#Anesthesia tools and equipment

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1. ANESTHESIA TOOLS AND EQUIPMENT Dr Nisar Ahmed Arain Assistant Professor Anesthesia/Critical Care/ ER

2. -Anesthesia Machine --Cylinders / Pipeline Gas supply --Reducing Valves --Vaporizers --Flow Meters --Soda lime Canisters --Breathing circuits --Accessories==Face Masks-Laryngoscopes-ET tubes metal stylets, airways

3. - Anesthesia Machine

4. -Cylinders --Constructed from Molybdenum --Colour coded according to gas supplied --Safety—Pin index system --Oxygen --Nitrous oxide --Pipe line gas supply

5. -Inhalational anesthesia Machine

6. -OXYGEN -In the form of gas – 130 bars -pressure gauge is there -Outlet valve can only connect the oxygen cylinder to the machine -Alarm – when oxygen is depleting

7. - Nitrous oxide -Liquid form – pressure 51 bars until the liquid vaporizes -Heat Vaporization -Pressure gauge – doesn’t indicate the measures of contents -Blue colour cylinder

8. -Pipe line gas supply -All gases in liquid form – economical -Pressure 4 bars -Identification – gas name, color code shape -Convenient

9. -Flow meters -Tapered glass tube contains spinning bobbins -Calibrated for a specific gas -Vaporizers -Vaporizes inhalational anesthetics in liquid form at room Temperature -Calibrated for a specific inhalational agent

10. -Breathing systems -Delivers anesthetic gases and oxygen to the patient and removes carbon di oxide a-Magill circuit b-T piece (pediatric circuit) c-Bain circuit d-Circle circuit – commonly used

11. -Mapleson classification -Mapleson system – A a-Magill system – most satisfactory with spontaneous respiration -Mapleson system B – not common -Mapleson system C – not common a-Waters system -Mapleson system D a-Bain co-axial system -Mapleson system E a-Ayer’s T piece – pediatric use -Efficiency of systems with spontaneous respiration A > D, E > C > B -Efficiency of systems with IPPV D, E > B > C > A -Most important closed circle or low flow system a-Rebreathing system

12. -Ventilator circuit – circle circuit -Re breathing system sodalime is needed to absorb CO2 from exhaled gas -Low fresh gas flows -Economical -Less theatre pollution -Humidification is better -Valves – not ideal for pediatric use -Heavy

13. -Bain circuit -Coaxial system – inspiratory limb inside and outer expiratory limb -Used both in spontaneous and controlled ventilation -Scavenging system is easy -Reservoir bag – 2 L

14. -Pediatric – T - Piece -No valves no resistance to respiration -Fresh gas flow should be twice the minute volume -Reservoir bag fixed on the open end – for controlled ventilation

15. -Soda lime -Used with circle circuit – rebreathing systems -Calcium Hydroxide (94%) Na (5%) and K(1%) hydroxides -Absorb CO2 – Colour changes when it becomes inactive -Face Masks -Rubber or Plastic -Transparent once show vomitus and secretions

16. -Ventilator

17. -Setting up a simple ventilator -Connect the gas supply – usually Nitrous oxide (66%) and Oxygen (33%) air------- -Connect the outlet to the breathing circuit -Select the a-Tidal Volume – 7 to 10 ml / kg b-Respiratory rate – 12 – 16 per minute c-Inspiration / Expiration ratio (usually 1:2) -Keep upper airway pressure 10 to 20 cm H2O -Negative upper airway pressure means patient voluntarily breathing

18. -Oxygen Mask -Look how this is connected to gas supply and to Ambu Bag -What happens if connection to Ambu Bag is lost

19. -Ambu Bag -Self inflating bag -Reservoir bag – 100% Oxygen -Valves a-Prevent forward leak b-Prevent backward leak c-Expiratory d-Inspiratory e-Pressure releasing if >40 mmHg -Ideal Valve should have a- No forward leak b- No backward leak c- Low resistance d- Minimal Dead space e- Light weight f- Minimal opening pressure without sticking g- Transparency h- Reliability and Durability

20. -FACE MASK -Triple manure 1-Head tilt 2-Extend to straighten the airway and prevent the tongue falling back 3-Jaw thrust -why DENITRATION is important ? -To increase the concentration of oxygen in the alveoli before intubation -This enables enough time to intubate

