Checking the Anesthesia

Machine

Gerard T. Hogan, Jr., CRNA, MSN

Clinical Assistant Professor
Anesthesiology Nursing Program
Florida International University
Checking the Anesthesia
Machine

"Apparatus of reliable appearance

engenders a strong feeling of security
which is often not supported by facts.
A critical attitude often forestalls
unpleasant surprises." Lucien Morris,
in Aldrete Lowe & Virtue Low Flow &
Closed System Anesthesia Grune &
Stratton 1979.
 Checking the Anesthesia
Machine
As a lawyer I also see that these procedures can protect the
anesthetist. Should the anesthetist be required to defend himself
or herself, it may be difficult to remember the exact details of an
anesthetic given years before. Sometimes, it is helpful to be able
to testify that certain matters are always done by following
careful procedures, even if you cannot remember what happened
in a particular case. Giving an anesthetic clearly requires thought
and judgment, but the importance of having and following
procedures can not be minimized. If you begin your day or each
operation checking out your anesthesia machine according to FDA
guidelines, then even if you cannot remember what you did on
February 1, 1995, you will know you checked the anesthesia
machine because that is what you always do." Gene Blumenreich
AANA J 2000;68:107-10.
 Checking the Anesthesia
Machine
Web sites that help:
www.fda.gov/cdrh/humfac/anesckot.html

www.wramc.amedd.army.mil/departments/surgery/Anesthe
siology/checkout.htm
http://www.anest.ufl.edu/~eduweb/vam/tutorial2main.html

http://ourworld.cs.com/_ht_a/doschm/part1.htm

http://www.virtual-anaesthesia-textbook.com/vat/machine.
htm
 Checking the Anesthesia
Machine
Verifythat backup ventilation equipment is
available and functioning
Make sure that there is at a minimum an Ambu bag
with an available source of O2 that is NOT the
anesthesia machine!!
If doing a pediatric case, ensure that the bag is age
appropriate
 Checking the Anesthesia
Machine
Check Oxygen Cylinder Supply
Open the O2 cylinder and verify that it is at least ½
full (about 1000 psi)
Close the cylinder

Bleed the line so that the gauge says “0”

 Checking the Anesthesia
Machine
Check central pipeline supplies
Check the gauges on the front of the machine to
ensure that the appropriate pressure from the central
pipeline is available
All gauges should read between 45-55 psi
 Checking the Anesthesia
Machine
Check the initial status of the Low Pressure
System (LPS)
Close the flow valves and turn the vaporizers off
Check the fill level of the vaporizers, add agent if
need be, and make sure you tighten the filler caps
 Checking the Anesthesia
Machine
 Perform leak check of machine LPS
Verify that the master switch and flow control valves
are OFF
Attach the “suction bulb” to the common fresh gas
outlet
Squeeze the bulb repeatedly until fully collapsed
Verify that the bulb stays collapsed for 10 seconds
Open one vaporizer at a time and repeat 3 & 4
Remove bulb and reconnect the fresh gas hose
 Checking the Anesthesia
Machine
Turnon the master switch and all other
necessary electronic equipment
 Checking the Anesthesia
Machine
Test Flow meters
Adjust flow of all gases through their full range,
checking for smooth operation of floats and
undamaged flow tubes
Attempt to create a hypoxic O2/N2O mixture and
verify correct changes in flow and/or alarm
 Checking the Anesthesia
Machine
 Adjust and check the scavenger system
 Ensure proper connections between the scavenging system
and both APL (pop off) valve and ventilator relief valve
 Adjust waste gas vacuum (if possible)
 Fully open APL valve and occlude “Y” piece
 With minimum O2 flow, allow scavenger reservoir bag to
collapse completely and verify that the absorber pressure
gauge reads about zero
 With the O2 flush activated allow the scavenger reservoir bag
to distend fully, and then verify that absorber pressure gauge
reads <10 cm H2O
 Checking the Anesthesia
Machine
Calibrate the O2 Monitor
Ensure that the monitor reads 21% on room air
Verify that the low O2 alarm is enabled and
functioning
Reinstall sensor in circuit and flush breathing circuit
with O2
Verify that monitor now reads greater than 90%
 Checking the Anesthesia
Machine
Check initial status of the breathing system
Set selector switch to the “bag” mode
Check that breathing circuit is complete, undamaged
and unobstructed
Verify that CO2 absorbent is adequate

