Evaluation of a Pitot type spirometer in helium/oxygen mixtures

OBJECTIVE

Mixtures of helium and oxygen are regaining a place in the treatment of obstruction of the upper and lower respiratory tract. The parenchymal changes during the course of IRDS or ARDS may also benefit from the reintroduction of helium/oxygen. In order to monitor and document the effect of low-density gas mixtures, we evaluated the Datex AS/3 Side Stream Spirometry module with D-lite (Datex-Engstrom Instrumentarium Corporation, Finland) against two golden standards.

METHODS

Under conditions simulating controlled and spontaneous ventilation with gas mixtures of He (approx. 80, 50, and 20%)/O2 or N2(approx. 21 and 79%)/02, simultaneous measurements using Biotek Ventilator Tester (Bio-Tek Instr., Vermont, USA) or body plethysmograph (SensorMedics System, Anaheim, USA) were correlated with data from the spirometry module. Data were analyzed according to a statistical regression model resulting in a best-fit equation based on density, voltage, and volume measurements.

RESULTS

As expected, the D-lite (a modified Pitot tube) showed density-dependent behaviour. Regression equations and percentage deviation of estimated versus measured values were calculated.

CONCLUSION

Measurements with the D-lite using low-density gases are satisfactorily contained in best-fit equations with a standard deviation of less than 5% during all ventilatory modes and mixtures.

Should nitrous oxide be discontinued before desflurane after anaesthesia with desflurane/N2O?

BACKGROUND

The appearance of hypoxaemia immediately after anaesthesia with nitrous oxide may be partially explained by diffusion hypoxia. This study was undertaken to evaluate circulatory and respiratory variables during emergence after desflurane/nitrous oxide anaesthesia, and whether there are any differences depending on which gas is discontinued first.

METHODS

20 patients were studied after gynaecological laparoscopic surgery. The depth of anaesthesia was reduced 10 min prior to the emergence by stopping the administration of one of the two inhalational agents. Desflurane was discontinued first in Group 1, nitrous oxide in Group 2. Ventilation was controlled with E'CO2 maintained at 5% until the administration of the second anaesthetic gas was discontinued. Thereafter, the patients breathed spontaneously.

RESULTS

The PaCO2 at which the respiratory drive reappeared after controlled normoventilation was similar in both groups, 6.1-6.5 kPa, and extubation was performed after 10-11 min. At extubation, the end-tidal CO2 and total MAC were similar in the groups, about 6.2 vol% and 0.16, respectively. Mean arterial blood pressure was significantly higher in Group 1. The cardiac output increased in both groups from about 6 l/min at the conclusion of anaesthesia to 9.0 and 7.6 l/min at 15 min in the recovery period. End-tidal O2 decreased and CO2 increased in both groups during the first 10 min in the recovery period. pH was reduced at 15 and 30 min in both groups.

CONCLUSION

Irrespective of which agent was discontinued first there was an increase in cardiac output decrease in oxygenation and a modest acidosis in the first 30-min recovery period. The only significant difference between the groups was in mean arterial blood pressure in the early emergence phase with a greater MAP when N2O had been used until the conclusion of anaesthesia.

A retrospective analysis of nitric oxide inhalation in patients with severe acute lung injury in Sweden and Norway 1991-1994

BACKGROUND

Patients with severe acute lung injury (ALI) have been treated compassionately on doctors' initiative with inhaled nitric oxide (INO) in Sweden and Norway since 1991. In 1994 the previously used technical grade nitric oxide was replaced by medical grade nitric oxide.

METHODS

We have carried out a retrospective data collection on all identified adult patients treated with INO for >4 h during the period 1991-1994 focusing on safety aspects and patient outcome. We used the following exclusion criteria (1) Age <18 years, (2) Simultaneous treatment with extracorporeal removal of CO2 (3) NO inhalation period <4 h, (4) Incomplete or missing patient charts, (5) Use of INO in order to treat pulmonary hypertension following cardiac surgery, with little or no acute lung injury.

