Chapter 13

Controlling Trace Gas Levels

Introduction
Bef ore scavengi ng was i nst i tuted, excess anesthet ic gases and vapors were
di scharged i nto room ai r. As a consequence, operat i ng room personnel were
exposed t o l ow concentrat ions of these drugs wi t h l i tt l e concern about any
det rimental ef f ects that coul d possibl y resul t f rom such exposure. Questi ons have
been rai sed about possibl e hazards f rom exposure t o trace amounts of anesthet ic
gases and vapors (1). (For t he remai nder of t hi s chapter, anesthet i c gases and
vapors wi l l be ref erred to as gases, because most vapors behave as gases.)
A trace l evel of an anest het i c gas is a concentrat i on f ar bel ow t hat needed f or
cl i nical anesthesia or t hat can be detected by smel l (2). Trace gas level s are
usual l y expressed i n parts per mi l l ion (ppm), whi ch i s vol ume/vol ume (100% of a
gas i s 1, 000, 000 ppm; 1% is 10,000 ppm).
Report ed trace gas concent rati ons i n operati ng rooms vary great l y, depending on
t he f resh gas f l ow, t he venti lati on system, the l ength of t i me that anesthesi a has
been admi ni stered, the measurement si te, anestheti c techni que, and other
vari abl es. Trace gas l evel s tend to be higher wi th pediatric anest hesi a (3,4), i n
dental operatori es (1, 5), and i n poorl y venti l at ed postanest het ic care uni ts
(recovery rooms) (6,7,8,9,10).
Methods of Study
Despi te many studi es and much di scussi on, opi ni ons di ff er on whether or not a
probl em exi sts and what l evel s should be al l owed i n t he worki ng envi ronment (11).
To i nterpret t he data, i t i s f i rst necessary t o understand how i t was col lected. Four
basic methods of study have been used. Al l have maj or l i mi tat ions and
di sadvantages.
Animal Investigations
During ani mal st udi es, laboratory ani mal s are exposed to varying l evels of gases
f or varyi ng peri ods of ti me and are st udied to determi ne the ef fects.
These st udi es shoul d be int erpreted wari l y. Large numbers of ani mal s need to be
studi ed to achi eve stat i sti cal si gni f icance. In animal s, diet af fects t umor
suscepti bi li t y, and stress af f ects reproduct ion (12). Toxici t y usual ly depends on
both exposure ti me and concentrat ion, and i t i s dif f i cul t t o correl ate exposure ti me
i n ani mals wi t h t hat in humans because thei r l i f e spans are so dif ferent. Fi nal l y,
vari ati ons in drug ef fects among species create uncertai nt y about the rel evance of
t hese f indi ngs to humans.
Human Volunteer Studies
Human volunt eers have been used t o study the eff ects of t race gases on ski l led
perf ormance, i mmune responses, and drug metabol i sm.
Epidemiologic Studies of Exposed Humans
A number of epidemiol ogic studies of exposed personnel have been performed.
Most were ret rospecti ve and used questi onnai res. They suff er f rom l ow response
rates, i nappropri ate cont rol groups, poor recoll ecti ons and biases on the part of t he
respondents, poor wordi ng, f ai l ure to i ncl ude si gni f icant points i n t he
questi onnai res,
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and mi si nterpretat ions due t o dif f erences i n educati on and experi ence on the part
of t he respondents (12,13, 14, 15,16). Data int erpretati on i s hampered by a lack of
agreement as to what l evel of signif i cance t o accept (12, 17). Fi nal l y, many of the
studi es have not been desi gned t o test the cause-and-eff ect rel at ionshi p bet ween
t race gases and probl ems in exposed personnel . Some studi es show i ncreased ri sk
f or speci f i c groups but not f or other equal l y exposed groups (18). Ot hers have
shown probl ems in groups wi t h and wi thout exposure to t race gases, suggesti ng
t hat the ri sk may be rel ated to some ot her factor. Fi nal l y, many of the studi es were
perf ormed before scavengi ng and ot her methods to control t race gas l evels were
i mplement ed.
Mortality Studies
St udi es on t he causes of death and the age at whi ch death occurred among
anesthesi ol ogi sts have provided interest i ng data. One study f ound that
anesthesi ol ogi sts do not have an i ncreased ri sk of deat h f rom cancer or heart
di sease but do have hi gher rates of death due to sui ci de, substance abuse, other
external causes and cerebrovascul ar di sease than int erni sts (19). There was al so
an i ncreased rate of death f rom HIV and vi ral hepati ti s i n male anest hesi ol ogi sts.
Another study f ound that whi l e anesthesi ol ogi sts have a si gni f icant l y younger mean
age of deat h, there was no stat isti cal di ff erence i n age-specif i c mortal i t y (20).
Problems Attributed to Trace Gases
Spontaneous Abortion
Epidemiologic Studies
Epi demi ol ogi c studi es f rom several count ri es have shown hi gher rates of
spontaneous abort i on i n operat ing room and dent al operatory personnel than i n
women i n di ff erent envi ronments (21,22,23,24,25,26,27,28,29,30,31, 32,33). Other
studi es have f ai l ed to f i nd si gni f i cant i ncreases i n spontaneous aborti ons i n
exposed personnel (34,35,36,37, 38,39,40). One study f ound t hat the f requency of
mi scarri ages among nurses working i n i ntensive care uni ts was approxi matel y equal
t o t hat of nurses i n the operati ng room, suggesting that other f actors such as st ress
may pl ay a role (27, 41). A study of mi dwi ves who were of ten exposed to ni trous
oxide f ound that the ri sk of spontaneous aborti on was not i ncreased wi t h ni t rous
oxide exposure but was i ncreased wi t h ni ght work and hi gh workl oad (42).
Animal Studies
Halogenated Agents
I nvesti gati ons have found no evi dence of i ncreased spontaneous aborti on i n mi ce
exposed t o hi gh level s of i sof l urane, enfl urane, or hal ot hane
(43,44,45, 46, 47,48,49).
Nitrous Oxide
One study f ound t hat prolonged exposure t o 1,000 ppm ni t rous oxi de caused f et al
death, but no eff ect was seen when 500 ppm was used (50). A l at er study f ound
t hat the threshol d f or fetal death was hi gher (bet ween 1,000 and 5, 000 ppm) wi t h
i ntermi ttent exposure (51).
Mixtures
I nvesti gati ons using mi xt ures of hal othane and ni trous oxide f ound no eff ect wi t h
concentrati ons as hi gh as 1, 600 ppm hal othane plus 100,000 ppm ni trous oxide
(49). Ni t rous oxi de 500,000 ppm pl us isofl urane 3, 500 ppm also had no eff ect on
spontaneous abort i ons (52).
Spontaneous Abortion in Spouses
Al though several studi es have shown an increased spont aneous abort ion rat e in
wi ves of exposed mal es (23,53, 54), the maj ori t y suggest that there i s no increase
(16,21,25, 40). One st udy f ound no changes i n sperm concentrat ion or morphol ogy
i n mal e anesthesi ol ogists worki ng in heal th care faci li ti es wi th scavengi ng
equipment (55). Studi es have f ai led to show any adverse ef f ect on reproduct ive
processes of mal e animals exposed to up t o 5,000 ppm enf lurane (44,56) or 10 ppm
hal othane plus 500 ppm ni trous oxide (57).
Infertility
Epidemiologic Studies
Several studi es have f ound hi gher-t han-expected rates of i nvol untary i nfert i l i t y
among exposed personnel (24,53, 58). A more recent st udy f ound no evi dence that
f emal e anestheti sts have i ncreased ri sk of i nf erti li t y (59). One study f ound
decreased f erti l i t y i n dental operatory staf f s who were exposed to consi derabl y
hi gher level s of ni trous oxi de than those who were operati ng room personnel (5).
One study f ound no eff ect f rom paternal exposure (25), and no changes i n sperm
count or morphol ogy were found in mal e anesthesi ol ogi sts worki ng i n scavenged
operati ng rooms (55).
Animal Studies
Halogenated Agents
Numerous studies of ani mal s exposed t o high concent rat i ons of i sof l urane,
enfl urane, or hal othane showed l i t tl e or no ef f ect on f erti l i t y (43,45,56,60,61, 62, 63).
Nitrous Oxide
No changes i n mal e f erti l i t y and no sperm abnormal i ti es were f ound i n mi ce af ter
exposure to up to 800,000 ppm (60,64). However, prol onged exposure of male rats
t o 200, 000 ppm resul t ed in abnormal i ti es i n spermatogenic cel l s (65). Exposure t o
up to 800,000 ppm caused no changes in f erti l i t y i n mal e or female f l i es (61).
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Mixtures
Decreased f ert i li ty was seen i n femal e rats exposed to hal ot hane 10 ppm pl us
ni trous oxi de 500 ppm bef ore mati ng (57). Mal e rats exposed to t hese
concentrati ons showed greater f requency of chromosomal aberrati ons i n
spermatogeni c cel ls, but the aberrat i ons were probabl y too i nf requent to cause
decreased f erti l i t y (61).
Birth Defects
Epidemiologic Studies
Several studi es i n humans have found an i ncrease i n congeni t al abnormal i t ies i n
chil dren of exposed personnel (21,23, 24,28, 34,37, 53,54,66, 67). I nt erpret ati ons of
t he dat a have been questi oned (12,17,18,68). Several i nvest igators have f ound no
i ncrease i n bi rt h def ects among the of fspri ng of exposed parents
(16,25,26, 27, 29,36,40). No i ncrease i n chromosomal abnormal i t ies i n exposed
nurses or changes i n sperm morphology have been f ound i n mal e anest hesiol ogists
worki ng i n operati ng rooms (55,69).
Animal Studies
St udi es of l aboratory ani mal s exposed to concentrati ons of i nhalat i onal agents wel l
above those f ound i n even unscavenged operat ing rooms have fai l ed t o f i nd any
si gni f icant t eratogeni c ef fects (44,45,47, 48,49,50,52,57,60,64,70,71, 72).
Impaired Performance
Operat ing room personnel are subj ected to many sti mul i that requi re precise, rapi d,
and compl icated responses. Because the pati ent ' s survi val depends on the
al ertness and perf ormance of the prof essional t eam, anything that i nterf eres wi t h
i ts abi l i t y t o percei ve changes and react qui ckl y and appropri atel y may resul t i n
harm to a pat ient.
Al though a f ew studies have f ound t hat vol unt eer exposure t o trace gas
concentrati ons caused si gni fi cant decreases i n perf ormance (73, 74,75,76), eff orts
t o dupl icate t hese resul ts have fai l ed (41,77,78,79,80,81,82, 83,84,85, 86). These
studi es f ound that t he concentrat ions needed to decrease perf ormance were
hundreds of ti mes greater than the average l evel s found i n unscavenged operati ng
rooms. I n another study, neuropsychol ogical symptoms and ti redness were report ed
more by individual s i n operati ng rooms where scavengi ng was used l ess of ten (87).
One study determi ned that personnel exposed to 51 to 54 ppm of ni t rous oxi de had
sl owed reacti on ti mes compared wi t h workers not exposed to t race gases (88).
Cancer
Epidemiologic Studies
A large st udy f ound no increase i n cancer in exposed males but i ndi cated that
f emal es in the operati ng room were at hi gher ri sk f or cancer t han nonexposed
f emal es (21). The si gni f i cance of these dat a has been questi oned (17,18). Si mi l ar
resul ts have been report ed f or female dent al operatory assistants (23). Two studi es
of dent ists have shown t hat the i nci dence of cancer is not si gni f icantl y di f ferent
among those exposed and those not exposed to t race concent rat i ons of anest het i cs
(23,54). One study f ound a hi gher rat e of mel anoma among anesthesi ol ogi sts (89).
A review of combi ned data f rom si x st udi es f ound an i ncreased cancer ri sk among
women but not men (41,90).
Mortal ity Studies
There i s no increased death rate f rom cancer i n mal e anesthesi ol ogi sts
(19,91,92, 93, 94,95,96). The deat h rat e f rom cancer among f emal e
anesthesi ol ogi sts is higher when compared wi th mal e anesthesi ol ogi sts and control
groups (93), but the numbers are t oo smal l t o permi t any strong concl usions.
Vari ous therapeut i c modal i t i es have resul t ed i n hi gher cancer cure rates, so the
i nci dence of cancer cannot be i nferred by usi ng onl y mortali t y data.
Animal Studies
St udi es have found no evi dence of i ncreased carci nogeni ci ty i n ani mals exposed to
up to 5,000 ppm hal ot hane or 10,000 ppm enf lurane (97,98,99). One study f ound
hepat ic neopl asms i n mi ce exposed duri ng gestat ion and earl y l if e to 1,000 to 5,000
ppm i sof lurane (100), but t he val idi t y of t hi s study has been questi oned, and i t
appears that the i ncreased i nci dence of tumors may have been the resul t of other
f act ors. In l ater studi es, no evi dence of i ncreased carci nogeni ci ty was f ound i n
ani mal s exposed to up to 6,000 ppm i sof l urane (98,101). No evi dence of i ncreased
carci nogeni ci ty i n mice has been f ound wi t h exposure to up to 800, 000 ppm ni trous
oxide (98,102). No i ncrease i n neopl asms was f ound i n rats exposed to 10 ppm
hal othane plus 500 ppm ni trous oxide (103).
Mutagenicity Testing
Human Studies
Cyt ogenet ic met hods are i ncreasingl y used f or evaluati ng t he ef f ects of exposure to
potenti al mutagens in the envi ronment
(105, 106,107,108, 109, 110,111, 112, 113,114, 115). Some studi es f ound no
associ at i on bet ween occupati onal exposure to waste anesthet ic gases and
cytogenet i c damage (104, 108,110, 113, 116,117,118,119,120). Others suggest that
t here may be an associ ati on (105, 106,107, 111,112,114,115, 121,122,123). One
study f ound that the waste gas level s recommended by the Nati onal Insti t ute f or
Occupat i onal Saf ety and Heal th (NIOSH) appear to be safe, whereas exposure t o
hi gher level s were associated wi th an i ncrease in chromosome damage (109).
Animal Studies
Several studi es have f ound that hal ot hane and i ts met abol i tes are not mutageni c
(124, 125,126,127, 128, 129). Ot hers have found that hal ot hane and/or i ts
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metabol i tes are weakl y mutageni c (130,131,132,133). I nvest igators have been
unabl e t o demonst rate mutageni c ef fects f rom enf l urane (125, 134,135) or i sof l urane
(125, 127,135). Investigati ons have f ound t hat ni t rous oxi de i s not mut agenic
(125, 136). One i nvesti gati on f ound that halothane pl us ni trous oxide di d not
i ncrease mutagenesis (128). Another found that ni t rous oxi de had no ef fect on the
mutagenici t y of halothane (130). The same study f ound that there was no
mutagenici t y wi t h mixtures of ni t rous oxi de and enf l urane or i sof l urane.
Liver Disease
Epidemiologic Studies
St udi es have found that operat i ng room and dental operatory personnel have
hi gher-than-expected rat es of hepat i c disease (11, 19,21,23, 54,89,90,137).
I nterpret at ion of these dat a has been questi oned (17).
Recurrent hepat i ti s foll owi ng exposure to halothane has been demonstrated in a
f ew i ndividual s (138,139, 140, 141,142), and exposure to t race anestheti c agents
enhances hepati c metabol i sm of some drugs (143, 144). El evated serum
autoanti bodies that react wi th speci f ic hepat i c protei ns have been f ound i n
anesthesi a personnel , especi al l y f emal es and pedi at ri c anesthesi ol ogi sts (145).
The rel evance of t hese f acts t o the ef f ects of trace concentrat ions is not cl ear.
Animal Studies
Hal othane exposure i n concent rati ons as l ow as 20 ppm may be associated wi th
mi ld t oxi c ef f ects to t he l iver i n rats (146,147, 148). No evidence of such ef f ects has
been f ound f rom exposure to enf l urane or i sof lurane (146,148).
Renal Di sease
One study f ound t hat f emale operati ng room nurses, t echni ci ans, and
anesthesi ol ogi sts had a hi gher ri sk of kidney di sease than di d comparabl e groups
outsi de the operat ing room (21). These resul ts have been quest ioned (17). Anot her
study f ai led to f i nd any i ncrease in kidney di sease in mal e anesthesi ol ogi sts (11).
A study showed an i ncrease i n renal di sease i n exposed denti sts and f emale chai r-
si de assi stants (23). No i ncrease i n deat hs caused by renal di sease has been found
among anesthesi ol ogi sts (93).
Hematologic Studies
Epidemiologic Studies
I n one st udy, a hi gher-t han-expect ed rate of l eukemi a was found in f emal e
anesthesi ol ogi sts, but the smal l dat abase made any val id concl usi ons dif f icul t (21).
Ot her st udi es f ound no si gni fi cant al terat ions in hematol ogic f uncti on i n exposed
i ndi vi dual s (149, 150,151,152). However, 3 of 20 denti sts exposed to concent rat i ons
of ni t rous oxi de hi gher than those normal ly f ound i n operat ing rooms showed
abnormal i ti es i n thei r bone marrow, and t wo had abnormal i ti es i n thei r peri pheral
bl ood (153).
Animal Studies
I n mi ce, no hematol ogi c ef fects were found f rom exposure to 500 ppm hal othane
(97). Exposure t o 3, 000 ppm enf l urane had no ef f ect on hematopoi esi s i n mi ce
(154). Exposure to 10,000 ppm ni t rous oxi de caused no changes in hematopoi esi s
i n rats (155). Cytogeneti c damage to bone marrow was found i n rats exposed to 10
ppm hal othane plus 500 ppm ni trous oxide (56).
Neurologic Symptoms
A nonspecif ic pol yneuropathy f ol lowi ng chroni c exposure to ni trous oxide has been
descri bed (156,157). Two studi es f ound an i ncrease i n neurol ogic symptoms
(numbness, t i ngl ing, and/or muscl e weakness) i n dent ists and f emal e chai r-side
assi stants who are exposed to anesthetic gases (23, 158). Another study showed no
di ff erence i n neurol ogi c symptoms or si gns, sensory percepti on, or nerve
conducti on bet ween dent ists who use ni t rous oxi de extensi vel y and t hose who use
i t spari ngl y or not at al l (159). Hi gh l evel s of ni t rous oxi de have not been shown t o
cause neuromuscul ar or neurol ogi c abnormal i ti es i n ani mal s (159).
Alterations in Immune Response
Several studi es have f ound that work i n operati ng rooms does not change the
i mmunol ogi c prof i l e of i ndivi dual s (160,161,162,163,164). A study of peopl e
worki ng i n unscavenged rooms wi t h trace gas concent rat i ons several t imes t he
recommended l evel s had changes that reversed when t hey were removed f rom t hat
envi ronment (165).
Cardiac Disease
St udi es have shown a greater-t han-expected f requency of hypert ension and
dysrhythmias (11, 166), and there i s one case report of at ri al f i bri l l ati on secondary
t o hal othane exposure (167). However, mort al i t y studi es gi ve no evidence that
anesthesi ol ogi sts have a higher-than-expect ed ri sk of dyi ng f rom heart di sease
(91,92,93, 94, 95,96).
Miscellaneous
Vari ous studi es have report ed hi gher-than-expected i ncidences of bone and joint
di sease (11), ulcers (11,166), ul cerati ve col i ti s (166), gal l bl adder disease (11),
mi graine (166), and headache and f at igue (168) i n exposed personnel . Case
reports of exposed personnel who developed asthmati c symptoms (169), laryngi ti s
(170), ophthal mi c
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hypersensi t i vi ty (171), conjunct ivit is (172), exacerbati on of myastheni a gravi s
(173), and ski n erupti ons (174,175) have been publ i shed. Mortal i ty stat i stics show a
hi gh i nci dence of suicide and substance abuserel at ed deat hs among
anesthesi ol ogi sts (19,91,93).
Summary
The evidence t hat trace anesthetic gases are harmful is at present suggestive
rather than concl usi ve (176). The hazard, i f i t exi sts, i s not great and i s more
properl y regarded as di squi et ing than alarmi ng. Researchers who have
systemati cal l y exami ned t he publ ished data have concl uded that reproduct i ve
probl ems i n women were t he onl y heal th ef fects f or whi ch there i s reasonabl y
convi nci ng evidence (14). Whi l e i t is reassuri ng to note t hat st udi es have shown
t hat anesthesiologists have a mort al i t y rate l ess than that expect ed f or physi ci ans
or t he general popul ati on (92, 93,94), reproduct i ve probl ems are not refl ected i n
mortal i ty data, and hi gh cure rates may be responsi bl e for the l ow mort al i ty. One
study showed an i ncreased rate of earl y reti rement as a resul t of permanent i l l
heal th and a hi gh rate of deaths whi l e worki ng among anesthesi a personnel (177).
A cause-and-ef fect relati onshi p between occupati onal exposure and the problems
descri bed has not been f i rml y establ ished. If t here is an i ncreased ri sk, i t may be
rel ated t o other f actors such as mental and physi cal stress; st renuous physi cal
demands; di sturbed night rest ; need f or constant alert ness; l ong and i nconvenient
worki ng hours that of t en interfere wi th domest ic l if e; i rregular routi ne; exposure t o
t ransmissi bl e i nf ect i ons, sol vents, propel lants, cl eaning subst ances, l asers,
methyl met hacryl ate, radi at ion, or ul t raviolet l i ght ; pre-exi sti ng heal th and
reproducti ve probl ems; hormonal or dietary di sturbances; the physi cal or emot ional
makeup of those who choose to work i n operati ng rooms; soci o-economic f actors;
or some other as yet undef i ned f act or (178).
The Commi t tee on Occupati onal Heal th of Operat ing Room Personnel suggests that
heal th care insti tuti ons bri ng to the at tenti on of operati ng and recovery room
personnel perti nent i nf ormat ion on t he cl ai med ri sks of excess anesthet ic gases
and ways by whi ch t hese risks can be mi ni mi zed (179). A sampl e l et ter is avai l able
(180).
Control Measures
Compl et e el imi nat i on of al l anesthet ic mol ecules f rom t he ambi ent atmosphere i s
i mpossible. The goal should be to reduce concentrat ions to the lowest l evel
consi stent wi t h a reasonabl e expendi ture of eff ort and money. To achi eve thi s,
at tenti on shoul d be focused on four areas: scavengi ng, equi pment leaks, work
t echni ques, and the room venti l ati on system.
Scavenging Systems
Scavenging i s the col lect ion of excess gases f rom equi pment used t o admi ni st er
anesthesi a or exhal ed by t he pat ient and t he removal of t hese gases to an
appropri at e place of di scharge outsi de the work envi ronment . Scavengi ng systems
are also ref erred t o as evacuat i on systems, wast e anestheti c gas disposal systems,
anesthesi a waste exhaust , and excess anesthetic gas-scavengi ng systems.
I nst al lat i on of an ef f icient scavenging system is t he most i mport ant step i n reduci ng
t race gas l evel s, l oweri ng ambi ent concent rat i ons by up t o 90%
(181, 182,183,184, 185, 186,187, 188, 189,190, 191).
A scavenging system consists of f i ve basic parts (Fi g. 13.1): a gas-col lecti ng
assembl y, whi ch captures gases at the si te of emission; a transfer tubing, whi ch
conveys col lected gases to the i nterface; t he i nterf ace, whi ch provi des posi t i ve
(and someti mes negative) pressure reli ef and may provi de reservoi r capaci ty; the
gas-disposal tubing, whi ch conducts the gases f rom the i nt erf ace to the gas-
di sposal system; and the gas disposal system, whi ch conveys the gases to a point
where they are discharged. Frequentl y, some or al l of t hese components are
combi ned.
A U.S. standard (192) and an i nternat ional standard (193) for scavengi ng systems
have been publ ished. The internat i onal standard di ff ers f rom the U.S. st andard i n
t hat some f i tti ngs are male rather t han f emal e and vi ce versa.
Gas-coll ecti ng Assembly
The gas-col lect ing assembl y (scavenger adapter; gas-capturi ng assembl y, devi ce,
or val ve; scavengi ng trap or val ve; col l ecti ng or col l ecti on val ve; scavenging exhal e
valve; evacuator; anti pol l uti on val ve; ducted expi rat ory val ve; col lecti ng system
exhaust val ve; scavengi ng t rap, col l ect i ng system) col lects excess gases and
del i vers them to the t ransf er means. I t may at tach to, or be an i ntegral part of , a
source. Frequentl y, the outl ets of t wo or more sources are joi ned together. The
American Soci et y of Test ing and Materi al s (ASTM) standard and internati onal
standards (192,193) speci f y that the outl et connecti on must be a 30-mm mal e
f i t ti ng. In the past , 19-mm fi tt i ngs were permi t ted, but they are bei ng phased out.
The si ze i s i mport ant , because i t shoul d not be possible to connect components of
t he breathi ng system to the out let. Some earl y assembl i es had 22-mm f i tt i ngs, and
cases of mi sconnecti on wi th breathi ng system tubes occurred (194,195).
Breathing Systems
Systems Containing an Adjustable Pressure-Limiting Valve
Systems wi t h an adj ust abl e pressure-l i mi ti ng
P. 379

