Interpretation of Blood Gas Reports - Made Easy: Dr. A K Sethi's EORCAPS-2010, Delhi

Dr.
A K SethisEORCAPS-2010, Delhi
1
Dr.AKSethisEORCAPS-2010
Interpretation of Blood Gas Reports
- Made Easy
Prof. A. K. Sethi
Importance of Interpretation
To establish diagnosis
To ascertain severity
To decide about intensity of monitoring
To further intervene in management
All Intensivists Anaesthesiologists Physicians h ld All Intensivists, Anaesthesiologists, Physicians should
KnowcorrecttechniquesinvolvedinperforminganABGanalysis
HaveanunderstandingofthechangesinABGsincommonly
encounteredclinicalconditions
Knowtoanalyzethebloodgasreportsystematically
Understandimplications
When to do ABGs
1. Assesstheadequacyofventilationandoxygenation
(whetherthepatientisonaventilatorornot!)
2. Establishthediagnosisandseverityofrespiratoryfailure
3. Guidetherapy O
2
administration,mechanicalventilation,weaning
4. Assesschangesinacidbasehomeostasis
5. Guidetreatmentforacidbaseabnormalities
When to do ABGs
6. ManagepatientsinICUsfor
Respiratorydysfunctionorfailure
Cardiacfailure
Renalfailure
Hepaticfailure
Polytrauma
Multiorganfailure
Diabeticketoacidosis
Sepsis
Burns
Varioustypesofpoisoningsetc.
When to do ABGs
7. Monitor patients during
Cardio-pulmonary surgery
Cardio-pulmonary exercise testing
Sleep studies
8. Determine prognosis in critically ill patients
Explanation of Terms
Hb, HCT, FiO
2
, PaO
2
, PaCO
2
, pH, Na
+
, K
+
, Ca
+
, O
2
Sat (%)
RQ CO
2
produced:O
2
consumed, Set value, Can be fed
HCO
3
A(Actual) Parameter for non-respiratory component
of acid-base balance
HCO
3
S(Standard) Parameter for non-respiratory component of acid-
base balance but reported after standardising at
PCO at 40 mm Hg Temperature 37C SO 100% PCO
2
at 40 mm Hg, Temperature 37 C, SO
2
100%
Baseexcess HCO
3
amount above or below normal content (0) of
buffer base, (+) or (-)
Depends upon entered Hb value and measured pH
and PCO
2
values.
Standard
Base excess
HCO
3
amount above (+) or below (-) normal content
(0) of buffer base
Calculated from a standard Hb value of 6 gm% and
the measured pH and PCO
2
values.
Dr. A K SethisEORCAPS-2010, Delhi
2
......Explanation of Terms
BB (Buffer bases)
Sum of all buffer anions in blood, Metabolic index
(Hb, HCO
3
, Protein, Phosphate)
TCO
2
Content HCO
3
concentration + dissolved CO
2
in plasma
O
2
CT, CaO
2
, O
2
content Hb bound O
2
+ Plasma dissolved O
2
A-aDO
2
Difference between
PO
2
Alveolar and PO
2
arterial PO
2
Alveolar and PO
2
arterial
P50 Semisaturation pressure = Partial pressure of O
2
at which Hb is 50% saturated
Ca 7.4 Calcium ion concentration computed for pH 7.4
Li Lithium ion concentration
LAC Lactate concentration
GLU Glucose concentration
Know Normal & Reference Values for Calculations
K
+
3.5 5.1
Ca
+
1.12 1.32
Cl
-
97 100
Base excess (mEq/L) 0 2
TCO
2
Content (mEq/L) 27
Hb (gm%) Measured, Fed or
calculated
(HCT/3)
HCT (%) Measured or
calculated (3xHb)
FiO
2
Fed
RQ 0 85
2
( q )
BB (mEq/L) 48
O
2
Sat (%) >95%
O
2
CT (ml/dL) 16 22
P50 mmHg 27
A-aDO
2
mmHg 5 25
RQ 0.85
PaO
2
(mmHg) 80 100
PaCO
2
(mmHg) 35 45
pH 7.35 7.45
HCO
3
A (mEq/L) 22 26
Na
+
135 145
Terminology
Acidemia : Blood pH < 7.35
Acidosis :
A primary physiologic process that,
occurring alone, tends to cause acidemia
(e.g., respiratory acidosis from hypoventilation
or metabolic acidosis from decreased perfusion or shock) p )
Alkalemia : Blood pH > 7.45
Alkalosis :
A primary physiologic process that,
occurring alone, tends to cause alkalemia
(e.g., respiratory alkalosis from acute hyperventilation
or metabolic alkalosis from excessive diuretic therapy)
Terminology
Primary acid-base disorders
Respiratory Acidosis, Respiratory Alkalosis, Metabolic Acidosis, Metabolic Alkalosis
manifestasinitialchangesinPaCO
2
orHCO
3
First
Change
Disorder Change Primary
disorder
Effect pH
Rises Respiratory Acidemia Falls
PaCO
2
Respiratory
Rises Respiratory
acidosis
Acidemia Falls
Falls Respiratory
alkalosis
Alkalemia Rises
HCO
3
Metabolic
Rises Metabolic
alkalosis
Alkalemia Rises
Falls Metabolic
acidosis
Acidemia Falls
Terminology
SecondarychangesinHCO
3
orPaCO
2
occurring inresponsetotheprimaryevent
tonormalizepH
Done by the organ system which is not primarily affected
Compensation
- when the acid-base imbalance exists over a period of time.
Donebytheorgansystemwhichisnotprimarilyaffected
Respiratorycompensationformetabolicdisorders
Metaboliccompensationforrespiratorydisorders
ResultantBloodGasStates
Uncompensated PartiallyCompensated FullyCompensated
Abnormal pH Abnormal pH NormalpH,
OtherValuesmay
remainabnormal
.........Compensations
Respiratory
Compensation
Renal Compensation
Characteristics Rapid,in1 3min,
Complete
Slow,inhourstodays,
Incomplete
Mechanismin Washoffexcessive SecreteH
+
ionsout
acidosis CO
2
byincreasing
ventilation
(asinmetabolicacidosis)
ReabsorbfilteredHCO
3
ions
ProduceofnewHCO
3
ions.
(asinrespiratoryacidosis)
Mechanismin
alkalosis
RetainCO
2
by
decreasing
ventilation
(asinmetabolicalkalosis)
ExcessHCO
3
filteredinto
renaltubules,eliminatedin
urine
(asinrespiratoryalkalosis)
3
Reading the Report Step-by-Step
Arterial, Venous or Mixed
Arterial Venous
Askthepersonwho
aspiratedthesample
Bloodpulsates Blooddoesnot pulsate
Syringeplungermay
riseonitsown
Syringeplungernever
risesonitsown
PO
2
PO
2
>40mmHg PO
2
<40
(often < 30 mmHg).
Sometimes, there is no way to know if the sample is arterial or venous !
(often<30mmHg).
O
2
saturationvalues SaO
2
>75% SvO
2
<75%
No.ofattempts Single
orMultiplepunctures
Singlepuncture,
rapidfilling
Multiple,LowerPO
2
duetovenousmixture
pH Abnormalornormal,
Notdiagnostic
Abnormalornormal,
Notdiagnostic
PCO
2
Abnormalornormal,
Notdiagnostic
Abnormalornormal,
Notdiagnostic
Venousadmixture(CHD) LowerPaO
2
values Venousadmixture.
Reading the Report Step-by-Step
Step 1
Check if the required parameters have been correctly fed ?
Barometricpressure
Patientstemperature
Haemoglobin Haemoglobin
(ifmachinedoesnotmeasure,doesnotcalculate)
FiO
2
Results in the report are bound to
change, get incorrect and misleading
if the above values are not correctly filled
Barometric pressure (P
B
)
(Weight of Atmosphere)
Air=O
2
21%,N
2
78%,Othergases1%
Compositiondoesnotchangewithaltitude,P
B
decreaseswithheight
P
B
=sumofPressuresofallconstituentgases
P=p
1
+p
2
+p
3
+p
4
EachgasexertsitsownPartialPressure
p=%gasxP
B
f (O CO ) ill h di t C t ti & P pofagas(O
2
orCO
2
)willchangeaccordingtoConcentration&P
B
Allmachinescalculate&adjustreadingsaccordingtoP
B
Alveolargasequation:PAO
2
=PiO
2
1.2(PaCO
2
)
PiO
2
=FiO
2
(P
B
47)
AllmachinescalculatePAO
2
fromPiO
2
(affectedbyFiO
2
andP
B
)
AaDO
2
willbeaffectedifP
B
&FiO
2
isnotfedproperly
FeedP
B
ifthemachinedoesnotmeasureP
B
onitsown
Temperature Effect on PaCO
2
& PaO
2
Machinealwaysanalysesbloodat37 C
HyperthermicPatient=>37 C(Sample)
MeasuredPaO
2
andPaCO
2
willbelessthanactual
(Pressure Temperature pdecreaseswhensubjectedtolowerrelative
temperatureofmachineandfalselylowerpressuresgetmeasured)
HypothermicPatient=<37 C(Sample)
MeasuredPaO
2
andPaCO
2
willbemorethanactual
(Pressure Temperature p increases when subjected to higher relative (Pressure Temperature p increaseswhensubjectedtohigherrelative
temperatureofmachineandfalselyhigherpressuresgetmeasured)
FeedingcorrectTemperaturevalueallowssomemachinesto
correctaccordingly,(orApplyformulaemanually)
ForeachCaboveorbelow37
0
C Example=Febrile patient,39
0
C
ChangeinPaO
2
5mmHg MeasuredPaO
2
=80 mmHg
TrueinvivoPaO
2
=90mmHg
ChangeinPaCO
2
2mmHg MeasuredPaCO
2
=40 mmHg
TruePaCO
2
=44mmHg
Temperature - Effect on SaO
2
Temperature affects position, shifting of ODC
WhenthemachinedoesnotmeasureactualSO
2
ButcalculatesSO
2
fromPO
2
(ODC)
,
SO
2
valuescanbefalse.
ChangeinTemperature ShiftingofODC CalculatedSO
2
at37C
Increase Right Higherthanactual
D L f L h l Decrease Left Lower thanactual
Temperature
Temperature
N
4
Haemoglobin
Derived(FromHaematocrit)
Measured(Cooximeters)
Notentered!(Defaultvalue Wrong)
Manuallyentered
Trueassessmentof
adequacyofO
2
inarterial
blood can only be made if
Value influences
CaO
2
Base Excess
bloodcanonlybemadeif
Hbvaluesareentered.
SaO
2
&PaO
2
donot
incorporateHbcontentin
theircalculations.
Hb affectsBufferBase
values
Total O
2
attached
to Hb Content +
Total Dissolved O
2
carried by Plasma
Hb content (gm%)
O
2
carried by 1 gm Hb (ml)
Saturation Hb
PaO
2
Solubility Coefficient
15 x 1 34 x 100 (sa ) = 20 10 100 x 0 003 = 0 30
+
15 x 1.34 x 100 (say) = 20.10 100 x 0.003 = 0.30
+
= 20.40 ml / dL
15 x 1.34 x 85 (say) = 17.09 50 (say) x 0.003 = 0.15
+
= 17.24 ml / dL
8 x 1.34 x 100 (say) = 10.72 100 x 0.003 = 0.30
+
= 10.75 ml / dL
Entering FiO
2
is very important
Most common mistake
FiO
2
notenteredwhilethesample
isfedinthemachine
%FiO
2
writtenonthereportlater
onmanually
Hb l t t d t th ti f
FiO
2
Hb alsonotenteredatthetimeof
feedingsamplebuttoldlateron
Interpretation of PO
2
affected adversely
A-aDO
2
values are wrongly calculated
(PAO
2
calculated from PiO
2
)
Interpretation of adequacy of Oxygenation
affected adversely if Hb not fed properly.
If FiO
2
not fed properly
Step - 2
Analyse the Adequacy of Oxygenation
(i) Look at PaO
2
and SaO
2
first
PaO
2
(mmHg) SaO
2
(%)
Normalvalues(onair) >80 >95
Mildhypoxemia 6079 9094
HealthyAdult SeaLevel,RoomAir,AaO
2
=4mmHg,PAO2=101
Moderatehypoxemia 4059 7589
Severehypoxemia <40 <75
PaO
2
- Important
Low PaO
2
= Surely something wrong in terms of Oxygenation
Low PaO
2
= degree of hypoxemia
Saturation of Hb (SaO
2
) is dependent upon PaO
2
Never rely totally on PaO
2
& SaO
2
Look at other parameters also (CaO
2
)
(ii) Relate PaO
2
with FiO
2
Classify Hypoxemia
Inspired O
2
% PaO
2
mmHg
30 > 150
40 > 200
O
2
x 5 = PaO
2
Uncorrected
Hypoxemia
<60
PaO
2
40 > 200
50 > 250
80 > 400
100 > 500
Excessively
Corrected
Corrected 60100,<predicted
>100,<predicted
Refractory
COPD ? x 3 Responsive
(iii) Find if Oxygenation is adequate or not CaO
2
PaO
2
and SO
2
may not give true estimate.
Low PaO
2
but still adequate oxygen Content. (V/Qimbalance)
Normal PaO
2
, still profound hypoxemia. (Anaemia, Altered affinity of Hb for O
2
)
Calculated SaO
2
may mislead & show false normal results. (CO, MHb )
Total Oxygen Content
CaO
2
measured directly or calculated by O
2
content equation.
CaO
2
= Hb(gm%) x 1.34 x SaO
2
+ 0.003 x PaO
2
(mmHg).
2
(If no co-oximeter in the machine, SaO
2
is calculated from PaO
2
)
5
Step 3 : Acid Base disturbances
Analyse pH
pH Analysis
7.35 7.45 (7.4) Normal No acid-base disorder
Or, Compensated disorder
< 7.35 Acidemia Uncompensated Acidosis
(or partially compensated)
7 45 Alk l i U t d Alk l i > 7.45 Alkalemia Uncompensated Alkalosis
(or partially compensated)
Acidemia (pH < 7.35) Alkalemia (pH >7.45)
Mild 7.30 7.34 7.46 7.50
Moderate 7.20 7.29 7.51 7.54
Severe < 7.2 > 7.55
Incompatible with life < 6.8 > 7.8
Step 4 Analyse the Primary disorder
- Respiratory or Metabolic ?
Respiratory
Change Disorder Change pH Primarydisorder
PaCO
2
Respiratory
>45 Respiratoryacidosis
<35 Respiratoryalkalosis
For every 20 mmHg rise in PaCO
2
= pH should fall by 0.10 F y mm g
2
p f y
For every 10 mmHg fall in PaCO
2
= pH should rise by 0.10
PaCO
2
= 65 (20 mm rise from 45)
pH = 7.25 (0.10 fall from 7.35)
PaCO
2
= 25 (10 mm fall from 35)
pH = 7.55 (0.10 rise from 7.45)
If pH & PaCO
2
move in opposite directions
Primary defect is Respiratory.
If pH is not moving in opposite direction as PaCO
2
Primary defect is Not Respiratory (Metabolic).
Change Disorder Change pH Primarydisorder
HCO
3
Metabolic
>26 Metabolicalkalosis
......Step 4
Analyse the Primary disorder
- Respiratory or Metabolic ?
Metabolic
HCO
3
(base)
Metabolic
<22 Metabolic acidosis
If pH moves in same direction as HCO
3
Primary defect is Metabolic