Install breathing circuit accessory equipment (e.g.

humidifier, PEEP valve) to be used during the case
 Checking the Anesthesia
Machine
Perform leak check of the breathing system
Set all gas flows to zero (or minimum)
Close APL (pop off) valve and occlude “Y” piece
Pressurize breathing system to about 30cm H2O with
O2 flush
Ensure that pressure remains fixed for at least 10
seconds
Open APL (pop off) valve and ensure that pressure
decreases
 Checking the Anesthesia
Machine
Test ventilation systems and unidirectional valves
Place a second breathing bag on Y-piece
Set appropriate ventilator parameters for next patient

Switch to automatic ventilation (ventilator) mode

Fill bellows and breathing bag with O2 flush and then

turn the ventilator on
Set O2 flow to a minimum, other gas flows to zero
 Checking the Anesthesia
Machine
Test ventilation systems and unidirectional valves
(con’t.)
Verify that during inspiration bellows delivers
appropriate tidal volume and that during expiration
bellows fills completely
Set fresh gas flow to about 5 liters per minute
Verify that the ventilator bellows and simulated lungs
fill and empty without sustained pressure at end
expiration
 Checking the Anesthesia
Machine
 Test ventilation systems and unidirectional valves (con’t.)
 Check for proper action of unidirectional valves
 Exercise breathing circuit accessories to ensure proper
function
 Turn ventilator OFF and switch to manual ventilation

 Ventilate manually and assure inflation and deflation of

artificial lungs and appropriate feel of system resistance and
compliance
 Remove bag from y piece and replace with patient mask
 Checking the Anesthesia
Machine
Check, calibrate, and/or set alarm limits of all
monitors
Capnometer

Pulse Oximeter
Oxygen Analyzer

Respiratory Volume Monitor (Spirometer)

Pressure monitor with high and low airway alarms

 Checking the Anesthesia
Machine
Check final status of machine
Vaporizers are off
APL valve is open

Selector switch is to “Bag”

All flow meters to zero

Patient suction level adequate

Breathing system is ready to use

 Setting up the Room
Remember the pneumonic “DAMMITSS”
DRUGS
 Prepare your medications appropriate for the case
 At a minimum, I expect:
> An appropriate hypnotic (Propofol, Thiopental, etc.)
> Succinylcholine
> Ephedrine
> Atropine
> Lidocaine
 Setting up the Room
“DAMMITSS”
Airway
 What do you need for the case? Keep in mind that blades
and tubes are appropriate for all cases. They are
emergency equipment
 At a minimum, I expect
> 7.5 oral ETT, styleted
> 2 laryngoscope handles, each with appropriate sized Miller and
Macintosh blades
> Appropriate sized oropharyngeal airway
> Wooden tongue blade
 Setting up the Room
“DAMMITSS”
Machine
I think we’ve covered that already…..
 Setting up the Room
 “DAMMITSS”
 Monitors
 Allcases require monitoring
 At a minimum, I expect

> Cardiac Monitor

> Pulse Oximeter
> Non Invasive Blood Pressure
 General Anesthetics also require
> Temperature monitor
> O2 monitor
> CO2 monitor
 Setting up the Room
“DAMMITSS”
IV
 Allpatients we take care of need an adequate IV access
 Start a new one if you don’t trust the old one

 May start after induction, if appropriate

 When in doubt, ask your instructor

 Setting up the Room
“DAMMITSS”
Twitch Monitor
 General Anesthetics that receive muscle relaxants need to
have a nerve stimulator on
 Check your “twitches” after induction (baseline)

 Check that they have returned BEFORE you give the

nondepolarizer (if you intubated off Succinylcholine)
 Setting up the Room
“DAMMITSS”
Suction
 Ensure that the suction reaches the patient and that it is
strong enough to hold onto your finger
 Have age and case appropriate suction devices readily
available (e.g. small people need small suction catheters,
right?)
 Setting up the Room
“DAMMITSS”
Stethoscope
 Esophageal for GETA
 Precordial for LMA, MAC
 Setting up the Room
How do I set up my syringes, etc?
Manypeople have different opinions, I will show you
at MSMC what I do, but the appropriate thing is to
make sure you have what you need and that you
know where you put it!
 Setting up the Room
Lets meet over at Miami Heart Institute in 1 hour.
I will wait for you in the lobby
We will break into 3 groups of 5 to make things
more manageable
Any questions???