(APL) valve (Chapter 7) i ncl ude the ci rcl e system and t he Mapl eson A, B, C, and D
systems. The APL val ve is essenti al l y f i t ted wi t h a shroud (Fig. 13.2). Wi th t he
ci rcle, Bai n, and Lack vari ant of the Mapl eson D systems, the wei ght of the
assembl y can be support ed by the anesthesi a machi ne, and the t ransf er means can
be qui te short. Smal ler and l i ghter APL val ves wi th gas-col l ecti ng assembl i es are
avai l able f or the other Mapl eson systems.

View Figure

Figure 13.1 Complete scavenging system. The gas-
collecting assembly may be an integral part of the breathing
system, ventilator, gas monitor, or extracorporeal pump
oxygenator. The interface may be an integral part of the
gas-collecting assembly or some other portion of the
scavenging system.

An APL valve may have a bui l t-i n mechani sm that prevents posi ti ve or negat ive
pressure f rom t he scavengi ng system bei ng transmi t ted t o the breathi ng system
(196).

View Figure

Figure 13.2 Gas-collecting assembly attached to an APL
valve.

T-piece Systems without an Adjustable Pressure-Limiting Valve
Numerous devi ces f or removi ng gases f rom the bag have been descri bed
(197, 198,199,200, 201, 202,203, 204, 205,206, 207,208,209,210,211,212,213,214).
Ot her methods use a cont ai ner that is at t ached to sucti on (215, 216). Ot her methods
at tach the gas-col l ect ing assembl y between the bag and i ts at tachment to t he
t ubi ng (217, 218, 219,220).
Resuscitation Equipment
Nonrebreathi ng valves wi t h a scavengi ng adapter are commerci al l y avai lable. It i s
f ai rl y simple t o att ach a col l ect i on assembl y t o the exhalat i on port of some exi st ing
nonrebreathing valves wi thout af fecti ng valve functi on.
Masks or Nasal Cannulae
I t i s common practice i n some i nst i tut i ons to administer anestheti c gases to
pati ents through a nasal cannul a or face mask f or sedat i on. Pl aci ng a tent or hood
around the pat i ent 's head and at tachi ng a sucti on source can reduce the ambi ent
concentrati ons of gases (221,222, 223). A doubl e mask consi sti ng of a small er i nner
mask separated f rom a l arger outer mask by a space connected t o a scavengi ng
device wi l l reduce ambi ent concentrat ions (224,225).
Ventilators
Anesthesi a venti lators are now equi pped wi t h gas-col l ect ing assembl i es. The waste
gas i s di rected t o the same i nterf ace that i s used by t he breat hi ng system. In most
cases, the dri ve gas whi ch i s composed of oxygen, ai r, or a combinati on of the t wo,
i s expel l ed i nto the room.
P. 380


On some ol der vent i l ators, t he exhaust includes not onl y excess breat hi ng system
gases but al so the dri vi ng gas f or the vent i lat or. In thi s si tuati on, a disposal system
t hat i s capabl e of handl i ng hi gh gas f l ows i s requi red. A scavengi ng system t hat
f uncti ons ef f i ci ent l y wi t h spontaneousl y breathi ng or manual l y vent i l ated pat i ents
may f ai l to do so when used wi t h vent i l ators t hat di scharge t he driving gas int o the
scavengi ng system (226).
Extracorporeal Pump Oxygenators
The outl et port of an ext racorporeal pump oxygenator is a pot ent i al source of
anesthet ic pol l ut ion (227,228). Gas-col l ect ing assembl i es f or t hese are avai l abl e
(229). I t i s i mportant to provide an eff ect i ve i nterface wi t h these devices because
si gni f icant posi ti ve or negat i ve pressure al terat ions at the outf l ow port can
markedl y al ter oxygenator f uncti oning (230).
Respiratory Gas Monitors
A di verti ng gas moni t or (Chapter 22) wi thdraws gas f rom the breathi ng syst em and
t ransports i t i nto t he moni tor. The gas then needs to be ei t her ret urned to the
breat hi ng system or diverted i nto t he scavengi ng system. This source of
contaminati on i s of ten i gnored (231,232,233,234). Moni tors manufactured i n recent
years are equi pped wi t h an out l et to f aci l i tate scavengi ng (235) (Fi g. 13.3).