If pH moves in opposite direction as HCO
3
Primary defect is not Metabolic (Respiratory)
Step 5 : Analyse and Correlate Compensation
Body tries to bring pH towards normal, with time
Lungs and kidneys are primary buffer response systems
pH outside normal range Uncompensated or Partially compensated pH outside normal range Uncompensated or Partially compensated
pH normal range Fully compensated (or no acid base disturbance)
pH = 7.4 No acid base disturbance or mixed disorder
Analyse and Correlate pH, PaCO
2
and HCO
3
Step 6 : Calculate the Expected Compensation
- Match it with actual
For every 10 mmHg change in PaCO
2
Disorder Change in PaCO
2
Compensation (Kidney)
Respiratory acidosis 10 mmHg Acute rise 1 mEq/L rise in HCO
3
10 mmHg Chronic rise 4 mEq/L rise in HCO
3
Respiratory alkalosis 10 mmHg Acute fall 2 mEq/L fall in HCO
3
10 mmHg Chronic fall 4 mEq/L fall in HCO 10 mmHg Chronic fall 4 mEq/L fall in HCO
3
For every 1 mEq/L change in HCO
3
Disorder Change in HCO
3
Compensation (Lungs)
Metabolic acidosis 1 mEq/L fall 1.25 mmHg fall in PaCO
2
Metabolic alkalosis 1 mEq/L rise 0.75 mmHg rise in PaCO
2
Match the Calculated Compensation with the Actual (Report)
Step 7 :
Find out if the Disorder is Mixed ?
(1) Check relative movement of pH PaCO
2
and pH HCO
3
If both pairs moving & in correct directions Mixed disorder
(2) Analyse compensation by Presuming Primary disorder
as Respiratory or Metabolic
If analysis supports no compensation Mixed disorder
6
Step 8 : Unmask Hidden Metabolic Disorders
Use concept of Serum Electrolytes
Do not interpret any ABG data without Serum Electrolytes
(Na
+
, K
+
, Cl
-
, CO
2
)
3 Parameters need to be determined
1. Anion Gap and its change from normal ( AG)
2. Venous CO
2
and its change from normal ( CO
2
)
3. Bicarbonate Gap (BG)
Anion Gap and its change from normal
AG = (Routinely measured Cations Routinely measured Anions)
AG = (Na
+
+ K
+
) (Cl
-
+ HCO
3
)
AG = (Na
+
) (Cl
-
+ CO
2
)
Normal AG = 12 4 mEq/L
Change in AG from normal ( AG) = Measured AG 12
Positive (+) or Elevated AG (> 16)
Metabolic Acidosis
Negative (-) or Low AG
Reduction in unmeasured Anions (Hypoprotienemia)
Excess unmeasured Cations (Lithium Toxicity)
Excess abnormal +vely charged proteins (Multiple Myeloma)
Halide ion measured as Chloride (Bromism, Cough syrups)
Venous CO
2
and its change from normal
Index of Plasma HCO
3
Total CO
2
= Plasma HCO
3
+ Dissolved CO
2
in Plasma
Normal = 24 30 mEq/L (27 mEq/L)
Change in Venous CO
2
from normal
( CO
2
) = 27 measured CO
2
Bicarbonate Gap
Unmasks the co-existence of 2 metabolic disorders
BG = AG - CO
2
BG = (Measured AG 12) (27 Measured CO
2
)
Positive (+) or Elevated BG = > + 6 mEq/L
Metabolic Alkalosis
Bicarbonate retention as compensation for Respiratory Acidosis
Negative (-) or Low BG = < 6 mEq/L
Metabolic Acidosis
Bicarbonate excretion as compensation for Respiratory Alkalosis
Steps (Summary)
Step 1 : Check if the required parameters have been correctly fed?
Step 2 : Analyse the Adequacy of Oxygenation.
Step 3 : Analyse pH Acidemia or Alkalemia?
Step 4 : Analyse the Primary disorder - Respiratory or Metabolic ?
Step 5 : Analyse and Correlate Compensation.
Step 6 : Calculate the Expected Compensation. Match it with actual.
Step 7 : Find out if the Disorder is Mixed ?
Step 8 : Unmask Hidden Metabolic Disorders.
Dr. A.K. Sethis EORCAPS-2010, Delhi
1

Perioperative Management of Diabetes Mellitus
Dir. Prof. Rakesh Kumar

Diabetes mellitus (DM) is the most common endocrinopathy and its incidence is on the rise and
it is also the commonest endocrine disorder encountered in anesthesia. It is important,
therefore, that all anesthetists should understand the disease and its complications, and use a
scientifically sound regimen for the perioperative management of diabetic patients. Both the
American Diabetic Association (ADA) and the WHO

advise that a more etiologically based
nomenclature of DM should be used (Table 1).

Table 1: Etiologic Classification of Disorders of Glycemia
3
Type 1 (Pancreatic beta cell destruction, usually leading to absolute insulin deficiency)
A. Autoimmune
B. Idiopathic
Type 2 (may range from predominantly insulin resistance with relative insulin deficiency to a
predominantly secretory defect with or without insulin resistance)
Others specific types
- Genetic defects of beta cell function
- Genetic defects in insulin action
- Diseases of exocrine pancreas (infections, immune-mediated)
- Endocrinopathies associated with increased secretion of counter-regulatory hormones
- Drug- or chemical- induced
- Infections
- Uncommon forms of immune-mediated diabetes
- Other genetic syndromes sometimes associated with diabetes
Gestational diabetes
Glucose intolerance which has its onset in, or is first diagnosed during, pregnancy

DIAGNOSTIC CRITERIA OF DM
The diagnostic criteria for DM and related stages of glycemia, revised earlier in 1997 by ADA and
accepted by the WHO in 1999, have been again revised somewhat by the Expert Committee of ADA in
2003 and are shown in Table 2. Because the hyperglycemia cutoff points for risk of diabetes
complications appear to apply similarly to older and younger populations, the classification and the ADA
diagnostic criteria for diabetes in adults are not modified by the patients age.
2

Table 2: Diagnostic criteria for DM and related stages of glycemia
Glucose concentration, mg/dl (mmol L
-1
)
Venous/Capillary whole blood Venous plasma
Diabetes mellitus
Fasting
2-h postglucose (75g)

110 (6.1)
200 (11.1)

126 (7.0)
200 (11.1)
Impaired glucose tolerance
2-h postglucose (75g)

140-199 (7.8-11.0)

140-199 (7.8-11.0)
Impaired fasting glycemia 90110 (5.0-6.1) 100125 (5.6-6.9)

Although the following discussion pertains to the management of an already diagnosed case of
DM, it will be worthwhile mentioning here that DM is now diagnosed by (a) reproducible
demonstration of fasting hyperglycemia i.e. fasting Blood Sugar (BS) > 110 mg% (6.1 mmol L
-1
)
(Serum or plasma sugar > 126 mg% [7 mmol L
-1
])* on two or more occasions, OR (b) A casual
(random) BS of > 180 mg% [10 mmol L
-1
], OR (c) Oral GTT producing a result in the diabetic
range. The ADA defines fasting BS concentrations between 100 110 mg% (5.6-6.1 mmol L
-1
)
as representing impaired fasting glycemia.

Medication for DM
Let us review the present anti-diabetic medication:

The anti-diabetic medications consist of Oral Medications (Table 3) and Insulins (Table 4):

Table 3: Oral Antihyperglycemic Drugs

* Venous Whole Blood Glucose Value + 15% = Venous Plasma Glucose Value
= Capillary whole blood glucose value
Thus venous Whole BG of 110 mg% = Plasma or capillary BG of 126 mg%

(Also1 mmol L
-1
BG = 18 mg% BG)
3
Drug Preparations Duration Remarks
Sulfonylureas
1
st
generation
- Tolbutamide

- Chlorpropamide

2
nd
generation
- Glibenclamide

- Glipizide

- Gliclazide
- Glimepiride

RASTINON
ARTOSIN
DIABINESE
DIABIGON

DAONIL
EUGLUCON
BETANASE
GLYNASE
MINIDIAB
DIAMICRON
AMARYL
GLYMER

6-8h

36-48h

18-24h

12-18h

12-24h
12-24h
1. Increase pancreatic
release of endogenous
insulin and insulin
receptor function
2. Cause hypoglycemia
3. Glimepiride has
stronger extra pancreatic
action through
translocation of GLUT4 to
plasma membrane & thus
less chance of
hypoglycemia
Biguanides
- Metformin

- Phenformin

GLYCIPHAGE
WALAPHAGE
DBI

6-8 h
1. ? improves insulin
receptor functions
2. Lactic acidosis (very
rarely with metformin
Glinides
- Repaglinide
- Natglinide

PRANDIN

4-6 h
Stimulate rapid insulin
secretion (early peak
without inter-prandial rise)
by closing the ATP
dependent potassium
channel.
-glucosidase inhibitors
- Acarbose

GLUCOBAY
PRECOSE

??
1. Decrease digestion, &
absorption of
carbohydrates
2. May cause diarrhea,
abdominal pain
Thiazolidinediones
1
st
generation
- Troglitazone
2
nd
generation
- Pioglitazone
- Rosiglitazone
- Darglitazone

ACTOSE
AVANDIA

12-24 h
12-24 h
Reverse insulin resistance
in liver, adipose tissue
and skeletal muscle,
possibly by raising the
number of glucose
transporters sensitization
of target cells to insulin).
Chance of hepato-toxicity.
Miscellaneous
- Guargum

DIATAID
Dietary fiber from Indian
cluster bean guar. Mixed
with food, it slows glucose
absorption.

The perioperative anesthetic management of DM varies with type of DM, the end-organ
changes in the patient, the nature and the urgency of surgery, the kind of medication the patient
is taking and the level of glycemic control. Does that mean remembering a protocol for each of
these innumerable situations created by the combination of the factors mentioned above (e.g.
55 year old type-2 diabetic lady with coronary artery disease for elective laparoscopic
4
cholecystectomy, poorly controlled on sulfonylureas)? Fortunately the answer is no, but with a
rider. And that rider is: Get hold of some strong building blocks, the basics, and use these to
find the way out of the situation faced.

I have discussed about these strong building blocks earlier too.

In my opinion, these are:
1. The major risk for diabetics undergoing surgery are the end-organ diseases associated with
diabetes.

2. There is no anesthetic technique or approach specifically indicated for the diabetic patient.
Surgical requirements and the presence of end organ pathology primarily dictate the anesthetic
choice and management.

