kinetics and monitoring of inhaled...
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Kinetics and Monitoring of Inhaled Anesthetics
© Copyright 1980 - 2014, James H Philip, all rights reserved
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Ready
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Kinetics and Monitoring of Inhaled Anesthetics
James H. Philip, M.E.(E.), M.D.
Anesthesiologist and Director of Anesthesia Bioengineering,
Brigham and Women's Hospital. Professor of Anaesthesia, Harvard Medical School
Medical Liaison for Anesthesia, Partners Biomedical Engineering
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Kinetics and Monitoring of Inhaled Anesthetics
James H. Philip, M.E.(E.), M.D.
Anesthesiologist and Director of Anesthesia Bioengineering,
Brigham and Women's Hospital. Professor of Anaesthesia, Harvard Medical School
Medical Liaison for Anesthesia, Partners Biomedical Engineering
In the past but not at present, I performed funded research on Sevoflurane, Desflurane, Isoflurane
I created Gas Man® but have no financial interest in it.
Gas Man® and Med Man Simulations, Inc. are a nonprofit corporation.
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Learner Goals and Objectives
Anesthetic Path from Vaporizer to Brain is
Del (D) -> CKT (I) -> Alv (A, E) -> art (a) -> Brain (VRG)
Tension rather than Concentration describes anesthetic behavior
Kety, 1950 article in Anesthesiology. All should read it.
ATC (Alveolar Tension Curve) The Inspired to Alveolar relationship
Monitor I and E agent with an agent analyzer
Monitor past, present. Plan and create future with graphic display
Use Gas Man computer simulation to explore concepts and practice
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Alveolar Tension Curve
Focus on the
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Alveolar response to an Inspired Step
Alveolar Tension Curve
The time course of alveolar tension = PA
in response to a step change in
inspired tension = PI
=
PI PA
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Path of Anesthetic Tension from Vaporizer to Brain
I Br
VRG
A a D
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Flows facilitate or impede the passage
I Br A a D
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Open (Non-Rebreathing) Circuit provides controlled Inspired Step
I Br A a I D
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0 1 2 0.0
1.0
A / I
3 minutes (time)
Axes and Labels
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0 1 2 0.0
1.0
A / I
3 minutes (time)
Inspired Step
Alveolar response to a step
change in inspired agent
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Inspired Tension
Alveolar Tension
exponential curve
0 1 2 0.0
1.0
A / I
3 minutes (time)
Pure Lung wash-in Without Uptake into Blood
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0.63
0.5 min t =
Alveolar Tension
Inspired Tension
Time constant, tau ( t )
is the time required to achieve
63% of the final value*
0 1 2 0.0
1.0
A / I
3 minutes (time) * Derive in long course
Time Constant
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0.63
0.5 min t =
Alveolar Tension
Inspired Tension
Time constant, tau ( t )
time required to fill the compartment
if there were no mixing
0 1 2 0.0
1.0
A / I
3 minutes (time) * Derive in long course
Time Constant
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Alveolar Tension
Inspired Tension
0 1 2 0.0
1.0
A / I
3 minutes (time) * Derive in long course
Pure Lung wash-in Without Uptake into Blood
is the same for:
Cardiac Output = zero ( CO = 0) or
Zerothane, Drug with solubility = zero ( = 0)
Xe, which has a very low solubility ~ 0
This is mixing a new gas into a container with old gas
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Now, add uptake into blood
Uptake into blood
produces
an Alveolar Tension
Plateau
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0 1 2 0.0
1.0
A / I
3 minutes (time)
Alveolar Tension
Inspired Tension
Pure Lung wash-in Without Uptake into Blood
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Plateau
0 1 2 0.0
1.0
A / I
3 minutes (time)
Inspired
Alveolar
Plateau is produced by
Anesthetic Removal by Blood
Alveolar Tension Plateau
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Tail
Plateau
0 1 2 0.0
1.0
A / I
3 minutes (time)
Inspired
Alveolar
Delivery
Removal
Alveolar Tension Plateau
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Tail
Plateau
0 1 2 0.0
1.0
A / I
3 minutes (time)
Inspired
Alveolar
Delivery = VA
Removal = CO •
Alveolar Tension Plateau
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Hal Enf
Iso
Sevo N O 2
Des
Xe or Zerothane
Infinithane
0 1 2 0.0
1.0
A / I
3 minutes (time)
Alveolar Plateaus
Several Drug Plateaus
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Alveolar Plateau Heights
.38
.54
.66
Ht
1
.24
.00
Hal Enf
Iso
Sevo N O 2
Des
Zerothane
Infinithane
0 1 2 0.0
1.0
A / I
3 minutes (time)
Plateau Heights
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Alveolar Plateau Heights and solubilities
.38
.54
.66
Ht
1
.24
.00
Hal Enf
Iso
Sevo N O 2
Des
Zerothane
Infinithane
0 1 2 0.0
1.0
A / I
3 minutes (time)
1.3
.67
.42
0
2.4
Inf.
