore can be suctioned in the usual way.

Manual Bagging
• Leave the AnaConDa in site when manual bagging is required, disconnection of the
ventilator circuit will only allow a small quantity of Isoflurane (the non-reflected fraction) to
enter the ambient environment.
• Consider an increase in the Isoflurane administration rate in response to increased tidal
volumes during hand ventilation.

Bronchoscopy/Tracheostomy insertion
• Prolonged bronchoscopy and suctioning may decrease alveolar concentration of levels of
isoflurane. Seek medical advice to ensure the maintenance of target MAC level. Consider
conversion to IV sedation during the procedure, then revert back to Isoflurane.

Suspicion of Isoflurane Leak

Environmental levels of volatile gas when AnaConDa is used are maximal 1.2ppm meaning
negligible exposure to surrounding patients as well as care givers (50 parts per million are
maximum accepted concentration in the UK).

• Possible sources of leak.

o Open/broken bottle.
o Uncapped Syringes.
o Poor connections in Ventilator circuit or Anaconda system.
o ET tube cuff leak.
o Chest drains with on-going air leak especially if not on suction.
o Circuit leak including manual bagging or Bronchoscopy.
• If an ongoing leak relates to the circuit/patient, isoflurane therapy via AnaConDa device
must be discontinued while it’s resolved with IV sedation management during the interim.

Spillage of Isoflurane

Every effort should be made to minimise any spillage and breakage. Aim to avoid
spillage/leakage of Isoflurane into the atmosphere at all times with above actions by stopping
infusions, capping syringes and bottles and handling glass bottles with care. Small spillages will
dissipate at normal room temperatures.

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To control large spillages:

Large spillages (1 or more bottles) can cause sedative effects, should be adsorbed using an
absorbent pad to contain them. Ensure maximum ventilation to area, removing any patients or
staff not need to remain in the area. Dispose of the pad into an orange clinical waste bag and
closed yellow container.

Storage of Isoflurane

Royal Site - Isoflurane is stored in the main pharmacy on ITU in the flammables cupboard to
protect from damage. Stock levels is 4x250ml bottles. Order any additional stock required via the
EPMA system or pharmacist. Any isoflurane bottle at the bedspace should be stored in a drawer
or cupboard until replaced in the main pharmacy.

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Appendix A: Wet Circuit Set Up (Aintree Site)

Instruction Photograph / Diagram
Ensure correct ordering, storage and supply of
required equipment: [Starter Kit]
• AnaConDa.
• AnaConDa syringe.
• FlurAbsorb gas scavenging filter.
• FlurAbsorb mount.
• FlurAbsorb accessory kit: 22mm flex tube,
8mm oxygen connection tube or 8mm
silicone tube, 22F/22M adaptor.
1.
• Filling adapter.
• AnaConDa gas sampling line.
• Nafion dryer tubing.
• Isoflurane bottle.
• Designated syringe pump for isoflurane with
upper pressure limit set to 900mmHg.
• Anaesthetic gas monitor {Philips} for MAC.

Ensure Critical Care ventilator is set up

• Ensure standard set up of ventilator with
non-humidified circuit and no HME filter. A
bacterial filter should be added immediately
2. between the FlurAbsorb and
adapter/connector (in place of the bacterial
filter on the ventilator expiratory port).

3. Setting up the FlurAbsorb gas scavenging filter to the Dräger ventilator

• Gather FlurAbsorb gas scavenging filter, FlurAbsorb mount and FlurAbsorb
accessory kit.
• Connect the FlurAbsorb mount to the standard rail of the ventilator.
• Secure the FlurAbsorb filter into the mount and remove the protective cap.
• Attach the 22F/22M green adaptor (with elbow connection) from the accessory kit to
the top of the FlurAbsorb.
• Remove the flow sensor and attach the 22mm tubing from the accessory kit. Replace
flow sensor and calibrate.
• Position the tubing over the ventilator and attach the other end of the 22mm tubing to
the green adaptor with elbow and FlurAbsorb.
• Attach the 8mm tubing to the elbow outlet of the green adaptor and Flurabsorb with
the other end attached to the anaesthetic gas monitor exhaust (NB. the tubing
connector can be cut if required, for better grip).

