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Department of Anaesthesia

University of Cape Town

Lecture 3
The Anaesthesia Machine and Monitoring

Anaesthesia delivery systems can be split into 2 broad categories:
Those that require a supply of Oxygen (O
) and other gases under pressure, such as the
anaesthetic machines


workstations found in most hospitals,
and Those which rely on atmospheric Oxygen, such as the draw-over anaesthesia apparatus, that
may be used in the field, where Oxygen cylinders may not be available. In these situations,
Oxygen cylinders or Oxygen concentrators may be used to augment the atmospheric Oxygen.

The basic machine consists of:
1. A supply of gases under pressure
Pipeline from a central depot
Cylinders on the machine (colour coded and pin indexed)
2. A means of controlling and measuring gas flow
Pressure reducing valves or regulators
Rotameters, which consist of flow control valves and tapered tubes for flow measurement.
3. A means of administering anaesthetic vapours
Vaporisers (each designed for a single agent)
4. A conduit to deliver gases and vapour to the patient - anaesthesia breathing system
5. Means for providing intermittent positive pressure ventilation (IPPV) - i.e. artificial ventilation
Reservoir bag for manual ventilation
Mechanical ventilator
6. Additional safety devices - e.g. an O
flush valve, an O
-supply failure alarm, a hypoxic guard to
prevent administering hypoxic mixtures, a "pop off" valve and optionally, a non-return valve.

The various components of the anaesthetic machine should be identified either in theatre or during the
tutorial. In addition, the machine checking procedure should be carried out with the anaesthetist.
High Pressure Zone

14 000 kPa -
Cylinder pressures)
Low Pressure Zone

9 kPa - Airway pressures)
Intermediate Pressure Zone

280 - 420 kPa - Central supply pressures)
The anaesthesia machine and monitoring
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Maplesons classification of anaesthesia breathing systems
W Mapleson (1954) classified the breathing systems, according to the position of the components of a
Magill system, and this nomenclature is still widely used.
Five different arrangements were proposed, labelled A to E. A sixth, labelled F, was added (1975) to
accommodate the Jackson-Rees modified Ayre's T-piece.

Magill System (1928)
Humphrey system in A mode (1981)


Water's system - Obsolete for anaesthesia, but still
used for resuscitation and transport

"Classic" Mapleson D system
Bain's System (1972)
Humphrey system in D mode

Ayre's T-piece (1937)

Jackson-Rees modified Ayre's T-piece (1950)

Mapleson systems are highly dependent on the fresh gas flow in limiting the rebreathing of Carbon
dioxide (CO
) to acceptable levels.

Magill breathing system (Mapleson A)
The original breathing system still found on many older rural machines, but not at major hospitals.
Excellent for spontaneous breathing, but unsuitable for IPPV as it requires a very high fresh gas flow.
Required fresh gas flow
Spontaneous ventilation 50 ml kg
3,5 l min
for adults
IPPV 200 ml kg
(with hyperventilation)
Bain system (Mapleson D)
A co-axial version of the Mapleson D system, with the fresh gas delivery pipe inside the system.
Not often seen in SA, but common in the UK.
Good for IPPV, but inefficient for spontaneous breathing
Required fresh gas flow
Spontaneous ventilation 150

200 ml kg

12 l min
for adults
IPPV 70 ml kg
(with hyperventilation) for normocarbia
100 ml kg
(with hyperventilation) for hypocarbia
Jackson-Rees modified Ayre's T-piece (Mapleson F)
The Ayres T piece (Mapleson E) with an open-ended reservoir bag. This system has no valves and
thus a low resistance, making it suitable for paediatrics; where it remains the preferred system
Required fresh gas flow
Spontaneous ventilation 200 ml kg
with a minimum of 3 l min

IPPV 70 ml kg
(with hyperventilation) for normocarbia
100 ml kg
(with hyperventilation) for hypoocarbia
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Humphrey ADE (Mapleson A & D)
A simple 2 tube system with a lever that converts the system from an A mode to a D mode.
The A mode is used for induction and spontaneous ventilation and the D mode for IPPV.
Popular in Natal (originally designed by D Humphrey in Durban) and often used by vets.
Required fresh gas flow
Spontaneous ventilation 50