21. -Face masks -Note:-How face mask is hold preventing air leak -Practice triple maneuver

22. -Airways -Air way maintenance by displacing the tongue from posterior pharynx -Oropharynx airway -Nasal airway – when unable to open the mouth and I oral surgeries -Paediatric and adult types Dotted Color coding

23. -Adult Guedel airways -Look for the dotted coding in Paediatric airway

24. -Nasal Airway --What are the Contraindications for Nasal intubation --What are the complications of Nasal intubation Note:-why gauze pack is put into the oral cavity in Nasal intubation

25. -Laryngeal Mask Airways -1-Short tube with a elliptical cuff -2-Placed in the laryngopharynx behind the inlet -3-Can avoid muscle relaxants no hemodynamic response like in ETT tube -4-Relieves Hypoxia in failed intubation -5-Blind intubation through mask is possible -6-Risk of regurgitation is there -7-It is alternative to face mask -8-Needs minimum skills Learn the procedure of putting laryngeal mask

26. -Laryngoscope -Curved blade—Macintosh -Straight blade—Magill -Battery in the handle—check whether the bulb is working before use -Use with the left hand -Put it in from the right side -Groove in the left side of the blade is for to keep the tongue apart and lifted -what are the uses of laryngoscope -Macintosh laryngoscope – curved blade

27. -Endotracheal tube--Cuffed -How to describe an endotracheal tube ? -Cuffed or not cuffed -Internal diameter -Main Parts From above downwards a-Universal airway connector b-Tube c-Radio opaque line d-Pilot tube e-Pilot inflator bag f- Cuff type 1-High flow low volume 2-Low flow high volume -Murphy's eye -Black lines use of each part and there importance -What are the uses of flexible and reinforced tubes - What is RAE tube

28. -IMPORTANCE -Universal air way connector a-external diameter is same in every tube (15 mm) -Tube Internal diameter a-Female – 7.0 to 8.0 mm b-Male -- 8.0 to 10.0 mm -Radio opaque line a-Identify it radiologically -Pilot tube a-to inflate the cuff -Inflating bag – 5 ml -Cuff a- High Pressure / Low volume (1)-High risk of aspiration and pressure necrosis b- Low Pressure High volume (1)-vice versa -Two black lines a-vocal cords should be in between – risk of damage is reduced -Murphy's eye a-To keep the patency when secretions block the tube b- To keep the patency of upper right bronchus

29. -Endotracheal tube – Plain / Non Cuffed -Indications for ET tubes a-when muscle relaxants given b-In patients with risk of aspiration c-To provide controlled ventilation d-For prolonged operations -why non cuffed is preferred in children -Their narrowest place is at cricoid tube fits nicely

30. -Endotracheal tubes -What is I.T on tube ? a-Implantation test for allergies has been done -What is importance 0of Re- inforced tube a-t is not liable to kink – in oral surgeries -What are indications of Proper intubation ? a-Feels expired air touching the dorsal surface of hand when it is neared to the air way connector b-See vapour in the tube c-Hold a piece of thread near the opening – it will move d- Posetive capnogram on monitor

31. -Tracheostomy tubes -Sized according to the internal diameter -Cuffed or uncuffed -Introducer is available -Winged flanged are to secure the tube with the skin -Indications a-In ICU patients who needs prolonged intubation b-Vocal cord Palsy c-OP Poisoning d-Oropharyngeal / Laryngeal carcinomas e-Chemical burns F- Guillian Bare syndrome--- ect

32. -Complications of Tracheostomy -EARLY -LATE - Hemorrhage -Displacement or obstruction -Injury to trachea -Tracheitis -Crust formation -Surgical Emphysema -Difficult insertion -Pneumothorax -Infection -Tracheal Ulceration -Tracheal Dilatation -Tracheal Stenosis -Cardiovascular collapse

33. -After care of Tracheostomy -Position the patient a-Adults - propped up b-Children – chin should not occlude -Suction – clean catheter used a-Deep suction + Physiotherapy or ventilation – in unconscious -Humidification a-Prevent drying and formation of crusts b-wet gauze in the opening -Tube changing a-After 2 to 3 days b-Silver tubes – remove inner tube and clean c-Cuffed tubes – regular deflation to prevent pressure Necrosis d-Air – Minimum to prevent air leak -Pain management -Management of hemorrhage