Table 4: Preparations of Insulin

Preparation Type Onset
(hrs)
Peak
(hrs)
Duration
(hrs)
Conventional
(standard)
[Contain 1%
i.e. 10,000 ppm
of other
proteins
(proinsulin,
proteins, insulin
derivatives
etc.)]
Short acting
Regular (soluble) Insulin
Prompt Insulin Zinc Suspension (amorphous) or
semilente

0.5 -1

1

2-4

3-6

6-8

12-16
Intermediate acting
Insulin Zinc Suspension or Lente (Ultra:
Semi=7:3)
Neutral Protamine Hagedorn (NPH) or Isophane
Insulin

1-2

1-2

8-10

8-10

20-24

20-24
Long acting
Extended Insulin Zinc Suspension (Crystalline) or
Ultralente
Protamine Zinc Insulin (PZI)

4-6
4-6

14-18
14-20

24-36
24-36
More Purified
(Purified pork
insulin-
proinsulin <20-
200ppm)
Single peak insulins
(Proinsulin=50-200 ppm)
Actrapid, Rapidica (=Regular insulin)
Lentard, Zinulin (=Lente insulin)
Actraphane, Rapimix (=Regular 30% + Isophane
70%)

0.5 -1
1-2

1-2

2-4
8-10

8-10

8
22

24
Monocomponent (MC) insulins
(Proinsulin<20 ppm)
Actrapid MC (=MC Regular)
Monotard MC (= MC Lente)

0.5 -1
1-2

2-4
8-10

8
22
Human
Insulins

Human Actrapid (=human Regular)
Human Monotard (=human Lente)
Human Actraphane (=human soluble 30% +
human Isophane 70%)
Lispro (human recombinant)
0.5 -1
1-2

1-2
-
2-4
8-10

8-10
1-2
8
22

24
4-6

5
3. Inadequate control of BG can lead to the problems of hyperglycemia, ketosis, academia,
hyperosmolar crisis with severe fluid and electrolyte imbalances on one hand and hypoglycemia
on the other.

4. In order to minimize morbidity in the diabetic patient undergoing elective surgery, the
anesthesiologist should mimic normal metabolism as closely as possible by avoiding
hypoglycemia, excessive hyperglycemia, lipolysis, ketogenesis, protein catabolism, and
electrolyte disturbances. This goal is best achieved by providing adequate insulin to
counterbalance the catabolic response to surgery and anesthesia. Adequate glucose should be
provided to meet the increased requirements of surgical stress in addition to basal caloric
requirements. Finally, a regimen that is simply and minimizes the possibilities of error in
administration must be devised.
5. Surgeries have been classified as minor, intermediate or major in relation to perioperative
glycemic control. Minor surgery has been defined as procedures lasting upto 30 minutes which
are unlikely to interfere with normal diabetic treatment e.g. cystoscopy, laparoscopy; Intermediate
surgery as procedures which last between 30 minutes and 2 hours and might interfere with
normal treatment on the day of surgery, e.g. Laminectomy, internal fixation of fracture; and major
surgery lasts more than two hours or is any surgery which is likely to interfere with normal
diabetic management and diet e.g. Cholecystectomy, bowel resection, major vascular
reconstruction. Although I too go by this classification but I do not give weightage either to the
time taken for the surgery or the examples cited above. I personally believe that the only criterion
of relevance to a diabetic is the duration of post anesthesia starvation. Thus in context with DM, a
surgery is minor if the patient can start oral intake within minutes of end of anesthesia,
intermediate if he is NPO overnight, and major if he is NPO for over 24 h.
6. Most of the poorly controlled diabetics (whether taking OHA or insulin) can be controlled in about
12 h of insulin infusion therapy. Start insulin infusion, check blood gases and capillary glucose
hourly, and give sufficient glucose (5-10g/h) and potassium (2-4 mmol/h). This has its clinical
implication in semi-emergency surgeries.
7. It is a mistaken belief that omission of carbohydrate & insulin are self-canceling. The requirement
of carbohydrates usually increases in the perioperative period because of stress and the
endogenous insulin becomes even less effective than usual because of increased
counterregulatory hormones. The absence of carbohydrates (no carbohydrate given) on one
hand and its inadequate disposal (no insulin administered) prompt the body to breakdown of
lipids and proteins.
8. The renal threshold for glucose is approximately 180-200 mg/dl in patients with normal renal
function (Fig. 1). Osmotic diuresis with resulting water and electrolyte losses occur when this
glucose level is exceeded.
6

9. Administration of IV boluses of insulin to regulate intraoperative hyperglycemia should be
considered both unphysiological and potentially dangerous. The half-life of IV insulin is 4-5 min
and the biologic half-life less than 20 min. Patients receiving IV insulin may have very high (short
lived) insulin concentrations, which may cause hypoglycemia, which may go unnoticed because
of infrequent monitoring. The insulin concentration can be extremely low in the 60-120 min period
prior to the administration of the next bolus of insulin. The roller coaster approach to glucose
regulation may result in an even greater rate of lipolysis & ketogenesis. A large insulin bolus can
cause significant extracellular-to-intracellular shift of potassium, phosphorus and magnesium and
may therefore predispose patients to cardiac arrhythmias.

10. One unit insulin decreases BG by 25-30 mg% in a 70-80 kg person and 10 gm glucose raises it
by 35-40 mg%. Thus 1 unit Insulin = ~7 g Glucose.

11. If there are symptoms and signs of gastroparesis or autonomic neuropathy, metoclopramide
should be a part of the premedication and may also be an effective postoperative antiemetic.

12. Diabetics with significant autonomic neuropathy may have impaired respiratory responses to
hypoxia and are particularly susceptible to the action of drugs that have depressant effects. Such
patients should be given premedicants with caution and may warrant very close, continuous
cardiac and respiratory monitoring for 12 to 24 hours postoperatively. In addition to the
symptoms, the presence of autonomic neuropathy may be detected by bedside tests like absence
of the normal variation in the heart rate on slow, deep respiration (~6 breaths per minute) or
Valsalva maneuver, and postural hypotension.

13. Documentation of peripheral neuropathy is absolutely essential in diabetics in whom a regional
block is contemplated. This not only keeps the patients and relatives informed but also avoids
medico-legal hassles later on.
14. It appears that central neural blockade has only a limited impact on metabolic function as
indicated by minimal changes in BG, lactate, alanine, FFA, glycerol, and ketones during epidural
anesthesia. The insulin response to hyperglycemia appears to be inhibited by a high thoracic (T1-
T6) blockade, whereas low blockade, (T9 - T12) has no effect on insulin secretion.
15. Scheduling the operative procedure early in the day avoids prolonging the catabolic state and
minimizes the risk of perioperative hypoglycemia. If not possible to schedule in the morning, keep
fasting to around 6 hours or start glucose and insulin.
7
16. An inability to approximate the palmer surfaces of the interphalangeal joints (prayer sign)
correlates with the presence of stiff joint syndrome. The atlanto-occipital joint may be involved,
contributing to difficulties in laryngoscopy for intubation of the trachea.
17. Fluid and volume replacement: lactated Ringers solution contains 28 meq/L of lactate and is a
gluconeogenic substrate. Hepatic conversion to glucose and aggravation of stress-induced
hyperglycemia makes it an inappropriate solution for the diabetic when large fluid requirements
are expected. Saline or other non-lactate containing crystalloids may be used for maintenance
and third space replacement. Bank blood contains variable amounts of lactate derived from
anaerobic metabolism during storage and serves as an additional gluconeogenic substrate.
Postoperative insulin requirements may increase significantly after large transfusions. It is
important to understand that Ringers lactate solution is NOT contraindicated but inappropriate as
it can confound the calculation of glucose load somewhat.

18. Emergency surgery in the diabetic: Usually associated with an infectious process, the diabetic
requiring emergency surgery frequently has pronounced hyperglycemia, dehydration and
hypovolemia and is in metabolic decompensation. If diabetic ketoacidosis (DKA) is present,
complete resolution is not possible without correction of the surgical problem. Before anesthetic
induction and surgery, through, volume resuscitation, partial correction of metabolic acidosis,
hyperglycemia and ketosis and a definite trend towards metabolic improvement must be made.
Insulin infusion is used as in the non surgical patient in DKA, although even more pronounced
insulin resistance may be seen. Urine output must be re-established and potassium
supplementation will be necessary. Anesthetic choice is based on the surgical requirements and
the physiological status of the patient.

19. There will usually be a rapid decrease in insulin requirements after surgery as metabolic control is
regained; the need for careful and frequent monitoring of BG and metabolic parameters cannot
be overemphasized.

20. The minimum amount of glucose is required to inhibit catabolic proteolysis, lipolysis and ketosis is
probably 0.1g kg
-1
h
-1
(=5g per h or 100 mL of 5% dextrose in a 50 kg person).

21. It is obvious that hypoglycemia is too bad to be allowed even for a short while, and the best
defense is frequent monitoring of BG during anesthesia and perioperative period, and then
treating it sooner rather than later. 4mmol.l
-1
(~70mg.dl
-1
) may be the useful lowest allowable limit,
with corrective steps starting at a little higher level, say 20% above the lowest limit (i.e., 4.8
mmol.l
-1
or 84 mg.dl
-1
).
8
22. Better perioperative glycemic control (BG<10.0 mmol.l
-1
or 180mg.dl
1
) means better wound
healing and less infection in cardiac surgical patients, and may be other deep surgical procedures
as well.
23. It seems that the safest course of action to prevent fluid and electrolyte imbalance will be not to
allow the BG level to stray into the zone of uncertainty. The best course is to keep BG at less
than 10 mmol.l
-1
(180 mg.dl
-1
) beyond which these fluid and electrolyte imbalances just begin.
Beyond 14 mmol.l
-1
(250 mg.dl
-1
) these start mounting steeply (Fig. 1). By keeping BG <10
mmol.l
-1
(180 mg.dl
-1
) there will be no fear of excessive diuresis and concomitant water and
electrolyte loss that may remain unaccounted for, especially during anesthesia in a non-
catheterized patient. It is safer to have HbA1c at < 9% for taking up a patient for routine surgery.

Plasma Glucose (mg.dl
-1
)

0 100 180 250 300 400 500
500

400
Glucose Reabsorbed
(mg.min
-1
)
300

200 Normal
Excreted
125
100 Threshold

0
0 125 220 320 400 500 600 700
Filtered load of glucose (mg.min
-1
)

Figure 1: Relationship among the filtered load of glucose, the rate of glucose reabsorption by
the renal tubules, the rate of glucose excretion in the urine, and the plasma glucose. (Modified
from Textbook of Medical Physiology 2000

24. In the perioperative period, if there are conditions of dehydration, pre-existing atherosclerosis,
high hematocrit, cold induced peripheral vasoconstriction, myocardial depression, and
hyperglycemia, it is easy to deduce that thrombogenesis is a very real possibility, especially in
less ambulatory older adults. Controlling perioperative BG to less than 10 mmol.l
-1
(180mg.dl
-1
)
can eliminate some of the precipitating causes.
9
25. It seems wise to keep BG under check in the perioperative period, because it signifies
appropriate levels of insulin and, most likely, good check on the levels of counterregulatory
hormones. Once these two are appropriately handled, unrecognized dehydration is avoided
automatically. This way all the etiological factors for the genesis of Diabetic Ketoacidosis (DKA)
and Hyperglycemic, hyperosmolar nonketotic state (HHNS) are tamed. In view of the fact that
perioperative period offers a number of precipitating factors for both DKA (stress of surgery and
anesthesia, trauma, infection, and dependence of patient on others for his insulin therapy) and
HHNS (surgical stress, infection, acute medical illness, postoperative dialysis, parenteral nutrition,
drugs such as diuretics, and vomiting), a BG level of < 180 mg.dl
-1
is probably worth aiming for.
12

The older adults are specifically prone to develop HHNS.
26. Hyperglycemia, for some poorly understood reason, has been shown to worsen neurological
outcome for patients after ischemic stroke. It has been suggested that the prudent course of
action is to minimize hyperglycemia in patients undergoing neurosurgical procedures. Similarly,
plasma glucose of 100-150 mg.dl
-1
is recommended during management of patients with stroke
or neurotrauma, and BG <250 mg.dl
-1
during the period of ischemia in diabetic patients about to
undergo surgery in which hypotension or reduced cerebral flow may occur. Older adults will
include lot of people with already jeopardized neurological status.
Now it will be worthwhile to have a feel of some of the tested (and published) recent regimens
for BS control in the perioperative period (previous perioperative regimens have been tabulated
and assessed by me earlier
4
):
(A) A Protocol for Continuous Intravenous Insulin Infusion in Intra Operative Diabetic Cardiac
Surgery Patients:

If taking insulin, give one half of the usual morning dose subcutaneously and start an
infusion of 5% dextrose with 0.45% sodium chloride solution @ 50 mL h
-1
. If taking OHA,
omit the morning dose. Check BG levels I h preoperatively and start insulin infusion:
Blood Glucose (mg%) Insulin (U/h)
<150 0
150 200 1
201 - 250 2
>250 3
Titrate further insulin as follows (BG every 15-30 min):
Blood Glucose (mg%) Action
10
75 - 100 Stop insulin; recheck BG until >150, restart with rate 50% of
previous rate.
101 - 150 Decrease rate by 0.5 U/h, or if BG is 10 mg% lower than last test,
decrease rate by 50%.
151 - 200 Continue same rate.
201 - 250 If lower than last test, same rate; if higher than last test, increase
rate by 0.5 U/h. (If the rate of glucose increase is rapid, increases
of 2-6 U/h acceptable).
> 250 If lower than last test, same rate; If higher than last test, increase
rate by 1U/h (see above).