70 ml kg

5 l min
for adults
IPPV 70 ml kg
(with hyperventilation)
The Circle system
The most frequently used system worldwide. It has become the universal system because of its ability
to use low flows (economical) and less pollution (cleaner). It has a Soda-lime canister to absorb
exhaled CO
and thus enable rebreathing of gas. Two one-way valves ensure a unidirectional gas
flow through the Soda lime. The reaction of CO
and Soda lime is exothermic and produces water.
Thus the gas is also humidified and warmed.
Minimum fresh gas flow
3 ml kg
200 ml min
for adults this equates to the basal utilisation of O

In practice we rarely achieve this fresh gas flow due to leaks etc., but flows of 500 1 000 ml min
the norm.
The Soda lime is eventually exhausted and will result in increasing hypercarbia.

Signs of exhausted Soda lime
Colour change (Indicator)
White to purple (some pink to white)
Exhausted Soda lime is cold
Rising baseline ( P
Signs of hypercarbia (too late!)

Most anaesthesia workstations


Boyles machines incorporate a ventilator to enable automatic artificial
ventilation of the patient. They are not essential, as artificial ventilation may easily be provided by
squeezing the reservoir bag, but do free-up the anaesthetist from a repetitive task that allows him to
concentrate on other matters.
Positive pressure ventilation is the normal mode of controlled ventilation applied during anaesthesia.
INHALATION is achieved by applying a positive airway pressure to enable gas flow to occur down the
pressure gradient. EXHALATION is passive (once the positive pressure is released) as a result of the
elastic recoil of the lung and thoracic cage increasing intra-thoracic pressure, allowing gas flow out of
the lungs.
In contrast, spontaneous ventilation (i.e. patient breathes normally) is a form of negative pressure
ventilation. INHALATION is achieved by contracting muscles, increasing intra-thoracic volume and
decreasing intra-thoracic pressure, allowing gas flow to occur down the pressure gradient.
EXHALATION is again a passive process and is identical to that occurring with IPPV.
Modes of intermittent positive pressure ventilation (IPPV) found on anaesthesia ventilators:
Continuous mandatory ventilation (CMV) - This is volume controlled where a preset tidal
volume is delivered and airway pressure varies - monitor the airway pressure.
Pressure controlled ventilation (PCV) - This is pressure controlled where a preset pressure is
applied and tidal volume varies - monitor the minute volume.
The former is usually used in adults with cuffed ETTs, whilst the latter is commonly used in
paediatrics with uncuffed ETTs as this mode compensates for leaks.
Positive end-expiratory pressure (PEEP) may be applied to any mode and aids oxygenation and
preventing atelectasis.
Synchronised intermittent mandatory ventilation (SIMV) and
Pressure support ventilation (PSV) are sophisticated ICU modes found on some ventilators.

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The purpose of anaesthesia is to provide varying degrees of hypnosis, analgesia and muscle
relaxation to patients undergoing an operation or distressing procedure. This is relatively easy to
achieve with the use of modern anaesthetic agents. However the drugs and methods used have
profound effects on physiological homeostasis (e.g. vasodilatation and hypotension). Similarly the
procedure may also have life threatening implications (e.g. excessive haemorrhage).
It is the responsibility of the anaesthetist to safeguard the patient throughout and restore him to a
condition at least as good as pre-operatively. You are the patients guardian. To achieve this it is
necessary to constantly provide all the body cells with Oxygen and nutrients by ensuring adequate:
Inspired Oxygen %
Airway patency
Diligent monitoring of the above enables the anaesthetist to constantly appraise the patients
condition and, by following trends, anticipate and treat the adverse effects of anaesthesia and surgery.
Depth of anaesthesia and degree of muscle relaxation can also be monitored to ensure adequate
anaesthesia and optimal surgical conditions.
Temperature monitoring is important, particularly in infants, as cold theatres and wet exposed patients
lead to hypothermia. Hyperthermia can also occur and Malignant Hyperthermia (MH) is a potentially
fatal complication of anaesthesia.



