GAS MAN

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by James H. Philip, ME(E), MD

Associate Professor of Anaesthesia
Harvard Medical School
Anesthesiologist & Director of Bioengineering in Anesthesia
Brigham and Women's Hospital
Boston, Massachusetts

A product of
Med Man Simulations,lnc. P.O. Box 67-160 Chestnut Hill, MA 02467
© Copyright 1995-2002 by Med Man Simulations, Inc.

Gas Man® is a registered trademark and Med Man'" is a trademark of

Med Man Simulations, Inc.
Microsoft® and Windows"\! are trademarks of Microsoft Corporation.
Macintosh@ is a registered trademark of Apple Computer Inc.

Gas Man is a simulation and teaching tool. Med Man Simulations, Inc.
disclaims any warranty for planning of actual medical treatment for patients.

Credits
Author James H. Philip, ME(E). MD

Editing, Design and Logo Ronald S. Waite, IV! r II

Gas Man Screen Icon Ben Philip
Gas Man Program for Windows Hal Franklin
Gas Man Program for the Macintosh Hal Franklin
IntelliMetrics Instrument Corp.
Peter Martin, ME
Daniel Litvack
Edwin Trautman, PHD
Gas Man® Preface

reface

There are many uses for computer technology within the practice of
anesthesia. Usually, computers are used to automate practices which are
already well-established. Using the computer to help teach difficult con-
cepts is another matter, however, that goes far beyond the automation of
procedure. Computer-aided learning is difficult to develop, but very
rewarding in its effectiveness. This program, Gas Man®, exploits the
potential of the computer to help students understand anesthesia uptake
and distribution.

The fundamental principles underlying anesthetic pharmacokinetics are

simple. The important rules are: a) conservation of mass, and b) physio-
logic maintenance of lung volume. Unfortunately, the dynamic implications
of these principles are not easy to comprehend. Indeed, it is the need for
explanation and demonstration of the dynamic changes in anesthetic
tension equilibration which led me to design and implement this
educational tool.

The Gas Man program is a powerful marriage of computer simulation and

image production with the printed word. In place of the instructor in a
simulation laboratory, we have the instructor's voice (in print) and a labora-
tory inside a personal computer (Gas Man). By using the set of Exercises in
this Manual, and by learning how to use Gas Man as a tool for further
exploration, users can study the simplicities and subtleties of the dynamic
properties of anesthesia uptake and distribution regardless of where they
are or what other resources are available to them.

I first began investigating the use of computers to help teach the concepts
of anesthesia uptake and distribution in 1980, when I received a grant from
the Apple Educational Foundation to explore the use of Apple II comput-
ers. In 1982 the first version of Gas Man for the Apple II was shown at the
American Society of Anesthesiologists meeting. The program was immedi-
ately well-received. The program and a set of exercises similar to this
Manual was published and distributed by Addison-Wesley in 1984. Mter
many colleagues clamored for an updated version of the program suitable
for microcomputers, we demonstrated in 1989 a version of Gas Man for the

llZ
Gas Man® Pllface

Macintosh. In 1994 we released Gas Man forWindows™, and Version 2.1,

with many new features, was released in cor~junction with this manual in
October 1995.

Gas Man's new features significantly broaden the base of users and uses.
The ability to compare and contrast anesthetic techniques and agent
choices should attract a solid follovving by hospital administrators, pharma-
cists, and anyone concerned with the cost of health care.

The ability of the Gas Man Overlay to normalize tensions to agent MAC and
then explore the effects of blood/ gas solubility provides drug and equip-
ment manufacturers with insights not previously available. Vaporizers for
the new agents sevoflurane and desflurane have maximum dial settings that
account for both ]'viAC and solubility, allowing the same relative alveolar
overpressure found with halothane and desflurane vaporizers. Meanwhile,
clinicians can use the same displays to compare and contrast administra-
tions with different drugs and different techniques.

Finally, with Gas Man's wider weight range - from 50 g to 1500 Kg - ani-
mals of interest to veterinarians can now be simulated with ease.

Gas Man has been reviewed favorably in numerous publicationsl.~,3,-t5.l().

Several studies have demonstrated the effectiveness of Gas Man as an edu-
cational tool in centers other than where it was written(i" and when com-
pared to lecture presentation". Ongoing study of its efficacy as a
simulation program has endorsed its accuracy'!. I am committed to the
wide-ranging audience of Gas Man users to continue to refine and enhance
the program and its applications.

tv
Gas Man®

o ACKNOWLEDGEMENTS
I gratefully acknowledge the help and support of family members, friends,
students, assistants, and teachers. I thank my family (Beverly, Noah, and
Ben) for allowing me the time required to prepare both the computer
program and this textbook. I thank the staff and especially the residents of
Brigham and Women's Hospital who afforded me the opportunity to de-
velop and test both the program and text. Daniel Raemer, PhD provided
insight and assistance in the initial system model. David Leith, MD pro-
vided information on scaling over wide weight ranges. Pauline Wong, DVM
and other veterinary anesthesiologists encouraged me to actually add the
wide range of weight capability. Iggy Calalang tested varous components of
the simulation for consistency. Khaled Khodr tested the implemention of
some of Gas Man's new features including the second gas effect and weight
scaling. Xin Bao Ji, PhD and Jeff Mandel, MD each tested various portions
of the mathematics using analytic and simulation techniques. Anne
Kamara, my trusted administrative assistant, supported me in all my tasks
related and unrelated to this endeavor.

Ronald Waife has served as the creative editor and designer for both edi-
tions of the book, enhancing its content and clarity. Hal Franklin imple-
mented Gas Man for Windows 2.0 and 2.l. In doing so, he added numer-
ous new features and ideas that only an insightful mathematician-engineer-
physiologist could envision and implement.

kid I thank the enthusiastic Gas Man users and teachers who continue to
encourage me to develop and release new versions, allowing a wider audi-
ence of users to draw benefit from this work.

James H. Philip, M.E. (E.), ~LD.

Chestnut Hill, Massachusetts
October 1995

v
Gas Man® Prej(lce

October 1995
1. Torda TA: Gas Man. Audio-Visual Review. Anaes Intens Care 13: Ill, 1984.

2. Schneider AJ: GAS J\lIAN. Educational Resources Review. News Soc Ed Anes 2: 2,
1985.

3. Brandom BW: GAS NIAN. Book Reviews. Anes Analg 65: 106,1986.

4. Shanks CA: Gas Man. Books. JAMA 255: 268, 1986.

5. DeanJM: GasMan. Software Review. MD Computing 3: 53,1986.

6. Paskin S, Raemer, DB, Garfield JM, Philip JH: Is computer simulation of anesthetic
uptake and distribution an effective teaching tool for anesthesia residents? J Clin Mon
1: 87,1985.

7. Garfield JM, Paskin, S, Philip JH: An evaluation of the effectiveness of a computer

simulation of anesthetic uptake and distribution as a teaching tool. Med Educ 23:
457,1989.

8. Philip JH, Lema J\llL Raemer DB, Crocker D: Is computer simulation as effective as
lecture for teaching residents anesthetic uptake and distribution? Anesthesiology 63:
A503,1985.

9. Philip JH: Gas Man simulation of overpressure is verified by correct alveolar plateaus.
Anesthesiology 73: A1025, 1990.

10. Gage,JS: Mathematics andjudgement: A review of the computer simulation Gas Man.
MD Computing 9:54, 1992.

vz
 able of Contents

o Preface
Preface ................................................................................................ iii

o 1: OVERVIEW OF Gas Man® AND ITS USES

Introduction ...................................................................................... 1-1
The Gas Man Approach .................................................................... 1-3
Uses for Gas ]\Iran ............................................................................... 1-4
Other Users of Gas Man .................................................................... 1-7
Summary ............................................................................................ 1-8

o 2: GETTING STARTED WITH Gas Man®

Introduction ...................................................................................... 2-1
Your Software License ....................................................................... 2-2
Installing Gas Man on Windows™ Computers ............................... 2-3
The Gas Man Picture & Graph ......................................................... 2-6
The Gas Man Menus & Toolbar ....................................................... 2-10
Installing & Using Gas Man on the Macintosh™ ............................ 2-20
Running a Gas Man Simulation ....................................................... 2-24
SUlnrnary ............................................................................................. 2-28

o 3: A ONE COMPARTMENT MODEL

Theory ................................................................................................ 3-1
Exercise 3-1: Wash-in of a single compartment ............................... 3-3
Exercise 3-2: The time constant for wash-in .................................... 3-11
Exercise 3-3: Exponential curves ...................................................... 3-14
Summary ............................................................................................ 3-16

o 4: TWO SEQUENTIAL COMPARTMENTS

Theory ................................................................................................ 4-1
Exercise 4-1: The step response ........................................................ 4-2
Exercise 4-2: The alveolar step response ......................................... 4-4
Exercise 4-3: Wash-in delays are additive ......................................... 4-7
Exercise 4-4: Overpressure ................................................................ 4-10
Summary ............................................................................................ 4-12

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Gas Man® Toble 0/ Con tents

o 5: THE ALVEOLAR TENSION CURVE

Theory ................................................................................................ 5-1
Exercise 5-1: Patient wash-in: the alveolar tension curve ................ 5-2
Exercise 5-2: The initial rise .............................................................. 5-5
Exercise 5-3: The initial rise and alveolar ventilation ..................... 5-7
Exercise 5-4: The knee and the plateau ........................................... 5-10
Exercise 5-5: Increasing alveolar ventilation ................................... 5-12
Exercise 5-6: Increasing cardiac ouput ............................................ 5-14
Exercise 5-7: The ratio of alveolar ventilation to cardiac output ... 5-16
Exercise 5-8: The tail: anesthetic returned to the lungs ................. 5-20
Summary ............................................................................................ 5-2Ll

o 6: PLATEAU HEIGHT & BLOOD/GAS SOLUBILITY

Theory ................................................................................................ 6-1
Exercise 6-1: Knee height varies with blood/ gas solubility ............ 6-3
Exercise 6-2: High blood/gas solubility and low knee .................... 6-11
Exercise 6-3: The A/I ratio, MAC and overpressure ....................... 6-13
Exercise 6-4: Overpressure-induced 1 MAC in the alveoli ............. 6-15
Summary ............................................................................................ 6-18

o 7: OVERPRESSURE & OPTIMUM ANESTHESIA

Theory ................................................................................................ 7-1
Exercise 7-1: Overpressure-induced 1 MAC in the alveolar
compartment ............................................................ 7-3
Exercise 7-2: Optimum anesthesia and constant brain tension ..... 7-9
Exercise 7-3: Optimum anesthesia and vaporizer adjustment ....... 7-16
SUlnmary ............................................................................................ 7-22

o 8: THE HIGH INSPIRED CONCENTRATION EFFECT

Theory ................................................................................................ 8-1
Exercise 8-1: The concentration effect ............................................ 8-3
Exercise 8-2: The concentration effect varies with
inspired concentration ............................................ 8-6
Exercise 8-3: Cardiac output and 100% inspired ............................ 8-8
Exercise 8-4: Removing the concentration effect ........................... 8-12
Summary ............................................................................................ 8-14

VlZZ
Gas Man® Table oj Conlnlls

o 9: lOW FRESH GAS FLOW ANESTHESIA

Theory ................................................................................................ 9-1
Exercise 9-1: Reducing fresh gas flow .............................................. 9-2
Exercise 9-2: Circuit flush reduces anesthetic tension faster ......... 9-5
Exercise 9-3: The ideal circuit .......................................................... 9-10
SlllTIrnary ............................................................................................ 9-12

o 10: CLOSED-CIRCUIT ANESTHESIA

Theory ................................................................................................ 10-1
Exercise 10-1: A closed-circuit liquid anesthetic injection ............. 10-3
Exercise 10-2: Closed-circuit optimal anesthesia ............................. 10-5
. ].0-~): CI
E< xerose d' .... .
~ ose -orcUlt ll1JectlOn USll1g t"- ..........................
<) I
II ")11 10- 10
SlllTIrnary ............... , ............................................................................ 10-14

o 11: THE SECOND GAS EFFECT

Theory ................................................................................................ 11-1
Exercise 11-1: Low concentration of first gas .................................. 11-3
Exercise 11-2: High concentration of first gas ................................. 11-5
Exercise 11-3: 70% nitrous enhances alveolar rise of isoflurane ... 11-9
Exercise 11-4: Second gas effect less with low solubility drug ........ 11-11
Sun1n1ary ............................................................................................ 11-13

o 12: PATIENT WAKE UP

Theory ................................................................................................ 12-1
Exercise 12-1: Wake up is the inverse of induction ......................... 12-2
Exercise 12-2: Alveolar tension during wake up is lower with a
low solubility drug .................................................. 12-5
Sun1n1ary ............................................................................................ 12-8

o 13: PATIENT SIZE

Theory ................................................................................................ 13-1
Exercise 13-1: Kinetics is faster with patients of smaller size .......... 13-2
Exercise 13-2: Kinetics is faster with small animals ......................... 13-4
Summary ............................................................................................ 13-6

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Gas Man® Table of Contents

o 14: ANALYZING COST

Theory ................................................................................................ 14-1
Exercise 14-1: Cost can be determined with Gas Man .................... 14-2
Exercise 14-2: Cost is lower with lower FGF ..................................... 14-5
Summary ............................................................................................ 14-10

o 15: ADVANCED FEATURES OF Gas Man®

Introduction ...................................................................................... 15-1
Setting Program Defaults .................................................................. 15-5
Using Overlays ................................................................................... 15-9
Printing & Export Options ............................................................... 15-12

o Appendix
Evolution of the Understanding, Modeling and Simulation of
Anesthesia Uptake and Distribution ............................................. A-I
Further Considerations on Use of Gas Man .................................... A-4
Gas Man System Defaults .................................................................. A-6

o Bibliography
Bibliography ....................................................................................... B-1

o Index
Index .................................................................................................. I-I

o license Agreement

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 (-\
Chapter 1 \\ )
Overvie~f'Gas Man® and its Uses
~
o

ntroduction

Welcome to Gas Man® 2.0, the innovative computer-based teach-

ing and simulation program. You are about to explore the con-
cepts of inhalation anesthesia pharmacokinetics in a way that has
proven to:

increase the clarity and retention of the material,

speed your learning time, and
enhance your appreciation and enjoyment of the subject.

Gas Man is a computer simulation tool that teaches about anes-

thesia. Specifically, Gas Man focuses on anesthesia uptake and
distribution, and the time course of anesthetic tension change.
The program was designed to be used in close conjunction with
this Manual, a text which guides the learner through a set of
Exercises that demonstrate the important concepts and features
of the administration of inhalation anesthetics.

The computer simulation depicts anesthetic tension (partial

pressure) in the anesthesia machine, breathing circuit, and
patient. The key component of the program is an interactive
schematic Picture which shows dynamically what the clinician
controls and how the patient's lungs and tissues equilibrate with
inspired anesthetic. The Gas Man Graph shows the evolving time
course of gas tensions in the locations and tissues of interest.
The Gas Man Overlay allows you to analyze your simulations
graphically, by displaying compartment ratios, and by comparing
one simulation to another. Gas Man also enables you to study the
cost of different anesthetic agents and administration techniques.

1-1
Gas Man® Overview 0/ Gas J\;[an'!9

Concepts Covered in the Gas Man Tutorial, by Chapter

3. The One Compartment Model & its Step Response or Wash-in.

4. Two Sequential Compartmenls.
5. The Alveolar Tension Curve.
A. The Initial Rise: Alveolar Wash-In
Detenninants:
. Inspired tension
.. Alveolar (lung) ventilation
. Alveolar volume (FRC)
B. The Knee: Equilibration with Blood
Deterlninants:
.. Alveolar ventilation
.. Cardiac output
.. Blood/gas solubility
C. The Tail: Augmentation by Venous Return
Determinants:
• Tissue blood flows
.. Tissue volumes
.. Tissue blood solubilities
.. Return of mixed venous blood
6. Plateau Height is Determined by Blood/Gas Solubilit)'
7. Overpressure & Optimal Anesthesia Course for Clinical Anesthesia
8. The Concentration Effect
9. Low Flow Anesthesia
10. Closed-Circuit Anesthesia with Liquid Injection
11. The Second Gas Effect

Table 1-1.
Concepts taught by Gas Man and the Exercises in the LVIanual.

1-2
Gas Man® OVI'J1!i('w 0/ Gas JVlan®

This manual is organized as follows:

Chapter 1 The many uses aJGas Man

Chapter 2 How to install and use the program on \;\Tindowsr'l and

Macintosh® computers.

Chapter 15 How to use the advanced features of Gas Man 2.0.

Chapters 3-14 These chapters are the tutorial portion of this manual.

Each tutorial chapter introduces an important concept and

follows it with Exercises to demonstrate and reinforce the con-
cept using Gas Man. These Exercises can serve as a standalone
curriculum on anesthesia uptake and distribution. An outline of
these Chapters is presen ted in Table 1-1.

he Gas Man® Approach

In Gas Man, the path of the anesthetic is depicted as beginning

with the anesthesiologist's hand adjusting the vaporizer setting,
and culminates with the anesthetic effect achieved in the
patient's brain. Along this path from vaporizer to brain, physical
and physiologic interactions affect anesthetic levels achieved and
the rapidity of change.

The Gas Man program is designed to be used hand-in-hand with

the Exercises in this manual. \;\Then the Exercises are completed
in order, the student will have constructed the breathing circuit
and the patient components in step-by-step fashion to form a
coherent, understandable model. The tutorial introduces simple
systems first, and then combines them while maintaining their
piece-by-piece simplicity. In the end, the student will have
achieved a system of sufficient complexity to explain clinical
events. With this clinical system, various administration tech-
niques can be demonstrated and their implications explored.

1-3
Gas Man® Overview 0/ Gas Alan")

The o~jective of this approach is to provide a high level of knowl-

edge, understanding and insight that can then be applied in every-
day clinical practice to provide both better patient care and greater
understanding, satisfaction, and enjoyment for the medical profes-
sional.

The overall approach follows that presented by Ketl9 in the origi-

nal explanation of inhalation anesthesia pharmacokinetics, pub-
lished in 1950. The equilibration of anesthetic partial pressure
from compartment to compartment is the seminal concept that
underlies the entire approach. Throughout, we used the data
obtained by Edmund 1. Eger IJII to validate the model, quantify its
parameters, and discover and elucidate its subtleties. We also
incorporated additional concepts and clinical techniques offered by
others.

ses for Gas Man®

Gas Man can be used in several ways:

• to learn the concepts, features and technical subtleties of

inhalation anesthesia by following the tutorial Exercises;
• to teach anesthesia principles and kinetics in the classroom;
• to experiment with various anesthetic administration
possibilities;
• to plan your administration in accordance with different
clinical or cost objectives;
• to better interpret your anesthetic monitors; and
• by the many people who serve the anesthesia clinicians
(manufacturers, designers, sales representatives) who need
to understand inhalation kinetics and administration
• to design clinical research experiments.

,.,. Note: It is important to stress that although one can plan a clinical strategy
with the Gas Man tool, it is not a substitute for the clinician's judg-
ment during the actual course of anesthesia administration in the
operating room. No claim is made that Gas Man can or should be
used to determine the actual medical treatment of any patient.

1-4
Gas Man® Overview of Gas iVlml®

o TO TEACH

Gas Man can be used by the teacher/educator in several ways.

The program and the Exercises can be incorporated into an
educational curriculum either as a primary educational tool to
teach inhalation anesthetic pharmacokinetics or as an educa-
tional adjunct - reinforcing, expanding, and deepening the
students' understanding of the subject. For instance, a lecturer
on inhalation anesthesia pharmacokinetics can easily produce
the artwork for a sequence of overheads or slides which explain
the points covered in the lecture by printing out the Gas Man
Picture and Graph of a particular simulation. Gas Man can also
be projected in the classroom quite effectively with a computer
projector or overhead LCD panel to provide real-time (actually,
accelerated time) simulations which can be viewed interactively
by a group.

o TO EXPERIMENT

Gas Man can be used several other ways, without following the
Exercises. For instance, the program can be used to simply
experiment with anesthetic administrations. The student, the
resident or the experienced clinician can simulate various anes-
thetic administration possibilities. Or a clinician can analyze a
recent anesthetic administration to understand why the observed
clinical events occurred or why the desired course was not
achieved.

o TO PLAN

A clinician can plan an anesthetic administration to optimize for

specific objectives. For instance, one possible objective is speed of
induction, where the goal is to minimize the time to perfect
anesthesia depth. Another objective is gentleness of induction,
where anesthetic depth is increased at a constant rate, up to a
desired endpoint. Under some circumstances, one may want to
maintain a constant depth of anesthesia. In this circumstance, the
relationship between fresh gas flow, vaporizer setting, and dura-
tion of anesthetization is often more complex than it seems, and
Gas Man can help the clinician simulate the interrelationships.

1-5
Gas Man®

o TO REDUCE COSTS

Gas Man calculates and displays the cost of anesthesia

adminstration, facilitating the analysis of new agents and tech-
niques. One can practice and analyze the use of low/low and
closed circuit anesthesia to minimize the quantity of drug used.
Another clinical goal can be rapid, controlled, alteration of anes-
thetic depth at various times during the course of anesthesia.

o TO INTERPRET MONITORS

Anesthetic agent monitors are common in clinical anesthesia

practice. First-time users, and even experienced llsers, of agent
monitors are often perplexed or disturbed by the difference
between what is set on the vaporizer and what inspired and end-
tidal measurements are displayed and recorded. Occasionally,
either the vaporizer or the monitor may not be functioning
properly, but usually, both are correct. In such situations, the
observed differences can be explained by the physics and physiol-
ogy of the machine, drug and patient. In this situation, Gas Man
can be used to produce a good approximation of what is ob-
served on the monitor, and helps the clinician formulate a more
correct explanation for what is observed as well as a more correct
expectation for the future.

-----------------~---"----~--------------

1-6
Gas Man®

ther Users of Gas Man

Gas Man can be used by many professions:

all medical personnel, including students, residents,

CRL'JAs, and practicing physicians, in any of the ways
described above;
hospital Clinical Engineers, Biomedical Equipment
Technicians and pharmacists;
hospital and managed care administrators;
manufacturers and marketers of agent monitors and
anesthesia delivery systems;
manufacturers and marketers of inhalation anesthetic
drugs; and
educators in other fields interested in the applicability of
simulation software for training and communication.

In hospitals, Clinical Engineers and Biomedical Equipment

Technicians can use Gas Man to better understand the technical
and clinical complexities inherent in their equipment, and the
interactions of drug, delivery system, and patient. Pharmacists
can better understand drug delivery system-patient interactions,
and administrators can better appreciate the trade-offs clinicians
make between quantity of drug used and clinical care provided
for the patient.

Administrators of hospitals and managed care organizations can

use Gas Man to analyze the cost of new agents or techniques, and
to calculate cost and price objectives.

Manufacturers of agent monitors - particularly their marketing,

sales and user education staffs - can better appreciate the ques-
tions that will be asked and the confusion that will initially be
engendered when their products are introduced in the operating
room. By preparing answers to these questions in advance, the
introduction and continued use of the monitor will be facilitated.

1-7
Gas Man® Overview of Gas IHan®

Manufacturers of gas delivery systems (anesthesia gas machines)

can use Gas Man to understand and explain why the concentra-
tion the patient inspires from the breathing circuit is not what
the clinician set on his vaporizer, even when the vaporizer is
performing perfectly. Understanding the clinical goals and
administrative objectives taught by Gas Man should in fact assist
in the design of new anesthesia machines.

Manufacturers of the anesthetic agents can better understand

and explain the pharmacokinetics of the drugs they market, sell,
or manufacture. The drug manufacturer can enhance patient
care by helping clinicians learn to use the drugs effectively,
unencumbered by limitations inherent in machine and patient
that were previously difficult to overcome. Also, vaporizer specifi-
cations can be better determined by carefully considering breath-
ing circuit kinetics and solubility of the drug in blood and other
tissues. In addition, the implications of drug attributes such as
solubility in blood and various tissues can be understood through
Gas Man's computer modeling and simulation.

Educators in other fields might also be interested in Gas Man,

since it demonstrates how the simulation of a complex process,
combined with straightforward user interaction with the model,
can effectively improve the user's understanding of his environ-
ment and enhance performance on the job.

ummary

The Gas Man program is a unique tool for teaching and simulat-
ing anesthesia uptake and distribution. It can be used with the
Exercises in this Manual for a clear, detailed presentation of
concepts, accompanied by direct, interactive simulations to
demonstrate these concepts and reinforce learning. It can also
be used as a general tool for the practicing anesthesiologist,
technician or product developer to simulate the interactions of
physiological, pharmacological and physical components.

1-8
 /~~

Chapter 2 ( )
Getting ~a)t-ed/ with Gas Man®
( ')
~
o

ntroduction

In this chapter, you will find:

your software license agreement

how to install Gas Man® on Windows™ and Macintosh nr
computers
an introduction to the Gas Man Pictw'e and Graph
an explanation of Gas Man's Menu Bar and Toolbar on
Windows and Macintosh computers
your first exercise in Gas Man, showing you how to run a
simple simulation
an introduction to some of Gas Man 2.0's newfeatures,
such as Rewind and Bookmarks.

When you finish this chapter, you will be ready to run Gas Man
simulations on your own, and can begin the tutorial section of
this manual by going on to Chapter 3. To learn more about the
advanced features of Gas Man 2.0, please refer to Chapter 15.

'-Note: This chapter assumes that you are already familiar with the
Windows or Macintosh computer on which you plan to run Gas
Man. If you are not comfortable with how your computer works,
please complete an introductory tutorial on your computer's
operating system before starting to use Gas Man.

2-1
Gas Man@ Gelling Started

our Software License

Gas Man® is licensed for use in two ways. The Single User Li-
cense and the Site License are fully described in the License
Agreement that accompanies this software and is printed in the
back of this Manual.

o THE SINGLE USER LICENSE

The Single User License includes one copy of this Manual and is
intended for a single user on one computer such as a desktop or
portable. Under the Single User License, you may not install the
Gas Man software on more than one computer. If you wish to
put Gas Man on a different machine of yours other than the one
where vou first installed it, vou must remove it from the original
/ /

machine. In addition, under the Single User License, you may

not make copies of the software or this Manual to distribute to
others.

o THE SITE LICENSE

Site Licenses are designed for single departments of universities,
hospitals, and manufacturers of drugs, monitors, and gas ma-
chines. The exact organization must be defined in the Site Li-
cense Agreement.

The Site License authorizes users to copy the Gas Man software,
but not the Manual, and to install it on computers within their
organization. Salespersons representing drug or device manu-
facturers are required to own individual licenses, and are not
authorized to make and distribute copies of the software or the
Manual.

The Site License includes a specified number of copies of the

Manual. Additional copies may be purchased only by Site License
holders. Please contact Med Man Simulations, Inc.

2-2
Gas Man® Gelling S'/(Irled

o COPYING & DISTRIBUTING THE MANUAL & SOFTWARE

This Manual is protected under applicable Copyright law and may not
be copied for redistribution under either the Single User License or the
Site License. Under both the Single User License and the Site
License, the user may make a backup copy of the software on a
diskette to protect against damage to the original disk.

!ling Gas Man on Windows™ Comp_u_te_r_s_ _ _ _ _ _ _ __

o HARDWARE REQUIREMENTS
ell a personal computer using an Intel® processor (486 or higher
preferred, 386 OK; the speed of the processor is not important,
although faster is always better) or a PowerMac processor run-
ning SoftWindows 2.0 or later.
Microsoft® Windows™ 95 or Windows 3.1, Windows for
WorkgroupsTtvl 3.1 or Windows/NTTtvl
" a VGA monitor, preferably color SVGA or better
" a hard drive with at least 2 mB available
ell a floppy drive (for installation only; can be external)
• 4mB RAM or more (2mB is OK but not desirable)

o INSTALLING THE SOFTWARE

1 Read the Software License Agreement.

2 Make sure you have enough space on your hard disk.

3 Make a backup copy of the Gas Man installation disk for your
protection.

4 Install like any other Windows program. Have Windows running

on your computer and the Program Manager open.

2-3
Gas Man® Cell illg SI (frted

5 Insert the Gas Man installation disk into the floppy disk drive.

6 Under File in the Program Manager menu bar, choose Run ...

7 In the Command Line space, type A:\INSTALL Select "OK" or

press ENTER.

8 After a few moments, you will see the Gas Man installation
screen, and a README.TXT file that contains important infor-
mation and reminders. Press CONTINUE.

9 The next window shows the directory on your hard drive where
the Gas Man prograrn will be installed. You can change this if
you wish by typing over it. There are also two buttons - FULL
and CUSTOM install. Press the FULL install button to have Gas
Man install automatically.

10 A progress dialog will show how the installation is progressing.

Then a dialog box will appear with a suggested location for the
Gas Man jJrograrn icon. This allows you to decide in which window
on your desktop you wish the icon to appear. You will be able to
launch Gas Man from this icon. You may either accept the sug-
gestion or select a different location from the drop-down listbox.
Either press CREATE to complete the install, or press SKIP to
prevent the addition of a program icon.

11 A dialog box will ask you for your name and organization, to
register your copy of Gas Man. Compete the information and
continue.

