Chapter 33

Equipment Checkout and Maintenance

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A checkout procedure i s anal ogous to t he pref l i ght check f or ai rl i ne pi l ots and i s
i ntended t o determi ne whether equi pment i s present , f uncti oni ng properl y, and
ready f or use. Fai l ure t o check equi pment properl y i s a factor i n many cri ti cal
i nci dents (1,2,3,4, 5,6,7,8,9, 10,11,12). Properl y checki ng equi pment can reduce
equipment -related morbi di ty and mort al i t y, i mprove preventi ve mai ntenance, and
educate the anesthesia provider about equipment (1,9,13,14,15,16,17). Defects
may be f ound even j ust af ter preventi ve mai nt enance has been performed (18).
Fai l ure t o perf orm a proper check bef ore use i s common
(4,19,20,21,22,23, 24,25,26, 27). Many anesthesia provi ders are unabl e t o i denti f y
i ntenti onal ly created f aul ts (28,29, 30, 31,32,33). Wi t h i ntensi ve trai ni ng,
perf ormance i mproves, but hi gh rates of compl eti on are not achieved (34).
User manuals t hat are provi ded by anesthesia machi ne manuf acturers have
detai l ed di recti ons f or checki ng. These should be read caref ul l y. Unf ort unatel y,
t hese procedures are of ten overl y compl i cated. When a procedure takes too long to
perf orm, i t i s of ten abri dged or ski pped al together.
The Food and Drug Admi nistrat ion (FDA), worki ng wi t h representat ives of the
anesthesi a communi t y and i ndustry, devel oped a preuse checkout procedure, whi ch
was publ ished i n 1986 (35). Unfort unatel y, thi s li st was too compl icated f or most
users, and a si mpl if ied, more user-f ri endl y version was publ i shed i n 1993. Thi s is
shown i n Tabl e 33.1. The new versi on retained or added checks of components that
f ai l more f requentl y than others and that can qui ckl y i nj ure the pat i ent when they
f ai l (36). Components t hat f ai l i nf requent l y and that do not immediat el y jeopardi ze
t he pat ient when t hey do malf uncti on were not i ncl uded i n the 1993 versi on but
must sti l l be checked during rout ine preventi ve mai ntenance. Checkl ists have been
publi shed in ot her countri es (16,17,37, 38,39).
Thi s chapt er i s constructed al ong t he l i ne of t he 1993 FDA checkout procedure.
One of t he defi ci encies of the 1993 FDA checkout was t hat whi l e i t sai d to check a
cert ai n i tem, i t di d not explain how. Many cl i ni ci ans devised thei r own methods to
f il l t hat void but i n f act were not correct l y checking cert ai n i t ems. We have
recommended a number of t est methods to overcome this defi ci ency. When an
al ternate test method i s gi ven, an at tempt wi l l be made to poi nt out t he advantages
and defi ci encies of that met hod.
Si nce anesthesia machines f rom dif f erent manufacturers and di ff erent model s f rom
t he same manufacturer vary, the user shoul d st udy the manuf acturer' s suggested
checki ng procedures and i ncorporate specif i c poi nts i nt o thi s generi c checkout.
Parts of the checkout procedure descri bed i n this chapter wi l l not appl y to machines
wi th an el ectroni c checkout. The user must determine whi ch parts are checked
automati cal l y and add those that are not covered.
The FDA checkout i s desi gned for workstati ons wi t h a ci rcl e system, venti l at or,
capnograph, oxygen anal yzer, respi ratory vol ume meter, and ai rway pressure
moni tor. Cl i ni ci ans who use equi pment that does not conf orm to thi s conf i gurati on
may need to modi f y the procedure to accommodate di ff erences. For example, if a
Mapl eson system i s t o be used, t he checki ng procedure shoul d incl ude this. Such
modi f icati ons shoul d have appropri ate peer revi ew. The manufact urer' s user manual
shoul d be consul ted f or speci al procedures.
A copy of the checkout procedure shoul d be kept i n, on, or near t he anesthesi a
machi ne. A record t hat the checkli st was used shoul d be made and kept . A pri nt ed
checkl i st may present a more organi zed and systemat ic approach than i f the
anesthesi a provi der uses a mental checkli st and may resul t i n i mproved f aul t
detecti on (9,33). A pi ctorial checkout may be easi er to read and f ol low t han a
t ypewri tt en l i st (5).
El ect roni c checkl i sts have been devel oped (40,41). Unl i ke the electroni c checkout
(see bel ow), t hese onl y l ist what the anest hesia provi der shoul d do. An el ect ronic
checkl i st may be more extensive than a paper checkli st .
Electronic Checking
Many of the newer anesthesia machines provi de an el ect roni c checki ng procedure
(Fi g. 33.1). When the machi ne
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P. 934

i s turned ON, i t reminds the user t o start t he checkout . Bef ore an electroni c
checkout i s performed, all components that are t o be used f or t he anesthet ic shoul d
be i n place. I f the breathing t ubing i s to be extended, i t should be extended to t he
desi red l ength prior to beginning the checkout . Duri ng t he checki ng procedure, the
machi ne may prompt the anest hesi a provider to make certai n adj ustments such as
openi ng or cl osing t he adj ustable pressure-l i mi t ing (APL) val ve, occl udi ng the Y-
pi ece, or adjusti ng t he gas f l ows.
TABLE 33.1 Anesthesia Apparatus Checkout Recommendations, 1993
This checkout, or a reasonable equivalent, should be conducted before administration
of anesthesia. These recommendations are only valid for an anesthesia system that
conforms to current and relevant standards and includes an ascending bellows
ventilator and at least the following monitors: capnograph, pulse oximeter, oxygen
analyzer, respiratory volume monitor (spirometer), and breathing system pressure
monitor with high- and low-pressure alarms.
Emergency Ventilation Equipment
*1. Verify that backup ventilation equipment is available and functioning.
High-pressure System
*2. Check the oxygen cylinder supply.
a. Open the oxygen cylinder, and verify that it is at least half full (about 1000
psig).
b. Close the cylinder.
*3. Check the central pipeline supplies.
Check that the hoses are connected and pipeline gauges read about 50 psig.
Low-pressure System
*4. Check the initial status of the low-pressure system.
a. Close the flow control valves and turn vaporizers OFF.
b. Check the fill level and tighten vaporizers' filler caps.
*5. Perform a leak check of the machine's low-pressure system.
a. Verify that the machine master switch and flow control valves are OFF.
b. Attach a suction bulb to the common (fresh) gas outlet.
c. Squeeze the bulb repeatedly until fully collapsed.
d. Verify that the bulb stays fully collapsed for at least 10 seconds.
e. Open one vaporizer at a time, and repeat parts c and d above.
f. Remove the suction bulb, and reconnect the fresh gas hose.
*6. Turn the machine master switch ON as well as all other necessary electrical
equipment
*7. Test the flowmeters.
a. Adjust the flow of all gases through their full range, checking for smooth
operation of floats and undamaged flow tubes.
b. Attempt to create a hypoxic oxygennitrous oxide mixture, and verify correct
changes in flow and/or alarm.
Scavenging System
*8. Adjust and check the scavenging system.
a. Ensure proper connections between the scavenging system and both the APL
(pop-off) valve and ventilator relief spill valve.
b. Adjust the waste gas vacuum flow, if possible.
c. Fully open the APL valve and occlude the Y-piece.
d. With minimum oxygen flow, allow the scavenger reservoir bag to collapse
completely, and verify that the absorber pressure gauge reads about zero.
e. With the oxygen flush activated, allow the scavenger reservoir bag to distend
fully and then verify that the absorber pressure gauge reads <10 cm H
2
O.
Breathing System
*9. Calibrate the oxygen monitor.
a. Ensure that the monitor reads 21% in room air.
b. Verify that the low oxygen alarm is enabled and functioning.
c. Reinstall the sensor in the circuit, and flush the breathing system with oxygen.
d. Verify that the monitor now reads greater than 90%.
10. Check the initial status of the breathing system.
a. Set the selector switch to Bag mode.
b. Check that the breathing circuit is complete, undamaged, and unobstructed.
c. Verify that the carbon dioxide absorbent is adequate.
d. Install the breathing circuit accessory equipment (e.g., humidifier, PEEP valve)
that is to be used during the case.
11. Perform a leak check of the breathing system.
a. Set all gas flows to zero (or minimum).
b. Close the APL (pop-off) valve, and occlude the Y-piece.
c. Pressurize the breathing system to about 30 cm H
2
O with an oxygen flush.
d. Ensure that the pressure remains fixed for at least 10 seconds.
e. Open the APL (pop-off) valve, and ensure that the pressure decreases.
Manual and Automatic Ventilation Systems
12. Test the ventilator systems and unidirectional valves.
a. Place a second breathing bag on the Y-piece.
b. Set the appropriate ventilator parameters for the next patient.
c. Switch to the automatic ventilation (Ventilator) mode.
d. Turn the ventilator ON, and fill the bellows and breathing bag with and oxygen
flush.
e. Set the oxygen flow to minimum and other gas flows to zero.
f. Verify that during inspiration, the bellows delivers appropriate tidal volume
and that during expiration, the bellows fills completely.
g. Set the fresh gas flow to about 5 L/minute.
h. Verify that the ventilator bellows and simulated lungs fill and empty
appropriately without sustained pressure at end expiration.
i. Check for proper action of the unidirectional valves.
j. Exercise the breathing circuit accessories to ensure proper function.
k. Turn the ventilator OFF, and switch to manual ventilation (Bag/APL) mode.
l. Ventilate manually and assure inflation and deflation of artificial lungs and
appropriate feel of system resistance and compliance.
m. Remove the second breathing bag from the Y-piece.
Monitors
13. Check, calibrate, and/or set alarm limits of all monitors.
Capnometer
Pulse oximeter
Oxygen analyzer
Respiratory volume monitor (spirometer)
Pressure monitor with high and low airway alarms
Final position
14. Check the final status of the machine.
a. Vaporizers OFF.
b. APL valve open.
c. Selector switch to Bag.
d. All flowmeters to zero.
e. Patient suction level adequate.
f. Breathing system ready to use.
*If an anesthesia provider uses the same machine in successive cases, these steps do
not need to be repeated or may be abbreviated after the initial checkout.