View Figure

Figure 13.3 A: Gas monitor with sample gas outlet (at
upper right). B: Connection of transfer tubing near the
interface.

Cryosurgical Units
Some cryosurgical uni ts use ni t rous oxi de. These can cont ri but e to operati ng room
contaminati on (236). These uni ts shoul d be f i t ted wi th scavengers, or carbon
di oxi de shoul d be used i nstead of ni trous oxide (237).
Leak Sites
When t here is a def i ni t e l eak si te (such as when a face mask i s used or a vaporizer
i s fi l l ed), or i n the post anesthesi a care uni t, close (l ocal ) scavengi ng of
contaminated ai r t hrough a separate scavengi ng device or a l ow negat ive pressure
hood can be used to l ower ambient concentrati ons (210,238, 239, 240,241). A f ace
mask t hat has the abi li t y t o reduce t he concent rati on of anest heti c gases in t he
recovery room has been descri bed (8).
Transfer Tubing
The t ransf er t ubi ng (exhaust tubi ng or hose, t ransf er means, t ransf er system)
conveys gas f rom the col l ecti ng assembl y to t he interf ace when t he i nterf ace i s not
an i ntegral part of the gas-col lecti ng assembl y.
The t ransf er t ubi ng is most commonl y a l ength of t ubi ng wi th a connector at ei ther
end. The i nl et and outl et f i tt ings should be ei ther 19 or 30 mm. It shoul d be as short
as possi bl e (t hi s i s f aci l i tated by mounti ng the i nterf ace on the anest hesi a machi ne)
and wi de enough to carry a hi gh f l ow of gas wi t hout a si gni fi cant increase i n
pressure. It should be resi stant to ki nki ng. I t shoul d not touch the f l oor, but i f i t
does, i t shoul d be desi gned to prevent occlusi on. I t shoul d be easi l y seen and easy
t o disconnect f rom the gas-col l ect i ng assembl y in the event of mal f unct i on or
scavengi ng system occlusi on. To di scourage mi sconnect i ons, i t i s recommended
t hat the transfer tubing be di f ferent (by col or and/or conf i gurati on) f rom t he
breat hi ng system t ubi ng (Fi g. 13.6).
Interface
The i nt erf ace (bal ancing val ve or devi ce, pressure bal anci ng valve or device,
i nterf ace system or bl ock, intermedi ate si te, saf ety bl ock, ai r break receiver,
receiver uni t, ai r break, receivi ng syst em, i nterf ace valve, scavenging val ve,
reservoi r) serves to prevent pressure increases or decreases in t he scavenging
system f rom being t ransmi tted to t he breat hi ng system, vent i l ator, or extracorporeal
oxygenator. The U.S. and i nternat i onal standards (192,193) requi re t hat t he
pressure i mmedi atel y downst ream of t he gas-col l ect ing assembl y be l i mi ted to
bet ween -0.5 and +3. 5 cm H
2
O duri ng normal operat ing condi ti ons and up t o +15
cm H
2
O wi th obstruct i on of the scavenging system.
The i nt erf ace i nl et must have a 19- or 30-mm (pref erred) male connector. The si ze
of t he outl et i s opt ional but shoul d be dif f erent f rom breathing system connectors
and f rom t he inlet connect or i f the devi ce i s sensi t i ve to t he di recti on of f l ow.
P. 381


The i nt erf ace shoul d be si tuat ed as cl ose t o t he gas-col l ecti ng assembl y as
possi bl e, where i t can be readi l y observed and reached by anesthesi a personnel .
There are three basic elements t o an interf ace: posi ti ve pressure rel ief , negat i ve
pressure rel ief , and reservoi r capaci ty. Irrespecti ve of what t ype of disposal system
i s used, posi tive pressure rel i ef must be provi ded t o protect the equi pment and
pati ent i f occl usi on of the scavenging system occurs. If an active disposal system i s
used, negat ive pressure rel i ef i s needed to l i mi t subat mospheri c pressure. A
reservoi r i s necessary to match t he intermi tt ent f l ow f rom the gas-coll ecti ng
assembl y to the conti nuous f l ow of t he di sposal system. A device t hat gives an
audibl e si gnal may be f i t ted to the int erf ace to i ndi cate operat ion of the posi tive or
negat ive pressure rel i ef device. A fl ow i ndi cat or may be provi ded t o moni tor f l ow
f rom the i nt erface to t he gas-di sposal system (Fi gs. 13. 4, 13.5).
The reservoi r may be a rigid container, wi de t ubi ng, a bag, or a combi nat ion of
t hese. A distensi bl e bag al lows gas removal by the scavengi ng system t o be
moni tored. I t should onl y be used wi th acti ve di sposal syst ems and shoul d be of a
di ff erent col or f rom, and si tuated away f rom, t he reservoi r bag i n the breathi ng
system. The connecti on bet ween t he bag and the i nt erf ace shoul d be a di ff erent
si ze f rom the mount f or t he reservoi r bag i n the breathi ng system.
I nterf aces can be di vi ded i nto t wo types: open and closed, dependi ng on the means
t o provide posi tive and negat i ve pressure rel i ef .
Open Interface
An open i nterface (ai r break receiver uni t ) (242,243,244) (Fi g. 13.4A) has one or
more openi ngs to atmosphere (al l owi ng posi ti ve and negat ive pressure rel i ef ) and
contai ns no val ves. It shoul d be used onl y wi t h an active disposal syst em. The
i nl et, t he di sposal system connecti on, and the openi ng(s) t o atmosphere shoul d be
arranged so that waste gases are removed before room ai r i s ent rained.
Because the di scharge of wast e gases is usual l y intermi t tent and f l ow t hrough an
acti ve di sposal assembl y i s cont i nuous, a reservoi r i s needed to hol d the surges of
gas that enter t he i nterface unt il the disposal system removes them. The reservoi r
al l ows the f l ow rat e i n t he di sposal system to be kept j ust above the average f l ow
rate of gases f rom the gas-col l ecti ng assembl y.
I t i s i mportant that the reservoi r have adequat e capaci t y, especi al l y if a venti l at or i n
whi ch the dri vi ng gas mi xes wi t h wast e gases i s used or i f hi gh ti dal vol umes or
hi gh ni trous oxide f l ows are used (245).
The safety af f orded by an open system depends on the patency of the vents to
at mosphere, so i t is i mportant t o have redundancy in case some are acci dental l y
bl ocked (246,247). The vents should be checked
P. 382

and cl eaned regul arl y. Pl astic bags and surgi cal drapes shoul d be kept away f rom
t he vents.

View Figure

Figure 13.4 A: An open interface. Note the escape-inlet
ports at the top of the reservoir. These provide positive and
negative pressure relief. B,C: are closed interfaces. (A) and
(B) are active systems. (C) is a passive system.


View Figure

Figure 13.5 Open interfaces. The open ports at the top of
the canister provide positive and negative pressure relief.
The flow control valve is used to regulate the scavenging
flow. The flowmeter indicates whether or not the flow is
within the range recommended by the manufacturer. The
float should be between the two markings on the flowmeter.
Inside the canister, one tube conducts waste gases to the
bottom. The other tube conducts gases from the bottom to
the disposal system.

Open i nterface are shown i n Fi gs. 13. 4A, and 13. 5. Anesthet ic gases f rom the
t ransfer means enter at t he top and are conducted t o the base where t hey are
di spersed. A paral l el tube is connected at the top t o the reservoi r. The space
around both t ubes acts as a reservoi r. The hol es at the top are open to
at mosphere. A f l owmet er measures the amount of vacuum that i s appl ied to the
i nterf ace by the acti ve di sposal system. I t al so provi des a vi sual i ndi cat ion t hat the
vacuum i s turned ON. Usual ly, there are two marks between whi ch the i ndi cat or
shoul d be located.
The open i nterf ace i s si mple but may pol l ute t he at mosphere i f the reservoi r does
not have suff i ci ent volume to contai n the bol uses of wast e gases. The acti ve
di sposal system must suppl y adequat e f l ow to remove t he scavenged gases f rom
t he i nterface. Turbulence wi l l i ncrease the vol ume of ai r contaminated wi t h
anesthet ic gases (242). Turbul ence is greatest when gases f rom the breathing
system f low agai nst the di sposal system fl ow and l east when f l ow i s i n the same
di recti on.
Closed Interfaces
A cl osed i nterf ace (Fi g. 13.4B,C) makes i ts connecti on(s) t o atmosphere through
valve(s). A posi t i ve pressure reli ef valve is al ways requi red to al l ow gases to be
rel eased i nto the room if t here is obst ructi on of the scavengi ng system downst ream
of t he i nterf ace. If an act ive disposal system i s to be used, a negat ive pressure
rel i ef (pop-i n, i nl et rel i ef ) valve i s necessary t o al l ow ai r to be entrai ned when t he
pressure i n the reservoi r f al ls below atmospheri c.
A reservoi r i s not requi red wi t h a cl osed interf ace and shoul d not be used unless an
acti ve di sposal system is used. I f an acti ve di sposabl e system i s used, a
di stensibl e bag i s usef ul for moni t oring scavengi ng system f uncti on.
Positive Pressure Relief Only
A cl osed i nterf ace wi t h onl y posi ti ve pressure rel ief shoul d be used onl y wi th a
passi ve di sposal system. An exampl e is shown i n Fi gure 13. 4C. The posi ti ve
pressure rel ief val ve remai ns cl osed unless there i s a problem downst ream of the
i nterf ace. The rel i ef devi ce may be spri ng loaded or work by gravi t y.
Positive and Negative Pressure Relief
I f an act i ve di sposal system i s used, a negati ve pressure rel ief val ve must al so be
present. Subatmospheric pressures greater than -0.5 cm H
2
O can raise or l ower t he
openi ng pressure of some APL val ves (248).
Examples of t he cl osed i nt erf aces are shown i n Figures 13.4B and C and Fi gure
13.6. When a passi ve di sposal system i s used, the negat ive pressure rel i ef wi l l
P. 383

remai n closed at al l t i mes. If an active di sposal system is used, i t shoul d cl ose
duri ng hi gh peak f low rat es f rom the gas-col l ect ing assembl y and open when t he
gas-disposal assembl y fl ow i s great er t han t he fl ow of gases enteri ng the gas-
coll ecti ng assembl y f rom the breat hi ng system.

View Figure

Figure 13.6 Closed interfaces. Note the wide-bore flexible
transfer tubing that is different in appearance from the
breathing system tubes.

The rat e of f l ow i nto t he gas-di sposal assembl y shoul d be adj usted to the opti mal
l evel by observing t he bag (i f present ) and the posi t ive and negat ive rel ief val ves.
I n an opt imal l y adj usted system, the bag expands and defl ates but never becomes
overextended or compl et el y def lated (249, 250,251). If the bag i s conti nual l y
coll apsed or t he negati ve pressure rel ief val ve opens f requent l y, the f l ow shoul d be
l owered. If t he bag becomes di st ended or t he posi t ive pressure rel i ef valve opens
f requent l y, f low shoul d be increased.
A cl osed i nterf ace can be used wi t h any type of di sposal system, but valves add t o
t he compl exi t y. They must be desi gned so that they do not sti ck or l eak. I nterf aces
wi th t wo negat i ve pressure rel i ef val ves are avai l abl e and add a margi n of saf et y.
Gas-disposal Tubing
The gas-di sposal t ubi ng (receiving hose, disposal tubi ng) connects the i nterf ace to
t he di sposal system (Fi g. 13.1). To avoid mi sconnecti ons, i t shoul d be di f ferent in
si ze and appearance f rom the breathi ng syst em hoses. It shoul d be resi stant t o
coll apse and f ree of l eaks. Wi th a passi ve gas-di sposal syst em, i t i s important that
t he hose be as short and wi de as practi cal to mi ni mi ze resi stance.
I deal l y, t he gas-di sposal t ubing shoul d be run overhead to mi ni mi ze the ri sk of
occl usi on and to avoi d the dangers of personnel tri ppi ng over i t or other apparatus
becomi ng entangl ed i n i t . I t may be hi dden i n a fal se cei l i ng. If the tubing must be
run across the fl oor, i t shoul d be rout ed where i t is l east li kel y to be stepped on or
have equi pment rol l ed over i t . I f i t must pass a doorway, i t should f ol l ow t he door
f rame.
Gas-disposal System
The gas-di sposal system (el imi nat i on system or route, di sposal -exhaust route,
di sposal assembl y) removes waste gases f rom the anestheti zi ng locat i on. The
gases must be vented at a poi nt that i s i solated f rom personnel and any ai r i nt akes.
Gas-di sposal syst ems are of t wo t ypes: acti ve, in whi ch a f l ow-i nducing devi ce
moves the gases, and passi ve, in whi ch t he pressure is rai sed above at mospheric
by t he pati ent exhal ing, by manual l y squeezi ng the reservoi r bag, or by a vent i l ator.
Wi th an act i ve system, there
P. 384