12 A dialog box will inform you that your installation was successful.
Press OK to end the installation process and return to the Pro-
gram Manager, where (if you didn't skip the icon step) you will
find the nevv Gas Man icon in the Group where you placed it.

2-4
Gas Man® Gelling Started

13 Try opening Gas Man by double clicking on its icon. You should
see the Gas Man start-up screen and then the Gas Man Picture.
The file name will be "Untitled". You may want to click on the
expand button in the upper right corner of the Gas Man menu
bar, and the file's menu bar, in order to have the Gas Man Picture
fill your screen. You close Gas Man as you would any Windows
program, by choosing Exit from the File menu or typing ALT +F4.

14 If you frequently use a suite of applications, such as Microsoft

Office™ or Lotus® SmartSuite™, you may want to add the Gas
Man program icon to the suite's toolbar.

o IF YOU HAVE AN INSTALLATION PROBLEM

Should you have any problem with the installation, or with run-
ning Gas Man once the installation is complete, record the cir-
cumstances and any messages that appear on the screen before
attempting to recover. Then try these remedies:

1 Respond to any messages appropriately. If the system complains

about being short of memory, for example, try shutting down all
non-essential applications.

2 Try it again. Floppy media and drives can make mistakes.

3 Try it again without changing any default responses, and by select-

ing FULL install even you wish a Custom installation.

4 Look for the README.TXT file in the Gas Man directory for
other instructions.

5 Ask someone who works with you. If none of these work, call or
fax Med Man Simulations, Inc. Have the details of the failure
handy, and the program open on your computer.

2-5
 Getting Started

he Gas Man Picture &

The Gas Man program uses interactive graphics to depict anes-

thetic tension in various locations from vaporizer to patient. Two
main windows - the Gas Man Picture and the Gas Man Graph -
are used. One of the convenient features of Gas Man is that
several of the key program controls are located on both windows,
in order to minimize toggling back and forth between windows.

The Gas Man Picture shows a schematic compartmental diagram

of the patient; each compartment is filled during the simulation

Alenll
Bar

Toolbar Agent: II soflur ane Circuit: ISemi-Closedl~1

,11017 = alveoli (lullgs)

II FiT = arteriat blood
Height = Flush I'HG 'Ie.wl rich groll/J
=
agmt tensioll
in % I aIm o (inc. brain)
MUS = muscle
FAT=f{ll
\fEN = venous blood
Breathing circuil

DE: 0 CK~2.521 AlVll. 78 1 11.781 11 . 70 1 10 . 15 1 10. 01 1 11 . 32 1

%at/~ ART VRG MUS FAT VEN
Deli< l eredfroll1 f1iil f1iil ~ Simulation Time
Iheva/!Orizer ~ ~ I 0:15:00 1 Time (h:mm:ssJ I
Volume of
0.52 I Uptake (ll agent in
'-----' ~ tissues & in
3.48 1 Delivered (ll circuit (toggles
'-----' with Cost)
Flows in
liters /Jer ____ FGF rR! VA CO Speed:
minnie lIm ~ LIm 4
1 .\3 1 LIm ~ I 60x ,+!I
Fresh Gas Flow Alveolar (lung) Ventilation Cardiac OlltjJllt (blood flow) Simulation SIJeed

I For Help, press F1

!
Slatus Bar
Figure 2-1 shows the Gas Man Picture after a simulation has been run,
annotated with descriptions of its components.

2-6
Gas Man® Gelling Slarted

according to its partial pressure. The heights of the fill represent

anesthetic tension. The bottom half of the Picture depicts the
rates of flow between compartments.

The Gas Man Graph shmvs the time course of anesthetic tension
in the tissues of interest. When a Semi-closed, Closed or Ideal
circuit has been selected, the top two panels show the trends of
the values of delivered anesthetic tension (DEL) and Fresh Gas
Flow (FGF). The fresh gas flow is the total gas flow from the
anesthesia machine common outlet into the breathing circuit.
The delivered tension is the anesthetic partial pressure (% of one
atmosphere) of the fresh gas. The bottom panel shows anes-
thetic tension in inspired gas (I), alveolar or expired gas (A),

Agent: Iisoflurane Circuit: 1Semi-Closed I

10--.-----------------------------------------------------.
FGF - Fresh Gas How ill lilen/mimlle
LIM --
o--~------------------------------------------------------~

3--~------------------------~----------------------_,
DEL - I = CKT = Inspired Ddi1l('mi anl'sliteslic ({,Jlsion/iYJ))! Ihl'
%atm - A=/iLI'=E:dzaled vajJorizer in S1a I aIm
0--'--------- R = VRG = vessel rich grolljJ ________________________________.........J
3 M = MUS = JllllScie
en F=FAT=Jat Desired M'-\ C level
ALV (minimuJJl alveo/ar
VRG (oncentration)

MUS

%atm
o
0:00 0:10 0:20 0:30
View: Length o/lime displayed in GrajJh window

130 MinI~f I+LJ· ...... . . ... )

I L~d ~{)rltinlJ~J
SO'oll bar enables .1'011 10 sec graphical re({mi beyond the li)))e liwl./ils in Ihe window

For Help.p(ess Fl

Figure 2-2 shows the Gas Man Graph, after a simulation has been run,
annotated with descriptions of its com.pone11ls.

2-7
Gas Man® Gelling Started

vessel-rich tissue group (R), muscle (M) and fat (F). Values are
expressed in percent of one standard atmosphere of the anes-
thetic chosen.

When an Open circuit is selected, the top 1:\'\10 panels display

alveolar ventilation (VA) and cardiac output (CO); in this situa-
tion, delivered tension equals inspired tension.

The height of the vertical scale of compartment tension (the

lower half of the Graph) is automatically determined by the
height of the DEL scale at the upper left of the Picture. You can
adjust your view of the compartment tension graph, therefore, by
changing the upper limit of the DEL scale. This is useful in
certain simulations to better see the anesthetic time course.

o SETTING PARAMETERS
The parameters and variables used by the Gas Man program can
be adjusted or controlled prior to and during a simulation in
three wavs:
j

click on the upl down buttons next to the control bars,

grab (click and drag) the control bar itself and move it
up or down (the fastest but crudest method), or
type a new numeric value in the appropriate box.

The numeric values you enter can be expressed in hundredths of

percent or Llmin for precise control.

2-8
Gas Man® Gelling Started

Gas Man Basic Parameter Choices

Agent Choose from desflurane, enflurane, halothane, isoflurane,

nitrogen, nitrous oxide, or sevoflurane.

Circuit Choose from Open, Semi-Closed, Closed or Ideal.

DEL (%) Acljust the anesthetic tension (% of one atmosphere)

from the vaporizer.

FGF Adjust the fresh gas flow (L/min).

VA A(~just the alveolar ventilation (L/min).

CO Aqjust the cardiac output (L/min).

Weight Acljust from 0.05 to 1500 kg.

Choose the simulated speed (compared to real time) at which you

wish the simulation to run. You can choose from lx, 2x, 5x, lOx,
20x, 60x, 120x and AFAP (as fast as possible). The actual speed of
these settings will vary depending on the speed of your computer.

Choose the duration of time shown on the Gas Man Graph.

The choices range from 5 minutes to 10 hours.

Table 2-1.
The basic Gas Man parameters and the available choices used to define
each simulation. Gas Man's advanced features employ additional param-
eters described in Chapter 15.

2-9
Gas Man® Gelling Started

he Gas Man Menus & Toolbar

This section describes each of the commands available to you

under the menu bar of the Gas Man application.

file Edit Anesthesia Qesktop Yiew ~pecial

Edit
Re~ind
East Fwd
Zero Timer Ctrl+Z Anesthesia
Clear All Liquid Inject Ctrl+L
.s.elect All Unit Qose ... Ctrl+D
Copy Selec!ion Ctrl+X Set ~ost...
~opy Data Ctrl+C EGF,DELVA,CO .. .
Agent 8, Circuit.. .

Y:iew
New View

Qraph CTRL+G
.Qverlay
.s.pecial
~ascade Disable !1ptake Ctrl+U
lile Disable Return Ctrl+R
Arrange Icons Enable Y:apor Ctrl+V
v 1 Untitled7 Change Eatient
Set .6.ookmark
Enable .s.crolling
tiide Numerics
Show ~ost

Figure 2-3 shows four of the drop-down menus from the Gas Man
application menu bar, in its Windows version.

2-10
Gas Man® Getting S'/arter!

o FilE
At the left of the menu bar is the File menu (not shown above).
Here you find the usual commands for opening, closing, creating
and saving files, including a list of recently saved or used files. You
can also Run simulations (or Run All if there are more than one
simulation open) from this menu. Many of these commands are
also available in the Toolbar (see fJage 2-16). The Print and Set
Default commands are more fully explained in Chapter 15.

DEDIT

At the left of Figure 2-3 is the Edit menu. Under this menu are
two kinds of commands - those for resetting or replaying the
simulation, and those for using the simulation data in other
applications .

Rewind .. . allows you to rewind in preparation for replaying the simula-

tion you have just paused or completed, keeping all the setting5 as
they were throughout the simulation, including any changes or manual
adjustments you made .

Fast Fwd ... takes you immediately forward to the next Bookmark or the
end of the simulation you have just completed, heefJing all the
settings as they were throughout the simulation, including any changes or
manual adjustments you made .

Zero Timer .. . allows you to begin again the simulation you have just paused
or completed, but retains the settings as you had when you choose
this command .

Clear All .. . erases the simulation you have just paused or just completed,
without saving it, and restores the settings to the current defaults.

Select All .. . creates a snapshot of the current Gas Man screen that can be
copied to the Windows Clipboard. From the Clipboard, the
screen image can be pasted into many other Windows applica-
tions, such as word processing or presentation software files. A
portion of the current display can be selected by positioning the
mouse where desired on the screen, holding down the right
mouse button, and dragging to surround your selection.

2-11
Gas Man® Getting Started

Copy Selection ... copies your display selection to the Clipboard .

Copy Data .. . copies the current data from the active simulation to the
Clipboard, allowing you to paste it into a spreadsheet or word
processing application for analysis and presentation.

o ANESTHESIA
The next menu to the right is the Anesthesia menu. Here you
will find commands that enable you to use the unique liquid
injection feature, to enter your costs for anesthetic agents, and to
make simulation parameter adjustments more quickly than
typing them in at their individual screen boxes .

liquid Inject .. .introduces a unit dose of liquid anesthetic into the breathing
circuit. You can also do this by clicking on the syringe icon in the
Gas Man Picture .

Unit Dose .. . allows you to set the volume in ml of the liquid injection.

Set Cost ... allows you to type in the bottle volume and bottle cost of the
anesthetic agent you have selected, in US dollars.

FGF,DEl,VA,CO ... allows you to set each or all of these parameters in one dialog
box. These can also be set directly on the Picture.

Agent&Circuit ... allows you to set each or all of these parameters in one dialog
box. These can also be set directly on the Picture.

o DESKTOP
The Desktop menu (not shown) has two choices, allowing you to
hide the Toolbar (shown later in this chapter) or the Status Bar,
which is at the very bottom of the Gas Man application window.
The Status Bar shows a message for each action that you take;
sometimes this can help explain a command. Once you are
confident with the program, you might want to hide either or
both of these items to give Gas Man more room to display on
your monitor.

2-12
Gas Man® Getting Started

o VIEW
The View menu allows you to create and manipulate multiple
views of the same simulation. As described in the previous sec-
tion, the Gas Man program uses both a Picture (showing the
compartments of the anesthesia circuit) and a Graph (showing
the time course of the value of each variable during the simula-
tion). These tvvo views, and indeed multiple versions of these
views, can be open simultaneously on your screen.

New View ... creates a new window of the same simulation you are running.
The new window will be labeled" [File Name] :2". You can use
this feature to view a Picture and Graph simultaneously, or to
administer an additional agent during the simulation.

Picture ... changes the current active view to the Gas Man Picture.

Graph ... changes the current active view to the Gas Man Graph.

Overlay ... invokes the Overlay dialog box, which is used in some of the
exercises in the tutorial chapters of this Manual and fully ex-
plained in Chapter 15. The Overlay feature of Gas Man allows
you to graph a curve showing the relationship between any two of
of the program's variables (such as alveolar concentration versus
circuit concentration). In addition, you can study that same
quotient across multiple simulations, and have the resulting
curves all shown on one graph. Overlay can also be invoked from
the Toolbar.

Cascade ... arranges the open windows in an overlapping display.

Tile ... arranges the open windows to fill the screen.

Arrange Icons ... arranges the icons representing open simulations and views on
your desktop (usually into the lower left portion of your screen).
v\Then you have a number of simulations or views of one simula-
tion open at a time, it is often helpful to "iconize" or reduce
some of the windows to avoid visual clutter.

You will also find at the bottom of the View menu a listing of any
open simulations and views, whether at full size or iconized.

2-13
Gas Man® Gelling Slaried

o SPECIAL
The Special menu allows you to use some of the advanced fea-
tures of Gas Man. ''''ith these commands, you can change the
way some aspects of the simulations run, and how information is
displayed on the screen. Each of these commands toggle: when
you select one, it is marked by a checkmark in the drop-down
menu; de-select it bv clicking· on the command again, and the
/ t...... t..

checkmark disappears.

Disable Uptake ... removes the effect of anesthesia uptake on alveolar ventilation.

Disable Return ... removes the effect on alveolar tension caused by anesthetic
agent in the venous blood.

Enable Vapor ... causes the simulation to use iffective fresh gas flow, which is the
sum of the FGF you set and the flow of agent added by the vapor-
izer (see Chapter 15).

Change Patient ... allows you to set or change a number of parameters for the
current patient, including Weight (in either kilograms or
pounds), compartment volumes and flow percentages, and
metabolic parameters (VA and CO). Some of these can be set
directly on the Picture, and all of them have defaults which can
be changed under the File menu (see Chapter 15). Note that
Gas Man will change c
the values for VA and CO automaticallv/
according to the weight you choose, but you can also changes
those values manually through this command.

Set Bookmark ... allows you to set times when you 'wish the simulation to pause.
This is explained further later in this chapter.

Enable Scrolling ... ensures that the simulation will keep running even if the
screen display of the Gas Man Graph is fully filled (othenvise, the
simulation will pause automatically when it reaches the time set
in the "View" box of the Gas Man Graph). For instance, you
would use this command if you wanted the simulation to run for
2 hours but like to see its progress displayed in the Graph in 15-
minute segments. If you wish your simulation to run only for a
specific length of time, set that time as the "View" time on the

2-14
Gas Man® Getting Slarted

Graph, and do not enable this command. If this command is

enabled, a checkmark will appear next to it in the menu's drop-
down window. Note that using scrolling will likely slow down the
simulation considerably.

Hide Numerics ... eliminates from the display the numbers under the compart-
ments for ALV, ART, VRG, MUS, FAT and YEN. You may find
the display more intuitive in this manner.

Show Cost ... changes the values in the "Uptake" and "Delivered" windows in
the Gas Man Picture from volume in liters to cost in US dollars.
To return to liters, click on this command again. You can also
control this through the Toolbar.

o HELP
The Help menu is found on the far right side of the program's
menu bar. Under this menu, you can find out more about using
the Help feature, and also find out which version number of Gas
Man you are using. The Help function in Gas Man works identi-
cally to other Microsoft® Help resources.

2-15
Gas Man® Getting Started

o THE TOOLBAR

The Gas Man Toolbar contains an iconographic set of commonly

used commands. You may find it helpful to use these icons in
addition to the drop-down menus and keyboard shortcuts.

Copy Data Picture/Graph Rewind

Copy Selection Print Fast Forward
\

About Gas Man Run/Stop

New Save Overlay
I
Gas N[an Help Run All/
Stop All

Figure 24 identifies the icons on the Gas Man Toolbar.

Starting from the left, the first icon will create a New simulation.
One click on this icon will open a new window and a new file (not
a new window of the current simulation, if one is already run-
ning.) A click on Open will bring up a dialog asking you to select
a simulation that has been previously saved. Save will enable you
to save the simulation running in the active window.

If you select a portion of the display for copying to the Clipboard

(by clicking on the right mouse button and surrounding the
selected area), then pressing Copy Selection will do the copying.
Copy Data will copy the current simulation data values to the
Clipboard.

Pressing Print will bring up the printing dialog.

About Gas Man will tell you the current application version num-
ber. The Gas NIan Help icon is a context-sensitive tool: pressing
on this icon will turn your mouse pointer into a question mark.
Point that question mark at the section of your screen you want
more information about.

2-16
Gas Man® Getting Started

Wilen you want to switch between the Gas Man Picture and GmjJh
in the active window, click back and forth on whichever icon is
showing (it will be the opposite of what is being displayed).

Show Cost will replace the volume of Delivered and Uptake in

liters with the cost of anesthetic Delivered and Uptake in US
dollars. Gas Man determines Cost by the bottle size and bottle
costs listed in the Set Cost command of the Anesthesia menu.

Pressing the Overlay icon will immediately open the Overlay

display, described briefly above and in more detail in this
Manual's exercises and in Chapter 15.

Set Bookmark allows Pause times to be set. This command is also

available from the Special menu. Bookmarks are described later
in this chapter.

Run and Stop is a toggle button, as is Run All and Stop All. These
commands are also found under the File menu. Rewind and Past
Forward are also found under the Edit menu. These commands
are described later in this chapter. In Figure 2-1, a simulation has
been run and stopped, so the Run/Stop toggle is showing Run
(the traffic light). Fast forward is grayed out because we are at
the end of the simulation. Similarly, because only one simulation
is open, the Run All button (racing cars) is grayed out.

2-17
 Gefling Started

o WORKING WITH MULTIPLE VIEWS

The multiple document interface (MDI), an operating system
feature which Gas Man fully utilizes, enables you to open more
than one window of the same file or document. You can also
have more than one file (simulation) open at a time. Although
this may be confusing at first, it offers the Gas Man user some
advantages in being able to display a wide range of information
as densely as possible on the screen.

Unlike the Macintosh version of Gas Man, in which the Picture

and Graph are in separate windows and must be toggled be-
tween, both the Picture and Graph are in a single Windows view
of a Gas Man simulation. They are separated by a three-dimen-
sional gray bar called the "splitter bar". Grab this bar at the
bottom of the Gas Man Picture with your mouse pointer, and
drag it upward. You will see the Gas Man Graph unfold as you
raise the bar.

Also note now that both the Picture and Graph have scroll bars
along their right edges. By moving the scroll button, or clicking
on the up and down arrows, you can determine which portion of
the Picture or Graph appears in the space you have for it on the
screen. By opening multiple windows, you are getting multiple
views of the same simulation. Any view of the simulation can
show anything any other view can show. Therefore, if you have a
small screen, such as that with a laptop computer, you can use
this feature to see different components of the simulation dis-
play, side-by-side, that would not otherwise be possible. This is
demonstrated in Figure 2-5.

In this example, two views of the simulation "Untitled" are open.

Each view in turn is split between Picture and Graph. The Pic-
ture ofUntitled:2 (on top) shows the compartments, while only
the FGF section of the Graph is showing. In Untitled:l, Cost is
shown on the right hand side of the window, while the Graph
shows the time course of compartment tensions.

2-18
 Gas Man® Getting Started

Flush
o
,Srro!! /Jars

SjJlilll'f /Jars

0.51 Uptake {$}

2.89 Delivered ($)

View: 0:00 0:05 0:10 0:15

Figure 2-5 shows two views of a simulation, and each view is split
between Picture and Graph.
Note that the Graph Paper is being used in the top view for
added contrast, but not in the bottom view. Similarly, if you
scrolled through the Picture in the top view, you would find that
volume is being shown instead of cost.

Keep in mind that you can still toggle between full screen views
of the Picture and Graph by pressing on the respective icons in
the Toolbar, or by the keyboard shortcuts. Also remember that
certain menu commands will only work on the active window.
This includes Close, Save and Print, and all the Edit menu
commands. This is also true of the bottom half of the Special
menu (scrolling, numerics, graph paper, cost). This enables you
to show cost in one view while keeping volume displayed in
another view. Other Gas Man commands, such as Disable Up-
take and Disable Return, and all the numeric parameter settings,
apply to all open views of the simulation.

2-19
Gas Man® Getting S'{arled

nstalling & Using Gas Man on the Macintosh ™

--------

Gas Man runs on nearly any Macintosh computer. As with any

software, the faster your machine, and the more RAM you have,
the better. The installation instructions assume you have a hard
disk.

o INSTALLATION ON THE MACINTOSH

To install Gas Man on a hard disk, insert the Gas Man disk into
the floppy drive of your Macintosh computer. The disk icon will
appear on your desktop. Double-click on the disk icon and a
window will appear with the Gas Man icon inside.

Figure 2-6 shows the Gas Man icon.

Pick the icon with the mouse pointer so that the icon is high-
lighted and drag the icon to your hard disk. The program will be
copied. Then drag the Gas Man disk to the Trash to eject it.

To open Gas Man, double click on the program icon. When the
program begins, a Title and Copyright statement appears on the
screen. Move the pointer to the OK button and click the mouse;
or press the Return key on your keyboard. Once you select OK,
the Gas Man Picture is displayed

2-20
Gas Man® Getting Slarted

o USING THE MACINTOSH WINDOWS & MENUS

When using Gas Man, you will be referring to both windows -
Picture and Graph - frequently. Depending on the size of your
monitor screen, you will either be able to place the Picture and
Graph beside or on top of each other, or you will toggle between
the two by selecting one window and then the other.

New :3€N Liquid Inject :3€L Normal

Unit Dose... :3€D Disable Uptake :3€U
f··········································· :3€G Disable Return :3€U
DEL, FGF, LIA, CO .. . ...................................................... ········t
Agent {} Circuit .. .
Enable Scrolling
····················································1
Hide Numerics
Page Setup .. 1 . - - - - - - - - - ,
Print:3€p ~ Both
··············································11 Graph Only
Quit :3€Q Picture Onl

Figure 2-7 shows all the menu choices available from the Gas Man
menu bar on the Macintosh.

Some commands have a "shortcut" key combination shown to the

right of the menu command. Usually this involves pressing the
Macintosh command key ( ) in conjunction with another key,
in order to execute the command without first opening the
menu.

If you look again at the File menu, you will notice that some
items appear dimmed, some have ellipses ( ... ) after their names,
and others have key combinations listed to their right. All
Macintosh applications follow certain menu conventions. These
conventions communicate additional information about the
menu commands, as shown in Table 2-2.

2-21
Gas Man® Getting Stalter!

MACINTOSH MENU CONVENTIONS

Menu Convention Meaning

Dimmed command name The command is not available at this time.

You might have to select something else
before you use this command, or else it may
be that the command is not available with
your application or hardware.

An ellipsis ( ... ) after the A dialog box will appear when the command
the command name. is chosen, asking for additional information
or confirmation before carrying out the
command.

A key combination after the The listed combination of keys is a

conllnand name. "shortcut." The command can be chosen
within Gas Man and without opening the
menu by pressing this key combination.

A triangle (t) to the right of the The command leads to a cascading menu,
command name. which lists additional commands that are
available.

A checkmark to the left of the The command or selection choice is active.

command (or selection choice). This convention is used [or selections or
commands that toggle.

Table 2-2.
Macintosh menu conventions that apply to Gas Man and most
other Macintosh software programs.

2-22
Gas Man® Getting ",'tarled

There are also several Pop-up Menus on the Gas Man Picture and
Graph. The functions of most of them are obvious from their
name. They can be opened and commands can be selected in
the same manner as menus on the Menu Bar

Nitrous OHide Gas Man(EiI Picture

Open
Agent: Halothane
Enflurane
I Ci rcui t: Semi-Closed
c
.J
r-+ .1 r+- ILL !::L Closed
Isoflurane ~-1:L-
,/
- SeLlofim-ane
.~-
(.) Ilesflurane
- Nitrogen

0
-
ffiI"'
~//
:~...../
\.
........
''-----; -,-- ..........-:::: --.--
15.00
DEL
10.00
CKT
I []i]"jL 10.00 I
AL\l' AIH
I 0.00 I
V~~G
10.00 I
r·1US
10.00
FAT
I oi%o
-'lEN

'~rn
5 Min I 0.0 I T 1~·lE ([11 N)
10 Min
L,'1'"1' ) 15 Min I 0.0 I UPTAKE (L)
o ffiI
30 Min
45 Min o .... c: 1H
2 H
DEL 1'v'ERED (L)
I 8.00 1 Hr 15.00 I 5 H ( Elegin J
Speed:
FGF
Viev'i:
2 Hr
5 Hr
v' 10 Hr
CO
Speed:
10 H
v'AFAP
_f
I:
IntetTupt
Continue
]
1
-
I

Figure 2-8 shows the Pop-up Menus and Buttons of the Gas Man
Picture.

For practice, find the Pop-up Menu for the anesthetic Agent and
change the selection to halothane.

2-23
Gas Man® Gelling Started

unning a Gas Man Simulation

In this section, you will actually run your first Gas Man simula-
tion. Open the application and follow the steps outlined below:

DEL
%atm
CKTlo.ool AlVlo.ool 10. 00 1 10.001 10 . 00 1 10 . 00 1 10 . 00 1
ART VRG MUS FAT VEN
I 0:00:00 I Time (h:mm:ss)
0.00 I Uptake ($)
0.00 I Delivered ($)
Speed:
FGF [QI VA co
lim U lim 14.00 1 lim 15. 05 1 I 60x I~:I

Agent: Iisoflurane Circuit: ISemi.Closed I

10
FGF
LIM
0
§
3

~
DEL
%atm
0
cn 3
AlV
VRG -
MUS ...:.:.:.:.:.:.:.,.:.:.:.:.:.:.:.:
-
%atm
0
! !
0:00 0:05 0:10 0:15
View:
11IIifII1:t)
Figure 2-9 shows the Gas Man Picture and Graph before a simulation
begins.

2-24
Gas Man® Gelting Started

1 Choose New from the File menu or use the keyboard short cut
Ctrl+N (holding down the control key and "N" at the same time).
A fresh Gas Man Picture will appear.

2 Click Begin to begin simulating administering an isoflurane

anesthetic with a Semi-closed breathing circuit.

3 Grab the control bar for the vaporizer (DEL) and drag it to the
top of the scale, if it is not there already. As the simulation
evolves, anesthetic tension rises in the breathing circuit (CKT).
The other compartments follow in succession, equilibrating with
inspired tension: the lung alveoli (ALV) and arterial blood
(ART); the vessel-rich group (VRG) con taining the brain, heart,
and other well-perfused organs; muscle (MUS), and finally fat
(FAT). Venous blood anesthetic tension (YEN) lies somewhere
between the vessel rich group and muscle since it contains an
anesthetic tension equal to the average of those leaving the
various body compartments, each weighted by relative blood now
to (and from) the compartment.

4 Grab the splitter bar or click on the Graph icon in the Toolbar to
bring up the Gas Man Graph and observe the time course of
anesthetic tension equilibration.

5 The simulation will stop at the time set in the View field in the
Graph. To save this simulation, choose Save from the File
menu, type Ctrl+S, or press the Save icon in the Toolbar. To
print, see Chapter 15.

2-25
Gas Man® Getting Started

o REPLAYING & REVISING THE SIMULATION

Gas Man 2.0 allows you several options for replaying and revising
your simulations, including saving and replaying simulations
from a previous session. Try the following steps to become
familiar with these features:

1 Return to the simulation you ran on the previous page. Choose

Rewind from the Edit menu or Toolbar, and choose OK in
response to the dialog box. Now click on Begin, or press the
traffic light in the Toolbar. The simulation will replay itself
exactly as it ran before. This is particularly useful if you make
manual acUustments during a simulation, and want to watch the
Picture or Graph again, perhaps at a different speed. Try run-
ning a new simulation, and make some manual adjustments
during its course. Choose Rewind, and then Begin, and watch
the changes occur again.

2 If you want to run a simulation with a different set of parameters,

you can either choose New again, which will create a new simula-
tion with a new name, or you can simply choose Zero Timer
(Ctrl+Z) from the Edit menu. You can adjust the parameters
either before or after selecting this command; when you choose
Begin the simulation will run using the new parameters.

3 To run a simulation using the default settings for all parameters,

choose Clear All and then Begin.

4 Save this simulation by choosing Save from the Edit menu or

click the Save icon in the Toolbar. You will see the standard File
Manager dialog box; the default directory for saving simulations
is the GAS MAN directory with the ".GAS" extension. Open the
simulation by choosing Open (Ctrl+O) from the File menu. You
will see the Gas Man Picture at its time-zero state. If you run this
simulation, it will play out exactly as you ran it before you saved
it.

2-26
Gas Man® Gettillg Star/cd

o USING THE BOOKMARK

A useful feature of Gas Man 2.0 is the ability to set bookmarks
during the simulation, pausing the experiment. You can add,
delete or change multiple bookmarks for each simulation. The
bookmarks are saved with the experiment, making this a useful
feature for lectures and presentations. It is also useful for setting
precise timings when comparing simulations.

The command Set Bookmark is found under the Special menu.

0:03:00
0:15:00

Figure 2-10 shows the dialog box of the Set Bookmark command.

