Professional Documents
Culture Documents
In the mid 50’s, when HAL was brought forth, the use of LFA
and closed system anesthesia diminished significantly.
This was largely due to the inherent problem of the first
generation HAL vaporizers, which was the unreliable delivery
of vapor at low FGF.
A SHORT HISTORY (con’t…)
Introduction of ISO in the early 1980’s gave way to a
renewed interest in LFA and closed circuit anesthesia. It
was further enhanced by the fact that anesthetic agents
are atmospheric pollutants, especially N2O, HAL, ENF,
.and to some extent ISO
The introduction of new low solubility agents, like DES and
SEVO, have initiated a renaissance in the use of LFA,
in order to contain costs associated with adapting FGF to
.patient demand
…A FEW DEFINITIONS
Low Flow Anesthesia (LFA) has been variously defined as an
inhalation technique in which a circle system with absorbent is used with a
fresh gas inflow of :
- less than the patient’s alveolar minute volume
- less than 1-1.5 l/min
- 3 l/min or less
- 0.5 – 2 l/min
- less than 4 l/min
- 500 – 1000 ml/min
- 0.5 – 1 l/min
Closed System Anesthesia is a form of LFA in which the FGF =
uptake of anesthetic gases and oxygen by the patient and gas sampling.
No gas is vented by the APL valve.
Dorsch and Dorsch
Understanding Anesthesia Equipment
…A FEW DEFINITIONS (con’t)
LFA:
Anesthesia delivery, where FGF is below 1.5 l/min, but maintained slightly
above the uptake of the patient. In addition, there is a low flow of excess
gas that leaves the circuit through the excess gas valve.
Reproduced with permission from “Low Flow Anesthesia with Draeger machines”
by Prof.J.A.Baum
Reproduced with permission from “Low Flow Anesthesia with Draeger
machines” by Prof.J.A.Baum
Reproduced with permission from “Low Flow Anesthesia with Draeger machines”
by Prof.J.A.Baum
THE REBREATHING SYSTEMS
Semi-open: VF ≥ MV
Semi-closed: MV > VF > Uptake
Closed: VF = Uptake
Where:
VF = FGF
MV = Minute Ventilation
Uptake = Total gas uptake of the patient
”THE “CATCH
Using a FGF of 5 LPM and a vaporizer setting
of 1%, we give to the patient:
5000mL/min x 0.01 = 50 mL/min
What would be the vaporizer setting if we
would use a FGF of 1 LPM for the same 50 mL
to be delivered?
1000mL/min X ? = 50 mL/min
? = ……
? = 0.05
That means that the vaporizer should be
opened to 5%!
Sounds bizarre, isn’t it! It really does, because
we are not used to it! And yet, mathematics is
all what it is about!
Under these circumstances the patient
receives EXACTLY the same amount of gas,
in fact the same amount of MEDICINE! This is
called : BIOAVAILABILITY!
= All over the world 5 X 1
=X 5 1
TECHNICAL ASPECTS
In LFA there are a few technical requirements. Typically
they are rather generic and more or less independent
of anesthesia machines used.
Disadvantages of LFA:
If you put little gas into the breathing system, little (or none)
will come out. As a result of this failure to flush gases out of
the system, any gases introduced which are not taken up
by the patient or absorbed chemically will tend to accu
.mulate
Such gases may be exhaled by the patient, be a contami-
nant of the medical gases or result from a reaction with the
.chemical agents used for CO2 absorption
:Substances exhaled by the patient
- Alcohol
Acetone -
CO -
CH4 -
!PRACTICALLY
HOW TO ADJUST FGF AT
DIFFERENT PHASES OF LFA
Premedication, pre-oxygenation and induction of
sleep are performed according to the usual
practice. Concerning adjustment of FGF
anesthesia can be divided into 3 phases:
1. Initial HIGH flow
2. Low flow
3. Recovery
1.Initial HIGH flow phase
At the beginning of anesthesia high FGF of 5-6
LPM is necessary to wash out nitrogen (N2) from
the patients body tissues.
High initial flow facilitates the filling of the breathing
system with the desired gas composition which in
turn influences patient uptake and distribution of
the anesthetic agents. (Remember the formulas in
the beginning? The patient takes , after all, what
he/she needs, provided the provider is providing
enough!)
Reproduced with permission from “Low Flow Anesthesia with Draeger
machines” by Prof.J.A.Baum
Reproduced with permission from “Low Flow Anesthesia with Draeger machines”
by Prof.J.A.Baum
Reproduced with permission from “Low Flow Anesthesia with Draeger
machines” by Prof.J.A.Baum
Reproduced with permission from “Low Flow Anesthesia with Draeger
machines” by Prof.J.A.Baum
Low flow phase .2
After the high flow phase of 5-15 min, or when the target
gas concentrations has been achieved FGF can be
reduced at the desired low flow level. The lower the FGF the
greater the difference between the vaporizer setting and
inspired concentration of the anesthetic agent in the breathing
circuit will be.
