Draw-over Anaesthesia

How does draw-over anaesthesia differ from anaesthesia

given with a Boyles machine?

During anaesthesia using a Boyles

machine (figure 1), compressed gases
(oxygen and nitrous oxide or air) pass
from cylinders mounted on the
machine to rotameters, (a type of flow
meter for gases), and then through the
vaporizer where a volatile agent such
as halothane is added to the gas
mixture. The resulting mixture is
delivered to the patient via an
anaesthetic circuit, such as the Magill
system. This type of anaesthesia
system, known as "a continuous flow
apparatus", is dependent on a supply
of compressed gases. If these run out
during an operation, so does the
anaesthetic!

A drawover system (figure 2) is

designed to provide anaesthesia
without requiring a supply of
compressed gases. Atmospheric
air is used as the main carrier gas
and is drawn by the patient's
inspiratory effort through the
vaporizer, where the volatile
agent, normally ether or
halothane, is added. The mixture
is then inhaled by the patient via a
non-rebreathing valve. The
components of a drawover circuit
are illustrated in figure 2.
Features of drawover apparatus:

1. Robust, compact and portable

2. Low purchase price and running costs
3. Straightforward maintenance
4. Not dependent on compressed gases

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 Function of the components of a drawover system vaporizer

During drawover anaesthesia the patient moves, (or "draws"), air through
the vaporizer which must have a very low resistance to the intermittent
gas flow which is generated. The volume of air passing through the
vaporizer is determined by the patient's tidal volume (the volume of air in
a single breath) and the respiration rate. Considerable variations in flow
through the vaporizer occur, depending on the type and depth of
anaesthesia, the age of the patient and whether the patient is breathing
spontaneously or being artificially ventilated. These conditions of gas
flow require the drawover vaporizer to be specially designed.

Vaporizers designed for continuous flow anaesthesia should never be

used in a drawover system as the high internal resistance to gas flow is
too great. They are designed to work under a continuous high pressure
and flow, and are called plenum vaporizers.

As air flows into the vaporizer it is

directed either to the vaporizing
chamber where it collects vapour
from the volatile agent being used,
or into a bypass chamber which
does not come into contact with
the volatile agent (figure 3). The
air from the two chambers mixes
as it leaves the vaporizer.
The ratio of air flow going to the different chambers determines the final
concentration of volatile agent leaving the vaporizer, and is determined
by the concentration control. The process of vaporisation removes heat
from the volatile agent and vaporizer, due to the latent heat of
vaporisation. This heat loss reduces the efficiency of vaporisation, and
may result in a fall in concentration of volatile agent being delivered by
the vaporizer. Some vaporizers compensate for cooling by a temperature
operated valve which automatically increases the ratio of air directed
through the vaporizing chamber as cooling occurs. Vaporizers with this
facility are said to be thermo-compensated. Other vaporizers partially
compensate for heat loss by containing a substance (such as water or
copper) which delay changes in vaporizer temperature by providing a
reservoir of heat. Vaporizers using this system are described as
thermally buffered. Some vaporizers, such as the EMO, utilise both
systems.

All vaporizers require regular maintenance, but schedules vary both in frequency
and complexity. Some models can be maintained by the anaesthetist, provided the

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essential tools are available, others require to be returned to the supplier for
maintenance.

The most widely available drawover vaporizers are the EMO (Epstein, Macintosh,
Oxford), OMV (Oxford Miniature vaporizer) and the TEC series (previously known
as the PAC series

The EMO (figure 2) is a temperature compensated vaporizer which produces an

accurate output of 0 to 20% ether. It is usually used in conjunction with the Oxford
Inflating Bellows (OIB) which is incorporated as a part of the EMO system.
Manufacturer Penlon (UK) Ltd.

The OMV (figure 4) is a small

thermally buffered vaporizer which
was originally produced to be used
together with the EMO in order to
speed the induction of anaesthesia.
Original models contained only
20mls of volatile agent, more
modern ones 50mls. A variety of
volatile agents may be used with the
OMV including halothane,
trichlorethylene, enflurane,
methoxyflurane and isoflurane.
Different scales are available for
each agent so that after draining the
vaporizer the anaesthetist may use a
different volatile agent.
Manufacturer Penlon (UK) Ltd.

The TEC or PAC (figure 5) vaporizers

consist of a range of thermo-
compensated drawover vaporizers with
different models available for ether,
halothane, methoxyfiurane and
trichlorethylene. Manufacturer-Ohmeda
(UK) Ltd.

Self-inflating bags or bellows allow controlled ventilation

of the patient during anaesthesia or resuscitation. They should
be the correct size for the patient to allow for an adequate tidal
volume. Bellows and self-inflating bags incorporate a non-
return valve through which they fill ensuring that fresh gas is
always delivered to the patient. When there is an oxygen port
on the bag or bellows this should be occluded, and oxygen

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added through a separate T piece (figure 2). Self-inflating bags
and bellows are used with a non-rebreathing expiratory valve at
the patient end to allow inspiration from the bag and expiration
to atmosphere.

The Oxford inflating bellows (OIB) is popular with many

anaesthetists using drawover anaesthesia. Unlike the self-
inflating bags the OIB can be seen to move during spontaneous
respiration. Two non-return flap valves are contained in the
base of the OIB. The distal flap valve needs to be immobilised
when the OIB is used with one of the non-rebreathing valves
mentioned below. A magnet is supplied with the bellows for
this purpose.

Connecting tubing should be of the antistatic type when ether

is used and connections conform to the international standards
of 22mm and 15mm tapered connections.

Patient expiratory valve. This

should be a non-rebreathing valve
such as an AMBU El, Laerdel or
Rubin's valve (figure 6). These
valves allow either spontaneous or
controlled respiration without
adjustment. They need regular
cleaning to prevent them becoming
sticky and should be resterilised if
used with a patient with chest
infection.

Oxygen T attachment. To add oxygen to a drawover

system a standard T piece is mounted on the intake side of the
vaporizer (figure 2). If it is mounted on the output side of the
vaporizer a dilution of the volatile agent will occur. A reservoir
tube (at least a metre in length) allows oxygen to accumulate
during the expiratory phase. An oxygen flow of one
litre/minute results in an inspired oxygen concentration of
around 30-40% and a flow of four litres/minute a concentration
of 60-80%.