Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham...

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Clinical Conference Anesthesia Machines don’t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002, James H Philip, all rights reserved

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Transcript of Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham...

Page 1: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Clinical Conference Anesthesia Machines don’t fail,

do they?

James H. Philip M(E)E, MD

Brigham and Women’s Hospital

October 30, 2002

© Copyright 2002, James H Philip, all rights reserved

Page 2: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Ready

Page 3: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Clinical Conference – Anesthesia Machines don’t fail, do they?

Page 4: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Case 1

57 yo F for Laparoscopy

PMHHypertension on Atenalol, GERD successfully Tx’s w Prilosec, Mild COPD.Otherwise healthy

5’2” 165# + COPD

Elect GETA

Plan Propofol, Succinylcholine, Tube, Desflurane, Vecuronium if necessary

Page 5: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Preparation

Resident starts IV

I check the Anesthesia Machine

Desflurane vaporizer is missing

I page Anes Tech

Tech and Vaporizer arrive

He attaches vaporizer

Page 6: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,
Page 7: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

What do I do next?

I have added a vaporizer

Page 8: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Negative Pressure Leak Test

Where do I find the bulb?

Page 9: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Bottom Drawer of Anesthesia Machine

Page 10: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Is there anything wrong here?

Page 11: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Cable does better here

Page 12: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Negative Pressure Leak Test

OK

Page 13: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

And, the Exclusion Interlock now works.

Page 14: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Remainder of Check out

What am I doing here?

What is my FGF set to?

What pressure am I trying to hold?

What pressure do I not want to exceed?

How big can the bag get?

Page 15: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

250 Liters

Page 16: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Pressure = 30 cmH2O

Page 17: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Actually find minor leak

Page 18: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Tighten Expiratory Valve Cover

Page 19: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Resident brings patient to OR

Apply Monitors,

Apply Bair Hugger

Prepare to denitrogenate

Page 20: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

What Fresh Gas Flow?

Page 21: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

What Fresh Gas Flow?Oxygen onlyFIO2 > 80Flow keeps bag mostly full

Page 22: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Apply mask

Page 23: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Denitrogenate

Mask - Tight or Loose?

FGF - High or Low?

Pop-off valve - Open or Closed?

Selector Switch - Bag or Vent?

Page 24: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Select Bag, Pop off open

Page 25: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Patient feels smothered. Why?

Page 26: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Patient feels smothered. Why?

Airway pressure

What does it mean?

Page 27: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Select Bag, Pop off open

Page 28: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

What is good about the bellows?

What is bad about the bellows?

Page 29: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

What is good about the bellows?

Low opening pressure

Page 30: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

What is good about the bellows?

What is bad about the bellows?Low opening pressure

Tachycardia and Hypertension

Page 31: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

What is good about the bellows?

What is bad about the bellows?Low opening pressure

Tachycardia and HypertensionIn the anesthesiologist

Who feels total obstruction

Page 32: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Select Bag, Pop off open

Smothered again!

Page 33: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

What can I do?

Remove Reservoir Bag

Page 34: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

IV Induction

Page 35: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Difficult to ventilate

Slow Exhalation

Page 36: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

What should I do?

Page 37: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Decide to Intubate

Page 38: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,
Page 39: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Airway Pressure normal?

Page 40: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

What should I do

Page 41: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

“Ambu Bag”

Page 42: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Ventilate and Monitor gases

Page 43: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

What was wrong?

Page 44: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Expiratory Valve - Missing O Ring

How did this happen?

PEEP Valve incorrectly removed

Note that Cage and Valve are depressed !

Page 45: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Valve and cage

Page 46: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Replace valve, cage, o-ring

Page 47: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Replace Cover

Page 48: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Normal airway pressure curve

Page 49: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Normal ventilation

Unremarkable case

Patient went home in time for Lunch !

Page 50: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Who ya’ gonna call

OR Biomedical Engineering

Page 3-1055

Call 3-1291

Page 51: Clinical Conference Anesthesia Machines don ’ t fail, do they? James H. Philip M(E)E, MD Brigham and Women’s Hospital October 30, 2002 © Copyright 2002,

Thank You


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