Low Flow Anesthesia

Pembimbing :
Herdy Sulistyono, dr., Sp.An., KIC., PGD. Pall. Med. (ECU) KMN
 1 Circle System

Low Flow
OUTLINE 2 Anesthesia

3 Case Report
Cyrcle
System
Circle System (simplified)
Low Flow Anesthesia
A Few Definitions
• Low Flow Anesthesia (LFA) has been variously
defined as an inhalation technique in which a circle
system with absorbent is used with a fresh gas
inflow
• Closed System Anesthesia is a form of LFA in which
the fresh gas flow = uptake of anaesthetic gases
and oxygen by the patient and gas sampling. No gas
is vented by the APL valve

Dorsch and Dorsch. Understanding Anesthesia Equipment 5th ed. 2008

Circle System (simplified)
Fresh Gas Flow Category
(Baker,1994)

Medium Flow
• 1-2 L/min
Low Flow
• 500-1000 ml/min
Minimal Flow
• 250-500 ml/min
Metabolic Flow
• 250 ml/min
Patient Uptake During Anesthesia
Oxygen uptake (Brody’s Formula)
 correspond to approximately the basal metabolic
rate
Nitrous Oxide uptake (Severinghaus Formula)
 High in initial minutes of anesthesia, but the
intake become slower as the duration of anaesthesia
increased
Inhalation Anesthetic agent uptake (Lowe’s Formula)
 Decreased during anaesthesia as a function of
tissue saturation
Total gas uptake for O2, N2O and isoflurane on 75 kg
adult patient
Low Flow Anesthesia
Ecologycal

Advantages
Economical

Physiological
1. Physiological
• Preserves heat and humidity

• Increases mucociliary clearance

• Improves airway epithelial health
2. Economical
• Reduced anaesthetic gas consumption
• Significant savings of the order of 60%-75% with
regard to volatile anaesthetic agents
3. Ecological & Environmental
• Reduce overflow of fluorocarbons and nitrous oxide
which damage the earth’s ozone layer
• Reduce greenhouse effect due to nitrous oxide and
volatile agents
• Reduced operating room pollution
• During average working day, administering N2O or
desflurane can contribute the CO2 ~ more than
1000 km of car driving
 Requirements for the use of Low
– Flow Technique
1. Flow meters calibrated to flows
down to 50 ml/min
2. A leak-proof circle breathing system
and airway devices like cuffed ETT
3. Gas Monitoring system providing
inspired and end-tidal concentration
of agents
4. Vapourisers capable of delivering
high concentrations and calibrated
to be accurate at low flow
Settings that aren’t suitable for
LFA techniques
1. Anaesthesiologist not familiar with LFA
2. Short-term anaesthesia with a face mask
3. Procedures with imperfectly gas tight airways
(i.e.. Bronchoscopies with a rigid bronchoscope)
4. Inadequate monitoring
5. Situations when other clinical issues like
haemodynamic instability and patients require
high fresh gas flow
Concerns while using LFA
• Dilution of anaesthetic agents : Low fresh gas flows
are added to significantly large reserve volume (+ 9-
10 litres), requires 3 times constants to effect 95%
change in gas composition to occur
• Ensuring enough oxygen for metabolism
• Delay in recovery from anaesthesia
Disadvantages of Low Flow Anesthesia

• Slower induction and emergence

• Continuous vigilance and frequent flow
adjustments are required to avoid hypoxic mixtures
• Higher consumption of CO2 absorbents and risk of
hypercarbia
• Possible accumulation of undesirable trace gases in
the system (CO, acetone, methane, hydrogen,
ethanol)
Delivery of LFA
• Premedication, pre-oxygenation and induction of
sleep are performed according to the usual practice
• The possible gases combinations are:
• O2 + N2O + volatile anesthetic
• O2 + Air + volatile anesthetic
• O2 + volatile anesthetic
Delivery of LFA (…cont)
Concerning adjustment of Fresh Gas Flow anesthesia
can be divided into 3 phases :

Initial Termination
High Maintenance &
Flow Low Flow Recovery
1. Initial High Flow Phase
• Sufficient denitrogenization
• Wash in of the wanted nitrous oxide in the
anesthetic gas of the circle system
• Establishing the wanted concentration of the
volatile anesthetic
• Stabilizing the anesthesia circuit system
2. Maintenance of Low-flow
Anesthesia
• Maintain steady-state concentration of the
anaesthetic agents
• Oxygen uptake remain constant at 200-250 ml/min,
but uptake of N2O will be minimal  maintain O2
concentration of at least 30% at all time
• Note : actual dial setting in the vapourisers often
over-estimates under delivers agent at low flows 
use agent analyser or haemodynamic stability
3. Termination of low-flow
anesthesia (Recovery Phase)
• Long-time constant  recovery is delayed
• Switch to high flow to accelerate the wash-out of
anaesthetic agents
• Nitrous oxide get washed off while changing over to
100% oxygen
Automated low-flow anaesthesia
Summary
• The safety features of anaesthetic machines and
the availability of accurate gas monitoring is very
important
• We can’t use low flow anaesthesia technique in all
patients
• Anaesthesiologist should take up LFA as their
professional obligation to the present and future
generations on the planet earth
Case Report
Identitas Pasien
• Nama : Ny. I
• Tanggal Lahir / usia : 19 Maret 1972 / 47 tahun
• Berat Badan / tinggi badan: 54 kg / 155 cm
• Diagnosis : Tumor Mammae Dextra
• Tindakan pembedahan : eksisi tumor mammae
Dextra
• Tanggal Operasi : 21 Mei 2019
Anamnesis
Keluhan Utama :
Benjolan di payudara kanan sejak 6 bulan yang lalu.
Benjolan tidak dapat digerakkan namun tidak terasa
nyeri. Riwayat penurunan berat badan disangkal

