Está en la página 1de 6

Use of this content is subject to the Terms and Conditions of the MD Consult web site.

Miller: Miller's Anesthesia, 6th ed., Copyright 2005 Elsevier

ANESTHESIA APPARATUS
Early Delivery Systems For the first public demonstration of ether anesthesia, Morton used a specially constructed glass bottle with an attached mouthpiece (see Chapter 9 ). In England, John Snow developed a new type of ether inhaler and took up the practice of ether anesthesia as a full-time endeavor. His apparatus provided valves to prevent rebreathing, and although he experimented with methods for carbon dioxide absorption, he did not develop it into a clinically useful technique. John Snow was aware of the difficulties associated with the simple mouthpiece that was used with a noseclip by Wells and Morton. In his book on ether published in 1847, [355] he states the following: For some of the adult patients, after they lost their consciousness, made such strong instinctive efforts to breathe by the nostrils, that the air was forced through the lachrymal ducts, and occasionally they held the breath altogether for a short time, and were getting purple in the face, when the nostrils had to be liberated, for a short time, to allow respiration of the external air, and thus a delay was occasioned. With the introduction of chloroform, several inhalers were developed to administer the agent. Ferdinand Junker[356] (18281901) devised a simple inhaler, consisting of a bottle to hold liquid chloroform, an inflow tube into which the anesthetist could squeeze air with a hand pump, and an outflow tube directed into the mask. The Junker inhaler underwent several modifications to improve its safety but was rarely used in the United States. Joseph T. Clover[357] [358] (18251882), the prominent English anesthetist after John Snow, devised several devices for the administration of nitrous oxide, ether, and chloroform. The Clover bag held more than 16 L of air, with chloroform vapor at approximately 4%. Smaller concentrations could be given by adjusting a valve on the facemask that allowed dilution of the chloroform with air. A clever solution to avoid the problem of high concentrations of chloroform was presented by Augustus Vernon Harcourt (18341919) in 1912. This apparatus was one of the several "draw-over" systems that brought the inspired air over a vaporizer heated by a small candle. The chloroform double-necked flask held the liquid chloroform and two beads that rose to the top or sank to the bottom, depending on the temperature of the liquid. Several draw-over chloroform delivery systems are described in Dudley Buxton's 1914 textbook.[359] The problem with these early delivery systems for longer procedures was the potential for hypoxia and partial rebreathing of expired carbon dioxide. Other types of anesthesia machines were developed to provide anesthesia with the insufflation method, whereby a small catheter was placed with its tip near the carina to deliver air and ether or chloroform. These were continuous-flow machines that did not rely on respiratory movements for oxygenation and were based on the work of Samuel Meltzer (18511920) and John Auer (1875 1948) demonstrating its safe use in animals.[360] It was one solution to the problem of pneumothorax and respiratory decompensation during thoracic surgery. C. A. Elsberg's (18711948) continuousflow machine was described in 1911 and went through several modifications.[361] The popular Shipway model was used by Francis E. Shipway (18751968) to provide anesthesia to King George V of England for rib resection and drainage of empyema, a feat for which Shipway was knighted. In retrospect, it is clear that these continuous flow machines were not capable of eliminating carbon dioxide in all cases,[362] and anesthesia machines eventually were developed that allowed to-and-fro respiration through one large-bore endotracheal tube.

Copyright 2005 Elsevier Inc. All rights reserved.

www.mdconsult.com

Bookmark URL: /das/book/view/44273446-2/1255/33.html/top

Use of this content is subject to the Terms and Conditions of the MD Consult web site.

Miller: Miller's Anesthesia, 6th ed., Copyright 2005 Elsevier

Compressed Gases and Reducing Valves Of major importance in the design of the modern anesthesia machine was the compression of gases in metal
34

cylinders. Oxygen and nitrous oxide were available under compression as early as 1885 through the manufacturers S. S. White of Philadelphia and Messrs. Coxeter of London. This allowed the development of compact machines capable of prolonged anesthetic delivery without the cumbersome feature of low-pressure reservoirs. Frederick Hewitt's first anesthetic gas machine designed for giving oxygen and nitrous oxide mixtures had two nitrous oxide cylinders and one oxygen cylinder and were fed into a large breathing bag through a double cylinder yoke.[139] Oxygen concentrations could be adjusted at the stopcock near the mask. His preferred oxygen concentrations were 5% to 8%. With the addition of oxygen, he attempted to "dispense with cyanosis, jerky and irregular breathing, deep stertor and clonic movements of the extremities." The invention of the reducing valve is accredited to Jay Albion Heidbrink (18571957), an anesthesiologist from Minneapolis who observed that the opening from high-pressure cylinders often froze closed as the gases were released. He described a valve that reduced the high tank pressures to working pressures and incorporated this device into his Heidbrink Anesthetizer. In Germany, Heinrich Drager (18471917) and his son Bernhard Drager (18701928) developed reducing valves to control an even, accurate flow of carbon dioxide gas drawn from beer cylinders, and these valves were later used in the early anesthesia machines. Further refinements to the early machines were added by James T. Gwathmey[363] and H. Edmund G. Boyle[364] (18751941) chiefly through the addition of bubble-through heated water baths for estimation of gas flows. The Boyle machine passed various amounts of oxygen through ether with a "water-sight" meter. This flowmeter estimated the flow through the vaporizer from how many of the holes were generating bubbles. Heidbrink further improved the flowmeter by using an inverted float in a tube of varying taper with calibrations marked on the side. Rotating floats, also called rotameters, have slanted grooves cut into the rim, causing them to rotate, and they are more accurate than the ball or nonrotating floats. Rotameters were introduced in 1908 by Karl Kuppers and first used in anesthesia in 1910.[365]

Copyright 2005 Elsevier Inc. All rights reserved.

www.mdconsult.com

Bookmark URL: /das/book/view/44273446-2/1255/34.html/top

Use of this content is subject to the Terms and Conditions of the MD Consult web site.