Height and Solubility
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Venous Return brings anesthetic back to alveoli
I Br A a V
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Tail of the Alveolar Tension Curve
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Tail
Plateau
0 1 2 0.0
1.0
A / I
3 minutes (time)
Inspired
Alveolar
Plateau produced by
Removal by Blood
Venous Return converts Plateau
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0 1 2 0.0
1.0
A / I
3 minutes (time)
Plateau
Tail Alveolar
Inspired
Alveolar
Venous Return converts Plateau into Tail
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0 1 2 0.0
1.0
A / I
3 minutes (time)
Inspired
Initial Rise
Knee
Tail
Plateau
Alveolar Tension Curve sections named
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0 1 2 0.0
1.0
A / I
3 minutes (time)
Inspired
Arterial = Alveolar (ignore shunt)
Arterial = Alveolar
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0 1 2 0.0
1.0
A / I
3 minutes (time)
Inspired
Tail
VRG = Brain, etc.
VRG follows arterial blood with t = 3 – 5 min
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Real drugs and real curves Next,
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Des
Sev
Iso
Hal
30 0 Minutes of administration 30 0
P I
P A
1.0
Yasuda & Eger, 1991
Real drugs and real curves
A / I
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Des
Sev
Iso
Hal
30 0 Minutes of administration 30 0
P I
P A
1.0
What is the same among these curves?
A / I
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Des
Sev
Iso
Hal
30 0 Minutes of administration 30 0
P I
P A
1.0
Initial rise follows the same Zerothane curve
Zero A / I
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Des
Sev
Iso
Hal
30 0 Minutes of administration 30 0
1.0
What is the difference between these curves?
Zero A / I
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Des
Sev
Iso
Hal
30 0 Minutes of administration 30 0
1.0 Zero A / I
Plateau Height is the only kinetic difference !
Des
Sev
Iso
Hal
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Des
Sev
Iso
Hal
30 0 Minutes of administration 30 0
1.0 Zero A / I
And, plateau height is determined by
Des Sev
Iso
Hal
1.3
.67
.42
0
2.4
inf.
.38
.54
.66
1
.24
.00
Ht
Inf
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Blood / Gas Solubility
Dominates Inhalation Kinetics
Determines
how closely
Expired Tension
approaches
Inspired Tension
in the first few minutes after you change inspired
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0
.2
.4
.6
.8
Des
Sev
Iso
Hal
P A
0
0.62
0.34
0.76
Knee
Initial Fall
= 0.5 min
0.46
0.00
E = all
tissues
0.12
0.29
0.44
0.17
Tail
30
Minutes of emergence
10 20
Emergence from a long 1 MAC anesthetic MAC
1
P MAC
Yasuda & Eger, 1991. Analysis by JHP.