wi l l be negati ve pressure i n the gas-disposal tubi ng. Wi th a passive system, the
pressure wi l l be posi t ive.
Act i ve systems are usual l y more eff ecti ve at keepi ng pol l ut i on l evels l ow, because
most l eaks wi l l be inward (182, 252,253). They al l ow smal l -bore tubing to be used,
and excessive resi stance i s not a probl em. They al so ai d room ai r exchange. They
are, however, expensive in t erms of energy costs. They are not automat ic and must
be turned ON and OFF. If they are not t urned ON, ai r pol luti on wi l l occur; i f they
are not turned OFF, t here wi l l be needl ess wast e of energy. Act ive systems are
more compl ex t han passi ve ones. Thei r use requi res that the i nterf ace have
negat ive pressure rel i ef .
Passi ve systems are si mpl er but may not be as eff ect i ve in l oweri ng trace gas
l evel s, because the posi t ive pressure encourages out ward l eaks. They are less
expensive to operate than active systems.
Passive Systems
Room Ventilation System
Venti lati on systems in operat i ng rooms are of two t ypes: nonreci rcul at ing (one
pass, single pass, 100% f resh ai r) and reci rculat i ng (187). A nonreci rcul ati ng
system t akes i n exteri or ai r and processes i t by f i l teri ng and adj usti ng the humi di t y
and temperat ure. The processed ai r i s ci rcul ated through the room and then al l of i t
i s exhausted to at mosphere. This t ype of vent i l at ion system can be used for wast e
gas disposal by securi ng t he di sposal t ubi ng t o a conveni ent exhaust gri l l e. Ai r
f lowi ng i nto t he gri l l e wi l l remove the gases f rom the room.
Economi c concerns has l ed to i ncreased use of vent i l at ion systems that reci rcul ate
ai r. Wi th t hi s type of system, a smal l amount of ai r i s taken i n f rom t he at mosphere,
whi l e t he remai ning ai r i s reci rculated. Most of the gases exhausted f rom the room
are shunted back i nto t he intake and reci rcul ated, whi le a volume equal to the f resh
ai r admi t ted i s exhausted. Wi t h thi s type of system, wast e gases must be vent ed
beyond t he poi nt of reci rcul at i on.
The heal th care faci l i ty engi neer should know whi ch type of venti l ati on system i s
present. If not, absence of reci rcul ati on can be det ermi ned by sampl ing t he room
ai r i nl et to see i f i t i s f ree of t race gases af ter t hey have been rel eased in another
room.
An i mportant considerati on when usi ng the room vent i l ati on system f or waste gas
di sposal i s the negative pressure i n the exhaust duct. I f waste gases are i ntroduced
at t he gril l e, t he negati ve pressure i s usuall y mi nimal and i ts ef f ect negl igi bl e (246).
I f they are i nt roduced at a distance downst ream i n t he duct (as they must be wi t h a
reci rculati ng system), negative pressure rel i ef must be provi ded i n the i nt erf ace.
I n many operat ing rooms, the exhaust gri l l es are not l ocated cl ose to t he
anesthesi a machine, posing probl ems wi t h t ubi ng on t he fl oor where i t may be
occl uded. In some cases, the disposal tubi ng can be extended t o a wal l - or ceil i ng-
mounted connecti on t hat l eads to a pi pe in the wal l (187). The pi pe t hen connects
t o t he exhaust duct.
Piping Direct to Atmosphere
Pi pi ng di rect to the atmosphere i s al so known as a di rect duct or vent , speci al i zed
duct system, di rect di sposal l i ne, or through-t he-wal l system (252,253,254,255).
Excess gases are vented through the wal l , wi ndow, ceil ing, or f l oor t o the outside,
using onl y the sl ight pressure of the gases and leavi ng the gas-col lecti ng assembl y
t o provide the f l ow. Thi s type of system i s not sui table f or an operati ng room t hat i s
f ar f rom an outsi de wal l (246).
To prevent cross f low between rooms, each room shoul d have i ts own duct . The
i nl et to the duct shoul d be close to the anesthesi a machi ne. There shoul d be a
means to cap t he openi ng to the duct when i t is not connected to the gas-disposal
t ubi ng. The duct shoul d be short wi t h a l arge di amet er t o avoi d excessi ve back
pressure. A uni di recti onal val ve may be pl aced in t he duct to prevent outsi de ai r
f rom enteri ng t he operat i ng room and to mi nimi ze t he ef fects of wi nd pressure on
t he di sposal system (254).
The discharge poi nt on t he outsi de shoul d be sel ect ed so t hat i t i s away f rom wi nd
pressures, i gni ti on hazards, wi ndows, and the i nl ets f or t he venti l ati on system. I t
may be advant ageous to attach a short T-pi ece as a t erminal (256). The open
end(s) should point downward t o prevent water and di rt f rom enteri ng and be f i t ted
wi th nett ing to prevent insects, rodents, and f orei gn matt er f rom enteri ng the pi pe.
The di rect pipi ng di sposal system i s easy t o use but requi res a speci al i nst al lat i on.
I n redesi gni ng an exi sti ng operat ing room or desi gni ng a new room, constructi on of
such a syst em shoul d be consi dered. If the operati ng rooms are not near the
outsi de of t he bui l di ng, thi s type of di sposal assembl y may not be practi cal .
Probl ems that can occur wi t h the di rect disposal system i ncl ude both posi ti ve and
negat ive pressure caused by wi nd currents, obst ruct ion f rom i ce bui l dup, and
accumul at ion of forei gn mat ter at the out let (255, 257). There needs to be a means
t o determi ne system patency. I t i s import ant t o do trace gas moni tori ng wi t h the
system i n use i n order to make certai n a f l ow-i nduci ng devi ce is not needed. A
study of thi s t ype of system found that i t worked ef fi ci ent l y and had l ow
mai ntenance costs (258).
Adsorption Device
An adsorpti on device removes some or al l excess anesthet ic agents by adsorbi ng
t hem or converti ng them to harml ess substances
(185, 255,259,260, 261, 262,263, 264). Canisters of varyi ng shape and capaci t y that
are f i ll ed wi th activated charcoal have been used f or waste gas disposal . Some can
be regenerated by autocl avi ng (265). Dif f erent vol at i l e agents are adsorbed wi th
varyi ng ef f i ci ency. The eff i ci ency of adsorpti on al so
P. 385

depends on t he f low rate t hrough t he canister (266). Moi st ure may reduce the
ef fi ci ency (267).
Adsorpti on devices are simple and port abl e and do not requi re expensive
i nstal lati on or mai ntenance. An addi ti onal advantage i s that hal ogenated anestheti c
vapors are not rel eased to t he ozone layer (266). An acti vat ed charcoal f i l ter has
been used successf ul ly t o scavenge ni t ri c oxi de and ni t rogen di oxi de (268).
Adsorpti on devices have a number of di sadvantages. At present, there i s no
adsorpti on devi ce f or ni t rous oxi de. They are fai rl y expensi ve and are eff ect i ve f or
onl y short peri ods of ti me. They must be replaced regul arl y and pose storage and
di sposal probl ems. In order to determine whet her or not t he adsorber i s saturat ed
requi res moni tori ng or wei ghi ng. Final l y, a l arge canister may impose si gni fi cant
resi st ance (259). I t i s recommended t hat adsorpt i on devi ces be l i mi ted t o si t uat i ons
where ni trous oxide i s not bei ng empl oyed and no other means of el i minati ng waste
gases i s avai l abl e.
Concerns about the rel ease of anesthet ic waste gases i nto the atmosphere and
t hei r contri buti on to global warmi ng and ozone deplet i on have been voi ced
(255, 269,270,271). Zeol i tes may be used to adsorb hal ogenat ed agents f rom the
outl et of t he scavengi ng system, thereby reduci ng at mospheri c pol l uti on
(269, 272,273).
Catalytic Decomposition
Catal yt ic decomposi ti on can be used to convert ni t rous oxi de to ni t rogen and
oxygen, reduci ng i ts contri buti on to the greenhouse ef fect (274,275).
Active Systems
Piped Vacuum
The cent ral vacuum system is a popul ar met hod of gas di sposal (276,277,278). The
system shoul d be capabl e of provi di ng hi gh vol ume (30 L/mi nut e) f l ow, but onl y
sl i ght negat ive pressure is needed. There shoul d be a means to al l ow the user t o
control t he f low. Thi s wi l l conserve energy, reduce t he l oad on the cent ral pumps,
and reduce the noise level . For some uni ts, this i s done by observi ng the bag and
t he posi t ive and negati ve pressure rel ief val ves. Others have a means to al low t he
user to adjust t he f l ow to t hat recommended by t he manuf acturer (Fi gs. 13. 5, 13.6).
A restricti ve ori fi ce may be pl aced i n the vacuum nipple t o li mi t the f l ow (279).
There are a number of probl ems associ at ed wi t h usi ng a central pi ped vacuum
system f or scavengi ng.
Inadequate Number of Vacuum Outlets
Many operati ng rooms have onl y t wo vacuum out lets. Thi s is barel y enough f or
some surgical procedures, l et alone anesthesi a use. Ideal l y, anesthesia personnel
shoul d have t wo vacuum outl ets avai l abl e, one for suct i oni ng the ai rway and one
f or scavengi ng waste gases.
I f there are not enough outl ets, a Y may be i nserted int o the vacuum l i ne to creat e
t wo l i nes. Unf ort unatel y, thi s may reduce t he fl ow so t hat i t becomes i nadequat e for
ei ther purpose.
Some anesthesia provi ders use a si ngl e vacuum li ne f or scavengi ng and pati ent
sucti oning. The vacuum l ine remai ns at tached to the i nterf ace most of the t i me and
i s det ached when needed for pat ient suct ioning. If the f low of anesthesi a gases is
not turned OFF, there wi l l be escape of anestheti c gases i nto the room ai r.
Inconvenient Outlets
I f a sucti on outl et is not near the anest hesia machi ne, l ong t ubi ngs must reach
across the f l oor, wi t h the hazards of occl usi on, trippi ng, and entangl ement wi t h
ot her apparatus.
System Overload
Because scavengi ng requi res high f l ows, t he central vacuum system may become
overl oaded if too many devi ces are i n use at t he same t ime. Overcomi ng this
probl em may requi re a maj or renovati on of t he system. System overl oad can be
reduced if anesthesia personnel adj ust the f l ow t o that necessary t o prevent gases
f rom bei ng spi l l ed int o room ai r and turn of f the f low af ter use.
Damage to the Vacuum System
Wear and tear on the vacuum pump can be expected t o i ncrease if the central
vacuum system i s used f or di sposal of waste gases. Vacuum pump f ai lure and
pump f i res have been report ed (280).
Personnel Exposure
I f the exhaust f rom the cent ral vacuum pump goes to an area f requented by
personnel or is si tuated near an ai r intake, open wi ndow, or door, t hi s wi l l resul t i n
addi ti onal exposure of personnel to wast e gases. I t may be necessary t o rel ocate
t he pump exhaust .
Inconvenience
To conserve energy, the vacuum syst em shoul d be t urned ON j ust bef ore
anesthesi a i s begun and turned OFF at t he t ermi nati on of a procedure. For f urther
energy conservati on, the anesthesia provi der shoul d adjust t he vacuum f l ow
accordi ng to the vol ume of waste gases. If these dut ies are neglected, t here wi l l be
ei ther wasted energy or operat i ng room pol l ut ion.
Acti ve Duct System
The other type of acti ve di sposal assembl y i s a dedi cated evacuati on system t hat
l eads t o the outside and empl oys f low-i nduci ng devi ces (f ans, pumps, blowers, etc. )
t hat can move l arge vol umes of gas at l ow pressures
(246, 252,278,281, 282, 283,284) (Fi g. 13.7). It has been recommended t hat two f low-
i nducing devi ces be provided and arranged so t hat i f one f ai ls, the second one wi l l
run. Several ducts may be connected together t o a common duct that l eads outside.
The f low-i nduci ng devi ce i s locat ed in the common duct and provi des movement of
gases at a l ow negati ve pressure. Bal ancing dampers should be provi ded t o prevent
pressure i mbal ances f rom developing bet ween the operat ing rooms that are
connected t o the syst em (248,278). The
P. 386

negat ive pressure hel ps to ensure that cross contaminati on bet ween operati ng
rooms wi l l not occur and prevents atmospheri c condi ti ons f rom af fecti ng t he outf l ow
f rom the system. The outl et to atmosphere shoul d be away f rom wi ndows and
venti l ati on i ntakes. A means to adj ust the f low may be i ncorporat ed i nto t he
common duct .

View Figure

Figure 13.7 Part of a piped anesthetic gas evacuation
system with a shut-off valve. The gauge is at the right.

Each operat ing room is suppl i ed wi t h an evacuati on inlet (Fi g. 13.8). I t shoul d not
be i nterchangeabl e wi t h ot her syst ems, i ncludi ng the pi ped vacuum syst em. It is
recommended t hat t here be a means to i ndi cate to t he user t hat the scavenging
system i s operati onal .
The advantages of the acti ve duct system are t hat resistance is not a probl em, and
wi nd currents do not af fect the system. Disadvantages i ncl ude those of any acti ve
system: added compl exi t y and t he need f or negat ive pressure rel i ef and reservoi r
capaci t y i n the interface. I t requi res a speci al i nstal l at ion, whi ch shoul d be
consi dered duri ng renovati on or when a new anest het i zi ng locat ion i s bei ng
designed. The f l ow-i nduci ng devi ce means added energy consumpt ion and requi res
regul ar mai ntenance.
Alterations in Work Practices
A number of work pract ices al low anest het ic gases to enter room ai r
(285, 286,287,288). Adheri ng to t he f ol l owi ng pract ices wi l l si gni fi cantl y reduce
contaminati on. Most can be fol l owed wi thout compromisi ng saf ety, and some of
t hem are benef icial to t he pat ient. Trace gas moni tori ng can be used to
demonst rate to personnel the techni ques needed t o avoid pol l ut i ng room ai r.
Adheri ng to good work pract ices should not di st ract f rom pat ient comf ort and
saf ety. For exampl e, i n pedi at ri c anesthesi a, use of uncuff ed t racheal tubes may
necessary, and hol di ng the mask t ightl y agai nst the face may be f ri ghteni ng to a
chil d.
Checking Equipment Before Use
Bef ore start i ng an anestheti c, al l component s of the scavengi ng system shoul d be
securel y connected and patent .
P. 387

I f an act i ve gas di sposal assembl y i s to be used, the f l ow shoul d be turned ON.

View Figure

Figure 13.8 Inlet for anesthetic gas evacuation (at right). A
probe attached to the gas transfer disposal tubing is inserted
into this.

