See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/355476008

Fundamentals of the Anaesthetic Machine

Chapter · May 2022

CITATIONS READS

0 355

1 author:

Daniel Rodger
London South Bank University
37 PUBLICATIONS   100 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Early life ethics View project

All content following this page was uploaded by Daniel Rodger on 22 October 2021.

The user has requested enhancement of the downloaded file.

 This is the authors’ copy of an in-press book chapter. It may be cited as:

Rodger, D. Fundamentals of the Anaesthetic Machine. In: Rodger, D., Henshaw, K.,
Rawling, P., Miller, S., eds. Fundamentals of Operating Department Practice. 2nd ed.
Cambridge University Press, 2022.

Fundamentals of the Anaesthetic Machine

Daniel Rodger, London South Bank University

ABSTRACT

The primary purpose of the anaesthetic machine is to deliver oxygen, other gases and volatile
agents (if used) safely to the patient—helping to maintain a suitable level of anaesthesia and
analgesia for surgery. It is vital that any clinician checking and using an anaesthetic machine is
familiar with the type of machine they are intending to use and possess a detailed knowledge of
how it operates. Machines must be rigorously checked and tested by a suitably trained person
before use and a breathing circuit check should take place between each patient. This chapter is
an introduction to the anaesthetic machine, highlighting the main components and features that
are essential to maintaining user and patient safety.

KEY WORDS: anaesthesia, perioperative, patient safety, vaporisers, anaesthesia, surgery,

ventilator, scavenging, adverse events

INTRODUCTION

The primary purpose of the anaesthetic machine is to deliver oxygen, other gases and volatile
agents (if used) safely to the patient—helping to maintain a suitable level of anaesthesia and
analgesia for surgery or other intervention [1]. It is vital that any clinician checking and using an
anaesthetic machine is familiar with the type of machine they are intending to use and possess a

1
detailed knowledge of how it operates. Machines must be rigorously checked and tested by a
suitably trained person before use and a breathing circuit check should take place between each
patient [2].

Modern machines commonly house patient monitors (or include an integrated monitor), are
easier to decontaminate, contain drawers, shelves, and additional space for customisation [3].
Some companies have subsequently developed machines that are portable and can be easily
transported to remote areas, whilst others have modifications that allow them to be utilised
during magnetic resonance imaging (MRI). Although different types and brands of machines can
look different, they all have several standardised features in common, ensured by safety
specifications in the United Kingdom (UK) [1]. Even with considerable development and
technological advances, the basic design and essential features of the anaesthetic machine have
changed very little since the early Boyle’s machine. This chapter is intended as an introduction to
the anaesthetic machine, highlighting the main components and features that are essential to
maintaining user and patient safety.

BACKGROUND

The first successful public demonstration of ether anaesthesia was performed by WTG Morton
on the 16th of October 1846 so that the surgeon JC Warren could remove a tumour from his
patient Gilbert Abbott’s jaw [4]. It was not until 1917, that HEG Boyle first designed his own
machine to deliver anaesthesia. Boyle’s machine was a modification of JT Gwathmey’s lesser-
known machine from 1912. Boyle identified some serious mechanical flaws following the
prolonged use of the Gwathmey machine—nevertheless, he incorporated several of its main
concepts into his own machine design [5].

THE ANAESTHETIC MACHINE

Modern anaesthetic machines still incorporate many of the features that were present on the
early Boyle’s machine, such as flowmeters, vaporisers, pressure reducing valves, and a breathing
system [6-7]. Electronically controlled machines frequently use software which drives the piston
ventilators, which are much more precise (especially at smaller tidal volumes), disposable carbon
dioxide absorbers that allow for less disruptive changeovers, electronic flowmeters, and can
incorporate an automatic self-check when the machine is first switched on. However, performing

2
just the automated machine self-check is not sufficient to establish the safety of the machine for
patient use. [Figure 1 here]

Electronically controlled machines have several advantages over conventional pneumatic

machines, though they can involve a degree of compromise in other areas. Electronically
controlled machines depend more heavily on a continuous supply of electricity and therefore
have a more limited backup power supply than conventional machines. For instance, all Dräger
electronically controlled machines have at least 30-minutes backup power following a mains
power failure, after which time the piston ventilator will cease to function. However, manual,
and spontaneous ventilation with anaesthetic gas delivery can continue after that time, although
alarms and monitors will no longer be functional [8].