Oxygen analyser for measurement of O
concentration at common gas outlet of the machine.
Ventilation: tidal volume, rate, inspiratory time, flow rate, I


E ratio, minute volume, etc.
Airway pressure


disconnect alarm
Agent monitor for measurement of inspired and expired vapour concentration
These complement clinical monitoring of the patient's vital signs by means of observation, palpation
and auscultation, with attention paid to the following: airway, breathing, circulation, oxygenation,
temperature, depth of anaesthesia, fluid balance and blood loss.
Blood pressure
Pulse oximeter
Temperature probe
Nerve stimulator

Urinary catheter
Central venous pressure
Arterial blood pressure
Pulmonary artery (Swan-Ganz) catheter or trans-oesophageal echo (TOE)

Oxygen and gas supply
1) Pressure gauges
1. Pipeline

400 kPa or 4 Bar
, N
O and Air pipeline gauges are all checked.
2. Oxygen cylinder

13 500 kPa
Litres available = volume of cylinder x pressure in 100 kPa units (Bar).

2) Oxygen analysers
Inspired % At the fresh gas flow outlet (confirms the gas is O
when set to 100

Inspired and expired % Aspirated at catheter mount (patient end of breathing circuit)

3) Rotameters or flowmeters
, N
O and Air Monitored to ensure correct fresh gas flow (FGF)
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1) Manometer (Pressure gauge)
Measured in hPa (SI unit) or cmH
O (more common) 1 cmH
O =

1 hPa
Airway pressures are usually limited to <

35 hPa (cmH2O) to prevent barotraumas

2) Clinical
A clear airway may be confirmed by feel (lack of vibration in the mask), by listening at the
airway or end of the endotracheal tube, or by using a stethoscope over the trachea.
Air entry to both lungs is also checked and monitored by a stethoscope after endotracheal
intubation. The tube depth may change with flexion or extension of the neck, so the presence
of bilateral air-entry should be rechecked after a position change.
Satisfactory respiratory monitoring e.g. a good capnograph (CO
) trace confirms a patent

Breathing monitors
1) Clinical
Observation of excursion of chest and reservoir bag.

2) Spirometer
Measures tidal volume (V
), Rate (f) and minute volume (MV). Normal V
is 6

10 ml kg
and a
normal MV is


100 ml kg

3) Pulse oximeter (O
This measures % O
saturation of haemoglobin in the peripheral skin arterioles, not the P
transport to the tissues depends on F
, Airway, Breathing, and Circulation
So, like the capnograph, it monitors multiple parameters. As O
transport to tissues is integral
in maintenance of cell life many people feel this is the most important monitor of all. (In infants
where application of the probe may be insecure two pulse oximeters are often attached)
It is vital that a sound (beep) is associated with each pulse. This sound must decrease in
pitch with each drop in the value of the O
saturation. This is an excellent early warning of an
impending problem. Anaesthetists become tuned to the beep of the pulse oximeter, and
recognise immediately if the O
saturations decreases without the need to look at it!
Normal O
saturation values in room air (RA) are 96

99 % and higher with increased fraction
of inspired O
concentration (F
). The maximum value is obviously 100 %. The drop in O

saturation is buffered by the shape of the Hb-O
dissociation curve and is gradual above 90 %
with decreasing P
but precipitous below 90 %.
The pulse oximeter is an essential monitor for anaesthsia, sedation or in
any situation where the airway or breathing may be compromised!
If saturation is unsatisfactory, give O
as a holding measure, BUT look for the cause and treat.

4) Capnograph
This measures and displays end- tidal CO
) levels. There is often an attachment for the
capnograph tubing on the heat moisture exchange filter (HMEF) or pitot tube. This attaches
directly to the endotracheal tube (ETT) on one side and the catheter mount on the other. This is
the closest placement that will give you an approximation of what the alveolar CO
The fraction of inspired CO
) should be zero. This ensures correct functioning of Soda
lime in the absorber and the one-way valves in a circle system; or adequate fresh gas flow in
other breathing systems.
End-tidal CO
should be 5,3 kPa or less. If its more, this may indicate under-ventilation.
Shape of the trace can indicate airway obstruction, patients own respiratory efforts,
disconnection, cardiac arrest and respiratory arrest.
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The normal capnogram
(Sourced from Anaesthesia UK)

