Physics in Anesthesiology: Basic Science Review

Keith E. Gipson, MD, PhD and Jeffrey B. Gross, MD

Department of Anesthesiology University of Connecticut School of Medicine Farmington, Connecticut

Learning Objectives: As a result of completing this activity, the participant will be able to  Explain how our equipment is supposed to work  Troubleshoot problems with anesthesia equipment when they occur, thereby avoiding potential patient complications  Use fundamental principles to instruct trainees in the proper use of anesthesia equipment Author Disclosure Information: Drs. Gipson and Gross have disclosed that they have no financial interests in or significant relationship with any commercial companies pertaining to this educational activity.

underlie the function of anesthesia equipment, including measurement of patient variables and prevention of common safety mishaps (see Supplemental Digital Content 1, http://links.lww.com/ASA/A124).

PRESSURE
Pressure is defined as force per unit area. The definition implies that even a small pressure may exert a large force if the area is large, and that even a small force can exert a large pressure if the area is small. Some common units of pressure and their clinical applications are listed in Table 1 (see Supplemental Digital Content 2, http://links.lww.com/ ASA/A125).

Pressure is defined as force per unit area. The

afety in the delivery of anesthesia is inextricably linked to the proper functioning of anesthesia equipment and resuscitative equipment, and to the presence of a consultant in anesthesia who can maintain safety in the face of equipment failure. This consultant relies upon basic principles in troubleshooting and evaluation of alternatives when equipment malfunction occurs. This chapter reviews the standards and principles that

definition implies that even a small pressure may exert a large force if the area is large, and that even a small force can exert a large pressure if the area is small.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML and PDF text of this article on the Journals Web site (www.asa-refresher.com).

Measurements of pressure may be expressed as gauge pressure or absolute pressure. Gauge pressures are measured relative to ambient pressure, e.g. tire pressure, pressure in a compressed gas cylinder, blood pressure. Absolute pressures are measured relative to vacuum, e.g. vapor pressures, blood gases, and situations involving gas laws. 40

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Table 1. Common Units of Pressure Used in Medical Applications

Clinical Application Compressed gas cylinder pressure Blood gases Blood/CSF pressure, blood gases Airway pressure Units Pounds per square inch (psi) Pa 1 N/m2 mm Hg cm H2O Atmospheric Pressure 14.7 psi 101.3 kPa (1 kPa 1,000 Pa) 760 mm Hg 1,029 cm H2O

Types of pressure gauges in the operating room:



DiaphragmUseful for measuring fairly low gas pressures, e.g. airway pressures, noninvasive blood pressures. Gas pressure at the inlet expands elastic capsules, which push a connecting rod that drives a gear/hair spring assembly to turn the indicator needle (Figure 1). Bourdon tubeUseful for measuring high gas pressures, e.g. compressed gas cylinder pressures. Gas pressure at the inlet deforms a curved metal tube to drive a lever arm assembly to turn the indicator needle (Figure 2). Strain gaugeUseful for precise electronic measurement of time-varying signals, e.g. arterial and central venous

Figure 2. Cutaway view of a Bourdon tube type pressure gauge commonly used for measuring relatively high pressures (e.g., pressures within compressed gas tanks and gas pipelines).

pressure waveforms. Fluid pressure deforms a diaphragm to which a zigzag pattern of conductive material is attached. As the conductor is stretched, its electrical resistance increases; a Wheatstone bridge circuit converts the changes in resistance into a voltage signal that can be displayed by electronic monitors (Figures 3 and 4). In the operating room, pressure regulators reduce tank pressures (750 to 2,000 psi) to approximately 50 psi for supply to the anesthesia machine. Wall gas pressures are around 50 psi as well. The pressure regulation is accomplished using a springdiaphragmvalve assembly in a negative feedback relationship between a high-pressure chamber and a low-pressure chamber. The spring provides an opening force for the valve, whereas valve opening is

Figure 1. Cutaway view of a capsule type pressure gauge commonly used for measuring relatively low pressures (e.g., arterial blood pressures, barometric pressure).