UNITS OF PRESSURE

Despite attempts at standardisation, a range of different units of pressure continue to be used,

which can cause confusion. The gas pressure within the anaesthetic machine is measured in
kilopascals (kPa). However, other units of pressure relevant to the machine are millimetres of
mercury (mmHg), centimetres of water (cmH2O) and pounds per square inch (psi). To better
understand the relationship between the different units of pressure, one atmosphere or one bar
(a close approximation of atmospheric pressure at sea level), is roughly equal to: 101 kPa, 15 psi,
760 mmHg or 1020 cmH2O [9].

BASIC FEATURES OF THE ANAESTHETIC MACHINE

Irrespective of the type of anaesthetic machine being used—there are several essential
components that must be present, along with their corresponding safety features [Figure 2 here].
These are:

● Metal frame
● Pipeline gas circuitry
● Connections for gas cylinders and pressure gauges
● Pressure regulators
● Needle valves or computer-controlled pressure and flow devices
● Rotameters or digital equivalent

3
 ● Back bar
● Vaporisers
● Common gas outlet and auxiliary gas outlets
● Scavenging and suction circuitry

GAS SUPPLY

Gases to the anaesthetic machine are provided through two primary means: piped supply and
cylinders, which have been attached directly to the anaesthetic machine.

PIPED GAS SUPPLY

Piped gases are provided to the anaesthetic machine via a central source in the form of a liquid
tank or a bank of large cylinders, or both. Oxygen originates from a liquid oxygen supply, which
is stored in large vessels known as vacuum insulated evaporators (VIE) that are usually situated
away from the main hospital building. The VIE helps to maintain a temperature of -150 to -170
degree centigrade at a pressure of approximately 10.5 bar [10]. The size of the VIE will depend on
the hospital demand and usually contains enough oxygen for 10 days’ use and is refilled on a
weekly basis.

Nitrous oxide and medical air are provided using a cylinder manifold that usually consists of two
banks of 4-6 size J cylinders. When the available gas in the first bank has been exhausted, the
supply is then automatically transferred to the second bank of reserve cylinders by a pressure-
sensitive control device that links both banks. From these central sources, the gases are
distributed through a network of colour coded pipelines made from high-quality copper to a self-
closing terminal outlet (Schrader valves), which are distinguished by size, shape, and colour. The
Schrader valves ensure that the gas flow is shut off until the appropriate Schrader probe is
inserted. In the operating department, the outlets for oxygen, nitrous oxide, medical air, and
suction are grouped together.

FLEXIBLE PIPELINE HOSES

Flexible pipeline hoses connect the piped supply from the terminal outlets to the anaesthetic
machine. Pressure reducing valves ensure that gases are supplied at a pressure of 4 bar (400 kPa).

4
Each individual gas pipeline hose is colour coded, has a non-interchangeable Schrader probe
made to a specific diameter for each gas, and at the anaesthetic machine end has a fixed gas
specific non-interchangeable screw thread which consists of a nut and probe, a specific diameter
shoulder with O-ring seal, and a specific diameter forward shaft (See Table 1) [10]. Importantly,
these pipelines should only ever be changed by someone certified to do so. The utilisation of a
one-way valve ensures the unidirectional flow of gases between the gas outlets and the
anaesthetic machine. These safety features help to minimise the risk of a hypoxic gas mixture
being mistakenly delivered to a patient.

Table 1 Gas pipeline details

Pipeline Schrader valve colour Hose colour Supply pressure

(UK) (UK)

Oxygen White White 400 kPa

Nitrous oxide Blue Blue 400 kPa

Medical air Black and white Black 400 kPa (anaesthetic

machine) & 700kPa (to
drive surgical
equipment)

Suction Yellow Yellow -53 kPa (-400 mmHg)

CYLINDER GAS SUPPLY

Cylinders provide a backup gas supply in the event of a central gas supply failure or where a
pipeline gas supply is not available. The back of the anaesthetic machine commonly has space to
accommodate two (older machines may have three) size E cylinders. One of these should always
be for oxygen. Each cylinder is made from a lightweight molybdenum steel and contains the
following important details: gas chemical symbol, tare weight, hydraulic test date, a serial number
and are colour-coded by gas contents. Cylinders are produced in several sizes with each denoted

