| ITEM | Who performs? | Frequency to
Check | How to Check? | Notes/Rationale | FDA # |
|
| System Switch to STANDBY position. | Provider
AND Tech | Daily | Standby
position allows cessation of minimum oxygen flow so that static leaks in the
ventilator may be checked. |
| Vaporizer filling. | Provider | Each
case. | Fill
any depleted vaporizers. Make sure fill port is closed tightly. | Loose
connections or depleted volatile agent might cause awareness under
anesthesia. | 7 |
| Low pressure leak test | Tech | Daily | Check
for level seating of vaporizers and tight locking knobs. Open each FGF knob
1.5 turns. Pump negative pressure bulb at the opened CGO repeatedly for each
opened vaporizer. Check for no bulb inflation in <30 sec. Close FGF knobs. | A
low pressure leak would cause the influx of room air, causing the bulb to
reinflate. Each vaporizer must be
opened to depress the back-bar valves, which then tests the integrity of the
back-bar port O-rings. | 8 |
| Vaporizer interlock. | Tech | Daily | Interlock:
while testing each vaporizer for leaks, attempt to turn on each of the other
vaporizers. | Vaporizers
are designed not to deliver two agents at once. |
| Check auxiliary oxygen flowmeter | Tech | Daily | Turn
on while watching indicator, then turn off. | Auxiliary
oxygen, when available, is a basic requirement during monitored care, and a
critical safety backup. |
| Look for exhaustion of carbon dioxide absorbent | Provider
AND Tech | Each
case. | As
absorbent is exhausted, it will turn purple from top down. Desiccation may be indicated by purple at
the bottom, or by discovery of fresh gas flow ON at the start of the day. | Exhaustion
is indicated by a majority of the agent turning purple. Clinical evidence for exhaustion is the
rebreathing of inspired carbon dioxide detected by capnometry. Purple color may revert back to white in
some absorbents, or the coloration may be hidden internally (channeling). | 11 |
| Replace CO2 absorbent when necessary. | Provider
AND Tech | When
necessary and Monday MORNING. | When
using cartidges, make certain that the wrapper is completely removed and
gasket/housing rims are wiped clean of dust. | We
use a “conventional” GE Medisorb absorbent. Change whenever
exhausted, or desiccated, or exposed to prolonged FGF, or not used for a
prolonged period. Desiccated absorbent may produce toxic substances. | 11 |
| Gas sampling line and water trap. | Tech | Each
case. | Ensure
firm, straight connections of tubing and empty the water trap if liquid is
present. Analyzer must be OFF for subsequent leak testing. | The
gas sampling line is an integral part of the breathing system and is included
in the leak testing, but must not be turned on. |
| Static ventilator leak check | Tech | Daily | Switch
to Vent mode. Occlude Y-piece. Press flush to fill bellows and release. Wait
to assure that bellows does not collapse. | This
test checks for leaks in the ventilator relief valve or bellows (or breathing
circuit), when no pressure is applied to the system. It can only be done when
the machine is off, so that the ventilator will not activate. | 12 |
| Ventilator scavenger circuit and oxygen flush. | Tech | Daily | Following
above test, press O2 flush and ascertain that breathing circuit pressure is
<10cm. Check that scavenger reservoir bag (if present) is not distended
under pressure. If so, increase scavenger suction to green zone indicator. | The
oxygen flush valve should not stick.