Figure 3. Magnified view of a strain gauge. As pressure is applied, the conductors lengthen slightly, increasing their electrical resistance. The change in resistance is measured using a Wheatstone bridge circuit whose output is amplified and sent to the monitor display.

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Figure 4. Wheatstone bridge circuit. When no pressure is applied to the strain gauge, the bridge is balanced and the voltmeter reads 0. A slight change in the resistance of the strain gauge causes a large change in the voltmeter reading.

opposed by force on the diaphragm by gas in the lowpressure chamber (Figure 5).

evaporation of some of the pressurized liquid. The pressure in the cylinder depends on the vapor pressure of the liquid at the tank temperature until the liquid is entirely consumed. For N2O, this pressure is E750 psi at room temperature; a full E cylinder of N2O contains 1,590 L. The remaining cylinder content is best determined by weight. The quantity of N2O in a full cylinder has a mass of about 3 kg. Once the liquid is consumed (when the tank is approximately onequarter full and the pressure in the tank drops below the vapor pressure of the gas), the amount of gas remaining in the cylinder is proportional to gauge pressure. Whether a gas behaves as an ideal gas or a pressurized liquid in an E cylinder is determined by its critical temperature. The critical temperature (T c) is the temperature above which a gas cannot be liquefied, regardless of pressure. For N2O, T c 36.41C; for CO2, T c 31.11C; and for O2, T c 118.61C. Some simple calculations involving gases and vapors:


Gas Cylinders
In the operating room, gas storage typically occurs in E cylinders. For ideal gases (e.g., oxygen, nitrogen, air), the cylinder contains compressed gas. A full E cylinder contains E660 L of oxygen at a pressure of E2,000 psi. The volume of gas remaining in the cylinder is proportional to the pressure. Thus, when an oxygen cylinder is half full, it reads 1,000 psi and contains 330 L; when it is one-quarter full, it reads 500 psi and contains 165 L. Some gases form liquids when compressed at room temperature (e.g., CO2 [carbon dioxide], N2O [nitrous oxide], C3H8 [propane], C3H6 [cyclopropane]). For these substances, when gas leaves the cylinder it is replaced by

What is the mass of N2O in an E cylinder? mole 44 g 2;900 g 2:9 kg 1;590 L 24 L mole (Note: The volume of 1 mole of an ideal gas at room temperature (201C) is approximately 24 L.) What is the internal volume of an E cylinder? Use Boyles Law: P1V1 P2V2 2;000 PSI VTANK 14:7 PSI 660 L 14:7 660 4:85 L VTANK 2;000 How many milliliters of sevoflurane vapor come from 1 mL of sevoflurane liquid? (see Supplemental Digital Content 3, http://links.lww.com/ASA/A126, and Supplemental Digital Content 4, http://links.lww.com/ASA/A127). 1:5 g 1 mole 24 L gas 1 mL liquid mL 200 g mole 0:18 L gas 180 mL If the fresh gas flow is 2 L/min, how many minutes of 2% sevoflurane anesthesia will 5 mL of sevoflurane provide? 180 mL gas 1 minute 5 mL liquid mL liquid 0:02 2; 000 mL gas 22:5 minutes

Figure 5. Schematic of pressure regulator. Gas from the cylinder (or other high-pressure source) enters the high-pressure chamber on the left side of the figure. Gas passes through the valve into the low-pressure chamber until the force of gas pushing the diaphragm to the right exceeds that of the spring pushing the diaphragm to the left, at which point the valve closes. When gas is drawn from the low-pressure outlet, the valve opens slightly, allowing additional gas to enter the low-pressure chamber keeping the pressure constant.