RESULTS

Inclusion criteria were met by 56 out of 73 identified patients. Mean age was 48+/-19 years and the median duration of INO treatment was 102 h. PaO2/FIO2 ratio at start of treatment was 85 +/- 33 mm Hg with a lung injury score (LIS) of 3.2+/-0.8. The aetiology of the lung injury was pneumonia (n= 27), sepsis (n=12) and trauma (n=8). Survival to hospital discharge was 41% and survival after 180 d was 38%. Three serious adverse events were identified, two from technical failures of the INO delivery device and one withdrawal reaction necessitating slow weaning from INO. No methaemoglobin values >5% were reported during treatment.

CONCLUSION

The overall mortality did not differ dramatically from historical controls with high mortality. Only a randomised study may determine whether INO as an adjunct to treatment alters the outcome in severe ALI. One cannot at present advocate the routine use of INO in patients with ALI outside such studies.

Emergence from isoflurane/N2O or isoflurane anaesthesia

BACKGROUND

The first goal of anaesthetic recovery is return of the patient's ability to independently maintain respiratory and circulatory functions. Nitrous oxide remains popular due to minor effects on the cardiovascular and respiratory systems. However, diffusion hypoxaemia can occur during recovery and there is a potential advantage of providing the patient with only a potent vaporised agent.

METHODS

This randomised study of 20 gynaecological patients evaluated respiratory and circulatory variables during emergence after anaesthesia with equipotent mixtures of isoflurane/nitrous oxide or isoflurane. Inspired, end-tidal and mixed expired gas concentrations, expired minute volume, pulse oximetry saturation and arterial blood gases were registered. Monitoring of cardiac output was performed by transthoracic bioimpedance.

RESULTS

Patients anaesthetised with isoflurane/N2O resumed their spontaneous breathing 16 min earlier and were extubated 22 min earlier than those anaesthetised with only isoflurane. At extubation, total MAC and end-tidal CO2 were similar in both groups, 0.22-0.26 and 5.5-5.9 vol%, respectively. The isoflurane/ N2O group had greater minute ventilation and CO2 excretion rates than the isoflurane group throughout the emergence period. There were no significant differences between the groups in blood gas variables or in heart rate, mean arterial blood pressure or cardiac index. Cardiac index was between 3.4 and 3.9 l m(-2) min(-1) throughout the emergence period in both groups.

CONCLUSION

Patients anaesthetised with only isoflurane had a longer delay until resumption of spontaneous breathing and extubation in the emergence period. Minute ventilation and carbon dioxide elimination were also significantly more suppressed throughout emergence after anaesthesia with isoflurane as compared with isoflurane/N2O.

Uptake of inhaled nitric oxide in acute lung injury

BACKGROUND

Despite the widespread use of inhaled nitric oxide (NO), little is known of its pulmonary uptake in patients with acute respiratory failure.

METHODS

Fourteen patients with acute lung injury (ALI) and ongoing NO therapy were studied. Three doses of NO (5, 10 and 40 ppm) were given for 20 min and at each dose level the following parameters were recorded: minute ventilation, inspiratory NO conc., mixed expired NO conc., end-tidal NO conc., mixed expired CO2 conc., end-tidal CO2 conc, and arterial CO2 tension. Total uptake was calculated and correlated to the total amount of NO inhaled, the amount of NO administered to the alveolar space, and the amount of NO administered to the perfused alveolar space.

RESULTS

About 35% of the total amount of NO delivered is taken up by the lungs, 70% of NO administered to the alveolar space is taken up, and 95-100% of the NO administered to perfused alveolar space is taken up. The size of the alveolar dead space varied between 10 and 60% of the alveolar space. At 40 ppm of inhaled NO there was no difference between inspired and mixed expired NO2 concentration, indicating that there is no significant NO2 formation taking place in the lungs during NO inhalation at the concentrations studied.