The Aestiva/5 scavenges patient fresh gas AND ventilator drive gas and
therefore requires high suction; otherwise, undesired PEEP may develop. | 9 |
| Suction for patient. | Provider
AND Tech | Each
case. | Ensure
adequate patient suction. | An
essential element for patient care. | 2 |
| Backup ventilation devices. | Provider
AND Tech | Each
case. | Ensure
self-inflating non-rebreathing
bag operates properly by squeezing with and without thumb occlusion. Test
and/or locate jet ventilator, LMA, Cook® transtracheal catheter. | The
clinician must be prepared to ventilate and oxygenate the patient in the
event of machine failure or patient difficulty. | 1 |
| Medical gas supply | Provider
AND Tech | Daily | Check
for approximately 50psi on all line pressures and check for adequate oxygen
cylinder supply by opening and then closing the oxygen cylinder. | Backup
oxygen must be ensured, both by checking the pressure, and by closing the
valve after checking. | 5,6 |
| Battery backup power | Tech | Daily | Open
the circuit breaker behind the machine, reach around to turn machine on, and
look for battery backup indicator on the orange screen. Then close the circuit breaker, observing
the illumination of the green LED “mains indicator” on the panel. | Although
the machine can operate for at least 30 minutes on battery, it should always
be operated on wall supply. With loss of all power, note that none is
required to deliver fresh gas, vapor, and manual ventilation. | 3 |
| System Switch to ON |
| Minimum oxygen flow,
alarm, calibration, and moisture drain. | Tech | Daily | Check
min. O2 flow of 25-75 ml/min. Remove O2 sensor and wait. Note audible low
FiO2 alarm. Press the 21% calibration wheel when reading is stable. Replace
sensor tightly, checking O-ring. Press drain button. Open/close absorber
drain cock. | The
oxygen flow control knob is mechancally set to remain slightly open, allowing
minimum oxygen flow. The sensor may also be calibrated to 100%. Water
normally accumulates in this trap and must be drained away from the flow
sensors. | 10 |
| Flow sensor calibration and vent settings. | Tech | Each
case. | Remove
flow sensor module and wait for “No Insp/Exp Flow Sensor”. Reinsert
flow sensor. | For
optimal volume measurement, compensation, and ventilator function, the flow
sensors must be calibrated for each case, or if the temp changes >5°C. | 15 |
| Breathing circuit leaks and alarms. | Tech | Each
case. | Set
O2 flow to 250ml. Occlude Y, flush to
> Plimit, then stop. Note high Paw alarm, then “Contg. Press.
Alarm”. There must be NO drop in pressure. | Leaks
<250ml/min are generally acceptable. Proper function of airway pressure
alarms is important for patient safety. | 12 |
| APL calibration, scavenger, and high O2 calibration. | Tech | Daily | Bleed
APL to 30 by dial, check calibration with circuit pressure gauge. Open APL
fully and press O2 flush, noting pressure <10cmH2O. Release and check for
NO negative press. O2 monitor should read >90%. | This
tests the approximate calibration of the APL valve, and its ability to
scavenge high flow of gas without obstruction or pressure buildup. The
elevation in oxygen concentration to 100% confirms that oxygen gas is the
source. | 9,10 |
| Manual ventilation, uni-directional flow, tidal volume and apnea
alarm. | Provider
AND Tech | Each
case. | Second
bag at the Y. Flush, actuate bi-directional manual ventilation. Check
uni-directional valves, tidal volume measurement and lack of resistance or
obstructions. Listen for “reverse flow” alarm. Pause and wait for
apnea alarm after 30 sec. | This
checks the ability to ventilate the patient in the manual vent mode.
Incompetent uni-directional valves will cause reverse flow and activate the
alarm. Testing the apnea alarms is critical. | 13 |
| Mechanical ventilation, leaks, and pressure limiter. | Tech | Daily | With
FGF still OFF, activate and adjust mechanical vent settings. Observe for any
loss of gas. Press O2 flush and note inspiratory cut-off when Pmax is
attained. Increase O2 and N2O each to 10 l/min. | Proper
function of mechanical ventilation, with limitation of unsafe airway
pressures, is critically important.
Inadequate scavenger function may cause pressure buildup at high FGF. | 12 |
| Proportionator | Tech | Daily | Lower
O2 until it drags down the N2O, then increase the N2O to see if it drags up
the O2. Check that FiO2 does not decrease to <21%. Turn off N2O and leave
O2 at 6 l/min. Check for PEEP <3cm.