These el ect ronic checking procedures t est the el ect roni c as wel l as some
mechani cal components of t he anesthesi a machi ne. In addi t i on, they may gather
i nformati on about breathing system resistance and
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compl i ance and l eaks. They may also remi nd the user t o check functions that are
not i ncl uded i n t he automati c checkout.

View Figure

Figure 33.1 Electronic checkout procedure on a newer
model anesthesia machine.

Most machi nes have a mechani sm t o l i mi t or skip t he el ect ronic checkout . Thi s i s
meant for emergency si t uati ons. Many cl i nici ans routi nel y bypass the checkout
(42,43,44). Thi s is not good practi ce. The el ect roni c check may provide a more
comprehensive check t han most people perf orm and may detect some problems
t hat probabl y woul d not have been f ound otherwi se. If an anest hesia machi ne has
been hel d i n a ready-to-use state f or emergenci es, i t shoul d be turned OFF at l east
dai l y and restart ed wi th a new checkout procedure.
Whether a f ul l el ect roni c check has been carri ed out or bypassed i s aut omat i cal ly
recorded i n the machi ne' s computer and can be accessed. If a probl em should
occur, fai l ure to use the checkout may be ci t ed as evi dence of substandard care.
A probl em wi t h electroni c checkouts i s that some anesthesia provi ders f eel t hat t he
el ect roni c check is al l t hat i s needed. Thi s i s not true. The user manual shoul d be
consi dered as the fi nal aut hori t y on what t asks need to be perf ormed on each
machi ne.
Si nce t hese electroni c checkouts di f fer among manufacturers and di f ferent model s
f rom the same manuf acturer and since they are subj ect to change, i t i s not f easible
t o discuss detail s of these i n a text such as this. The Commi ttee on Equipment and
Faci l i ti es of t he American Soci et y of Anesthesi ol ogi sts i n conj uncti on wi th
manuf acturers, t he American Associ at i on of Nurse Anest het i sts, and the American
Society of Anest hesi a Technologists and Technicians is worki ng t o create a new
checkout procedure t hat wi l l i ncl ude anest hesia machi nes wi th el ect roni c checkouts
(45). Anesthesi a providers shoul d f ol l ow thi s process cl osel y.
Daily Checks before Beginning Anesthesia
Emergency Ventilation Equipment
Resuscitation Bag
Though rare, certain mal funct ions can render the anesthesia machi ne inoperat ive
(36,46,47). Somet i mes, the probl em cannot be di agnosed or qui ckl y corrected. In
t his si tuat i on, a manual resusci tat or (Chapter 10) wi l l al l ow t he user to provi de
posi t i ve-pressure venti l ati on whi l e the probl em is corrected or t he machine
repl aced.
The pati ent port should be occl uded and the bag squeezed (Fi g. 33.2). Pressure
shoul d bui ld up rapi dl y to a poi nt at whi ch the bag can no l onger be compressed. If
t here i s a pressure-l i mi ti ng device, i t can be checked by connect i ng a pressure
manometer bet ween t he pati ent port and the bag, usi ng a T-fi t ti ng. If t here is an
override mechanism on the pressure-l i mi ti ng devi ce, thi s should be checked.
The resusci tator shoul d be i nspected for si gns of wear such as cracks or tears. A
reservoi r bag shoul d be pl aced over the pat i ent port (Fi g. 33.3). Squeezing t he
resusci tati on bag shoul d cause t he reservoi r bag t o inf l at e. Af ter the reservoi r bag
i s ful l y i nf l ated and the resusci t ati on bag has been rel eased, the reservoi r bag
shoul d def lat e easi l y. This t ests bot h the i nspi ratory and exhalati on pat hs f or
patency.
To check t hat t he bag ref i l l val ve opens, the bag shoul d be squeezed, t hen t he
pati ent port occl uded, t hen t he bag released. The bag shoul d re-expand rapi dl y.
I f the resusci tator has a cl osed reservoi r, i ts f uncti on can be checked by perf ormi ng
several compressi on-rel ease cycl es wi t h no oxygen f l ow i nto t he reservoi r. The
reservoi r shoul d def late, but t he resusci tat ion bag should cont inue to expand. Thi s
checks that the ai r i nl et valve f uncti ons wi t h an empty reservoi r.
Oxygen Source
A source of oxygen to connect to the resusci t at ion bag shoul d be avai labl e. An
oxygen f lowmeter at tached to t he pi pel i ne out let (Fi g. 33.4) or t he court esy
f lowmeter on the anesthesia machi ne (Chapter 5) wi l l provi de a source of oxygen.
Difficult Airway Equipment
I f there i s any i ndi cat i on that the pati ent' s ai rway or tracheal i nt ubat i on wi l l be
di ff i cul t, the di f f i cul t ai rway cart shoul d be in t he room. Emergency ai rway devices
are discussed i n Chapter 21. Whatever devi ce expected t o be used needs to be
present and i n working order.
Suction
The adequacy of suct ion can be checked by placi ng the end of the sucti on tubi ng
on the undersi de of the thumb (Fig. 33.5). Wi th t he hand at wai st hei ght , the t ubi ng
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shoul d stay att ached wi t hout support. A rigi d sucti on catheter (Yankauer) shoul d be
i mmedi atel y avai lable.

View Figure

Figure 33.2 Squeezing the resuscitation bag with the patient
port occluded.

Gas Supply
Cyli nder Pressure
Oxygen cyl i nders shoul d be checked f or correct mounti ng. If there is a date-expi red
l abel on a cyl i nder i t shoul d be checked (48, 49). Yokes shoul d be scanned to make
cert ai n t hat any yoke not contai ning a cyl inder i s f i tted wi th a yoke (bl anking) pl ug
(Chapter 5). Al l t ags shoul d indicate f ul l or i n use.
Bef ore proceeding f urther, al l f l ow cont rol val ves shoul d be cl osed by turni ng them
compl etel y cl ockwise. Excessive torque shoul d be avoided. Opening a cyl inder or
connecti ng a pi pel ine hose when a f low cont rol val ve
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i s open may cause t he indicator to shoot up to t he top of the t ube and be damaged,
stuck at the t op, or not not iced.

View Figure

Figure 33.3 The resuscitation bag is further checked by
placing a reservoir bag over the patient port. Squeezing the
resuscitation bag should cause the reservoir bag to inflate.
The reservoir bag should then deflate easily when it is
squeezed.


View Figure

Figure 33.4 A flowmeter that is separate from the
anesthesia machine can provide a source of oxygen in an
emergency.

The pressure i n an oxygen cyl i nder is checked by turning t he val ve sl owl y
counterclockwi se whi l e observi ng t he rel ated pressure gauge (Fig. 33.6). If a
hi ssi ng sound occurs, the cyl i nder should be t ightened i n t he yoke. I f ti ghteni ng t he
cyl i nder fail s to stop t he sound, t he washer shoul d be checked f or damage. If the
hi ssi ng sound persi sts, the cyli nder shoul d be repl aced.
The cyl i nder(s) shoul d contai n suf f ici ent gas that i n the event of a probl em wi t h the
pi pel i ne suppl y, li f e support can be mai nt ained unti l the pi pel i ne probl em can be
correct ed or more cyl inders obt ai ned. How l ow a pressure is acceptable wi l l depend
on whether addi ti onal cyl inders are readi l y avai lable, how l ow a f resh gas f low can
be used, whether mechani cal vent i lat i on is necessary, and what t ype of vent i l ator i s
present. Some venti lators use oxygen t o dri ve t he bel l ows. Ot hers use ai r or a
mi xture of ai r and oxygen as t he dri vi ng gas. A pi ston venti l at or wi l l not requi re any
oxygen to dri ve i t. A f ul l E cyl i nder wi l l contai n about 625 L of oxygen wi t h a
pressure of around 2000 psi g. One f ul l cyl i nder wi l l l ast l ess than 3.5 hours at a
f low of 3 L/mi nute.

View Figure

Figure 33.5 Check of suction. The strength of the vacuum
is tested by determining that the weight of the suction
tubing can be supported at waist height by the seal between
the tubing and the underside of a finger. If the vacuum is
unsatisfactory, the tubing will not remain in contact with the
finger.

The FDA checkli st recommends that t he cyl i nder be at l east hal f full (about 1, 000
psig). I f there are two cyl i nders and one is compl etel y f ul l , a l ower pressure in t he
second cyl i nder may be accept abl e. The authors bel ieve that 500 psig i n an oxygen
cyl i nder is adequate, provi ded cyl i nders wi l l not be t he primary oxygen suppl y (i .e. ,
t here i s a pi pel i ne suppl y) and the anesthesi a provider is aware of the steps
needed to conserve oxygen. Venti l ators that use oxygen as the dri vi ng gas must be
t urned OFF and manual venti l ati on used. Even if there i s onl y one cyl i nder and i t is
onl y 25% f ull , i t woul d del i ver oxygen at 1 L/ mi nute f or over 2 hours. Empty or near-
empt y cyl i nders shoul d be l abeled as empt y and replaced wi th f ul l cyl i nders (see
Chapter 1).
Anesthesi a machi ne cyli nders are f requent ly checked and repl aced by anest hesi a
t echnicians or other operati ng personnel . If anesthesi a provi ders are not
accustomed t o checki ng and repl aci ng cyl i nders, they wi l l not react ef f i ci entl y and
ef fectivel y i n the event of an oxygen suppl y f ai l ure (50).
I t has been suggested that merel y checki ng a cyl inder f or adequate pressure i s not
enough (38,51). The check valve that prevents cyl i nder gas f rom bei ng used when
t he pi pel ine i s connected may st i ck, preventi ng f l ow f rom t he cyli nder i f the pi peli ne
i s not i n use. To check thi s val ve, the pi pel i ne hoses shoul d be disconnect ed and
f low at t he f lowmeters demonst rated af ter the cyl inder
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i s opened. This wi l l al so test the non-return val ves i n the pipel i ne hose inlet (see
Chapter 5). Oxygen shoul d not l eak back t hrough the di sconnected pi pel i ne hose
(52).