The dialog box has three choices - add, delete and clear all. To
add a bookmark, type in the hours, minutes and/or seconds.
Then press "Add", (If you set the time and click OK without
pressing Add, no bookmark will be set.) The time of the book-
mark will now appear in the white space on the left of the dialog
box. To delete a bookmark, highlight it with the mouse pointer
and click delete.

Note: if you choose this command in mid-experiment, the de-

fault time for the bookmark will be that moment in the simula-
tion minus one second. Press Add to use that time for a bookmark,
or select a new time. You can pick any time earlier or later than
the moment of the simulation you have paused. Once the book-
marks have been set, the simulation will automatically pause at
those times whenever the simulation is run.

2-27
Gas Man® Getting Started

ummary
---=------

You now know enough about using Gas Man to go on to Chapter

3 and begin the Exercises which teach anesthesia uptake and
distribution. You have set up the correct hardware, installed the
software, reviewed the basic features and commands of the Gas
Man program, and run an actual Gas Man simulation.

As you work your way through the Exercises in this Manual, you
will learn the use of all of the program options available. Remem-
ber to look at Chapter 15 for a description of the more advanced
features of Gas Man 2.0/2.1.

2-28
Chapter 3 (-~
A One cU'!m~ent Model
o

Compartments are real or theoretical containers which initially

contain no anesthetic. A compartment has an actual volume,
which could be measured with a ruler. If the compartment
contains body tissues rather than air, the capacity or effective
volume of the compartment will be different from the actual
volume. The ratio of effective volume to actual volume is the
tissue/gas solubility or tissue/gas partition coefficient:

AT/G = tissue/gas solubility

with the tissue specified by name. For example:

AH/G = heart/gas solubility

AB/G = blood/gas solubility.

Thus, capacity or effective volume equals volume times solubility:

c = V X AT/G.
For a gas-filled compartment (breathing circuit or alveolar
space) :

AT/G =1 ml gas/1 ml volume = 1.

For non-gas filled compartments, depending on the organ, one

milliliter of tissue or blood may be able to absorb more or less
than I milliliter of anesthetic gas or vapor. For nitrous oxide the
blood/ gas solubility is equal to 0.47; for desflurane it is 0.42.
Thus, less than I ml (0.47 or 0.42 ml) of these gases will be con-
tained in I ml of blood. For halothane, the blood/gas solubility is

3-1
Gas Man® il (Jne ComjJ(lrtmml Alude!

2.47; that is, 2.47 ml of vapor will be contained in 1 ml of blood.

For isoflurane, the value is 1.30; 1.3 ml of vapor will be contained
in 1 ml of blood. Tissue/gas solubilities are tabulated in the
Appendix.

The terms anesthetic tension and anesthetic partial pressure will be

used interchangeably in this book. Partial pressure is the pressure
of the anesthetic if it were present by itself. "Vhen compartments
are in equilibrium, their anesthetic tensions are equal.

Anesthetic tension difference is the drivingforce which

causes gas molecules to move from an area of high
partial pressure to one of lower partial pressure.

In fact, this is the fundamental rule upon which all of the Gas
Man simulation is based. It is the direct result of the law of
concentration of mass. In this program, anesthetic tensions are
expressed as percent of one atmosphere; they are shown as
vertical heights, either in containers or on graphs.

The interaction of a compartment with an inflow of anesthetic-

laden or anesthetic-devoid flow determines how the anesthetic
tension in the compartment changes with time. Anesthetic
arrives in the compartment in some carrier gas or liquid. It is the
flow of this carrier fluid, compared to the capacity of the com-
partment, which determines the time course of anesthetic tension
change. With time, anesthetic tension within the compartment
approaches and finally equals anesthetic tension in the inflow.

With each inflow there must be an equal outflow of carrier

(venous blood) from the tissues. The venous anesthetic tension
leaving the tissue is assumed to equal average tissue tension. This
assumes perfect mixing and no shunting within the compart-
ment. The response of a compartment to a sudden or step
change in inflow tension is termed the step response. Less for-
mally, the step response is called the wash-in of the compartment.
This term evokes the way the sudden change in inflow tension
"washes in" to the compartment.

3-2
Gas Man® A One ComjJartment Model

xercise 3-1

Wash-in of a single compartment produces an exponential curve.

In this first exercise you will simulate the step response of a single
compartment - the breathing circuit - and watch the changes
in the Gas Man Picture and Graph.

The circuit volume is 8 liters and the gas/gas partition coefTicient

is 1. The circuit capacity is therefore 8 liters. The inf10vv carrier
gas is the fresh gas flow (FGF) , adjustable with the FGF display and
control bar (FGF control) at the left edge of the bottom of the
Gas Man Picture. The anesthetic tension in the fresh gas flow is
that delivered from the vaporizer, and is termed the delivered
tension, which is adjustable with the DEL display and control bar
at the left edge of the top of the Gas Man Picture. This circuit
type is called semi-closed.

o SETUP
Parameter
Selection
Agent ................... Nitrous Oxide
Circuit ................... Semi-Closed
DEL (%) ............................. 100
FGF (Ljmin) ........................... 8
VA (Ljmin) ............................. 0
CO (Ljmin) ............................ 0
VIEW (min) ........................... 10
SPEED ................................ lOx
For each exercise in this book, you will
adjust the parameters of the Gas Man
program as shown in the summary box,
seen to the left here. The parameters
are explained on the following page.
Use of the display and control bar is
described in Chapter 2. As a reminder,
to raise or lower the displayed value,
either: click and hold the up or clown
arrow, drag anywhere on the indicator
bar, or click on the numerical value
displayed and enter a new value through
the Dialog Box.

Special ........................... .

3-3
Gas Man® A Ollt ComjJar/lI1en { Model

1 Choose New from the File menu in the Menu Bar at the top of
the screen. The settings that appear are the defaults set for the
program. See Chapter 14 to find out how to change these de-
faults.

2 Select Nitrous Oxide as the anesthetic, using the Agent popup

menu in the upper left corner of the Gas Man Picture.

3 Select Semi-Closed for the breathing circuit (upper -right cor-

ner) .

4 Adjust the tension of nitrous oxide delivered (DEL) to 100%

using the control bar.

5 Adjust Fresh Gas Flow (FGF) to 8 L/min (bottom left corner).

For values not at the top or bottom of the adjustment range,
typing in the value is the safest way to enter parameters.

6 Set alveolar ventilation (VA) to 0 (zero) L/min.

7 Set cardiac output (CO) to 0 (zero) L/min. Setting both VA and

CO to zero will simulate a breathing circuit without a patient
connected.

8 Set the Speed to 10X by using the popup menu in the bottom
right corner.

9 Move the cursor to the Toolbar and click on the Graph icon.
This will bring the Graph forward as the active window. At the
bottom of the Gas Man Graph, select a View of 5 minutes in the
popup menu.

10 When you are ready to run the simulation exercise, select Begin.
You can do this from either the Picture or the Graph.

3-4
Gas Man® A One Comj;artment iVlodel

o OBSERVATION

Agent: 1Nitrous Oxide I±j ~Weight [Kg) Circuit: 1Semi-Closed!±!

DEL
%atm
1 100 1 CKT~ ALV~ ~ ~ ~ ~ ~
ART VRG MUS FAT VEN

1 0:00:00 I Time [h:mm:ssl

~UPtake[Ll
~ Deliyered (LI

Speed:
FGF f8I VA CO
lim ~ lim 10 _00 1 lim 10 _00 1 110x I±j

Agent: INitrous 0 xide I Circuit: 1Semi-Closed 1

FGF
LIM 1: ~ I
DEL 10: ~
%atm
I
en
ALV
VRG
MUS

%atm '] 0:00

I
0:01 I
0:02
I
0:03 0:04
I i
0:05

Figure 3-1 a shows the Picture and Graph displayed at the completion
of parameter adjustment for Exercise 3-1, which will show a single
compartment step response or wash-in.

Because alveolar ventilation (VA) is zero, only the breathing

circuit (CKT) need be considered. If you have not already done
so while reading the text above, change the parameters now.
VVhen you are ready, start the simulation and watch the Time
window in the Picture. Press Pause after one minute.

3-5
Gas Man® A OTIC ComjJartJllent jHode1

INitrous Oxide L±j ~Weight (Kg)

Flush
~ 0
:i'I

f100l
AlV~ ~ ~ ~ ~ ~
DEL
<:atm ~
CKT@J
ART VRG MUS FAT VEN

I 0:01:00 I Time (h:mm:ss)

~ Uptake(l)

~ Defivered (ll

FGF 101 VA InOi;l CO

Speed:
110x I:!:j I Conti.nue
LlmU lim ~ lim 10 . 00 1

Agent: !Nitrous Oxide I Circuit: ISemi~Closed I

FGF
LIM

DEL
%atm
10: ~
en 100

J/~
ALV
VHG
MUS

7:;atm
I I I
0:00 0:01 0:02 0:03 0:04 0:05

Figure 3-1b shows the Picture and Graph displayed after 1.0 minute of
simulated time in Exercise 3-1.

Note in the Picture and the Graph that circuit (CKT) has
reached about 63% of the 100% delivered at the end of the one
minute simulated so far. To view the Graph, click on its Toolbar
icon to bring it forward on the screen; to return to the Picture,
click on the Picture icon. You can toggle back and forth between
Picture and Graph in this manner.

3-6
Gas Man® A One ComjJartll1ent Model

Agent: 'Nitrous Oxide' ±j IECJWeighl (Kg) Circuit: 'Semi.Closedl±' I

I

Flush
±J 0
:id

DEL f100l CKT~ ALV@] @] @] @] @] @]

%alm ~
ART VRG MUS FAT VEN

I 0:05:00 I Time (h:mm:ss)

~ Uptake(L)

~ Delivered (L)

FUF fBI VA CO
Speed:
1- Continue .1
lim L-J LIm 10.001 LIm 110 . 00 1 1 10x I±j

Agent: 'Nitrous Oxide I Circuit: ISemi*Closed I

10

~
FUF
LIM
o

OEL
%atm

CKT
ALV
VRG
MUS

%atm

Figure 3-1 c shows the Picture and Graph displayed at the end of the
full five minutes of Exercise 3-1.

Note that after five minutes, inspired tension has reach> 99% of
DELivered. Since alveolar ventilation is zero, alveolar (ALV) and
vessel rich (VRG) group tensions remain zero, along with muscle
(MUS) and fat (FAT).

3-7
Gas Man® ;l One ComjJartment i\1odel

o DISCUSSION
Observe the anesthetic tension height within the semi-closed
breathing circuit. The circuit fills rapidly during the first minute
(Figure 3-1b). Then the filling process progressively slows (Figure
3-1c). This is because there is initially a large gradient between
the 100% anesthetic tension in the delivered gas (PDELJ and the
0% anesthetic tension in the breathing circuit (PI or Pcrcr). As
the breathing circuit "fills" with anesthetic, this difference - and
hence the rate of rise - decreases. As these tensions become
closer, the circuit tension changes more slowly.

Remember that there is a constant carrier flow from the breath-

ing circuit out the pop off valve, exactly equal to the inflow of
fresh gas. The anesthetic tension in the outflow is equal to the
anesthetic tension in the circuit. It is interesting to realize that
the anesthetic leaving the circuit is essentially wasted. Had the
circuit been emptied and refilled with fresh gas, a smaller deliv-
ered quantity (8 L rather than 40 L) would have been required
to change its composition.

The curve shape you have just seen is an exponential curve and is
described by the equation

The "P" represents partial pressures in inspired (I), breathing

circuit (CKT) and delivered (DEL) gas; "e" is the base of natural
logarithms, 2.718 .... ; "t" is time and "'"[" (tau) is the time constant,
explained below.

It is convenient to measure the time delay associated with this

curve using a defined time measure. Sometimes a half-time, t1/2,
is used, which is the time required for the curve to reach 50% of
its final value.

3-8
Gas Man® A One ComjJartment Alodel

~Weight (Kg) Circuit: !Semi-Closed!:!:1

Flush
o
DEL 1100.1 CKT~ ALV~ ~ ~ ~ ~ ~
%atm
ART VRG MUS FAT VEN

I 0:00:41 I Time (h:mm:ssJ

~UPtake(LJ
~ Delivered (L)

Speed:
FGF VA CO
LIm EJ lim 10. 00 1 lim 0 . 00 1
1 1 10• !±!

Agent: INitrous Oxide I Circuit: ISemi-Closed I

FGF
LIM 1:1
DEL
%atm
10: 1

'" 1/~
CKT
ALV
VflG
MUS

%atm
Or I I I I
0:00 0:01 0:02 0:03 0:04 0:05

Figure 3-1d shows that under the settings for this Exercise, t1/2 (half
time) = 0.69 minute (41.4 seconds).

Mathematicians prefer to use a different measure, the time

constant 1:. When t 1: in the equation above:

PI =P OEL (:1.-e-1.) =P OEL X (:1.-2.7:1.8-1.) =P OEL X (:1. - 0.37) =P OEL X 0.63.

Thus 1: is the time required for the curve to reach 1 - e- 1, or 63%

of its final value, 1: = to.()3 .

3-9
Gas Man® A One ComjJartment iVIodel

In this experiment, the final value, or asymptote, is the delivered

tension, P OEL . The final value, P OEL., is never actually reached, but
is approached closely. Values for inspired tension expressed as a
fraction of delivered tension are tabulated below:

o 2 3 4
o .63 .86 .95 .98

We often measure time in units of time constant. Thus we might

say at the end of 1, 2, 3, and 4 time constants, the circuit tension
equals 63%, 86%, 95%, and 98% of that delivered from the
vaporizer. Because Gas Man separates the process into individual
breaths, the simulated values are slightly different.

In explaining first order kinetics, the rate coefficient, K, is often

computed. There is a specific relationship between the rate
coefficient and the time constant: they are reciprocals. That is, K
= 1/1:. The units for 1: and K are sec and sec-I, respectively. The
time constant measures time while the rate coefficient measures
rate or speed.

3-10
Gas Man® A One ComjJartment Model

xercise 3-2

The time constant for wash in of a single compartment equals

effective volume divided by effective inflow rate 1: =V IF.

Look back at Figures 3-lb and 3-1c, and note that circuit tension
reaches 63% at a time of 1 minute. In Exercise 3-1, volume
equaled 8 L and flow equaled 8 LI min. This exemplifies the
extremely simple quantification of the relationship between
volume, flow, and time constant:

1: = VjF.
Stated in words:

The time constant for a compartment is equal to the

ratio of the capacity of the compartment to the flow
through that compartment.

To test this hypothesis, we'll change the fresh gas flow in the next
exerCIse.
o SETUP
To demonstrate the relationship be-
Parameter Selection
tween inflow rate and time constant,
Agent ................... Nitrous Oxide adjust parameters as shown.

Circuit ................... Semi-Closed

DEL (%) ............................. 100

FGF (Ljmin) ........................... 4

VA (Ljmin) ............................. 0

co (Ljmin) ............................ 0

VIEW (min) ............................. 5

SPEED ................................ lOx

3-11
Gas Man® it One Compartment JVIodel

o OBSERVATION
Agent: INitrous Oxide 1:!:j ~Weight (Kg) Circuit: 1Semi-ClosedL±j

DEL 1100.1 CKT~ ALV~ ~ ~ ~ ~ ~

%atm
ART VRG MUS FAT VEN

1 0:05:00 I Time (h:mm:ss)

~ Uptake(l)

~ Delivered (L)

Speed:
FGF r:;ru}] VA CO
L1m~ LIm
ro;;;}J
~ LIm 10. 00 1 110K I±j

Agent: INitrous Oxide I Circuit: ISemi-Closed I

FGF
LIM
1:1___________________________________________
~

DEL
%atm

CKf
"LV
VHG
MUS

%atm

Figure 3-2 shows the Picture and Graph of Exercise 3-2.

Watch the Gas Man Picture briefly and note that progress seems
to be going about half as fast as before. Bring the Graph forward
and visually determine the half-time and time constant. Notice
that the time constant is again equal to the ratio of volume to
flow. This time,

'I =VjF =8 lj(4 ljmin) =2 min.

3-12
Gas Man® it One ComjJartment Model

o DISCUSSION
In this exercise, when time reaches two minutes, inspired tension
has reached 63% of delivered. This is twice the time required
with FGF = 8 L/min in Exercise 3-1. In Exercises 3-1 and 3-2, the
relationship between half-time and time constant was tl/2 = 0.69 ,
or tIn/' = 0.69. The exact value for the constant relating, to
tl/2 is the natural log of 2 (In 2 = loge 2 = 0.6931...).

3-13
Gas Man® A (Jill' COIII/)(lrtment l\;[oriel

xercise 3-3

Time scale compression shows that all exponential curves have

the same shape.

o SETUP
Selection
Agent ................... Nitrous Oxide
Circuit ................... Semi-Closed
DEL (%) ............................. 100
This next exercise repeats Exercise 3-2,
but you will set View to 10 minutes to
compress the time scale. To compress
the time scale, adjust the parameters as
shown.

FGF (L/min) ........................... 4

VA (L/min) ............................. 0

CO (L/min) ............................ 0

VIEW (min) ........................... 10

SPEED ................................ lOx

Special ................................ n.a.

3-14
Gas Man® A One Compartment j\lIodel

o OBSERVATION

Agent: INitrous Oxide I Circuil: ISemi-Closed 1

10
FGF
LIM o - + - - g- - - - - -

DEL
%atm

en 100
ALV
VRG
MUS

%atm

0:02 0:06 0:08

View:
110 Min !±! .Ctlfltifl~!lJ

Figure 3-3 shows the Gas Man Graphfor Exercise 3-3.

You should see a curve that has the same exponential shape as
you saw in Exercise 3-2. This curve, however, is being drawn only
half as fast.

3-15
Gas Man® A One C01nj)(lrlmenl Nlodel

ummary

In this chapter, you have observed anesthetic tension when a

constant flow of anesthetic-laden fresh gas enters a compartment,
mixes completely, and simultaneously forces out an equal quan-
tity of mixed compartment gas. You have seen that this response
to a step change in input, called the step response or wash in, is
represented by an exponential curve that has a time constant L =
V IF, and follows the equation Pr(t) = P DEL (l-e-th). The rate
coefficient, K, is the reciprocal of the time constant L: K = lh.

3-16
 /-~
( \
Chapter4 \ )
Two Sequ-E\rtti-af/
( ,
Compartments
U
o

In this chapter, you will observe the interaction of two sequential

compartments: the breathing circuit and the patient's lungs. You
have already experimented with a single compartment (the
breathing circuit) and its equilibration with gas inflow. The rate
at which the second compartment, the lungs, moves toward
equilibrium with the first is determined by two factors. One
factor is the effective volume of the second compartment, which
here is the alveolar volume or functional residual capacity of the
patient's lungs (FRC). The second factor is the flow of gas be-
tween the two compartments, here the alveolar ventilation (VA).
Considered alone, the lungs' response to a step change in circuit
(or inspired) tension is an exponential curve with a time con-
stant (1) equal to the ratio of alveolar volume (FRC) to alveolar
flow:

1: = FRCjVA.

You can determine the effect of 1:\vo sequential compartments

with the Gas Man program. In the following exercises, you will
observe wash-in of the breathing circuit alone, the alveolar vol-
ume alone, and the two in combination. You will also observe
that increasing delivered and inspired tensions above that de-
sired in the alveoli (overpressure) speeds achieving the desired
alveolar tension.

4-1
Gas Man® Two ,)'cqllcntial C:om!)(/rlmenls

xercise 4-1

The step response of a perfectly mixed breathing circuit is an

exponential curve with height equal to the tension delivered
from the vaporizer, and the time constant equal to circuit volume
divided by fresh gas flow:

1: = VCKT/ FGF.

o SETUP
Circuit ................... Semi-Closed
DEL (%) ............................. 100
Repeat Exercise 3-2 demonstrating wash-
in of a single 8 L compartment with a
fresh gas flow of 4 L/min, but let the
simulation run as fast as possible (Speed
= AFAP). The other parameters to be set
are shown below.

FGF (Ljmin) ........................... 4

VA (Ljmin) ............................. 0

CO (Ljmin) ............................ 0

VIEW (min) ........................... 10

SPEED ............................. AFAP

Special ................................ n.a.

4-2
Gas Man® Tzuo Sequential Comj}(trtllleJlls

Agent: INitrous Oxide I±! ~Weight (Kg] Circuit: ISemi-Closedl ±j

Flush
o
CKT~ ALVQJ QJ QJ QJ QJ QJ
ART VRG MUS FAT VEN

I 0:10:00 I Time {h:mm:ss]

~ Uptake(L]

~ Delivered (l]

FGFrAI VA 101 CO
Speed:
160 x I±j
lIm~ lImU lIm[]

Agent: INitrous Oxide I Circuit: Is emi-Cfosed I

FGF
LIM 1: q
DEL
%atm
10: q
CKl
AlV
VRG
MUS

%atm

Figure 4-1 displays the Picture and Graph displayed at the end of
Exercise 4-1, showing wash-in of th e 8 L circuit volume with a fresh gas
flow of 4 L/min.

'Watch the picture for a simulated minute and then observe the
shape of the graph. Make a note of the half-time and time con-
stant. The circuit tension rises toward that delivered from the
vaporizer, with a time constant equal to the circuit volume di-
vided by fresh gas flow, as we observed in Chapter 3.

4-3
Gas Man® Two Sequential Comj){{rl men!:;

xercise 4-2
------------ ~-~~--~--~--~~-~--~~-~----~

An open or non-rebreathing circuit demonstrates the alveolar

step response.

Next, perform a similar experiment with a single 2.5 L alveolar

compartment and 2.5 L/min alveolar ventilation, using an open
or non-rebreathing circuit, in which inspired anesthetic equals
that delivered from the vaporizer.

The step response of the alveolar compartment (FRC) is an

exponential curve with height equal to inspired tension, and
time constant equal to FRC divided by alveolar ventilation:

1: = FRC/VA.

o SETUP
Parameter Selection Set the parameters as shown. Note that
fresh gas now (FGF) is automatically
Agent ................... Nitrous Oxide shown as 10 L/min when Open circuit is
chosen.
Circuit .............................. Open

DEL (%) ............................. 100

FGF (Ljmin) ......................... 10

VA (Ljmin) ............................. 2.5

CO (Ljmin) ............................ 0

VIEW (min) ........................... 10

SPEED ............................. AFAP

Special ................................ n.a.

4-4
Gas Man® Two Sequential Compartments

o OBSERVATION
Agent: INitrous Oxide I~J ~Weight (Kg) n _---'I=~l
Circuit: c::.IO.::..:pec..:..

Flush
~ 0
.Yl

DEL 1100.1 CKT~ AlVl 100 1 ~ OJ OJ OJ OJ

%atm
ART VRG MUS FAT VEN

I 0:10:00 I Time (h:mm:ssl

~Up!ake(L)

1100.00 I Delivered (Ll

Speed:
FGF r:1fll VA CO
l/m~ LIm ~ lim [J IAFA? I±j

Agent: INitrous Oxide I Circuit: L::..C___----'

1: ~~-------------------------
VA
LIM

CO
LIM 1: ~

MUS

%atm

Figure 4-2 displays the Picture and Graph at the end of Exercise 4-2,
showing wash-in of the patient's 2.5 L alveolar volume (FRC) with a
flow (alveolar ventilation) of 2.5 L/min.

Note that the graph displays an alveolar tension curve (ALV) ,

which looks identical to the inspired tension curve (CKT)
achieved with a semi-closed circuit in Exercise 4-1. Again, note
the half-time and time constant, and make sure that they are the
same as the ones you recorded for the circuit compartment in
Exercise 4-1.

4-5
Gas Man® Two Sequential COll1jJartments

o DISCUSSION
For the alveolar compartment, just as for the breathing circuit,

1: = VjF;

the time constant equals volume divided by flow. This time,

volume equals functional residual capacity (FRC) and flow equals
alveolar ventilation (VA).

4-6
Gas Man® Two Sequential COll1jJarlmeJ?ts

xercise 4-3

Wash-in of two compartments in series is slowed by each in an

additive fashion.

MTT (mean transit time) = '1:1 + '1:2-

The interaction of 1:\,yo compartments in series can now be stud-
ied. (The words series, sequence, and cascade will be used inter-
changeably.) In this exercise, you will observe the behavior of
the breathing circuit and alveolar volume in series.

o SETUP
Selection
Set the program parameters as shown .
................... Nitrous Oxide

................... Semi-Closed

............................. 100

........................... 4

............................. 2.5

............................ 0

(min) ........................... 10

............................. AFAP

................................ n.a.

4-7
Gas Man® T'zuo Sequential Comj)({rimellls

o OBSERVATION
Agent: INitrous Oxide I!:j ~Weight (Kg) Circuit: ISemi.Closedl !:j

Flush
o
DEL 1100.1 CKT~ AlV~ ~ IT] IT] IT] IT]
%atm
ART VRG MUS FAT VEN

I 0:10:00 I Time (h:mm:ss)

~ Uptake(L)

~ Delivered IL)

Speed:
FGF iii VA CO
LIm ~ LIm [IT] LIm ~ IAFAP I!:j

Agent: INitrous Oxide I Circuit: ISemi-Closed I

FGF
LIM 1
1:
DEL
%atffi
10: 1
I
ALV
VRG
MUS

%atm

--------- ----

Figure 4-3 shows the Picture and Graph of the results of Exercise 4-3,
displaying a completed 10-minute simulation of anesthetic tension
equilibration in two sequential compartments.

At the end of tvvo minutes of simulation, observe the Gas Man

Graph and watch it evolve. Inspired anesthetic tension (I) ap-
pears to be an exponential curve with']; a little longer than 2
minutes. Looking at points of equal anesthetic tension (equal
height) on the graph, it appears that the delay from the time
inspired tension (I) reaches a level, to the time alveolar tension
(A) reaches the same level, is approximately one minute. \l\Tash-

4-8
Gas Man® Two Se(jllcllti([/ COlI/jJartme11ts

(A) reaches the same level, is approximately one minute. \I\Tash-

in of Lhe two compartments in series has been slowed by wash-in
of each, in an additive manner. The mean transit time is equal to
the sum of the two time constants:

MTT total = 't1 + 't2.

o DISCUSSION
Theoretically, the average delay between the second and first
curves is exactly one minute. The definition of average delay
between two curves is a measure called the mean transit time
(MTT). It is the time, on the average, for a substance to move
from one location (breathing circuit) to another (alveolar com-
partment). For each of our simple, fully mixed compartments,
the mean transit time is equal to the time constant (MTT = T).
When compartments are in sequence as these are, the total mean
transit time through the system is equal to the sum of the mean
transit times through the individual compartments:

MTT = MTTCKT + MTTALV·= 'tCKT + 'tALV.

4-9
Gas Man® Two Seq1lClltial Co 1I1jmrlmcn Is

xercise 4-4

Overpressure can speed the rise in anesthetic tension two com-

partments away.

The next exercise will explore ways to produce a step rise in

alveolar anesthetic tension by briefly increasing delivered and
inspired tension above that desired in the alveoli. Use of el-
evated partial pressure to achieve a rapid change to a lower level
is termed overpressure.

o SETUP
Parameter Selection
Agent ................... Nitrous Oxide
Circuit ................... Semi-Closed
DEL (%) ......... prepare to adjust!
FGF (L/min) ........................... 4
VA (L/min) ............................. 2.5
CO (L/min) ............................ 0
VIEW (min) ........................... 10
SPEED ................................ lOx
Special ................................ n.a.
To understand overpressure and the
vaporizer adjustments needed to control
anesthetic tension in the alveolar com-
partment, set the Gas Man parameters as
shown. The o~jective in this exercise is
to achieve 70% alveolar tension. By
acljusting anesthetic delivered to the
breathing circuit (DEL), try to achieve
70% alveolar tension smoothlv and /
quickly, without allowing it to rise above
70%. You will see that it is difficult to
control a variable (alveolar tension)
when you can only control an input
(delivered tension) two compartments
away.

4-10
Gas Man® Two Sequential Com,j)artmenls

o OBSERVATION
Agent: INitrous Oxide I!oj §C]Weight (Kg) Circuil: ISemi.Closedl :!:I

Flush
~ 0
yj

DEL
%atm
CKT~ ALV~ ~ QJ QJ QJQJ
ART VRG MUS FAT 'lEN

1 0:10:00 1 Time {h:mm:ss]

~ Uptake(L]

~ Delivered (LJ

Speed:
FGF fA! VA CO
Llm~ LIm 12 . 5 °1 LIm [J 110K I:!:j

Agent: 1Nitrous Oxide I Circuit: ISemi~Closed I

FGF
LIM l: q~-------------------------------------------
DEL
%atm

CKT
ALV
VHG
MUS

%atm

Figure 44 displays the Picture and Graph as a result of Exercise 44,

showing how overpressure can speed the rise in anesthetic tension two
compartments away from the location controlled.

Alveolar tension fluctuates as you try to keep it at 70% byadjust-

ing delivered tension (DEL). Your results may differ depending
on how you adjusted DEL during the course of this experiment.