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4. Filling of syringe with isoflurane with two-person check

• Ensure 2 person checking prior to

administration

To prepare the AnaConDa syringe with

isoflurane:
• Attach the red cap to the Isoflurane bottle if
not already in place.
• Ensure the cap clicks securely in place.
• Draw 10-20ml of air into the AnaConDa
syringe to allow for easy filling.
• Connect the AnanConDa syringe to the
bottle.
• To fill the syringe, carefully move the syringe
plunger back and forth (5-10 times) to avoid
over/under pressure in the bottle.
• Fill with the syringe with 50ms of Isoflurane
solution then cap both the syringe and cap
bottle, to contain the Isoflurane until syringe
is required for connection.
• Fill in the required information in the syringe
label.

5.
Setting up AnaConDa device and syringe pump

• Place designated syringe driver on opposite

side of bedspace from intravenous infusion
syringe drivers.
• Remove the purple ‘monitor’ label from the
gas sampling port.
• Connect the Nafion dryer line to the gas
sampling port.
• Connect one end of the gas sampling line to
the Nafion dryer line and the other end to
the gas analyser monitor.
• Remove the red cap from the AnaConDa
and insert on ventilator tubing between Y-
piece and ETCO2 monitor. Ensure optimal
positioning of black side up and sloped
downward toward the patient.
• If nebulisation is required, place a inline high
peep nebuliser system between the
AnaConDa device and catheter mount.

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Priming and start of AnaConDa

• Insert the isoflurane syringe into the designated syringe pump and open the red
syringe cap.
• Firmly screw the AnaConDa anaesthetic agent line onto the syringe. Do not over-
screw.
• Using the syringe driver, administer a bolus of exactly 1.2ml to fill the anaesthetic
agent line to avoid overfilling. DO NOT MANUALLY PRIME syringe.
• Set the pressure limit alarm of the syringe pump to maximum of 900mmHg
• Set initial pump rate as prescribed. The pump rate must be titrated to meet desired
MAC and RASS (Richmond Agitation Scale Score) as prescribed.
• For deep sedation or bronchospasm management, start at 5ml/hr and for standard
6. sedation management start the rate at half the minute volume.
• Increase by 1ml/hr every 2-5 minutes as required monitoring for potential fall in the
blood pressure.
• If required, give a bolus of 0.3ml (only as directed by ICU doctor).
• The gas analyser will display a MAC value greater than zero. Aim for MAC of 0.3-0.8
(but higher doses may be required to achieve an adequate RASS level).
• Continue to titrate rate to desired RASS.
• Expected max delivery is between 16-25ml/hr, however, licencing is up to 40ml/hr.
Prescription will need to be changed to reflect medical decision.
• Document each syringe used on the FlurAbsorb, start with ‘1’.
• Once sedation is established with Isoflurane, stop IV sedation and opiates
unless opiates are in use for pain management.

7. Changing of isoflurane syringe

• Following the SOP, prepare a new
AnaConDa syringe with isoflurane. Stop the
syringe pump.
• Remove the empty syringe from the syringe
pump and seal the end with the attached
cap.
• Disconnect the AnaConDa anaesthetic
agent line from the empty syringe. Do not
kink the anaesthetic agent line or place
any clamps on it as may damage or
destroy the line. The agent line has a non-
return valve which prevents any isoflurane
escaping.
• Insert the new syringe, remove the cap and
connect the AnaConDa anaesthetic agent
line.
• Start the syringe pump at the previous rate.
The line does not need to be re-primed.
• Document the syringe change, score
through the ‘1’ on the FlurAdsorb and
document ‘2’, repeat on the 3rd change by
scoring through the ‘2’ and document ‘3’.
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• The FlurAbsorb can only absorb the

volume of 3 syringes and will require
changing before the 4th syringe, see
below for FlurAbsorb change.

Changing of AnaConDa device and FlurAbsorb : Change the Anaconda every 24

8.
hours or as filter saturates and FlurAbsorb at the end of 3rd syringe

To change AnaConDa:
• Open a new AnaConDa filter.
• Stop syringe pump.
• Disconnect the anaesthetic agent line from the syringe and close the syringe with the
red cap.
• Detach the gas sampling line from the current AnaConDa and seal the gas sampling
port with the attached cap.
• Remove the purple ‘monitor’ label from the new AnaConDa device and attach the gas
sampling line.
• Uncap the syringe and attach the new AnaConDa anaesthetic agent line, and prime
with a bolus of 1.2ml via the pump.
• Remove the used AnaConDa device from the ventilator circuit using ‘manual
disconnect’ option, clamp if needed and disconnect the ventilator side first and then
the patient side.
• Insert the new AnaConDa into the ventilator circuit between the Y-piece and the
patient/nebuliser.
• Connect the anaesthetic agent line of the new AnaConDa to the isoflurane syringe.
• Discard the used AnaConDa and anaesthetic line in general clinical waste as per
wastage SOP.