Adiabatic Compression. According to the ideal gas law (PV nRT), compression of a quantity of gas by increasing pressure (P) produces an increase in temperature (T). Adiabatic compression implies that the compression occurs rapidly without a chance for heat to escape. When adiabatic compression occurs in the presence of fuel (e.g., in a diesel engine cylinder), ignition can occur. Adiabatic compression occurs in the yoke or in a pressure regulator when a compressed gas cylinder is opened rapidly. The use of lubricants on these components can provide fuel for ignition and lead to explosions in the operating room.

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Flows of Liquids and Gases

Laminar flows of fluids are characterized by streamlined flow patterns in which particles are traveling mostly in parallel in the direction of flow. For example, laminar flow predominates during calm inspiration in the normal airway. During laminar flow, Pressure Flow Resistance, where the resistance is given by the Poiseuille law: 8 LZ Resistance p R4 where Z viscosity of fluid, R radius of tube, and L length of tube. Turbulent flow is a less efficient pattern of flow characterized by randomness in the direction of flow of individual particles. Turbulent flow may be favored by changes in the diameter of the tube in which flow occurs (e.g., branch points or obstructions) as well as by high flow velocities and low fluid viscosity (the molecules are less likely to stick together, making flow more chaotic). During turbulent flow, Pressure a Density Flow2. The tendency of fluid flow to be turbulent is described by the Reynolds number (Re), where turbulent flow is favored at Re42,300: Re rVD Z

Figure 6. Schematic of Thorpe tube flowmeter. When the flow control knob is turned counterclockwise, the needle valve is pulled toward the left, allowing gas to flow from the inlet into the flowmeter. The bobbin then rises to the point where the upward force of the gas acting on the bobbin equals the weight of the bobbin. As gas flows increase, the bobbin rises and more gas flows around the bobbin, restoring the balance of forces.

where r density of fluid, V velocity of flow, D diameter of tube, and Z viscosity of fluid.

of hypoxia in the case of a cracked flow tube by minimizing the chance that O2 will leak out through a cracked flow tube closer to the common gas outlet of the machine.

Flowmeters. The basic construction of a gas flowmeter (Thorpe tube) involves a tapered glass tube whose diameter increases toward the top (Figure 6). A needle valve is opened to allow gas flow upward through the tube. The gas exerts a drag force as it flows around and raises a bobbin in the tube. This drag force at a given flow rate decreases as the bobbin moves upward and the annular space around it grows larger. The bobbin assumes an equilibrium position where the upward drag force from gas flow equals the downward force from gravity. Meters using spherical bobbins are designed to be read in the center of the bobbin, whereas those using cylindrical bobbins are designed to be read at the top of the bobbin. Rotation of the bobbin in the gas stream is an important indicator that the bobbin is not stuck, and is encouraged by rifling on cylindrical bobbins. At low flow rates, laminar flow predominates around the bobbin and the upward force is proportional to the viscosity of the gas. At high flow rates, turbulent flow predominates around the bobbin and the upward force is proportional to the density of the gas (see equations in previous section). At higher altitudes, both the density and viscosity of gases are decreased; this reduces the upward force on the bobbin for any given gas flow. As a result, the actual gas flow may be significantly greater than indicated by the flowmeter. The arrangement of flowmeters in an anesthesia machine routinely locates the O2 flow tube closest to the common gas outlet. This arrangement minimizes the risk

Fail-Safe Valve. The fail-safe valve resides in the lowpressure system of the anesthesia machine and is designed to prevent delivery of a hypoxic gas mixture. This mechanism does not prevent dialing in of a hypoxic gas mixture by the operator; rather, it prevents the flow of nitrous oxide from the wall or tank source unless an adequate O2 supply pressure is present. To test the fail-safe, one should turn on both O2 and N2O flows, then disconnect the wall O2 supply, being sure that the O2 tank is closed. As the O2 pressure decreases to zero, observe that the N2O flow stops. The O2 flush valve may be pressed to test more quickly. Proportioning Systems. Proportioning systems are designed to prevent the anesthesiologist from dialing in a hypoxic gas mixture involving nitrous oxide. Two general designs (i.e., link- or pressure-operated) limit N2O flow to roughly three times the O2 flow. To test the proportioning system, the user should attempt to create a hypoxic mixture by raising the N2O flow or decreasing the O2 flow, then observing the adjustment of the other gas by the proportioning system. A link-operated system uses a proportioning chain between the N2O and O2 flow knobs. The chain mechanically turns down the N2O needle valve if the O2 flow is reduced; it also opens the O2 needle valve if the N2O flow is increased beyond the 3:1 ratio. Of note, the chain only affects the N2O:O2 proportion when the user attempts to violate the