If Blood Glucose >250 mg% and has not decreased after 3 successive increases in insulin, then
the insulin administration rate doubled.

(B)

The Portland Protocol for Continuous Intravenous Insulin Infusion in Post Operative
Diabetic Cardiac Surgery Patients:
Start infusion via pump piggyback to maintenance I.V. as follows:

Test blood glucose by finger stick method or arterial line drop sample.
Blood Glucose Insulin units/hr.
<125 0
125 - 175 1
175 - 225 2
>225 3
Frequency of cBGs:
a. Every 1 hour until: glucose is 125-175 with <15 mg/dl change and insulin rate remains
unchanged x4 hours. Then test @ 2 hours.
b. When weaning vasopressors, (e.g. Adrenalin) check @ 30 minutes until stable.
c. May stop @2 hour testing on POD (postoperative day) #3 [See item 4 below]
d. Test @2 hours during the night on telemetry if glucose < 200mg/dl.
Insulin titration:
Blood
Glucose
Action
<75 Stop insulin; give 25 cc D50W and recheck Blood Glucose in 30
minutes. When Blood Glucose >150, restart with rate 50% of
previous rate.
75 - 100 Stop insulin; recheck Blood Glucose in 30 minutes. When Blood
11
Glucose >150, restart with rate 50% of previous rate, unless the
dose is less than 0.25 u/hr.
101 - 125 If less than 10% lower than last test, decrease rate by 0.5 u/hr.
If more than 10% lower than last test, decrease rate by 50%. If
neither continue current rate.
126 - 175 Same rate.
176 - 225 If lower than last test - same rate.
If higher than last test - increase rate by 0.5 u/hr.
> 225 If >10% lower than last test - same rate.
If <10% lower than last test OR if higher than last test increase
rate by 1u/hr.

If Blood Glucose >225 and has not decreased after 3 hourly increases in insulin, then double
insulin rate.
Start "Continuous Intravenous Insulin protocol" during surgery and continue through am
of the 3rd POD. Patients who are not taking enteral nutrition on the third POD should
remain on this protocol until taking at least a soft ADA (American Diabetic Association)
diet.
ADA Diabetic diet starts with any PO intake.
On third POD: Restart preadmission glycemic control medications when tolerating soft
diet. If not tolerating soft diet consult M.D. for new orders at that time.
For patients with previously undiagnosed DM and hyperglycemia: start PDX protocol if
blood glucose > 200 mg/dl. Consult endocrinologist on POD #2 for DM workup and
follow-up orders.

(C) The Vellore Regimen (Table 5) is a simple to follow regimen for Immediate pre- and intraoperative
BG control, but says nothing about the post-operative BG control, which is carried out by the treating
surgeons.

Table 5: The Vellore regimen

Blood glucose Treatment
< 70 mg/dL

Stop insulin if on infusion. Rapid infusion of 100 mL of D5W, measure blood glucose
after 15 min
71100 mg/dL Stop insulin, infuse D5W at 100 mL/h
101150 mg/dL 1 U of insulin + 100 mL of D5W/h
12
>300 mg/dL 1 U of insulin for every 150 mg more than 100 mg/dL + 100 mL of normal saline/h
D5W = 5% dextrose in water.

PERSONALLY USED REGIMEN
And with all this background, it may now be in order to remind you that I shared with you for the first time
the regimen that I had evolved over the years in 1996. The regimen discussed at that time

was probably
the first time anybody had put on record that diabetics well controlled on OHAs need not be compulsorily
switched over to insulin preoperatively! New studies and ideas have come in since then and these have
led us at our institution to evolve further to device regimen that, while conforming to most of the present
concepts, is simple to use and applies to almost all setups:

I. Diabetics controlled and stable on diet
Regimen: Treated as non-diabetics in the perioperative period. Like non-diabetics they are given glucose
0.1 g/kg/h and the rest of the fluids are non-glucose in the perioperative period.
Justification: This amount of glucose is required to inhibit catabolic proteolysis, lipolysis and ketosis.

II. Others (Patient taking OHA or Insulin) (Grading of surgery - Point 5 of General Building Blocks)

a. Preoperative
Step 1: If there is Adequate control, as shown by BG <180 mg/dl (All: F, PP, R), HB A
1
c 9% and
absence of hypoglycemic episodes, patient is taken up for surgery irrespective of the class of surgery (as
mentioned above Point 5 of General Building Blocks). If there is Inadequate control, as shown by BG
>180 mg/dl (Any: F, PP, R), HB A
1
c > 9% and history of hypoglycemic episodes, the patient is stabilized
by modifying the OHA/Insulin regimen or using combinations. We love to do it ourselves but it can be
done by anyone, provided adequate control is achieved with or without switching over (or adding) insulin.

Justification: Irrespective of grading of surgery, we see no reason to disturb a stable regimen
preoperatively. If a patient has been referred (by the surgeons) to a physician before being sent for PAC,
we do not ask the physician to stabilize the inadequately controlled patient only on insulin (it is his
choice). There is no report to indicate that patients likely to undergo major surgery require insulin
preoperatively. Intra- and post-operatively, when expected catabolism in high we manage them on insulin
irrespective of the preoperative regimen.

Step 2: Omit insulin or oral anti-hyperglycemic agent on the morning of surgery (to ensure that their
action peaks before the onset of anesthesia)
13
Justification: Timing the drugs so as not to allow their peak during anesthesia affords a margin of safety
against intra-anesthesia hypoglycemia even if the level of monitoring reduces due to some reason.
Although oral anti-hyperglycemic agents other than sulfonylureas do not cause significant hypoglycemia,
omitting these helps in making the protocol uniform while not harming the patient

Step 3: Morning BG (F) from the lab, blood and/or urine ketones
Justification: To document the immediate pre-operative status

(B) In the OT
Step 1: Do capillary BG (cBG)
Justification: To confirm the authenticity of cBG (glucometer or visual) in comparison with lab BG

(i) Minor Surgery
Step: Give only non-glucose fluids
Justification: The minor surgery is so short and allows the oral intake so quickly that it is remarkably
different from no insulin no glucose regimen

(ii) Intermediate or major surgery
Step 1: Set up an infusion of non-dextrose fluids (isotonic saline-0.9% NaCl) using a wide bore IV
cannula. Use this to give all non-dextrose solutions
Step 2: Start an infusion of 5% dextrose, 500 ml containing 10 mmol of potassium, run @ 0.1 g
dextrose/kg/h
Step 3: If infusion pump is available, mix 20 units of regular insulin (of any type bovine/human - if the
patient was not taking insulin or of the type that the patient was taking) in 20 mL of isotonic saline and set
up the infusion pump; OR
If infusion pump is NOT available, mix 8-u regular insulin in 500 ml isotonic saline (1U in nearly 60mL)
and discard the first 50-60 mL of solution to flush the tubing

Other fluids

5% Dextrose

Infusion pump

Patients
Forearm
14

Insulin

Figure 2. Arrangement of IV lines for Variable rate infusion regimen.

Step 4: Piggy-back the insulin infusion onto the dextrose infusion through a three-way, with or without an
infusion pump, to go @ (cBG/150) units of insulin per hour (Figure 2). Stop insulin infusion if cBG is
below 100 mg% (70-110 range visually)
Justification: If a reliable infusion pump is not available, then this 8 U/vac works well. We find this
concentration perfect as this way the drop rate calculations are simple (1U in 60 mL and 60 min in an
hour, thus to give insulin @ 1U/h, give 1mL/min of the solution!)
Step 5: Carry out BG half hourly and make adjustments. The units of insulin infused per hour can be
scaled up or down on the basis of the response (e.g. if 1U/h at a BG of 150 mg% leads to rise in BG to,
say 225 mg%, it may be left at 1.5 U/h once BG returns to 150 mg%)
Justification: The new thinking of improved outcome with tight perioperative BG control necessitates
more frequent BG monitoring. Although not written on the lines of discussed protocols, this scheme ends
up giving almost similar amounts of insulin and BG control

(C) Post Operative
(i) Minor Surgery
Step: Give metoclopramide IM during surgery itself (about 20-30 min before reversal). Resume
preoperative glycemic control regimen with the second (proper) meal.
Justification: Metoclopramide reduces the incidence of vomiting and allows smooth transition. We prefer
IM metoclopramide as IV metoclopramide has a short duration of action

(ii) Intermediate/Major surgery
Cases who do not go through major fluid shifts (Examples: Intermediate=Open reduction internal
fixation fracture tibia or unilateral total knee replacement under RA or GA; Major=Hemicolectomy)
(a) Keep only one IV line to give the required fluids. For an average 50 kg adult the IV order till next
morning will be:
- 4 vacs of 5% dextrose
- 1 vac of 5% dextrose in NS (DNS)
- Each vac to contain 10 mmol of KCI and to run over 4-5 hours.
- cBG 6 hourly and plain insulin subcutaneous as below:
cBG (mg%) Insulin (Units)
150-200 4
200-250 8
15
250-300 12
300-350 16
350-400 20

Justification: Single IV line is obviously simpler to manage especially in a small setup. Beginning the
sliding scale at a lower BG than I earlier used to practice
17
makes it possible to keep the BG within the
range of tight control quite regularly with 6 hourly SC insulin. The mentioned IV fluid order ensures ~0.1
g/kg/h glucose, 1.5 mmol/kg/day Na
+
and 1 mmol/kg/day K
+
. Avoiding adding insulin to the IV fluids and
managing the BG by SC insulin makes the regimen easier to apply without compromising on the quality of
glycemic control

If more than usual fluids or blood is required, continue the second IV line for these patients as long as
required and continue the rest as in (a).
Justification: Keeping another IV line for extra fluids maintains the constancy of the regular line, paving
way for easier compliance

(iii) Special Intermediate and major surgeries (neurosurgery especially with a likelihood of global
CNS ischemia, surgery requiring CPB, surgery in pregnant patient, low-flow states, hypothermia,
sepsis and severe surgical stress):
Step: Continue with the intraoperative arrangement of the fluids and insulin till they are in the PACU, and
if possible till the morning of 3
rd
postoperative morning. Carry out BG monitoring hourly till BG readings
show settling trend and then 2 hourly.
Justification: Insulin delivery by SC route may be inadequate or inappropriate in low-flow states,
hypothermia, sepsis and severe surgical stress. On the other hand the harms of violating the limits of the
tight control are overwhelming in other conditions mentioned. Where it is uncommon to manage such IV
lines, a resident or nurse specially assigned to look after these patients is helpful.

Common Steps and justification
Step 1: In either of situations (ii) or (iii), blood or urine ketones and ABG are asked for if deemed
necessary.
Justification: Ketones and ABG may be needed when postoperative period has been turbulent and the
management of hyperglycemia induced problems is continuing.

Step 2: We routinely ask for S. electrolytes every morning till the patient is receiving variable rate insulin
infusion and IV fluids.
16
Justification: This is to monitor changes due to IV administration of electrolytes and glucose-insulin
solution

Step 3: In either case, continue the chosen regimen till the second meal. Then switch over to the
preoperative regimen and regular meals The second meal is the meal after the first has been accepted
and retained; the meal which has not been well accepted is not taken into account.
Justification: This prevents the chances of hypoglycemia that is possible if the patient takes his anti-
diabetic drugs and then is unable to retain his meal. Otherwise too, the first meal is usually very small.

SUMMARY: The classification and diagnostic criteria of DM have changed in recent years. Similarly it has
become clear now that even a temporary perioperative good control of DM has clinically important
implications. Meanwhile, newer insulin preparations and newer oral antiglycemic agents have also
appeared on the scene. Based on all these and guided by some popular regimens, we have been able to
device an all-weather-regimen that, I believe, can be molded according to the situation of most
institutions. The aim of perioperative management is not only to obtain a good glycemic control but also to
remember that the surgical outcome of diabetics is not very different from non-diabetics if the diabetic
induced end-organ involvement is looked for carefully and managed properly. The anesthesiologist has to
himself define his perioperative goals, devise a simple regimen to achieve these goals within the
constraints of the setup she/he has and the needs of the particular clinical situation, and accordingly
adjust the intensity of monitoring.