4-11
Gas Man® Two Sequential Compartments

In this chapter, the response of two sequential compartments to

a step input to the first compartment has been investigated. The
measure of the delay of each compartment is the mean transit
time, MTT. For each simple, fully-mixed compartment, MTT = 'to
The effects of the two compartments are additive in delaying the
response to a step input; the mean transit time is the sum of the
individual mean transit times. With some difficulty, delivered
tension can be adjusted to optimize the response in the alveolar
compartment. This is done by the use of overpressure.

4-12
In this chapter you will study the response of the alveolar com-
partnlent to a step change in inspired anesthetic tension. The
resulting curve is termed the alveolar tension curve. Analogous to
the one compartment example, this could be termed the wash-in
of the patient including lungs and tissues, or simply, patient wash-
in. But it is far from a simple exponential.

To demonstrate and dissect the alveolar tension curve into its

component parts, use the Gas Man Program to simulate anes-
thetic administration at constant inspired concentration (ten-
sion) through an open circuit. Open circuit is the term used to
signify that the clinician has perfect control over inspired tension
without the patient rebreathing exhaled gases and diluting
inspired tension. The terms open and non-rebreathing are used
interchangeably.

The alveolar tension curve shape has several important compo-

nents, each of which must be understood. In this chapter, effects
of alveolar ventilation, cardiac output, blood/gas solubility, tissue
uptake, and venous return of anesthetic will be demonstrated
and explained.

The alveolar tension curve is extremely important; it is

the key to understanding inhalation anesthesia uptake
and distribution and the process of anesthetic tension
equilibration from the vaporizer to the patient's brain
and anesthesia depth.

5-1
Gas Man® The Itl1lm/of Tension Curof'

xercise 5-1

The open circuit alveolar tension curve is the alveolar response

to a step change in inspired tension, representing patient wash-in.

o SETUP
To observe the response of the alveolar
Parameter Selection
compartment to a step change in in-
Agent ........................ Isoflurane spired tension, adjust the parameters as
shown.
Circuit .............................. Open

DEL (%) ................................. 5

FGF (L/min) ......................... 10

VA (L/min) ............................. 4

CO (L/min) ............................ 5

VIEW (min) ........................... 15

SPEED ................................ 60x

Special ................................ n.a.

5-2
Gas Man® The Alveolar Tension Curve

o OBSERVATION
Agent: II sollurane I~ j §]Weight (Kg) Circuit: I,-O,-pe_n_-"i.=l±j

Flush
:tJ 0
:tJ

DEL 15 . 00 1 CKT15.001 ALV13. 62 1 13.621 13.511 10.341 10.021 12.731

%atm
ART VRG MUS FAT VEN

I 0:15:00 I Time (h:rnm:ssJ

~UPtake(lJ

~ Delivered (lJ

Speed:
FGF f10iil VA ~ co r.;t;;;l
LIm ~ LIm ~ LIm ~ iAFAP I±j

Agent: II soffurane Circuit: I,-Op,-e_n_--,

VA
LIM 1: ~
CO
LIM 1: ~
en
ALV
VBG
MUS

7.atm

Figure 5-1 shows the Picture and Graph of the results of Exercise 5-1
after 15 minutes, displaying anesthetic tension in response to 5%
delivered and inspired isojlurane.

VVhile watching the Gas Man Picture, note the initial rapid rise in
ALV (alveolar anesthetic tension). Note also the more sluggish
rise in VRG (vessel-rich group) and barely discernable rise in
MUS (muscle) and FAT (fat). After about 2 minutes of simu-
lated time, observe the Gas Man Graph. Observe especially the
Gas Man Graph and focus on the alveolar curve.

5-3
Gas Man® The Alv('olar Tl'lIsioll (;11)(1(,

o DISCUSSION
Descriptive names are used to designate segments of the alveolar
tension curve. The initial rise occurs rapidly. A knee terminates
this rise in a plateau that instantly merges into an ascending tail,
which continues indefinitely, approaching (asymptotically)
inspired tension. The causes of the initial rise, knee, and tail of
the alveolar tension curve are important in understanding up-
take and distribution of anesthetics and equilibration and equal-
ization of anesthetic tension from location to location. They will
be explained in the remainder of this chapter.

5-4
Gas Man® The Alveolar Tension CU'rUI?

xercise 5-2

The initial rise in the alveolar tension curve results from alveolar
wash-in responsive to a step change in inspired tension.

The initial rise of the alveolar tension curve is caused by wash-in

of the alveolar space with inspired gas, carried by alveolar ventila-
tion. The shape of the initial rise is determined by the interac-
tion of inspired tension, alveolar ventilation, and alveolar volume
(FRC). To observe the initial rise in its purest form, the effect of
body uptake will be eliminated; we do this by eliminating cardiac
output (CO=O) in the Gas Man model.

o SETUP
Set the parameters as shown, putting CO
Parameter Selection
at zero. Set a bookmark for 3 minutes.
Agent ........................ Isoflurane

Circuit .............................. Open

DEL (%) ................................. 5

FGF (L/min) ......................... 10

VA (L/min) ............................. 7.5

CO (L/min) ............................ 0

VIEW (min) ........................... 15

SPEED ............................. AFAP

Special ... Set Bookmark @ 3 min.

5-5
Gas Man® The Alveolar Tension Curve

Agent II.anurane 1"'1 ~\>Ieight (Kg) Circuit IL0,-pe_n_-11="'1

Flush
~ 0
:tl

DEL ""
%atm ~ CKT15.001 ALV15.001 15.001 10.001 10.001 10.001 10.001
ART VRG MUS FAT VEN

I 0:15:00 I Time {h:mm:ssJ

~UPtake{LI

~ Delivered (L)

Speed:
FGF f10l VA CO
Llm~ LIm 17. 50 1 LIm 10 . 00 1 IAFAP 1"'1

Agent: Iisoflurane Circuit <-IO,-pe_n_......J

VA
LIM 1: ~
CO
LIM 1: ~
CKT
ALV
VRG
MUS

%atm

Figure 5-2 shows the Picture and Graph of the results of Exercise 5-2,
displaying alveolar anesthetic tension in response to 5 % inspired
isoflurane with cardiac output (CO) = 0 and alveolar ventilation (VA)
= 7.5 L/min.

Note the rapid rise in alveolar tension as it approaches and

equals inspired tension. The time constant, T, appears to be
about 0.3 minutes, and can be calculated to be:

T = VjF = FRC j VA = [2.5 l] j [7.5 ljmin] = 0.33 minute.

5-6
Gas Man® nw Alveolar Tensioll Curve

xercise 5-3

The initial rise in alveolar tension is slower with lower alveolar

ventilation but alveolar tension asymptotically approaches in-
spired.

o SETUP
Set the parameters shown, lowering
Parameter Selection
alveolar ventilation to 1.25.
Agent ........................ Isoflurane

Circuit .............................. Open

DEL (%) ................................. 5

FGF (L/min) ......................... 10

VA (L/min) ............................. 1.25

CO (L/min) ............................ 5

VIEW (min) ........................... 15

SPEED ................................ 60x

Special ................................ n.a.

5-7
Gas Man® 17ze AlveolaT Tension Curve

Agent: !Isoflurane I~,1 ~Weight (Kg) Circuit: I,--O,-pe_n_-,I-,,-,~I

Flush
±l []
.:tl

DEL
%atm
15. 00 1 CKTls.ool AlV15.001 15.001 10.001 10.001 10.001 10.001
ART VRG MUS FAT VEN

~J ~~
~ I 0:15:00 I Time (h:mm:ssl
±l
.:tl

FGF ~
.:tl

VA
±l
.:tl

CO
] ~ Uptake{ll

~ Delivered (l)

Speed:
lim 10.0 LIm 11 . 25 1 lim 10 . 00 1 IAFAP L~l

Agent: !Isoflutane Circuit: IOpen

'--'----'

VA
LIM 1: ~
CO
LIM 1: ~
en
ALV
VRG
MUS

%atm

0:05

Figure 5-3 displays the Picture and Graph of the results of Exercise 5-3,
showing the iffect of low alveolar ventilation (VA = 1.25 L/min) with
CO= o.

The only change you have made is to change alveolar ventilation

(VA) from 7.5 L/min to 1.25 L/min. Observe how much slower
alveolar tension rises. The time constant is observed to be 2
minutes and is calculated to be:

'r =V/F =FRC / VA =[2.5 L] / [1.25 L/min] =2 minutes.

5-8
Gas Man® The Alveolar '['ension Curve

o DISCUSSION
In this and the previous exercise, alveolar tension reached a final
value equal to inspired tension. This complete equalization
between inspired and alveolar gas is not possible when there is
uptake by blood. Instead, as cardiac output removes anesthetic
from the alveolar volume, less anesthetic remains, and alveolar
tension is held at a lower value. This will be shown in the next
exerCise.

5-9
Gas Man® The Alveolar Tension Curer!

xercise 5-4

Uptake of anesthetic by cardiac output produces a knee and

plateau in the alveolar tension curve.

vVhen alveolar tension is viewed graphically, a knee interrupts

the rise in alveolar tension when (nonzero) cardiac output re-
moves anesthetic from the alveoli. That is, the previous complete
wash-in of the alveolar space is interrupted by uptake into blood.
This knee would continue as a flat plateau if anesthetic-contain-
ing venous blood did not later return to the lungs. Gas Man has
a special feature to demonstrate this. In the Menu Bar at the top
of the Gas Man screen is a drop-down menu labeled Special. If
you choose Disable Return from this menu, the simulation will
show the effect of cardiac output removing anesthetic from the
alveoli, but without the effect of venous blood returning some of
it later. This is indicated by the empty venous anesthetic tension
bar (YEN) on the right edge of the top half of the screen. In
essence, anesthetic is "removed" from venous blood before it
returns to the heart and lungs.

o SETUP
Selection
........................ Isoflurane
.............................. Open
(%) ................................. 5
To observe the knee and plateau of the
alveolar tension curve, add cardiac
output and adjust the other parameters
as shown. After 3 simulated minutes, press
the Pause button on the Picture or Graph to
interrupt the simulation.

(L/min) ......................... 10

(min) ........................... 15

................................ lOx

............... Disable Return

5-10
Gas Man® The Alveolar T'emion Curve

o OBSERVATION
Agent: Iisoflurane Circuit: I'-
O -'-pe_n_---'

VA
LIM ]
10

~
CO
LIM
o

ALV -
vnG -
MUS
-~
%atm

View:
115Minl±j Ij;l i

Figure 54 shows the Graph of Exercise 54 at the end of 3 minutes of

simulation.

Note the knee continuing to a plateau in the alveolar tension

curve at approximately 2.1 % isoflurane, In the upper panels of
the Graph, and in the Picture, you see that a small alveolar venti-
lation is bringing 5% iso-flurane from the breathing circuit to the
patient's lungs, Simultaneously, a small cardiac output is carry-
ing blood and anesthetic away to the body tissues. Tissue anes-
thetic tensions rise but have no effect on alveolar tension because
anesthetic has been removed from venous blood before it returns
to the lungs using the Special/Disable Return feature.

5-11
Gas Man® The Alveolar Tension Cume

xercise 5-5

Increasing alveolar ventilation raises the knee and plateau of the

alveolar tension curve.

vVhile anesthesia administration is still interrupted, the param-

eters can be adjusted to explore the effects of alveolar ventilation
and cardiac output on the knee or plateau height. We will show
that plateau height is elevated by alveolar ventilation and de-
pressed by effective cardiac output. Effective cardiac output is
equal to actual cardiac output multiplied by the blood/gas solu-
bility, AB/G.

o SETUP
Parameter Selection
(Time elapsed = 3 minutes)
Agent ........................ Isoflurane
Circuit .............................. Open
DEL (%) ................................. 5
FGF (L/min) ......................... 10
VA (Ljmin) ............................. 7.5
CO (Ljmin) ............................ 1.25
You should already have completed 3
minutes of anesthesia administration and
the simulation should be paused. No
anesthetic is returning to the lungs in
venous blood since venous return is
disabled. To observe the effect of alveo-
lar ventilation on alveolar tension with-
out starting a new simulation, increase
alveolar ventilation and then continue
the simulation-in-progress by setting the
parameters as shown. JiJ'hen the clock
reads 6 minutes, die!? Pause and obseroe
the Graph again.

VIEW (min) ........................... 15

SPEED ................................ lOx

Special ............... Disable Return

5-12
Gas Man® The Alv('olar Tension Curve

o OBSERVATION
Agent: Iisoflurane Circuit: '-'-_ _-'

10

~ I
VA
LIM
0

CO
LIM
']
5
en
ALV
VRG
MUS

%atm
0
0:00
View:

115 Min I!I

Figure 5-5 shows the Graph of Exercise 5-5 at the end of 6 minutes of
simulation.

Note that alveolar tension has reached a new, higher plateau of

approximately 4.1 % because of increased alveolar ventilation.
Note also that the time course of this new change is much more
rapid than for the first change. The higher alveolar ventilation
(7.5 L/min vs 1.25 L/min) has resulted in a smaller (shorter,
faster) time constant as well as a higher plateau.

5-13
Gas Man® The AJv(!olar Tension CI/.rue

xercise 5-6

Increasing cardiac output lowers the knee and plateau of the

alveolar tension curve.

o SETUP
You should have completed 6 minutes of
Parameter Selection anesthesia administration and the simu-
(Time elapsed = 6 minutes) lation should be interrupted. To observe
the effect of cardiac output on alveolar
Agent ........................ Isoflurane tension, continue where Exercise 5-5 left
off by increasing cardiac input to 7.5 L/
Circuit .............................. Open
min, as shown. Obseroe the Graph and
DEL (%) ................................. 5 click Pause at 9 minutes.

FGF (L/min) ......................... 10

VA (L/min) ............................. 7.5

CO (L/min) ............................ 7.5

VIEW (min) ........................... 15

SPEED ................................ lOx

Special ............... Disable Return

5-14
Gas Man® The Alveolo,. Tel/sion Curve

o OBSERVATION
Agent: II soflurane Circuit: '----'-_ _-'

VA
LIM I
CO
LIM ] I
en 5-.,-----------------~----------------------_.

ALV
VRG
MUS

%atm

0:00 0:05 0:10 0:15

View:
115Minl~1 I~ll I~I

Figure 5-6 shows the Graph of Exercise 5-6 at the end of 9 minutes of
simulation.

Note that alveolar tension has again fallen to approximately

2.1 %. This is the same level that was reached when cardiac
output and alveolar ventilation were both equal but lower (1.25
L/min each, compared with 7.5 L/min each, now).

5-15
Gas Man® The ;llveol([}" Tension Curve

xercise 5-7

The ratio of alveolar ventilation to effective cardiac output

determines the height of the knee and plateau of the alveolar
tension curve.

You have seen that the knee or plateau height of the alveolar
tension curve appears to be determined by the ratio of alveolar
ventilation to cardiac output. To verify this, return to Gas Man
for yet another simulation. Reconfirm that the plateau height is
unchanged when the ratio of alveolar ventilation to effective
cardiac output is constant by selecting new values for VA and CO
that are again equal to each other, but different from the previ-
ous exerClse.

o SETUP
Adjust VA and CO each to 5 L/ min and
Parameter Selection
continue the simulation at 9
(Time elapsed = 9 minutes) minutes, as shown.

Agent ........................ Isoflurane

Circuit .............................. Open

DEL (%) ................................. 5

FGF (L/min) ......................... 10

VA (L/min) ............................. 5

CO (L/min) ............................ 5

VIEW (min) ........................... 15

SPEED ................................ lOx

Special ............... Disable Return

5-16
Gas Man® The Alveolar Tension Curve

o OBSERVATION
Agent: Iisoflurane ':!oJ ~Weight (Kg) Circuit: 'L0,-pe_n _-"-",,,:!oj

DEL
CKT15.001 AlV12. 24 1 12 .24 1 12 . 23 1 10 . 21 1 10.011 10 . 00 1
%atm
ART VRG MUS FAT VEN

I 0:15:00 I Time (h:mm:ss)

~ Uptake(l)

~ Delivered (ll

Speed:
FGF VA CO
lim ~ 5 15
lim 1 . 1 lim 15 . 00 1 IAFAP If I

Agent: Ifsoflurane Circuit: <-::1D..::..pe::.:.:n_---'

VA
LIM 1: ~ I \

CO
LIM 1: ~ I \~------------~

CKf
AlV
VRG
MUS

%:atm

Figure 5-7a displays the Picture and Graph at the conclusion of Exer-
cise 5-7, showing the r1Ject of alveolar ventilation and cardiac output
on knee height of the alveolar tension curve.

Note that the alveolar tension plateau height is unchanged

despite changes you have made in alveolar ventilation and car-
diac output. Mter 3 minutes of 5% delivered isoflurane, alveolar
ventilation (VA) is increased from 1.25 to 7.5 L/min. At 6 min-
utes, cardiac output (CO) is likewise increased from 1.25 to 7.5
L/min, restoring the ratio VA/CO to its previous value of 1:1,

5-17
Gas Man® The Alveolar Tension Curve

and the ah'eolar tension plateau to its previous height. At 9

minutes, alveolar ventilation (VA) and cardiac output (CO) are
each ac:ljusted to 5 L/min, and the alveolar tension plateau is
again unchanged.

Agent: Iisoflurane Circuit: IOpen

'--'----'

VA
LIM

CO
LIM ': ~~------------------------------------------~
ALV
VriG
MUS

%atm

0:05 0:10 0:15

View:
115 Min I±I 1.+1.

Figure 5-7b demonstrates the relationship between knee height and

alveolar ventilation.

Alveolar ventilation has been stepped 1 L/min at a time from 0

to 10 L/min with a constant cardiac output of 5 L/min.

5-18
Gas Man® The Alveolar Tension Cnrlle

Agent: Iisoflurane Circuit: ,-IO-,--pe_n_---,

LIM ': g~------------------------------------------4

':~~
CO
LIM

ALV
VRG
MUS

%atm

0:05 0:10 0:15

View:
\15 Min \±j I!:j

Figure 5-7c shows the rise in knee height as cardiac output is decreased
in a stepwise manner from 10 to 0 L/min with an alveolar ventilation
0/5 L/min.

You may want to reproduce these figures yourself but diligence is

required to produce perfect Graphs. You may also want to use
Gas Man's Overlay feature for comparisons (see Chapter 15).

o DISCUSSION
You have seen that the knee and plateau height of the alveolar
tension curve is determined by the ratio of alveolar ventilation Lo
effective cardiac output. Remember that effective cardiac output
is equal to the product of cardiac output and blood/gas solubil-
ity, AB/C. Anesthetics with different solubilities will have differ-
ent plateau heights for the same alveolar ventilation and cardiac
output. This will be explored in Chapter 6.

5-19
Gas Man® The Alveolar Tension ell me

xercise 5-8

Anesthetic returned to the lungs in venous blood converts the

alveolar tension curve plateau into a gently-rising tail.

When anesthetic-laden venous blood is allowed to return to the

lungs, total anesthetic delivery to the alveoli increases. Venous
delivery increases as tissue anesthetic tensions increase. This
converts the previously-seen plateau in alveolar tension into an
ascending tail. To demonstrate this, in this next exercise you will
suddenly allow the anesthetic in venous blood to reach the lungs
normally. This will augment the total quantity of anesthetic
delivered to the lungs and hence increase alveolar tension.

o SETUP
Parameter Selection
Agent ........................ Isoflurane
Circuit .............................. Open
DEL (%) ................................. 5
FGF (L/min) ......................... 10
VA (L/min) ............................. 5
CO (L/min) ............................ 5
To understand the tail of the alveolar
tension curve created by anesthetic
returning from the lungs, proceed as
shown. Remember that in the previous
exercises you selected Special/Disable
Return, and this is still preventing anes-
thetic from returning to the lungs in
venous blood. Set a bookmark at 2
minutes.

VIEW (min) ........................... 15

SPEED ................................ lOx

Special ............... Disable Return

5-20
Gas Man® The Alveolar 'Tension Curve

o OBSERVATION
Agent: Iisoflur ane 1±j ~Weight (Kg) Circuit: ,-IO-,--pe_n_--,-!±""J

Flush
~ 0
±l

DEL
%atm
CKTls.oo! AlV12.241 12 . 24 ! 11. 13 ! 10.03! 10. 00 1 lo.oo!
ART VRG MUS FAT VEN
I 0:02:00 I Time (h:mm:ssl
~UPtaKe(ll

~ Delivered (ll

Speed:
FGF VA CO
LIm §J LIm 15. 15 ! LIm 15. 00 1 IAFAP L±j

Agent: Iisoffurane Circuit: 'L0.:...pe_n_--,

VA
LIM 1: ~
CO
LIM 1: ~
en 5
ALV
VRG
MUS

%atm
0
0:00 0:05 0:10 0:15

Figure 5-8a displays the Picture and Graph of the alveolar tension
curve with anesthetic in venous blood removed before it retunzs to the
lungs.

Observe the flat plateau on the Graph and view the Picture again.
As you continue the Exercise, watch the empty venous anesthetic
tension display bar on the right edge of the Picture.

Next, you will allow anesthetic to return to the lungs in venous

blood. Use the Special menu in the Menu Bar and deselect
Disable Return; then click Continue.

5-21
Gas Man® The Alveolar Tl'IIsioli CurvE'

Agent: II soriurane Ifl ~Weight (Kgl Circuit: t...:10c:...pe::.;.:n_--LI:::.JfJ

Flush
1:1 0
::tJ

DEL
%atm
[J CKT@J@ ALV13. 84 1 13 . 84 1 13. 74 1 [iill] 10 .02 1 12 .91 1
ART VRG MUS FAT VEN

~ ~ ~

j
1 0:15:00 I Time (h:mm:ssl

+l
~J
+i, :!l ~ Uptake(LI
::tJ ::tJ ±l ~ Delivered (Ll

FGF
[!IJ
VA
5 06
CO
5 00
Speed:
IAFAP If I I :~oniin~e
lim lim 1 . 1 lim 1 . 1

Agent: IlsoflUJane Circuit: LI0-,,-pec....n,-----.J

VA
LIM
1: ~~---~______--__--__--------------------~
10
CO
LIM o ~1----------I
en
ALV
VRG
MUS

%atm

Figure 5-8b displays the Picture and Graph after the transition from
venous return disabled to normal venous retunl.

Notice that anesthetic tension in the alveolar compartment

suddenly begins to rise. Observe that the previous knee and flat
plateau has been transformed to a knee leading to an ascending
tail. This is caused by the return of anesthetic to the lungs in the
venous blood.

5-22
Gas Man® The Alveolar Tension Cume

Circuit: 10pen
'--'----'

10

~
VA
LIM
0

CO
LIM ']
en
ALV
VRG
MUS

%atm

View:
115 Min I±]

Figure 5-8c shows superimposed graphs with and without anesthetic in

venous return.

Note that in Figure 5-8c the flat plateau caused by the absence of
venous return has been transformed to an up-going tail as anes-
thetic returning from tissues re-enters the lungs as a second
source of anesthetic.

5-23
 The !llveolar Tension CUJ(H'

o DISCUSSION
The slowly ascending tail of the open-circuit alveolar tension
curve has been produced by the addition of anesthetic returning
in venous blood. The actual venous anesthetic tension is the
average of the tissue anesthetic tensions, weighted by their re-
spective blood flows. For each tissue, the anesthetic tension is
determined by the history of arterial blood anesthetic tension
and by tissue blood flow and tissue capacity.

If arterial anesthetic tension were constant, tissue anesthetic

tension would be an exponential with the time constant appro-
priate for the tissue and blood flow. The equations that ex-
presses this are:

PT (t) == P a X (1-e -t/'T) , where

1: == (VT X AT/B) / FT-

That is, tissue time constant is the ratio of effective tissue volume
to the effective flow to the tissue.

In this chapter, the open (or non-rebreathing) circuit alveolar

tension curve has been dissected into its component parts, initial
rise, knee, and tail. The maximum possible height is the inspired
anesthetic tension. The time constant of the initial rise is the
ratio of alveolar ventilation (VA) to alveolar volume (FRC). The
knee height is determined by the ratio of alveolar ventilation to
the product of cardiac output and blood/gas solubility, which
together comprise effective cardiac output. This will be explored
in Chapter 6. The multi-exponential tail of the curve is pro-
duced by anesthetic returning in venous blood augmenting
alveolar tension; its shape is determined by the rate of tissue
equilibration.

5-24
Plateau l) ~;
Cha fer 6
, )
& Blood/Gas Solubility

Each anesthetic has a different value for the blood/gas partition

coefficient, referred to as blood/gas solubility (AB/C). The effect
of blood/ gas solubility on the time course of anesthesia can be
observed using the Gas Man program. We will see that high
blood/ gas solubility lowers the knee of the alveolar tension curve;
and low blood/gas solubility raises the knee, making expired
more closely approach inspired.

The drugs we will study are halothane, enf1urane, isoflurane, the

newer agents sevoflurane and desflurane, and the older insoluble
nitrous oxide. Nitrogen is also simulated. The blood/gas solubili-
ties and other values for these exercises are shown in Table 6-1.

6-1
Gas Man® Pla/call Height (;' Blood/Gas S'olilbility

BLOOD/GAS SOLUBILITY & ITS EFFECT ON

PLATEAU HEIGHT, A/I RATIO & OVERPRESSURE a
- - - - - -.. ~--~"~-

:1 PATIENT PARAMETERS VA= 4.00 CO= 5.00

2 DRUG Iso Enf Hal Sevo Des N2 0 NZ

3 BLOOD/GAS SOLUBILITY 1.30 1.90 2.47 0.65 0.42 0.47 .014

PL\TEAU HEIGl-IT FOR MAX DEL

4 Inspired setting (%) 5.0 5.0 5.0 5.0 18.0 100 4Atm
5 Alveolar plateau height (%) 1.90 1.48 1.22 2.76 11.8 63 3.93

PLATEAU AND OVERPRESSURE RATIOS

6 Alveolar / Inspired Plateau Ratio 0.38 0.30 0.24 0.55 0.66 0.63 0.98
7 Inspired / Alveolar (OverP Ratio) 2.63 3.38 4.10 1.8] 1.50 1.59 1.02

OVERPRESSURE FOR 1 MAC

8 MAC (% arm) 1.1% 1.7% 0.8% 2.1% 6.0% 110%b 7 Atm C
9 Inspired Overpressure for 1 J'v1AC 2.9% 5.7% 3.3% 3.8% 9.0% 175%

a Anesthetic has been removed from venous return to maintain the plateau height.

Table 6-1.
Parameters and computations for each agent including blood/
gas solubility ratio, plateau height, overpressure ratio, lVIAC
value, and overpressure tension to achieve I lVIAC in the alveoli.

6-2
Gas Man®
xercise 6-1
----------
The alveolar tension curves for different anesthetic agents have
generally the same shape. Knee height of the curve varies with
blood/gas solubility. Tail shape varies with tissue/gas solubilities.
o SETUP
Agent ................. Halothane, etc.
Circuit .............................. Open
DEL (%) ............ top of the scale
FGF (L/min) ......................... 10
VA (L/min) ............................. 4
CO (L/min) ............................ 5
VIEW (min) ........................... 15
SPEED ............................. AFAP
Special ...................... .
Pla!mu Heip,h! & Bfood/(;as ";oll/bili!)'
-----------------
To observe the effect of agent choice on
the shape of the alveolar tension curve,
adjust parameters as shown. After simu-
lating a halothane anesthetic with con-
stant inspired tension, do the same for
isoflurane, enflurane, sevoflurane, and
clesflurane. Each time, set delivered
tension from the vaporizer (DEL) to the
top of its control bar scale. Anesthetic
tensions in body compartments will
shows higher values than those used
clinically, but we use the maximum
setting of DEL for graphic demonstra-
tion of this effect.
Finally, repeat the experiment for ni-
trous oxide, but use the Special menu to
Disable Uptake this time. This will avoid
confusion by eliminating the effect of
uptake on ventilation - the concentration
if.{ect, explained in Chapter 8. A similar
comparison could be made by disabling
venous return for all the agents (Disable
Return). The graphs resulting from these
simulations are shown in Figures 6-1
a,b,c,d,e,f.
6-3
Gas Man® Plateau Height & Blood/Gas Solubility

o OBSERVATION
Agent: I Halothane I ±j ~Weight [Kg) Circuit: I,--O-,--pe_n_--<.I=J~;j

Flush
~ 0
~

DEL 15 . 00 1
%atm
CKT15.001 I I
AlV 2.76 12.761 12. 59 1 10. 22 1 10 . 01 1 12 . 01 1
ART VRG MUS FAT VEN
I 0:15:00 I Time (h:mm:ss)
~UPtakell)

~ Delivered ILJ

Speed:
I _c;~ntinue
FGFI1iiI
lim ~
VA
LIm 14.09 1
CO
lim ro IAFAP I:!:j

Agent: IHalothane Circuit: 10pen _ - '

VA
LIM 1: f
CO
LIM 1: ~
en
AlV
VRG
MUS

%atm

0:15

Figure 6-1 a shows the Picture and Graph after administering

halothane at constant inspired tension of 5 %for 15 minutes.