presence in expired gas is not only dependent on ventilation, but circulation (i.e. delivery)
and metabolism (i.e. production) as well.
Changes in end-tidal carbon dioxide (P
Increased Reduced
Decreased alveolar ventilation
Reduced respiratory rate
Reduced tidal volume
Increased equipment dead-space
Increased alveolar ventilation
Increased respiratory rate
Increased tidal volume
Increased CO
Hypercatabolic state
o Malignant hyperthermia
o Thyrotoxicosis
Reduced CO
Hypocatabolic state
o Myxodoema
Increased inspiratory CO
Exhausted Soda lime
External source of CO

o CO
cylinder on ?
Increased alveolar dead-space
Reduced cardiac output
Pulmonary embolus
High PEEP during IPPV
Sampling error
Inadequate tidal volume
Line occlusion
o Water
o Obstuction
Air entrainment
Large sampling dead-space

Capnography is thus a multiple-parameter monitor
, airway, breathing, circulation and metabolism).
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Cardiovascular monitoring
(Oxygen saturation and capnography have already been described)
Cardiac output (CO) is the most important cardiovascular parameter but not easily measured
during anaesthesia. Heart rate and blood pressure are directly proportional to CO:
BP = CO x Resistance (R)
When we measure BP we should take into account the warmth of the peripheral tissues, which
gives an indication of the peripheral resistance. If the peripheries are warm and the BP is normal
we can extrapolate that CO is normal or higher.
CO = HR x Stroke volume (SV)
When we note the HR, we should also feel the pulse to assess the volume. A good volume pulse
with a normal HR indicates a normal CO. A thready pulse indicates a poor SV, often due to
hypovolaemia. The accompanying tachycardia is an attempt by the heart to increase theCO.
Tachycardia with normal SV may be due to pain-induced adrenaline release or other stress.

1) Blood pressure (BP)
Non-invasive blood pressure (NIBP) measurement using a sphygmomanometer or
oscillotonometer has been superseded by automated NIBP measuring devices. Frequency of
measurement may be set according to how labile the patient is and the readings stored or
printed. Usually measured every 2,5


5 min. Systolic-, diastolic- and mean- pressures all have
Invasive BP or arterial line. A cannula is placed in an artery and connected to a pressure
transducer, which is attached to the monitor. This displays a continuous trace of the arterial
pressure waveform; and the systolic-, diastolic- and mean- values, beat by beat.
Fix the transducer at the same level as the heart. This is different to zeroing. Zero is obtained
by opening the transducer to air and confirming the reading is zero. Both must be done.
An arterial line is essential when on cardiopulmonary bypass as the pressure (mean) created by
the mechanical pump is not measurable with a BP cuff.
The arterial trace can also be used as a monitor of cardiac filling by measuring the swing
associated with positive pressure ventilation, ( up and down). Increased swing is associated
with under-filling.
The cannula is also used for sampling arterial blood, and serial measurements of arterial blood
gas (ABG, Astrup) and chemistry are another way of monitoring respiration and perfusion which
can be invaluable in long cases and in the ICU post-op.
2) Heart rate (HR)
Continuous heart rate monitoring is a minimum requirement for anaesthesia. It is traditionally
monitored with an ECG but an O
saturation monitor or arterial line can be used. It is important
that a sound (beep) is given with each beat.
3) Electro-cardiograph (ECG)
Besides heart rate ECG monitors rhythm and ischaemia (s-t ), dysrhythmias are common
under anaesthesia and may indicate:
Ischaemic myocardium
Halothane overdose (relative) it is dysrthymogenic
Catecholamine levels high
levels high
4) Central venous pressure (CVP)
A CVP monitor requires a catheter tip in the central veins of the thorax e.g. superior vena cava
(SVC). There must be no valves between the tip and the right atrium (RA). Like an arterial line,
it is usually connected to a transducer for continuous wave monitoring; and zeroing and
levelling are required for meaningful readings. It can also be measured by a water column.
The zero is at the level of the RA.
CVP measures the right ventricles (RV) ability to deal with the venous return. A failing RV will
show a rising CVP. Hypovolaemia is usually associated with a low (normal) CVP. The CVP is
not a blood volume monitor as such. It will also not be able to tell you what the cardiac output is
as it has no ability to measure what is happening on the left side of the heart.
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The catheter may have 1- (single), 2- (double), 3- (triple) or even 4- (quad) lumens, used for:
CVP measurement
Administration of inotropes
Blood sampling
Approximation of mixed venous saturation (not the true mixed venous saturation)
Administration of irritant drugs Potassium, chemotherapy
Total parenteral nutrition (TPN)
Patients with difficult IV access or the need for long-term IV therapy
ICU multiple lumens for drug administration
5) Pulmonary artery catheter (Swan-Ganz catheter)
This invasive monitor has a balloon tip enabling flow directed placement in the pulmonary artery
(PA). It is placed like a CVP into the SVC, floated into the RA and then the RV, and finally into
the PA. It is used to measure cardiac output, right atrial pressure (RAP), pulmonary artery
pressure (PAP), and pulmonary capillary wedge pressure (PCWP - an indirect measure of left
atrial pressure). Mixed venous O
saturation and core temperature can be continuously
measured with more sophisticated catheters.
Blood samples can be drawn to measure mixed P