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3:1 ratio. A pressure-operated system uses a diaphragm system to keep the N2O:O2 ratio at or below 3:1. In contrast to the link-operated system, if a pressure-operated system reduces the N2O flow in response to inadequate O2 flow, the N2O will be restored to its previous value when the O2 flow is restored by the user.

ANESTHESIA VAPORIZERS
Copper Kettle
The predecessor to modern anesthesia vaporizers was the copper kettle (Figure 7). Its vapor output depends on the O2 inflow and the vapor pressure of the anesthetic, as shown in Table 2. For example, consider a copper kettle containing sevoflurane through which oxygen is flowing. As the vapor pressure of sevoflurane is about 1/4 atm, approximately 1/4 of the output molecules will be sevoflurane and 3/4 will be oxygen. Hence, the output will contain 1/3 as much sevoflurane as O2 (1/4 vs. 3/4). For every 100 mL O2 input, we would thus expect 100 mL O2 output plus 33 mL sevoflurane 133 mL total output. (The concentration of sevoflurane in the copper kettle output would be 33/133 25%, as expected from the vapor pressure.) When using a copper kettle with sevoflurane, anesthesiologists typically used a total gas flow (O2 plus either N2O or air) of 3,300 mL/min (the so-called magic number for sevoflurane). Under these conditions, 100 mL of oxygen flowing through the kettle resulted in 1% sevoflurane at the common gas outlet (33 mL/3,300 mL). To give 2% sevoflurane, one simply increased the kettle flow to 200 mL/ min. Modern vaporizers do the calculations automatically; the amount of fresh gas diverted through the vaporizing chamber depends upon the dial setting as well as the temperature of the anesthetic liquid. As the anesthetic is vaporized, cooling the liquid and lowering its vapor pressure, a temperature-sensing mechanism (usually a bellows or bimetallic strip) slightly increases the flow through the vaporizing chamber to compensate. Supplying desflurane vapor poses a particular challenge. Its vapor pressure is close to atmospheric pressure, leading to its low boiling point of 23.51C. In a copper kettle, each 100 mL O2 input would yield E900 mL desflurane output at 201C. The output would be strongly variable with temperature, making precise control difficult. To avoid this problem, desflurane is delivered from a heated boiler whose output is pure desflurane gas. The gas is delivered through a needle valve, much like O2 or N2O. Electronics control the pressure of desflurane flowing through the needle valve to ensure delivery of a predictable percentage of desflurane at the prevailing fresh gas flow rate. At higher altitude, both vaporizer output and anesthetic effect change in predictable ways. Even though we speak of anesthetic minimum alveolar concentration (MAC) in terms of a percentage of alveolar gas at sea level, it is important to recognize that anesthetics act on the brain in proportion to their partial pressure in blood. Thus, we could

Figure 7. Copper kettle vaporizer. Each 100 mL of oxygen picks up 33 mL of sevoflurane vapor as it bubbles through the liquid sevoflurane. If the total gas flow is set to 3,300 mL (the magic number), then the delivered concentration of sevoflurane will be 1%.