5
a capital letter in ascending order from A to J marked on each cylinder. The tare weight refers to
the empty combined weight of the cylinder and valve for all cylinders. Oxygen and medical air
are stored as a gas whereas nitrous oxide is stored as a liquid and gas. As the nitrous oxide is
withdrawn the number of gaseous molecules decreases and consequently molecules pass from
the liquid to the gaseous phase until an equilibrium is re-established. When all the liquid has been
converted into gas the internal cylinder pressure will begin to fall in a similar manner to an
oxygen cylinder.

CYLINDER SAFETY FEATURES

Cylinders are colour-coded and clearly labelled to identify the correct cylinder more easily and
minimise the risk of attempting to attach the wrong one. The gas specific pin-index system was
introduced in 1952 and ensures that an incorrect cylinder cannot be attached to the anaesthetic
machine [5]. Pins on the yoke of the anaesthetic machine must align with holes on the valve of the
cylinder that conform to British Standard (BS) and equivalent International Standards
Organisation (ISO). Each gas has a unique combination of two numbers between one to six that
correspond to a specific space where the yoke and cylinder can meet (See Table 2). This
significantly reduces the risk of the wrong cylinder being connected to the anaesthetic machine.
There must also be a Bodok seal, which is a compressible neoprene washer with a metal
periphery that separates the cylinder from the yoke to form a gas-tight joint and was first used in
1958 [5,11]. The thread where the valve screws into the neck of the cylinder is sealed with a
material that melts when exposed to intense heat. This reduces the risk of an explosion occurring
during a fire by allowing the gas to escape around the threads of the joint. [Figure 3 here]

Table 2 Gas cylinders details

6
 Gas Physical Colour (UK) Capacity Pin- Pressure
state in (litres) index when full
cylinder

Oxygen Gas Body: black Size E: 2&5 13,700 kPa

Shoulder: 680
white

Nitrous oxide Gas + Body: blue Size E: 3&5 4,400 kPa

liquid Shoulder: 1800
blue

Medical air Gas Body: grey Size E: 1&5 13,700 kPa

Shoulder: 680
white/black

PRESSURE GAUGES

Pressure gauges indicate the pressure of pipelines and cylinders being used and must be present
on all anaesthetic machines. They are commonly found at the front of the anaesthetic machine.
In older machines, Bourdon gauges are used, mainly because they are inexpensive, strong, and
able to withstand high pressures. A bourdon gauge consists of a flexible coiled tube that is
connected to a needle pointer that moves over a dial. The other end of the tube is exposed to the
gas supply and pressure causes the tube to uncoil and a gear mechanism to move the calibrated
dial indicating the pressure. However, on newer machines pressures may be indicated by a digital
display figure.

PRESSURE REGULATORS

Cylinders supply gases at a variable and much higher pressure than what would be safe to deliver
to the patient. Primary pressure regulators reduce the cylinder pressure from 13,700 kPa to an
operating pressure of less than 420 kPa [1]. These pressures are much more consistent with the
pipeline-supplied gases, which are typically around 400 kPa. Secondary pressure regulators

7
reduce the gas supply to a much lower and uniform pressure that can be delivered safely to the
patient through a breathing circuit. The pressure that can be safely delivered to the patient
should not exceed 3 kPa [12]. These much lower pressures are measured in cm H2O instead of
kPa.

FLOWMETERS

Flowmeters (or rotameters) measure the flow of gas passing through them, commonly oxygen,
nitrous oxide, and air. They are made up of a needle valve that is situated at the base of the
relevant flowmeter tube (valve seat). Each anaesthetic gas uses two flowmeter tubes which are
controlled by a single needle valve. The smaller tube measures gas flow up to 1 L/min and the
larger one measures gas flow up to 15 L/min. Each flowmeter tube is a tapered (wider at the
top) transparent plastic or glass tube with a lightweight rotating bobbin (or ball) inside it,
controlled by a spindle. The bobbin is always visible as it stops at either end of the tube and gas
flow is indicated by it spinning. The flow rate should be measured from the top of the bobbin
(midpoint for a ball). The rotation of the bobbin is facilitated by slits made in the rim which as
gas flows past it causes the bobbin to rotate freely; providing the tubes are mounted
appropriately and that no dirt is present. A dot on the bobbin indicates to the user that the
bobbin is rotating and that a gas flow is present. The height of the bobbin is maintained by the
delicate balance between gravity, which acts to force the bobbin down, and the gas flow which
acts to push the bobbin up the tube [11].