Leaks i n the anest hesi a machi ne and breathing syst em can contri bute t o operati ng
room contami nat ion. The preuse checkout (Chapt er 33) shoul d reveal these l eaks
so t hat t hey can be corrected (289).
Ni trous oxide shoul d be t urned ON onl y momentari l y duri ng the preuse equipment
checkout. Most tests shoul d be conduct ed by usi ng oxygen or ai r.
Using Scavengi ng Equi pment
Fai l ure t o use avail able scavengi ng equi pment correct l y i s common (290, 291). I n
some cases, the reasons rel ate to equi pment design and specif i c ci rcumstances.
More f requentl y, however, l ack of concern is the probl em.
Proper Mask Fit
Obt ai ni ng a good mask f i t requi res ski l l but i s cri tical to mai nt ai n the l owest
possi bl e l evel s of anestheti c gases i n t he room. Mask f i t is especial l y i mport ant
duri ng assisted or cont roll ed venti l ati on, when hi gher pressures wi l l magni f y t he
l eak bet ween t he pati ent and the mask. Anesthesia by f ace mask causes the
hi ghest l evels of pol lut i on (234, 240,289,292,293,294,295). Poll uti on is al so a
probl em wi t h supragl ot t ic ai rway devi ces, al t hough l ower l evel s of anesthetic gases
are f ound wi t h these devices than wi t h f ace masks (234,292,293,296,297). An
acti ve scavengi ng devi ce near the mask (210, 241, 298) or t he use of a doubl e mask
can reduce room pol l ut ion f rom a poor mask f i t (299,300).
Preventi ng Anestheti c Gas Fl ow Directl y i nto the Room
Ni trous oxide and other agents should not be turned ON unt i l the mask i s f i tted to
t he pat ient' s f ace. Turni ng the gas f l ow (but not the vapori zer) OFF duri ng
i ntubat ion i s al so good practi ce (301,302,303, 304, 305,306). Thi s maintai ns
posti nt ubati on concent rati ons cl ose to prei nt ubat ion l evel s and decreases operat i ng
room pol lut i on.
The pati ent connect ion port on the breathi ng system can be bl ocked duri ng
i ntubat ion (307,308,309,310), but care shoul d be taken that part of t he bl ocking
device does not become di slodged and enter t he breathing system (311). The f resh
gas f l ow shoul d be turned OFF or the APL val ve opened to prevent t he bag f rom
overf i l l ing.
Di sconnecti ons can be prevented by making cert ai n that al l connecti ons are ti ght
before use. Disconnect ions for act ivi t i es such as taping t he tracheal tube or
posi t i oni ng the pat ient shoul d be kept to a mi ni mum. I f i t is necessary t o make a
di sconnecti on, rel ease of anesthet ic gases i nt o the room can be mi ni mi zed i f the
reservoi r bag i s fi rst gradual l y empt i ed into t he scavengi ng syst em and the f resh
gas f l ow i s turned OFF. Al ternatel y, the pati ent port can be occl uded and t he APL
valve opened so that the gases wi l l enter t he scavenging system. If a venti l ator
( whi ch has i ts own spil l valve) i s bei ng used, the APL valve does not need to be
opened.
Washout of Anesthetic Gases at the End of a Case
At t he end of a case, 100% oxygen shoul d be admi ni stered before extubati on or t he
f ace mask or supragl ot ti c device is removed t o fl ush most of t he anesthet ic gases
i nto t he scavenging system.
Preventi ng Liquid Agent Spill s
I t i s easy to spi l l l i qui d agent when f il l ing a vapori zer, so care shoul d be exercised.
The use of an agent -speci f i c f i l li ng devi ce (Chapt er 6) wi l l reduce spi l l age. Devi ces
t hat reduce spi l l age when usi ng f unnel -f i ll vapori zers are avai labl e.
Usi ng l ocal scavenging wi l l reduce cont aminati on associated wi th f i l l i ng and
drai ni ng vapori zers (176, 240). A portable vapori zer may be f i l l ed in a hood wi t h gas
extract ion.
The connecti ons f or f i l l i ng and draining a vapori zer shoul d be kept ti ght . If one of
t hese connecti ons i s l oose, agent may escape (312).
Avoiding Certai n Techniques
I nsuf f l ati on techni ques in whi ch an anestheti c mi xture i s i ntroduced i nto the
pati ent 's respi ratory system duri ng i nhalat i on are somet i mes used for l aryngoscopy
and bronchoscopy. These techni ques resul t i n f loodi ng the ai r around the f ace wi t h
anesthet ic agents. Hi gh f low rates are requi red to avoid di l uti on wi th room ai r and
resul t i n a cloud of anesthetic gases escaping i nto t he room ai r. Local scavengi ng
shoul d be used t o remove the anestheti c gases i f an i nsuff lati on t echnique is used.
Proper Use of Airway Devices
The use of cuff ed tracheal tubes wi l l reduce envi ronment al contami nat ion f rom
waste anesthetic gases (313). Onl y smal l l eaks shoul d be permi tted around
uncuf fed t ubes i n pediatri c pati ents. When usi ng an uncuff ed tube, cont ami nat ion
can be reduced by pl acing a suct ion catheter i n the mouth (314) and usi ng a t hroat
pack (176).
Supragl ot t ic ai rway devices usual l y have a great er l eak than cuff ed t racheal tubes
but cont ri bute l ess t o t race gas contami nat ion than anesthesia conducted wi th a
mask (234,292,293,296,297).
Where i t i s not possible t o use a l eak-ti ght devi ce, a hood can be placed around the
head and sucti on used to remove the trace gases (313,315,316).
Disconnecti ng Nitrous Oxide Sources
Ni trous oxide and oxygen pi pel i ne hoses leadi ng to t he machi ne shoul d be
di sconnected at the end of t he operati ng schedul e. The disconnect ion should be
made as
P. 388

cl ose to the t ermi nal uni t as possi bl e and not at the back of the anest hesi a machi ne
so t hat i f there is a l eak in the hose, no gases wi l l escape to room ai r whi l e t he
hose is di sconnected. This wi l l resul t in l ower l evels of ni trous oxide i n the
operati ng room and conserve gases.
When cyli nders are used, the cyl i nder valve shoul d be cl osed at t he end of the
operati ng schedul e. Gas remai ni ng i n t he machine should be bled out and
evacuated t hrough the scavenging system.
Using Low Fresh Gas Flows
Usi ng l ow f resh gas f l ows wi l l reduce the pol l uti on resul ti ng f rom di sconnect i ons i n
t he breathi ng system and f rom i neff i ci ent scavengi ng (317,318,319). I t al so al l ows
l ow removal f lows to be used wi t h act i ve di sposal assembl i es, resul ti ng in energy
conservat i on and reduced wear and tear on the disposal device. The use of a trace
gas moni t or may l ead t o use of l ower f resh gas fl ows (320). Usi ng l ow gas f l ows
does not make scavengi ng unnecessary, because hi gh f l ows must st i l l be used at
t i mes.
Using I ntravenous Agents and Regional Anesthesia
Usi ng i nt ravenous i nduct ion t echni ques signif i cant l y reduces t race gas exposure
(321).
Keeping Scavenging Hoses off the Floor
A scavenging hose on the fl oor can be obstructed or damaged by equi pment rol l ing
over i t, reducing scavengi ng.
Leak Control
Some l eaks are unavoi dable, but they shoul d be mini mi zed
(14,25,198,287,288,322,323). Leak control may requi re repl acement of equipment
t hat cannot be made gas ti ght .
Most anesthesi a machi nes are servi ced at regular intervals. Unf ort unatel y, thi s
servi ci ng does not al ways ident if y or correct al l l eak poi nts. In addi ti on, l eaks in
some equi pment devel op f ai rl y f requent l y, so quart erl y servi ci ng i s not suff icient.
I n-house moni tori ng and mai ntenance are necessary t o mi ni mi ze l eakage.
Pressure Termi nology
Some l i terature on scavengi ng has referred to al l equi pment upst ream of the f l ow
control val ves as t he hi gh-pressure system and al l equi pment bet ween the fl ow
control val ves and the pat i ent pl us the scavenging equi pment as the l ow-pressure
system (287). I n thi s book, the hi gh-pressure system refers t o those components
t hat cont ai n gas whose pressure is normal l y above 50 psig (340 kPa). Thi s i ncludes
t he components bet ween the cyl i nder and the regulator. The i nt ermedi ate-pressure
system i ncl udes components normal l y subj ected to a pressure between 50 and 55
psig. Thi s incl udes t he pi pel ine hoses and the components of the machi ne bet ween
t he pressure regul ators or pipel i ne i nl ets and the f l ow cont rol val ves. The l ow-
pressure system consists of components downstream of the fl ow control valves to
t he pat ient, plus the scavengi ng system.
Identifyi ng Leak Sites
There are several techni ques for l ocati ng l eak si tes (234). A cont inuous i nf rared
ni trous oxi de anal yzer can be used. The equipment under t est i s pressuri zed wi th
ni trous oxi de and the sampl i ng probe di rected at suspected l eak si tes. The meter
readi ng i ndi cates t he presence or absence of leaks. Thi s wi l l i dent i f y most leaks.
An except i on woul d be leakage i nt o a vapori zer.
Some l eak si tes can be i denti f i ed by appl icati on of a soluti on of 50% l i qui d soap
and 50% water or a commerci al l eak t est sol uti on. Anot her method i s to put al cohol
on one's hands and move the hands over the equipment. A l eak wi l l cause cool i ng.
Leakage can be assessed by testi ng t he capaci ty of the equi pment t o sustai n
pressuri zati on. The total l eak rate is determi ned, af t er whi ch a component is
excl uded and the l eak rate determi ned again. The di ff erence i s the l eak rate for t hat
component.
High-pressure System
To test f or l eaks i n the hi gh-pressure system, t he pi pel i ne hoses should be
di sconnected and the f l ow cont rol val ves closed. The val ve on a ni trous oxi de
cyl i nder should be opened f ul ly, the pressure recorded, and the cyl inder valve
cl osed. The pressure should be recorded agai n 1 hour l at er. I f l i t t le or no pressure
drop has occurred, there i s no si gni f icant l eakage. If i t f al l s, t he hi gh-pressure
system i s not t i ght . The test shoul d be repeat ed wi th t he other ni t rous oxi de
cyl i nder if t here i s a doubl e yoke.
I f a si gni fi cant leak is f ound, t he most common si te i s the yoke, and appl i cat i on of a
l eak t est sol uti on wi l l demonstrat e a poor seal . Tight eni ng the cyl i nder i n i ts yoke
wi l l of ten seal the leak. Ot her easi l y correct abl e causes i ncl ude doubl e, absent, or
deformed washers. If damaged parts are f ound, they shoul d be replaced. If f i xi ng
t hese probl ems does not cause the pressure t o hol d, t he leak is i nsi de t he machi ne
and must be corrected by the manuf acturer' s servi ce representat i ve.
Because l eakage i n t hi s area does not occur of ten, checking every 2 t o 4 months as
wel l as af ter a cyl i nder has been changed should be suff i ci ent (202,285,287).
Intermediate-pressure System
Leaks i n the i ntermediate-pressure system components can be determined by
measuri ng the ni trous oxide concent rat i ons i n the operati ng room when no
anesthesi a i s bei ng admi ni stered (287). The survey shoul d begi n at l east 1 hour
af ter admi ni st rat ion of anesthesi a has been di sconti nued. I f a
P. 389

reci rculati ng ai r condi ti oni ng system i s in use, a l onger period may be requi red. The
earl y morni ng i s an excell ent ti me to perf orm this test .
Fl ow cont rol valves should be closed, pipel i ne hoses connected, and cyl i nder
valves cl osed. Room ai r should be sampl ed at t he anesthesi a breathing zone (4 t o
5 feet above the f l oor wi t hi n 3 f eet of the f ront of t he anesthesi a machine) and the
room ai r i nt ake and out let. Ni t rous oxi de concent rati ons shoul d be less than 5 ppm
(153, 230). I f a hi gher l evel i s found, t he pi pel i ne hoses shoul d be di sconnected and
t he measurements repeated af ter a peri od of t ime. If a hi gh l evel is sti l l present ,
t his i ndi cates a l eak i n the ni t rous oxi de pi pe leadi ng i nto the room or the stat i on
outl et and shoul d be reported to the heal th care f aci li t y engi neer. I f the l evel f al ls,
t his i ndi cates a l eak i n the pipel i ne hose or t he anesthesi a machi ne.
Common probl ems wi th pi pel i ne hoses incl ude worn or l eaki ng connecti ons
(especi all y qui ck connects), def ormed compressi on f i t ti ngs, and hol es. These
shoul d be corrected or the hoses repl aced. Leaks i nsi de the anesthesi a machi ne
requi re correct i on by a servi ce representat ive.
Once l eaks are corrected, i t i s suggest ed that t est i ng of the intermedi at e system be
perf ormed every 2 t o 4 months (198,230,285, 287).
Low-pressure System
The l ow-pressure porti on of the system devel ops leaks more f requentl y than other
parts. The preuse test for l eaks i n the breathi ng system (Chapter 33) i s suf f i ci ent
f or the saf e conduct of anesthesi a, yet can mi ss l eaks that emi t l arge amounts of
anesthet ic gases i nto room ai r.
One way t o quanti f y l eakage i n most of t he l ow-pressure system i s shown i n Figure
13.9. The breathing syst em is assembl ed f or use. Al l components that are normal l y
used should be present i n thei r usual posi tions. The pati ent port i s occl uded. The
bag i s removed and t he bag mount occl uded. Thi s is necessary because the bag' s
compl i ance makes i t hard to quant i tate low l eak rates. The bag shoul d be t ested
separately f or l eaks. A vapori zer on t he anesthesia machine shoul d be turned ON.
The APL val ve shoul d be f ul l y open and t he scavengi ng system occl uded upst ream
of t he i nterf ace. The oxygen f low cont rol val ve i s now opened suf f i ci ent l y to
establ i sh and mai ntai n a steady pressure of 30 cm H
2
O on the pressure gauge i n
t he breathi ng system. The f l ow on the oxygen f l owmeter i s the l eak rate and shoul d
be l ess t han 1,000 mL/minute. Leakage of 1,000 mL/mi nute of ni t rous oxi de woul d
resul t i n a mean concent rati on of only 30 ppm i n a 4,000 cubi c f oot room wi t h 15 ai r
changes per hour (248). The l eakage test shoul d be repeat ed wi t h the other
vapori zers t urned ON.

View Figure

Figure 13.9 Test for quantifying low-pressure leakage. (1)
The reservoir bag is removed, and the bag mount is
occluded. (2) The patient port is occluded. (3) The APL
valve is opened fully. (4) The transfer means is occluded
just upstream of the interface. (5) Oxygen flow is turned on
and adjusted to maintain a pressure of 30 cm H
2
O on the
pressure gauge in the breathing system.