express the MAC of sevoflurane as 2% 760 mmHg 15.2 mmHg. The worlds highest city of La Rinconada, Peru, lies at 5,100 m above sea level and boasts an atmospheric pressure of about 380 mmHg (E1/2 atm). Here, we need a greater percentage of vapor to achieve the same partial pressure. In this case, the MAC of sevoflurane is 15.2 mmHg/380 mmHg 4%. Despite the difference in atmospheric pressure, the vapor pressure of sevoflurane is the same in La Rinconada as at sea level as it depends only on temperature. However, the vapor pressure of sevoflurane in La Rinconada is approximately 1/2 of the ambient atmospheric pressure; therefore, for every 100 mL O2 flowing through the vaporizing chamber, the output is 100 mL of O2 Table 2. Vapor Pressure of Commonly Administered Inhalation Anesthetics
Anesthetics Sevoflurane Enflurane Halothane Isoflurane Desflurane Vapor Pressure (mmHg) (at 251C) 197 218 299 295 798 Vapor Pressure (atm) E1/4 E1/4 E1/3 E1/3 41

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plus 100 mL of sevoflurane. The vaporizer output is thus three times as high as at sea level for a given dial setting, so if we dial in 2% sevoflurane, the vaporizer will actually deliver 6% of the gas! As the MAC of sevoflurane is only 4%, we actually need to turn the vaporizer down to 1.33% to get a vaporizer output of 4% which will give 1 MAC of anesthetic effect. For a desflurane vaporizer (really a boiler, see above), the percentage vapor output is unaffected by altitude. However, the MAC of desflurane in La Rinconada, Peru, is 12%, and we thus would need to dial in 12% desflurane to achieve 1 MAC of anesthetic effect.

Contemporary Anesthesia Machines Low-pressure Leak Test. The low-pressure leak test performed during an anesthesia machine checkout is done to detect leaks in flowmeters, vaporizers, and the common gas manifold. To check for leaks, turn the machine fully off so that the minimum mandatory flow of O2 does not look like a leak. Then, apply a suction bulb to the common gas outlet and verify that it remains deflated for at least 5 seconds. This test should be repeated with each vaporizer turned on to verify that there are no leaks within the vaporizers themselves. On many machines, there is a check valve just before the common gas outlet. This allows the patient to be ventilated with O2 from the flush valve even if there is a leak in the low-pressure system. Therefore, the fact that the breathing circuit holds pressure does not guarantee that there are no leaks in the low-pressure components of the anesthesia machine. Breathing Circuits. There are four types:


Figure 8. Bagvalvemask system showing the three valves used to prevent rebreathing while allowing either spontaneous or positive-pressure ventilation. When the bag is squeezed, the inlet and mushroom valves close, forcing air into the patients lungs. When the bag is released, the mushroom valve opens, allowing the patient to exhale to the atmosphere; the inlet valve opens, allowing fresh gas to fill the bag; and the inspiratory valve closes, preventing exhaled air from reentering the bag.

Open breathing circuits are characterized by the lack of rebreathing of exhaled gases and include nasal cannulas, simple face masks, and bagvalvemask systems (e.g., Ambus). Bagvalvemask systems use three valves to allow either spontaneous or controlled ventilation while preventing rebreathing (Figure 8). Semiopen circuits (e.g., Mapleson or Bain circuits) are valveless systems in which the fresh gas flow serves to wash out the patients exhaled gases to reduce rebreathing (Figure 9). Semiopen circuits are most efficient at removing exhaled CO2 for a given gas flow when the pop off valve is nearest the source of the ventilatory power. For spontaneous ventilation a Mapleson A circuit is advantageous, whereas a Mapleson D is the most efficient for controlled ventilation. Of note, the Mapleson A is very inefficient (i.e., requires high gas flows to prevent rebreathing) during controlled ventilation, whereas the Mapleson D is reasonably efficient for both controlled and spontaneous ventilation. Due to its versatility, the Mapleson D design is preferred for most applications; fresh gas flows of twice the minute ventilation are usually sufficient to minimize rebreathing. The Bain circuit uses a Mapleson D design with coaxial circuit tubing.