CONCLUSIONS

Practically all NO administered to the perfused alveolar space is taken up. The total uptake differs from that of healthy persons probably because of differences in the alveolar dead space.

A study of mixing conditions during nitric oxide administration using simultaneous fast response chemiluminescence and capnography

We have evaluated the mixing properties of nitric oxide in inspired gases for five different administration techniques. Nitric oxide and carbon dioxide were delivered to the ventilator system before the ventilator or after the ventilator as a continuous flow, either directly into the inspiratory limb or into a mixing chamber positioned in the inspiratory limb. Both gases were delivered as above but synchronized with inspiration. Mixing conditions were evaluated using fast response chemiluminescence for nitric oxide and capnography for carbon dioxide analysis. Administration of nitric oxide and carbon dioxide directly into the inspiratory limb as a continuous flow or with a magnetic valve-controlled synchronized flow resulted in peak concentrations of 236% and 220%, respectively, of expected values. The use of a mixing chamber reduced these values to 104% and 102%, respectively. Administration of nitric oxide as a continuous flow into the tubing of an intermittent flow ventilator resulted in highly fluctuating inspiratory peak concentrations, which could be avoided with a mixing chamber.

Nitric oxide administration after the ventilator: evaluation of mixing conditions

BACKGROUND

Because of the potential toxicity of nitric oxide (NO) and its oxidising product nitrogen dioxide (NO2), any system for the delivery of inhaled NO must aim at stable and predictable levels of NO and as low concentrations as possible of NO2.

METHODS

In a laboratory set-up, we have evaluated mixing conditions in a system where NO is added after the ventilator with continuous flow. Mixing was studied by using carbon dioxide (CO2) as a tracer gas since capnography has a short response time (360 ms) in comparison with measurements of NO with electrochemical fuel cells (response time of 18 s). CO2 (in volumes corresponding to an ideal mixture of 1, 3 and 6%) was fed, after the ventilator, either into plain breathing tubing, into one or two soda lime absorbers, or into an empty and a soda lime-filled canister, at different ventilatory rates and different I:E ratios. Samples were drawn from the inspiratory limb close to the Y-piece. NO was added in the same way and in the same volume as the highest concentration of CO2.

RESULTS

CO2 added to plain tubing resulted in peak levels up to five times the set levels, while addition to a mixing box with an empty and a soda lime-filled canister resulted in even mixing with gas concentrations close to the ideal. When NO was fed into plain tubing, low levels were measured at the Y-piece, indicating poor mixing. Gas supply to a mixing chamber resulted in even concentrations.

CONCLUSION

Even and predictable levels of NO can be obtained with continuous flow of NO to the inspiratory limb, after the ventilator, if a mixing chamber is used. To obtain adequate mixing, the volume of the mixing box should be greater than the tidal volume.

Response to nitric oxide inhalation in early acute lung injury

OBJECTIVE

To evaluate the dose response of inhaled nitric oxide (NO) on gas exchange and central haemodynamics in patients with early acute lung injury (ALI).

DESIGN

Prospective, multicentre clinical study.

SETTING

General ICUs in university and regional hospitals.

PATIENTS

18 Patients with early ALI according to specified criteria.

INTERVENTIONS

During controlled ventilation an inhalation system was used to deliver NO (1000 ppm in N2) and O2/air to the low pressure fresh gas inlet of a Siemens 900C ventilator. Haemodynamics and pulmonary gas exchange variables were measured at baseline and at stepwise increased inspiratory NO concentrations of 0.1, 0.3, 1, 3, 10, 30 and 100 ppm, each dose being maintained for 15 min. Dose testing was repeated the next day, and the response to prolonged (2 h) NO inhalation at 1 and 10 ppm was also tested.