Further Reading & References

1. Blaum CS and Halter JB. Treatment of Older Adults with Diabetes. In ed. Kahn CR, Weir GC,
King GL, Jacobson AM, Moses AC, Smith RJ. Joslins Diabetes Mellitus. 14
th
Ed. Philadelphia,
Lippincott Williams and Wilkins, 2005:737-746
2. Gavin JR III, Alberti KGMM, Davidson MB, et al. Report of the expert committee on the diagnosis
and classification of diabetes mellitus. Diabetes Care 1997; 20: 1183-97
3. WHO Consultation group. Definition, diagnosis and classification of diabetes mellitus and its
complications. 2
nd
ed. Part I: Diagnosis and classification of diabetes mellitus WHO/NCD/NCS/99
Geneva: World Health Organization, 1999:1-59
4. Genuth S, Alberti KG, Bennett P, et al. Follow-up report on the diagnosis of diabetes mellitus.
Diabetes Care 2003;26:3160-3167
5. Roizen MF and Fleisher LA. Anesthetic implications of concurrent diseases. In: Miller RD ed.
Anesthesia, 6
th
Edition. Philadelphia, Elsevier Churchill Livingstone Inc., 2005:1017-1149
17
6. Roizen MF: Are you as young as you can be? New York, HarperCollins, 1999
7. Wei JY: Age and cardiovascular system. N Eng J Med 1992;327:1735
8. Eldelstein SL, Knowlers WC, Bain RP, et al. Predictors of progression from impaired glucose
tolerance to NIDDM: an analysis of six prospective studies. Diabetes 1997;46:701-710
9. Halter J. Aging and carbohydrate metabolism. In: Masoro EJ, ed. Handbook of physiology.
Section 11: Aging. Oxford University Press, 1995;119-145
10. Kumar R. How important is blood glucose control in perioperative period. Lecture Notes, ISACON
2001; pp 194-202
11. Hjotrup A, Rasmussen BF, Kehlet H: morbidity in diabetic and nondiabetic patients after major
vascular surgery, Br Med J 1983: 187: 1107
12. Hirsch IB, McGILL JB, Cryer PE White PF: Perioperative management of surgical patients with
diabetes mellitus. Anesthesiology 1991:74:346-359
13. Joslins diabetes mellitus, 13
th
Edition. Edited by Kahn CR, Weir GC. New Delhi, BI Waverly (P)
Ltd, 1996, pp 739-765, 976-98
14. Dunnet JM. Homoman RR, Turner RC, Sear JW, Diabetes mellitus and anesthesia:, a survey of
the peri-operative management of the patient with diabetes mellitus. Anaesthesia 1988:43:538-42
15. Alberti KGMM, Thomas DJB. The management of diabetes during surgery. BJA 1979: 51:693-
709
16. Anesthesia and co-existing Disease. Third Edition 1993. Edit, Stoelting RK, Dierdorf SF. Churchill
Livingstone
17. Kumar R. Perioperative management of diabetes mellitus. Continuing Medical Education
Programme Book ISACON 1996; pp360-77
18. Kumar R. How important is blood glucose control in perioperative period. Lecture Notes, ISACON
2001; pp 194-202
19. Miriam A and Korula G. A Simple Glucose Insulin Regimen for Perioperative Blood Glucose
Control: The Vellore Regimen Anesth Analg 2004;99:598602
20. Verhofstad MHJ, Hendriks T. Complete prevention of impaired anastomotic healing in diabetic
rats requires preoperative blood glucose control. Br J Surg 1996; 83: 1717-21
21. Furnary AP, Zerr KJ, Grunkemeier GL, Starr A. Continuous intravenous insulin infusion reduces
the incidence of deep surgical wound infection in diabetic patients after cardiac surgical
procedures. Ann Thorac Surg 1999; 67: 352-62
22. Zerr KJ, Furnary AP, Grunkemeier GL et al. Glucose control lowers the risk of wound infection in
diabetics after open heart operations. Ann Thorac Surg 1997; 63: 356-61
23. Textbook of Medical Physiology, 10
th
Edition. Edited by Guyton AC, Hall JE. Singapore, Harcourt
Asia PTE Ltd, 2000
18
24. Sonksen P, Sonksen J. Insulin: understanding its action in health and disease. Br J of Anaesth
2000; 85 (1): 69-79
25. Werner C, Engelhard K. Cerebral resuscitation: current concepts and perspectives. Recent
advances in anesthesia and analgesia (No. 21) 2000; 77-90
26. Rassias AJ, Marrin CAS, Arruda J et al. Insulin infusion improved neutrophil function in diabetic
cardiac surgery patients. Anesth Analg 1999; 88: 1011-6