Alergi:
Obat golongan “gin”, manifestasi : mata bengkak
Anamnesis (…lanjutan)
Medikasi :
Pasien tidak sedang mengkonsumsi obat – obatan
rutin, riwayat kemoterapi disangkal
Obat – obatan preoperatif : (diberikan jam 06.00 di
ruangan)
• Esomerazole 40 mg
• Granisetron 3 mg
• Estazolam 2 mg
Anamnesis (…lanjutan)
Riwayat Penyakit Dahulu :
Riwayat tumor mammae Dextra 2 tahun yang lalu 
eksisi tumor
Riwayat operasi Sectio Caesarea tahun 2003 dan 2008,
anestesi dengan regional
Riwayat penyakit asma, hipertensi, penyakit jantung
koroner, penyakit ginjal disangkal
Puasa :
makan terakhir jam 24.00 dan minum air putih terakhir
jam 04.00
 Pemeriksaan
Fisik A: Bebas
Sistem
Respirasi B : Spontan , RR 16x/ menit, SpO2 96% dengan udara bebas,
suara nafas vesikuler (+), Rhonchi ( - ), Wheezing ( - )
Sistem Perfusi hangat, nadi 84 x menit reguler,
Kardio Tekanan Darah 117/75 mmHg; S1 S2 tunggal regular, murmur
vaskular (-), gallop (-),
Kesadaran compos mentis, Pupil bulat isokor 3/3 mm, refleks
Sistem CNS cahaya +/+
Sistem Buang air kecil spontan
Urogenital
Sistem Abdomen supel, bising usus ( + )
Digestif
Sistem Edema ekstremitas negative, temp 36.8oC
Muskulo
skeletal

35
 Laboratorium

20/5/2019

Hb 11,4 BUN 6,3 SGOT 16,2

Hct 35,5 SK 0,37 SGPT 11,2

Wbc 5,4 HbsAg reaktif PPT 13,8

Plt 293000 APTT 37,2

36
Diagnosis dan ASA Score
Diagnosis :
Tumor Mammae Dextra

ASA score : 2
- Alergi obat
- HbsAg reaktif
Prosedur Anestesi
Premedikasi
• Midazolam 2mg IV
Induksi
• Fentanyl 100 mcg
• Propofol 70 mg
• Vecuronium 6mg
Prosedur Anestesi (…lanjutan)
• Preoksigenasi dengan O2 100%, Intubasi dengan
ETT 7,0 dengan cuff, batas bibir 19 cm, suara nafas
simetris kanan dan kiri
• Dial Desflurane dibuka hingga konsentrasi
Desflurane mencapai 4 Vol%
• N2O dinyalakan sehingga tercapai fiO2 50%, flow O2
diatur 0,5 ml/menit dan flow N2O diatur 0,5
ml/menit
• Desflurane dipertahankan pada 4 Vol.%
Mode Ventilator : IMV, Pmax
25, PEEP 5, TV 360 ml,
Plateau 10%, I:E 1:2, freq :
15 bpm
fiO2 47%
Desflurane 4 vol.%
Hemodinamik Durante
Operasi (operasi 08.00 – Balans Cairan Durante
10.00) operasi

• Tekanan darah sistolik : • Input : Kristaloid 300 ml

100-130 mmHg • Output : darah 50 ml
• Tekanan darah diastolik
: 60-80 mmHg
• Nadi : 58-85
• SpO2 : 98-100%
Prosedur Anestesi (…lanjutan)
• Saat operasi akan selesai (saat menjahit kulit) N2O
dimatikan
• Air dinyalakan, flow 0,5 lpm
• Mengubah mode ventilator ke spontan, mencari
nafas spontan pasien dan dilakukan support
• Bila operasi selesai dan nafas spontan adekuat,
Desflurane dimatikan
• Beri high flow untuk menguras Desflurane dan N2O
Hemodinamik di Ruang Recovery
Sistem A: Bebas
Respirasi B : Spontan , RR 16x/ menit, SpO2 98% dengan udara bebas,
suara nafas vesikuler (+), Rhonchi ( - ), Wheezing ( - )
Sistem Perfusi hangat, nadi 68 x menit reguler,
Kardio Tekanan Darah 110/70 mmHg; S1 S2 tunggal regular
vaskular
Kesadaran compos mentis, Pupil bulat isokor 3/3 mm, refleks
Sistem CNS cahaya +/+
Sistem Buang air kecil spontan
Urogenital
Sistem Abdomen supel, bising usus ( + )
Digestif
Sistem Edema ekstremitas negative, temp 36.8oC
Muskulo
skeletal

