LOW FLOW ANAESTHESIA

Nurita Dian Kestriani Saragi sitio, dr., SpAnKIC

DEFINISI
Klasifikasi FGF menurut Baxter :

Metabolic flow < 250 mL/mnt

Minimal flow 250 - 500 mL/mnt

Low flow 500 - 1.000 mL/mnt

Medium flow 1 - 2 L/mnt

High flow 2 - 4 L/mnt

Very high flow > 4 L/mnt

The basic requirement for conducting anaesthesia with a low fresh gas flow is the use
of a rebreathing system  the unused gases and anaesthetic contained in the
patient’s exhaled air are reused in the inhalation gas

A characteristic of these systems is a carbon dioxide absorber: it chemically removes

and binds exhaled carbon dioxide from the breathing circulation system
PRACTICAL USE OF LOW- AND MINIMAL-
FLOW
Demands on the technology deployed
•Leak tightness of the breathing system : The less components and connections, the
better the system is suitable for low flow
•Returning the exhaust sample gas from gas measurement back into the breathing
system (rebreathing system)
•Robustness and precision of O2, CO2 and anaesthesia gas measurement in a humid
environment
•Performance of the anaesthetic vaporisers
 REQUIREMENT FOR LFA
1. The breathing systems must be sufficiently tight (no leakaes)
2. The anesthesia machines must allow a setting to even the lowest fresh gas flow
3. Dosing of the anaesthetic gas must also be sufficiently accurate in the low flow
range
4. Machine monitoring must guarantee comprehensive monitoring of the composition
of the anesthesia gas
BENEFIT OF LOW FLOW
ANESTHESIA
•Clinical benefits—humidifying, warming, pulmonary function
•Cost savings—economic benefits
•Ecological benefits
•Less contamination with volatile anaesthetics
MANFAAT TERHADAP SISTEM
RESPIRASI
Pemasangan ETT/LMA akan menghalangi fungsi fisiologis saluran nafas atas utk
melembabkan dan menghangatkan udara
Mekanisme pelembaban udara inadekuat —> mengganggu fungsi epitel siliaris
dan mucociliary clearance
Resiko aliran udara kering —> merusak epitel saluran pernapasan yang
mengakibatkan, refluks sekresi, obstruksi refluks bronkiolus dan mendorong
terjadi mikroatelektasis.
Manfaat bagi pasien —> menjaga panas tubuh, mencegah shivering dan
pengeringan saluran napas dan bronkus (fluid loss) selama terpasang ETT.
CONSEQUENCES OF COLD AND DRY INSPIRED GASES

• Changes in the tracheobronchial epithelium

• Reduced Mucus Viscosity
• Secreting with atelectasis
• ↓ pulmonale compliance
• ↑ Breathing Work postoperative
• Heat and Fluid Loss

Branson RD, Campbell RS, Davis K, Porembka DT. Anaesthesia circuits, humidity output, and mucociliary structure and function. Anaesthesia and intensive care 1998;26:178–183.
Button B, Cai LH, Ehre C, Kesimer M, Hill DB, Sheehan JK, et al. Periciliary Brush Promotes the Lung Health by Separating the Mucus Layer from Airway Epithelia. Science (New York,
N.Y.) 2012;337:937–941.
Kleemann PP. The climatisation of anesthetic gases under conditions of high flow to low flow. Acta anaesthesiologica Belgica 1990;41:189–200
Williams R, Rankin N, Smith T, Galler D, Seakins P. Relationship between the humidity and temperature of inspired gas and the function of the airway mucosa. Crit Care Med
1996;24(11):1920-1929.
Gross JL, Park GR. Humidification of inspired gases during mechanical ventilation. Minerva anestesiologica 2012;78:496–502.
Kilgour E, Rankin N, Ryan S, Pack R. Mucociliary function deteriorates in the clinical range of inspired air temperature and humidity. Intensive Care Med 2004;30(7):1491-1494.
Zuchner K. Humidification: measurement and requirements. Respir Care Clin N Am 2006;12(2):149-163.
MANFAAT EKONOMI
> 80% gas anestesi terbuang jika digunakan aliran 5 L/menit.
Beberapa penelitian menunjukkan —> penggunaan LFA dan MFA secara dramatis
mengurangi biaya (tahunan) anestesi volatile.
Biasanya pengurangan FGF dari 3 L/menit —> 1 L/menit menghasilkan
penghematan sekitar 50% dari total biaya gas anestesi.
MANFAAT EKONOMI
DAMPAK LINGKUNGAN
HFA pasti menghasilkan pencemaran lingkungan. N2O —> "gas rumah kaca" yang
signifikan
Penurunan FGF —> menghasilkan lebih sedikit polusi.
Semua gas dari mesin anestesi dibuang ke atmosfer. HAL, ENF, ISO mengandung
klorin. Mereka diyakini memiliki potensi penipisan ozon (O3) yang signifikan.
Stabilitas molekul ini memungkinkan perjalanan mereka ke stratosfer di mana
peningkatan radiasi UV menyebabkan disosiasi yg membebaskan klorin —>
bertindak sebagai katalis dalam pemecahan O3. Reaksi ini merupakan penyebab
utama rusaknya lapisan O3, terutama di atas Kutub Selatan.
ECOLOGICAL REASONS
Hole in the ozone layer