Remove the test lung and turn vent selector to bag. | This
checks the minimum oxygen ratio controller and scavenger exhaust. |
| Vaporizer back pressure test | Tech | Daily | With
oxygen at 6 l/min, turn on one vaporizer at a time to 1%. Check that oxygen
flow remains >5 l/min. | If
there was abnormal resistance in the vaporizer, then the oxygen flow would
drop more. |
| “Exit Room” to silence alarms | Provider
AND Tech | Each
case. | Press
“exit room” button and confirm. | Alarms
must be reset for the subsequent patient and silenced when leaving the room. | 4 |
| Checking during the case. | Provider | Each
case. | Some
functions are most easily, effectively, and safely checked when the patient
is initially pre-oxygenated and then attached to the machine. |
| Verify availability and proper function of required monitors and
alarms. | Provider | Each
case. | Is
the capnogram present? The function of
numerous monitors is verified as they are connected to the patient. Default alarm limits must be checked for
appropriateness while “auto-set” limits are convenient once the
patient is connected and has stable, desired vital signs. | Audible
and visual alarms help to alert the clinician to potentially dangerous
situations. | 4 |
| Verify adequacy of absorbent and competence of uni-directional
valves. | Provider | Each
case. | The
clinician should verify the absence of inspired carbon dioxide. | Either
exhausted absorbent or incompetent uni-directional valves could cause
inspired carbon dioxide. | 13 |
| Verify proper vaporizer output | Provider | Each
case. | The
clinician should ascertain that expected levels of volatile agents are shown
on the anesthetic gas analyzer. | Accurate
output of the vaporizer is expected, although it is not appropriately or
accurately measured at the endotracheal tube. Vaporizer calibrations are
checked by biomedical PM. | 7 |
| Document completion of checkout procedure per department policy | Provider
AND Tech | Each
case. | Document
the checkout on the anesthetic record and Tech Check log. | The
clinician is ultimately responsible for basic operation of the machine, and
responsible for proper response to an intraoperative machine failure. To
promote backup safety measures, the anesthesia technician will perform the
indicated tests. | 14 |
| TIME OUT! | Provider | Each
case. | Do
I have all of the following: Oxygen? Agent? Pressure? Absorbent? Suction?
Monitoring? Backup vent? | The
clinician should follow customary JCAHO recommendations for “TIME
OUT” to overcome potential errors or omissions from distractions. | 15 |
| Do the following between cases: | The
machine must be prepared adequately for subsequent cases. |
| All gas flows OFF between cases. | Provider
AND Tech | Each
case. | Turn
fresh gas flow knobs to the off position whenever the machine is not in use. | Leaving
flows on is wasteful and may desiccate the absorbent. |
| Breathing circuit drain and flow sensor humidity. | Tech | Each
case. | Press
the drain button >10 sec. Check for humidity on the flow sensors and
replace if wet. | Moisture
droplets around the flow sensors will cause them to fail. Replace with a dry
unit and allow existing unit to dry out. |
| Change the circuit and suction apparatus | Tech | Each
case. | Check
for tight connections and damage to the circuit. | Both
systems are contaminated. Hoses may have cuts or kinks. |
| Review and perform all “each case” items in this list. | Tech | Each
case. | Follow
the same sequence. | Changing
a circuit, filling a vaporizer, or opening the absorbent canister may create
a leak. |
| Alarm resets | Tech | Each
case. | Press
“exit room” button and confirm. | Alarms
must be reset for the subsequent patient. |
| End of day |
| Machine off to STANDBY | Provider
AND Tech | Daily | At
the conclusion of the day’s list, power down the machine. On-call machines
should be left ON, following the above step, and re-booted in the morning for
checkout procedures. | STANDBY
mode allows trickle charge of battery and stops all gas flow to prevent
dessication of the absorbent. ON mode allows immediate use of machine and
continuous flushing with minimum O2 flow. |
