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Low Flow Anesthesia

Bambang Wahjuprajitno
Dept. of Anesthesiology & Reanimation
Faculty of Medicine - Univ. of Airlangga
Rumah Sakit Bedah
Surabaya
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History

1850: John Snow recognized that a considerable amount


of inhalation anaesthetics were exhaled unchanged in
the expired air of anaesthetized patients reinhaling?
1924: CO2 absorbers were introduced into anaesthetic
practice by Ralph Waters (to and fro) and CJ Gauss-HD
Wieland (circle system)
1933: highly combustible cyclopropane FGF to
reduce pollution
1954: halothane, high anesthetic potency yet narrow
therapeutical width high FGF and low proportion of
rebreathing was kept patient safety
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Ideal technique, but low


adoption

Familiar with high FGF Constant inspired


anesthesia agent

Loss of control over anesthetic concentration


Complex process the need of knowledge, skill,
training and sophisticated apparatus

No suitable anesthetic agent available


No suitable anesthetic machine and monitor
available

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Kyoto Protocol

An international treaty that sets binding

obligations on industrialised countries to reduce


emissions of greenhouse gases

carbon dioxide (CO2)


methane (CH4)
nitrous oxide (N2O)
sulphur hexafluoride (SF6)
two groups of gases: hydrofluorocarbons (HFCs) and
perfluorocarbons (PFCs)
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Anesthesiologist
contributions

Use room air/oksigen, avoid N O as carrier gas


Gases with less impact: xenon
Avoid unnecessarily high FGF, use low flow as
2

routine LFA

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Characteristics of low fresh


gas flow techniques

Increased rebreathing volume


Less excess gas
Difference of gas composition Fresh gas
versus gas in the circuit

Long time constants


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Low Flow Anesthesia

Low flow anesthesia occurs when the FGF rate


is significantly less than minute ventilation

A technique where significant re-breathing


occurs

Re-breathing fraction increases with the

reduction of FGF with a reciprocal decrease in


the volume of excess gas
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Definition

Low flow anaesthesia: an inhalation

anaesthetic technique via a rebreathing system


in which the rebreathing fraction at least
amounts to 50% 50% of the exhaled gas
volume is led back to the patient after carbon
dioxide absorption in the next inspiration.

Using modern anaesthetic machines this will be


gained at a fresh gas flow rate between 2 to 1
L/min
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Classification of anesthesia circuits


according to Baker and Simionescu
Circuit

Fresh gas flow

Metabolic flow

~ 250 ml/min

Minimal flow

250-500 ml/min

Low flow

500-1000 ml/min

Medium flow

1-2 L/min

High flow

2-4 L/min

Open

> 4 L/min

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Advantages

Economy (desflurane & sevoflurane)


Climatization of the inspired gases (inspired

gas humidity & temperature)


Ecology: Reduced atmospheric pollution
(chlorine destruction of ozone layer)
Anesthesiologist promotes greater
understanding of:

breathing systems
pharmacokinetics of inhalation anaesthesia
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Cost savings by Low Flow versus


Minimal Flow Anaesthesia

Nitrous oxide workplace


concentration

Inspired gas humidity &


temperature

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Disadvantages

Capital investment
Increased consumption of absorbent
Limitations of currently available vaporizers
Accumulation of unwanted gases in the
breathing system

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Concerns about safety in LFA

Hypoxia
Gas volume deficiency
Misdosage of volatiles
Reduced controllability
Exhaustion of the absorbent
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Requirements

Flow meters calibrated to flows down to 50 ml


min-1

A leak-free circle system


A near-gas-tight breathing system
CO absorber
Anesthesia gas monitor
2

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Requirements

Qualified personnel
Suitable anesthetic machine

Accurate fresh gas delivery


(Accurate and consistent settings, accurate readability)
Very low leakage of the system (must not exceed 100
mL/min)

Monitoring for safe performance

Standard : EKG, pulse oximetry, NIBP, EtCO2


Continous measurement with alarm: Paw, MV, FiO2
Optional : gas monitor
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Calibrated Flowmeters

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Leak-free circle system

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Vaporizers

The vaporisers should feature pressure-, temperature-,


and flow compensation

Maximum output of the vaporisers at a concentration


equalling 3-5 times the respective MAC impossible
for halothane & enflurane

Future: Liquid injection vaporizers

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Trace gases
Due to decreased wash-out

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Caution!

Sevoflurane interaction with carbon dioxide


absorbents Compound A

fluoromethyl-2,2-difluoro-1-(trifluoromethyl)vinyl ether

Factors

low-flow or closed-circuit
concentrations of sevoflurane
higher absorbent temperatures
fresh absorbent
Baralyme dehydration compound A concentration
Soda lime dehydration compound A concentration
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Caution!

Desiccated soda lime and Baralyme

carbon monoxide
after disuse of an absorber for at least 2 days, especially over
a weekend

Several factors appear to increase the production of CO and


carboxyhemoglobin:

Anesthetic agents (desflurane enflurane > isoflurane


halothane = sevoflurane)

The absorbent dryness (completely dry absorbent produces


more carbon monoxide than hydrated absorbent)

The type of absorbent (at a given water content, Baralyme


produces more carbon monoxide than does soda lime)
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Caution!