Nitrous oxide is
the most important ozone-depleting
and heat-trapping greenhouse gas.
Hole in the ozone layer over the Antarktis (July 2005): nitrous oxide, the
new danger for the ozone layer? (Spiegel online)

http://theresilientearth.com/files/images/Anthro+Natural_Forcings-ipcc.jpg
16
Conditions for low-flow Anesthesia
OXYGEN CONSUMPTION
Patients’ oxygen consumption during anaesthesia corresponds to their metabolic
consumption and can be assumed to be roughly constant
The rule of thumb is that oxygen consumption in mL/min corresponds roughly to :
 VO2 = 3.5 X kg (ml/min)
For a patient with a weight of 100 kilograms, for example, this means that an oxygen
uptake of 350 mL/min must be expected
ANAESTHESIA GAS UPTAKE
Major clinical importance is that the greatest anaesthesia gas uptake occurs in the
first minutes  uptake phase
The further phase of constant anaesthesia, the anaesthesia gas uptake is roughly
constant
MAC VALUE
The MAC value is the minimal alveolar concentration of a volatile anaesthetic at
which 50% of patients no longer respond with a defensive reaction to an incision in
the skin
FACTORS INFLUENCING THE MAC VALUE : drugs that act on the central
nervous system reduce the MAC value , opioids and co-anaesthetics, such as
sedatives, reduce the MAC value , Hypothermia and pregnancy, also lead to a
reduction in MAC values
MONITORING
•Monitoring also includes continuous reading of the electrocardiogram, regular
checks of blood circulation parameters, measurement of respiratory tract pressure
and expiratory volume.
•Continuous monitoring of the inspiratory oxygen concentration, of the expiratory
anaesthesia gas concentration and expiratory CO2 concentration, of the respiratory
tract pressure and minute volume are mandatory.
•Monitoring of sodalime
Performing LFA/MFA
PERSIAPAN DAN INDUKSI
Premedikasi
Induksi- pre oksigenasi dg oksigen 100% 6 L/mnt selama 1-3 menit,
menggunakan face mask
Hipnotik intravena atau induksi inhalasi
Analgetik dan relaksan
Intubasi ett atau insersi LMA
Koneksi pasien dengan sistem sirkuit
 FASE INISIAL
Seting FGF : O2 1 L/mnt, air 3 L/mnt (40% O2 dan FGF 4 L/mnt)
Seting Vaporizer :
isoflurane 2,5%
sevoflurane 3,5%
desflurane 6 %
Konsentrasi fraksi inspirasi oksigen stabil di 35-40%
 FASE INISIAL
Saat tercapai nilai MAC 0,8-1 ;
FGF O2 menjadi 0,3 L/mnt, air 0,2 L/mnt (68% O2 dan 0,5 FGF)
Seting vaporizer dinaikkan :
isoflurane 5 vol%
sevoflurane 5 vol%
desflurane 8 vol%
 MONITORING
Low flow anesthesia
1. The lower alarm of the inspiratory oxygen concentration should be set between
28% and 30%.
2. Minute volume monitoring: lower alarm limit 0.5 L/min below nominal value
3. Inspired volatile anesthetic concentration: Upper alarm limit for halothane,
enflurane and isoflurane: 2.5 vol% sevoflurane: 3.5 vol% & desflurane: 8.0 - 10 vol%
4. Disconnect alarm: lower alarm limit 5mbar below peak pressure
 REVERSAL
Low flow anesthesia

Turunkan seting vaporizer ke 0%, 10 menit sebelum operasi selesai

Pertahankan low flow 0,5 L/mnt - ganti ke pernafasan spontan
Setelah operasi selesai, buka FGF 6 L/mnt dengan 02 100%
 WARNING ! INSPIRATORY O2
ALARM
Jika konsentrasi O2 inspirasi turun < 28 vol%, naikkan FGF O2 dari 0,3 ke 0,5
L/mnt dan hentikan FGF air menjadi 0 (100% O2 dan 0,5 L/mnt FGF)
 WARNING ! FGF TOO LOW
Jika Minute volume turun, peak airway pressure turun, reservoir bags kolaps —>
mesin mengeluarkan alarm fresh gas
Naikkan FGF menjadi 4 L/mnt (1 L O2, 3 L air)
Cari sumber leakage (hose system, BVM, CO2 absorber terpasang dg baik)
Jika kebocoran tdk berhasil diatasi, ubah Minimal flow menjadi Low Flow (0,3
L/mnt O2 dan O,7 L/mnt air)
Jika konsentrasi CO2 naik, evaluasi kemungkinan penggantian soda lime
 Contraindications of low-flow anaesthesia

• Patient with smoke intoxication (carbon monoxide, cyanide intoxication)

• Malignant hyperthermia
• Patients in a ketoacidotic coma (diabetes mellitus) or for patients suffering from a
ketoacidotic metabolic condition (for example, anorexia nervosa)
• Patients with alcohol or acetone poisoning,

In most cases of anaesthesia, a low fresh gas flow can be provided and
has proven reliable under various circumstances.
Despite the benefits, many anesthesiologists are uncomfortable using low fresh gas
flows because of the following concerns:
• Uncertain agent concentration (dilution effect)
• Uncertainty on the oxygen concentration in the delivered gas (possibility of
hypoxic concentrations of delivered gas)
• Concerns on the adequacy of flow
 KESIMPULAN
Low flow anestesi dapat digunakan hampir pada setiap pasien
Low flow Anestesi sangat tergantung pada teknologi yaitu mesin anestesi yang
memenuhi requirement
Hal ini memberikan keuntungan menyangkut praktik klinis, lingkungan,
farmakologis, teknologi dan penghematan biaya.
“Terima Kasih”