It is only used in exceptional circumstances as it has many associated risks. This is the gold-
standard monitor for measurement of cardiac output, however there are now many modern and
less invasive monitors that can measure cardiac output.

Depth of anaesthesia monitors
Cardiovascular responses to surgery (HR and BP) have traditionally been used to monitor
adequacy of anaesthesia. Several new neurological monitors are available to measure
anaesthetic depth (BIS, Entropy, and AEP). There remains a lack of consensus as to whether
depth of anaesthesia is a lack of recall, non-response to painful stimuli or hypnosis.
1) Bi-spectral index monitor (BIS)
This measures the frequency of the most powerful electro-encephalo gram (EEG) waves. Slow
waves indicate deeper anaesthesia. Depth of anaesthesia can be expressed as a single
number. 0 indicates an isoelectric EEG and 100 = awake. Target 40

60. The same value
may mean different levels during different phases of anaesthesia. BIS monitoring, therefore,
does not ensure lack of awareness if the patient is in the target range.
2) Auditory evoked potentials (AEP)
Aural stimuli are applied and the EEG is monitored. EEG response to the stimuli is analysed.
Anaesthesia should suppress the mid-latency AEP. This measure may be used to predict
movement, response to verbal command, explicit and implicit memory. A 0 to 100 scale is also
used but is not the same as BIS at different levels of anaesthesia.

Neither monitor measures depth of anaesthesia directly, but rather the brains response to
stimulation and is affected by analgesics or other drugs. They are useful but not totally reliable.
Agent analysers
The fraction of inspired (F
AA) and end-tidal (F
AA) anaesthetic volatile agents (AA) can be
measured. End-tidal concentration of AA is an indication of the % of the minimum alveolar
concentration (MAC) that is being delivered. This gives an indication of an adequate dose of
inhaled anaesthetic agents and is by extension a depth of anaesthesia monitor.

Muscle relaxation monitors
Electrodes are attached over a nerve (often forearm or temporal) to stimulate it and measure the
resultant related muscle response.
Single twitch, train of four, double burst stimulation and tetanus patterns can tell the anaesthetist
the type and intensity of paralysis, and when it is safe to give the reversal agents. Unfortunately
these tests are useful only at relatively low levels of muscle relaxation.

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Temperature monitoring
The patients temperature should be measured for any procedure longer than 15 minutes. This is
important in general and regional anaesthesia (although more difficult to measure with regional).
Temperature probes can be inserted orally, nasally, oesophageally, rectally, on the skin, in the
bladder and in the outer ear. Core temperature

(oesophageal and bladder) will be warmer. As the
patient loses heat, the core gets smaller, buffering the temperature drop. Peripheral temperature is
subject to ambient conditions, but the trend is useful. Usually measured via a naso- or
oropharyngeal probe.
Heat loss is common during anaesthesia due to the cold ambient theatre temperatures, cold air
increasing heat loss via convection, exposed area of body, vasodilatation from anaesthetic agents,
and the inability to shiver and generate heat. Make every attempt to keep the patient warm with
warm fluids and gases, and the forced air warmer blanket e.g. Bair hugger

In open-heart surgery both core and peripheral temperatures are measured as deliberate cooling,
to 28

32 C, occurs. Warming requires the rise of both temperatures to normal before coming off
bypass. Oesophageal T reflects heart temperature and nasal the brain.