MEASUREMENTS AND RESULTS

Inhalation of NO produced a significant increase in PaO2 (P < 0.0025). The degree of response, as well as the optimal NO dose varied in individual patients and between different days. Venous admixture (QVA/QT) was reduced (P < 0.02) from 38% (31-46%) to 33% (26-41%). In our patients with early acute lung injury and only a moderate elevation in pulmonary arterial pressure NO inhalation did not reduce mean pulmonary artery pressure significantly, being 27.0 (21-30) mmHg at baseline and 26.0 (21-30) mm Hg at 100 ppm.

CONCLUSIONS

This study shows that improvements in arterial oxygenation in response to inhaled NO may show great inter- as well as intraindividual variability, and that improvements in arterial oxygenation occur without any measurable lowering of the pulmonary artery pressure.

Continuous non-invasive monitoring of energy expenditure, oxygen consumption and alveolar ventilation during controlled ventilation: validation in an oxygen consuming lung model

BACKGROUND

We have developed a combined indirect calorimetric and breath-by-breath capnographic device (GEM) for respiratory monitoring: oxygen consumption (VO2), carbon dioxide excretion (VCO2), respiratory quotient (RQ), energy expenditure (EE), alveolar ventilation (VA) and dead space/total ventilation (VD/VT).

METHODS

The device was tested in a lung model in which VO2 was achieved by combustion of hydrogen. VCO2 was achieved by delivering CO2 into the single alveolus combustion chamber. VO2, VCO2, compliance, and anatomical dead space could be varied independently.

RESULTS

Measured VO2 was 101 +/- 3% (SD) of set value at a F1O2 < 0.6 and 101 +/- 7% at a F1O2 > 0.6 during 15 hours of testing. The corresponding VCO2 values were 99 +/- 2% and 102 +/- 7%. The GEM could with good accuracy measure accumulated energy expenditure (EE) during simulated unstable patient conditions up to a F1O2 of 0.8. At F1O2 above 0.8 VCO2 and VO2 could be estimated using a default RQ value of 0.85. On-line estimated VA and VD/VT values could be obtained at any F1O2 up to 1.0. In a test sequence with stable VO2 and VCO2 the GEM adequately followed changes in VA, induced by changes in anatomical dead space, breathing frequency and compliance.

CONCLUSION

The overall performance of the device is satisfactory and well comparable with any equipment tested. It allows near-continuous non-invasive monitoring of EE, VO2, VCO2, VA, VD/VT in ventilated, critically ill patients, providing a rationale for ventilator settings and nutritional support.

Gas kinetics during nitrous oxide analgesia for labour

Hypoxaemia may occur after hyperventilation with nitrous oxide during labour. The purpose of this study was to assess whether diffusion hypoxia is a contributory factor. Twenty-four parturients were randomly allocated to receive 50 or 70% nitrous oxide in oxygen. The median nitrous oxide inhalation time per contraction was 58 s and 33 s, respectively. The end-tidal carbon dioxide and the minute ventilation remained unchanged. The end-tidal oxygen concentration was lowest at 120 s, reaching 15.4% in both groups. The oxygen saturation did not differ between the groups with a lowest median value of 96% before the start of nitrous oxide inhalation. Two parturients had episodes of desaturation. Both had low end-tidal oxygen concentrations in association with the desaturation but, as the end-tidal nitrous oxide concentrations were low, the desaturations could not be attributed to diffusion hypoxia.