View Figure

Figure 33.6 Top row: Pipeline pressure gauges. Bottom
row: Cylinder pressure gauges.

The 1993 FDA recommendati ons do not menti on checki ng cyli nders containi ng
gases other t han oxygen, because t hese are not essenti al for l i f e support . If i t i s
pl anned to use one of these gases, i t is reassuring to know t hat cyl i nder suppl ies
are avai l abl e on the machi ne. As discussed i n Chapter 1, t he contents of a ni t rous
oxide cyl i nder are not ref l ected by the pressure unl ess al l of t he l iquid has
evaporated and t he cyl i nder i s nearl y empt y. The pressure gauge wi l l conti nue to
read 745 psi g unti l al l t he l i quid has vapori zed. If t he pressure i s less than 600
psig, the ni t rous oxi de cyl i nder is nearl y empt y and shoul d probabl y be replaced.
Af ter the pressures are checked, al l cyl inder valves should be cl osed, unl ess there
i s no pi pel ine suppl y f or that gas. During use, t here wi l l be pressure f l uct uat i ons i n
t he machi ne and the pi pel i ne hoses, especial l y when a venti l ator is i n use. As the
venti l ator cycl es, there wi l l be a transient decrease i n pressure in t he machi ne. If
t he pressure fall s bel ow that suppl ied by the regul ator f or t he cyl i nder, gas can f l ow
f rom the cyl i nder i f the cyl i nder valve is open. This gas l oss wi l l at some poi nt
deplete t he cyl i nder contents, and there wi l l not be an emergency suppl y avai l abl e.
When pi ped gases are not goi ng to be used, t here should be one f ul l or nearl y f ul l
cyl i nder of each gas t o be used and t he valve on one cyl i nder should be f ul l y open
af ter the pressure is checked.
Pipel ine Pressure
Some i nst i tut i ons di sconnect the pipel i ne hoses f rom the machi ne at night to al l ow
t he anesthesi a machi ne t o be moved f or cl eani ng and reduce gas l oss f rom l eaks. I f
t his i s the case, the hoses need to be reconnected t o the pi peli ne system. Fi tt ings
shoul d hol d f i rml y, no l eaks should be audibl e, and t he hoses should be arranged to
prevent occl usi on. The pi pel ine pressure i ndicators (Fig. 33.6) shoul d read 345 to
380 kPa (50 t o 55 psi g).
As di scussed i n Chapter 5, a pi pel ine pressure gauge wi l l regi ster onl y pi pel i ne
pressure i f i t is posi ti oned upst ream of the check val ve at t he pi pel i ne i nl et , as
requi red by the Ameri can Society f or Testi ng and Materi als (ASTM) workstat i on
standard (53). If i t i s l ocated downst ream of t he check valve, as i t i s on some ol der
machi nes, the pressure regi stered wi l l refl ect the pressure i n the machi ne, but not
necessari l y that in t he pi pel i ne (54).
Low-pressure System
The l ow pressure system i s di scussed i n Chapter 5 and diagrammed i n Fi gure 5.1.
Vaporizers
The l ow-pressure system check i s begun by checki ng the l i qui d level i n each
vapori zer, addi ng more i f needed. Fi l l er caps and drai n val ves shoul d be ti ght .
Vapori zers shoul d be checked to make certain t hat t hey are not t i l t ed and cannot be
l if ted f rom thei r mounti ngs.
Leaks
Leaks i n the l ow-pressure part of t he anesthesi a machi ne can cause hypoxia or
pati ent awareness (55,56). Prof ound hypercarbi a can occur i f a Mapl eson system i s
i n use (57).
Sel ecti ng an appropri ate l eak check can be confusi ng, because some anesthesi a
machi nes have a check valve ei t her at the common gas outl et or j ust downst ream of
t he vapori zers. This check valve prevents gas t hat i s
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under posi t ive pressure i n the breathi ng system f rom f lowi ng back i nto t he machi ne
and through a l eak.

View Figure

Figure 33.7 The suction bulb is attached to the common gas
outlet and squeezed until it is collapsed. It should remain
collapsed for at least 10 seconds. Following this, each
vaporizer in turn should be turned ON and the maneuver
repeated.

The mi ni mum mandat ory oxygen f l ow on most machi nes may decrease t he abi l i t y to
detect smal l l eaks (58). The l eak t est should be perf ormed wi t hout the basal f l ow.
To el i mi nate this mi ni mum mandatory fl ow, t he machine needs to be turned OFF.
I rrespective of whi ch test i s used, the test should be repeated wi t h each vapori zer
t urned ON t o i ts minimum set t ing. If t hi s is not done, t he machi ne wi l l pass t he test
f or l eaks, but a l eak associ ated wi th t he vapori zer or i ts mounti ng wi l l not be f ound
(59).
Negative Pressure Test
The negative pressure test uses a sucti on bul b to create a negat ive pressure i n the
machi ne (55, 60). The bul b i s at tached to a tubi ng wi th a 15-mm adapt or, whi ch wi l l
f i t the anesthesi a machine common gas outl et on t he ot her end (Fi g. 33.7). This
device is avai lable commercial l y or can be const ructed by taki ng a
sphygmomanomet er bul b, reversi ng the ai r i nl et valve i n the bul b, and connecti ng
one end of a short t ubi ng to t he bulb and the other t o a 15-mm tracheal tube
adapt or. When reversed, t he valve wi l l pul l ai r f rom the machi ne si de of the bul b.
Al ternatel y, t he devi ce can be const ructed f rom t he bul b pump of a disposabl e
i ntravenous blood admi ni strat ion set (61).
To perf orm the t est, al l f l owmeters are turned OFF. If there i s a mi ni mum
mandatory oxygen f l ow, t he enti re machi ne must be turned OFF. Squeezi ng t he
bul b unt i l i t is remai ns col l apsed creates a negat i ve pressure in t he machi ne. If the
bul b remai ns col lapsed f or 10 seconds, t here is no signi f i cant leak present . If there
i s a l eak, the bul b wi l l i nfl at e. This test should be repeated wi th each vapori zer
t urned ON. The sucti on bulb i s then removed and t he f resh gas hose reconnected.
Thi s negative pressure l eak test wi l l work f or al l makes and model s of machi nes,
whether there i s a check val ve or not (55). For this reason, i t i s someti mes cal led
t he uni versal l eak test. I t di f ferent i ates between breathi ng system l eaks and leaks
i n the machi ne. St udi es comparing thi s wi t h other l eak tests f ound that i t was the
onl y one t hat identi f ied all l eaks and was t he most sensi t ive at f i nding smal l leaks
(55,56).
Unf ortunatel y, i t is not possi ble t o use t his t est on some new anesthesi a machines
because t he common gas outl et i s not accessi bl e to the user. An uni nt ent ional
conti nuous gas f low wi l l resul t i n a f al se-posi tive test (56).
Positive Pressure Test
When perf ormi ng a posi t i ve pressure leak test, care must be taken that the
pressure does not i ncrease beyond the prescribed li mi ts. There i s l i t tl e room f or
compressi on i n the machine tubi ng, and no bag to buf f er pressure i ncreases. I t is
possi bl e t hat the pressure coul d increase t o a point where a f l owmeter or other part
of t he machine coul d be damaged.
Pressure Gauge Test
A pressure gauge (t he gauge f rom a standard sphygmomanometer wi l l do) is
at tached t o the common gas outl et (Fi g. 33.8), and a f low control val ve is sl owl y
opened unti l the pressure on the gauge reaches 30 cm H
2
O (22 mm Hg) (57,62).
The f low i s then l owered unt i l that pressure i s steady. The f l ow rat e on the
f lowmeter is then equal to the l eak rat e i n the machi ne at t hat pressure. I t shoul d
be l ess t han 50 mL/minute. Thi s test cannot be performed if there i s a mi ni mum
mandatory f low, because t hese f l ows are usual l y around 200 mL/minute.
Fresh Gas Line Occlusion Test
Wi th this t est , a fl ow of 50 mL/mi nute is set on the oxygen f l owmet er and the f resh
gas l i ne ki nked. The i ndi cat or i n the f l owmet er t ube
P. 940

shoul d move downward. An advantage of thi s test i s that i t can be performed duri ng
a case (55). This t est cannot be performed i f t here i s a mini mum mandatory fl ow,
because t hese f l ows are usual l y around 200 mL/mi nute.

View Figure

Figure 33.8 A pressure gauge from a blood pressure cuff is
attached to the delivery hose from the machine. Sufficient
flow is established on a flowmeter to maintain a pressure of
22 mm Hg on the pressure gauge. The flow that is required
to maintain that pressure should be less than 50 mL/minute.