I f the l eak rat e exceeds 1,000 mL/ minute, the APL val ve shoul d be cl osed and the
l eak rate agai n determi ned. The di ff erence i s the l eak rate in t he scavengi ng
system. The remai ni ng l eakage can be di vi ded i nto t hat associated wi t h t he
machi ne and that associ ated wi th t he breathing syst em by at tachi ng a
sphygmomanomet er bul b to the anesthesia machi ne common gas outl et and
determining t he oxygen f low necessary to achieve and mai ntai n a pressure of 22
mm Hg. Thi s is t he port ion of the l ow-pressure l eakage associ ated wi t h the
machi ne. The machi ne l eak si te can be f urther ref i ned by turni ng the vapori zer OFF
and agai n det ermi ni ng the l eak rate.
Probl ems in t he scavenging system may be as si mpl e as a crack in a tubi ng
(especi all y where i t becomes ki nked) or a poor connect ion.
The breathi ng system i s the most common l ocati on f or si gni f icant l ow-pressure
l eaks, and the most common si te i s the absorber. Common probl ems i ncl ude
defective gaskets or seal s, i mproper cl osure, inadequat e ti ghteni ng, and open or
l eaki ng drai n cocks. Absorbent granul es on the gaskets can prevent a t i ght seal .
Di sposabl e canisters may be cracked during t ransi t and l eak af ter bei ng i nstal l ed.
Most of t hese probl ems are easi l y corrected. Compl i cat ed repai rs shoul d be done
onl y by t he servi ce representat i ve.
The above t est does not check for l eaks i n the venti l ator. The vent i lat or and the
l ow-pressure system can be t ested by using an i nf rared ni t rous oxi de anal yzer. The
anesthesi a machine and breathing system are set up f or cl inical use. The pati ent
port outl et i s occl uded and the bag/venti l ator sel ector swi t ch put i n the bag mode.
The APL val ve is cl osed. Using the f l owmeters, the breathi ng system i s pressuri zed
t o 30 cm H
2
O wi t h a 50% mi xture of ni t rous oxi de and oxygen. The machi ne and
breat hi ng system are scanned f or ni trous oxi de l eaks. The sel ector valve is t hen put
i n the venti l ator mode and t he f lowmeters set to del i ver 2 L/ mi nut e oxygen and 2
L/ mi nute ni t rous oxi de. The vent i l ator i s t urned ON and set to a
P. 390

t i dal vol ume such that a peak pressure of 30 cm H
2
O i s reached. The scavenger
system i s act i vated. The machi ne, vent i l ator, breathi ng system, and scavenging
system are scanned. Readings should not be greater t han 25 ppm ni trous oxide.
A venti lator wi t h a standi ng bel lows can be checked for l eaks by f i l l i ng t he bel l ows
wi th gas, t hen swi t chi ng the bag/vent i lator sel ector swi t ch to the bag posi ti on. The
bel l ows shoul d remai n ful l y i nfl ated. A hangi ng bel l ows can be t ested f or leaks by
stoppi ng i t duri ng inspi rati on and pl aci ng the bag/vent il ator sel ector swi tch i n the
bag posi ti on. The bel l ows should remai n compressed.
I t i s cont roversi al as to how of ten the low-pr essure system shoul d be test ed for
l eakage. Suggested i nterval s vary f rom dai ly (230, 285) to every other week (287) t o
monthl y (198). It shoul d be repeated wi th new equi pment and when t he absorbent i s
changed.
Room Ventilation System
The room venti lati on system serves as an import ant adj unct to t race gas control by
di l uti ng and removing anesthet i c gases resul t i ng f rom l eaks, errors i n techni que,
and scavengi ng system mal f unct i ons (324,325,326,327,328). Reci rcul at ing syst ems
are less eff ecti ve at removing t race gases than nonreci rcul ati ng systems. A
downward displ acement venti l ati on system i s more eff ect ive than a turbul ent f l ow
system (183). A turnover rate of 20 exchanges per hour i s considered necessary to
prevent bacteri a f rom sett l i ng (329).
The anesthesi a machi ne should be pl aced as cl ose to t he exhaust gril l e as
possi bl e. Thi s wi l l ensure maxi mum gas removal by the vent il at i on system and
make i t easy to use the vent i l at ion system as the gas-di sposal system. Thi s shoul d
be taken i nto considerati on when const ructi ng a new operati ng room or renovati ng
an ol der one.
Onl i ne ambi ent ai r cont rol has been proposed (10,330). This would permi t the room
venti l ati on to be matched t o the actual contami nat i on level .
Hazards of Scavenging Equipment
Misassembly
Mi sconnecti ons i nvol vi ng the scavenging system are not uncommon (331, 332). Most
scavengi ng components have 19- or 30-mm connect ions rather than the 15- and 22-
mm si zes found i n breathi ng systems. This wi l l not compl et el y prevent
mi sconnecti ons, because t here may be other apparatus i n the room t hat wi l l accept
19- or 30-mm connecti ons (325,325A), and someti mes a 19- or 30-mm connector
can be f i tted ont o a 22-mm one (333,334). The saf et y provided by 19- and 30-mm
connectors can be bypassed by using cheater adapters or tape for maki ng
connecti ons.
A ci rcl e system hose may be connected t o the outl et of the APL val ve col lect ing
assembl y (194,195,335,336). Measures t o prevent thi s i ncl ude turning t he exhaust
port of the gas-col lecti ng assembl y so t hat i t poi nts i n the opposi te di rection f rom
t he breathi ng system ports, use of t ransf er and gas-di sposal t ubi ngs of di ff erent
colors and/or conf igurati ons f rom breathi ng system t ubes, and using 30-mm
connecti ons i n the scavengi ng system.
Pressure Alterations in the Breathing System
The scavengi ng system extends the breathing syst em al l the way t o the gas-
di sposal poi nt. When a scavengi ng syst em mal f unct i ons or i s misused, posi ti ve or
negat ive pressure can be t ransmi t t ed to the breathing system. This i s more l ikel y to
occur wi t h closed interf aces.
Measures to prevent these untoward i nci dents i ncl ude empl oying col l apse-resi stant
materi al in al l di sposal l i nes, maki ng t he transf er means easy to di sconnect, usi ng
scavengi ng tubi ng that has a di sti ncti ve appearance, i ncorporat ing posi ti ve and
negat ive pressure rel i ef valves i n the interface, regularl y checki ng the valves f or
proper f unct ioning, usi ng an open interf ace, and usi ng ai rway pressure moni tors
(Chapter 23).
Positive Pressure
Posi t i ve pressure in the scavenging syst em can resul t f rom an occl uded t ransf er or
gas-disposal tubing. This can be caused by the wheel of an anesthesi a machi ne or
ot her equi pment rol l i ng onto t he tubi ng (195,337,338,339,340), ice (257), i nsects,
wat er, or ot her f orei gn matter. Another cause is defective components (341).
Mi sassembl y of the connecti on to t he exhaust gri l l e (342) and f ai l ure t o i nclude an
openi ng bet ween the inner and out er tubes of a tube-wi thi n-a-tube int erf ace (343)
have been report ed.
These mal funct ions may not resul t i n a pressure bui l dup when a posi t i ve pressure
rel i ef mechanism i s i ncorporated i nt o the i nterface. The posi ti ve pressure rel ief
mechani sm may be i ncorrectl y assembl ed, may not open at a l ow enough pressure,
or may be blocked (344). Obstruct i on or misconnect i on of the transfer t ubi ng may
occur (334, 345,346, 347, 348,349). Because t hese probl ems are on the pati ent si de
of t he i nterf ace, di sconnecti ng the t ransf er means f rom the gas-col lecti ng assembl y
may be necessary t o prevent a dangerous increase i n pressure. I n one reported
case, t he transf er tubing was ki nked, causi ng back pressure to develop in t he gas
j acket of an extracorporeal oxygenator. This resul ted in gas bei ng forced int o the
bl ood (350). Al l tubi ngs that conduct scavenged gas shoul d be of f t he f l oor or
protect ed so that t hey cannot become obst ructed (339).
Wi th some ol der APL val ves, subatmospheri c pressure can resul t i n obstructi on and
a bui l dup of posi tive
P. 391

pressure i n the breathi ng system (343,351). In one report ed case, subatmospheri c
pressure i n the scavengi ng system drew a venti lat or rel ief val ve di aphragm onto i ts
seat and closed the valve, resul t i ng in a pressure i ncrease i n the syst em (352).
I n anot her report ed case, l ow scavengi ng f low resul ted in an i ncrease in pressure i n
t he bag at t he i nterf ace. Thi s caused the vent i l ator t o fai l , and t here was sustai ned
posi t i ve pressure i n t he pati ent ci rcui t (353). On newer model s, onl y f ul l f l ow can be
used for scavengi ng.
Negative Pressure
I f an act i ve di sposal system i s i n use and the APL val ve i s ful l y open, there i s
danger t hat subambient pressure wi l l be appl i ed to the breathi ng system.
Moni tori ng expi red volume (but not ai rway pressure) may f ai l to detect a
di sconnecti on i n the breat hi ng system because the scavengi ng system may draw a
consi derabl e fl ow of room ai r through t he expi ratory pathway (354,355,367).
Gas may be evacuated f rom t he breathi ng system i f the APL val ve al lows gas to be
drawn through i t and into t he scavenging system at a pressure l ess t han t hat
needed to open t he negati ve pressure valve on the i nterf ace (356,357). Thi s
probl em can be correct ed by part i al l y cl osi ng the APL valve (358), i ncreasi ng the
f resh gas fl ow, or l oweri ng the f l ow i n t he gas disposal system.
The negative pressure rel i ef mechani sm may mal f unct ion
(344, 359,360,361, 362, 363). Another probl em is usi ng an interf ace designed f or a
passi ve system ( whi ch has no means to prevent a subatmospheri c pressure) i n an
acti ve scavengi ng system (346). In some scavengi ng systems that use the cent ral
vacuum system, a restricti ve orif i ce is i ncorporat ed i nto the vacuum hose f i tt ing to
l i mi t gas evacuat ion, regardl ess of the pressure appli ed by t he central vacuum
source (279). If t his ori f i ce i s omi t t ed or becomes damaged, excessi ve vacuum wi l l
be appl i ed t o the i nterf ace and the capaci t y of the negati ve pressure rel ief
mechani sm may be exceeded.
Ways t o prevent negati ve pressure f rom bei ng t ransmi tted to t he breat hi ng system
i ncl ude provi si on of one or more negati ve rel i ef mechanisms i n the i nt erface wi t h an
acti ve di sposal system (364), adj ust ing the f low t hrough the gas di sposal system to
t he mini mum necessary, and protecti ng the openi ngs t o atmosphere f rom acci dental
occl usi on.
Loss of Monitoring Input
A scavenging system may mask the strong odor of a vol ati l e anestheti c agent,
del aying recogni ti on of an overdose (345,365). Use of anestheti c agent moni tori ng
(Chapter 22) should l argel y el i mi nate thi s probl em.
Alarm Failure
A case has been report ed in whi ch negat ive pressure f rom the scavengi ng system
i nterf ace prevented the vent il ator bel l ows f rom col l apsi ng when a disconnecti on i n
t he breathi ng system occurred (366). The l ow ai r way pressure al arm i n the
venti l ator was not act ivated. I n another case, room ai r was drawn i nt o the breat hi ng
system t hrough a di sconnecti on, preventi ng the l ow mi nute volume alarm f rom
soundi ng (367).
Monitoring Trace Gases
Rationale
Ai r moni tori ng i s the best i ndi cat or of the success of a waste gas cont rol program.
I t ref l ects how wel l l eaks and errors i n technique are bei ng cont rol l ed as wel l as t he
ef fi ci ency of t he scavenging and room venti l at ion syst ems and documents that l ow
t race l evel s are bei ng mai ntai ned. Some anestheti c depart ments do not moni tor
t race gas l evel s in t he bel i ef that scavengi ng devices have sol ved the probl em
(368).
Moni tori ng i s necessary because a scavengi ng system that appears adequat e i n
design may perform i neff icientl y in use. Si t es where gas can l eak are di verse,
f requent l y obscure, and someti mes i naccessibl e. Even relati vel y large l eaks may be
i naudi bl e. Ni t rous oxi de i s odorl ess, and the t hreshold f or smel l ing hal ogenated
agents may be as hi gh as 300 ppm (369). Wi t hout moni tori ng, operati ng room
personnel may be unaware t hat atmospheri c cont aminati on i s at unacceptabl e
l evel s. A properl y conducted moni tori ng program can provi de a construct ive met hod
of remi ndi ng anesthesi a personnel t o avoi d carel ess work habi ts. Anot her
advantage of moni tori ng is that i t can detect probl ems wi th gas del ivery to
equipment (370).
Al though such a program wi l l i ncrease a heal th care f aci l i t y' s operati ng expense, i t
wi l l hel p t o reduce t he i nst i tut ion's l i abi l i t y to cl ai ms by empl oyees all eging t hat
exposure to waste gases cont ri but ed to a spontaneous abort i on or other medi cal
probl ems. Correct i ng certain l eaks such as t hose associated wi t h t he pi pel i ne or
pi pel i ne hose can resul t i n a savi ngs t o the f aci li t y.
In-house versus Commercial Laboratory
The moni tori ng program shoul d be di rected by an i nterested and qual i f i ed person,
pref erabl y f rom the anesthesi a depart ment . Sampl es may be anal yzed by ei t her
f aci li t y-based personnel or outside commercial l aboratori es. The use of an outsi de
l aborat ory avoi ds the cost of purchasi ng, operati ng, maintai ni ng, and cal i brati ng a
gas anal yzer. The responsibi l i t y for record keepi ng i s shared.
P. 392