Safety aspects of delivery and monitoring of nitric oxide during mechanical ventilation

In the presence of oxygen NO is oxidised to NO2, which is toxic in higher concentrations. In this technical investigation, we evaluated a dosage system, modified from Stenqvist et al. 1993 (1), regarding NO and NO2 levels. NO was administered before the ventilator and NO2 scavenged using a soda little absorber in the inspiratory limb close to the ventilator. NO/NO2 levels were measured using fuel cell technique. We tested the duration of soda lime scavenging, put in additional soda lime absorbers, used charcoal as absorber and exchanged tubing material. NO was delivered after the ventilator and we studied effect of interruption of ventilation. With concentrations of NO at or below 40 parts per million (ppm) at F1O2 0.9, NO2 levels were 1.2 ppm or lower. Corresponding values for 20 and 10 ppm were 0.4 and 0.2 ppm, respectively. Duration of the soda lime absorber was at least 72 hours. Additional soda lime absorbers did not further reduce NO2 levels. Charcoal absorbers reduced NO2, but also NO by 45% from set value. Tubing materials had no influence on NO and NO2 levels. When administering NO at the Y-piece, levels of NO were increased by 35-60% and NO2 levels by 110-230% compared to set values. Oxidation of NO to NO2 is continuously taking place in the breathing system. Doses of up to 40 ppm NO should be considered safe regarding NO2 levels. Administration of NO at the Y-piece gives high and unpredictable levels of NO2.

Do changes in cardiac output affect the inspiratory to end-trial oxygen difference?

BACKGROUND

The paramagnetic technique has made it possible to monitor the end-tidal oxygen concentration and P(1-ET)O2, i.e. inspiratory to end-tidal oxygen difference, breath-by-breath. Little is known about the implications of a changing P(1-ET)O2, but so far studies have shown it to be a quick and sensitive variable to detect hypoventilation. This study was designed to observe the circulatory effects on P(1-ET)O2 in an experimental setting but monitored as in a clinical situation.

METHODS

We assessed the oxygen difference during changes in cardiac output induced by intravenous ephedrine-hydrochloride in 12 healthy male volunteers. P(1-ET)O2 was measured with a fast-response paramagnetic differential oxygen sensor. Cardiac output was measured with non-invasive transthoracic electrical bioimpedance. As simultaneous changes in metabolism and ventilation will also influence P(1-ET)O2 oxygen uptake and expired minute volume were monitored. After a rest period, the subjects had an intravenous injection of ephedrine-hydrochloride 0.1 mg.kg-1 followed by a 30-min observation period.

RESULTS

Cardiac output increased significantly as did the oxygen uptake and the ventilation. We found no biological significant correlation between cardiac output and P(1-ET)O2. The P(1-ET)O2 was influenced by ventilation and metabolism.

Conversion of inhaled nitric oxide to nitrate in man

1. Nitric oxide (NO) is potentially useful as a selective vasodilator drug in infants and adults with pulmonary hypertension. In vitro and in vivo observations demonstrate that NO may be converted to nitrate in the blood, to be further excreted into the urine. The aim of the present study was to assess quantitatively the importance of this pathway for inhaled NO in human subjects. 2. Healthy subjects inhaled 15NO (25 p.p.m.) for 1 h. The plasma and urine levels of 15NO3- were followed for 2 and 48 h, respectively. 3. The measured retention of 15NO in the lungs was 224 +/- 13 mumol, corresponding to 90 +/- 2% of the inhaled amount. Plasma 15NO3- increased during the inhalation of 15NO, to about 15 mumol l-1, and fell when inhalation of 15NO was terminated. 4. Urinary excretion of 15NO3- during the first 24 h after inhalation was 154 +/- 12 mumol. During the following 24 h another 8 +/- 2 mumol of 15NO3- appeared in the urine. 5. We conclude that conversion of inhaled NO to nitrate is a major metabolic pathway in man, covering more than 70% of its inactivation. The metabolic fate of the remaining NO inhaled requires further study.