Combination Breathing System and Machine Leak Tests
The f ol lowi ng t ests can be used t o check f or l eaks i n the breathing syst em and
parts of the machi ne downst ream of the check valves.
Retrograde Fill Test
The APL val ve is cl osed and the pat ient port occl uded. The master cont rol swi tch
needs to be t urned ON. The oxygen f l ush or a hi gh f low f rom t he f l owmet er i s used
t o f i l l the reservoi r bag. As the bag begins to di st end, the pressure on the
manometer i n the breat hi ng system is observed. As the pressure st arts to rise, t he
f low on t he f l owmet er i s adj usted so t hat a pressure of 30 cm H
2
O is mai ntai ned i n
t he breathi ng system. I f this pressure i s overshot , the APL valve should be opened
bri ef l y. The f l ow necessary t o mai ntai n a steady pressure shoul d be no great er than
350 mL/mi nut e. The pressure should be released by openi ng the APL val ve rather
t han removi ng the occl usion f rom the pat i ent port at the Y-pi ece.
The advantages of thi s test are t hat i t can be performed qui ckl y wi t hout accessory
equipment and that i t checks the breathi ng system as wel l as the l ow-pressure
parts of the machi ne i n those model s that do not have a check valve (63). I t al so
al l ows the conti nuous ai r way pressure al arm t o be checked. Disadvantages are that
i t is rel at ivel y i nsensi ti ve to smal l l eaks, and i t does not l ocali ze t he source of the
l eak bet ween t he breathi ng system and the machi ne.
Squeeze Bulb Test
Wi th the machi ne master swi t ch and f low cont rol val ves turned OFF, t he Y-pi ece i s
occl uded and the APL valve closed. A suct ion bulb wi t h a 22-mm connect or i s
at tached t o the reservoi r bag mount and squeezed repeatedl y unt il t he breathi ng
system pressure gauge reads 50 cm H
2
O. The gauge i s observed. If a drop i n
pressure f rom 50 to 30 cm H
2
O t akes 30 seconds or l onger, the l eak rate is
acceptabl e.
In-use Test
During use, a l eak i n the machi ne or breat hi ng system can be quanti f i ed by
l oweri ng the f resh gas f l ow as l ow as possible (64). If t he venti l at or bel l ows or
reservoi r bag cont inues to f i ll , t he leak rat e i s l ess t han t he f resh gas f l ow.
When a l eak i s suspected, a systematic search of t he anesthesi a machi ne and
breat hi ng system shoul d be made, f ol l owi ng the route of gas t ravel . A l eak can
someti mes be l ocated by pl acing alcohol on the hands and movi ng the hands over
components whi l e gas f l ow i s occurri ng. The l eaking gas evaporates t he al cohol
and cool s the ski n.
When t he machi ne l eak t est i s complete, residual vapors should be f lushed out of
t he machi ne by t urning ON an oxygen f l ow at 1 L/mi nute for 1 mi nute wi th al l
vapori zers OFF (63). There shoul d be no noti ceabl e odor i n the gas comi ng f rom
t he common gas out l et . Usi ng t he oxygen f lush cont rol wi l l not f lush vapors out of
t he machi ne, because i ts f low enters the f resh gas f l ow downstream f rom the
vapori zers.
Turn the Machine' s Master Switch and Al l Other Necessary
Equipment ON
To conti nue t he checkout, the machi ne mast er swi t ch needs to be turned ON t o
enabl e t he pneumat ics and el ect roni cs. The machi ne shoul d be all owed to complet e
i ts own di agnost i c checks and any automated checki ng procedure. Any el ect ri cal
equipment to be used duri ng t he anestheti c shoul d be t urned ON at t his t i me wi t h
t he except ion of a divert i ng gas moni tor, whi ch shoul d be t urned ON af t er t he
breat hi ng system i s checked f or l eaks.
Flowmeter
Each fl owmeter shoul d be exami ned wi t h t he f low control val ve cl osed t o make
cert ai n t he i ndi cator i s at the zero posi t ion (or at mi ni mum fl ow i f t he machine is so
equipped). Each f l ow cont rol val ve shoul d be sl owl y opened and cl osed whi l e
observi ng the i ndi cator. The f loat shoul d move smoothl y and respond to small f l ow
P. 941

control val ve adj ustments. If the indicator i s a rot amet er or ball , i t shoul d rotat e
f reel y. An indicator that moves errat ical l y or f ai ls to ret urn to zero may be
di spl aying erroneous f l ow rates, and the machi ne shoul d be taken out of servi ce
unti l the problem i s corrected.
An at tempt shoul d be made to creat e a hypoxi c mi xture by adj usti ng the ni t rous
oxide f l ow up or the oxygen fl ow down whi l e both ni t rous oxi de and oxygen are
f lowi ng. Turni ng the ni t rous oxi de fl ow up shoul d cause t he oxygen f low t o i ncrease.
Si mi l ar resul ts shoul d occur i f a hi gh ni trous oxide f l ow i s present and t he oxygen
f low i s adj usted downward. Some anesthesi a machines wi l l not al ter the oxygen
f low but wi l l l i mi t the ni trous oxide f l ow. I f t he machi ne has a ni trous oxi de : oxygen
rati o al arm, i t shoul d be act ivated.
Adjustable Pressure-limiting Valve and Scavenging
System
The APL val ve and venti l ator should be connected to the scavengi ng system
i nterf ace. If an act ive disposal system i s bei ng used, t he f l ow shoul d be adjusted.
Adjustable Pressure-li miting Valve
The scavengi ng system and APL val ve are checked by cl osi ng the APL val ve,
occl udi ng the pati ent port, and f i l l i ng the system by usi ng t he oxygen f l ush so that
t he breathi ng system pressure gauge reads 50 cm H
2
O. The APL val ve is then
opened. There shoul d be a gradual l oss of pressure f rom t he system. Thi s
establ i shes proper APL f uncti on and t ransf er t ubi ng pat ency. If the scavengi ng
system i nt erf ace has a reservoi r bag, i t shoul d inf l at e when the APL valve i s
opened and then defl ate (65).
I f the pressure is released by removing t he occl usi on at t he pat ient port , the APL
valve and scavengi ng system patency wi l l not be checked. In addi t i on, t hi s coul d
cause a cl oud of absorbent dust to enter the breathi ng system (66,67).
Scavenging System
Closed System
Air Intake Valve (Negative Pressure Relief)
Wi th mi ni mal or no f l ow f rom the anesthesi a machi ne, t he APL valve shoul d be f ul l y
opened and the pat i ent port occl uded. Scavenging suct i on should be turned ON. I f
t here i s a bag at the scavengi ng interface, i t shoul d col l apse. The reservoi r bag i n
t he breathi ng system may al so col l apse. At t his poi nt, the breathi ng system
pressure gauge shoul d i ndicate a pressure of 0 to -2 cm H
2
O.
Positive Pressure Relief
To test t he posi t i ve pressure rel i ef valve on the scavengi ng i nterf ace, the APL valve
i s ful l y opened and the breathi ng system pat i ent port occluded. The oxygen f lush is
acti vated. The breathing system pressure i ndi cator shoul d read l ess than 10 cm
H
2
O.
An al ternate t est can be used. The vacuum f low t o the scavengi ng system i s turned
OFF and t he APL valve f ul ly opened. The reservoi r bag and the scavengi ng syst em
bags are f ul l y i nf l ated by using the oxygen f l ush. A f l ow of 2 L/mi nut e is t hen set on
t he oxygen fl owmeter. The pressure gauge i n the breathi ng system shoul d read not
more than 3 cm H
2
O.
Open System
Open scavengi ng systems do not have val ves t hat need t o be checked, as the
system i s open t o at mosphere. The f l ow i ndi cator on t he scavenging i nt erf ace
shoul d be checked t o make certai n that t he f l ow i s adequate.
Breathing System
Oxygen Monitor Cal ibration
Not al l oxygen anal yzers requi re a dai l y cali brati on check. The i nst ructi on manual
shoul d be consul ted t o det ermi ne what procedures are needed and how of t en they
shoul d be carri ed out .
I f dai l y cal ibrat ion i s requi red, t he sensor shoul d be removed f rom the breathi ng
system and moved wel l away f rom sources of gas that mi ght change t he ambient
oxygen concentrati on. I t should be cali brated to 21% and t he l ow oxygen alarm
checked by set ti ng i t above 21%. The sensor shoul d t hen be placed securely i n i ts
mount in t he breathi ng system and the breat hi ng system f l ushed wi th oxygen. Thi s
shoul d resul t i n a readi ng of over 90%.
Initi al Breathing System Status
The breathi ng system shoul d be inspected to determine that no parts are damaged
or mi ssi ng and that al l accessory equi pment [ e. g. , humi di f i er, heat and moi sture
exchanger, f i l ter, posi t ive end-expi ratory pressure (PEEP) valve] for t he proposed
anesthet ic are in pl ace. Al l connecti ons shoul d be made secure by push and t wi st.
I f a divert i ng gas moni tor i s to be used, t he sampl i ng l ine shoul d be checked f or
ki nks or occlusion and connect ed t o the breat hi ng system, but t he moni tor shoul d
not be turned ON at t hi s ti me. Transparent breathi ng t ubes shoul d be checked f or
f oreign bodi es (68). The bag-venti l ator sel ector swi t ch shoul d be i n the bag
posi t i on. The pressure gauge should read zero. I f the absorber is detachable, i t
shoul d be checked t o make sure that the attachment i s secure.
The absorbent col or shoul d be not ed. If t here is any col or change, the absorbent
shoul d be discarded and repl aced wi t h f resh absorbent. I f there i s a dual -chamber
absorber, both chambers shoul d be changed at the same t i me. I f the machi ne is
rarel y used or i f i t has been si t t ing wi t h gas f l owi ng through i t f or an undetermined
t i me, the absorbent should be changed even i f there i s no col or change, unless an
absorbent t hat does not cause
P. 942

f ormati on of carbon monoxi de i s bei ng used. The eff ects of desi ccated absorbent
are discussed i n Chapter 9. Accumulated absorbent dust and wat er shoul d be
removed f rom t he absorber dust cup, taki ng care not to spi l l ei ther.

View Figure

Figure 33.9 Test for leaks in the breathing system. With all
gas flows set to zero or minimum, the APL valve is closed
and the patient port occluded. The reservoir bag is filled by
using the oxygen flush until a pressure of 30 cm H
2
O is
shown on the gauge. With no additional gas flow, the
pressure should remain at this level for at least 10 seconds.