6-4
Gas Man® Plateau Height & Blood/Gas Solubility

Agent: IEnflurane I;:J ~Weight (Kg)

Flush
~ 0
~

DEL
%atm 15. 00 1 CKT15.001 ALV13.241 13.241 13 .14 1 10.421 10 . 02 1 12.461
ART VRG MUS FAT VEN
L!TI L!TI 1 0;15;00 I Time (h;mm:ss)

+l ~UPtake(L)
.1:l
.id ~ Delivered (L)

Speed;
FGF VA fAi17l co ~
lim LIm ~ LIm ~ IAFAP I±j

Agent: IEnflurane Circuit: LIO.:.p_eo'--_-'

10 - , - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ,
VA
LIM ~~~--------------------------------------------_4
O--L-------------------------------------------~
10

CO
LIM ~~--------------------------------------------_4
0--'--------------------------------------------'
CKr
ALV
VflG
MUS

%atm

0:05 0:10 0:15

Figure 6-1 b shows the Picture and Graph after administering enJlurane
at constant inspired tension of 5% for 15 minutes.

6-5
Gas Man® Plateau Heighl & Blood/Gas Solubility

Agent: II .GnUrane I!! ~Weight (Kg) Circuit I,--O-,-p_en_ _..L1!...,l

Flush
~ 0
:tl

DEL 11 5. 00 1 CKT15.001 ALv13.621 13.621 13 . 51 1 10. 34 1 10. 02 1 12 .73 1

%atm
ART VRG MUS FAT VEN
I 0:15:00 I Time (h:mm:ss)
@::J Uptake (LJ

~ Delivered (LJ

Speed:
FGF VA
14.06 1 co " "
LIm LIm LIm~ IAFAP I!!

Agent: Iisoflurane Circuit O.:....pe_n_-----'

,-I

10

VA
LIM ~r------------------------------~
OI~L------------------------------~
10

L~~ ~r--------------------------------------------~
o =1
eKr
AlV
VRG
MUS

%atm

Figure 6-1 c shows the Picture and Graph after administering isojlurane
at constant inspired tension of 5 %for 15 minutes.

6-6
Gas Man® Plateau Height & Blood/Gas S'OI11bilitv

Agent: ISevoflurane I :l:j ~Yleight (Kg] Circuit: '--'-_ _--'=-'

DEL
%atm
15. 00 1 CKT15.001 I 1 14.201
ALV 4.2 0 14. 12 1 10 .401 1°. 02 1 13.20 1
ART VRG MUS FAT VEN
I0:15:00 I Time (h:mm:ss)
~UPtake(L]

~ Delivered (L]

Speed:
FGF r:tnl VA co
lIm~ lim 14. 03 1 lim [J IAFAP I±j

Agent: ISevoflurane Circuit: I,-O-,-pe_n_--,

10

VA
LIM ~~---------------------------------------~
O-J-------------------------~
10

CO
LIM ~~-------------------------------------~
O-J-------------------------~

cn
ALV
VRG
MUS

!';.;atm

Figure 6-1 d shows the Picture and Graph after administering sevq,flu-
rane at constant inspired tension of 5% for 15 minutes.

6-7
Gas Man® Plateau Height (5 Blood/Gas Solubility

Agent: IDesflurane I !j ~W'eight (Kg) Circuit: Ic::0,,-pe..:cn_--LI!c:J1

DEL
%atm
CKT118. 0 1 ALV116.51 116. 5 1 §l @] @] 112.9 1
ART VRG MUS FAT VEN

GIl GIl

]
1 0:15:00 1 Time (h:mm:ss)

+!
__ 1 ~UPtake{LI
:otl ~ Delivered (ll

Speed:
FGF f1ill VA r:;n:;l CO
LIm ~ LIm ~ LIm IAFAP L~:l

Agent: IDesflurane Circuit I'-O- -'-pe_n_---'

10

VA
LIM ~~~------------------------------------------~
O;~~------------------------------------------~
10

S~ ~~------------------------------------------~
o =!
CKf
IILV
VRG
MUS

%atm

Figure 6-1 e shows the Picture and Graph after administering de~flu­
rane at constant inspired tension of 18% for 15 minutes.

6-8
Gas Man® Plateau Height (5 Blood/Gas S'olubilily

Agent: INitrous Oxide I!:1 170.0 IWeight (Kg) Circuit: cIO"-,pe'-.-o_--L:I±",,,J

DEL
%atm ~ CKT~ AlV~ ~ ~ ~ l:JI] [£]
ART VRG MUS FAT VEN

~]
GIJ I 0:15:00 I Time (h:mm:ss)
~ ~ Uptake{L)
:i-J :i-J I 150.00 I Delivered (ll
Speed:
~ VA CO
FGF
LIm 10. lim 14.00 1 lim @=:J IAFAP !±l

Agent: INitrous Oxide) Circuit: I-IO-'-pe_n_----'

VA
LIM 1: q -+---------!I I
CO
LIM 1: ~ I
en
ALV
VRG
MUS

%atm

Figure 6-1f shows the Picture and Graph after administering constant
inspired tension of 1 00% nitrous oxide for 15 minutes.

The concentration effect has been eliminated by disabling the

effect of uptake (Special menu, Disable Uptake) on alveolar
ventilation, explained in Chapter 8.
Gas Man® PlalNlu Hcip;hl {5 Blood/Gas Solubility

o DISCUSSION

Note that the different anesthetic agents have alveolar tension

curves that are similar in overall shape. They all possess an
identical initial rise. Knee height differs with agent solubility.
Tail shape varies slightly from agent to agent. In all cases, alveo-
lar tension rises rapidly at first, and then more slowly after what is
termed the knee. Vessel-rich group (VRG) anesthetic tension
follows alveolar soon thereafter (1-3 minutes). Muscle and fat do
not develop any significant anesthetic partial pressure during the
15 minutes viewed.

6-10
Gas Man® Plateau Height & Blood/Gas Solubility

xercise 6-2

Drugs with high blood/gas solubility have low alveolar knee and
plateau heights and low A/I (Alveolar/Inspired) or E/I
(Expired/Inspired) ratios.

To see the effect of blood/gas solubility independent of tissue

effects, you will next eliminate the eflect of anesthetic in venous
blood returning to the lungs and heart. To do so, you will use
the Special menu and select Disable Return, as in Chapter 5.
This will produce a well-defined plateau rather than an ill-de-
fined knee leading to a rising tail. It will then be easy to see the
effect of blood/ gas solubility on the plateau height.

o SETUP
Parameter Selection
Agent ................. Halothane, etc.
Circuit .............................. Open
DEL (%) ............ top of the scale
FGF (L/min) ......................... 10
VA (L/min) ............................. 4
CO (L/min) ............................ 5
VIEW (min) ........................... 15
SPEED ............................. AFAP
Special ............... Disable Return
To demonstrate the plateau height for
each anesthetic, adjust parameters as
shown. After observing alveolar tension
reach a plateau after 2 minutes, note its
height or use the File menu and Print
the picture and graph. Next, select
enflurane, isoflurane, sevoflurane, des-
flurane, and nitrous oxide and observe,
record, or print the plateau height of
each.
""'Note: When simulating nitrous oxide
administration, use the Special menu to
Disable Uptake before clicking Begin, to
eliminate the concentration effect.

6-11
Gas Man® Plateau Height & Blood/Gas Solubilitv

o OBSERVATION
1.0--~----------------------------------------------~

A/I
Ratio
.75
Desjlurane
Sevojlurane
.50
Isojlurane
Enflurane
.25 Halothane

0:00 1:00 2:00 3:00 4:00

Figure 6-2 shows the Graphs of the alveolar tension plateau for each
anesthetic agent plotted on the same axes to allow easy comparison.

The alveolar plateau heights for 5% inspired agent are tabulated

in Table 6-1, lines #4 and #5. The effect of venous return of
anesthetic to the lungs was removed by using Disable Return.

6-12
 Pla/emf Heigh/ & Blood/Gas Solubility

xercise 6-3

Alveolar plateau height or A/I ratio, combined with MAC, deter-

mine the initial overpressure value required to produce 1 MAC in
the alveoli.

In this exercise, we take a break from running Gas Man simula-

tions and explain the concept of Minimum Alveolar Concentra-
tion (MAC), and the relationship of alveolar to inspired tension.

Plateau heights are described in terms of ratios of alveolar to

inspired tension. Because expired tension is a reasonable ap-
proximation of alveolar tension, the two terms are often used
interchangeably, alveolar/inspired = expired/inspired or A/I =
E/I. In reality, they may be different. Expired is what we mea-
sure with an airway gas analyzer. Alveolar is what is present in the
lungs. From the results of Exercise 6-2 we can compute the A/I
ratios for each drug (see Table 6-1, line #6). The important point
here is that relative plateau height is inversely related to blood/
gas solubility. That is, anesthetics with low blood/gas partition
coefficients produce high alveolar anesthetic plateaus. This
relationship can be quantified:

1
1 + CO'A/VA

where PA and PI are alveolar and inspired anesthetic tensions, 'A

is the blood/gas partition coefficient, and VA and CO are alveo-
lar ventilation and cardiac output, respectively.

One note of caution is required here. In addition to depending

on the blood/gas solubility, the plateau height depends on both
alveolar ventilation and cardiac output. In the clinical setting,
neither of these values can be easily and continuously quantified.
If real measurements of plateau height could be made for an
agent of known blood/gas solubility, the ratio of cardiac output
to alveolar ventilation could be inferred.

6-13
Gas Man® Pla/eau Heip;/zf & Blood/Gas Solubility

If the objective here were to control alveolar tension to a certain

plateau height, then it is not the A/I ratio that is useful, but
rather the l/A ratio. The relationship between the two is simple:
one is the reciprocal of the otherl The II A ratio can be thought
of as the overpressure ratio required to achieve the desired tension
in the alveoli. The overpressure ratio can be calculated for each
of the anesthetic agents (see Table 6-1, line #7). Thus we see that
as blood/gas solubility decreases toward 0, the overpressure ratio
(II A) decreases wward 1.

We know that each of the anesthetic agents requires a different

brain level to achieve anesthesia:

The value of brain, blood, and alveolar anesthetic

which anesthetizes 50 % of patients is 1WA C, defined as
the Minimum Alveolar Concentration for anesthetization
at 1 atmosphere pressure.

At the MAC value, 50% of patients fail to move in response to a

surgical incision. The value is assessed by measuring end-expired
anesthetic tension 15 minutes after constant expired tension has
been established. End-expired gas is taken to represent alveolar
gas. Alveolar gas tension is taken to precisely equal arterial
blood tension. And brain tension is assumed to equal arterial
tension after 15 minutes of equilibration. A surgical incision is
then made. A record is made of whether or not the patient
moves. This definitive end-point of yes or no makes statistical
analysis convenient. !vIAC is often measured by successive ap-
proximation in a series of patients.

To make the same MAC value applicable at any barometric

pressure, the concentration value should be thought of as partial
pressure or tension, expressed in percent of one sea level atmo-
sphere. This is the approach consistently used in Gas Man.

The !vIAC values for each gas simulated here are shown in Table
6-1, line #8. To combine the concepts of MAC and overpressure,
assume that the desired alveolar level is 1 MAC. Thus, if vou /

know the overpressure ratio and the MAC value for an anes-
thetic, you can easily calculate the inspired tension required to

6-14
Gas Man® Plateau Heig:ht & Blood/Cas Solubility

produce an alveolar plateau of 1 MAC - iL is the product of the

two:

Inspired overpressure for 1. MAC = 11.MAC = VA ratio x MAC.

Use of appropriate overpressure brings alveolar anesthetic ten-

sion to ] YVU\C rapidly. You will explore this in the next exercise.

xercise 6-4 -----~------~--~~-~-----~------------------~-----~--~-~--~~-~---~

By choosing the solubility-adjusted overpressure value, you can

achieve and maintain I MAC in the alveoli.

o SETUP
Selection
........................ Isoflurane
.............................. Open
(%) ................................. 5
FGF (L/min) ......................... 10
VA (L/min) ............................. 4
co (L/min) ............................ 5
VIEW (min) ............................. 5
In this exercise, you will simulate an
overpressure-induced step in alveolar
tension to 1 rvlJ\C with each of the anes-
thetics. By leaving venous return dis-
abled in the Gas Man model, you will see
a flat plateau in alveolar tension in
response to constant inspired tension. By
choosing the solubility-adjusted overpres-
sure value, you will achieve and maintain
the 1 MAC you desire. Adjust the param-
eters as shown. Remember to use
Disable Return to remove the effect of
venous return of anesthetic to the lungs.

SPEED ............................. AFAP

6-15
Gas Man® Pla/mll Height & Blood/Gas Solubility

o OBSERVATION
Agent: Iisoflurane I.:!:! 1170.0 IWeight (Kg I Circuit: I~Op,,-=e,-,-n_-,1.=J:!:1

Flush
~ 0
Yl

DEL
%atm
CKT12. 90 1 AlVI1.121 11.121 10 .96 1 10 . 04 1 10 .00 1 ~
ART VRG MUS FAT VEN
I 0:05:00 I Time (h:mm:ssl
~ Uptake(ll

~ Delivered (Ll

Speed:
FGF r:1Ol VA CO r;:;--l
LIm ~ LIm 4. 07 1
1 LIm ~ IAFAP It]

Agent: /Isoflurane Circuit: I'-O,--pe_n_ - '

VA
LIM 1: ~
CO
LIM 1: ~
CKf
ALV
VRG
MUS

%atm

Figure 6-3 shows the Picture and Graph of the result of Exercise 6-4
after administering 2.9 % isoflurane with an open circuit.

The effect of venous return of anesthetic to the lungs was re-

moved by using Disable Return. The 2.9% overpressure value
was calculated based on the blood/gas solubility ratio of iso-
flurane and a value for ventilation (VA = 4 L/min) and perfusion
(CO = 5 L/min).

At the end of 1 minute of simulation, note that vou have J

achieved 1 MAC already. Note also that the alveolar tension does

6-16
Gas Man® Plateau Height & Blood/Gas Solubility

not change as the simulation continues to 5 minutes; you have

achieved a 1 :MAC plateau. A flat plateau is created in this educa-
tional simulation because venous return has been disabled. The
plateau height is formed by the balance between anesthetic
delivery in ventilation and removal by cardiac output. The pla-
teau is at 1 MAC (1.1 % isoflurane) because you correctly calcu-
lated the inspired tension to use, based on the alveolar tension
desired and the MAC value for the anesthetic agent you selected.

Now that you have produced 1 MAC isoflurane, do the same for
the other anesthetic agents: enflurane, halothane, sevoflurane,
desflurane, and nitrous oxide. Set DEL according to Table 6-1
(Inspired Overpressure for 1 MAC) or calculate it yourself for
each anesthetic. Note that for enflurane, the setting required is
5.7%. Adjust the scale of the picture display by entering "6" in
the box to the left of the scale, and then adjust the control bar to
5.7 as vou normally, would.
/

'-Clinical Note: If you have seen anesthetic vaporizers, you may have noticed that
some brands and models of enflurane vaporizers deliver up to
7%, others only up to 5%. Now you know why 7% is an advan-
tage for this drug that has both low potency (high MAC) and
relatively high solubility.

6-17
Gas Man® Pla/eau Heighl (;; Blood/Gas Solubility

ummary

In this chapter, you have compared various anesthetic agents and

seen that blood/gas solubilities (blood/gas partition coefficients)
significantly affect the height of the knee of the alveolar tension
curve. You have calculated and simulated the A/I plateau ratio
and the 1/A overpressure ratio, along with the overpressure for 1
MAC for each agent. Table 6-] tabulates pertinent data and
calculations you can consider in clinical practice. By choosing the
solubility-adjusted overpressure value, you can achieve and main-
tain 1 MAC in the alveoli. You have also noted that the tail of the
alveolar tension curve is removed by disabling venous return of
anesthetic to the lungs.

6-18
 //~--------'-.~\
I .

Chapter 7 II )
Overpressure-8i
/ '\
Optimum Anesthesia
U ()

The concept and technique of overpressure has been used for a

long time. With proper use of overpressure, inspired anesthetic
tension is continually or frequently adjusted to produce a con-
stant tension somewhere else, notably the brain or alveoli. In this
chapter, we will explore the judicious use of overpressure to
achieve a rapid rise and stable maintenance of anesthetic tension
somewhere other than where we are controlling it. First we will
consider the alveoli (actually the expired gas). Then we will
consider the brain as the location in which anesthetic tension is
to be controlled.

Overpressure is the term for using a higher partial pressure in

the inflow than is desired in the compartment being controlled.
In Exercise 4-4, we saw that overpressure could speed the rise in
anesthetic tension two compartments away. That is, we adjusted
the vaporizer setting to control alveolar anesthetic tension. In
Chapter 6 we saw the level of inspired overpressure required to
achieve I MAC in the alveoli and exhaled gas during the time
before anesthetic returns in venous blood. In this chapter we
apply the same principle to control alveolar anesthetic tension by
adjusting inspired tension in the face of returning anesthetic in
venous blood. You will reproduce the halothane simulation
published by Eger l 4, as well as perform similar simulation experi-
ments for the other agents.

To make our work easier, we will eliminate the delay and diffi-
culty in prediction introduced by the breathing circuit and use a
perfect non-rebreathing, or open, circuit. In practice, some
breathing circuits and anesthesia machines are designed to do
this. With conventional anesthesia machines commonly available

7-1
Gas Man® OVeJjJrCSSlIlP & OjJlimum Anesthesia

in the US, a fresh gas flow of 10 L/ min will do an adequate job,

but it is still not perfect. Vve will use 1 J\!IAC as our target level.

The dotted line in the alveolar (ALV) and vessel rich group
(VRG) compartments represents the MA.C level. Your goal in
each exercise will be to bring either alveolar or vessel-rich group
tension up to 1 MAC and maintain that level.

You may have to continuously adjust the vaporizer setting (DEL)

to do this perfectly. First, slow the Speed to 5X or lOX. You can
use any of three ways to adjust the vaporizer:

Drag the DEL control bar by clicking and holding the

mouse button

. Click the down arrow next the the DEL scale

.. Select Pause and type in new values as needed or desired .

You may find that dragging the control bar is the most enjoyable
method. With the simulation running, move the mouse pointer
onto the control bar and click the mouse button. When you do
this, the simulation automatically pauses until you release the
button, at which time the simulation automatically resumes.

A logical vaporizer starting value for each agent is found in Table

6-1, line 9. The inspired tension shown there will raise ALV to 1
MAC immediately. These numbers are the starting values in the
Exercises.

7-2
Gas Man®
xercise 7-1
Carefully adjusted inspired overpressure can achieve and main-
tain 1 MAC in the alveolar compartment and exhaled gas.
o SETUP
Parameter
Agent ................. .
Circuit ........................ .
DEL (%) ....................... .
FGF (L/min) ................. .
VA (L/min) ................... .
CO (L/min) ........................... .
VIEW (min) ........................... 15
SPEED .................................. 5x
Special ................................ n.a.
OVCljJr(,SSUFI' & OjJli mum A nest liesia
To achieve 1 MAC in the alveolar com-
partment, measured as exhaled gas,
a~just the parameters as shown.
Immediately after beginning the simula-
tion, start reducing DEL in one of the
three ways described on the previous
page. Remember, your goal in each
exercise is to bring alveolar tension up to
the dotted line (l MAC) and maintain
that level. Keep your eye on the alveolar
tension as you a~just the vaporizer set-
ting.
At the end of the 15 minute simulation,
you should have produced a graph
something like Figure 7-1a. You can
repeat this exercise with each of the
anesthetic agents, producing graphs like
Figures 7-1 b,c,d,e.
7-3
Gas Man® OvmjJ)"essure & OjJtimum Anesthesia

o OBSERVATION
Iisoflurane L±j ~Weight (Kg) Circuit: LI
O-,-pe_n_--LI:!:::JJ

Flush
o
DEL
%atm
11.441 CKII1.HI ALvl 1.07 I 11.071 11. 07 1 10 . 12 1 10. 01 1 1°. 83 1
ART VRG MUS FAT VEN
I 0:15:00 I Time (h:mm:ss)
~ Uptake(L)

~ Delivered (Ll

FGF r1ilill VA CO Speed:

I. Continue
Llm~ LIm 14. 02 1 LIm 15 . 00 1 ~

Agent: Iisoflurane Circuit: LI0-,-pe""n_-----,

VA
LIM 1: g
CO
LIM 1: g
eu
ALV
VRG
MUS

%atm

---------

Figure 7-1a shows the Picture and Graph resultingfrom keeping

anesthesia administration at a constant alveolar tension with
is'?/1urane, achieved by continuolls manual adjustment ofinspired
tension.

7-4
Gas Man® OveljJressure & OJ!til71u1I1 Anesthesia

Agent: !Enflurane ! ±J 170.0 IWeight (Kg) Circuit: 10pen

'-'----"'--'
I±J

12 . 52 1 CKT12.521 I 1 11.691 11.69

ALV 1.69 1 M 1°. 01 1 11 . 33 1
ART VRG MUS FAT VEN

~ ~

]
I 0:15:00 1 Time (h:mm:ss)

~ :tl ~UPtake(LJ
~ ~ ~ Delivered (LJ

Speed:
FGF VA CO ~
lim §] lim 14 . 03 1 LIm U I 5. I±j

Agent: !Enflurane Circuit: c.:IO.::.pe:.:.:n_----'

VA
LIM
10

t~--------------------------------------------~
O·~~------------------------------------------~
10

CO
LIM ~~--------------------------------------------~
O·~~------------------------------------------~

cn
ALV
VRG
MUS

%atm

Figure 7-1b shows the Picture and Graph resultingfrom keeping anes-
thesia administration at a constant alveolar tension with enflurane,
achieved by continuous manual adJustment of inspired tension.

7-5
Gas Man® OverjJrCSSllTC & OjJtimlUlI Ancsthesia

Agent: Ilsoflurane I:!:j ~Weight (Kg) Circuit: ISemi-Closedl ~l

Flush
o
DEL 10.001 CKTlo.221 ALV10.331 10.331 10.501 1°.051 10.001 1°. 39 1
%atm
ART VRG MUS FAT VEN

1 0:10:00 I Time {h:mm:ssl

~UPtake{lJ

~ Delivered {Ll

FGF f3I VA CO
Speed:
I:!:j
I.Cont.inue.. 1
LIm L-J LIm 14 . 00 1 lim [ ] 160x

Agent: Iisotrurane Circuit ISemi-Closed I

FGF
LIM
:~ 4-----------------~A~ __________________ 1

DEL
%atm
:§ \
CKl
AlV
VRG
MUS

%atm

Figure 7-lc shows the Picture and Graph resultingfrom keeping anes-
thesia administration at a constant alveolar tension with halothane,
achieved by continuous manual adjustment of inspired tension.

7-6
Gas Man® ()ZJe1jJressure & ()jJtim.wn Anesthesia

Agent: 1Sevoflurane L±j 170.0 IWeight (Kg) O-=-pe_n_--LI±.. .Jj

Circuit: ,-I

DEl
%atm
CKT!Z.3S! AlV!1.991 11.9 9 1 11.97 1 10. 21 1 10 . 01 1 11. 53 1
ART VRG MUS FAT VEN
I 0:15:00 I Time (h:mm:.s)
~UPtake(l)

~ Delivered (l)

Speed:
VA r::;-;;:)l CO
lIm ~ lim EJ Eill
Agent: ISevoflurane Circuit: Ic0-,,-pe:..:.n,--_.

VA
LIM 1: ~+--_ _ _ _----II
CO
LIM 1: ~l-----------ll

:~===-~~.~;======1',~
en
ALV
VHG
MUS

%atm

0:05 0:10 0.15

Figure 7-ld shows the Picture and Graph resultingfrom keeping

anesthesia administration at a constant alveolar tension with sevoflu-
"
rane, achieved by continuous manual adjustment of inspired tension.

7-7
Gas Man® Ouel!Jressure & Ojitilll1l1n Anesthesia

Agent: IDesflurane I:tJ ~Weight (Kg) Circuit: I,-O"-..pe_n_--1-1:tl

....

DEL
%atm
@] CKT@] ALV~ ~ ~ @] @]@]
ART VRG MUS FAT VEN

~]
1 0:15:00 I Time (h:mm:ssl

~ ~UPtake(L)
~ ~ Delivered (Ll

Speed:
§J VA co
FGF
LIm 10. lim 14.03 1 LIm ~ I 5. L:tl

Agent: !Desflurane Circuit: LIO"-pe_n_---'

VA
LIM 1: ~~----------------------------------------~
CO
LIM 1: ~r--------------------------------~
CKI
ALV
VRG
MUS

%atm

Figure 7-1e shows the Picture and Graph resultingfrom keeping anes-
thesia administration at a constant alveolar tension with desflurane, J

achieved by continuous manual adjustment of inspired tension.

Note that when using drugs of lower solubility, such as desf1urane

and sevof1urane, you need less overpressure to achieve and
maintain 1 MAC.

7-8
Gas Man®
xercise 7-2
Optimum anesthesia uses inspired and alveolar overpressure to
achieve and maintain constant brain anesthetic tension.
o SETUP
Parameter
Selection
Agent ........................ Isoflurane
Circuit .............................. Open
DEL (%) ................................. 5
FGF (L/min) ......................... 10
VA (L/min) ............................. 4
CO (L/min) ............................ 5
VIEW (min) ........................... 15
SPEED ............ .
OVCljJr('SSlirc & Optimum Anesthesia
To attempt optimum administration of
anesthesia which maintains brain partial
pressure perfectly controlled, adjust the
parameters as shown.
Adjust the vaporizer to achieve constant
brain (VRG) tension at 1 MAC = 1.1 %,
overlying the dotted line. As you adjust
inspired tension. Observe alveolar
tension carefully; allow it to overshoot
the 1 MAC line a bit. The alveolar over-
shoot is the alveolar overpressure which
is achieved in the blood which perfuses
the brain, temporarily driving it toward a
higher level than its final value. The
overpressure you use in the alveolar
compartment should be transient; there
should be no overpressure achieved in
the brain.
It must be recognized, with some drugs
and with some patients, that the high
and rapid rise in inspired, alveolar or
VRG tension may not be desirable on
clinical grounds.
7-9
Gas Man® OVeljJreSSllre & Optimum Anesthesia

o OBSERVATION
Agent: Iisoflurane I :!:1 §:]Weighl (Kg) Circuit: LIO-,-pe_n_--l..I:!:o-Ji

DEL 11.36 1 CKTI1.3 6 1 AlVll.021 11.021 11.031 10.131 10.011 10.811

%"atm
AAT VAG MUS FAT VEN

I 0:15:00 I Time (h:mm:ssl

~UPtake(Ll

~ Delivered (Ll

Speed:
FGF f1ill VA CO
LIm t.:..::::...J LIm 14. 01 1 LIm 15 . 00 1 1 10x I:!:l

Agent: Itsoflurane Circuit: !,--Op,-e_n_--,

10

~
VA
LIM
0
10

~
CO
LIM
0

CK!
ALV
VflG
MUS

%atm

------~--

Figure 7-2a shows the Picture and Graph of Exercise 7-2, showing an
optimum anesthetic course (1 .MAC in VRG) with isq,flurane.

For each volatile anesthetic agent (isoflurane, enflurane,

halothane, sevoflurane, desflurane), the dotted line on the
picture and graph represen ts 1 :MAC (see Table 6-1). Repeat this
exercise with the other anesthetic agents, trying to achieve vessel-
rich group tensions that overlay the dotted line at 1 MAC as
quichly as possible. In each case, start with the vaporizer set to the
top of the control bar. Many variations are possible.

7-10
Gas Man® Ollfllm'SSlIlP (5' OjJtimum Anesthesia

Agent: IEnflurane l.:!:i ~Weight (Kg)

Flush

o
DEL 12. 36 1
%atm
CKT12. 36 1 ALVI1. 62 1 11.621 11.641 10.271 10.021 11.291
ART VRG MUS FAT VEN

I 0:15:00 I Time (h:mm:ss)

~ Uptake(l)

~ Delivered Il)

Speed:
VA r:;n:;]
FGF
lIm~
"'"
lim ~ co "
lim~ " 110x I:!:j

Agent: IEnflUfane Circuit: O-,-pe__n_--,

<-I

VA
LIM 1: f
CO
LIM 1: ~
en
ALV
VRG
MUS

%atm

Figure 7-2b shows the Picture and Graph of Exercise 7-2, showing an
optimum anesthetic course (l MAC in VRG) with enflurane.

Figures 7-2 b,c,d,e show examples of the Picture and Graph for
each anesthetic. Yours may look different, depending on the
frequency of the adjustments you made and your facility with
using the mouse.

7-11
Gas Man® 01Je1jJressure (5 OjJtimw71 Anesthesia

/ Halothane L!l ~Weight (Kg) Circuit: IOpen

~.~-~~
I!I
..

DEL
%atm
IUS/
'O'~ DOD ~
cn/usl ALVI0.791 10.791 10.811 10.091 10.001 10.631
ART VRG MUS FAT VEN

I 0:15:00 I Time [h:mm:ssl

~Uptake(LI

Delivered [Ll

Speed:
FGF r:1ill VA CO
LIm ~ LIm 14 . 02 1 lim 110x I!l

Agent: IHalothane I
Circuit ,-O-,-pe_n_-"

VA
LIM
1: ~~_________________________________________
CO
1: ~~__________________________________________
LIM

ALV
VRG
MUS

%atm

Figure 7-2c shows the Picture and Graph of Exercise 7-2, showing an
optimum anesthetic course (1 MAC in VRG) with halothane.