The chief di sadvantage i s the delay in reporti ng resul ts. The precise ci rcumstances
at t he t ime the sampl es were taken are l i kel y to have been f orgot ten, and the ef f ect
of corrective measures cannot be i mmedi atel y assessed. In addi ti on, anal ysi s of a
l arge number of sampl es i s expensive.
Advantages of in-house anal ysi s i nclude a vi rt ual l y unl i mi t ed number of anal yses at
modest cost and i mmedi at e on-si te reporti ng. Leaks can be f ound quickl y and the
ef fectiveness of the correcti on assessed i mmediatel y. An on-si t e cont i nuous
moni tor i s usef ul f or demonst rati ng the eff ects of t echni que errors on t race gas
l evel s and the resul ts of correcti ons.
A smal l f aci li t y mi ght periodical l y l ease an i nstrument or share one wi t h other
heal th care faci l i ti es i n t he area rather than purchase i ts own.
Equipment for Determining Trace Gas Concentrations
Infrared Anal yzers
I nf rared gas analyzers were discussed in Chapter 22. These moni tors are the most
pract i cal f or t he average heal th care i nst i tuti on because t hey are rel i abl e, relati vel y
i nexpensive, and easy to use (371). They are usef ul f or l ocati ng l eaks, especi al ly
t hose i n unusual l ocati ons. They give cont i nuous measurements so that exposed
personnel and those responsi bl e f or ai r moni tori ng are gi ven an i mmedi ate reading.
When operated on battery power, a number of l ocati ons can be sampl ed quickl y. A
recordi ng at tachment may be hel pf ul .
These inst ruments are most of ten used f or moni tori ng ni t rous oxi de. Unfort unat el y,
carbon dioxi de and wat er vapor i n hi gh concent rat i ons wi l l int erf ere wi th t he
analysi s. This can be avoi ded by sampl ing at least 6 t o 10 inches away f rom
personnel . Anal yzers capabl e of measuri ng hal ogenated anesthet ics are avail able
but have many techni cal dif f icul ti es; alcohol s and ot her substances i n the operati ng
room cause i nt erf erence (66,371,372).
Proton Transfer Reaction Mass Spectrometry
Proton t ransf er reacti on mass spect rometry al lows measurement of t race gases i n
parts per bi l li on (373). It has been used to measure trace gases both i n ambient ai r
and exhal ed gases (10,296,374). This technol ogy i s not avai lable f or i n-house use.
Dosimeters
Passi ve dosimeters measure the amount of ni trous oxide t hat di ff uses i nto a
mol ecul ar si eve (375). Anal ysis (usual l y by t he manuf act urer) requi res extract ion of
t he ni trous oxide.
Passi ve dosimeters have many advantages. They can give a t i me-wei ghted average
(TWA) concent rati on for as l ong as a month. They are conveni ent to use. They can
be made l i ght wei ght and compact so that t hey can be worn f or personal sampl ing.
A variant of the passive dosimeter i s t he gas cart ri dge sampl er, whi ch i s a smal l
contai ner that i s f i ll ed wi th a sample of operat ing room ai r and then sent to t he
l aborat ory f or anal ysi s.
Act i ve dosimeters depend on energy outsi de of the absorbi ng medi um to obtai n the
sampl e. A pump is used to t ake i n gases that are then stored i n a gas-t i ght bag in
an absorbi ng medi um. The sampl es are aspi rat ed i nto an anal yzer.
Ionizing Leak Detector
The i oni zi ng l eak detector (l eak meter) consi sts of three components: an el ect ron
capture det ector housed wi t hi n a hand pi ece and f i tt ed wi th a probe, a cont rol uni t
t hat processes the si gnal f rom the detector and displays the out put on a meter, and
a carri er gas suppl y (198,376). The inst rument is compact, rel at ivel y i nexpensive,
portabl e, and can be operated on bat teri es.
The i oni zi ng l eak detector is sui tabl e for measuri ng low concent rati ons of
hal ogenated agents. However, there may be i nterference f rom other hal ogenat ed
agents i n the area, i ncl udi ng anti bi oti c and ski n-prot ecti on sprays. It i s not usef ul
f or ni trous oxide det ection. I t is somewhat unst abl e i n use, requi ring f requent
zeroi ng and recal i brati on (198, 324).
Oxygen Analyzer
An oxygen moni tor can be used to check the scavengi ng system. Usi ng 100%
oxygen, the sensor is posi ti oned at the interface where overfl ow would exi t i nt o the
room. Any i ncrease in oxygen i ndi cates that anestheti c gas wi l l be rel eased duri ng
normal use.
Carbon Dioxi de Anal yzer
The eff icacy of scavengi ng wi th an open i nterface can be checked by anal yzi ng the
open end of the reservoi r f or carbon di oxide (243). I f any of the pati ent' s expi red
gases overf l ow, carbon dioxide wi l l be det ected.
Sampling Methods
Instantaneous Sampling
I nst antaneous (grab, si ngl e-shot , peri odi c, snatch) sampl i ng i s performed by
drawi ng a sampl e of ai r i nt o a container and subsequentl y measuri ng the trace gas
concentrati on. The container must not adsorb or absorb t he contami nant or l eak.
Nyl on bags are the preferred storage contai ner when ni trous oxide l evel s are
measured (176,377).
When an i nstant aneous sampl e i s taken, i t i s import ant to record the date and t i me
of col lecti on, the work practices, anesthesi a machi ne, breathi ng system, f resh
P. 393

gas f l ow, ai rway devi ce (face mask, supragl ot ti c ai rway devi ce or t racheal tube),
t ype of venti l at ion, venti l ator, anestheti c agents used, l ocati on of sampl ing si te, and
t he person admi ni steri ng anesthesia.
Thi s met hod i s rel at ivel y i nexpensi ve, quick, and simple t o perf orm and does not
i nvol ve taki ng bulky equi pment i nto the operati ng room. There are some seri ous
di sadvantages. A l ong i nterval bet ween sampl ing and report i ng makes i t di f f i cul t t o
remember t he preci se ci rcumstances under whi ch the sampl e was t aken. The ef fect
of corrective measures cannot be i mmedi atel y assessed. It i s of l i mi t ed val ue i n
determining l eak si tes and assessi ng leak correcti on. Another seri ous disadvantage
i s that each sampl e represents the l evel at one l ocati on i n a rel at ivel y smal l vol ume
and over a very short t i me peri od. Fai lure to sampl e i n the ri ght place at the ri ght
t i me can produce resul ts that are mi sl eadi ng (14). One invest i gat ion concluded that
gradi ents i n operati ng rooms were suf f i ci entl y l arge to i nval i dat e est i mati on of
personnel exposure f rom i nstantaneous sampl es (378). Thi s disadvantage can be
decreased by t aki ng mul t ipl e samples, but thi s i ncreases the expense.
The i nst antaneous sampl e i s probabl y best empl oyed for anal ysis of steady-stat e
contaminati on, that is, sampl i ng bef ore start i ng anest hesi a f or i ntermedi ate
pressure l eaks or when equi li brium has been achi eved. If good techni ques are
empl oyed and l eaks have been corrected, trace gas level s tend to ri se i n a
f luctuati ng pattern duri ng t he earl y part of an anestheti c and t hen roughl y
equil i brate, reachi ng a l evel t hat represents the net ef fects of leaks, ai r
condi ti oni ng, inf l owi ng gas, scavenging eff iciency, and personnel movement (378).
Under these ci rcumst ances, an i nstantaneous sampl e 30 to 45 mi nutes af ter
i nducti on i s probabl y a good i ndex of the average t race gas level s (230,378). I f
poor techni ques are employed and/or no attempt has been made to el i minate l eaks,
pol l ut ion l evels wi l l vary markedl y and i nstant aneous sampl es may be qui te
mi sl eadi ng. If unaccept abl y hi gh level s are f ound, one cannot be sure whet her t he
cause i s a l eak, poor techni que, or a f aul t in t he scavengi ng system.
Sampl ing at the Air Conditi oni ng Exhaust
Samples may be t aken at t he ai r condi t i oni ng exhaust gri ll e (289,379). This l ocat i on
gi ves a general i ndi cat i on of t he overal l l eakage i nto t he room but not of
i ndi vi dual s' exposure to t race gases.
Time-weighted Average Sampl ing
The t oxi ci t y of anestheti cs i s probabl y a funct ion of bot h dose and exposure ti me.
Hence, a method t hat gives an average exposure l evel duri ng a peri od of t i me (an
i ntegrated sampl e) i s of i nterest. TWA sampl i ng i s al so known as i nt egrated or
t i me-i ntegrated sampl i ng.
TWA sampl es can be obtai ned by using acti ve dosi metry i n whi ch gases are
pumped conti nuousl y over a peri od of t i me i nt o an inert contai ner (372,380,381) or
a device contai ni ng an adsorbent mat erial (176,382,383,384,385,386).
Passi ve dosimet ry, whi ch depends on gas di ff usi on i nto a mol ecular si eve, can be
used to obtai n TWAs (387). Smal l , rugged, l i ght wei ght dosi meters (dif fusi ve
sampl ers) are avai lable (318,387,388,389). They are unobt rusive, easi l y at tached,
and requi re a mi ni mum of mai ntenance (182). They can be used ei ther as personal
or area moni tors f or up to 40 hours (388). They have been found to be qui t e
accurate (387,388). Separat e sampl ing medi a have to be used f or ni trous oxide and
t he hal ogenat ed agents (2). However, more than one hal ogenated agent can be
measured f rom one sampl er.
Ot her ways of obtai ni ng a TWA are t o average the resul ts of many instantaneous
sampl es, average the concentrat ions measured at equal ti me i ntervals throughout
t he recorded traci ng of a conti nuous anal yzer, or i ntegrat e the output of a
conti nuous anal yzer (390).
By el i mi nati ng errors due to t emporal f l uct uat i ons, TWA sampl ing ref l ects personnel
exposure bet t er than inst antaneous sampl i ng. I t requi res onl y a modest capi tal
i nvestment, and there i s consi derabl e t i me and labor savi ngs compared wi t h taking
and anal yzi ng mul ti pl e instant aneous sampl es.
There are several di sadvantages to ti me-wei ght ed sampl i ng. I t does not help wi th
detecti ng l eaks or improvi ng work techni ques. Delayed resul ts make i t di f f i cul t t o
correlate wi th activi ti es at the t i me of col lect i on. If concent rati ons i n excess of
t hose recommended are f ound, one cannot tel l whether the probl em is t echni que
errors, l eaks, or inadequate scavengi ng.
Continuous Sampling
Conti nuous (di rect -readi ng, real ti me) moni tori ng i s carri ed out by usi ng an i nf rared
analyzer, l eak meter, or proton t ransf er reacti on mass spect rometry. The use of a
bat tery-powered i nstrument al lows f or easy movement wi thi n and bet ween rooms. I f
a wri t er i s att ached and t he anal yzer i s run over a period of ti me, a TWA sample i s
obtai ned (176,390).
Conti nuous moni tori ng can be used to detect l eaks and to det ermi ne i f a l eak has
been reduced or el i mi nat ed. A conti nuous anal yzer operated whi l e anesthesi a is
bei ng admini st ered can be used to demonstrate t he ef fects of improper work
pract i ces on t race l evel s and the i mprovement f rom modi f yi ng t hose pract ices.
The conveni ence and i mmedi ate f eedback of conti nuous moni t ori ng are disti nct
advantages over i nstantaneous or TWA sampl ing. When hi gh readi ngs are obtai ned,
t he causes can usual l y be determi ned i mmedi at el y and correcti ve measures taken.
A di sadvantage of cont inuous moni tors is that t he t ime and expense requi red t o
mai ntai n t he i nst rument
P. 394

may make i t unsat isfactory f or a smal l f aci li t y. I n such ci rcumst ances, several
f aci li t ies mi ght consider shari ng an i nst rument, or a manuf acturer' s service
representati ve might use one during routi ne quarterl y mai ntenance cal ls. Thi s
method tends to di srupt t he operat ing room routi ne more than i nstantaneous or
TWA sampl i ng. Fi nall y, rapi dl y changi ng concent rati ons are di ff icul t to i nt erpret i n
t erms of personnel exposure unl ess i ntegrati on over t i me i s empl oyed.
Personnel Sampli ng
End-t idal samples of gases may be t aken f rom exposed personnel af ter a peri od of
exposure (8,186, 374, 378,391,392, 393,394,395,396). This method i s most sui tabl e
f or potent hal ogenat ed agents. Ni t rous oxi de i s so rapidl y absorbed and excreted
t hat i ts l evel i n end-ti dal gas refl ects onl y the most recent exposure.
Bl ood sampl es can be drawn f rom personnel at the end of an exposure peri od and
analyzed (183, 391,393,397). Uri nary concentrati ons of anesthet ic agents show a
si gni f icant correl ati on wi th envi ronmental exposure
(395, 398,399,400, 401, 402,403, 404).
Agents to Be Monitored
I deal l y, al l gases empl oyed in t he conduct of anesthesi a wi th t he excepti on of
oxygen shoul d be measured. Anal yzers t hat can scan the i nf rared spect rum and can
be programmed t o disti ngui sh i ndi vi dual i nhal at ional agents are avai labl e. Li kewi se,
mass spect romet ry and gas chromatography can measure al l agents. However, i t is
si mpl er t o moni tor a single gas. The NI OSH cri t eri a document (285) does not
recommend moni toring of al l anesthet ic agents but onl y t he one most f requent ly
used.
Nitrous Oxide
Many peopl e bel i eve that ni t rous oxi de is the most l ogical agent t o moni tor because
i t is administered i n higher concentrat ions than other agents, is easy to measure,
and i s more l i kel y to be subj ect to occul t leakage than volati le l i qui d agents.
Because ni t rous oxi de and other agents are not separat ed by buoyancy eff ects
(198, 324), t hey wi l l be present i n a room i n t he same rati o i n whi ch t hey are
i ntroduced. Because of thi s, many peopl e contend that ni trous oxi de can serve as a
t racer f or other agents admi ni stered wi t h i t t o a degree of accuracy suf f icient t o
assess occupati onal exposure. Thi s t racer concept works best under steady-state
condi ti ons and l ow equipment l eakage. It does not work wel l when a vapori zer i s
bei ng f il l ed or drai ned, duri ng cardiopul monary bypass, duri ng i nducti on or recovery
f rom anesthesi a, or when t here i s a large ni t rous oxi de l eak or a leak i n a
vapori zer.
Volatile Agents
Moni tori ng agents other than ni trous oxide can be worthwhi l e (405,406). Vol at il e
agents can l eak independentl y of ni t rous oxi de. Anal yzers that measure potent
agents are more expensi ve than those that measure onl y ni t rous oxi de.
Sites to Be Monitored
Moni tori ng shoul d be schedul ed so that t he work of each anesthesi a provider and of
each operat i ng room i s checked whi le usi ng a mask, supragl otti c devi ce, and
t racheal tube. Moni t ori ng shoul d be performed duri ng spontaneous, manual l y
assi sted, and manual l y cont rol l ed and automati c venti l ati on. The resul ts of the
moni tori ng shoul d be anal yzed and di scussed wi t h al l parti es concerned.
Personal Monitori ng
When moni tori ng worker exposure to waste anesthet ic gas l evel s, t he Occupati onal
and Saf et y Heal th Organi zat ion (OSHA) mandates that sampli ng be perf ormed i n
t he worker' s breat hi ng zone (407). Anesthesia personnel are consi dered the most
i mportant to moni t or, because t hey usual l y are exposed t o higher concentrat ions
t han ot her operati ng room personnel (389) and are more l i kel y to remai n in the
room for t he enti re durat i on of anesthesi a admi ni st rat i on.
Passi ve dosimeters can be at tached t o the person' s cl othing and worn f or
prol onged peri ods. Sampl i ng di rectl y i n t he subject 's expi rat ory pathway must be
avoided if measurement of ni t rous oxi de by i nf rared anal ysis i s used.
Area (Room) Sampling
The exhaust gri l l e of the ai r condi t ioning system or t he open door wi l l be
representati ve of average personnel exposure i f gases are evenl y di st ri buted i n t he
room. Fi f t een or more ai r exchanges per hour are suff icient t o produce near
homogenei t y of anest het ic concentrat i ons in al l l ocati ons except those cl ose t o the
l eak (66, 82,324). Wi th l ower exchange rates, mixing may not be compl ete, and
l ocal i zed areas of high (hot spots) or l ow (col d spots) concent rat i on may occur.
Area sampl i ng may be l ess di srupt ive to the operat ing room routi ne t han personal
moni tori ng.
Monitoring Frequency
At t he i ni t i ati on of a waste gas control program, f requent moni tori ng under actual
worki ng condi t i ons wi l l be necessary. As experi ence i s gai ned and equi pment is
mai ntai ned l eak ti ght, t he f requency can be decreased. Whenever hi gher-than-
acceptabl e concent rati ons are f ound,
P. 395