Leaks in the Circl e Breathing System
I f leaks i n t he ci rcl e system were checked for previ ousl y in combi nati on wi t h
machi ne l eaks, t hi s test does not need to be perf ormed.
To i ni ti ate t he breat hi ng system l eak test , al l gas f l ows shoul d be at zero. The APL
valve shoul d be cl osed and the pati ent port occluded. The breathing system shoul d
be pressuri zed t o 30 cm H
2
O by usi ng t he oxygen f l ush (Fi g. 33.9). I f there i s no
l eak, the pressure wi l l remai n near t hi s l evel f or at l east 10 seconds. The APL val ve
i s then opened. The pressure shoul d decrease.
The l eak can be quanti fi ed by adjust ing t he oxygen f lowmeter to mai nt ai n a
pressure of 30 cm H
2
O in t he breathing system (wi th t he Y-pi ece occluded and the
APL valve closed). The breathi ng system standard requi res that thi s does not
exceed 300 mL/mi nut e (69).
Leak i n a Mapl eson Breathi ng System
A Mapl eson breathi ng syst em shoul d be connected t o the f resh gas source wi t h the
APL valve closed. Wi th t he pat i ent port occl uded, t he system shoul d be pressuri zed
using t he oxygen f lush. I f there i s no l eak, the syst em wi l l retai n the pressure for at
l east 10 seconds. The pressure shoul d be rel eased by openi ng the APL val ve.
The l eak rat e can be quanti f ied by attachi ng a manomet er to the pat i ent port and
determining t he f low needed t o sustai n a certai n pressure (70).
Bain System Inner Tube
The i nt egri t y of the Bai n breathi ng system inner t ube (Chapt er 8) i s essenti al t o
avoid excessi ve dead space. Prof ound rebreathing and hypercarbia can occur i f the
i nner t ube has a hol e, i s detached at the machi ne end, or does not extend to the
pati ent end of the outer t ubi ng. For this reason, i t i s essenti al t hat thi s i s tested.
Inspection
The Bai n syst em shoul d f i rst be i nspect ed to determine i f t he center tube i s
properl y connected to the absorber end of the tube. The i nner t ube must al so be
connected near t he pat i ent end. Any retracti on or di sconnecti on f rom ei ther end
shoul d cause t he system t o be rej ected.
Inner Tube Occlusion Test
NOTE: I f t he system has side hol es or sl ots at t he pat ient end of the i nner tubi ng,
t his test wil l not work (75, 76).
To perf orm this test , a 2 L/mi nute fl ow i s set on one of the f l owmet ers
(26,71,72, 73, 74). The pl unger f rom a smal l syri nge or a f inger i s inserted i nt o the
pati ent end of the outer t ube, occl udi ng the i nner t ube (Fig. 33. 10). The f l owmet er
i ndi cator shoul d fal l .
P. 943



View Figure

Figure 33.10 Bain system inner tube test. The plunger from
a small syringe is inserted into the patient end of the system
over the end of the inner fresh gas delivery tubing. The
flowmeter indicator should drop.

A variati on of thi s procedure i s to at tach a manometer t o the end of the inner t ube
and determi ne the f l ow needed to cause a sustai ned pressure (70).
Oxygen Flush Test
To perf orm this test , t he reservoi r bag i s fi l l ed (77). The pat i ent port must be open
t o atmosphere. The oxygen fl ush valve on the machi ne is acti vated. The hi gh gas
f low t hrough the i nner t ube wi l l produce a Venturi ef fect , whi ch lowers t he pressure
i n the l arger outer t ube. If there are no probl ems wi t h the i nner tube, t he bag
shoul d def lat e. If t he bag does not def l at e or i nfl ates, the i nner tube should be
checked. This t est may f ai l t o detect maj or f aul ts t hat can be detected by t he i nner
t ube occlusi on test (74,78, 79,80).
Lack System I nner Tube
To test t he i ntegri t y of the i nner l imb of t he Lack system, a t racheal tube can be
i nsert ed int o the i nner t ube at t he pat i ent end (81,82). Bl owi ng down t he tracheal
t ube wi th t he APL val ve cl osed wi l l produce bag movement i f there i s l eakage
bet ween t he i nner and outer l imbs.
An al ternati ve method i s to occl ude both the i nner and outer l i mbs wi t h the APL
valve f ul l y open (82). There shoul d be no gas escape when appl ying pressure to the
reservoi r bag. If the i nner l i mb is defective, gas wi l l f l ow through the APL val ve,
and the bag wi l l col l apse.
A thi rd t est is t o i nsert a tracheal t ube i nto the i nner t ube at the pati ent end (83).
The cuff is i nf l at ed t o obst ruct t he opening between the outer and i nner t ubes. Wi th
t he APL val ve f ull y open, t he reservoi r bag shoul d be fi l led using the oxygen f l ush.
Squeezi ng t he bag shoul d cause t he f lowmeter i ndicator to drop, but no gas should
be released t hrough t he APL valve.
St i l l another t est uses a pressure manometer and i nf l at i ng bul b (62). A 7-mm nasal
ai rway that is connected to the bul b and manometer is i nsert ed int o the i nner t ube
wi th t he APL val ve cl osed. The i nf l ati ng bulb i s used to pressuri ze the i nner tube to
30 cm H
2
O. There shoul d be mi ni mal decl i ne i n pressure over 30 seconds. The APL
valve i s then opened. The pressure shoul d f al l i mmedi atel y.
Coaxial Circl e System
Hypercarbia rel ated to a faul t y coaxi al ci rcle system has been report ed (84). This
can be detected by having the anest hesi a provi der or pat ient breathe through the
system wi t h t he APL valve open and observi ng the capnograph. If t here i s a
connecti on bet ween t he t wo l i mbs, t he capnograph basel i ne wi l l be el evated.
Smel l Test
Some authors recommend that the anesthesi a provider smel l the gas f rom the
pati ent port wi t h a 3 L/ mi nute f l ow of oxygen set on the f l owmet ers. No odor
i ndi cates t hat a vaporizer i s not l eaki ng or l ef t ON (85).
Manual and Automatic Ventilation Systems
A second reservoi r bag shoul d be pl aced on t he pati ent port (Fi g. 33.11). The
oxygen f lowmeter should be set at t he mi nimum f low or 300 cc/mi nut e i f there is no
mi nimum f low. The bag-vent i l ator selector swi tch shoul d be i n the bag posi ti on. As
t he reservoi r bag on t he bag mount i n the breathi ng system i s squeezed, the bag on
t he pat ient port shoul d inf l ate (Fi g. 33.11). The bag on the pat ient port shoul d then
be squeezed. The reservoi r bag on t he bag mount should i nf late. System resistance
and compl iance shoul d be eval uated duri ng this test . Thi s i s usef ul t o det ect
i nadvert ent PEEP or an obstructi on in the system (86,87).
Venti lator parameters appropri ate f or the pati ent should be set and t he bag-
venti l ator sel ector swi t ch pl aced in t he venti l ator mode. The oxygen f l owmeter
shoul d be set at the mi ni mum f l ow or 300 cc/mi n if t here is no mi ni mun f l ow. The
bel l ows and reservoi r bag on the pati ent port shoul d be f i ll ed by using the oxygen
f lush and the venti lat or t urned ON. The bag on the pati ent port shoul d i nf late and
defl ate (Fi g. 33.12). The appropriate t idal vol ume shoul d be del ivered and the
bel l ows f i l l compl etel y duri ng expi rati on. If use of the PEEP val ve i s anticipated, i t
shoul d be adj usted to dif f erent val ues and the breathi ng system pressure gauge
observed to veri f y correct perf ormance. The bag shoul d be removed f rom the
pati ent port and the venti l at or al l owed t o cont inue cycl i ng (88). The l ow ai rway
pressure and t i dal or minute volume alarms shoul d annunciate af ter an appropri ate
del ay.
P. 944



View Figure

Figure 33.11 Test of manual ventilation system. A reservoir
bag is placed on the patient port. The bag-ventilator switch
is turned to the bag position. As the reservoir bag in the
breathing system is squeezed, the bag on the port should
inflate. Squeezing the bag on the patient port should cause
the reservoir bag in the breathing system to inflate.


View Figure

Figure 33.12 Test of ventilator. A reservoir bag is placed on
the patient port. The oxygen flowmeter is set for a flow of
300 mL/minute. Ventilator parameters that are appropriate
for the next patient are set. The bag-ventilator selector
switch should be in the ventilator position. The bellows and
reservoir bag are filled, and the ventilator is turned on. The
bellows should move freely and fill completely as the
ventilator cycles. The unidirectional valves should be
observed to make certain that the discs open properly.

P. 945


Wi th the venti l at or sti ll cycli ng, t he pati ent port should be occl uded and t he bell ows
f il l ed usi ng the oxygen f l ush. The breat hi ng system pressure shoul d ri se no hi gher
t han that set on the high pressure saf et y rel i ef pressure device. The high pressure
al arm shoul d sound.
To check f or a l eak in an upri ght bel lows, t he bel l ows shoul d be occl uded, the
pati ent port occl uded, and t he f lowmeters turned OFF. Al ternatel y, the bag-
venti l ator sel ector swi t ch can be set to bag. The bel l ows should stay i nf lated. If i t
f al l s, there i s a l eak.
To check f or a l eak in a venti l ator wi t h a hangi ng bel l ows (Fi g. 33.13), al l
f lowmeters shoul d be t urned OFF or t o the mi ni mum f l ow and the vent i l ator t urned
ON. When the bel l ows i s f ul l y cont racted, the pat ient port i s occl uded (or the bag-
venti l ator sel ector swi t ch i s put i n the bag posi t ion) and the venti l ator swi tched
OFF. The bel l ows should remai n cont racted at t he top of the housi ng. If i t expands
downward, a l eak is present . Another way of perf ormi ng thi s test is to occl ude t he
pati ent port (or put t he bag-venti lator sel ector swi t ch i n t he bag posi ti on) wi t h the
venti l ator turned OFF and lower t he bel lows stop. The bel l ows shoul d not expand
downward.

View Figure

Figure 33.13 Test for leak in ventilator with hanging
bellows. The flowmeters should be turned off or at
minimum flow. The APL valve is closed and the ventilator
turned on. When the bellows is fully contracted against the
head of the bellows assembly, the patient port is occluded
(or the bag-ventilator selector switch is put in the bag
position), and the ventilator is turned off. The bellows
should remain at the top of the housing for at least 10
seconds.