7-12
Gas Man® Ovel1m~SS1lre & Optimum Anesthesia

Agent: !Sevoflurane L~:1 ~Weight (Kg) Circuit: <..:IO-'-pe.:...."_------il""'f!

Flush
o
OEl \2. 28 1 CKT12. 28 1 AlV\1. 94 1 \1.941 11.951 1°.23\ 1°.011 11.521
%atm
ART VRG MUS FAT VEN

I 0:15:00 I Time (h:mm:ss)

@=:J Uptake (Ll

@:=J Delivered (Ll

Speed:
FGF fliJl VA CO
LIm L:..J LIm 14. 01 1 lIm EI 110K Ifj

Agent: !Sevoflurane Circuit: O.!::pe::::n~---..J

t.:l

VA
LIM

CO
LIM

e~"====,=,,
CKT
ALV
VHG
MUS

%:atm ==1, I
0:05 0:10 0:15

Figure 7-2d shows the Picture and Graph of Exercise 7-2, showing an
optimum anesthetic course (1 .MAC in VRG) with sevoflurane.

7-13
Gas Man® OVl'ljJr!'SSlIIP & Oplimwn Anesthesia

,-------------------------------------------------

Agent: \Desflurane \±l ~Weight (Kg) Circuit IL0-'-pe=-:n_---<.I""'±j

Flush
o
DEL
CKT~ ALV~ ~ ~ ~ ~ ~
%atm
ART VRG MUS FAT VEN

1 0:15:00 1 Time (h:mm:ss)

~UPtake(L}

~ Delivered (L)

Speed:
FGF ~ VA CO ~
LIm ~ LIm /4. 03 1 LIm ~ 1 1 0x !±j

Agent: 1Desflurane Circuit: LIO-'--pe_n_---'

VA
LIM 1: -+--~ ---------ll
CO
LIM 1: ~I----- _ _ -----jl
CKT

]as: ;=, d
ALV
VRG
MUS

%atm
I
0:05 0:10 0:15

Figure 7-2e shows the Picture and Graph as a result of Exercise 7-2,
showing an optimum anesthetic course (1 .MAC in VRG) with
desflumne.

7-14
Gas Man® OveJjJressure & OJ)/i Inurn Anesthesia

o DISCUSSION
Ideally, one would like to monitor anesthetic tension in the brain
to precisely predict anesthesia depth. This is not practical, so the
brain is usually monitored by observing the clinical signs of
anesthesia (pupil size, blood pressure, pulse, respiration, reflex
responses to surgical stimulation, etc.). Occasionally, the
electroencephalogram (EEG) or evoked potential (EP) are used.
These techniques have not yet been shown to be reliable.

Inspiratory and expiratory anesthetic tensions can be measured

easily with commercial monitors using anyone of several tech-
nologies. End-expiratory tension is a good approximation to
alveolar tension and arterial anesthetic tension. Monitoring
inspired and end-expired tensions has proven useful in clinical
management.

7-15
Gas Man® OVe!preSS?lre & OJ)timw/l Anp,sthesia

xercise 7-3

Optimum clinical anesthesia uses vaporizer adjustment for

inspired overpressure and alveolar overpressure to achieve and
maintain constant brain anesthetic tension.

o SETUP
Parameter Selection
Agent ................. Isoflurane, etc.
Circuit .................... Semi-closed
DEL(%) ................................. 5
FGF (L/min) ......................... 10
VA (L/min) ............................. 4
CO (L/min) ............................ 5
VIEW (min) ........................... 15
You will now use a high-flow, semi-closed
circuit to attempt optimum clinical
administration of anesthesia. Adjust the
parameters as shown.
With the delivered isoflurane tension set
to 5%, adjust the vaporizer to achieve
constant brain tension. At the end of 2
minutes, decrease the delivered
isoflurane tension to 3.5%. You should
observe that ALV and VRG anesthetic
tensions are approximately 1.1 %, overly-
ing the dotted line.

SPEED ................................ lOx It must be recognized, with some drugs

and with some patients, that the high
Special ................................ n.a.
and rapid rise in inspired, alveolar or
VRG tension may not be desirable on
clinical grounds.

7-16
Gas Man® OverjJressure & OjJtimum illlesthesia

o OBSERVATION
Agent: Ilsoflurane til ~\IIeight (Kg) Circuit: ~~:5~

DEL 11 .52 !
%atm
CKT!1.3S! ALVll.OS! Il.OS I 11.OS! 10.13! 1°.011 1°.851
ART VRG MUS FAT VEN

I 0:15:00 I Time (h:mm:..)

~UPtake(L)

~ Delivered IL)

FGF r:;(ll VA co Speed:

lIm~ lim 14 . 01 1 lim [ ] 120K l:!oj

Agent: Iisoflurane Circuit: ISemi-Closed I

FGF
LIM

DEL
%atm

en
ALV
VRG
MUS

%atm

0:05 0:10 0:15

Figure 7-3a shows the Picture and Graph of clinical optimum anesthe-
sia administration (1 MAC in VRG) with isoflurane, achieved by
continuous manual adjustment of the vaporizer with FGF = 10 L/min.

Repeat this exercise with the other anesthetic agents, trying to

achieve vessel-rich group tensions that overlay the dotted line at 1
MAC as quickl)) as possible. Many variations are possible. Figures
7-3 b,c,d,e show examples of the Gas Man Picture and Graph for
each anesthetic. Yours may look different, depending on the
frequency of the adjustments you made and your facility with
using the mouse.

7-17
Gas Man® OveljJrr'sslIJ'e & OjJtimum Anesthesia

Agent: IEnflurane 1:!:1 ~Weight (Kg) Circuit: ISemi~Closedl :!1

Flush
~ 0
:t:l

DEL 112. 96 1 cnl2.6ll AlVI1. 73 1 11.731 11.721 10.251 10.021 11.361

%atm
ART VRG MUS FAT VEN

I 0:15:00 I Time (h:mm:ss)

~ Uptake(L)

~ Delivered (ll

Speed:
FGF r::;n-] VA CO
lim ~ LIm 14.0,1/ LIm [J 1 20x I:!:I

Agent: IEnflurane Circuit: ISemi·Closed I

FGF
LIM

DEL
%atm :~ ~'-----l

:1G:2:-~;;;~I
en
ALV
VRG
MUS

%atm

0:05 0:10 0:15

Figure 7-3b shows the Picture and Graph of clinical optimum anesthe-
sia administration (1 .MAC in VRG) with enjlurane, achieved by
continuous manual adjustment of the vaporizer with FGE equal to 10
L/min and an initial vaporizer setting equal to 7%.

7-18
Gas Man® OverjJressure & OjJtimulIlllneslhesia

--~-----~------------------~

Agent: IHalothane I:!:j ~Weight{KgJ Circuit: ISemi.Closedl:!:l

DEL 11.721
%atm
CKTI 1.48 I AlVlo.ssl 10. 8s l 10.871 1°.091 1°.°°1 10.681
ART VRG MUS FAT VEN

I 0:15:00 I Time {h:mm:ssJ

~ Uptake{lJ

@=:J Delivered {ll

Speed:
VA CO
lim 14.02 1 lim ~ 120K I:!:j

Agent: IHalolhane Circuit: ISemi-Closed I

FGF
LIM 1: ~
DEL
%atm

en
AlV
:~
VRG
MUS

%atm

Figure 7-3c shows the Picture and Graph of clinical optimum anesthe-
sia administration (1 .MAC in VRG) with halothane, achieved by
continuous manual adjustment of vaporizer with FGF = 10 L/min.

7-19
Gas Man® Ov(!1jJTessure & Optimum ilnesthesia

Agent: ISevonurane I~J ~\y'eighl (Kg) Circuit: ISemi~Closedt:tl

Flush
o
DEL 12 . 36 1
%atm
CKT12. 23 1 ALV~ ~ 11 . 94 1 10. 22 1 10. 01 1 11 . 51 1
ART VRG MUS FAT VEN
I 0:15:00 1 Time (h:mm:ss)

@J Uptake (L)
~ Delivered {L}

Speed:
FGF 1101 VA co r<:!
Llm~ LIm 14. 01 1 LIm L.J 120• I±l

Agent: !Sevoflurane Circuit: ISemi~Closed I

FGF
LIM 1: ~ I
DEL
%atm
5 ~ L1'--_~_ _ 1

en

J~ I I
ALV
VRG
MUS

%alm

0:05 0:10 0:15

Figure 7-3d shows the Picture and Graph of clinical optimum anesthe-
sia administration (1 .MAC in VRG) with sevq,flurane, achieved by
continuolls manual adjustment of vaporizer with FGF = 10 L/min.

7-20
Gas Man® OVClj;resslIre & Optimum Anesthesia

Agent: IOesflurane 1#:1 ~Weight (Kg) Circuit: ISemi~Closedl;i

Flush
o
DEL
4:atm
CKT@] ALV~ ~ ~ @] ~ @]
ART VRG MUS FAT VEN
I 0:15:00 I Time (h:mm:.s)
~UPtake(LI
~ Delivered (Ll

Speed:
VA co ~
LIm 14 . 02 1 LIm U \20. L~I

Agent: IOesflurane Circuit: Isemi~Clo$ed I

FGF
LIM

OEl
%atm

en
AlV
VBG
MUS

%atm

Figure 7-3e shows the Picture and Graph of clinical optimum anesthe-
sia administration (1 .MAC in VRG) with desjlurane, achieved by
continuous manual adjustment of vaporizer with FGF = 10 L/min.

7-21
Gas Man® OVI'JjJrl'ssure & OjJtimum Anesthesia

ummary
---~-

Overpressure can be used to bring alveolar or exhaled anesthetic

tension to any desired level quickly and easily. In an open cir-
cuit, frequent or continuous adjustments of delivered anesthetic
tension are required to maintain the desired level. Initial in-
spired tension should be the target alveolar tension multiplied by
the solubility-acUusted overpressure ratio. Il must be recognized,
with some drugs and with sorne patients, that the high and rapid
rise in inspired, alveolar or VRG tension may not be desirable on
clinical grounds.

In this chapter, you have reproduced the classic simulations of

anesthesia administration at constant alveolar concentration with
an open (non-rebreathing) circuit", and have designed optimum
administration of othel- anesthetic agents on your own.

An optimum anesthetic course provides constant brain anes-

thetic tension. This is achieved by briefly providing the correct
level of arterial overpressure to the brain. Since arterial blood
anesthetic tension is considered to equal alveolar, this overpres-
sure can be controlled by controlling alveolar or expired tension.
In turn, inspired overpressure achieves the alveolar overpressure
required. Finally, because of the limitations of today's breathing
circuits, an additional level of vaporizer overpressure is required
to bring inspired up to the levels required. Because the brain
comes to perfect equilibrium with blood in only a short time,
alveolar overpressure will be required only transiently, unlike
inspired overpressure which must be maintained as long as
anesthetic is being taken up by other tissues, notably muscle and
fat.

7-22
Chapter 8 \
11\\
)
The Higl}J~Spir~d Concentration Effect
U o

The concentration rjJect explains the observation that alveolar

tension approaches inspired tension more rapidly with high
inspired concentration than with low. This is explained in the
following manner.

When a gas is administered to a patient's lungs, uptake of that

gas into the bloodstream attempts to decrease lung volume below
normal. This volume reduction, were it to occur, would be
equal to anesthetic uptake into the blood. Anesthetic uptake
into the blood is governed by inspired tension, cardiac output,
and blood/gas solubility. To maintain constant lung volume,
additional gas is drawn into the lungs with each breath, and
inspired alveolar ventilation is elevated.

In the extreme case when the inspired concentration is 100%,

the increased inspired ventilation exactiy compensates for gas
uptake into blood. This is sometimes practiced clinically with
nitrous oxide 17 • The end result is that uptake does not delay the
rise in alveolar anesthetic tension as is the case with lower in-
spired tensions. In other words, inspired alveolar ventilation is
augmented to bring 100% nitrous oxide into the lungs as fast as
nitrous oxide is removed from the lungs by cardiac output.
Thus, alteration of cardiac output should not affect the alveolar
tension curve.

If inspired nitrous oxide concentration is less than 100%, lung

volume is replaced with a nitrous oxide-plus-oxygen mixture that
does not fully compensate for nitrous oxide uptake. Hence, the
rise in alveolar tension is not accelerated as much as with a

8-1
Gas Man® High insjJireri Concentration EJIect

higher concentration. There is a continuum in compensation

for uptake between the extremes of 100% anesthetic and trace
concentrations.

To study the concentration effect, you will first observe the rapid
rise in alveolar tension with 100% nitrous oxide and the slower
rise with 40% nitrous oxide inspired. Next you will demonstrate
that cardiac output does not affect the alveolar tension curve
when 100% nitrous oxide is inspired. Finally, you will observe
the slowed alveolar tension curve when the augmentation of
inspired alveolar ventilation is totally eliminated in the simula-
tion.

(.- WARNING: Administering 100% nitrous oxide to patients is potentially

hazardous. It should rarely be used except for short periods
(typically less than 1 minute), and only after previous administra-
tion of oxygen (de-nitrogenation, or pre-oxygenation). An
oxygen monitor (with alarms) must be used. The Gas Man
program allows you to try this and other hazardous anesthetic
administrations in simulation so that you can learn basic prin-
ciples without risking patient harm.

8-2
Gas Man® High InsjliFed COTu:entmtio1/ FJpct

xercise 8-1

The concentration effect is demonstrated by administering 100%

inspired nitrous oxide followed by administering a lower concen-
tration, and observing the alveolar tension curve in response to
each.

o SETUP
Parameter Selection Set the program parameters as shown.
To observe the concentration effect most
Agent ................... Nitrous Oxide dramatically, simulate administering
100% inspired nitrous oxide.
Circuit .............................. Open

DEL (%) ............................. 100 ~Note:

This is not meant to suggest using 100%
FGF (Ljmin) ......................... 10 anesthetic in clinical practice; 70-75% is
a more reasonable maximum.
VA (Ljmin) ............................. 4

CO (Ljmin) ............................ 5

VIEW (min) ........................... 10

SPEED ................................ 60x

Special ................................ n.a.

8-3
Gas Man® High fnsjJired CO}7centration Lffect

o OBSERVATION
INitrous Oxide I :!:1 BC]Weignt (Kg) Circuit: I,-O-,-pe_n_--LI±....Jl

DEL
%atm
1100.1 CKTI 100 1 AlVIJ!] IJ!] ~ Q2J QJ ~
ART VRG MUS FAT VEN

I 0:10:00 I Time {h:mm:ssl

~ Uptake(ll

1100.00 I Delivered III

Speed:
FGF f1fll VA CO '·.Conlinue
lIm ~ lim 14. 00 1 LIm [::::J IAFAP I±j

Agent: INitrous ORide I Circuit: I,-,-O.::.;pe",n_--,

VA
LIM l: q~-----------------------------------------~
CO
LIM
1: q~ ________________________________ ~

en
ALV
VRG
MUS

%atm

Figure 8-1 shows the Picture and Graphfrom Exercise 8-1, demonstrat-
ing anesthetic tensions after administering 100 % nitrous oxide for 10
minutes.

The concentration effect has augmented inspired alveolar venti-

lation (VA) and sped equilibration betw·een inspired and alveolar
tensions. This should never be attempted in clinical practice.

8-4
Gas Man® High ImjJired Concentration Effect

o DISCUSSION
Observe how rapidly the alveolar anesthetic tension rises toward
100%; in the Graph alveolar tension reaches inspired tension in
about 2.7 minutes. The time constant appears to be 0.6 minutes.
Notice also that alveolar ventilation increases from 4.0 to 5.6 L/
min, and then returns slowly toward its original value. The value
shown represents inspired alveolar ventilation. Inspired alveolar
ventilation is the alveolar ventilation you selected plus the addi-
tional inspired ventilation necessary to maintain constant lung
volume (FRC) on a breath-by-breath basis. Total body uptake of
nitrous oxide is 7.3 L after 10 minutes.

8-5
Gas Man® High insjJired Concentration Effect

xercise 8-2 ----~~.--~

The concentration effect is smaller with 40% nitrous oxide

inspired than with 100%.

o SETUP
Parameter Selection Set delivered tension (DEL) to 40%
while maintaining the other settings, and
Agent ................... Nitrous Oxide observe the alveolar tension curve.
Circuit .............................. Open

DEL (%) ............................... 40

FGF (Ljmin) ......................... 10

VA (Ljmin) ............................. 4

CO (Ljmin) ............................ 5

VIEW (min) ........................... 10

SPEED ................................ 60x

Special ................................ n.a.

8-6
Gas Man® High ImjJired Concentration E[(ect

o OBSERVATION
Agent: INitrous Oxide I:!:j ~Weight (Kg)

Flush
~ 0
:tJ

DEL f4iil en[§] AlVCE] CE] CE] QJ QJ ~

%atm L..:::J
ART VAG MUS FAT VEN

I 0:10:00 I Time (h:mm:ss)

~ Uptake(l)

~ Delivered (lJ

Speed:
FGF f1rll VA ~ CO r;;--]
lim ~ lim ~ lim ~ 160x I:!:I

Agent: INitrous OKide I Circuit:

~-~

VA
LIM ': ~~~------------------------------------~
CO
LIM

AlV
VRG
MUS

%atm

Figure 8-2 displays the Picture and Graph from Exercise 8-2, showing a
small concentration effect when 40 % nitrous oxide is inspired.

Alveolar tension does not quite equal inspired, even after 10

minutes. Note that alveolar tension no longer reaches inspired
tension in the first 3 minutes. Rather, a curve similar to those
observed with halothane, enflurane, and isoflurane is produced.
Here, the concentration effect plays some role, since alveolar
ventilation is seen to rise slightly.

8-7
Gas Man® Hip,!1 InsjJired Concentration £jJect

xercise 8-3

Cardiac output has no effect on alveolar tension when 100%

anesthetic is inspired.

The concentration effect brings inspired gas into the lungs as

cardiac output takes it away. You will next test whether this works
in the limiting cases when cardiac output is taken to extremes.

o SETUP
In the next three simulations, vary car-
Parameter Selection
diac output as follows: first set co at 1 L/
Agent ................... Nitrous Oxide min; then 10 L/min; and finally 0 L/
min. For each simulation, the param-
Circuit .............................. Open
eters should be set as shown.
DEL (%) ............................. 100

FGF (L/min) ......................... 10

VA (L/min) ............................. 4

CO (L/min) ... 1, then 10, then 0

VIEW (min) ........................... 10

SPEED ............................. AFAP

Special ................................ n.a.

8-8
Gas Man® High fllsjlired COllcentration E1!ect

o OBSERVATION
Agent: INitrous O.ide 1:!oj §:]weight (Kg) Ci,cuit:1'- :!o
O-,-pe_n_--,-I.... I

Flush
o
f100l
DEL
%atm ~
CKT~ AlV~ 1 100 1 ~ QJ OJ ~
ART VRG MUS FAT VEN

1 0:10:00 I Time (h:mm:ss)

~UPtakelll

1100.00 I Delive,ed III

FGF f1ill VA CO
lim ~ lim ~ lim 11.00 1

Agent: INitrous Oxide I Circuit: LeiO-'-pe_n_---'

VA
LIM l:f I
CO
LIM 1: ~ I

'~~
CK1
AlV
VRG
MUS

%atm

0:02 0:04 0:06 0:08 0:10

Figure 8-3a shows the Picture and Graph of anesthetic tensions after
administering 100 % nitrous oxide for 10 minutes with cardiac output
ofl L/min.

Alveolar reaches inspired tension in about 2.7 minutes. Total

body nitrous oxide uptake is 2.9 L after 10 minutes. Alveolar
ventilation rises slightly.

8-9
Gas Man® High InsjJirrd Concentratiol7 Effect

Agent: INitrous OHide I.~l ~Weight (Kg)

Flush
~ 0
:t:l

DEL 1100_1
%atm
CKlllOol ALVllool ~ 1 100 1 ~ ~ [£J
ARl VRG MUS FAl VEN

1 0:10:00 1 lime (h:mm:s.l

~UPtake(LI

1100_00 1 Delivered (Ll

Speed:
FGF f1(i"I VA CO
Llm~ LIm
U8
I 1 LIm Imol IAFAP If)

Agent: INitrous Oxide I Circuit: LI0-'--pe_n_---'

VA
LIM 1: ~_.__--__--------------------------------~
CO
LIM

en
ALV
VRG
MUS

%atm

Figure 8-3b shows the Picture and Graph of anesthetic tensions after
administering 100 % nitrous oxide for 10 minutes with cardiac output
of 10 L/min.

Alveolar tension again reaches inspired tension in about 2.7

minutes, and the alveolar tension curve is again unchanged
despite the increase in tissue uptake. Total body nitrous oxide
uptake is l1A L after 10 minutes of simulation. Alveolar ventila-
tion rises slightly.

8-10
Gas Man® H(gh Inspired Concentration j,jj(xi

Agent: !Hitrous Oxidili ~Weight (Kg) Circuit: ' - ' - _ - - - ' - '

~ ]~----O'"fr
:]'0'
Il [l [l
rJ J J J
[l
DEL
%atm
CKT~ ALVl 100i
~ OJ OJ OJ OJ
ART VRG MUS FAT VEN

I 0:10:00 I Time (h:mm:ssl

~ Uptake(Ll

1100.00 I Delivered (Ll

FGF VA CO Speed:
I Continue
LIm §] lIm 14. 00 1 lim 000
1 1 IAFAP I±I

Agent: INitrous Oxide I Circuit: lL:.op::..::e~n_--,

VA
LIM

CO
LIM 1: ~

%atm

Figure 8-3c shows the Picture and Graph of alveolar anesthetic tension
if there were no uptake into blood (CO=O).

As before, alveolar reaches inspired tension in about 2.7 minutes

and the alveolar tension curve is unchanged. With no cardiac
output, tissue uptake is of course zero. Alveolar ventilation rises
slightly.

8-11
Gas Man® High InsjJired Concentration E,ffi:ct

xercise 8-4

The concentration effect is removed by eliminating uptake's

augmentation of inspired alveolar ventilation.

Next, you will use a special feature of the Gas Man program that
eliminates the effect of uptake on alveolar ventilation. This is not
possible physiologically, of course, but it serves to emphasize that
the concentration effect is caused by increased inspired alveolar
ventilation secondary to anesthetic uptake into blood. By using
the Special menu and selecting Disable Uptake, you can totally
eliminate the concentration effect. When you do, you will see a
curve shape representative of the response to trace or low anes-
thetic tension administration, no matter how high the actual
concentration.

o SETUP
Parameter Selection
Set the parameters for this exercise as
Agent ................... Nitrous Oxide shown, using the Special menu to
Disable Uptake.
Circuit .............................. Open

DEL (%) ............................. 100

FGF (L/min) ......................... 10

VA (L/min) ............................. 4

CO (L/min) ............................ 5

VIEW (min) ........................... 10

SPEED ............................. AFAP

Special ............. Disable Uptake

8-12
Gas Man® High InsjJired Concenlralion hfJect

o OBSERVATION
Agent: INitrous Oxide I:!:J ~Weight (Kg) Circuit: t.::IO-'=-pe::.:.:n_---LI-::.J+!

Flush
±l [J
:tl

DEL
%atm
1100.1 CKT~ ALV~ ~ ~ Q!] IT] ~
ART VRG MUS FAT VEN

I 0:10:00 I Time (h:mm:ssl

~ Uplake{LI

1100.00 I Delivered (Ll

Speed:
FGF f1nl VA CD ~ IC(lOli.nue .
10
LIm ~ LIm 14. 00 1 LIm L IAFAP If I

Agent: INitrous Oxide I Circuit: IL-Dp=-e_o_-,

VA
LIM
1: + - q_ _ _ _ ---II
CO
LIM 1: ~f--------il

'~~I'I I
CKT
ALV
VRG
MUS

%atm

0:02 0:04 0:06 0:08 0:10

Figure 84 shows the Picture and Graph of Exercise 84, demonstrating

anesthetic tensions with 100 % nitrous oxide inspired with the concen-
tration iffect removed.

Notice that although alveolar tension rises rapidly at first, a knee

occurs at about 1 minute, when alveolar tension reaches about
60% of inspired. The curve is qualitatively similar to the open
circuit alveolar tension curves observed earlier for halothane,
enflurane, and isoflurane administered in low concentrations.
The initial rise, knee, and tail are clearly seen.

8-13
Gas Man® High IusjJired Conrel1lmlioll Efji:c/

The second gas 1fect is the result of rapid uptake of one gas in-
creasing the alveolar tension of a second, simultaneously admin-
istered, gas. This is discussed in detail in Chapter 11.

In this chapter, you have seen that the concentration effect

describes the accelerated alveolar tension rise that occurs at high
inspired concentration. It is due to the increased inspired alveo-
lar ventilation and increased alveolar anesthetic delivery that
accompanies uptake into the bloodstream. ,Vhen inspired con-
centration is 100%, this effect is maximized, and alveolar tension
rise becomes independent of cardiac output. In Chapter 11, you
will see that if a second gas is administered simultaneously, the
alveolar tension of the second gas rises higher and faster than it
would have if it were present alone. This is termed the second
gas effect.

8-14
 ~\
Chapter 9 ( )
low Fre~\Ga~FIOW Anesthesia
! )
\~
o

heory

In a semi-closed breathing circuit, high fresh gas flow allows the

inspired anesthetic tension to closely approximate that delivered
from the anesthesia machine, even during induction. This
relationship is important, since it is the delivered tension that the
anesthetist controls. As anesthesia proceeds, expired anesthetic
tension rises toward inspired tension. The fresh gas flow may
now be lowered, since the only consequence is rebreathing the
warm, humidified, anesthetic-containing expired gas. For this
reason, low flow anesthesia is used by some clinicians for mainte-
nance of anesthesia after induction is completed. Reducing flows
from 8 to 2 L/min, for instance, reduces anesthesia cost by about
75%3U'l,41,42 while simultaneously providing heat and humidity to
inspired gas8 .

When real breathing circuits are used with low fresh gas flow,
agents can be removed by flushing with oxygen. The Flush but-
ton in the Gas Man Picture allows you to simulate this action.

Gas Man also provides the user an ideal circuit for experimenta-
tion. Real breathing circuits behave in a manner somewhere
between Gas Man's fully mixed semi-closed circuit and the un-
mixed, first-in first-out ideal circuit. The ideal circuit has all of
the properties of the non-rebreathing or open circuit whenever
FGF exceeds ventilation. W11en FGF is less than ventilation, fresh
gas is breathed in preference to exhaled gas. Thus, inspired gas is
dominated by fresh gas as long as FGF is high.

9-1
Gas Man® Low Fresh Gas Flow Anl!sthesia

xercise 9-1

Fresh gas flow can be reduced without changing clinical course.

o SETUP
Parameter Selection
Agent ........................ Isoflurane
Circuit ................... Semi-Closed
DEL (%) ..................... 5% - See Text
FGF (L/min) ................. 8 - See Text
VA (L/min) ............................. 4
To demonstrate the effect of reducing
fresh gas flow during anesthesia, adjust
the Gas Man parameters as shown. Set
Bookmarks at 1 minute and 4 minutes
for convenience. Start with DEL set to
5 %. After 1 minute, instead of decreasing
the vaporizer setting as most do clinically,
decrease the fresh gas flow to 2 L/min. At 4
minutes, decrease DEL to 2%.

CO (L/min) ............................ 5

VIEW (min) ........................... 15

SPEED ................................ 20x

Special ................................ n.a.

9-2
Gas Man® Low Fresh Gas Flow A1?I'sthesia

o OBSERVATION
Agent: Iisoflurane L~l ~Weight [Kg)

DEL
%atm
12.°°1 CKT\1.37\ AlV\l.04\ \1.041 11.071 \°.121 \0.01\ \0.83\
ART VRG MUS FAT VEN

I 0:15:00 I Time [h:mm:ss)

~ Uptake[l)

~ Delivered IL)

Speed:
FG F r;-;;;)l VA ~ CO
LIm ~ LIm ~ lim [ ] IAFAP L±\

Agent: Iisoflurane Circuit: ISemi-Closed I

FGF
LIM
':0
DEL
%atm

CKT
AlV
:~ \

VRG
MUS

%atm

Figure 9-1 shows the Picture and Graph of Exercise 9-1, demonstrating
the response to high jlow induction with isojlurane for 1 minute, fol-
lowed by a reduction of FGF and, later, delivered tension (DEL).

Note in Figure 9-1 that the patient's VRG tension rises to and
remains constant at 1 MAC despite the changes in FGF and DEL.
You can perform additional experiments, adjusting fresh gas flow
and delivered tension while trying to produce the same alveolar
anesthetic tension curve.