Each flowmeter tube is calibrated for a specific gas because medical gases have varying densities
and viscosities. Calibration takes place at room temperature (20 degrees C) and atmospheric
pressure (101 kPa) and is accurate to about +/-2.5% [13]. Tubes are considered leak proof, using a
neoprene washer at either end and have an outer and inner antistatic coating to reduce the build-
up of an electrostatic charge, which can affect accuracy by up to 35%. Oxygen is added last to the
gas mixture delivered to the back bar in case of damage to the flowmeter, reducing the risk of
creating a hypoxic gas mixture. Some machines also provide a basal flow of oxygen (between
100-300 mL/min) that ensures that oxygen flow cannot be completely discontinued, although
the amount varies between manufacturers [14]. Flowmeters and the control spindles that control
them are colour-coded and labelled clearly to indicate each gas. In the UK, the oxygen spindle is
situated on the far left and is commonly larger with a ridge to make it more distinguishable.

8
Some newer electronic anaesthetic machines no longer use conventional rotameters; instead, the
fresh gas flow is entirely controlled by a microprocessor. On the Dräger Primus for example, the
fresh gas flow is mixed and controlled by electronically controlled valves. They function
according to the intended total gas flow and oxygen concentration set by the user. The user
chooses the fraction of inspired oxygen (FiO2) and then selects which secondary carrier gas
(either nitrous oxide or air) to use [12]. A type of digital rotameter on the display indicates the
fresh gas flow and it is likely that this will become the predominant gas mixing system used in all
new anaesthetic machines. The digital displays on newer machines are frequently illuminated
which allows them to be more easily identified in a setting that may require low lighting. In the
event of a system failure, gas can still be delivered into the circuit by utilising the oxygen safety
control (delivering 0-12 L/min) which delivers gas via the vaporiser. The downside to using
electronically controlled systems are that they require mains or battery power to function,
something that conventional systems do not require.

BACKBAR AND VAPORISERS

The back bar describes a horizontal section of the anaesthetic machine where the vaporisers can
be mounted. The fresh gas flow (oxygen, air or nitrous oxide and inhalational agent) is mixed
and transported from the back bar to the common gas outlet by which point the pressure has
been reduced so that it can be safely delivered to the patient [10]. Most anaesthetic machines have
the capacity to house at least two vaporisers. They are seated and can be secured using an
interlocking system (e.g. selectatec) which prevents more than one vaporiser being switched on
at a time and avoids inadvertently administering more than one inhalational agent. It also ensures
that fresh gas flow can only enter the vaporiser when it has been locked in place and turned on.
When two vaporisers are mounted on the back bar and one is switched on, a small pin protrudes
out towards the other vaporiser, preventing it from being switched on. Each vaporiser sits on a
valve-post with a changeable rubber O-ring that creates a gas tight seal. A damaged O-ring
should be replaced, as this can become the source of a leak. Also situated on the back bar or
further downstream is a non-return pressure relief valve which opens when pressure in the back
bar exceeds 35 kPa [11]. This prevents excess pressure in the back bar damaging the flowmeters
and the vaporisers. Other safety features are an anti-spill mechanism that prevents the wrong
agent being introduced into an inappropriate vaporiser and a clear indicator of how filled the
vaporiser is. Additionally, each specific vaporiser is colour-coded to indicate which volatile agent
they contain.