Unidirectional Valve Tests
The FDA checkli st does not specif y how t he uni di recti onal val ves are t o be checked
(89). Many practi t i oners feel that watching the i nhal at i on val ve di sc ri se duri ng
i nhal at i on and the exhalat i on valve ri se duri ng exhal ati on whi l e the venti l at or i s
cycl ing i s an adequate check. This veri f i es that they open but not t hat t hey cl ose
compl etel y.
During use, i ncompet ent uni di recti onal val ves can be detect ed by an i nspi red
carbon dioxi de greater than zero when usi ng a capnograph (Chapt er 22). Some
respi rometers can detect reversed f l ow.
Uni di recti onal valves may be checked by several methods.
Breathi ng Method
Wi th the APL val ve cl osed, t he inspi ratory l i mb of t he breathing system is detached
f rom the absorber and occl uded. Weari ng a mask, the t ester t ri es t o breath t hrough
t he Y-pi ece (Fi g. 33.14A). It shoul d be possi ble to exhale f reel y but not i nhal e.
Next, the exhal ati on tube i s det ached and occl uded. The tester should be able t o
i nhal e but not exhal e (Fi g. 33.14B).
Valve Tester
Thi s met hod uti l i zes a device consisti ng of a bulb wi th a 22-mm f emal e f i t ti ng that
can attach t o the i nspi rat ory and exhalat i on ports (90, 91). To test t he inspi ratory
valve, the compressed bul b is at t ached to the i nspi rat ory port . I t shoul d
i mmedi atel y rei nf l ate. When the bul b i s compressed, i t shoul d meet f i rm resi st ance
(Fi g. 33.15A).
To check t he expi ratory valve, the tester is at tached wi t h t he bul b i nf l ated. It shoul d
be possi bl e to squeeze the bul b, and i t should remai n def l ated (Fi g. 33. 15B).
Pressure Decl ine Method
To check t he val ves by t hi s method, an ext ra reservoi r i s placed on t he inspi ratory
port (92, 93,94). The ot her bag remains on the bag mount . The f resh gas f low i s set
t o a mi ni mum and the APL val ve is cl osed. The ci rcl e system i s pressuri zed to 30
cm H
2
O by using the oxygen f l ush. If t he bag on the bag mount remai ns i nf l ated,
t he expi ratory valve i s competent. Next , t he APL valve i s opened. I f the reservoi r
bag on the i nspi ratory port does not def l at e, t he i nspi ratory valve i s competent.
P. 946



View Figure

Figure 33.14 Checks for incompetent unidirectional valves.
A: The inspiratory limb is detached and occluded. The tester
tries to breathe through the Y-piece. It should be possible to
exhale freely but not inhale. B: The exhalation tubing is
detached and occluded. The tester should be able to inhale
from the Y-piece but not exhale.

Final Configuration and Obstruction Check
At t hi s poi nt , breathing system accessory equi pment (e. g., PEEP val ve, heated
humi di f i er) shoul d be in pl ace and turned ON. Obstructi ons i n the breat hi ng system
can be detected by having the pat i ent breathe 100% oxygen through a mask,
provi ded a t ight mask f i t is achi eved (95,96). Thi s can al so be done by the
anesthesi a provi der weari ng a mask (Fi g. 33.16) (97). The reservoi r bag shoul d
i nf l ate and def l at e, and the breathi ng system pressure i ndi cator shoul d show no
PEEP. Negat i ve pressure wi l l reveal an obst ructi on i n t he i nspi ratory l imb; posi t ive
pressure wi l l reveal an obst ructi on i n the expi ratory l i mb (98). Whi l e thi s is being
done, t he capnogram should be checked to make cert ai n that a normal waveform
appears.
P. 947



View Figure

Figure 33.15 Checking the inspiratory unidirectional valve.
The bulb should be compressed (A) and then attached to the
inspiratory port. It should inflate. Then, it should not be
possible to compress the bulb. B: Testing the expiratory
unidirectional valve. The bulb should compress easily and
remain compressed.

Monitors and Controls
Al l moni t ors shoul d be turned ON (36). Alarms shoul d be tested by simulat i ng al arm
condi ti ons, and appropri at e l i mi ts shoul d be set .
The f inal st atus of all cont rols shoul d be checked bef ore the machi ne is put i n use.
Thi s i ncl udes havi ng al l f low control val ves cl osed, al l f lowmeters i ndi cat i ng zero
f low, al l vapori zers turned OFF, t he bag-venti l ator swi tch set to BAG, the PEEP
valve OFF, and t he APL val ve open. The breathing system should be ready t o use
wi th al l components connect ed by usi ng a push and twi st moti on. The scavenging
system vacuum shoul d be ON.
Subsequent Checks on the Same Machine on the Same
Day
I f a thorough check is perf ormed bef ore the f i rst case of t he day, a l ess compl ete
procedure can be used bef ore subsequent cases. Those steps are i ndi cated in
P. 948

Table 33.1 by an asteri sk (*). The tests so marked may not be repeated or may be
abbreviated i f t he machi ne i s used by the same anesthesia provider f or successive
cases on the same day.

View Figure

Figure 33.16 Breathing system patency can be confirmed
by inhaling and exhaling through the patient port.

I t i s i mportant f or the breathi ng system to be checked bef ore the next case begi ns
(47). One of the most common al terat i ons made between cases is changi ng of the
carbon dioxi de absorbent. The absorber may not be cl osed properl y. This may
cause a large l eak and inabi l i ty to vent i l ate.
Procedure at the End of the Case
At t he concl usi on of a case, f l owmet ers, vapori zers, and sucti on shoul d be turned
OFF. Moni tors that woul d need recal i brat ion i f turned OFF should be l ef t ON or put
i n a standby mode. The absorbent should be checked f or signs of exhausti on and
changed i f i ndi cated (Chapt er 9).
Other Machine and Breathing System Checks
Whi le t he FDA checkout recommendati ons are adequate for dai l y use, other parts
may need to be checked ei ther dai l y or as the need arises. This i s especi al ly t rue
af ter the machi ne has been al tered or serviced.
Oxygen Pressure Failure Alarm
Most anesthesi a machi nes are equipped wi t h an oxygen pressure f ai lure al arm,
whi ch i s activated if there is no or l ow oxygen pressure i n the machi ne. To test this
al arm, the oxygen pipel ine hose is disconnected and al l oxygen cyl i nders closed.
Any pressure remai ni ng i n t he machi ne shoul d be bl ed of f by usi ng the oxygen
f lush. The alarm shoul d sound. Thi s step was not i ncl uded i n the FDA checkout
recommendat ions, because isol ated f ai l ure of t hi s component wi l l not injure a
pati ent (36). The Associat i on of Anaestheti sts of Great Bri t ai n and Irel and
recommend that thi s al arm i s tested on a weekl y basi s (39).
Leaks at the Yoke
I f a cyl inder i s not properl y ti ghtened in a yoke, t here wi l l be a gas l eak when the
cyl i nder is t urned ON. A large l eak wi l l be qui te apparent by the sound. A small leak
wi l l not be heard but could cause si gnif icant gas l oss. To check f or a l eak at the
yoke, af ter t he cyl i nder pressures have been checked and the val ves cl osed, t he
cyl i nder pressure i ndi cat ors shoul d be observed f or 2 to 5 mi nutes, wi th no f l ow on
t he f l owmeters. A drop of more than 50 psi g i ndicates signi f i cant l eakage. If there
i s a mi ni mum mandatory oxygen fl ow, t he machine must be t urned OFF. The
mi nimum f low wi l l mask any l eaks i n the hi gh-pressure system.
Oxygen Failure Safety Valve
The oxygen f ai l ure saf et y valve was i ncluded as a routi ne t est i n the f i rst edi ti on of
t he FDA checkout but was not made part of the l ater version because i t rarel y fai l s,
and there are many other methods of detecti ng oxygen pressure f ai l ure (36). This
t est can be performed by using ei t her t he pi pel i nes or cyl i nders as the gas source.
A cyl i nder of each gas on the machi ne i s turned ON whi l e t he pi pel ine hoses are
di sconnected. Fl ows of 2 L/mi nute are establ i shed on the f lowmeters f or each gas.
The oxygen cyl i nder i s then turned OFF. As the oxygen pressure fal l s, t he f l ows of
al l other gases except ai r i n some machi nes, as i ndi cat ed by t hei r fl owmeters,
shoul d decrease i n proporti on t o the decrease i n oxygen f l ow and eventual ly shut
OFF. Rest ori ng t he oxygen pressure shoul d cause the i ndi cators to return to t hei r
previ ous posi ti ons.
To perf orm the t est by usi ng pi pel i ne gases, al l cyl inder valves should be closed
and the f low control val ves opened unti l t he cyl inder pressure i ndicators regi ster
zero. The pi pel i ne hoses are connected and f l ows establ i shed on al l f l owmet ers.
The oxygen hose i s then disconnect ed. The i ndicat ors of the anestheti c gas
f lowmeters shoul d f al l j ust bef ore the oxygen indi cat or.
Spare Components
Ext ra components of the breathing system should be i mmedi atel y avai l able (99).
These incl ude an addi t i onal disposabl e system or i ndivi dual components of
reusable systems (Y-pi ece, tubings, bag).
Electrical System
Tests of the el ectrical system vary wi t h t he di ff erent makes and model s of
machi nes. Most have a means to test the reserve batt ery. I n addi ti on, there i s
usual l y an i ndi cati on that the machi ne i s working on the battery power. To check
t his, the machi ne i s disconnect ed f rom the mai ns power. The bat tery power
i ndi cator shoul d be i l l umi nat ed. Many el ectroni c machines wi l l have an i ndi cat or of
t he bat tery charge (see Chapt er 5).
Vaporizer Exclusion System
Most anesthesi a machi nes have a mechani sm t o al low onl y one vapori zer t o be
t urned ON at a t i me (Chapter 6). To test the vapori zer excl usi on system, one
vapori zer shoul d be turned ON and an at tempt made t o turn each of the other
vapori zers ON, one at a ti me.
P. 949