9-3
Gas Man® Low i'Jes/z Gas Flow Anesthesia

o DISCUSSION
After each simulation you run in this Exercise, observe the Pic-
ture and note the volume of anesthetic delivered to the circuit
(Delivered) and the volume taken up by the patient (Uptake).
You can infer the efficiency of anesthesia administration by
computing the ratio of uptake to delivered quantity. The poten-
tial for monetary savings can be seen from the difference be-
tween delivered and uptake. This is discussed in more detail in
Chapter 14, Analyzing Cost. For now, select the Show Cost icon
from the toolbar and note how the differences in volume with
different techniques translate to dollars

9-4
Gas Man® IJJW Fresh Cas Flow A nes[//{~sia

xercise 9-2

Circuit Flush reduces anesthetic tension faster than turning off

the vaporizer.

o SETUP
Parameter Selection
Agent ........................ Isoflurane
Circuit ................... Semi-Closed
DEL (%) ..................... 5% - See Text
Set the parameters as shown to start this
Exercise. Set Bookmarks at 5 minutes
and 10 minutes. At the end of 5 minutes,
reduce DEL to 0%, and continue the
simulation to its end.

FGF (L/min) ........................... 3

VA (L/min) ............................. 4

CO (L/min) ............................ 5

VIEW (min) ........................... 10

SPEED ................................ 60x

Special ................................ n.a.

9-5
Gas Man® Low Fresh Gas Flow Anesthesia

o OBSERVATION
Agent: !Isollurane ! :!1:j ~Weight [Kg} Circuit:

DEL 10 . 00 1
%atm
CKTI 0.42 I AlV10. 58 1 1°.581 10.S31 10.071 10.001 10.641
ART VRG MUS FAT VEN

I 0:10:00 I Time {h:mm:ssl

~ Uptake(l}

~ Delivered ILl

Speed:
FGF r:>i VA co ~
LIm ~ LIm 4. 00 1
1 lim ~ 160x Ifj

Agent: II sollur ane Circuit: ISemi-Closed I

FGF
LIM
:j
DEL
%atm
:j
CKT

Figure 9-2a shows the first Picture and Graph of Exercise 9-2, wherein
DEL is reduced to 0 % halfway through a 10 minute anesthetic.

Reducing DEL from 5% to zero after 5 minutes results in 10-

minute values of 0.42% for CKT, 0.58% for ALV, and 0.83% for
VRG. Save this simulation (you will need to name it) and reduce
it to an icon on your desktop by clicking on the down arrow in
the upper right corner of the simulation's window.

9-6
Gas Man® Low Fresh Gas Flow Anesthesia

Agent: IlsoHwane I:!:] ~\IIeight (Kg]

EJ
~
:!:l
IT Flu. S.h
0

DEL
%atm
10.001 cnlo.221 AlV10.331 10.331 10.5°1 10051 10.001 1°.391
ART VRG MUS FAT VEN

I 0:10:00 I Time (h:mm:ssl

~ Uptake(L)

~ Delivered (L]

FGF r:>I VA rAnnl co ~

Speed:
I. Continue .J
l/m~ lim ~ lim ~ ISO. I±!

Agent: Iisoflurane Circuit: ISemi~Closed I

4-__________________-JA~ ___________________
FGF
LIM
:j
DEL
Zatm
:j
en
ALV
VRG
MUS

Figure 9-2b shows the second Picture and Graph of Exercise 9-2,
wherein the circuit is flushed halfway through a 10 minute anesthetic.

Open a New simulation and run it using the same parameters,

but this time, at 5 minutes, reduce DEL to 0% and press the Flush
button, located between the DEL control bar and the CKT com-
partment. Press Continue. The results are shown in Figure 9-2.
Once the circuit is flushed, CKT tension immediately falls to
zero. Then, anesthetic again returns to the circuit in exhaled gas
and circuit tension rises slightly. With this technique, you see 10-
minute values of 0.22% for CKT, 0.33% for ALV, and 0.50% for
VRG.

9-7
Gas Man® Low Fresh Gas Flow A lIes/ hesia

o DISCUSSION
vVith a low fresh gas flow (3 L/min), you see that despite the
vaporizer being switched off, inspired tension slowly fell to 0.35%
by the end of 10 minutes. However, \vhen you flushed the circuit
after setting DEL to zero, circuit tension fell to zero immediately
and rose only to 0.22%. Because of this, alveolar tension and
vessel rich group tension were much lower after the circuit was
flushed than when it was not.

You can further analyze these two techniques by using Gas Man's
Overlay feature. Keeping the second simulation open, find the
icon of the first simulation on your desktop and double-click to
open it. Select Overlay from the View menu or click on the
Overlay icon in the Toolbar. Select MAC in the right ("Over")
column by clicking the radio button to its right. Then observe
each compartment's tension over MAC by selecting in sequence
in the left ("Show") column DEL, CKT, ALV and VRG. As you
move through these overlays, note the following: DEL is the same
for both; CKT falls to zero and then rises slightly in the flush
technique; ALV falls rapidly in the flushed circuit; and VRG falls
more rapidly with the flush technique.

In Chapter 13, you will see that wake up occurs when the VRG
falls to some threshold value. It is clear that with low FGF, a flush
is needed if the clinician wants the circuit, alveolar, and VRG
tensions to fall to a wake up level quickly.

9-8
 Low Fresh Gos Flow Anesthesia

Show Over
o DEL 0
®CKT 0
ALV 0
OVRGO
o MUSO
o FAT 0
OVEN 0
0:00 0:02 0:04 0:06 0:08 0:10 MAC ®
Time (HH:MM)
One 0
legend:
o Cost

Figure 9-2c shows the Overlay View comparing the CKTjMAC CU17JeS
with and without a flushed circuit.

Show Over
2--~----------------------------~
o DEl 0
OCKT 0
®ALV.O
OVRGO
OMUSO
OFA.tO
OVEr-tO
0:00 0:02 0:04 0:06 0:08 0:10 MAC®
Time {HH:MMI
One> 0
legend:
o Cos!
t . . . . ~.~!~...... J
I... £~()!~ ... JJ
Figure 9-2d shows the Overlay View comparing the ALVjMAC curves
with and without a flushed circuit.

9·9
Gas Man® Low Fresh Gas Flow Ii nesthesia

xercise 9-3

In an Ideal circuit, fresh gas fills the circuit first and then mixes
with exhaled gas.

The ideal circuit represents what would happen if there were no

gas mixing in the semi-closed circuit. In that case, inspired ten-
sion would approach delivered tension more closely. At very low
fresh gas flows, both circuits would behave similarly. As fresh gas
flow approaches minute ventilation, the ideal circuit behaves
more and more like an ideal circuit. The behavior of clinical
circuits lies somewhere in between that of the semi-closed and
ideal circuit.

o SETUP
-------------
For this Exercise, you will run two simu-
Parameter Selection
lations according to the parameters
Agent ........................ Isoflurane shown at left - first using a semi-closed
circuit and then using an ideal circuit.
Circuit .......... Semi-Closed; Ideal

DEL (%) ................................. 3%

FGF (L/min) ........................... 3

VA (L/min) ............................. 4

CO (L/min) ............................ 5

VIEW (min) ........................... 10

SPEED ................................ 60x

Special ................................ n.a.

9-10
Gas Man® Low Fresh Gas Flow Anesthesia

o OBSERVATION
Agent: II soflur ane Circuit: ISemi·Closed I

FGF
LIM
:j
DEL
%atm
:j
en
ALV
VRG
MUS

%atm

Agent: !Isoflurane Circuit: t.:.:11d::.:ea:.:.-I_-l

FGF
LIM
:j
DEL
%atm
:j
en
AlV ,--
VRG
MUS -
.r--
%atm
0
/ ;...----
I I I I
0:02 0:04 0:06 0:08 0:10
View:
110 Min I!l

Figure 9-3 shows the Graphs of Exercise 9-3, simulating low jlow
administration ofisojlurane in a semi-closed (toP) and ideal (bottom)
circuit.

The Graphs from these two simulations (Figure 9-3) show that
with a semi-closed circuit, inspired rises exponentially toward the
5% set on the vaporizer. In an ideal circuit, inspired rises to near
4% very quickly and then begins to level off. This is expected,
because in an ideal circuit, inspired gas is comprised preferen-
tially of fresh gas, augmented by the requisite exhaled gas to
provide minute ventilation. This augments circuit concentration.

9-11
Gas Man® Low Fresh (;as Flow lll1esl/zesia

In low flow anesthesia, fresh gas flow can be decreased after the
initial period of rapid anesthesia uptake without sacrificing
control of inspired tension. Cost savings can be achieved while
maintaining the same inspired anesthetic tension, and hence the
same clinical anesthesia course, as with high flow technique.

To allow rapid lightening of anesthetic depth, pushing the oxy-

gen flush button clears the breathing circuit of anesthetic agent,
at least transiently.

If actual breathing circuits were not well mixed, they could

perform more like the Ideal circuit, in which the patient breathes
fresh gas in preference to exhaled gas.

9-12
 /~-~

I "\
Chapter 1 0 ( )
Closed-(;Jr~~Anesthesia
,I \
I
\ /
"---"
o

Closed-circuit anesthesia is a drug administration technique in

which quantities of anesthetic are administered to the patient-
breathing circuit combination in an effort to produce a constant
level of anesthesia. Unlike other anesthesia techniques, no gases
are allowed to leave the system other than carbon dioxide which
is absorbed chemically. In a closed system, delivered or inspired
tension is usually not adjusted directly. Rather, the rate of anes-
thetic added to the breathing circuit is controlled.

A prediction of anesthetic uptake based upon patient size allows

the amount and timing of anesthesia administration to be de-
cided before the patient's actual response is observed. If the
prediction is wrong, the desired anesthesia level will not be
attained and the rate of administration will require modification.
The use of a moni tor for end-expired (or approximately alveo-
lar) anesthetic tension allows this modification to be made easily.
Using these monitors, anesthetic drug administration can be
tailored to achieve the inspired, alveolar or brain tension desired.

To achieve the same anesthesia time course with a closed system,

the inspired anesthetic tension should be the same as with any
other system. "With semi-closed and open breathing circuits,
inspired anesthetic tension can be controlled indirectly or di-
rectly; uptake cannot easily be measured. \t\Tith the closed-circuit
technique, inspired and expired tensions can be measured, and
uptake is observed by monitoring the required quantity adminis-
tered.

To understand a closed-circuit liquid-injection anesthetic induc-

tion, remember that the time course of inspired anesthetic

10-1
Gas Man® Closeri-Cirwil A 17esl hesia

should be similar to that required for a conventional semi-closed

or open-circuit anesthetic, during both induction and mainte-
nance. Figures 7-1 through 7-3 in Chapter 7 provide guidelines
for a desirable time course of inspired anesthetic tension. Using
the Gas Man computer simulation, you can iruect liquid anes-
thetic into the breathing circuit and allow it to vaporize there.
You can administer these injections so that the inspired anes-
thetic tension curve is similar to that produced with the semi-
closed or open circuit. If you properly control the inspired
tension, you should expect the same time course of exhaled or
alveolar anesthetic tension you observed before. The same holds
true for the anesthetic tension in the brain.

One of the unique features of Gas Man is the ability to represent

liquid anesthetic administration. The red-and-black syringe icon
is located on the Gas Man Screen, attached to the breathing
circuit. A single click on the syringe will simulate liquid injection
into the breathing circuit.

The default unit dose of the liquid injected is 1.0 mL for desflu-
rane, enflurane and sevoflurane, and 0.5 mL for halothane and
isoflurane. This can be adjusted by using the Anesthesia menu,
selecting Unit Dose, and typing in the desired value. This "unit
dose" should not be confused with the Standard Unit Dose, calcu-
lated using formulas found in the closed-circuit anesthesia litera-
ture22, 23. 24.

For each of the volatile liquid anesthetics, I mL of liquid will

vaporize the following amounts:

desflurane 1 mL liquid = 209 mL vapor

enflurane 1 mL liquid = 198 mL vapor
halothane 1 mL liquid = 228 mL vapor
isoflurane 1 mL liquid = 196 mL vapor
sevoflurane 1 mL liquid = 183 mL vapor.

vVhen liquid is irUected, the plunger in the syringe moves, and

the circuit and inspired tensions rise as if liquid was instanta-
neously mixed in the single breathing circuit compartment.

10-2
Gas Man® Closed-Circuit Anesthesia

xercise 10-1

A closed-circuit liquid anesthetic injection induction can be

simulated with Gas Man.

o SETUP
Parameter Selection
Agent ........................ Isoflurane
Circuit ........................... Closed
DEL (%) ................................. 0
FGF (L/min) ........................... 0.25
VA (L/min) ............................. 4
CO (L/min) ............................ 5
To simulate a closed-circuit, liquid-
injection anesthetic induction, adjust the
Gas Man parameters as shown. To
demonstrate a closed-circuit induction,
click the Begin button, move the cursor
an d click on the anesthetic syringe icon four
times over a period of a simulated minute or
two. Each click will inject 0.5 mL of
liquid isoflurane. The unit dose injected
can be changed with the Anesthesia
menu, by selecting Unit Dose.

VIEW (min) ........................... 15

SPEED .................................. 5x

Special ................................ n.a.

10-3
 Closed-Circllit A nesl hesi({

o OBSERVATION
Agent: !Isoflurane =w I2!CJWeight (Kg) Circuit: '--_ _-'---'

DEL
10 _00 1 CKT10_ 59 1
Zatm

~~I]
~ I 0:15:00 I Time (h:mm:ss)
±l ~UPtake{ll
:i:J :;Id ~ Delivered {ll

FGF VA CO
Speed:
I Continue
LIm M LIm 1400 1 LIm ~ ~

Agent: !fsoffurane Circuit: IClosed

FGF
LIM

DEL
%atm

i\l V

MUS

Zatm

Figure 10-1 shows the Picture and Graph of Exercise 10-1, demonstrat-
ing four injections of 0.5 mlliquid isoflurane into the breathing circuit.

Note in the Graph that inspired anesthetic tension reaches

approximately 4% and then trails off to 1% near 7 minutes.

10-4
 C{osfd-Ci rru it A nesl/zesia

xercise 1.0-2

Closed-circuit liquid injection can produce optimum anesthesia,

achieving and maintaining 1 MAC in the brain.

o SETUP
Selection
Agent ........................ Isoflurane
Circuit ........................... Closed
DEL(%) ................................. 5
FGF (Ljmin) ........................... 0.25
VA (Ljmin) ............................. 4
CO (Ljmin) ............................ 5
To simulate closed-circuit induction and
Inaintenance at 1 MAC using liquid
injection, acljust the parameters as
shown. Mahe liquid iTifectiol1s by click-
ing on the syringe icon at appropriate
times to produce anesthetic induction
and maintenance similar to Exercise 7-
2a, which demonstrated constant brain
tension. Each time the inspired tension
falls below the desired level, click on the
.. .
synnge Icon agam.

VIEW (min) ........................... 15

SPEED .................................. 5x

Special ................................ n.a.

10-5
Gas Man® Closed-Circuit Anesthesia

o OBSERVATION
Agent: Iisoflurane L~l ~Weight (Kg) Circuit: IClosed L!oi

Flush
o
DEL r:;-o-]
%atm ~ CKTI U9 1 ALV~ ~ /1.17/ /°.131 /0.01/ /0.91/
ART VRG MUS FAT VEN

/ 0:15:00 I Time (h:mm:ssJ

~UPtake(L)

~ Delivered (L)

Speed:
FGF 1025 1
VA CO
LIm . LIm /4. 01 1 LIm [J 110x Letl

Agent: II.oflurane Circuit: IClosed

FGF 10 ~
LIM
O--~--------------------------------------~
DEL
%atm
:~ A I

:J~,:;t;d
CKT
ALV
VRG
MUS

%atm

005 010 015

Figure 10-2a displays the Picture and Graph of Exercise 10-2, showing
a simulated closed-circuit anesthetic with isoflurane.
"

You will note that about four injections, or 2 mL, of liquid anes-
thetic is required to elevate inspired tension and that 0.5 mL
increments are then required with decreasing frequency. Try
similar inductions for enjlurane and halothane and observe results
analogous to those shown in Figure 10-2a. Note the volumes
delivered and taken up, and consider the potential monetary
savings as well as the elegance of the technique.

10-6
Gas Man® Closed-Circuit Anesthesia

Agent: IEnflurane I:!:! ~Weight (Kg] Circuit: IClosed L:!:j

Flush

o
DEL
%atm
IHOI CKT12. 15 1 ALVI 1.60 I 11.601 11.701 10.241 1°.011 11.341
ART VRG MUS FAT VEN

I 0:15:00 I Time (h:mm:ss]

~UPtake(L]

~ Delivered (Ll

VA CD ~
Speed:
I. Continue .!
LIm
4
1 .°°1 LIm ~ ~

Agent: IE nflur ane Circuit: IClosed

FGF
LIM

DEL
%atm

en
ALV
VRG
MUS

%atm

Figure 10-2b displays the Picture and Graph of Exercise 10-2, showing
a simulated closed-circuit anesthetic with enflurane.
"

10-7
 Closed-Circuit Anesthesia

Agent: IHalothane I !l ~Weight (Kg) _J..l!->!

Circuit: I,-C_los_e_d

Flush
:tl 0
~

DEL
%atm 13. 3°1 CKTI1.011 ALVlo. 74 1 1°.741 1°. 83 1 1°. 09 1 10.°°1 1°. 65 1
ART VRG MUS FAT VEN

~]
~ 10:15:00 I Time (h:mm:ss)
f:l f:l ~ Uptake(Lj
!!d ±J ~ Deliyered (L)

FGF ~ VA CO
[J
Speed:
! Cont~n~e
lim 0.25 LIm 14.0 0 1 lim ~

Agent: IHalothane Circuit: IClosed

FGF
LIM

DEL
%atm

ALV
VnG
MllS

Figure 10-2c displays the Picture and Graph of Exercise 10-2, showing
a simulated closed-circuit anesthetic with halothane.

10-8
Gas Man® Closer/-Circuit AllCstizesia

o DISCUSSION
The closed-circuit anesthetic inductions you have just performed
are similar to those described by Lowe~~, and Lowe and Ernst2\
but use smaller, more frequent injections. Lowe's technique
requires standard unit dose liquid injection at predetermined
times based upon a model of the closed system, and on the
observation that nitrous oxide requirement decreases approxi-
mately in proportion to the square root of time 3li :

(1/~ t = 1/f1./2 = t -:1/2).

In the next exercise, you will administer closed-circuit anesthesia

"by the book".

10-9
Gas Man® Closed-Circnit it nesthesia

xercise 10-3

Liquid injection following the "t- 1/2" regimen is a classic closed-

circuit approach.

o SETUP
Parameter Selection
Agent ....................... .
Circuit .......................... .
DEL (%) ............................... .
FGF (L/min) ......................... .
VA (L/min) ........................... .
CO (L/min) .......................... .
VIEW (min) .......................... .
SPEED .................................. 5x
To simulate closed-circuit liquid injec-
tion anesthesia following the t- 1/ 2 model
with isoflurane, adjust the parameters as
shown. Immediately after clicking the
Begin button, administer a priming dose
of 0.5 mL isoflurane by clicking on the
syringe icon. Interrupt the simulation by
clicking Pause and adjust Unit Dose to
0.7 mL and click Continue. Next, click on
the liquid syringe at 1 minute, 4 minutes, and
9 minutes. You can use Special/Set
Bookmark to stop the Exercise at these
precise time intervals.

Special ................................ n.a.

10-10
Gas Man® C;losed-Circuit Anesthesia

o OBSERVATION
Agent: /Isoflurane L~J ~Weight (Kg) I
Circuit: Closed I±!

Flush
~ 0
.id

DEL rill
%atm ~ ALVlo. 90 1 10.901 11.031 ~ 10.011 10.801
ART VRG MUS FAT VEN

I 0:15:00 I Time (h:mm:ssl

~ Uptake(L)

~ Delivered (Ll

Speed:
1025 1 VA co
FGF
LIm . LIm l·tOOI LIm [::J I I±l

Agent: !Isoflurane Circuit: IClosed

FGF
LIM

DEL
%atm

CKT
ALV
VRG
MUS

%atm

Figure 10-3a displays the Picture and Graph of Exercise 10-3, showing
a completed 15-minute course of closed-circuit anesthesia with liquid
isojlurane, using predetermined times of administration following the
t-1/ 2 regimen.

Repeat the closed-circuit liquid injection technique with desflu-

rane and halothane. For deflurane, chose a priming dose of 2.0
mL and a unit dose of 0.9 mL. For halothane, chose a priming
dose of 0.5 mL and a unit dose of 0.7 mL. Again, make injec-
tions at 1, 4, and 9 minutes. These are examples of the classic
closed-circuit approach introduced by Lowe 22 and refined by
Ernst23 . Priming doses used here are smaller.

10-11
Gas Man® Uosl'd-Cirrll i/ AlIl's/ Iztsia

Agent: IDesflurane I~i ~Weight (Kg) Circuit: IClosed I:!: I

Flush
±l 0
:t{

DEL
%atm
CKT16.59 I ALVI6. 12 1 16 . 12 1 16 . 33 1 10 . 94 1 10.061 14.98 1
ART VRG MUS FAT VEN

I 0:15:00 I Time (h:mm:ss)

~ Uplake{L)

~ Delivered (L)

Speed:
FGF ~ VA co
lim ~ lim 14 . 02 1 LIm ~ ~

Agent: IDesflurane Circuit: 1Closed

FGF
LIM

DEL
%atm

AlV
VRG
MUS

%atm

Figure 10-3b displays the Picture and Graph of Exercise 10-3, showing
a completed 15-minute course of closed-circuit anesthesia with liquid
desjlurane using predetermined times of administration following the
t- I / 2 regimen.

Note that when using desflurane, the volume of the priming dose
exceeded the volume of the subsequent unit doses, while in
isoflurane and halothane, the opposite is true. This is because
desflurane's low blood/ gas solubility decreases uptake into blood
and tissues, but not into the breathing circuit.

10-12
Gas Man® Closeri-CirCllit Anesthesia

Agent: IHalothane L~l ~"'eight [Kg] Circuit: IClosed I!j

DEL 10. 00 1
%atm
CKTI 0.69 I ALV~ 1°.561 10.66! 10.06! [ilOO] !0.51 I
ART VRG MUS FAT VEN

I 0:15:00 ! Time {h:mm:ss]

~ Uptake(Ll

~ Delivered {Ll

FGF r;;-:;;;J VA CO
LIm ~ LIm [Ulii] LIm EJ
Agent: IHalothane Circuit: IClosed

FGF
LIM

DEL
%atm

CKT
AlV
VflG
MUS

%atm

Figure 10-3c displays the Picture and Graph of Exercise 10-3, showing
a completed 15-minute course of closed-circuit anesthesia with liquid
halothane using predetennined times of administration following the
t-1/ 2 regimen.

10-13
Gas Man® Closcr/-Cirruil Anesthesia

o DISCUSSION
The simulations in Exercises 10-2 and 10-3 have shown that liquid
anesthetic injection into the breathing-circuit can produce satis-
factory anesthesia. Viewing the vessel-rich group has shown that
anesthetic tension in the location of interest (the brain) follows a
relatively smooth time course. This is evident even when alveolar
and especially inspired tension changes dramatically between
injections.

ummary

Closed-circuit anesthesia with liquid injection into the breathing

circuit can produce the same time course of inspired anesthetic
tension, alveolar anesthetic tension, and brain anesthetic tension
that conventional high-flow techniques allow. The Gas Man
program allows various drug administration techniques to be
tested and visualized in simulation.

10-14
 w
--~

Chapter 11
The see · 1
s Effect
Uo

If a second gas is administered along with a first gas of high

concentration, the alveolar tension of the second gas achieves a
greater height than if the first gas weren't present. This is called
the second gas iffect. This phenomenon was described by Epstein
et al. 16 and reviewed well by Eger ll .

The second gas effect is composed of two parts. First, the concen-
tration iffect describes the higher concentration of the second gas
after a large amount of the first (high concentration) gas is
removed. Second, the ventilation iffect describes the increased
inspired ventilation which restores lung volume after the large
quantity of the first (high concentration) gas is removed.

In Chapter 8 we learned that the concentration effect increases

the alveolar concentration achieved by a gas of high concentra-
tion as a result of its own uptake. This effect causes alveolar
tension to rise relatively higher when inspired concentration is
high than when it is low. The concentration effect is most no-
table with inspired concentrations above 70%. When inspired
concentration is 100%, this effect is maximized, and alveolar
tension rise is unaltered by cardiac output, no matter how high
its value.

In order to study the second gas effect using Gas Man, you will
look at two simultaneous Views of the same simulation, one for
each agent:

11-1
Gas Man® The Second Gus EjJfY/

1 Open a new simulation by opening the File menu and selecting

New. Change the agent shown to nitrous oxide. Gas Man calls
this the "primary" anesthetic.

2 Use the View menu and select New. This is a new view of the
same simulation, not a nevv simulation. In the new View, change
the Agent to isoflurane. A dialog box asks if you want to add an
additional agent or change the primary anesthetic. Click on Add.

You have now created two linked simulations. The uptake of one
gas will correctly affect the other gas - the second gas effect.

11-2
Gas Man®
xercise 11-1
---------------------------
With the concentration of the first gas 1 %, there is little effect on
the uptake of a second gas.
o SETUP
Agents. Nitrous oxide; isoflurane
Circuit .............................. Open
DEL (%) ......................... each 1%
FGF (L/min) ......................... 10
VA (L/min) ............................. 4
CO (L/min) ............................ 5
VIEW (min) ............................. 5
SPEED ............................. AFAP
Special ................................ n.a.
The .c;ccond Gas Effect
Select the first or "primary" view (by
clicking in it or using the View menu)
and set the nitrous oxide concentration
to 1 % (type" 1" in the box below the
DEL scale). To best visualize the Exer-
cise, the top of the scale should also be
set to this value (type "1" in the box aL
the top left of the DEL scale). In this
way, the 1 % dial setting fills the entire
available vertical height. In the second or
"additional" view, set the isoflurane
control to 1 %. To make the isoflurane
concentration more visible, set the top of
the DEL scale to 1 %. Make sure the
breathing circuit selected is an Open
(non-rebreathing) circuit. Click Begin.
11-3
Gas Man® The Secolld Gas E/j(!c/

o OBSERVATION
INitrous Oxide I±\ ~Wei9ht (Kg) Circuit:

Flush
1:1 0
i:l

iii
DEL
%:atm ~ AlVQJ QJ QJ QJ QJ QJ
AAT VAG MUS FAT VEN

I 0:15:00 I Time (h:mm: ..)

~Uptake(l}

~ Deliyered (l)

Speed:
FGF IffiOl VA r.n:;] CO
lim ~ lim ~ lim [ ] IAFAP I±j

Agent: !Isoffurane I~t ~Wei9ht (Kg) Circuit: IOpen I:!:

'---'------" .....I

Flush
1:1 0
:i:l

DEl f1.OO1 CKT~ AlV~ ~ §] ~ ~ ~

%atm L..:.:::::l
AAT VAG MUS FAT VEN

I 0:15:00 I Time (h:mm:ss)

~ Uptake(l}

~ Delivered (l)

Speed:
FGF IffiOl VA CO
lim ~ lim ~ lim [ ] IAFAP I±j

Figure 11-1 shows both Views of the Picture for Exercise 11-1, in which
1 % of both nitrous oxide and isoflurane were administered.

Note that in both views, alveolar ventilation (VA) has increased

from 4.00 to approx. 4.02 Lim. This increase occurred because
the small uptake of both nitrous oxide and isoflurane enhanced
inspired alveolar ventilation, albeit slightly. Save this simulation
(you will need to name it something). Next, reduce both views to
an icon by clicking in the down-arrow box in the upper right
corner of each view. You will view these again later in Overlay
mode.

11-4
Gas Man®
xercise 1.1-2
When the concentration of the first gas is almost 100%, the
uptake of a second gas is enhanced dramatically.
o SETUP
Parameter
Agents. Isoflurane;
Circuit ....................... .
DEL (%) ..................... .
FGF (L/min) ............... .
VA (L/min) ................. .
CO (L/min) ................ .
VIEW (min) ....................... .
SPEED ............................ .
Special .............................. .
The Second Gas Effect
Open a new simulation of two gases,just
as you did in exercise 11-1. This time,
for logic's sake, change the name of the
first agent to isoflurane. Mter you open
a second view, change the agent in that
view to nitrous oxide. This will be a
reminder that isoflurane is the first gas
and nitrous oxide is the second gas,
whose uptake is augmented by the high
concentration of the first gas. Now, set
the nitrous oxide control to 100% ni-
trous oxide. You will want the top of the
nitrous oxide scale to read 100% also.
Set the isoflurane control to 1 %. Click
Begin.
11-5
Gas Man® The Second Gas F!j(!ct

o OBSERVATION

~,-ofl-u,a~-e-I---~-- -------------C;,-cu;-, I:p-en---I~

I _~ ___ n 1~

0t 0 ~-------------------------------------4
CO
LIM 1: ~r--------------------------------------~
en
ALV
VflG
MUS

%atm

View:
I 5MinJ!i I Continue. f
Agent: INitrous Oxide I Circuit: LC--_---'
IOpen

VA
LIM 1: t:
CO
LIM 1:
100
1
CKT
AlV
VRG
MUS

%atm

0:00 0:01 I
0:04
I
0:05
View:
I 5 M;n L~! ""Lt"",I~'::.J.;cl__-'--_______----1=lL!.l I Cont;nuel

Figure 11-2a shows the Graphs of both Views of Exercise 11-2, using
1 % isoflurane and 100 % nitrous oxide.