To change the FlurAbsorb:

• Remove the used FlurAbsorb from the mount
• Place the new FlurAbsorb filter in the mount and remove the protective cap.
• Attach the 22F/22M connector on top of the FlurAbsorb.

If COVID-19 patient : please ensure ICU doctor present – as the ETT will need
clamping – and the ventilator will need stopping during change of AnaConDa.

9. Weaning, stopping therapy and removal of device

A wean and / or trial ‘off Isoflurane’ should be performed

• Titrate down 1-2ml every 20-30min until stopped. Because of the reflectance of the
AnaConDa, levels will decrease slowly even if infusion is stopped.
• Alternatively for rapid wake up, remove the AnaConDa device from the circuit (see
below – removal of device).
• If using for bronchospasm monitor for clinical wheeze, ETCO2 trace and value, Peak
Inspiratory Pressure, Tidal Volumes, PEEPi and SpO2 / arterial blood gas values.
Wean from Anaconda but keep in circuit.

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• If appropriate to keep sedated, ensure substitution with an alternative IV sedative

agent, to target RASS.

Removal of device
• Stop the syringe pump. Remove syringe and cap securely with red-cap.
• Dispose of capped Isoflurane in a yellow HSW disposal container.
• Replace AnaConDa device with HME or convert to water-humidified circuit.
• Cap AnaConDa device and dispose of in a clinical HSW container.

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Appendix B: Dry Circuit Set Up (Royal Site)

Image shows
1.AnaConDa mounted at Y-
piece
2.Scavenge hose connecting
2 from Draeger ventilator flow
sensor to Flurabsorb with
1 adaptor and bacterial filter.
Note.
Breathing circuit from Hospital
Bacterial filter from Hospital.

Detail of how scavenge hose

connects to Draeger flow sensor

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Isoflurane syringe

Image showing Anaconda

syringe connecting to Nafion line and gas sampling line
AnaConDa.
Nafion line connecting to sample
port of AnaConDa and gas
sampling line (from AnaConDa to
Draeger Scio gas monitor).

AnaConDa

Scavenge hose
Gas sample return line

Image showing scavenging hose

with adaptor, connecting to Adaptor
Flurabsorb via bacterial filter.
Note gas sample return line from Bacterial filter
gas monitor connected to
adaptor.
Flurabsorb
Flurabsorb mount fixes to
mount
ventilator side rail to support
Flurabsorb.

Flurabsorb

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Appendix C: Gas monitoring
Aintree Site
Draeger Scio with
water trap
Sampling line
from AnaConDa
Gas sampling line from
AnaConDa connecting to
water trap on back of
Draeger Scio.
Royal Site: Philips Intellivue MX550 with Draeger Water trap and MP40 with Philips
Philips Intellivue
MX550 with Draeger
water trap for sample line
connection
MX550 Return gas
tubing outlet to
flurabsorb
Phillips Intellivue MX550 GM 7
gas monitor with Draeger
watertrap on side of the
monitor to attach the sampling
line and gas scavenging tubing
from the outlet to flurabsorb.
AnaConda Device in Critical
Care
Valid from: Jun 22-Jun 25
Data cable in back of
Scio
Data cable into
patient monitor from
Scio
Return gas sample
exiting back of Scio
Data cable exiting Data cable entering back
Draeger Scio to patient of patient monitor.
monitor and return gas
sample line exiting Scio
to port on Flurabsorb
adaptor.
Return gas tubing
Philips Intellivue outlet to flurabsorb
MP40 water trap & exiting the back of
sample line port Intellivue MP40
Philips Intellivue MP40 GM with Philips Intellivue
Philips watertrap on front with MP40 GM with gas
sample line connection port. scavenging tubing
from the outlet to
flurabsorb at the
back.
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Appendix C: Malignant Hyperpyrexia

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