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Clinical Care – precise control of anesthetic depth
Every time you make a change, up or down, the same thing happens - Initial change, plateau
Good clinicians use the shape of this curve to contour the course of inspired, expired, and brain tension to produce the anesthetic they desire
It is the tail of the curve that lets your patient drift too deep or too light after the plateau turns into a knee and ongoing tail
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Sevoflurane, 6 hrs on, then off
Leeson S, Roberson RS, Philip JH. Hypoventilation after Inhaled Anesthesia
Results in Reanesthetization. Anesth & Analg, August 2014
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Clinical Control Measurements and Adjustments
Inspired = Inspired
End-Tidal ~ Alveolar [10% dead space error]
Alveolar ~ arterial [5% shunt error]
Beware
Inspired ≠ Delivered [FGF mixing error]*
Brain ≠ End-Tidal [Brain time constant]
* Another lecture
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Agent Monitor
ET Value now will be in the brain in about 3 minutes
ET Trend Graph value 3 minutes ago is in the brain now
Philip, Gas Man 2008
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JHP photo of Case elsewhere (Rex Hospital, Raleigh NC, 5/28/09)
GE Solar 8000 6 minute window shows this
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Note BIS and ET Desflurane trends
JHP photo of Case elsewhere (Rex Hospital, Raleigh NC, 5/28/09)
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Draeger Apollo VCI with optimized control of I and E
Draeger Apollo 30 min trend
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Longer Graphic Trend shows whole case
GE Solar 90 min
Sevoflurane VIMA with optimized control of I and E
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Desflurane Ramp Apollo
JHP photo of JHP case
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Cook County Hospital 4-28-05
GE Solar 8000
Desflurane ramp up
HR & BP ramp down, slightly
JHP photo 4-28-05
Cook Co Hosp case
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Bolus down and up (GE Solar 6 min)
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Bolus up, bolus down (GE Remote View 1 hr)
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Bolus down before wake up (GE Solar 6 min)
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Computer simulation can explain what we observe
during clinical anesthesia and can help us to plan and create
effective clinical techniques
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Gas Man download directions
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Thank you
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Introduction: Core competency in inhalation anesthesia is important for Anesthesiology Residents. Recently, Eger and Shafer published a Tutorial that demonstrated that the Gas Man® Computer Simulation Program1 can teach complex topics in inhalation anesthesia kinetics. Their example was context-sensitive decrement times2. In order to understand whether Anesthesia Residents could demonstrate Core Competency in Inhalation Kinetics, Gas Man homework was assigned to residents on the BWH Ambulatory Anesthesia service between September and December 2005.
Methods: An e-mail stating the homework assignment was sent to each resident at the beginning of their 1-month rotation. The assignment was to simulate administering 1 MAC (alveolar) anesthesia for 1.5 hours, simulate emergence, and measure wake up time (time for Brain to reach 0.33 MAC). This was to be performed with Isoflurane (I), Sevoflurane (S) and Desflurane (D) using a standard semi-closed breathing circuit. The educational goals were: 1) maintenance of anesthesia at constant depth, 2) wake up with high fresh gas flow and normal ventilation, and 3) ability to use the Gas Man® program.
James H. Philip, M.E.(E.), M.D.1,2,3,4, Beverly K. Philip, M.D.1,2
Residents Can Complete Gas Man Homework and Demonstrate Core Competency in Inhalation Kinetics
Results: Twenty-five (25) of 26 residents completed the homework. Of these, 22 of 25 demonstrated they mastered all 3 goals. Three (3) residents failed to grasp 1 goal: administering anesthesia at constant depth. Instead, they gave constant inspired concentration resulting in increasing depth. All 25 responders used the Gas Man® program successfully. Wake up (VRG = 0.33 MAC) times (Mean ± SD [min]) reported by residents were I = 10.7 ± 1.8, S = 7.9 ± 2.2, D = 5.8 ± 1.0 min. These did not differ from the instructor’s times of I = 10.9, S = 7.7, D = 5.4 minutes.
Summary: Residents can demonstrate core
competency in inhalation kinetics by using
the Gas Man® computer simulation.
Those residents who did not initially grasp
the didactic concepts were identified,
given additional instruction, and then
demonstrated competency.
1Department of Anesthesiology, Perioperative & Pain Medicine, Brigham and Women’s Hospital, 2Harvard Medical School, Boston MA, 3Med Man Simulations Inc., Chestnut Hill MA, a nonprofit corporation, 4Center for Medical Simulation, Cambridge MA
References:
1. Philip JH. GAS MAN® -
Understanding anesthesia uptake
and distribution. Med Man
Simulations Inc., Chestnut Hill, 2004.
[Dr. Philip has a financial interest but
draws no profit or income from Gas
Man®)
2. Eger EI, Shafer SL. Tutorial:
Context-Sensitive Decrement Times
for Inhaled Anesthetics. Anesth
Analg 2005 101: 688-696.
Figure 1: Typical Gas Man® simulation results including overlay comparing wake up.
Disclosure: Gas Man is a registered trademark of James H. Philip. Med Man Simulations is a non-profit corporation and is in the process of applying for tax-exempt status under Internal Revenue Code 501(c)(3).
Philip JH, Philip BK. Residents Can Complete Gas Man
Homework and Demonstrate Core Competency in Inhalation
Kinetics. 7th Annual International Meeting of the Society for
Simulation in Healthcare (IMSSH), Orlando FL, USA, January 15,
2007. [email protected]