Effects of hyperventilation on the inspiratory to end-tidal oxygen difference

We assessed the inspiratory to end-tidal oxygen difference (PIO2-PE'O2) during voluntary hyperventilation in 10 healthy male volunteers. The oxygen difference was measured with a fast-response paramagnetic differential oxygen sensor. As simultaneous changes in metabolism and cardiac output also influence (PIO2-PE'O2), oxygen uptake was measured with indirect calorimetry and non-invasive transthoracic electrical bioimpedance was used for measurement of cardiac output. After a rest period, subjects were instructed to double their minute ventilation volume (VE) and after 5 min triple their resting VE for another 5 min. (PIO2-PE'O2) decreased from a zero value of 6.4 kPa to 3.9 kPa at 5 min (P < 0.01) and 2.9 kPa at 10 min (P < 0.01). At 15 min (i.e. 5 min after the end of hyperventilation) there was an increase in (PIO2-PE'O2) to 8.3 kPa (P < 0.05). Regression analysis between (PIO2-PE'O2) (kPa) and VE (litre m-2 min-1) gave the formula: (PIO2-PE'O2) = 1/(0.059 + 0.034 VE), r = -0.92, n = 158. Oxygen uptake and cardiac output did not change significantly during hyperventilation, but decreased in the post-hyperventilation period. An oxygen difference of more than 8 kPa was associated with significant arterial desaturation.

Complement system activation during orthotopic liver transplantation in man. Indications of peroperative complement system activation in the gut

Sixteen patients with acute and chronic liver disease undergoing OLT were studied regarding the role of the liver and the gut in complement activation. Also, the relation between complement activation and clinical manifestations during the liver transplantation reperfusion period was investigated. Blood samples for measurement of complement anaphylatoxin C3a (C3a), complement anaphylatoxin C5a (C5a), and terminal C5b-9 complement complex (TCC) were taken simultaneously from the central venous catheter and the radial arterial line before starting the operative procedure, 1 min before declamping, and 1-2 min, 5 min, 30 min and 6-12 hr after declamping. Simultaneous blood sampling from the radial arterial line, central venous catheter, portal vein, and hepatic vein was performed 1-2 min and 5 min after completed unclamping. Elevated plasma levels of C3a and TCC were found upon reperfusion, while C5a levels remained unchanged throughout the operation compared with the preoperative levels. The levels of C3a in the portal vein were higher compared with the levels in the simultaneously obtained samples from the radial artery. The results indicate complement cascade activation located to the gut during the reperfusion phase of OLT. Seventy-five percent of the patient studied suffered from the postreperfusion syndrome, indicated by profound hypotension upon reperfusion of the transplanted liver. There was a significant correlation between high concentration of C3a anaphylatoxin and development of profound hypotension.

Inhaled nitric oxide in the evaluation of heart transplant candidates with elevated pulmonary vascular resistance

The reversibility of elevated pulmonary vascular resistance in heart transplant candidates is currently evaluated with intravenous vasodilators. The aim of this study was to evaluate the effects of increased concentrations of inhaled nitric oxide (20, 40, and 80 ppm) on central hemodynamics and right ventricular function in heart transplant candidates with elevated pulmonary vascular resistance (> 2.5 Wood units). Comparison was made with intravenous vasodilators, sodium nitroprusside, and prostacyclin in doses that lowered the mean arterial pressure by about 15%. Inhalation of nitric oxide did not change systemic or pulmonary arterial pressure, cardiac output, right ventricular function, or systemic vascular resistance. Pulmonary capillary wedge pressure increased and transpulmonary pressure gradient and pulmonary vascular resistance decreased (-34% +/- 4% and -36% +/- 4%, respectively; p < 0.01) during 20 ppm nitric oxide, with no further effects at higher doses. Prostacyclin and sodium nitroprusside decreased pulmonary vascular resistance (-50% +/- 6% and -33% +/- 5%; p < 0.01). Prostacyclin reduced to some extent (p = 0.08) transpulmonary pressure gradient, which was not seen during sodium nitroprusside infusion. Systemic vascular resistance decreased during both sodium nitroprusside (-37% +/- 5%) and prostacyclin (-44% +/- 4%) infusion. The pulmonary vascular resistance/systemic vascular resistance ratio, used as an index of pulmonary selectivity, was decreased by nitric oxide (p < 0.01) but not by the intravenous vasodilators. Metabolic data indicate that inhaled nitric oxide is metabolized in the same way as that formed endogenously. In conclusion, inhaled nitric oxide is a selective pulmonary vasodilator that can be used safely in the hemodynamic evaluation of heart transplant candidates with elevated pulmonary vascular resistance.