With low FGF, time to reach the desired concentration in the
inspiratory gas will be prolonged.
Hence, monitoring of oxygen and anesthetic agent
concentration is essential and necessary in LFA.
Reproduced with permission from “Low Flow Anesthesia with Draeger
machines” by Prof.J.A.Baum
Reproduced with permission from “Low Flow Anesthesia with Draeger
machines” by Prof.J.A.Baum
If the flow provided is too small for the patient’s
needs the bellow will gradually go down, down
...down
Reproduced with permission from “Low Flow Anesthesia with Draeger machines”
by Prof.J.A.Baum
Reproduced with permission from “Low Flow Anesthesia with Draeger machines”
by Prof.J.A.Baum
Reproduced with permission from “Low Flow Anesthesia with Draeger machines”
by Prof.J.A.Baum
Low Fresh Gas Flow
Oxygen and Agent Considerations
JAMES H. Philip MEE MD CCE
Anaesthesiologist and Director of Bioengineering
Department of Anaesthesiology, Perioperative and Pain
Medicine Brigham and Woman’s Hospital
Medical Liaison for Anesthesia
Department of Anaesthesia
Harvard Medical School
Author of GasMan® and President of MedMan Simulations Inc., a
charitable Organization distributing gas man
http://gasmanweb.com
The following X slides have been added with the author’s permission
Copyright 1984-2011, James H Philip, all rights reserved
Copyright 1984-2011, James H Philip, all rights reserved
Copyright 1984-2011, James H Philip, all rights reserved
Copyright 1984-2011, James H Philip, all rights reserved
Copyright 1984-2011, James H Philip, all rights reserved
Copyright 1984-2011, James H Philip, all rights reserved
Copyright 1984-2011, James H Philip, all rights reserved
Copyright 1984-2011, James H Philip, all rights reserved
Copyright 1984-2011, James H Philip, all rights reserved
Copyright 1984-2011, James H Philip, all rights reserved
Copyright 1984-2011, James H Philip, all rights reserved
Copyright 1984-2011, James H Philip, all rights reserved
Recovery phase .3
At the end of anesthesia high FGF, usually 100% O2, is
necessary, to facilitate the washout of the anesthetic agent
from the patient and to remove the agent to the scavenging
system.
…SOME COMMENTS
Today, LFA is such a safe and simple procedure that
there are no reasons not to use it routinely. It can be
even argued that the use of unnecessary FGF
should be regarded as inappropriate. However, it is
still possible to find anesthesia departments where
LFA is not used in special situations (prone position,
thoracic surgery) or simply not at all.
The most common misconception about is that it
cannot be used in spontaneous breathing patients or
with those having an LMA. There is, however, no
rationale for such a view. The LMA has been shown
to be effective both in pediatric and adult LFA.
www.clinicalwindow.net
The majority of anesthesiologists, during their clinical practice
usually avoid working with FGF < 1 LPM due to their cultural
and practical beliefs including:
- requirement of in depth knowledge on gas laws and physics
applied to clinical
pharmacokinetic andanesthesia (oof, learn
pharmacodynamic again?)of haloge -
features
nated agents used until the mid 90’s
lack of accuracy, expense and limited performance of anes -
thesia machines utilized in anesthesia up to the end of the
.90’s
In 1994, in the United States, 90% of anesthesiologists utilized
2-5 l/min of FFG and only 12% of physicians used an FFG infe
.rior to 1l/min
The recent introduction on the market of low solubility halogena-
ted agents and the technological development of high- performing
anesthesia ventilators, supplied with feed-back control systems
and high precision monitoring systems, make LFA/CSA safe and
feasible on a daily basis. This occurrence represents a great
advantage as far as clinical practice, cultural, environmental,
.pharmacological, technological and cost savings concerns
As with any other anaesthetic technique, LFA has its relative
and absolute contraindications, and anaesthetists have to
know the risks and limitations of this method. The potential
risks associated with low-flow anaesthesia are accidental
hypoxia, hypercapnia, inadequate depth of anaesthesia
and the accumulation of potentially toxic trace gases. A
basic knowledge of the uptake and distribution of anaesthe-
tic gases and appropriate patient monitoring such as pulse
oxymetry, capnometry, inspired oxygen monitoring and
anaesthetic gas analysis are required for safely delivering
.general anaesthesia with low fresh gas flows
The extent of patient monitoring, however, is similar to that
?for any other anaesthetic technique. Sounds familiar again
Awareness during
anesthesia
If you want to be
Like the guy in the figure
All the time
With the finger on the
… trigger
Or enjoy a cozy sleep
…”While the machine does gently “beep
…In a simple way, we can say
The LFA is the mathematical art of volatile
…anesthesia
?Questions anyone