Miller: Miller's Anesthesia, 6th ed., Copyright 2005 Elsevier

Carbon Dioxide Absorption Anesthesiologists from the first half of the 20th century were not privileged to visit just one hospital during a day's work. Visits to several institutions might take place in a single day, with the practitioners bringing their own delivery systems and drugs with them as they traveled. Understandably, there was a priority for portability and elimination of waste, because these anesthesiologists paid for the agents themselves. One development that conserved gases and vapors was the use of systems that absorbed expired carbon dioxide and allowed rebreathing of expired gases. Several ineffectual attempts were made to introduce carbon dioxide absorption methods in the 19th century. John Snow and Alfred Coleman (18281902) were motivated to conserve anesthetic gases that escaped into the atmosphere through nonrebreathing valves. Coleman devised a system of absorbing carbon dioxide by passing the expired gases over slaked quick lime.[366] [367] The recovered gases were then used for subsequent anesthetics ( Fig. 1-15 ). Franz Kuhn (18661929) described soda lime absorption of exhaled carbon dioxide in 1905, but the report did not attract attention.[368] Dennis Jackson demonstrated the use of soda lime absorption to maintain stable levels of anesthesia for several hours in animals with minimal ether consumption.[369] The animals were given additional oxygen to meet metabolic needs, but the anesthetic gases were rebreathed, resulting in economy and improved maintenance of body temperature and airway humidity. In 1923, Ralph Waters (1884 1979) (see Fig. 1-18B ), working then as an anesthesia practitioner in Sioux City, Iowa, contacted Jackson and devised a soda lime canister for clinical use.[370] The canister was attached to a breathing hose close to the face, and although it was cumbersome to use, the device was widely distributed. The in-line soda lime canister launched the academic career of Waters, who later became one of the most prominent figures in anesthesiology during the first half of the 20th century. In 1930, Brian C. Sword[371] altered the Waters canister by attaching it to the chassis of a movable cart with two hoses directed to the airway, one for inspired gases and one for exhaled gases.

Copyright 2005 Elsevier Inc. All rights reserved.

www.mdconsult.com

Bookmark URL: /das/book/view/44273446-2/1255/35.html/top

Use of this content is subject to the Terms and Conditions of the MD Consult web site.

Miller: Miller's Anesthesia, 6th ed., Copyright 2005 Elsevier

Controlled Vaporizers With the introduction of more potent volatile anesthetics such as halothane it became important to control the concentration of inspired vapor carefully. To solve this problem, Lucien Morris[372] invented the copper kettle to vaporize liquid anesthetics. Its advantage rested on the

Figure 1-15 Alfred Coleman's economizing device. The anesthetic gases entered the lower bag and passed into the upper bag through a one-way valve. Gases were inhaled and exhaled through the tube (h), passing over a lime container (1, 2) held in frame (k) that eliminated carbon dioxide; (c) is gas inlet. The conserved gas in the upper bag was used during a later anesthetic administration. (From Coleman A: Mr. Coleman's economizing apparatus for re-inhaling the gas. Br J Dent Sci 12:443, 1869.)

35

fact that as the agent was vaporized, there was little change in the temperature of the anesthetic liquid. The copper kettle could be used with any agent provided that the practitioner was cognizant of the vapor pressure of the agent and the flow rates of the inspired gases. Without the addition of diluent gases such as nitrous oxide or oxygen, the copper kettle could deliver lethal concentrations of vapor. The vaporizers in common use today use bimetallic strips that bend as the temperature drops, permitting more fresh gas to enter the vaporizing chamber. Vaporizers have been designed for all the agents in use today, including halothane, enflurane, isoflurane, desflurane, and sevoflurane. The modern anesthesia machines are also equipped with scavenging systems designed to minimize escape of anesthetic vapors and nitrous oxide into the operating room. Although controversial, some studies have shown that daily exposure to anesthetic vapors in low concentrations can have deleterious side effects. [373]

Copyright 2005 Elsevier Inc. All rights reserved.

www.mdconsult.com

Use of this content is subject to the Terms and Conditions of the MD Consult web site.

Miller: Miller's Anesthesia, 6th ed., Copyright 2005 Elsevier

Ventilators in the Intensive Care Unit The earliest ventilator, the Fell-O'Dwyer apparatus, was described in 1892.[374] It was used as early as 1896 to provide respiratory support in cases of opium poisoning. Rudolph Matas, a surgeon in New Orleans who contributed significantly to the early development of regional anesthesia in the United States, was one of the first to use the Fell-O'Dwyer ventilator during thoracic surgery.[375] During the polio epidemic, thousands of afflicted patients were kept alive with the Drinker respirator,[376] often referred to as the iron lung, a negative-pressure device that surrounded the patient and provided for air movement in and out of the lungs. A Swedish ventilator called the Spiropulsator was introduced in 1934 and modified in 1947 by E. Trier Moerch.[377] This ventilator used a piston pump to deliver a fixed volume of gas. Ventilators today are usually an integral part of the anesthesia machine and direct compressed air into a rigid container containing a bellows that inflates the lungs. Bjrn Ibsen [378] (1915-), a Danish anesthesiologist, initiated the concept of intensive care units in the early 1950s to care for polio patients and guided the transition from iron lungs to modern ventilators. Intensive care units have since become an integral part of the modern hospital, with anesthesiologists actively involved in their daily operation.

Copyright 2005 Elsevier Inc. All rights reserved.

www.mdconsult.com

Bookmark URL: /das/book/view/44273446-2/1255/37.html/top