Prof. A. K. Sethis EORCAPS-2010, Delhi
1
Prof.A. K. SethisEORCAPS-2010
Anaesthesia for Scoliosis
Dr. M.K. Arora
Case history
A 12 year old girl diagnosed to have
idiopathic scoliosis and is scheduled for
posterior instrumentation surgery for
correction of deformity correction of deformity.
Her past history was unremarkable but
she started to have short of breath more
easily while playing and while doing some
physical exertion
Definition
Lateral curvature of the spine combined with
a rotational component, due to various
etiologies, according to the Scoliosis
Research Society (SRS).
Prevalence
Curves >10 -2-3% of the population
Curves >20 affect about 1 in 2500 people.
Curves convex to the right are more common
'C' curves are slightly more common
than double or 'S' curve patterns.
Males are more likely to have infantile or juvenile y j
scoliosis
Female predominance of adolescent scoliosis.
Girls are 7 times more likely than boys
to develop a significant progressive curvature
Adolescent Idiopathic Scoliosis, there is a clear
mendelian inheritance but with incomplete
penetrance
What are the various causes and
associated conditions of Scoliosis?
Causes
Congenital
result of an abnormality of the development of the
vertebrae-hemivertebra
Neuromuscular
caused by cerebral palsy, spina bifida, muscular
dystrophies spinal cord injuries dystrophies, spinal cord injuries
Traumatic :unequal leg length ,Irradiation, surgery
Poor posture
Idiopathic scoliosis
cause unknown
most common form (80%)
2
Associated conditions
Cerebral palsy
Spinal muscular dystrophy
Familial dysautonomia
Friedreichs ataxia
Skeletal d splasia Skeletal dysplasia
Marfans syndrome
Neurofibromatosis
Connective tissue disorders
Craniospinal axis disorders (e.g., syringomyelia)
What are the various signs &
t f S li i ? symptoms of Scoliosis?
Signs & Symptoms of Scoliosis
Bachache
Uneven shoulder heights
Uneven hips or waist
Prominence of shoulder blade
Increased space between the body and the
elbow while standing in natural posture
One leg appears longer than the other
One breast appears larger than the other
Appearance of leaning to one side
Chest or rib prominence
Signs of scoliosis
Physical Findings
Uneven shoulders
Prominent shoulder
blade
Uneven waist Uneven waist
Elevated hips
Leaning to one side
What is cobbs angle? g
3
Cobbs angle
Cobbs angle
Cobbs angle and symptoms
<10 normal curvature
>25 ECHO evidence of increased
pulmonary artery pressure
40 i l i t ti >40 surgical intervention
>65 restrictive lung disease
>100 dyspnoea on exertion
>120 alveolar hypoventilation
What are the abnormalities found
in pulmonary function tests?
What are the various at a e t e a ous
manifestations of the respiratory
system?
Respiratory system
Decreased compliance
Decrease in lung volumes and capacities,- Restrictive
Lung Disease, however FEV1:FVC ratio is normal
Decreased ventilatory response to CO2
V/Q i t h i d ti f VD/VT V/Q mismatch, increased ratio of VD/VT
Arterial hypoxaemia
Hypercapnia
Respiratory failure in patients with untreated severe
Scoliosis
4
Deformity spine
V/Q mismatch
Deformity rib
cage
Impaired
Idiopathic scoliosis
Compliance
Response CO2
P[A-a]O2,VD/VT
Hypoxemia
Hypocapnia
Respiratory
failure
Impaired
development
vasculature
Pulmonary
HTN
NM scoliosis Respiratory function
Central respiratory drive
Coordination of swallowing
Innervation of upper airway
Respiratory muscle
clearance of secretion
respiratory infection
risk of aspiration
sensitivity to CNS depressants
How does scoliosis affect the
cardio vascular system?
Cardiovascular system
Right ventricular hypertrophy
Pulmonary hypertension
Mitral Valve Prolapse
Cardiomyopathy Duchennes Muscular y p y
Dystrophy
Mitral / Aortic Insufficiency Marfans
syndrome
Congenital Heart disease - common
Treatment
Observation (Below 20 degrees)
patients are seen by a spine specialist about every six
months until skeletal maturity is reached
B i (25 40 d ) Bracing (25-40 degrees)
control any worsening of a spine curvature, but do
little to correct an existing deformity
most effective when used in children that are rapidly
growing and have worsening scoliosis curves
Treatment...
Surgery (45 degrees or greater)
best option for more severe curves.
fuse vertebrae in a more normal anatomic fuse vertebrae in a more normal anatomic
position
severe curves carry a risk that lung and heart
function may become affected
5
Surgical procedure
Aim of surgery is to achieve spinal fusion
in the corrected position.
Done by decortication and maintaining
correction till bony fusion with help of correction till bony fusion with help of
instrumentation
Erector spinae, spinous process,
intraspinal ligament, facet joint removed
Vertebrae decorticated and bone graft
placed
Surgical Options
Posterior correction and instrumentation
Anterior correction and instrumentation
Anterior release / fusion, plus posterior
instrumentation instrumentation
Posterior release/fusion, plus anterior
instrumentation
Combined anterior and posterior
instrumentation and fusion
Growth Rod in small children
Prof.A. K. SethisEORCAPS-2010 PreoperativeXRays
AnteriorInstrumentedfusion
PostoperativeXRays
N.16/fIdiopath.RtTL
Scoliosis
Post
Pr e
94
76
116
7
3
12
84
22
36
PreoperativeXRays
54
68
PosteriorInstrumentedfusion
PostoperativeXRays A.13/MIdiopathicScoliosis
Prof.A. K. SethisEORCAPS-2010 PreoperativePhotographs
PostoperativePhotographs
A.13/MIdiopathicScoliosis
6
Dual
Growth
Rod
Surgery
88
46
Preoperative
PostoperativeXRays
Prof.A. K. SethisEORCAPS-2010 PreoperativeXRays
Postop
Singlegrowthrod/VEPTR
PostoperativeXRays
Pre operative
Respiratory system involvement
Cardiovascular system involvement
Congenital anomalies
Airway assessment
What are the various intra
operative & post operative
concerns in patients of scoliosis?
Intra operative concerns:
Spinal cord monitoring (EP or wake up)
Blood loss and replacement
Hypothermia
Position related complications
Venous air embolism
Postoperative concerns:
Pain
Pulmonary function
Post operative ventilation
Bleeding and Coagulation abnormalities
Hyponatraemia due to inappropriate
secretion of ADH
7
How do you evaluate the patient
prior to surgery?
Preoperative evaluation:
Standard Anaesthetic Technique
Wide variety of anaesthetic techniques
have been used
Premedication: Diazepam/ Midazolam
Glycopyrrolate IV prior to induction
St d d t h i d d h th Standard technique depends on whether
wake up test or SSEP to be used.
Our technique ; thio or propofol for
induction , fentanyl , medium acting
NDMR, and maintenance with O
2
/Air ,
fentanyl infusion , low concentration of
isoflurane/ Sevoflurane
Standard Anaesthetic
Technique..
For SSEP / Wake up test : high dose of fentanyl
, Propofol infusion and very low or no isoflurane/
Sevoflurane.
An ideal technique Remifentanil- high dose , q g
Propofol, Desflurane
-Tranexamic acid - Bolus followed by infusion.
Suxamethonium to be avoided in muscle
disorders
Spinal/ epidural/ caudal for post operative pain
relief
Monitoring and lines
Two wide bore IV lines , one with hot line
Arterial line , Triple lumen , Foleys, Temp, NG
tube
Standard monitoring ; SpO
2
, ETCO
2
, ECG, BP ,
Pulse, Vapour concentration, Airway pressure u se, apou co ce t at o , ay p essu e
Bair Hugger, warm fluids, warm blanket
Care of eyes, pressure points and positioning
SSEP/ Wake up test ; infusion pump for propofol
,Fentanyl. MR
ABG, HCT, Platelets, PT
Postoperative analgesia
Fentanyl infusion 0.5- 2g/kg/hour /
morphine infusion20-40 g/kg/hour
continued for 36-72 hours
NSAIDs either Paracetamol diclofenac NSAIDs- either Paracetamol, diclofenac
suppositories or oral paracetamol,
Ketorolac
VAS kept around 2-3, allowing incentive
spirometry & deep breathing
8
What are the problems
associated with prone position?
Prone position
Unintentional extubation
Eye complications
Corneal abrasions
Conjunctival and periorbital oedema of the dependent eye
Retinal ischaemia
Postoperative visual loss because of ischaemic optic
neuropathy (ION)
Accidental dislodgement of access and monitoring lines
Abdominal compression leading to impaired ventilation, increased
bleeding from epidural plexus, and decreased cardiac output
Improper head and neck positioning leading to venous and
lymphatic obstruction
Macroglossia
Possibility of venous air embolus
Neuropathies
Visual loss
Optic nerve ischemia
Perfusion depends on MAP and IOP/ CVP
Combination of decrease BP and Increase
th t t i k venous pressure pose the greatest risk
Risk factors: position, hypotension,
anaemia, prolonged surgery.
Avoid pressure on eye, slight head up.
CPR in prone position
If spine stable, wound covered and patient
turned for CPR
External cardiac massage in prone
position position
Posterior thoracotomy for internal cardiac
massage and defibrillation.
? Prior placement of external defibrillation
pads in DMD
Neurological complications
Neuro injury due to direct injury to spinal cord
or nerves due to instrumentation, excessive
traction ,compromised perfusion of S. cord
Varies with type of instrumentation
H i t d (0 23%) Harrington rod (0.23%)
Lugue correction (epidural hematoma), (1%)
Cotrel Dubousset (0.6%)
Complication rate decreased by use of EP
monitoring.
Increased risk in non idiopathic scoliosis
How do we monitor spinal cord
functions intra operatively?
9
Spinal cord monitoring:
Wake up test: gold standard
Continuous intraop neurophysiological
it i SSEP MEP monitoring: SSEP, MEP
Wake up test
Pt. is woken up to assess motor function
Explain the procedure prior to surgery
Repeat it before induction
Switch off inhalational and muscle relaxant
Maintain on opioids Maintain on opioids
First ask to grip hand followed by move leg
Be prepared to restrain patient to avoid
unwanted movement
Disadvantage: Accidental extubation , Air
embolism, Injury, dislodgement of
catheters/equipment
SSEP
Dorsal sensory pathway
Stimulation peripheral nerve (posterior tibial,
peroneal/ Median Nerve)
Recorded from scalp or thoracic/cervical
id l l t d epidural electrodes
Muscle activity disturbance eliminated by NMB
Affected by anaesthetics
Suspect S. cord injury intraoperative decrease
in amplitude, increased latency or loss of
waveform
Effect of anesthetic agents:
MEP
Electric or magnetic transcranial
stimulation
Epidural, neurogenic or myogenic MEP
M i MEP t ti f Myogenic MEP more representative of
motor tracts
More sensitive to anesthetic interface
Myogenic MEP requires incomplete NMB
What are the various neurologic
complications in scoliosis and p
causes of neurologic injury?
10
Causes of neurological injury
Direct injury due to instruments
Spinal cord distraction
Hypotension
Loss of blood supply (ischaemic)
What are the various ways to
handle blood loss?
Reduction in blood loss
Anaesthesia Technique: Avoid light
anaesthesia, intraoperative hypertension,
increased venous pressures,
hyperdynamic circulation hypercapnia hyperdynamic circulation, hypercapnia.
Proper positioning: avoid raised IAP
Infiltration with vasoconstrictors
Prevention and treatment of hypothermia
Hb , Hct. monitoring hrly.
Pharmacology
Aprotinin
significant blood loss in spine surgery
inhibits plasmin and kallikrein
1 2 million KIU bolus followed by 1-2 million KIU bolus followed by
0.25 0.5 million KIU/hr
Desmopressin
Tranexamic Acid (Anesth-Analg, 2001)
10mg/kg and infusion 1mg/kg/hr
Deliberate/Induced Hypotension
Ensure adequate monitoring
Different agents can be used NTG , SNP,
Ganglion blockade , Inhalational agents.
U b t bl k i f t h di Use beta blockers in case of tachycardia
Induce slowly over 10- 15 mins
MAP above 70 mmHg
Monitor and normalize acid base status
Avoid hypocapnia
Pre-operative Autologous Blood
Donation
Hb not less than 11 g/dL or Hct 33%
No age or weight limits
May donate 10-15% blood volume
At least 4 days before 2 donations (usually At least 4 days before 2 donations (usually
1/ wk), but the last should occur no less
than 72 hours before surgery.
Started 1 month before
Oral Fe or erythropoietin
11
Acute Normovolemic Hemodilution
Removal of whole blood shortly before an
anticipated significant surgical blood loss
Blood collected in standard blood bags
containing anticoagulant
Simultaneous inf of crystalloid (3: 1 ) or Simultaneous inf. of crystalloid (3: 1 ) or
colloid (1:1)
Stored at room temperature
Re-infused during surgery after major
blood loss has ceased, or sooner
Blood re-infused in the reverse order of
collection
Blood Salvage
Lost blood collected, anti-coagulated,
filtered for clots and debris, centrifuged
and re-suspended in saline.
Only half the blood lost can be collected Only half the blood lost can be collected.
Contain residual anti-coagulant
Platelet and clotting factor deficient
Unsuitable in infection and malignant cells
in field
When would you decide to
extubate the patient after
surgery & what are the
predictors of post operative
ventilation?
Predictors of Post-op
Ventilation
Patient factors:
Severe Restrictive Lung Disease:
Vital Capacity < 35 %
Pi max > - 40cmH2O
Pe ma < +40cmH2O Pe max < +40cmH2O
PaO2 < 60mmHg
PaCO2 > 50mmHg
Right Ventricular Failure
Pre-existing neuro-muscular diseases
Congenital heart disease
Obesity - BJA, 2003.
Predictors of Post-op
Ventilation
Surgical factors:
Blood loss > 30ml/kg
S i l i i t th i it Surgical invasion to thoracic cavity
How do you provide post op
analgesia in patients of
scoliosis? scoliosis?
12
Post operative analgesia
Parenteral opioids
continuous infusion / iv PCA
NSAIDs
opioid sparing effect
t th t k t l i hibit i l f i reports that ketorolac inhibits spinal fusion
? COX 2 inhibitors
Epidural analgesia
single/two catheter by surgeon
local anaesthetic + opioid infusion
Intrathecal opioid
morphine 5 -10g/kg
AIIMS, Scoliosis Data (Aug 2009 Feb 2010)
No. of pts : 36
Age - 12.675.39 years
Sex M/F - 14/22
ASA status : I III
Associated syndrome
Klippel Fiel syndrome one patient
Arnold chiari malformation one patient
Type of scoliosis
Congenital 21
Idiopathic 10
Secondary 4 cases
Cobbs angle 70.3624.59
Pre op PFT Restrictive lung defect
Surgical procedure performed
(n= 36)
Number of segments - 9.282.86
Post release and instrumentation - 21
Ant release and intsumentation - 7 Ant release and intsumentation 7
Growth rod distraction /
manipulation - 8
Duration of surgery 6 9 hrs
Growth rod 1.5 2.5 hrs
Intra operative Events
Event Cause No. of pts. Managemen
t
Hypotension Bleeding 7 IV fluid
Blood
Dopamine
Bradycardia Distraction
f 8
9 Atropine
forces- 8
Cold saline
lavage-1
Cardiac
Arrest
Manipulation
of growth rod
1 Pt turned
supine
CPR done,
revived - ICU
Blood loss & Transfusion
practice
Procedure Blood Loss Transfusion
Ant release and 1000 4500 2 10 units RBC
Post instrumentation Post instrumentation
Growth rod application 400 1000 ml 0 2 units
Post operative ventilation
(n = 36)
No. of patients required ventilation 6
Extubation : POD 1 - 1
POD 2 - 1
POD 3 - 1
POD 8 - 1
Tracheostomy 2(POD 9)
Total ventilator days 15 & 17
Non Invasive CPAP - 1
13
Surgical Complications
Post op tingling, numbness 1
Continuous oozing 1
Right lung collapse 1
Dura puncture - CSF leak 1 Dura puncture CSF leak 1
Paraplegia 2
Emergency CT & re-explored
immediately. Motor power improved 2/5 in
one & 3/5 in the other patient.
Other post op complications
(n = 36)
VP shut malfunction - 1
Gastritis / Abd. Pain - 1 Gastritis / Abd. Pain 1
Jaundice - 1
Facial & tongue edema- 1
Case Scenario 1
12 yr old girl operated for scoliosis surgery (posterior
instrumentation)
- 24 hrs after surgery developed
Respiratory distress : Tracheal tug, accessory
muscles working, RR 60/mt, shallow breathing
Trachycardia : HR 160/mt
SaO2 : 98% on 100% oxygen
ABG - pH 7.28, Pao2 90, PaCo2 52
Auscultation No air entry left upper part of the
chest and overall decreased intensity of breath
sounds.
X-ray chest - collapse left upper lobe
Case Scenario 1 - Management
NIV
CPAP + Pressure support - Bipap
Sedation / Analgesia Morphine infusion
Physiotherapy & stepping up of antibiotic Physiotherapy & stepping up of antibiotic
With hold enteral feeding
Pt Improved with above management
,shifted to ward after 4days
Intubation & ventilation could be deferred
Case Scenario 2
6 hrs after scoliosis surgery lab investigation showed
Hb 9.8 gm%
Platelets 60,000
PT 12/20
TLC 8,000
B.Sugar 120
B.Urea 36
Na 128
K 4.9
Serum calcium 7.8
Case Scenario 2 - Management
Administration of normal saline& avoid
hypotonic solutions
Administration of Calcium
Gi FFP 10 15 l/k b d i ht Give FFP 10 - 15 ml/kg body weight