34. -Intravenous Fluid set - Priming an I/V line -Take out from the pack – mark to scratch in the packet -Clamp it -Never touch the connector -Open the cap of fluid bottle and connect the line -Open the line till half of the syringe fills -Open fully and allow fluid to come out – to assure no air bubbles inside -Connect to the cannula - RISKS -Septicemia -Air embolism

35. -IV Canula -Gauges – colour code a-Orange – 14 G b-Ash -- 16 G c-White -- 17 G d-Green -- 18 G e-Pink -- 20 G f –Blue -- 22 G g-Yellow -- 24 G (Spinal needle – 25 G – French grading) -Demonstrate how IV cannulation is done discuss importance of each step

36. -Control syringe Learn the use of syringe

37. -Syringe Pumps -Electrically driven – battery back – up is there -Alerts provided for a-Power failure b-Empty syringe c-Occlusion of delivery pipe -Applications a-Pain relief b-Total IV anesthesia c-Sedation in intensive care d-CVS support e-Relaxants f- Control of diabetes

38. -Dose calculation for syringe pump -Dobutamine solution – 200 mg in 500 ml -Dose – eg : 2.0 Micro gram / kg / min -Body weight of the patient – eg : 50 mg -so, amount of mg per hour =2.0 micro gm X 50 K gm X 60 =6 mg 1000 -Amount of solution needed per hour =500 ml X 6 mg = 15 ml / hr 200mg -So the infusion rate = 3.8 per minute

39. -Magill's forceps -Guide the ET tube into Larynx – Nasal intubation -Guide the nasogastric tube into oesophagus show how this is held

40. -Blood transfusion set -Normal Blood amount a-Adult Male = 70 ml / kg b-Adult Female = 60 ml / kg c-Child = 80 ml / kg =Discuss how blood loss is Assessed in the theatre =Discuss management of Hemorrhagic shock Learn the appropriate use of three way Tap

41. -Transfusion Bags -List the blood components and their indications

42. -Hemodialysis tubing

43. -CVP Manometer - Measure -Adequacy of blood or fluid replacement -Easy and rapid transfusion of blood -Normal – 3 to 10 cm H2O -Low CVP a-Hypovolemia b-Septic shock -High CVP a-Heart Failure b-Increased intrathoracic pressure (1)-IPPV, PEEP pneumothorax c-Over transfusion d-Constrictive pericarditis e-Pulmonary vasoconstriction

44. -Central venous pressure - >50% of the total blood volume is in venous system -alteration in venous tone play a large part in regulation of hemodynamics - Zero at mid axillary line Normal – 3 to 10 cm H2O Complications 1-Thrombophlebitis, infection, septicemia 2-Pneumothorax, Hydrothorax, Hemothorax 3-Bracheal plexus injury 4-Air embolus 5-Pericardial infusion 6-Lymphatic leakage 7-Arrhythmias 8-Catheter breaking

45. -Peritoneal dialysis - set

46. -Peritoneal dialysis - catheter

47. -Double lumen Dialysis

48. SPINAL AND EPIDURAL SETS

49. -Spinal needle -Whitacre spinal needle – 25G commonly used -Subarachnoid anesthesia a-Take the consent b-Look for contraindications 1-CNS lesions – ideally full CNS examination should be done 2-Sepsis around the area of pricking 3-Any coagulopathies -It should be a completely sterile procedure

50. -Spinal Needles

51. -Foley’s Catheter -Learn the aseptic procedure of catheterization

52. -Guide wire – External pace Maker

53. -SUCTION CATHTERS

54. -Nasogastric Tube -INDICATIONS -1-Aspiration of gastric juices for the diagnostic and therapeutic purposes -2-Confirmation of gastroduodenal hemorrhage -3-Feeding -4-Confirmation of its presence in the stomach -5-Syringing the air down the tube while listening over epigastrium -6-Suck the tube to see the juices are coming -7-Vapour inside in accidental tracheal intubation

55. -For Identification ????

56. - For Identification ????

57. -Anesthesia Instruments

58. -IV CANULA -Why do you Tap to find appropriate vein for cannulation -Why veins in the periphery are selected first -What should be done if peripheral veins are not visible -What do you use low grade canulae for adult’s -What are the complications -Why anti cubital fossa is not selected as a good site for cannulation

59. THANK YOU