Effects of hypothermia
Adverse effects Vasoconstriction, shivering, poor enzyme function (including cardiac
contractility and conduction, coagulation), respiratory depression, diminished
muscle relaxant effect, slowed emergence from general anaesthesia
Beneficial effects Protects brain cells from hypoxia (used to our advantage during certain
cardiac surgical procedures and cardio-pulmonary bypass)

Monitoring patient safety
While the patient is under anaesthetic, as mentioned, you are their guardian. They are unable to
protect themselves from harm or injury. You must check the patients position and cushion their
pressure points; tape their eyes; check no part of their skin is in contact with metal or water as they
may be burned by the diathermy (cautery) unit; and be concerned for their modesty.

Monitoring is essential for safe anaesthesia. The emphasis is on maintaining physiological
homeostasis while conducting effective anaesthesia. Minimum monitoring standards proposed by
SASA (The South African Society of Anaesthetists) are HR, BP, O
Saturation and Capnography.
These and other physiological variables should be noted on the anaesthetic chart every 5 minutes in
black ink. This is a medico-legal document.

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The following is a suggested method of checking a basic anaesthesia machine


workstation. These
guidelines may be modified to accommodate different types of machine and some checks may not be
necessary for modern electronic workstations with an automated self-check.
Switch ON if an electrical machine, turn off all flows and connect breathing system
Check O
monitor in room air - calibrate to 21

% & place at the common gas outlet (if possible)
Verify correct assembly of breathing system (hoses, reservoir bag, Y-piece etc.)
Occlude or park the patient-end of the system, and fully open the APL valve
If present - Open Air rotameter @ 6 l min
monitor should read 21


%) - and close
Open O
rotameter @ 2 l min
monitor should rise)
Open N
O rotameter @ 8 l min
monitor drops, but >

25 % - i.e. Hypoxic guard OK)

Disconnect wall O
(or close 1 O
cylinder) and :-
Check that N
O flow ceases (i.e. O
failure cut-off switch functional)
Wait for O
failure alarm
Open O
cylinder (or 2 O
cylinder) and check pressure (P >

5 000 kPa)
Check O
flush (Manometer < 5

hPa - i.e. valve


s not sticking & O
monitor should rise)

Close O
cylinder and reconnect wall O
(or open 1 O
cylinder) and :-
Perform "tug test" on O
, suction and other wall probes
Check all pipeline (or cylinder) gauge pressures

Replace O
monitor in normal position
Occlude the breathing system, close APL valve and perform :-
Positive pressure leak test of CIRCLE and machine - Vaporisers ON sequentially
Check vaporiser interlocks
Check function of valves of circle system
Check Soda-lime
Check APL valve pressure release (Manometer

60 hPa or cmH2O)
Close all gas flows

Check function of ventilator
Check presence and function of self-inflating manual resuscitator (e.g. AMBU-, Laerdal- bag etc.)

Check function (>

50 kPa negative pressure)
Check for presence of suction nozzle (e.g. Yankauer) & catheters

Check if properly attached

Ancillary equipment
Check laryngoscopes (x 2)
Check for presence of Magill forceps
Endotracheal tubes


Supra-glottic- airway (e.g. LMA)
Check monitors Sphygmomanometer
Pulse oximeter



Most important checks
1. Is there a constant flow of O
available via the O
flowmeter and O
flush button (1 O
2. Is there enough O
in the reserve cylinder (2 O
3. Is the self-inflating resuscitator (e.g. AMBU bag) present and functioning (3 O
supply - room air)?
4. Is there no leak in the breathing system with pressure testing and the vaporiser open?
5. Is the suction working with tubes and nozzle


catheters present?

Disclaimer - These guidelines are provided for the sole purpose of guiding students and junior doctors in performing the pre-
operative check of an anaesthesia workstation. It is not a comprehensive checklist, nor a recommendation for the checking of
anaesthesia machines or workstations in clinical practice. These guidelines have not been peer reviewed and have not been
sanctioned by the South African Society of Anaesthesiologists.