Predictable nitrous oxide uptake enables simple oxygen uptake monitoring during low flow anaesthesia

The uptake rate of oxygen and nitrous oxide were studied during low flow anaesthesia with enflurane or isoflurane in nitrous oxide with either spontaneous or controlled ventilation. The excess gas flow and composition were analysed. The nitrous oxide uptake rate was in agreement with Severinghaus' formula VN20 1000.t-0.5. The composition of excess gas was predictable and the following formula for oxygen uptake could be derived: VO2 = VfgO2-0.45 (VfgN2(0)-(kg: 70.1000.t-0.5)) where oxygen uptake rate (VO2, ml.min-1) equals oxygen fresh gas flow (VfgO2) minus 0.45 times the difference between the fresh gas flow of nitrous oxide (VfgN2O), ml.min-1 and estimated uptake of nitrous oxide. The equation assumes constant inspired gas concentrations of 30% oxygen and 65-70% nitrous oxide. The oxygen uptake rates calculated from this formula were in good agreement with measured uptake rates. Thus, continuous monitoring of oxygen uptake rates is possible by using only reliable flowmeters and analysis of inspired oxygen concentration.

Nitrous oxide uptake during spontaneous and controlled ventilation

The rate of uptake of nitrous oxide was studied in 40 orthopaedic patients anaesthetised with either enflurane or isoflurane in nitrous oxide and with either spontaneous or controlled ventilation. A variant of the Douglas bag method was used in combination with low fresh gas flows to a circle system. There were no significant differences in nitrous oxide uptake between the groups and the uptake rates followed 'the square root of time concept', with an overall best fit curve of 1080.t-0.505 ml.70 kg-1 x min-1. During spontaneous ventilation, the nitrous oxide uptake rate was similar or even higher than the corresponding rate during controlled ventilation, in spite of lower minute volumes.

Sampled gas need not be returned during low-flow anesthesia

OBJECTIVE

The purpose of this investigation was to study the N2 flux between the patient and the breathing circuit, and the excess gas during N2O anesthesia with the low, fresh gas flow technique.

METHODS

Forty patients were studied. After a 6-minute high, fresh gas flow denitrogenation period, the O2 fresh gas flow was set at about 4 ml/kg/min and the N2O fresh gas flow was set to maintain an inspired O2 fraction of 0.30. The excess gas flow and N2 excretion were measured by a variant of the Douglas bag method.

RESULTS

The mean inspired N2 concentration reached a peak of 5.9% at 40 minutes. The estimated mean N2 excretion was 39 ml/min at 10 minutes, declining to 18 ml/min at 60 minutes. A calculation of N2 homeostasis during closed-circuit anesthesia based on the results of the patient study indicated that sampling for gas analysis actually reduces the gas costs if the sampled gas is scavenged instead of returned to the circle system, since intermittent flushing with high, fresh gas flow for denitrogenation is unnecessary in the former situation.

CONCLUSIONS

Regardless of the fresh gas flow used, sampled gas need not be returned during N2O anesthesia.