9
 ● Sevoflurane: Yellow
● Isoflurane: Purple
● Desflurane: Blue

The purpose of the vaporiser is to accurately deliver the desired concentration of a volatile
inhalational agent. Inhalational agents such as sevoflurane, desflurane and isoflurane are supplied
and stored as liquids. The vaporisers convert the volatile agent from a liquid to a gas, which can
be administered to the patient. Each vaporiser is calibrated for use with a specific volatile agent.
A vaporiser must be appropriately locked in place on the back bar and turned on (additionally, a
desflurane vaporiser must be plugged in) before the fresh gas flow can enter. Most modern
vaporisers divide the fresh gas flow into two different streams. The larger stream bypasses the
vaporiser and is unaffected, whilst the smaller stream passes through the vaporiser chamber
where it becomes saturated with the volatile agent. By changing the dial on the vaporiser, the
ratio of fresh gas flow divided into each stream is modified. Increasing the selected percentage of
volatile agent will cause an increase in fresh gas flow to pass through the vaporising chamber.

Desflurane has a unique physical composition that makes using a variable bypass vaporiser
unsuitable and so there is no need to split the incoming fresh gas flow. This is because desflurane
has a boiling point close to room temperature (23.5°C) which means the output of the volatile
agent would fluctuate depending on the room temperature [15]. The specialised pressurised
vaporiser therefore heats the desflurane to 39°C, which becomes a vapour; this ensures that the
fresh gas flow can be sufficiently saturated. The desflurane vapour is then added to the fresh gas
flow and controlled by an electronic pressure regulator, sensors, and a variable flow restrictor [2].
[Figure 4 here]

COMMON GAS OUTLET

The common gas outlet is situated towards the front of the anaesthetic machine and has a 22
mm male (external) and 15 mm female (external) tapered outlet and supplies the fresh gas flow
to the patient via a breathing circuit. Some anaesthetic machines also include an auxiliary
common gas outlet which allows the fresh gas flow to be redirected for use of a Jackson-Rees
modification of Ayre's T-Piece (Mapleson F) or for supplemental oxygen. Connecting the patient

10
to the incorrect breathing circuit or choosing the wrong gas outlet will result in no gas flow being
delivered to the patient, leading to hypoxia. In electronically controlled machines, errors can
occur when the correct circuit is not confirmed, or the wrong breathing circuit is selected on the
user interface.

CIRCLE BREATHING SYSTEM AND VENTILATOR

Modern anaesthetic machines utilise a closed circle breathing system that consists of a fresh gas
supply, two unidirectional one-way valves (inspiratory and expiratory), reservoir bag, a carbon
dioxide absorber, adjustable pressure limiting (APL) valve and a y-piece for connection to the
patient [16]. Removal of carbon dioxide allows the inhalational agents and anaesthetic gases to be
recycled. Soda lime is the substance used to absorb the patients exhaled carbon dioxide and is
stored in a canister and mounted vertically to the anaesthetic machine. Soda lime contains
approximately 80% calcium hydroxide, 4% sodium hydroxide, 1% potassium hydroxide, and the
remainder is water. Ventilators are an integral part of the modern anaesthetic machine and
provide the means for an extended period of ventilation of the anaesthetised patient. They can
be mechanically, pneumatically, or electronically controlled, with newer ventilators comparable to
those used in intensive care. Many of the newer ventilators incorporate technology that facilitates
more precise delivery of smaller tidal volumes required for neonatal and infants. Breathing
systems are discussed in detail in chapter X.

EMERGENCY OXYGEN FLUSH

Because of the high pressures produced by the emergency oxygen flush it has been designed to
only be activated by a non-locking button which incorporates a self-closing valve to avoid
accidental operation [11]. High flow oxygen upward of 35L/min is generated at pressures of up to
400 kPa. Because the emergency oxygen flush bypasses the flowmeter and vaporiser the gas flow
only contains oxygen. It is sometimes used to inflate the breathing circuit reservoir bag after a
leak and must always be used cautiously; incorrect use could cause barotrauma. Similarly, because
the oxygen flush bypasses the vaporiser there is an inherent risk that using it will dilute the
inhalational agents and may increase the risk of patient awareness [17].

OXYGEN FAILURE WARNING DEVICE

11
An early oxygen failure warning system was the Ritchie whistle which was introduced in the mid-
1960’s and was powered by the falling oxygen pressures in the system. Modern anaesthetic
machines must have a built-in oxygen failure device that is situated upstream of the rotameter
block. It is activated when oxygen pressure falls below 200kPa which instigates an audible alarm
> 60 db at a distance of 1 metre and will only stop when sufficient oxygen pressure has been
restored [18]. When the oxygen supply pressure falls below 137 kPa the delivery of any other gases
will be halted so that only oxygen can be delivered. The oxygen supply failure alarm is designed
to remain operational even in the absence of battery or mains power supplies.