Other Equipment
Tracheal Tubes
Appropri at e t racheal t ubes of the si zes usef ul f or t he pat i ent shoul d be ready f or
use. Lumen patency shoul d be checked. Wi th cl ear t ubes, si mpl e observati on wi l l
suff ice. Wi t h other t ubes, i t is necessary to l ook i n both ends or i nsert a st yl et . The
cuff shoul d be hel d infl ated f or at l east 1 mi nute to veri f y that there are no leaks.
The cuff should i nfl ate evenl y and not sti ck t o t he t ube wal l or decrease t he si ze of
t he l umen. One l arger and one smal ler than the t racheal tube that i s i ntended for
use shoul d be readi l y avai l abl e.
Rigid Laryngoscopes
Laryngoscope mal funct ion i s a f requent probl em. At least t wo handl es shoul d be
present, each f i t ted wi t h the t ype of blade that the user ant ici pates wi l l be best f or
t he pat ient. The l i ghts shoul d be checked f or adequat e intensi ty. Blades of other
si zes and shapes shoul d be i mmedi atel y avai l abl e and checked f or proper f unct ion.
Accessory Intubation Equipment
A st yl et and bougi e should be i mmedi atel y avai labl e. I f a rapid sequence intubati on
i s planned, the styl et shoul d be f i t t ed to t he tracheal t ube. An int ubati ng f orceps
shoul d be i mmediat el y avail abl e. If a di ff i cul t i ntubat ion i s ant i ci pated, speci al i zed
equipment f or di f f i cul t i ntubat ion descri bed i n Chapters 18 and 21 shoul d be in t he
operati ng room and checked f or completeness, def ects, and proper assembl y.
Masks and Airways
An assortment of masks and ai rways i n a vari et y of si zes shoul d be readi l y
avai l able.
Other Equipment
Speci al equipment t hat i s requi red f or part icul ar cases, such as extensi on pi pel i ne
hoses, extensi on breathi ng hoses, pati ent warmi ng equi pment , and i nf usi on
devices, shoul d be present and checked bef ore use.
Procedures at the End of the Day
Fol l owi ng the l ast case, the pipel i ne hoses shoul d be di sconnected at the wal l or
ceil ing (not at t he back of the machi ne) and coi led over t he machine. I f the hoses
are disconnected at the back of the machi ne, they wi l l cont inue to be pressuri zed,
and gas may be l ost i nto t he room through l eaks. I f a f l ow control valve is open and
t he pi pel ine suppl y i s connected, dry gas can desi ccat e the absorbent , promot ing
t he format ion of carbon monoxi de (Chapt er 9). Cyl i nder val ves shoul d be cl osed.
Each fl ow cont rol val ve shoul d be opened unt i l the cyl inder and pipel i ne pressure
gauges read zero, then closed. I f the fl ow control valve i s l ef t open, restorat i on of
t he gas suppl y may f orci bl y rai se t he indi cat or t o t he t op of the tube, causi ng
damage.
Vapori zers shoul d be f i ll ed at t he concl usi on of the day af ter most operat i ng room
personnel have vacated the room. Thi s wi l l decrease personnel exposure t o
anesthet ic agents.
Checking New or Modified Equipment
Each new anesthesi a machi ne, vent il ator, or ot her compl ex pi ece of equi pment
shoul d be checked f or proper functi oning before bei ng put into use. Thi s i s best
perf ormed by a manuf act urer' s represent at ive, who may gi ve i n-servi ce instruct i ons.
A document cert i fyi ng that the equipment has been checked f or proper assembl y
and f uncti on shoul d be obtained and kept.
A manual that contains assembl y and i nstal l at ion i nst ruct ions, mai nt enance
requi rements, checki ng procedures, and inst ructi ons f or use i s suppl i ed wi t h each
pi ece of equi pment. This must be read caref ul l y and revi ewed peri odical l y. A copy
shoul d be kept in t he cent ral equipment f il es and wi t h t he equipment i tsel f .
Preventive Maintenance
Many i tems in an anesthesi a machine and venti lator deteri orate wi t h t i me and use.
Preventi ve mai ntenance is desi gned t o ant icipate predi ctabl e f ai l ures and repl ace
weakened components bef ore they f ai l . I n some cases, an improved part has
become avail abl e and can be substi tuted. The recommended f requency of
preventi ve mai nt enance (usual l y every 4 to 6 mont hs) i s det ermi ned by the
manuf acturer and wi l l be stated i n the operator' s instruct i on manual .
Proper preventive maintenance has been shown to be eff ect i ve in preventi ng
equipment f ai lure (100). One study determined that an adequat el y mai ntained
anesthesi a machine t hat was 10 years ol d had no more fai l ures than new machi nes.
Lack of a preventive mai nt enance program may l ead t o an unacceptabl y hi gh rate
of breakdowns, premature repl acement of maj or equi pment , and unnecessary ri sks.
There are a number of ways that equi pment can be servi ced.
P. 950


Equipment Manufacturer Service Contract
Wi th a servi ce contract , t he manuf acturer' s servi ce representat i ve comes to the
heal th care faci l i ty. Dif f erent l evel s of service are avail abl e. The cost wi l l depend
on the number of parts covered, the f requency of t he vi si ts, and t he necessary
response ti me.
Independent Service Company
I ndependent compani es that are not associated wi t h a part icul ar manufacturer may
perf orm servi ce on cert ai n equi pment on a cont ractual basi s. I t may be di f f i cul t f or
t he anesthesi a provider t o determi ne the qual if i cati ons of an i ndependent service
provi der. Some manuf acturers cert i f y i ndependent provi ders t o servi ce t hei r
equipment . To become certi f i ed, they must sati sf actori l y complete the same
courses as the company' s own servi ce techni ci ans. I t may not be possi bl e for an
i ndependent company to procure manuf acturer-approved parts unl ess the service
t echnician has been cert if i ed by the manuf acturer. Al ternatel y, t he faci l i ty may be
abl e to purchase part s f rom the manufacturer.
Laws enacted i n at l east one st ate (New Jersey) requi re t hat t he credenti al s of each
servi ci ng person are approved by t he machi ne manufacturer or det ermi ned by the
physi ci an di rector of t he anesthesi a depart ment t o be equi val ent to the credenti al s
of t he manufacturer' s service person (101).
In-house Biomedical Services
I n-house bi omedical services may be a sat isfactory opt i on for much equi pment,
especi al l y i n insti t ut ions where there are a l arge number of si mi l ar machi nes.
Bi omedi cal techni ci ans can at tend courses and become cert i f i ed to service specif ic
equipment . Of t en, a combi nati on of an outsi de servi ce agency and in-house
bi omedical servi ces i s used. The i n-house bi omedi cal techni ci ans do i ntermediate
checks and respond to immediat e probl ems bet ween services f rom the outsi de
servi ce agency (102).
Advantages of in-house bi omedical mai nt enance i ncl ude mi ni mal response ti me and
t he abi li t y t o observe probl ems whi l e the equi pment is i n use. The servi ce i ntensi ty
f rom outsi de sources and down t i me f or equi pment can be reduced. The bi omedical
t echnicians can assist wi th cl i nical educati on, provide l i ai son bet ween users and
manuf acturers, help wi t h equi pment sel ection, and keep abreast of modi f i cat ions
and service bul l eti ns issued by manuf acturers.
The quest i on of l i abil i ty exposure must be addressed when consi deri ng i n-house
servi ce (103). I f a probl em occurs as a resul t of t he act i ons of a bi omedical
t echnician, the f aci l i t y wi l l l i kel y have l i abi li t y.
Record Keeping
Record keepi ng on equipment has f requentl y been negl ected i n the past. Of t en, i t i s
assumed t hat t he servi ce representat i ve who does periodic preventive mai nt enance
wi l l take care of this task. Experi ence does not support thi s assumpt i on. Record
keepi ng is i mportant f or several reasons.
I t provi des proof that an effort has been made to keep the equi pment i n
proper working order. This coul d have medicolegal or Joi nt Commi ssi on f or
Accredi tat ion of Heal thcare Organi zat ions (JCAHO) si gni fi cance.
The state of New Jersey requi res that records be mai ntai ned of al l servi ce
and mai ntenance perf ormed on all anesthesi a machi nes, venti lators, and
vapori zers. The record must i ncl ude machi ne ident if i cati on, servi ci ng agent,
work performed, and date of the work. The mai ntenance must conf orm to that
requi red by the machi ne manuf acturer. The servi ci ng agent' s credenti al s
must be determi ned to be equival ent t o the credenti al s of the manuf acturer' s
servi ce agents. New York has simi lar requi rements (101).
JCAHO requi res that an equipment management program desi gned t o assess
and cont rol the cl i ni cal physical risks of equi pment f or t reatment, care, and
pati ent moni tori ng be i n pl ace. Wri tten cri teri a must incl ude the
characteri st ics of equipment f unct i on, mai ntenance, and i nci dent hi story
(101).
I t provi des a means of communicati on wi th the servi ce representat i ve.
Represent atives f requentl y come i n the l ate af ternoon or evening, af ter
anesthesi a personnel have l ef t . I f there i s no wri t ten record of probl ems that
have occurred wi th the equi pment, t he servi ce representat i ve may not
perf orm the i ndicated repai r(s).
I t provi des a compl ete, up-t o-date record f or each pi ece of equi pment . I f one
pi ece of equi pment mal f unct ions more f requentl y t han others, considerati on
shoul d be given to repl aci ng i t.
I t provi des a wri t ten record that mai ntenance by a servi ce representat ive was
performed and shows what was done. Service representati ves may present
onl y a bi l l for service and parts and no record of what was actual l y done to
whi ch machine.
I t provi des a check on the servi ce rendered by the represent ati ve. Af ter
equipment i s servi ced, i t shoul d perf orm wel l . I f a machine devel ops a
probl em soon af ter servi ci ng or i f t here i s an i ncreased f requency of repai rs
t hat can be traced t o a change i n servi ce representati ves, one may wi sh to
questi on t hat represent ative's abi l i ti es.
Wi th pi eces of equipment such as vapori zers that need to be sent to t he
manufacturer peri odical l y for servi ci ng or oxygen anal yzers t hat need to have
cert ai n
P. 951