Evaluation of a new system for ventilatory administration of nitric oxide

A new system for delivery of nitric oxide (NO) to inspiratory gas consisting of two mass flow regulators and a soda-lime absorber for scavenging of nitrogen dioxide (NO2) is described. The system was evaluated using three different techniques for NO analysis (infrared, chemiluminescence and electro-chemical fuel cell technique). The electro-chemical fuel cell was less sensitive to humidity in the sample and is suitable for clinical routine use. The infrared analyser was very sensitive to humidity and the gas sample must be dried by silica gel, which absorbs NO2 and will cause falsely low NO2 values. NO2 was analysed with ultra-violet methodology. NO2 is highly toxic and the highest recommended occupational health and safety level for inhalation is 5 ppm. The highest values of NO2 in our system were detected before the absorber in the inspiratory limb of the breathing system, being 5 ppm at 100% oxygen and 100 ppm NO using "infant" respiratory settings (3 l/min in ventilation, frequency of 30/min). The corresponding value for "adult" respiratory settings (10 l/min in ventilation, frequency of 15/min) was 3.2 ppm. The absorber reduced these levels to well below 1 ppm. When clinically relevant levels of NO were used (20 ppm), no NO2 could be detected after the absorber, irrespective of oxygen concentration in the breathing gas. It was observed that gas cylinders with NO mixed in nitrogen may initially have a high NO2 concentration (around 12 ppm) and should be flushed thoroughly before use.

Nitrous oxide elimination and diffusion hypoxia during normo- and hypoventilation

We studied the elimination rate of nitrous oxide in 36 patients undergoing orthopaedic surgery. They were allocated randomly to one of six groups which differed in time of nitrous oxide exposure and mode of ventilation. In order to simulate recovery conditions, nitrous oxide administration was discontinued after 30, 60 or 120 min of exposure. Either normoventilation or hypoventilation was used. The mean excretion rate was 1 litre min-1 at 1 min, declining to 100 ml min-1 at 30 min, with relatively small effects of different modes of ventilation and times of exposure. In spite of an FIO2 of 0.30, there were significant decreases in SpO2 during both normo- and hypoventilation. The smallest end-tidal oxygen concentrations were reached at 10-15 min in the groups with hypoventilation, after 1 or 2 h of nitrous oxide exposure.

[Respiratory gas exchange. Anesthesia with enflurane or isoflurane in nitrous oxide during spontaneous and controlled ventilation]

The estimation of oxygen consumption and carbon dioxide elimination is essential for predicting the metabolic activity and needs of any patient having anaesthesia. During anaesthesia oxygen consumption can be measured and compared to a predicted value. However, oxygen uptake is affected by anaesthetic agents, which complicates the interpretation of measured oxygen uptake rate. The purpose of this study was to investigate whether there are any differences in respiratory gas exchange during anaesthesia with enflurane and isoflurane and also to assess the effects of spontaneous versus controlled ventilation. METHODS. Forty orthopedic patients were randomized to enflurane or isoflurane anaesthesia in nitrous oxide with either spontaneous or controlled ventilation. A fresh low-gas-flow technique was used. Inspiratory oxygen and end-tidal carbon dioxide concentrations and expiratory minute ventilation were measured in a circle absorber system between the y-piece and the endotracheal tube with a sampling analyser. Between the mixing box and the absorption canister, carbon dioxide concentration was continuously measured. The carbon dioxide elimination was calculated from mixed expired concentration and expiratory minute ventilation. Excess gas was collected every 10 min in a non-permeable mylar plastic bag connected to the excess valve. The excess gas flow was calculated and the oxygen uptake rate was assumed to be the difference between the oxygen fresh gas flow and the oxygen excess gas flow. RESULTS. The grand mean oxygen uptake rate was 2.5 ml.kg-1 x min-1 or 100 ml.min-1 x m-2. There were no statistically significant differences in oxygen uptake between enflurane and isoflurane anaesthesia or between spontaneous and controlled ventilation. The mean oxygen uptake rate at 10 min was between 2.0 and 2.2 ml.kg-1 x min-1 in all groups. At 30 min the mean oxygen uptake rates were 2.6 to 2.8 ml.kg-1 x min-1. Carbon dioxide elimination was closely associated with expired minute ventilation, with a carbon dioxide excretion of about 30 ml per litre gas exhaled, irrespective of ventilatory mode employed.