PREVENTION OF HYPOXIC GAS DELIVERY

● Pin index system, non-interchangeable screw thread connections, colour-coded

and labelled cylinders, and colour-coded pipelines.
● Colour-coded Schrader valves which are size specific for each gas.
● Colour-coded and non-kinkable pipeline hoses with gas specific Schrader probes.
● Oxygen supply failure alarm is activated when the oxygen supply pressure falls
below 200 kPa (some older machines may still feature the pneumatic Ritchie whistle).
● Two means of supplying oxygen: pipelines and cylinders (a manual means of
oxygen delivery such as a bag valve mask should also be available on every machine).
● Oxygen analyser.
● Hypoxic guard or Link-25 system that does not allow the user to deliver oxygen
less than 25% of the total gas mix. For every 2.07 revolutions of the nitrous oxide
flow control spindle, the oxygen at the lowest oxygen flow, rotates once.
● Oxygen is the last gas added to the fresh gas flow.
● Oxygen pressure gauge (Bourdon gauge or digital indicated during an automated
self-check).
● Colour-coded flowmeters, uniquely sized oxygen control spindle which is always
situated on the left in the UK.

ADJUSTABLE PRESSURE LIMITING VALVE

The purpose of the APL valve is to enable the escape of exhaled or excess gases from the
breathing system when a pre-set pressure has been exceeded [Figure 5 here]. This helps reduce
the risk of causing barotrauma to the patient. It is also used to adjust the circuit pressure during

12
spontaneous ventilation or manual ventilation with the reservoir bag [2]. The APL valve is a one-
way spring-loaded valve that can adjust the pressure required to open the valve. During
spontaneous ventilation, the patient will generate positive pressure during expiration and
therefore resistance to expiration should be minimal. When the dial is fully open, positive
pressure from expiration causes the valve to open under a pressure of less than 1 cm H2O (0.1
kPa). Screwing down the dial on the APL valve increases tension in the spring and the pressure
required to open the valve during manual ventilation. In some modern machines, the APL valve
is electronically adjustable and calibrated. When the dial is fully closed it will release excess
pressure at 60 cm H2O (6 kPa)—this pressure occurs at a gas flow rate of 30 L/min [1].

SCAVENGING SYSTEMS

Scavenging describes the removal of expired waste anaesthetic gases and ensures that it does not
vent into the operating theatre environment. Exposure to nitrous oxide and inhalational agents
can have adverse effects on staff and are therefore considered hazardous substances which must
be safely and effectively disposed of. Exposure to hazardous waste gases most commonly occurs
from leaks around ill-fitting facemask or supraglottic airway device, spillage during the refilling of
a vaporiser, expired gas exhaled from the patient following emergence from anaesthesia, and
from open-ended breathing circuits [19]. The volume of waste gases can be minimised by using
low-flow anaesthesia and taking additional care when refilling vaporisers. An unscavenged
operating theatre can show nitrous oxide levels up to 3000 particles per million (ppm) compared
with the recommended maximum accepted concentration of a 100 ppm (in the UK) time-
weighted average over an 8-hour period [11].

Waste gases are commonly removed through two types of system: passive or active. Passive
systems remove waste gases by relying on the expiratory effort of the patient to force it through
additional tubing out into the atmosphere. The risks of this system are that the outflow of waste
gases can become obstructed which can generate negative pressure or high positive pressures in
the tubing. These effects can be mitigated by using pressure relief valves within the system.
Passive systems offer less protection to theatre staff and are considerably less efficient than
active systems.