Semiclosed circle systems involve partial rebreathing of exhaled gas after removal of CO2 by an absorber. This implies that the fresh gas flow is greater than the patient uptake of gases but less than the minute ventilation. In modern semiclosed systems, direct rebreathing is prevented by a pair of one-way valves so that the patient always inhales from the fresh gas side of the circuit and exhales through the waste gas side of the circuit. The dead space of such a system begins at the Y-piece where the circuit connects to the mask or endotracheal tube (Figure 10). Closed systems use complete rebreathing of exhaled gases with fresh gas flows equal to the patients uptake of O2 and anesthetic. If using a sidestream gas analyzer, one must route the exhaust gases back into the patient circuit to achieve a truly closed circle system. Flow rates for closed-circuit anesthesia can be titrated using FiO2 and inhaled anesthetic data from the gas analyzer. Starting values for flow rates should include 3 to 4 mL/kg/min O2. Anesthetic flow rates should match their rates of uptake, which can be estimated as: First-minute uptake p Time minutes Some sample starting uptakes are listed in Table 3.

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Figure 10. Circle absorber breathing system. Exhaled, CO2-containing gas is indicated in gray; CO2-free gas is indicated in green. Dead space begins at the Y piece and extends down through the patients conducting airways.

Figure 9. The two most common semiopen circuits, Mapleson A and D. The A circuit is very efficient for spontaneous ventilation, but very inefficient for controlled ventilation. The D circuit is most efficient for controlled ventilation, but also reasonably efficient for spontaneous ventilation.

Moisture is necessary for CO2 absorption and reduces the likelihood of anesthetic breakdown (Supplemental Digital Content 5, http://links.lww.com/ASA/A128). The chemistry of CO2 absorption includes the following three steps: CO2 H2O-H2CO3 H2CO3 2 NaOH-Na2CO3 2H2O heat Na2CO3 Ca(OH)2-CaCO3 2NaOH The zone of maximum absorption in the canister feels warm to the touch, or could feel hot in the case of malignant hyperthermia. When there is insufficient Ca(OH)2 to regenerate the NaOH, acidification causes the indicator (ethyl violet) to turn violet in color; when the violet zone extends more than halfway through the canister, it is time to replace the absorbent. Note that if it is allowed to rest overnight, the residual Ca(OH)2 may be sufficient to decolorize the violet indicator, making it appear as if the absorber is fresh despite the fact that little absorbing capacity remains. Thus, the decision to change the absorbent should be made at the end of the day.

In modern semiclosed systems, direct rebreathing is prevented by a pair of one-way valves so that the patient always inhales from the fresh gas side of the circuit and exhales through the waste gas side of the circuit.
Once closed-circuit anesthesia has been established, total flow of gas into the circuit should be adjusted to maintain the volume of the bag or bellows constant and submaximal (to prevent gas from popping off). The ratio of O2 to N2O or air should be adjusted to maintain the desired FiO2, and the vaporizer setting should be adjusted to maintain the desired inspired anesthetic concentration.

BLOOD PRESSURE AND CARDIAC OUTPUT

Invasive Blood Pressure Measurement
Pressure transducers measure pressures using the variable resistance of a strain gauge incorporated into a Wheatstone bridge circuit. In most cases, a continuous flush deTable 3. Approximate First-minute Uptake of Selected Anesthetics in an 80-kg Patient
Agent (%) Nitrous oxide (80%) Sevoflurane (2%) Desflurane (6%) First-minute Uptake (mL) 1,600 50 100

CO2 Absorption. Granules of CO2 absorbent are sized

small enough to have a large surface area for reaction but large enough to avoid channeling of gas flow. This size is typically 4 to 8 mesh; this means that the granules are small enough to pass through a 4 mesh (i.e., wire grid spaced at 1/4-inch intervals), but not so small that they can pass through an 8 mesh (i.e., wire grid spaced at 1/8-inch intervals). Granules are composed of a weak base (Ca(OH)2 or Ba(OH)2) plus a strong base catalyst (NaOH or KOH). Soda lime is composed of NaOH and Ca(OH)2, whereas Baralyme contains KOH, Ca(OH)2, and Ba(OH)2. Baralyme is more likely to react with anesthetics to form CO (with desflurane) or compound A (with sevoflurane).