new equi pment i s install ed, or ol d equi pment i s modi f i ed, moni tori ng shoul d be
repeated.
The f ol lowi ng schedul e has been suggested (14):
An annual comprehensi ve survey i n whi ch exposure level s are measured,
l eaks detected and corrected, and TWA exposure l evels are cal cul ated or
measured.
Quarterl y foll ow-up wi th a less-det ai led survey; i f there appears t o be a
probl em, a comprehensive survey should be perf ormed to determi ne causes
and assess correcti ve acti ons.
A repeat comprehensi ve survey i n the event of maj or changes to the
venti l ati on system, anesthesi a equipment, or scavenging syst ems.
TWA moni tori ng of each member of the staff f or a short peri od, such as a
week, repeated on a 6-mont h basi s al so has been suggested (372).
Role of the Federal Government
I n 1970, the U.S. Congress passed t he Occupati onal Saf et y and Heal th (OSHA) Act
(14,408,409). I t created two separat e executi ve-branch agenci es to carry out t he
provi si ons of the act: the Nat i onal Insti t ute of Saf ety and Heal th (NIOSH), an
agency wi th t he Centers for Disease Control and Prevent ion under the Depart ment
of Heal th and Human Services, and OSHA, under t he Depart ment of Labor (176).
NI OSH i s responsi bl e f or conducti ng and f undi ng research and educat ion and f or
prepari ng cri t eri a documents to be used to devel op standards. Cri teri a documents
prepared by NI OSH are t ransmi tted to t he secretary of l abor f or revi ew by t he
OSHA staf f .
OSHA is responsi bl e for enacti ng j ob saf et y and heal th standards, est abl i shi ng
reporti ng and recordkeepi ng procedures, i nspect i ng workpl aces, and enforci ng the
requi rements of the act by usi ng ci tat i ons and f i nes (176).
A cri t eri a document on trace gases was publ ished and t ransmi tt ed to OSHA i n 1977
(285). I t i ncluded t he fol l owi ng provi si ons.
Al though a safe l evel of exposure to t race anestheti c gases could not be
defi ned, maxi mum concent rati ons to whi ch a worker in t he operat ing room
shoul d be exposed were recommended. For ni trous oxide al one, a TWA
exposure l imi t of 25 ppm was recommended. For hal ogenated agents used
al one, the l i mi t was 2 ppm TWA. When hal ogenat ed agents are used i n
combi nati on wi th ni t rous oxi de, the recommended l imi ts were 25 ppm ni trous
oxide and 0.5 ppm of the halogenated agent. For dental f aci l i t ies, a l evel of
50 ppm ni trous oxi de was recommended. These were arbi t rary l evels and
were not based on t oxi c ef fects. Isof l urane, desfl urane, and sevofl urane were
not i ncl uded i n t he recommended exposure l i mi ts because they were not i n
cl i nical use i n 1977. Hi gher l i mi ts are recommended i n ot her count ri es
(255, 294,410,411).
I sof lurane and desf l urane l evel s can be kept bel ow t he NIOSH l evels
rel ativel y easi l y (409, 410, 412,413, 414). Except duri ng a mask i nducti on,
l evel s of sevof l urane can al so be kept under 2 ppm (415, 416,417,418).
However, i t may be di ff icul t to achi eve this l evel when usi ng a f ace mask
(418, 419). One study determi ned that sevofl urane in combi nati on wi t h ni t rous
oxide commonl y exceeded the recommended l imi t (416).
Moni tori ng exposure l evel s i s recommended i n al l areas wi th potenti al f or
worker exposure on a quart erl y basi s and f ol l owi ng changes to venti l ati on
systems, anesthetic equi pment , or scavengi ng techniques. Breathi ng zone or
work area sampl es are most desi rabl e. Resul ts of moni t ori ng and correcti ve
measures are to be maintai ned and retai ned f or 20 years (176).
Recommendati ons were made regardi ng scavenging, venti l ati on systems,
l eak t esting, and work pract i ces ai med at mi ni mi zi ng employee exposure
(176).
Medi cal survei l l ance, includi ng comprehensi ve empl oyee prepl acement
medi cal and occupati onal hi stori es, annual updat ing of empl oyee medi cal
hi stori es, and prepl acement and annual physi cal exami nati ons of empl oyees
exposed t o wast e anestheti c gases were recommended.
Empl oyees were t o be i nformed on assi gnment and at l east yearl y thereaf ter
of t he possi bl e heal th ef f ects of exposure t o t race anestheti cs, especi al l y
possi bl e eff ects on reproduct i on. Appropri ate si gns and l abeli ng were
recommended.
NI OSH part i ci pat ion came to a hal t af ter this cri teri a document on t race gases was
t ransmi t t ed to OSHA. To promulgate t hi s as a standard, OSHA woul d have to go
t hrough an extensi ve rul e-maki ng procedure, i ncl udi ng a publ i c comment peri od.
Thi s has not occurred to date.
Medicolegal Considerations
Because the NI OSH document does not const i tute a promul gated OSHA standard,
empl oyers are not obl i gated to compl y wi th i ts recommendati ons. However, t he
general dut y cl ause of the 1970 act gives OSHA the aut hori t y to i nspect workpl aces
t o determi ne whether empl oyers are providing a workpl ace f ree f rom hazards, even
i n the absence of a rel evant standard.
The act gives each empl oyee the right to request an OSHA i nspecti on i f an
empl oyee bel i eves that he or she i s in i mminent danger f rom a hazard or if OSHA
standards are bei ng viol ated. Several i nspect i ons i n response to empl oyee
compl ai nts were carri ed out i n the 1970s. Fi nes and ci tat ions were i ssued because
empl oyees were exposed t o concent rat i ons of ni t rous oxi de i n excess
P. 396

of t he NI OSH recommended l evels or because exposure was not reduced t o the
l owest feasi bl e l evel (406,409).
The Ameri can Society of Anest hesi ol ogists (ASA) l egal counsel has advised that i t
i s wi t hi n t he ri ght of an employer t o ref use to permi t an OSHA representati ve to
enter t he f aci l i t y unl ess that i ndi vi dual has ei ther a search warrant or a court order
compel l i ng the i nspecti on. OSHA would need to seek a search warrant f rom a
f ederal court and show probabl e cause f or maki ng an i nspecti on (406). If faced wi th
a vi si t f rom an OSHA representat ive, obtai ni ng legal counsel i s advi sabl e. Fai l ure
t o demand a search warrant or court order normal l y woul d consti t ute a wai ver of
any l at er ri ght t o obj ect t o the vali di ty of an i nspecti on.
Al l st ates have workers' compensati on l aws so that i ndi vi dual s suff eri ng f rom
occupati onal di seases can col l ect benef i ts, i rrespect ive of whether or not the
empl oyer' s negl i gence caused the disease. I t i s possi bl e that a workers'
compensati on case coul d arise f rom an operati ng room empl oyee suff ering f rom
one of the probl ems descri bed in t he f i rst sect ion of thi s chapter, provided the
empl oyee coul d show t hat the i l l ness was work connected and t hat employment in
t he operat i ng room subjected hi m or her to speci al ri sk in excess of those
experienced by t he general publ i c.
I n most stat es, workers' compensati on l aws precl ude private l awsui ts by an
empl oyee agai nst hi s or her employer. However, in addi t i on to making a cl ai m f or
workers' compensat ion, an employee can bri ng a civil sui t for damages agai nst a
t hi rd party (such as an anesthesi a provider) whom the employee cl ai ms caused
i nj ury.
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P. 402


Questions
For the f ol lowing quest ions, sel ect t he correct answer
1. Trace amounts of the foll owi ng anesthetic agent have been shown to have
an effect on anesthesia personnel performance in the operati ng room?
Hal othane
Ni trous oxide
Enf l urane
I sof lurane
None of these
Vi ew Answer2. Which of the foll owing anesthetic agents is most l ikely to
be associated wi th spontaneous aborti ons in animals?
Hal othane
Ni trous oxide
Enf l urane
I sof lurane
Sevof l urane
Vi ew AnswerFor the fol l owing quest i ons, answer
i f A, B, and C are correct
i f A and C are correct
i f B and D are correct
i s D i s correct
i f A, B, C, and D are correct .
3. The fol lowing measures are necessary to mi nimi ze trace gas concentrati ons
i n the operating room:
A scavenging system
Changi ng work t echni ques
El i mi nat i on of l eaks
The room ai r condi t i oni ng system
Vi ew Answer4. Gas-collecti ng devices need to be attached to
Anesthesi a breat hing systems
Pump oxygenat ors
Anesthesi a agent moni tors
Venti lators
Vi ew Answer5. Parts of the scavengi ng system connected by the transfer
tubing i nclude
The i nt erf ace and an adsorpti on device
The i nt erf ace and venti lator
The i nt erf ace and the room venti lati on system
The i nt erf ace and the APL val ve
Vi ew Answer6. Passi ve di sposal assembl ies incl ude
The room venti lati on system.
Pi ped vacuum system
Pi pi ng di rectl y to atmosphere
Duct system wi th a fan
Vi ew Answer7. Possi ble problems associated wi th the use of pi ped
sucti on systems for gas disposal include
I nadequat e number of outl ets
Damage to the sucti on pump
Vacuum system overl oad
Exposure of personnel in ot her parts of t he f aci li t y
Vi ew Answer8. Components connected by the gas disposal tubi ng
i ncl ude
The i nt erf ace and an adsorpti on device
The i nt erf ace and the sucti on system
The i nt erf ace and the vent il at ion system
The i nt erf ace and the APL val ve
Vi ew Answer9. The fol l owing wi ll reduce exposure of operati ng room
personnel to trace anesthetic gases:
Use of cuf fed t racheal tubes
Use of hi gh f resh gas f l ows
Di sconnecti on of the ni trous oxide pipel i ne hose when t he machine i s not i n use
Use of insuf fl ati on techni ques
Vi ew Answer10. The maxi mum time-weighted average concentrati ons to
which a worker in the operati ng room should be exposed according to the
Occupational Safety and Heal th Admi nistrati on include
5 ppm for hal ogenat ed agents
2 ppm for hal ogenat ed agents
180 ppm f or ni t rous oxi de
25 ppm f or ni trous oxide
Vi ew Answer11. Hazards associated with scavengi ng equi pment i ncl ude
Negati ve pressure i n the breathi ng system
Mi sconnecti ons
Barot rauma
Venti lator malf uncti on
Vi ew Answer12. Sampl ing methods for determi ni ng trace gas
concentrati ons include
Si ngl e shot
Ti me-wei ghted average
End-t idal sampl i ng
Uri ne sampl ing
Vi ew Answer13. Size(s) of the inl et and outl et fi tti ngs of the transfer
tubing i nclude
15 mm
19 mm
22 mm
30 mm
Vi ew Answer14. Ways in which leak si tes can be i denti fi ed include
Appl i cat i on of a 50% soap sol uti on t o a component
Testi ng t he capaci ty of the machine to sustain pressure
Usi ng a ni trous oxide anal yzer to check suspected si tes
Opening t he ni t rous oxi de cyl i nder and wat chi ng the pressure drop
Vi ew Answer15. When the l ow pressure system is checked for leaks,
The preuse machi ne checkout wi l l reveal even smal l l eaks
The bag port and t he Y-piece should be occl uded
The vapori zers shoul d be i n t he OFF posi ti on
The l eak rat e shoul d be l ess than 1 L/mi nute
Vi ew Answer16. Concerni ng the room air condi ti oni ng system,
Ai r exchanges shoul d be 25 to 35 per hour
Reci rcul at ing systems are less eff ecti ve t han nonreci rcul at ing syst ems
The f low shoul d be upward rather than downward
The anesthesi a machi ne should be pl aced near t he exhaust gri l le
Vi ew Answer17. Problems that could cause posi tive pressure i n the
breathing system include
Occl usion of the gas di sposal assembl y
Mi ssassembl y of the connecti on to t he gas-di sposal system
I ncorrect assembl y of the posi t ive pressure rel i ef valve
Appl i cat i on of subambi ent pressure to t he APL val ve
Vi ew AnswerP. 403


18. Concerni ng monitors that can be used for detection of trace gases,
I nf rared anal yzers are most of ten used to measure vol ati l e agents
A carbon di oxide anal yzer can be used to check t he eff i ci ency of scavenging wi t h
an open interface
The i oni zi ng l eak detector is best sui ted to measure ni t rous oxi de
An oxygen anal yzer can be used t o moni tor the scavengi ng syst em i nt erface
Vi ew Answer19. Which factor(s) affect trace gas concentrations i n the
operating room?
Room venti l ati on system
Durati on of the anesthet i c
Fresh gas f l ow
The t ype of surgery bei ng perf ormed
Vi ew Answer