Platelets : 6-8 units
Monitor Coagulate profile and oozing
1
VAPORIZERS
D P M i i Dr Poonam Motiani
Related Physics
Critical temperature: It is that temp., above which no
amount of pressure will convert a gas to a liquid.
O2 = -118.4 C; N2O = 36.5 C; CO2 = 31 C
Vapor: is the gaseous phase of an agent which is
normally a liquid at room temp. and atmospheric pr.
Related Physics
What is a Vaporizer ?
A Vaporizer is an instrument designed
to facilitate the change of a liquid
anesthetic into its vapor
And
add a Controlled amount of this vapor to
the flow of gases.
Related Physics
Vapor pressure: When enclosed in a container,
molecules of a volatile liquid break away to form
vapor. Vapor pressure is the pressure with which they
bombard the walls of the container .
Saturated Vapor Pressure: is the Maximum Vapor
i l pressure at a particular temperature.
Boiling point: of a liquid is that temperature at which
the Vapor pressure is equal to the atmospheric
pressure.
The lower the atmospheric pressure , the lower the
boiling point
Agent B.P(C) Vapor
Pr(20C)
Ether 36.5 440
Halothane 50 2 243
Properties of Common Anaesthetic Agents
Halothane 50.2 243
Enflurane 56.5 175
Isoflurane 48.5 238
Desflurane 22.8 669
Sevoflurane 58.6 157
2
Concentration of Gases
Expressed as
- Partial Pressure Partial Pressure
- Volumes Percent
Partial Pressure (P.P):The part of the total pressure
due to any one gas in the mixture. Depends on - Nature
of liquid & Temperature
Patient uptake and Anaesthetic depth are
directly related to Partial pressure
Volumes Percent (Vol %): the number of units of
volume of a gas in relationship to a total of 100 units
for the total gas mixture.
Gas and Vapor concn. delivered by a
vaporizer are expressed in Vol %
Volume % expresses the relative ratio of gas
molecules in a mixture
Partial Pressure expresses an absolute value Partial Pressure expresses an absolute value.
Partial pressure = Volumes percent
Total pressure 100
Heat of Vaporization: It is the number of calories
needed to convert 1g/1ml of liquid to vapor.
Specific Heat :Quantity of heat required to raise the
temperature of 1 g / 1ml of the substance by 1C mp f g m f y
- Liquid anesthetics with low specific heat vaporize easier.
- Vaporizer construction material with high specific heat
Provides more stable temperature.
Thermal Conductivity:A measure of speed
with which heat flows through a substance.
- Higher the thermal conductivity, better a
b t d t h t substance conducts heat
- Thermostabilization achieved if vaporizer
constructed of metal with high thermal
conductivity. Eg-Copper, bronze
MAC (Minimum Alveolar Concentration)
The MAC of an inhaled
anaesthetic is the
alveolar concn. that
prevents movement in
50% of patients in
Agent MAC in
O2(%)
Halothane 0.75
Isoflurane 1 15 50% of patients in
response to a
standardized stimulus
(eg. Surgical incision)
Vol % of alveolar gas
at 1 atm .
Isoflurane 1.15
Enflurane 1.68
Desflurane 6.4
Sevoflurane 2.0
3
Earlier Classification of Vaporizers
A. Method of regulating Output Concentration
1. Variable Bypass
2. Measured Flow
B. Method of Vaporization
1. Flow Over
2. Bubble Through
3. Flow over or Bubble Through
C. Location
1 O id h B hi S 1. Outside the Breathing System
2. Inside the Breathing System
D. Temperature Compensation
1. None
2. By Supplied Heat
3. By Flow Alteration
E. Specificity
1. Agent Specific
2. Multiple Agent
New Classification of Vaporizers
A Concentration calibration
1. Variable Bypass Vaporizers
2. Electronic Vaporizers
B. Vaporization Methods
1. Flow Over
22. Injection
C. Temperature Compensation
1. Mechanical Thermocompensation
2. By Supplied Heat
3. Computerized Thermocompensation
Method of Regulating Output
Concentration
Variable Bypass (Direct Reading, Concentration
Calibrated, Dial Controlled,Automatic Plenum)
Fresh gas flow (FGF) enters the inlet of the vaporiser and splits into -
Carrier gas (20%) Bypass gas( 80%)
At the outlet, the Bypass gas meets the Carrier gas
(fully saturated with vapor)
Measured Flow Vaporizer
Uses a measured flow of carrier
gas to pick up agent. Consists of:
(1) Vaporizer
(2) Flowmeter assembly
(3) Vaporizer Circuit Control
Valve
Limitations:
Cumbersome calculations
If the bypass flowmeter is
turned off, it is possible to
supply gas fully saturated
with anesthetic to the
patient !!
Method of Vaporization
4
Method of Vaporization
The Pathway followed by the carrier gas as it
travels through the vaporizing chamber
Factors affecting rate of vaporization:
Vapor pressure of the liquid
Efficiency of Vaporization
Method of Vaporization contd..
Flow over : a stream of gas passes over liquid surface
Efficiency depends on
- Gas-liquid interface e.g. baffles, spiral tracks, wicks
- Velocity of carrier gas flow; Height of gas flow
Method of Vaporization contd..
Bubble through: Bubble the gas through the liquid
Efficiency depends on
- Size; Depth of the liquid; Velocity
Eg. sintered diffuser, cowl in Boyles Bottle
Injection :
Injecting a known amount of liquid anesthetic from a
reservoir in the vaporizer /an agent bottle into a
known volume of gas
1 ml of halothane = ? ml hal vapor at 20 C
Density of halo is 1.86 so 1 ml weighs 1.86 gm
Avogadros law- Equal volumes of gas at the same temperature and
pressure contain equal number of molecules; One gram-MW (mole) of
gas occupies 22.4 litres STP (760mm Hg and 0
0
C).
1 GMW(197 g) of halothane occupies 22.4 l at STP (0C/273 K)
At 20 C (293 K) ( )
Using Charles Law- V1/T1 = V2/T2
= 22.4/273 = V2 /293 = 24 L
197 gm(1 GMW) occupies 24 L at 20C
1.86 g( 1 ml) will generate 24/197 x 1.86 = 0.227 L = 227 ml
If FGF is 4000 ml/min for a 1% conc need 40 ml vapor/min
How much liquid agent does a vaporiser use
per hour?
Ehrenworth & Eisenkraft (1993) gave
formula formula
3 x FGF (L/min) x vol % = ml liquid used / hr
Location
Out of System Vaporizers (VOC)
- All Measured flow vaporizers
- Most Variable Bypass Vaporizers
In-System Vaporizers (VIC)
l - In Circle Vaporizers
- Drawover vaporizer Gas is pulled into the
vaporizer by the patients own inspiratory effort eg.
Goldman, EMO, OMV, BSIU
- Inhalers (A Drawover vaporizer in which carrier
gas is air)
5
Location
Out of System
(VOC)
In-System
(VIC)
Resistance High Low
Determinants Vap Output Vap Output Determinants
of Vap. Output
Vap.Output
= Vap. Conc
Vap. Output
>Vap.Conc
Factors Affecting Vaporizer
Performance in Basic Design
1. The flow rate of fresh gas.
2. Extremes of temperature. . E tr m f t mp ratur .
3. Pumping Effect/Pressurizing Effect
4. Barometric pressure
1. Problem of High Flow
At high flows, the vaporizer delivers less anesthetic
concentration than is set on the dial.
Problems of the Basic Design contd
Increase the surface area of contact between the
fresh gas and anesthetic agent .
Wicks
Bubbling through a sintered disc
e.g. "Copper Kettle"
2. Problem of Temperature
As anesthetic molecules escape temp. ses more
difficult for the remaining molecules to escape.
Thus at lower temperatures, there is less vaporization.
Solution - Giving Heat
- Giving Flow
6
Giving Heat:
- Vaporizer material
- Good conductor (high thermal conductivity)
- Acts as a Heat reservoir (High Specific heat)
- Supplied heat (tec 6 - electrically heated) pp ( y )
Giving Flow (Thermocompensation) by alteration in
Splitting ratio
- Mechanical. Eg-Bimetallic strip in Tec Series
- Computer controlled
3. THE "PUMPING EFFECT
(Hill and Lowe effect)
The effect of changing pressure during IPPV
increasing the output of the vaporizer is called the
"pumping effect".
During positive pr. ventilation, pressure transmitted
back results in compression of gas.
Since the vaporizing chamber volume is much larger than
the 'by pass' channel volume more fresh gas gets
compressed into it.
This extra fresh gas that enters the vaporizing
chamber collects anesthetic vapor .
Some of the rapidly expanding gas (containing vapor)
enter the inlet of the vaporizer and cross over into the
'bypass' channel .
7
The addition of the 'bypass' vapor to the V.C vapor
raises the final concentration of anesthetic
delivered.
The 'pumping effect' increases the delivered
concentration of anaesthetic agent.
Modifications to reduce the 'pumping
effect'
Bypass Channel made larger
Inlet Tube made longer
Exclude wicks from the inlet
Increased Resistance
A high internal resistance to "resist" changes to flow
One Way Valve:
Also called unidirectional valve can be put between the
vaporizer outlet and the ventilator / breathing system
MODIFICATIONS contd..
MEASURED FLOW VAPORISERS
- Decrease size of the V.C
- Longer outlet tube
- Check valve to prevent backward flow
- Relief valve to limit maximum pressure
ANAESTHESIA MACHINE
- Pressure relief valve
- Check valve at outlet of the vaporizer Fluotec 2
8
Mechanism of Pressurising effect
(Cole Effect)- output of anesthetic agent
An in pressure (p) causes an in pressure - p inside the
vaporizer.The carrier gas is compressed but the vapor pressure
of the volatile anaesthetic is unaffected.
Net result- in concn of anaesthetic delivered
Specific vaporizers
Early Methods
Open Drop Method - Inhalation anesthesia by
vaporization of a liquid anesthetic placed drop by
drop on a gauze mask covering the mouth and nose
Devices: Schimmelbusch mask
Other modifications Yankauer, Bellamy Gardner
Semiopen - A frame added to keep the ether in
in an enclosed area permitted some degree of
rebreathing Eg. Ogston inhaler, Junkers
chloroform apparatus, Flaggs can
Schimmelbusch Mask
Early Devices-Open Drop method
Bellamy Gardner wire mask with dropper
Yankaeur mask
Early Devices-SemiOpen Drop method
Ogston mask with schimmelbusch frame
Flaggs can
Technique:
-Volatile anesthetic was dripped onto a gauze (16 layers
gauze for ether) covered mask.
- For chloroform/ethyl chloride (12 layers of gauze/1
layer lint & chloroform dropped over half the area) layer lint & chloroform dropped over half the area)
- Gradually increased no. of drops/ min.
-During inspiration: air passed through the gauze and
vaporized the liquid anesthetic into high conc.
9
ADVANTAGES
Easy to administer; No specialized
apparatus required
Low Dead Space 40-60 ml
Low Resistance
Wide Margin of Safety
Relatively Cheap
Disadvantages of Open drop anesthesia
Significant rebreathing
Hypoxic mixtures may occur
Poor control of inspired gas concentrations
Inability to assist or control ventilation
No conservation of heat or humidity
Difficult airway management especially during
head and neck procedures
Pollution of the operating room
Hazardous especially with flammable agents
In-System Vaporizers (VIC)
There are two ways that gas flows
through a vaporizer
- Push Through
- Drawover
Drawover Anaesthesia
Drawover system :
Provide anaesthesia without a supply of
compressed gases.
Atmospheric air - main carrier gas
- drawn by the patient's inspiratory effort - drawn by the patient s inspiratory effort
- volatile agent( ether or halothane) added
to vaporizer.
Inhaled by the patient via a non-
rebreathing valve.
The components of a drawover circuit
EMO Vaporizer (Epstein Macintosh
Oxford Vaporizer)
Inlet for air
Temperature
Control lever
Ether Level
Indicator
Outlet for ether
and air
Filler
Temperature
indicator
10
EMO vaporizer -can be a part of a Drawover
system or used as a plenum vaporizer
Wt- 5.5 kg ; ht 24 cm ; diameter
23cm
CONTROL lever 0 to 20%; In
TRANSIT position control lever
seals ether chamber.
Inlet
Control lever
Outlet
Inlet to Outlet- R to L
LEVEL INDICATOR- moves only
after 150 ml ; add 300ml for full
FILLER - depress to fill ether
(control lever should be at 0-not
transit- for air to escape)
springs back automatically.
Ether Level
Indicator
EMO-Physical characteristics
Temperature Indicator - rod
with black & red bands &
metal top
- At 20-25 C-black line with
metal top visible
- At > 32 C - red band also
Temperature
Indicator
Filler
visible- temp above working
range
TAP for filling /draining
water chamber at bottom
EMO
(Epstein Macintosh Oxford Vaporizer)
CLASSIFICATION
Concentration calibrated
Flow over with wick
In System (Inhaler) y ( )
Temperature compensation by supplied
heat & flow alteration
Agent specific (diethyl ether, halothane,
chloroform, trilene, ether-halothane
azeotrope)
EMO Vaporizer - Working
Air enters inlet
If control lever ON
-One stream from
Bypass to Mixing
chamber
-Other stream to
p i in h mb vaporizing chamber
(V.C)
Control lever, on-off
valve at inlet of V.C
V.C -donutshaped,
wicks
EMO(contd)
Surrounding V.C Water reservoir-1250cc (Heat
reservoir)
(Al in Mark I, stainless steel in Mark II, III)
At outlet of V.C
- Thermocompensation mechanism.
Metal bellows with liquid Ether[ether q [
capsule] connected to plunger
Working temp. range 15-29 C
Tropical climates may require
precooling.
Care and cleaning
Mark I-empty of water every 3 months/when not
in use
The components of a drawover circuit
11
OMV
(Oxford Miniature Vaporizer)
OMV
The OMV is a small thermally buffered vaporizer
- originally produced to be used with the EMO
- to speed the induction of anaesthesia
CLASSIFICATION
Concentration calibrated Concentration calibrated
Flow over with wick
Temp compensation by supplied heat
Low resistance
Can operate as Plenum vaporizer
Multiple agent
OMV
Versatile, most portable drawover vaporizer
Original models contained 20 ml,modern ones 50 ml .
Body stainless steel/Metal mesh wicks
Arrow indicates direction of flow
- With EMO flow is R to L
- With continuous flow machine indicates flow L to R
Suitable for multiple agents - halothane, isoflurane,
chloroform, methoxyflurane; Different dial with
calibrated scales is attached for each agent.
OMV
Thermal compnsn. (reservoir of glycol within a
metal heat-sink)
Designed for continuous flow rates of 3-8L/min or
drawover rates of 4-10 L/min;,ambient temp.18 to 28C.
Do not use in Circle system can produce very high conc Do not use in Circle system can produce very high conc
Cleaning:
- Drain by tipping after pressing filler lever
- Wash out with alcohol or Ether.
Disadvantages
- Holds only 20 ml ; cannot mount on backbar
Oxford inflating bellows (OIB)
Self inflating bellows used with
spontaneous / controlled
ventilation.
Bellows sit vertically; internal
volume maintained by a
spring;6 bellows -150 ml each
2 unidirectional flap valves
Originally designed for use
with a simple spring loaded
valve (heidbrink valve)
Arrangement works well for
spontaneous ventilation; Not so
for IPPV
Spontaneous ventilation
To facilitate gas flow through the OIB there are two oneway
valves in the form of metal discs on circular seats.(A & B)
This arrangement works well for SV
Less satisfactory for IPPV as constant adjustment of the
Heidbrink valve required.
12
Assisted ventilation
1. Non-rebreathing valves (e.g.
Laerdal, Ambu) used to
facilitate IPPV with OIB.
2. Disable the downstream valve
with the magnet (hold it in
open position)to avoid jam.
3 If th OIB j ms th p ti nt 3. If the OIB jams the patient
cannot exhale as an air lock
develops. The patient must be
disconnected from the circuit
to allow exhalation.
4. More common with IPPV
When using MODERN valves, use a MAGNET.
Advantages of Drawover Anaesthesia
Simple
The equipment is robust, versatile,
easily maintained, relatively inexpensive,
portable
D d i d l Does not need a pressurized gas supply,
regulators or flow meters.
The drawover vaporizers are less
complex
Have basic temperature compensation.
Goldman Vaporizer
Low resistance vaporizers
Goldman, Mckesson
CLASSIFICATION
Flow over without wick Flow over w thout w ck
No temperature compensation
Multiple agents- Halothane , trilene
In or out of system
Goldman Vaporizer
Small glass bowl
Capacity 20 cc
Bowl attached to a head, which
divides gas between bypass and V.C
Control lever at top; max. conc
delivered at 3
rd
mark of 2.21%
Young modification -Added a wick
Halls modification-2 in series
13
Goldman Vaporizer
Mark I Mark II Mark III
Locking Self locks
in Off
Click stops No locking
in Off
Divisions Off-1-2-3-
on
Off-1-2-3-
on
Off-1-2-on
Max.
Concn.
At 3 At 3 At on
Boyles Bottle
BOYLES BOTTLE
CLASSIFICATION
1. Concentration calibrated
2. Flow over or bubble through
3 No temp compensation 3. No temp. compensation
4. Multiple agent (ether, halothane,
trilene)
5. Out of system
P - Plunger
C Cowl/hood
Propotionating
valve
U - U/inlet tube
O - Outlet
Boyles Bottle
Control
lever
Boyle Bottles
Ether Bottle
Larger V.C-300 ml filled fully
Inlet tube & hood - Cu
Has 4 lines between off & on-begins