Several factors appear to increase the

production of CO and carboxyhemoglobin:

The temperature (a higher temperature increases


carbon monoxide production)

The anesthetic concentration (more carbon monoxide


is produced from higher anesthetic concentrations)

Low fresh gas flow rates (LFA)

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Prevention

Educating anesthesia personnel regarding the cause of carbon


monoxide production
Turning off the anesthesia machine at the conclusion of the last case of
the day to eliminate FGF, which dries the absorbent
Changing carbon dioxide absorbent if fresh gas was found flowing
during the morning machine check
Rehydrating desiccated absorbent by adding water to the absorbent
Changing the chemical composition of soda lime (e.g., Dragersorb 800
plus, Sofnolime, Spherasorb) to reduce or eliminate potassium
hydroxide
Using absorbent materials such as calcium hydroxide lime that are free
of sodium and potassium hydroxides
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How we do it?

Arterial
blood
FI

FGF
Breathing
circuit

Lungs

Anesthesia machine

Venous
blood

FGF (fresh gas flow) is determined by:


the vaporizer and flowmeter settings
FI (inspired gas concentration) is determined by:
1.FGF rate
2.Breathing circuit volume and
3.Circuit absorption.
FA (alveolar gas concentration) is determined by:
1.Uptake: Uptake = b/g x C(A-V) x Q
2.Ventilation and
3.The concentration effect and second gas effect
a)Concentrating effect
b)Augmented inflow effect
Fa (arterial gas concentration) is affected by
ventilation/perfusion mismatching

Uptake at MAC (mL/min)

Uptake of volatile anesthetic agents

Minutes of Anesthesia

Pharmacokinetic and pharmacodynamic


properties of different inhalation anesthetics

3 phases of LFA

1. Initial high flow


2. Low flow
3. Recovery

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Initial High Flow Phase

Sufficient denitrogenation
Rapid wash in of the desired gas composition
into the breathing system

Establishing of the desired anaesthetic


concentration

Avoiding gas volume deficiency


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Initial High Flow Phase


high FGF lasting 10 to 20minutes

Denitrogenation

Wash-in

Oxygen concentration during


low fresh gas flow

During Low Flow Anesthesia (1.0 L/min)

Oxygen concentration shall be increased to 50 vol.%

Oxygen concentration shall be increased to 60 vol.%

At least to 40 vol %

Minimal Flow Anaesthesia (0.5 L/min)


O2 300 mL/min + N2O 200 mL/min

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Insp. O2 Concentration during


Low Flow Phase

Insp. oxygen concentration during the course of Low Flow


Anaesthesia, different oxygen concentrations of the fresh
gas

Expiratory isoflurane concentration (nominal value, 0.9 vol% 0.8


MAC, patient 75 kg) and vaporiser settings required for the different
FGFs

LFA

The lower the fresh gas flow, the higher the concentration to be dialled at the vaporiser to maintain a
desired expiratory sevoflurane concentration of about 1.7 vol% during the remaining course of anaesthesia

Expiratory sevoflurane concentration (nominal value,1.7 vol% 0.8


MAC, patient 75 kg) and vaporiser settings required for the different
FGFs

Expiratory
sevoflurane
concentration

The lower the fresh gas flow, the higher the concentration to be dialled at the vaporiser to maintain a
desired expiratory sevoflurane concentration of about 1.7 vol% during the remaining course of anaesthesia

Expiratory desflurane concentration (nominal value, 3.5 vol% 0.8


MAC, patient 75 kg) and vaporiser settings required for the different
FGFs

When desflurane is used in Low Flow Anaesthesia the flow can be reduced from 4.5 to 1.0 L/min already 10
minutes after induction without any alteration of the vaporiser setting.

How can anaesthetic depth be changed


rapidly during low flow inhalation
anaesthesia?

Increase
depth of anesthesia

Decrease
depth of anesthesia

Changing from long to short time constant by varying not only vaporiser setting but also fresh gas flow
during performance of Minimal Flow Anaesthesia to quickly alter the depth of anaesthesia.

Absolute contraindications
Continuous wash out of potentially dangerous gases
is required Smoke or gas intoxication

High Individual gas uptake Malignant hyperthermia


The equipment does not meet essential requirements

Soda lime exhaustion

Failure of the anaesthetic agent monitor (if it is part of the


dosing system itself)

Failure of the oxygen monitor (unless pure oxygen is used as


carrier gas)

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Relative contraindications

Inhalation anaesthesia lasting less than 10-15min risk of:


Insufficient denitrogenation
Inadequate depth of anaesthesia
Gas volume deficiency
Leakage in the anesthesia system
Risk of accumulation of potentially dangerous trace gases:
Decompensated diabetes mellitus
The state of long-term starvation
Chronic alcoholics or acute alcohol intoxication
Heavy smookers

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References

Thank you for your kind


attention
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