components repl aced at intervals, records serve to remi nd the user when t he
equipment needs to be servi ced or a component repl aced. Af ter a vapori zer
i s servi ced, i t may be hel d i n reserve bef ore bei ng put i nto use. This woul d
extend t he t ime bef ore servi ci ng woul d be due. Thi s can be not ed on t he form
by recordi ng the ti me when a vapori zer i s recei ved f rom the manuf acturer
and when i t i s actual l y put i nto servi ce on a machi ne.
Recordi ng equi pment problems may be usef ul for i mprovi ng qual i ty by
analyzi ng causat ive factors and suggesti ng preventati ve st rategies (104).
A record shoul d be kept f or each piece of complex equi pment such as an
anesthesi a machine, venti l ator, vapori zer, or moni t or. Thi s shoul d i ncl ude
i denti f i cat i on i nformat ion; dat e of purchase; i nstructi ons f or servi ci ng; and the
name, address, and tel ephone number of t he servi ce representat i ve. I f a probl em
wi th t he equi pment arises, t he date, probl em, and correct ive acti on shoul d be
recorded. When routi ne servi ci ng i s perf ormed, thi s shoul d be noted, al ong wi t h any
probl ems or part s replaced. Each ent ry should be si gned by the person maki ng the
ent ry. Laws recentl y enacted i n at least one state sti pul ate t hat records must be
kept f or each machi ne, i ncludi ng t he name of the service person, work perf ormed,
and date the work was performed. The amount of t ime needed to retai n these
records vari es wi t h the heal th care f aci l i t y' s pol icies. Certai nl y, the records need to
be kept beyond the st atute of l i mi tat ions f or possible l i t i gat ion i n the state where
t he equi pment is l ocated (105).
Accident Investigation
Any t i me a pat i ent has an unexpl ai ned probl em, equi pment mal f unct i on or mi suse
shoul d be suspected and t he apparatus not used agai n unt i l thi s has been
di sproved (106,107,108,109,110).
When t here has been an i nj ury to a pat i ent , the heal th care f aci l i t y saf ety off icer (or
ri sk manager) shoul d be contacted at once to supervi se i nvest igati on of t he
i nci dent. An establi shed protocol shoul d be fol l owed so t hat al l import ant areas are
covered systemati cal l y. Al l i ndi vi dual s i nvol ved i n the incident shoul d document
t hei r observati ons soon af ter the event , whi l e detai ls are sti l l f resh i n thei r mi nds.
Thi s shoul d be a simpl e statement of facts, wi thout j udgments about causali t y or
responsi bi li ty.
The f ol lowi ng quest i ons need to be asked:
What was the date and ti me of the problem?
I n what area di d the probl em occur?
What moni tors were being used?
What were t he set alarm l i mi ts?
What was the f i rst i ndicati on t hat t here was a probl em?
At what t i me di d thi s occur?
Who f i rst noted the probl em?
What changes at tract ed at tenti on? Were any al arms act ivated?
What signs or symptoms did t he pat i ent exhi bi t?
Had t here been any recent modif icati ons to t he elect ri cal system or gas
pi pel i nes i n t hat area?
Was anything al tered shortl y bef ore the i nci dent?
Was t his t he f i rst case performed i n t hat area that day?
Were t here any probl ems duri ng previ ous cases perf ormed i n that area on
t hat day or the previous day?
Were t here any unusual occurrences i n other areas on that day or the
previ ous day?
Had any equi pment been moved into that area recentl y? Were t here any
probl ems not ed i n the room where i t was previousl y used?
What preuse checks were made of t he anest hesi a equipment?
Who l ast f il l ed the vapori zers on the anest hesia machine?
I f a vapori zer was recent l y at t ached to the machi ne, were precauti ons taken
t o prevent l i qui d f rom bei ng spi l l ed i nt o the outf l ow t ract?
Af ter the i ni ti al i ndicati on of a probl em, what was the sequence of events that
occurred?
An i mportant st ep invol ves const ructi on of a t i me l i ne, on whi ch al l events are l i st ed
i n chronol ogi cal order (81). Thi s wi l l help t o sort out events and may l ead to
i denti f i cat i on of mi ssi ng data.
Numerous phot ographs shoul d be taken of the area f rom various angl es, wi th al l
equipment si tuat ed where i t was at t he ti me of the incident . Each piece of
equipment shoul d be phot ographed separatel y.
Af ter pictures have been t aken, al l suppl i es and equipment associated wi th t he
case should be saved and sequest ered i n a secure l ocati on and l abeled DO NOT
DI STURB. Set ti ngs shoul d not be changed. Relevant identi f yi ng informati on such
as t he manuf acturer and lot and/ or seri al numbers should be recorded.
I f af ter all thi s has been accompl ished i t appears possi bl e that t he equi pment may
be i mpli cated i n causi ng the probl em, a thorough i nspecti on of t he equi pment by an
uni nvol ved thi rd party i n the presence of the pri mary anesthesia personnel ,
i nsurance carri er, heal th care f aci l i t y saf et y off i cer, pat i ent representati ve, or
equipment manuf acturers shoul d be conduct ed. The invest i gati on shoul d consi st of
an i n-depth exami nati on of t he equi pment si mi l ar t o the checking procedures
descri bed earl i er i n thi s chapter. Vapori zers shoul d be cal i brated and checked t o
determine i f vapor i s del i vered in t he OFF posi t ion. An anal ysi s should be made of
t he
P. 952

vapori zers' contents, if necessary. Foll owi ng t he invest i gat i on, a report should be
made t hat detai l s al l f acts, anal yses, and concl usi ons.
I f a problem wi th t he equipment i s found, an att empt shoul d be made t o reconst ruct
t he acci dent i f this can be done wi thout danger to anyone, and t he equi pment
shoul d agai n be locked up unti l any li t igati on i s set tl ed. If t he invest i gat ion reveal s
no probl ems, the equi pment can be returned t o servi ce wi t h the consent of al l
part ies.
The Safe Medi cal Devi ces Act of 1990 requi res medi cal devi ce user faci l i ti es to
report i nci dents that reasonabl y suggest there i s a probabi l i t y that a medi cal devi ce
has caused or contributed to the death, seri ous i nj ury, or seri ous i l lness of a
pati ent (87). The report i s due as soon as possi ble but no l ater than 10 working
days af ter t he user faci l i t y becomes aware of the i ncident .
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P. 954


Questions
For the f ol lowing quest ions, answer
i f A, B, and C are correct
i f A and C are correct
i f B and D are correct
i f D i s correct
i f A, B, C, and D are correct .
1. What actions are requi red by the Safe Medical Devi ces Act?
A. Probl ems whi ch must be reported i ncl ude death of a pat ient
B. Reporti ng is done by the cl ini ci an who experienced the probl em
C. Seri ous i nj ury resul t ing f rom equi pment must be reported
D. I nci dents must be reported wi thin 20 worki ng days
Vi ew Answer2. If there i s a loss of pipeli ne oxygen, which steps should
be taken to conserve oxygen from the cylinder?
A. Di scont inue usi ng ni trous oxide
B. Use ai r and i ntravenous agents
C. Di scont inue usi ng a piston vent il ator
D. Use a l ow oxygen fl ow
Vi ew Answer3. Which are important poi nts to remember when checking
the gas cyl inders?
A. The pressure i n the oxygen cyli nder should be at l east 500 psi g
B. The cyl inder valve should remai n open to suppl y gas i f the pi pel i ne f ai l s
C. The val ve is turned count erclockwi se to open the cyl inder
D. The pressure in t he ni trous oxide cyl inder ref l ects contents i n the cyl i nder
Vi ew Answer4. How can the l ow-pressure system in all anesthesi a
machines be checked for l eaks?
A. Posi ti ve pressure f rom the breathing system test
B. El apsed ti me pressure test
C. Fresh gas li ne occlusi on test
D. A negati ve pressure t est
Vi ew Answer5. What actions shoul d be taken if a pi ece of equi pment i s
suspected to have caused harm to a patient?
A. Document the ci rcumstances surroundi ng t he ti me the probl em f i rst occurred
B. Determine i f si mi lar probl ems occurred i n other operat ing rooms at the same
t i me
C. I sol ate the equi pment unti l t he probl em can be i nvesti gated
D. Have the company service representati ve service the equipment
Vi ew Answer6. Concerni ng cal ibration of the oxygen anal yzer
A. I t shoul d read 21% when the sensor is exposed to room ai r
B. The sensor shoul d f i rst be removed f rom the breathi ng system
C. Repeat ed oxygen f lushi ng wi t h the sensor i n t he breathi ng system shoul d cause
t he anal yzer t o read over 90%
D. Al l oxygen anal yzers need to be cal i brated dai ly
Vi ew Answer7. Concerni ng testi ng the i nner tube on the Bain System.
A. The i nner t ube can be occl uded wi t h a pl unger
B. I f there are hol es i n the i nner tube at t he pati ent end, the i nner tube occlusion
t est wi l l not work
C. The bag shoul d be open to atmosphere when t he oxygen f l ush i s used
D. using t he oxygen f lush shoul d cause the bag to infl ate i f the tubing is i ntact
Vi ew Answer8. Leaks i n the venti lator bellows and transfer tubi ng can be
detected by which of the fol lowing tests?
A. Isol ati ng these parts wi th t he bag-venti l at or sel ector swi tch
B. Veri f ying t hat a hangi ng bel l ows remai ns f ul l y cont racted af ter t he bag-vent il at or
swi t ch is put i n the bag posi ti on.
C. Using a mi ni mum f low f rom t he oxygen f l owmeter and observi ng the bel l ows
return to the ful l y i nf l at ed posi t i on
D. Observing the excursi on of the bel l ows duri ng i nspi rat ion
Vi ew Answer9. How should the uni di recti onal valves be checked?
A. Observi ng the mot i on of the l eaf l et as the venti l ator cycles
B. Occl udi ng the i nspi ratory t ubi ng and not bei ng able t o inhal e through the
expi ratory t ube
C. Removi ng the val ve leafl et to inspect for damage to the l eafl et or i ts seat
D. Occludi ng the expi ratory tubing and not bei ng abl e to exhal e through the
i nspi ratory t ube
Vi ew Answer