46
Terapi Post Operatif
• Granisetron 3 mg IV tiap 12 jam
• Paracetamol 1 gram IV tiap 8 jam
Perhitungan Biaya Gas Anestesi
Desflurane = Fresh Gas Flow x lama operasi (menit) x dial
208
(Desflurane : Rp. 4.505.600 / 240 mL)

Isoflurane = Fresh Gas Flow x lama operasi (menit) x dial

183

(Isoflurane : Rp. 2.057.344 / 250 mL)

Oksigen : Rp 40,- / liter

Nitrogen : Rp 700,- / liter

Thank You
Desflurane
DESFLURAN
BIOTRANS- DRUG
PHYSICAL PROPERTIES TOXICITY CONTRAINDICATION
FORMATION INTERACTION
Tasks
› Struktur sangat mirip
dengan isofluran
Management
Objectives

Schedules

Customer
Objectives

Resources

05/26/2020 50
 DESFLURAN
BIOTRANS- DRUG
PHYSICAL PROPERTIES TOXICITY CONTRAINDICATION
FORMATION INTERACTION
› Struktur sangat mirip › Minimal metabolisme › Di degradasi pada › Hipovolemia berat › Potensiasi NMBA
dengan isofluran pada manusia desiccated CO2 › Hipertermi malignan Tasksnondepol
› Vapor pressure pada › Perubahan kadar absorbent (biasanya › Epinefrin dapat
› Hipertensi intrakranial
200C = 681 mmHg,Management
pada fluroda inorganik pada barium hydroxide lime, digunakan sampai dosis
high altitudes  Objectives serum dan urin jarang tapi pada sodium dan 4.5 mcg/kg (karna tidak
mendidih pada suhu terjadi potassium hydroxide sensitisasi miokardium
ruangan › Insignificant juga) into potentially terhadap efek
› Low solubility  very clinically important level aritmogenik epinefrin)
percutaneous loss
of CO
rapid induction
› Keracunan CO sulit Schedules
› FA mencapai FI much
didiagnosa saat GA, tapi
more RAPIDLY than with dapat dilihat dari
other volatile agents adanya
› Wakeup times are carboxyhemoglobin
Customer
approximately 50% less pada AGD atau lower
than those observed Objectives than expected pulse
following isoflurane* oximetry reading
› High vapor pressure, Resources
ultrashort duration of
action, moderate
potency

51
 EFFECTS ON ORGAN SYSTEMS
Cerebral:
Respiratory: • Vasodilatasi pembuluh darah cerebral  CBF dan volume darah
• RR  (takipneu) otak   TIK  pada normotensi dan normokapnia
• Tidal volume  • Untuk melawan penurunan resistensi vaskular cerebral ditandai
• Turunkan ventilasi alveolar   resting PaCO2 dengan CMRO2   cenderung menyebabkan vasokontriksi
• Iritasi saat induksi desfluran dapat berupa: salivasi, cerebral
breath-holding, batuk, dan laringospasme • Vaskularisasi cerebral tetap responsif pada perubahan Pa CO2,
• Resistensi airway dapat meningkat pada anak-anak
sehingga TIK dapat diturunkan dengan hiperventilasi
dengan suspek reaktif airway  maka bukan • Konsumsi oksigen cerebral 
pilihan untuk induksi • Saat periode desflurane-induced hypotension (MAP = 60 mmHg)
CBF tetap adekuat untuk mempertahankan metabolisme
Hepatic: aerobik walaupun dengan tekanan perfusi cerebral yang rendah
•Tidak berpengaruh pada hepar
•Metabolisme minimal  risiko anesthetic-
induced hepatitis minimal Cardiovascular:
• Konsentrasi   SVR   TD arteri 
Renal: • Cardiac output tidak berubah atau sedikit  pada 1-2
Cardiac output   Aliran darah renal  MAC
 • HR, CVP, Tekanan Arteri Pulmonal sedikit  (tidak pada
GFR dan Urine Output low dose)
• Peningkatan desflurane secara cepat  elevasi
Tidak ada bukti nefrotoksik transient (bisa serius) HR, TD, katekolamin  dapat
diturunkan dengan pemberian fentanil, esmolol,
klonidin
Neuromuscular:
Dose-dependent decrease sebagai respon train-of- 52
four dan stimulasi saraf perifer tetanik