The active gas scavenging system (AGSS) is either connected to the outlet for the APL valve or
directly to the circle system. AGSS generates negative-pressure suction to remove waste

13
anaesthetic gases towards a reservoir, which is then propelled into the outside atmosphere.
However, the system is powered, it must be able to accommodate 75 L/minute of constant flow
and be able to function at a peak rate of 135 L/min. The use of a pressure-limiting device within
the system ensures that excess negative pressure is not generated, which could interfere with
patient ventilation [16]. Scavenging systems utilise a conical 30 mm connector to minimise the risk
of it being incorrectly connected to a breathing circuit. Some systems will have a visual indicator
situated on the back or to the side of the anaesthetic machine to check the scavenging is
functioning optimally. Irrespective of the system used, it is vital that the tubing is never occluded
when attached to the patient as this could produce increased resistance to patient expiration.

Waste anaesthetic gases—especially desflurane and nitrous oxide—are also potent greenhouse
gases and new technology is being developed to reduce their impact on the environment. New
scavenging devices aim to limit their release into the atmosphere by capturing, reusing, or
destroying the gases, although there are still several unanswered questions regarding the
feasibility of such technologies [20].

SUCTION APPARATUS

Effective high-pressure suction should be available in some capacity—commonly it is attached to

the anaesthetic machine. Suction is used to clear mucus, blood and debris from the pharynx and
trachea and should be able to maintain a negative pressure of at least -400 mmHg at the outlet.
The negative pressure vacuum can be manually adjusted depending on the needs of the patient
and incorrect use can cause trauma. Safely functioning suction should always be available and
tested before anaesthetising any patient. Suction apparatus consists of a vacuum source, suction
unit, suction tubing and a yankauer suction tip or catheter. The suction unit consists of a
reservoir container, vacuum control regulator and a vacuum gauge. The suction unit utilises a
hydrophobic bacterial filter that removes 99.999% of bacteria and prevents fluid and smoke
from contaminating the medical vacuum system.

WHY IT IS IMPORTANT TO KNOW HOW TO CHECK AN ANAESTHETIC

MACHINE

Failure to perform an appropriate anaesthetic machine check can lead to serious patient harm.
An inappropriate check or unfamiliarity with the anaesthetic machine, ventilator, vaporisers or

14
breathing circuit can compromise patient safety. In some cases, leading to hypoxic brain injury,
awareness under general anaesthesia, cardiac arrest, and death. Causes of harm are multifactorial
and commonly arise from human error, lack of knowledge and a technical fault [21]. In most
cases, adverse outcomes can be prevented by performing an appropriate check of the anaesthetic
machine [22].

CHECKING THE ANAESTHETIC MACHINE

It is essential that users ensure that all the mandatory manual and automated checks (where
required) are performed prior to use. Checks should be in accordance with the most recent
Association of Anaesthetists of Great Britain and Ireland (AAGBI) guidance [23]. In the case of
ventilator failure, an alternative means of ventilating a patient should always be readily available,
such as a self-inflating bag. Although an operating department practitioner or nurse often
performs the routine checks, it remains the final responsibility of the end user (e.g. anaesthetist
or anaesthesia associate) to ensure that the anaesthetic machine is safe.

REFERENCES
1. C. Sinclair, M. Thadsad and I. Barker. Modern anaesthetic machines. Continuing Education
in Anaesthesia Critical Care & Pain 2006; 6 (2): 75-78.
2. G. Briggs and J. Maycock. The anaesthetic machine. Anaesthesia & Intensive Care Medicine
2013; 14 (3): 94-98.
3. F. Rosewarne. The Anaesthetic Machine. In: Harley I., Hore, P., eds. Anaesthesia: An
Introduction. 5th ed. East Hawthorn, IP Communications, 2012; 329-336.
4. S. J. Snow. Blessed Days of Anaesthesia: How anaesthetics changed the world. Oxford, Oxford
University Press, 2008.
5. O. M. Watt. The evolution of the Boyle apparatus, 1917-67. Anaesthesia 1968; 23 (1): 103-
118.
6. V.P Patil, M. G. Shetmahajan and J. V. Divatia. The Modern Integrated Anaesthesia
Workstation. Indian Journal of Anaesthesia 2013; 57 (5): 446-454.
7. C. L. Gurudatt. The Basic Anaesthesia Machine. Indian Journal of Anaesthesia 2013; 57 (5):
438-445.
8. J. M. Feldman. The Anesthesia Ventilator. Lübeck, Germany, Dräger. 2015.
https://www.draeger.com/Library/Content/9049447_the_anesthesia_ventilator_8seitig
_en_101209_fin.pdf (Accessed October 1, 2019.)