d
k to operate at 2
nd
mark
Trilene bottle -100ml
Chrome plated U tube& hood; cowl
adjusted by stainless steel plunger
Delivers 0.5-2 %
14
Boyle Bottles
Halothane bottle
Uses only control lever no plunger/hood
Inlet tube plugged at end, side hole 1 cm
above 100 cc mark.
Control lever scale longer
Calibrated in numbers from 0-10; starts
at 3 , 1% at 4 , 8% at 10.
Boyles Bottle
FACTORS AFFECTING OUTPUT
1. Temp. of liquid
2. Plunger level
3. Control lever position
4. Level of liquid . L f qu
5. Eccentricity of hood
6. Agitation of vaporizer (Concn > 5 % for
upto 15 secs)
Difficult to develop a meaningful calibration
curve; Unpredictable with potent and
highly volatile agents
BOYLES BOTTLE
CARE & CLEANING
Empty after use/allow to dry
UNIQUE CONSIDERATIONS
Special grease for free rotation of drum
If Plunger loose-tighten the gland nut f g g g
Replace packing in gland nut-cotton, neoprene,
nylon
Bottle may chip off leading to leakage
Bottle washer may get damaged
Pressure build up in unused ether bottle
Static charges on cork-chain
Copper Kettle Vaporizer
Classification
Measured flow
Bubble through
Out of system
Temperature Temperature
compensation by
supplied heat and manual
flow alteration
Multiple agent
- 2 models 400ml/ 160 ml
- Constructed of Copper
Measured gas
centre tube
surge chamber
passes down around
centre tube
enters diffuser
sintered bronze
disc bubbles
vapor laden gas
rises discharge
tube
Evaluation
Acceptable over wide range of flows
Incomplete temp. compensation
Hazards Hazards
Errors in calculation
Overfilling in older models possible
May neglect to turn VCCV to ON posn.
If the bypass flowmeter is turned off, it is
possible to supply gas fully saturated with
anesthetic to the patient !!
15
Precision Vaporizers
Precision vaporizers deliver precise concentrations of
anesthetic.
Regulation of the vaporizer output may be fully
automated or manually controlled by the anesthetist.
A fully automated precision vaporizer will deliver the
concentration of anesthetic indicated by the vaporizer
dial even when there are changes in temperature fresh dial even when there are changes in temperature, fresh
gas flow rate, and circuit pressure
Automated precision vaporizers are designed for use
with only one anesthetic.
V.C has network of wicks/channels to ensure emerging
gas is fully saturated with vapor.
Include Ohmeda Tec series, Drager Vapor 900 series,
Forreger, Penlon, Ohio vaporizers.
Tec 2 Vaporizer
TEC 2 VAPORISER
CLASSIFICATION
Flow over with wick
Out of system Out of system
Temp. compensation by automatic flow
alteration
Agent specific (halothane or
methoxyflurane)
Plenum
TEC II
Internal Construction
V.C round; 135 ml; concentric, circular wicks
Filling tap at side, drain at bottom
Window on side for liquid level
Temp. Compensation-Bimetallic strip at outlet of V.C
Care and Cleaning
Fluotec - Drain Halothane every 2 weeks & discard as
THYMOL accumulates Sticking of spindle and
bimetallic strip
Hazards
Tipping; Agitation; Reverse flow
Fluotec Mark 2 Vaporizer
TEC II-Performance
Very inaccurate at
low flows
Good for flow rates Good for flow rates
> 5 L/min
16
Tec 3 Vaporizers
Classification
Conc. Calibrated
Flow over with wick
Out of system
Temp. compensation by automatic flow
alteration
Agent specific (Halothane,
Methoxyflurane, Enflurane, Isoflurane
TEC 3
Differences
Tec II Tec III
External
Structure
Has one bypass and V.C
Side filling tap, Drain
at bottom,Side window
for liquid level
Has 2 sections-lower V.C &
upper duct and valve system
Side filling tap, Drain at
bottom,Side window for
liquid level
Not so Can be placed upright
Switching
on
Spindle pulled out &
rotated anticlockwise
Depress locking lever
Turn Concentration dial
Differences
Tec II Tec III
Bypass
Channel
One ; Smaller
Not so
Two; Larger
Bimetallic strip( regulates
flow)
Vaporizing
Chamber
Round; Concentric wicks
Bimetallic strip at outlet
Not so
Wicks excluded from inlet
Not so
Tube leading to VC longer Not so Tube leading to VC longer
Differences
Tec II Tec III
Performanc
e data
Inaccurate at lower
flowrates (< 4L/min)
At flowrates <2L/min
- Dial settings < 2% -
delivers less
Accurate at lower
dial settings
At high dial settings
-conc at low flowrates
- Accurate at high delivers less
- Dial settings > 2% -
delivers more
- Accurate at high
flowrates
17
TEC 4
TEC 4
CLASSIFICATION-Same
Differences:
Depress release button on left of Control
dial to turn on
Control dial on top - Rotate p
counterclockwise
Locking lever on the rear-Vaporizer can be
turned on only if locked on the manifold
Two filling mechanisms
1. Screw cap with drain plug
2. Keyed filling Device
TEC 4
Tec 4 Vaporizer
Helix
Bypass
Rotary valve
Inlet
Outlet
Vaporizing
chamber
Bypass
chamber
Helix
Temperature sensitive
device
Wick
filler
TEC 4
Improvement over Tec III:
- Output unaffected by back pr. changes under clin condns.
- Unaffected by Tipping even upto 180 .
Limitations
- Excess pressures( > 400 mmHg )cause in output - Excess pressures( > 400 mmHg )cause in output
- Not so Accurate at low flowrates, low dial settings and
larger pressure fluctuations
- Overfilling possible
- Use of N2O decreases output
Responding to criticism of the TEC 4,ie..
1. difficulty in operation one-handed
2. poor performance
3. and yearly service interval.
18
Tec 5 Vaporizer
Tec 5 Vaporizer
Features:
-Internal Baffle System
-V.C lies within the
bypass
-Bypass along side of
the vaporizer the vaporizer
-Bimetallic strip in the
base of bypass
-Before reaching VC
helical IPPV assembly-
spiral wick
Tec 5 Vaporizer-Improved features
a) Bypass chamber at the base; an improved
bimetallic strip.
b) Improved response to fluctuating back pr.
c) Agent capacity sed from 125 ml to 300 ml.
e) One-handed dial control;more obvious 'off'
position.
f) Improved safety interlock
g) Service interval now three yearly.
h)Improved characteristics with tubular woven
cotton wicks
TEC 5
Evaluation
Greatest Accuracy at Fresh Gas flow
less than 5L/min and dial settings < 3%.
At higher flows and higher dial settings At h gher flows and h gher d al sett ngs
output decreases.
Pumping Effect
Greatest Accuracy between 15 to 35C
Carrier gas composition affects output.
TEC 7
TEC 7
The TEC 7, an improved version of the TEC 5 was
introduced in July 2002
Modifications include:
a) Three filling devices
- Funnel-filler
Quik Fil - Quik-Fil
- "Easy-fil" filler mechanism(for sevoflurane)
b) Soldered sump assembly eliminating seals
c) Improved sight glass design
d) New ergonomics and design
e) Planned factory service free
19
Tec 7
Evaluation
Performance curves and characteristics
similar to Tec 5 similar to Tec 5
Hazards
Tilting affects output
Overfilling can occur
Tec 6 Vaporizer(Desflurane)
Desflurane is extremely volatile (Boiling Point= 22.8C)
Precludes use of a normal variable-bypass vaporizer.
The Tec 6 vaporizer avoids this problem by
- heating the desflurane liquid to above its B.P in a heating the desflurane liquid to above its B.P in a
sealed chamber and mixing pure desflurane gas with
the carrier gas.
The Tec 6 is electrically powered and electronically
controlled
Since the V.C is sealed from the atmosphere, a special
filler arrangement is required.
Tec 6 Vaporizer
Classification
Injection
Thermocompensation by supplied heat Thermocompensation by supplied heat
or Electrically heated, dual circuit Gas /
Vapor blender
Single agent-Desflurane
TEC 6 Vaporizer
H-Heating element
O-Orifice
P-Differential
Pressure Transducer
R1-Resistor
R2 2 d R i t
Desflurane heated to 39C in a sealed chamber, adjusts by H
Carrier gas flow restricted by O,so that pr. is proportional to
flow
Pr sensed by P-which readjsts R1 so that flow of des ~ carrier
gas flow
Control dial adjusts R2,and thus the output concentration
R2-2nd Resistor
TEC 6
Evaluation
Output almost linear at3%,5%,7% settings.
Slightly lower output at <5L/min flow;Ideal
temp 18-30*C.
Tilting Resistant.
Pumping effect insignificant.
The output decreases with Air or N2O as
carrier gas.
20
Aladin Vaporizer
Cassettes containing liquid
anesthetic inserted into a
port
Agent recognized & dispensed
into the stream of FGF.
Tipping resistant &
maintenance free.
Power or battery backup &
adequate O2 (or air) pressure
mandatory
Fixed output irrespective of
fresh gas mixture
Extremely light& can be
removed with one hand.
Hazards Of Vaporizers
Incorrect agent
Tipping
Foaming Foaming
Overfilling
Reversed flow
Leaks in vaporizers
Filling Systems
1. Funnel Filler
Isotec 4 vaporizer with funnel-filler
Filling Systems contd..
2. Keyed Filling System
Isotec 4 vaporizer with key-filler
Agent Specific Filler Tube
(Bottle Adaptor)
Filler
block-
fits into
vaporizer
receptacle
Bottle cap-keyed & color coded
Filling Systems contd..
Quik-Fil System (only for sevoflurane)
E Fil S (U d ll f 7 Easy-Fil System (Used on all four tec 7
vaporizers)
21
Vaporizer Mounting Systems
If >1 vaporizer can be switched on at a time the
patient exposed to a overdose of anesthetic agent.
The downstream vaporizer is contaminated.
S l b k b A i h h b k b Selectatec back bar -A switch on the back bar may
be used to direct gas flow through only one vaporizer
at a time, e.g. the Fraser Harlake Selectatec back bar
A mechanical locking system may be used that only
allows one vaporizer to be switched on, e.g. Ohio
selector manifolds and Drger 19.3 vaporizers.
A mechanical inter-connector
Vaporizer Mounting Systems
If none of the above is possible
Vaporizers should be arranged in the order
- most volatile agent downstream
- High SVP downstream
- If explosive downstream
- Trilene downstream
- Easy to clean downstream
IDEAL VAPORISER
DELIVER A FIXED DESIRED CONC. (EQUAL
TO CONC. ON DIAL SETTING)
INDEPENDENT OF TEMPERATURE , FLOW
RATE AND CARRIER GAS ALTERATIONS
NO EFFECT OF BACK PRESSURE
EASY TO MAINTAIN AND CLEAN
AGENT SPECIFIC
Vaporizers ASTM standards
1. Effects of variation in temp, Pr., tilting, back pressure
and input flow rate and gas mixture composition on
vap. performance should be stated.
2. Average delivered conc. not more than 20% or 5%
of the max.setting.
3. System that prevents gas from passing through the
V.C or reservoir of one and then through another
should be provided.
4. Output of the vaporizer should be < 0.05% in the
OFF or zero position if the zero is also Off.
ASTM Standards contd..
5. All vaporizer control knobs must open
counterclockwise
6. Either the max or min filling levels or the actual
usable vol. and capacity should be displayed.
7 Cannot be overfilled in normal operating position 7. Cannot be overfilled in normal operating position.
8. If unsuitable for use in breathing system,
noninterchangeable 23 mm fittings; inlet male, outlet
female,direction of gas flow must be marked
9. If suitable for use in breathing system, standard 22
mm fittings ; inlet female, outlet male, direction of
gas flow marked.

Interpretation of Blood Gas Reports - Made Easy: Dr. A K Sethi's EORCAPS-2010, Delhi

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