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vice is located between the pressurized flush solution and the tubing connected to the patient. Since the flow through the flush device is only a few mL/h, the flush solution does not usually affect pressure measurements. However, if the monitoring catheter is totally occluded (as in a kinked arterial catheter), the flush solution will pressurize the patient connection and the pressure reading will quickly rise to that of the flush solution. The accuracy with which the transducer system reproduces the intravascular pressure depends on the resonant frequency (higher is better) and the degree of damping. The resonant frequency of the transducer system is increased by keeping the connecting tubing short and noncompliant. Damping is increased if the diameter of the tubing is small, or if there is air in the tubing, resulting in increased motion of the fluid and friction within the system. If the resonant frequency of the system is approximately 1/rise-time of the pressure waveform, the waveform may be exaggerated; this will cause overestimation of systolic pressures and underestimation of diastolic pressures, particularly if the system is underdamped. In contrast, if the system has too much damping, peaks and troughs of the pressure waveform tend to be smoothed out, resulting in underestimation of systolic pressures and overestimation of diastolic pressures. Damping can be assessed by observing the pressure waveform while squeezing and then releasing the manual flush valve. If the pressure trace returns very slowly to its baseline, then the system is overdamped; if it returns very quickly and oscillates around the baseline waveform, then the system is underdamped. The ideal situation is for the trace to return quickly to the baseline without excessive oscillation (critical damping) (Figure 11). Zeroing the pressure transducer requires attention to a few factors. At the time of zeroing, the transducer may be at any height relative to the patient, but the system should be opened to air at heart level while zeroing is performed. After zeroing, the height of the transducer relative to the patient must remain constant. The site of arterial pressure measurement has some effect on the arterial waveform. Wave reflection causes systolic pressure to be higher and diastolic pressure to be lower when there is an acute change in vessel diameter (e.g., at the radial or dorsalis pedis arteries). The mean pressure is unaffected by wave reflection, but resistance to flow does produce a very slight decrement in the mean pressure as we progress from the aorta to more distal vessels.

Figure 11. Pressure waveforms after the flush valve is squeezed and then released. Critical damping provides the best response to the rapid upstroke of the arterial pressure waveform without excessive overshoot or undershoot.

blood pressure. Many of these systems require calibration with a standard blood pressure cuff (located on the same extremity) that inflates at regular intervals.

Cardiac Output Measurement

Cardiac output is measured most purely using the Fick principle, which is based on conservation of mass. In the absence of a cardiopulmonary shunt, the patients oxygen uptake (VO2) equals the difference between arterial and mixed venous oxygen content (CaO2CvO2) times the cardiac output (Q). Rearranged, this yields: VO2 Q CaO2 CvO2

Cardiac output is measured most purely using the Fick principle, which is based on conservation of mass. In the absence of a cardiopulmonary shunt, the patients oxygen uptake (VO2) equals the difference between arterial and mixed venous oxygen content (CaO2CvO2) times the cardiac output (Q).

Noninvasive Blood Pressure Measurement

Most standard blood pressure cuff systems detect blood pressures using oscillometry. The cuff is inflated until arterial flow is occluded, then pulsations in the cuff pressure are monitored as the cuff deflates. The initial pulsations occur just above systolic pressure, and the maximal pulsations correspond to the mean pressure. The diastolic pressure is determined using a mathematical algorithm. Most continuous noninvasive blood pressure monitoring systems use a sensor placed over the radial artery at the wrist, with stronger pulsations corresponding to a higher