15
9. P. J. Simpson and M. Popat. Understanding Anaesthesia. 4th ed. London, Elsevier, 2006.
10. B. Al-Shaikh and S. G. Stacey. Essentials of Equipment in Anaesthesia, Critical Care and
Perioperative Medicine. 5th ed. London, Elsevier, 2018.
11. N. Robinson, G. Hall and W. Fawcett. How to Survive in Anaesthesia. 5th ed. Cambridge,
Cambridge University Press, 2017.
12. P. Greig and N. Crabtree. Introducing Anaesthesia: A curriculum-based guide. Oxford, Oxford
University Press, 2014.
13. A. Diba. The anaesthetic workstation. In: Davey A. J., Diba A., eds. Ward’s Anaesthetic
Equipment. 6th ed. London, Saunders, 2012; 65-105.
14. A. P. J. Lake. Basal oxygen flow, Anaesthesia 2001; 56 (11): 1120-1121.
15. M. C. Kapoor and M. Vakamudi. Desflurane – Revisited. Journal of Anaesthesiology Clinical
Pharmacology 2012; 28 (1): 92-100.
16. J. Roberts and L. Darwin. Anaesthetic breathing systems. In: Cottle D., Laha, S., eds.
Anaesthetics for Junior Doctors and Allied Professionals: The Essential Guide. London, Radcliffe
Publishing, 2013; 39-45.
17. A. Crosby and S. Laha. The anaesthetic machine. In: Cottle, D., Laha, S., eds. Anaesthetics
for Junior Doctors and Allied Professionals: The Essential Guide. London, Radcliffe Publishing,
2013; 32-38.
18. E.S. Lin. Anaesthetic Equipment. In: Smith, T., Pinnock, C. and Lin, T., eds.
Fundamentals of Anaesthesia. 3rd ed. Cambridge, Cambridge University Press, 2009; 828-863.
19. M. C. Mushambi and S. Francis. Anaesthetic Apparatus. In: Aitkenhead A.R., Moppett
IK., Thompson JP., eds. Smith and Aitkenhead's Textbook of Anaesthesia. 6th ed. London,
Elsevier, 2013; 262-311.
20. M. Charlesworth and F. Swinton. Anaesthetic gases, climate change, and sustainable
practice. Lancet Planet Health 2017; 1: e216-7.
21. J. L. Bourgain, Y. Coisel, D. Kern, et al. What are the main “machine dysfunctions” to
know? Annales Françaises d'Anesthésie et de Réanimation 2014; 33 (7-8): 466–71.
22. S. P. Mehta, J. B. Eisenkraft, K. L. Posner, et al. Patient Injuries from Anesthesia Gas
Delivery Equipment: A Closed Claims Update. Anesthesiology 2013; 119 (4): 788-795.
23. Association of Anaesthetists of Great Britain and Ireland Guidelines:
Checking Anaesthetic Equipment. 2012.
https://www.aagbi.org/sites/default/files/checking_anaesthetic_equipment_2012.pdf
(Accessed October 1, 2019.)

16
Figures 1-5:
- Figure 1 Caption: Machines such as the Dräger Primus incorporate an automated self-check
function.
High resolution image provided in additional file.
- Figure 2 Caption: Basic components of an anaesthetic machine
This image was previously published in Fundamentals of Anaesthesia, edited by Tim Smith,
Colin Pinnock and Ted Lin, 3rd Edition, 2009. Cambridge University Press, p. 834, figure EQ7.
- Figure 3 Caption: Pin index system for gases and detail of the cylinder head.
This image was previously published in Fundamentals of Anaesthesia, edited by Tim Smith,
Colin Pinnock and Ted Lin, 3rd Edition, 2009. Cambridge University Press, p. 831, figure EQ4.
- Figure 4 Caption: Desflurane and Sevoflurane vaporisers
High resolution image provided in additional file.
- Figure 5 Caption: Adjustable pressure-limiting expiratory valve
This image was previously published in Fundamentals of Anaesthesia, edited by Tim Smith,
Colin Pinnock and Ted Lin, 3rd Edition, 2009. Cambridge University Press, p.843, figure EQ19.

17
 18

View publication stats