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Determining Q using this method requires access to arterial and mixed venous (via pulmonary artery [PA] catheter) blood samples. More problematic during anesthesia is measurement of VO2, which requires collection and analysis of mixed exhaled gases or determination via closed-circuit techniques. The NICOs monitor applies the Fick principle to elimination of CO2 rather than uptake of O2. In this case, intermittent insertion of a partial-rebreathing circuit allows estimation of arterial and mixed venous CO2 content. These, along with measurement of CO2 elimination, allow for calculation of cardiac output as follows: Q VCO2 CaCO2 CvCO2

the frequency of ultrasound waves when reflected from moving objects (e.g., erythrocytes). Erythrocyte velocity (v) is related to Doppler shift (fd), ultrasound frequency (fi), the velocity of the ultrasound wave (c), and angle (y) at which the ultrasound waves penetrate the vessel by the formula: c v fd 2f i cosy The esophageal Doppler monitor computes a velocitytime integral (VTI) by integrating erythrocyte velocities through the cardiac cycle. VTI, along with heart rate (HR) and an estimate of aortic cross-sectional area (CSA, estimated on the basis of patient weight, height, and age) are used to calculate cardiac output (Q): Q HR CSA VTI There are two potential sources of error in estimating the cardiac output by this method: (1) unless the ultrasound beam is directed to the center of the aorta, flow velocity may not be accurately estimated; and (2)

In a patient with a PA catheter, cardiac output is frequently measured by thermodilution. This method relies upon injection of a fixed of quantity of room-temperature or ice-cold fluid via a proximal port in the PA catheter and measuring the time course of the temperature change at a distal point on the catheter within the PA. When blood flow (Q) is low, the bolus of cold fluid remains in the PA for a relatively long time, causing the area under the temperature versus time curve to be large. In contrast, when blood flow is high, the cold fluid is rapidly washed out of the PA, resulting in a smaller area under the temperature versus time curve. As shown in Figure 12, the temperature curve does not return all the way to baseline because of recirculation; the cardiac output computer accounts for this by extrapolating the return to baseline. The cardiac output is computed from the extrapolated curve by the formula: Q Quantity of indicator 1 R D Temp dt
t0

where Quantity of indicator (Volume of indicator) (TPatientTIndicator) (Supplemental Digital Content 6, http://links.lww.com/ASA/A129). There are a few important sources of error to keep in mind with thermodilution measurements. The Quantity of indicator is entered into the computer based on the volume of indicator to be injected and the temperature of the injectate. If the volume injected is lower than expected, the 1 R temperature change D Temp dt will be artificially small
t0

and the calculated cardiac output will be falsely high. If the injectate is too cold (e.g., using iced rather than room-temperature saline), the temperature change 1 R D Temp dt will be artificially large and the calculated
t0

cardiac output will be falsely low. In the absence of a PA catheter, cardiac output can be estimated by a variety of less invasive approaches. One such approach involves a Doppler probe in the esophagus that measures blood flow velocities in the descending aorta. Esophageal Doppler relies on detection of a change in

Figure 12. Thermodilution curve for cold saline injection. The temperature does not return to baseline as quickly as predicted because of recirculation of the cold indicator through the coronary vessels (dotted line). The cardiac output computer compensates for this by extrapolating the curve back to baseline temperature. When cardiac output is increased, the cold indicator passes the temperature sensor more quickly, decreasing the area under the middle curve. When the cardiac output is decreased, the cold fluid remains in proximity to the temperature sensor for a longer period of time, increasing the area under the bottom curve.

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the ultrasound beam should be nearly parallel to the direction of blood flow, so that cosyE1. Otherwise, the velocity needs to be corrected according to the formula above.

terpret results, recognize and troubleshoot malfunction, and ensure the safety of our patients.
FURTHER READING

CONCLUSIONS
On a daily basis, anesthesiologists use equipment whose function depends upon basic physical principles. Only through an understanding of how these devices function can we appropriately apply them to clinical situations, in-

1. DorschJA, DorschSE: Understanding Anesthesia Equipment. 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2008. 2. ScurrC, FeldmanSA, SoniN: Scientific Foundations of Anesthesia. 4th ed. London: Butterworth-Heinemann, 1991.