Observe the alveolar tension curves for isoflurane and nitrous

oxide when 100% nitrous oxide is used as the second gas (Figure
11-2a) .

11-6
Gas Man® The Second Gas E1I;1C/

In order to compare the two simulations you have run in Exer-

cise 11-1 and 11-2, use the Overlay feature of Gas Man. First,
analyze nitrous oxide:

1. Reduce the isoflurane graph.

2 Open the nitrous oxide icon from the previous Exercise.

3 Choose Overlay from the View menu (remember to set the View
time to .5 minutes in your primary view, if you did not already do
so when you ran the simulations).

4 Observe alveolar over inspired by clicking on the ALV radio

button in the left ("Show") column and the CKT radio button in
the right ("Over") column.

Note in the resulting Overlay graph (Figure 11-2b) that the high
concentration of nitrous oxide (100%) caused alveolar to closely
approach inspired in the first few minutes. With 1 % inspired
nitrous oxide, however, alveolar tension rises in a manner similar
to other agents in low concentration.

leg~nd:

Figure 11-2b shows the Overlay View comparing the A/I ratios for
nitrous oxide in Exercises 11-1 and 11-2.

11-7
Gas Man® The Second Gas L'fjix;t

Once you have verified the concentration effect for the first gas
(nitrous oxide), iconize the nitrous oxide windows and open
both the isoflurane windows. vVhen you do this, you will notice
that their graphs are quite different. The graph obtained in the
presence of 1 % nitrous oxide (Exercise II-I) looks like any other
1% isoflurane graph. The graph of isoflurane in the presence of
100% nitrous oxide (Exercise 11-2) shows alveolar tension ap-
proaching inspired tension a little more closely in the first few
minutes. This is the second gas effect. The rapid uptake of the
first gas (nitrous oxide in I % and 100% concentrations) has
minimally and maximally affected the uptake of the second gas,
isoflurane, administered in 1 % concentration. This overlav is /

shown in Figure 11-2c.

Figure 11-2c shows the Overlay View comparing the A/I ratios for
isojlurane in Exercises 11-1 and 11-2.

11-8
Gas Man® The ",'erond Gas Effect

xercise 11-3

The addition of 70% nitrous oxide enhances the rise of alveolar

isoflurane toward inspired isoflurane concentration.

o SETUP
Because 100% nitrous oxide is not com-
Parameter Selection
patible with life and should never be
Agents. Nitrous oxide; isoflurane administered, in this Exercise you will
see the impact of administering nitrous
Circuit.,,, ...... " .. " .......... " .. Open
oxide plus isoflurane anesthetic at clini-
cally relevant concentrations. Open a
DEL (%) """"."""""",,,.70%; 1%
new simulation and add a second gas, as
FGF (L/min) ".""""".",,,,,.,,. 10 before. Use nitrous oxide 70% com-
bined with isoflurane 1 %. Using an open
VA (L/min) """"""""".""."".4
circuit, click Begin.
CO (L/min) ".""",,,,,.,,,,,,,,,,,,.5

VI EW (m in) """."."""""",,.,," 5

SPEED """"""""",,,,,,,.,,. AFAP

Spec i a I .". " " " " . " " " " " " " " " . n .a.

o OBSERVATION
Overlay the isoflurane curve from Exercise 11-3 with the
isoflurane curves from Exercises 11-1 and 11-2. Notice that the
alveolar tension for isoflurane rises higher with 70% than with
1 % nitrous oxide, and lower than with 100% nitrous oxide (Fig-
ure 11-3). This effect is ever more prominent as inspired nitrous
oxide concentration approaches 100%.

11-9
Gas Man®

1--.-------------------------------. Show Over

o DEL 0
OCta ®
®ALV 0
0.5
OVRGO
OMUSO
o FAT 0
OVEN 0
0:01 0:02 0:03 0;04 0:05 MAC 0
Time (HH:MM)
One 0
Legend:
o Cost
EX111.GAS
L- ..H,~lph~J
L{~:!9i~Lh_. JI

Figure 11-3 shows the Overlay of the isojlurane A/I cllroes from each of
Exercises 11-1 through 11-3, comparing the second gas effect of 1 %,
70 % and 100 % nitrous oxide.

In this chapter, you have studied the second gas effect, in which
the simultaneous administration of a second gas with a first gas in
high concentration causes the alveolar tension of the second gas
to rise higher than it would if it were present alone. One percent
of nitrous oxide exerts almost no effect, 70% nitrous oxide a
moderate effect, and 100% nitrous oxide a great eflect.

11·10
 ~,

Chapter 12 \ \)
Patient yv:~k~--up
! ')
\,~~/
(-,
v

heory

Wake up from a long anesthetic is analogous to induction. Dur-

ing induction, anesthetic tension in all compartments begins at
zero. Tissue tensions then rise toward the value set on the vapor-
izer. "Fast" compartments (alveolar, vessel-rich group) arrive
there quickly, while "slow" compartments (muscle, fat) take
longer. At the end of a theoretical "infinite length" anesthetic,
all tissue tensions would equal that set on the vaporizer.

For ernergence, or wake up, the vaporizer is set to zero and tissue
tensions fall toward this zero value. Again, fast compartments
drop to zero quickly while slow compartments take longer. At
the end of wake up, all tissue tensions again equal that set on the
vaporizer - zero.

When looked at graphically, the course of anesthetic tensions

during induction and wake up appear flipped horizontally, or as
inverted images of each other. This will be shown in this
chapter's simulations.

12-1
Gas Man®
xercise 12-1
Wake up is the inverse of induction.
o SETUP
Parameter Selection
Agent ...................... Desflurane
Circuit .............................. Open
DEL (%) ................................. 9
FGF (L/min) ........................... 8
VA (L/min) ............................. 4
CO (L/min) ............................ 5
VIEW min) ............... 10 hours; 5
SPEED ....................... AFAP; lOx
Special ................................ n.a.
12-2
Patient Wake UjJ
To demonstrate that wake up is the
inverse of induction, this Exercise simu-
lates a long anesthetic using an open
circuit. Acljust the parameters as shown
at left, and run the simulation for 10
hours (the fastest way to do this is to set
View in the Gas Man Graph to 10 hours
and run the simulation at AFAP speed).
At the end of 10 hours, s,vitch off the
vaporizer (reduce DEL to 0 in the Gas
Man Picture) and change the simulation
speed to lOx and View to 5 minutes.
Run the simulation for 5 more minutes
while observing the Graph.
Gas Man® Patient Wake [/1)

o OBSERVATION
.
"-~--- ~-------- .

Agent: IOesflurane Circuit: 10pen

10

~
VA
LIM
0
10

~
CO
LIM
0
CKT
AlV
VRG
MUS

%atrn

I I I
0:00 0:01 0:02 0:03 0:04 0:05
View:

I 5 Minl;!:J LtU l!tl I ,t;.~nt~~~.~ ~ I

Agent: IOesflUJane Circuit: 10pen

10

~
VA
LIM
0
10

~
CO
LIM
(I

CKr
AlV
VRG
MUS

%atm

10:00 10:01 10:02 10:03 10:04 10:05

View:
I 5 Mini:!:) IConti,;ue: I

Figure 12-1 shows the Graphs of the first and last 5 minutes of Exercise
12-1, simulating patient wake up after a 10-hour anesthetic with
desjlurane.

Observe in the bottom graph of Figure 12-1 the effect of sud-

denly switching off the vaporizer using an open circuit. Note
that alveolar tension falls 66% of the way to zero in the first few
breaths. Compare the two graphs and note their inverse relation-
ship. You can view both Graphs on your screen by opening a
second view using New View. Push the slider bar at the bottom of
the Graph in the new view all the way to the left to see the first 5
minutes of the simulation.

12-3
Gas Man® Patient Wake Up

o DISCUSSION
Although these two graphs of induction and wake up are nearly
identical inverted images, they vary slightly because the anes-
thetic administration was not "infinite". The difference between
these two situations is that after the 10-hour anesthetic, fat ten-
sion was approximately 33% of that in the other compartments,
whereas after an infinite duration anesthetic, tension in fat would
equal 100% of that in all other areas. For this reason, the wake
up curve here is actually slightly different from the induction
curve. During wake up from the 10-hour anesthetic, alveolar
tension was slightly closer to inspired than during induction (or
after an infinite length anesthetic). The difference is so small,
however, that it is not visible on the computer screen or in the
Figure.

12-4
Gas Man®
xercise 1.2-2
During wake up, alveolar tension is relatively lower at all times
with less soluble agents.
o SETUP
Parameter Selection
Agents. Iso-, Sevo- & Desflurane
Circuit ................... Semi-Closed
DEL (%) ................ 1.2%; 2.05%; 6%
FGF (L/min) ........................... 8
VA (L/min) ............................. 4
CO (L/min) ............................ 5
VIEW ...................... 10 hrs; 10 mins
SPEED ....................... AFAP; lOx
Special ................................ n.a.
Patient Wake UfJ
In this Exercise, run the same simulation
as in the previous Exercise, but with
three different agents at their clinically
relevant concentrations. Open three
simulations (and keep them open),
using isoflurane in the first, sevoflurane
in the second, and desflurane in the
third. In this way you are using the
agents in their order of solubility. Run
each simulation for 10 hours (you can
use Run All command from the File
menu or click on the Run All icon). At
the end of 10 hours, in each simulation,
switch off the vaporizer, change View to
10 minutes, and set a Bookmark for
10 hours 10 minutes. Run the simula-
tions for 10 more minutes and then
observe their Graphs (if you have a large
screen, you can see all three at once
using Tile from the View menu).
12-5
Gas Man® Patient Wake UtJ

o OBSERVATION
Keeping all three simulations open, use the Overlay feature to
view anesthetic tension in the alveoli and the vessel-rich group
normalized to MAG You will see that as solubility of the anes-
thetic decreases, alveolar and VRG tension is relatively lower at
all times during wake up (Figures 12-2a and 12-2b).

Figure 12-2a shows the Overlay ofALV/1\1ACfr0m the simulations run

in Exercise 12-2, simulating patient wake up after a 10-hour anesthetic
with isoflurane, sevoflurane and desjlurane.

12-6
Gas Man® Patient H'alw UI)

Because anesthetic tension is lower at all times with the less

soluble agent, wake up will always be faster. The actual difference
in wake up times will depend on the MAC level required for wake
up. Although this is often 0.33 MAC in the VRG, this factor can
sometimes be lower. "Vhen MAC awake is lower, there will be
more of a distinctive difference between wake up times of agents
of different solubilities.

Show
()OElO
Oc:KTO
OAlVO
0.5
@VBGO
'0 MUS. 0
o FAT 0
OVENO
10:00 MAC@)
One 0
legend:
O>Cost
WAKEOES.GAS (Oesfluranel
J
Lc~~~ f-Ielp~_~~_
1.• ~_J~!i!~~~~,"JI

Figure 12-2b shows the Overlay ofVRG/MACfrom the simulations run

in Exercise 12-2, simulating patient wake up after a 10-hour anesthetic
with isoflumne, sevoflumne and desflurane.

12-7
Gas Man® P([lll'nl Wake Up

o DISCUSSION
Look at each of the Graphs in the simulations you ran in Exercise
12-2. Measure the time required to reach 0.33 MAC in the ALV
and VRG for each agent. These numbers are tabulated below
(keep in mind these numbers are based on the parameters set in
the simulations and actual clinical results will vary slightly):

Time to Reach 0.33 MAC

(minutes)

ALV VRG
Isoflurane 6.5 9.9
Sevoflurane 2.4 6.3
Desflurane 1.0 "1.1

Because wake up from a very long anesthetic is the approximate

inverse of induction, it can be inferred that kinetic comparisons
among agents during induction will apply similarly during wake
up. Thus, the plateau heights seen in the first few minutes of
anesthesia in Chapter 6 will provide plateaus during emergence.
In each case, the fall in agent tension during wake up will mimic
the rise during induction.

Keep in mind that during induction, overpressure can be used to

compensate for solubility. During wake up, however, there is no
way to use "underpressure" to compensate (the vaporizer cannot
be set below zero) .

ummary

In this chapter, you saw that wake up from a very long anesthetic
is the inverse of induction. Because of this similarity, comparing
alveolar or brain tension curves during induction provides great
insight into tensions expected during wake up. Wake up from
less soluble agents occurs earlier than after more soluble agents.

12-8
Chapter 13 C)
Patient Size
/ "-
! \

~~
o

Patient size affects the volumes of body compartments as well as

the flows (ventilation, cardiac output) which link these compart-
ments. In general, volumes scale linearly with patient weight.
This is because most tissues are of reasonably uniform density.
However, the flows that link the compartments are generally not
linear4 • The effect of weight on many body processes (eg., oxy-
gen consumption, carbon dioxide production, spontaneous
alveolar ventilation, cardiac output, and fluid requirements) has
been shown to be proportional to body weight raised to the 3/4
power. That is, metabolic processes are proportional to Kg 3/4.

For these reasons, Gas Man scales alveolar ventilation and cardiac
output as Kg 3/1, while it changes compartment volumes linearly
with weight (KgI). Values for volumes and flows for a 70 kg
patient are those found often in the literature: VA 4 L/min,
CO = 5 L/min, and oxygen consumption = 250 mL/min.

The fact that inter-compartment flows scale up less than compart-

ment volumes as weight increases means that kinetic processes
speed up in patients of lower weight and slow down in patients of
higher weight. By using the simulation capabilities of Gas Man,
you can experiment with the effect of different agents and ad-
ministrations in patients of varying size. Within the normal range
of human size, the variation is surprisingly small. In addition,
because you can vary weights in Gas Man to the extremes of very
low or very high weight, you can simulate inhalant anesthetic
adminstration in animals.

13-1
Gas Man®
xercise 13-1
Kinetics is faster with patients of smaller size.
o SETUP
Parameter Selection
Agent ........ "" ....... " ... Isoflurane
Circuit .............................. Open
DEL (%) ................................. 1
FGF (L/min) ......................... 10
VA (L/min) ............................. 4
CO (L/min) ............................ 5
........................... 15
......................... AFAP
........... 10; 60; 120
13-2
Patient S'izl'
To see this effect, simulate administering
1 % isoflurane to patients of weights 10
kg, 60 kg, and 120 Kg. First, open a new
simulation with isoflurane 1 %, using an
Open circuit, and set body weight to 10
kg. Next, open two new simulations (not
new Views) and set 1 % isoflurane with a
60 kg and 120 kg patient respectively.
Choose Run All from the File menu, or
click on the Run All icon in the tool bar.
Now, with the three simulations com-
pleted, choose Overlay to observe their
respective A/I ratios. Leave these simula-
tions open in order to use them in the
next Exercise .
Gas Man® Patient Size

o OBSERVATION

Figure 13-1 shows the Overlay of the A/I ratios achieved through
administration of 1 % isoflurane to patients of 10, 60 and 120 kg in
weight.

Note in Figure 13-1 the progressive lowering (and secondary

slowing) as weight is increases. Also note how small the differ-
ence is within normal adult sizes, even when varying the weight as
much as 60kg.

13-3
Gas Man@ Patient Size

xercise 13-2

Kinetics is faster with small animals than with large animals.

o SETUP
Parameter Selection
Agent ........................ lsoflurane
Circuit .............................. Open
DEL (%) ................................. 1
Add two more simulations to those from
Exercise 13-1. Run one simulation using
the weight ofa large mouse, 0.1 Kg, and
another using the weight of a small
elephant, 1500 kg. Then choose Overlay
to view the results.

FGF (L/min) ......................... 10

VA (L/min) ............................. 4

CO (L/min) ............................ 5

VIEW (min) ........................... 15

SPEED ............................. AFAP

Weight (kg) .................... 0.1; 1500

13-4
Gas Man® Palienl Size

o OBSERVATION
Show Over
ODElO
OCKT @
.® AlV 0
0.5
OVRGO
o MUSO
o FAT 0
OVENO
0:00 0:05 0:10 0:15 MAC 0
Time (HH:MMJ
One 0
legend:
o Cost
UntiUed3 (60 Kg}
Untitled4 (120 Kg)

Figure 13-2 shows the Overlay of the A/I ratios achieved through
administration of 1 % isoflurane to patients of 0.1, 10, 60, 120 and
1500 hgin weight.

Figure 13-2 shows the curves of alveolar tension one would ex-
pect in very small and very large animals. \I\lhile the curve of a
very small animal is quite different from human weights, as size
increases, the change in the curve lessens.

These simulations all used an open circuit, so the effect of anes-

thetic uptake did not diminish inspired tension in the larger
animals. In a semi-closed circuit with limited fresh gas flow, the
effect can be dramatic. In addition to a high FGF, larger circuit
volumes are needed for larger animals. Circuit volume in Gas
Man can be adjusted in the Simulation Settings window of the
Set Defaults command found under the File menu.

13-5
Gas Man® Patient Size

ummary

In this chapter, you have seen that volumes can be modelled as

linear with patient weight, while flows are modelled as propor-
tional to weight to the 3/4 power. vVhen this is done, the alveo-
lar tension curves for animals and patients slow as body weight
increases. Very large variations in weight are necessary to demon-
strate significant changes in the time course of anesthetic ten-
SIon.

13-6
Chapter 14 (j
AnalYZi"ejbsY
o

Awareness of the cost of the anesthetic used in surgical proce-

dures is increasingly critical to hospital practice. Cost is affected
directly by the anesthetic agent chosen but also by the adminis-
tration technique used. The pharmacokinetics of an anesthetic
agent and the resulting impact on the patient can lead to the
actual cost of a particular anesthetic being quite different from
the expectation based solely on price per volume.

Gas Man enables you to analyze the cost of administration in two

ways. First, you can choose to view Cost instead of Volume in the
Uptake and Delivered boxes located in the lower right portion of
the Gas Man Picture. You can toggle the display of Cost or
Volume by using the "$" icon in the Toolbar or choosing Show
Cost in the View menu. You can also analyze cost by using the
Overlay feature, and choosing the Cost versus time curve for
different agents or techniques. It is interesting to compare the
"efficiency" of different agents by comparing Delivered and
Uptake costs. The Exercises in this chapter demonstrate these
features.

Cost computations are done automatically in Gas Man by com-

puting the product of Delivered Volume and Unit Cost of the
Agent selected. Delivered Volume in turn is the product of fresh
gas flow (FGF) and the vaporizer setting (DEL). Both FGF and
DEL can be adjusted continually throughout a simulation as with
an actual anesthetic. Bottle size and Bottle cost can be set and
changed using the Set Cost command under the Anesthesia
menu, so that you can adjust these figures depending on your
institution's actual costs. You can modify these values as prices
change, or simulate the effect of price changes.

14-1
Gas Man® tinalw:.ing Cost

xercise 14-1

The cost to achieve and maintain 1 MAC of isoflurane in the

vessel-rich group can be determined with Gas Man.

o SETUP
Parameter Selection
Agent ........................ Isoflurane
Circuit ................... Semi-Closed
DEL (%) ..................... 2% - See Text
FGF (Ljmin) ........................... 8
VA (Ljmin) ............................. 4
Set the parameters as shown at left. Set a
Bookmark at 13 minutes. Click Begin
and watch the anesthetic tensions ap-
proach 1 MAC in the Graph while ob-
serving the Cost data in the Picture. At
13 minutes, reduce DEL to 1.5%, and
continue the simulation through to 60
minutes. Keep this simulation open for
later use.

CO (Ljmin) ............................ 5

VIEW (min) ........................... 60

SPEED ................................ 60x

.................... Show Cost

14-2
Gas Man® A 11 {[[yzi liP; Cos!

o OBSERVATION
Agent: I'soflurane I:!:) ~Weight (Kg) Circuit !Semi.Closed! ~ I

Flush
~ 0
±l

DEL IL501
%atm
cnl 1.35 I ALV11.051 IL051 11. 05 1 10. 33 1 10. 02 1 10 . 37 1
ART VRG MUS FAT VEN

11:00:00 I Time (h:mm:ssJ

~Uptake($)

~ Deliyered ($)

Speed:
ro-J VA co
FGF
lIm~ lim l,tOlI lim [.J IAFAP \±1

Agent: Jisotlufane Circuit: ISemi-Closed I

FGF
LIM 1: ~
DEL
%atm

CKT
AlV
:~
VRG
MUS

%atm

Figure 14-1 shows the Picture and Graphfor Exercise 14-1, which
determined the cost of maintaining 1 l\-1AC of isoflurane for 1 hour.

14-3
Gas Man® :i l7(1),zing Cost

o DISCUSSION
By observing the Graph in Figure 14-1, you will note that ALV has
reached 1 NlAC (the dotted line) at the end of 9 minutes 20
seconds. At the end of 13 minutes, VRG has rcached 1 MAC and
induction is considered complete. vVhen you paused the simula-
tion at 13 minutes, you should have observed that the Delivered
cost (anesthetic delivered to the breathing circuit) so far was
$8.32 and Uptake cost (anesthetic uptake in patient tissues) was
$1.26. After you reduced DEL to 1.5% and completed the 1
hour anesthetization, you observed a Delivered cost of $30.88 of
isoflurane, which provided tissue uptake of $3.70. These adminis-
tration costs are based on a bottle cost of US$78.00 per 100 ml.

14-4
Gas Man® Analyzing Cost

xercise 14-2

Cost to achieve and maintain 1 MAC in the VRG is lower with

lowerFGF.

o SETUP
Parameter Selection
Agent ........................ Isoflurane
Circuit ................... Semi-Closed
DEL (%) ..................... 5% - See Text
FGF (L/min) ........................... 1
VA (L/min) ............................. 4
In this Exercise, you will again simulate a
1 hour anesthetic with isoflurane, but
with a higher vaporizer setting combined
with a much lower FGF. Set the param-
eters as shown. Set a Bookmark at 13
minutes. Click Begin. At 13 minutes,
reduce DEL to 2.7%, and continue the
simulation through to 60 minutes.

CO (L/min) ............................ 5

VIEW (min) ........................... 60

SPEED ................................ 60x

Special .................... Show Cost

14-5
Gas Man® A /I(l/yzing Cost

o OBSERVATION
Agent: Iisoflurane I :!:J ~Weight (Kg) Circuit ISemi-Closedl ~l

DEL
%atm
12.70 1 CKTI1.41 I ALVIl.l01 §] 11. 09 1 10. 39 1 10. 02 1 10 . 90 1
ART VRG MUS FAT VEN

~]
~ ~ 11 :00:00 I Time (h:mm:ss)
Uptake ($)
!:1 1:]
Vi
-~! +1
~'.l ::t! ~ Delivered ($)

VA CO
Speed:
I t;o.nti~u~ 1
LIm 14.011 LIm ~ IAFAP I:!:l

Circuit: !Semi-Closed I

Figure 14-2a shows the Picture and Graph of Exercise 14-2, using a
FGF of 1 L/min to achieve 1 MAC of isoflurane.

Reducing the FGF from 8 L/ min to 1 L/ min, and increasing

DEL to 5%, resulted in ALV reaching 1 .!VlAC only slightly later
(10 minutes) than in Exercise 14-1, 'while 1 Iv1AC in 'lRGwas
again achieved by 13 minutes. At this point, Delivered cost so far
was $2.62 (compared with $8.32) and Uptake cost was $1.17. At
the end of 1 hour, Delivered cost was $7.68, compared with
$30.88 in Exercise 14-1. Therefore, the 8 L/ min administration
was four times more costly than the 1 L/ min anesthetic while
achieving the same effect.

14-6
Gas Man® Analyzing Cost

The cost advantage of low flow technique can also be discussed in

terms of efficiency. Using a flow of 8 L/min at 2%, the ratio of
Delivered cost to Uptake cost after one hour was 8.3 (eight times
as much anesthetic was used as was taken up in the tissues), while
using a flow of 1 L/min at 5% results in a ratio of2.0 (twice as
much anesthetic was used as was taken up in the tissues).
o DISCUSSION
You can also compare Exercises 14-1 and 14-2 by using Gas Man's
Overlay feature. With both simulations open, select Overlay from
the View menu or click on the Overlay icon in the Toolbar.
Select Cost from the left ("Show") column and One from the
right ("Over") column. Note the difference in the slopes of the
two curves (Figure 14-2b).

Figure 14-2b shows the Overlay View comparing the Cost mrves in
Exercises 14-1 and 14-2.

To confirm that the anesthetic administrations in Exercises 14-1

and 14-2 were clinically similar, first overlay ALV over MAC
(Figure 14-2c). Note that in the two simulations, ALVreached 1
MAC at the same time. Next, overlay VRG over MAC and see that
VRG tension reached 1 MAC at the same time in the two simula-
tions as well (Figure 14-2d).

14-7
Gas Man® Analyzing Cost

Figure 14-2c shows the Overlay View of the ALV/.MAC curves In

Exercises 14-1 (high flow) and 14-2 (low flow).

Figure 14-2d shows the Overlay View of the VRG/.MAC curves In

Exercises 14-1 (high flow) and 14-2 (low flow).

14-8
Gas Man® An({lyzing Cost

xercise 14-3

Low flow techniques also decrease the anesthetic cost of new

agents.

o SETUP
Selection
............... Desflurane
.............. Semi-closed
................. see text
Run two simulations similar to Exercises
14-1 and 14-2, but this time use desflu-
mne. In the first simulation set FGF to 4
L/min and set the vaporizer at 10% for
the first eight minutes; then reduce it to
7% for the rest of the hour.

....................... 4; 1 In the second simulation, set FGF to 1 L/

min and set the vaporizer at 18% for the
............................. 4
first ten minutes and reduce it to 8%
co (L/min) ............................ 5 thereafter.

VIEW (min) ........................... 60

SPEED ................................ 60x

Special ................................ n.a.

14-9
Gas Man® Ii nalyzing; Cost

o OBSERVATION
>Show ··Over
OOElO
OCKTO
OAtVO
OVRG·O
o MUs 0
OFA(O
O'VENO
;~AtYO
One@
@;Cost

Figure 14-3 shows the Overlay comparing the Cost curves of administer-
ing desflurane with regular and Zowflow techniques.

14-10
Gas Man® Alwlyzing Cnst

o DISCUSSION
When you have completed all four of the simulations in this
Chapter, you will have documented comparative costs as shown
in the table below.

Cost of One Hour Anesthetic

FGF Cost
Isoflurane 8 $30.88
Desflurane 4 25.02
Desflurane 1 8.10
Isoflurane 1 7.68

These simulations show that the cost of anesthesia administration

is more sensitive to FGF than to the agent chosen. Indeed, if you
compare the costs of closed circuit anesthesia with isoflurane and
desflurane, you would discover that desflurane is actually less
expensive than isoflurane at these bottle prices.

Of course, bottle prices in the marketplace can change. The

prices used here are the prices of isoflurane and desflurane when
desflurane was first sold in the USA, i.e., $78.00 per 100 mL
bottle of isoflurane and $70.00 per 240 mL bottle of desflurane.
As prices change, quantitative and qualitative results may change.
Nonetheless, assuming prices remain at these levels or lower, the
maximum cost of one hour of anesthesia with FGF = 1 L/min is
around $8.00 or less.

14-11
Gas Man® Analyzing Cost

ummary

Gas Man allows cost comparison between agents and among

techniques. In general, cost is more sensitive to fresh gas flow
than to agent chosen. All the variables necessary to compare costs
can be adjusted in the program - vaporizer settings, length of
induction, gas flow, agent supply costs. Questions and answers
are limitless.

14-12
roduction.------------------------ .. ----~-

Numerous features have been added to Gas Man since Version

1.0 for the Macintosh was released in 1989. Many of these fea-
tures were a natural benefit of the Windows™ platform for which
Version 2.0 was first written. But additionally, the goal in Version
2.0 was to provide a broader and deeper set of analytical tools
which would make the Gas Man model even more useful to
students, teachers, and practicing anesthesiologists. This goal
was further served in Version 2.1, and will continue to be the
focus of future releases.

Table 15-1 lists those features which are new in Version 2.0/2.1
compared to Version 1.0. In this first section, some of these
features are reviewed quickly. In the rest of this chapter, you will
explore the following in more detail:

• Setting program defaults

e Overlays
• Printing options
" Data export.

Most of the features listed in Table 15-1 have been described in

other chapters of this Manual. For instance, using multiple
windows and setting bookmarks are explained in Chapter 2.
The Flush function and the Ideal circuit are demonstrated in
Chapter 9. The use of multiple agents is introduced in Chapter
11. Patient Weight is the subject of Chapter 13 and analyzing
Cost is covered in Chapter 14.

15-1
Gas Man® Advanced Feal1./'fes

Gas Man Features New to Versions 2.0/2.1

ED Windows™ platform
'" Color Picture & Graph
ED Context-sensitive Help
• Split Window for simultaneous display of Picture & Graph
'" Replay simulations
o Save simulations
'" Bookmarks
o Adjust parameters during simulation, and save and replay
ED Multiple Views of same simulation
ED Multiple simulations run concurrently
• Multiple agents can be used in same simulation
'" Adjustable scale heights
'" Compare and contrast through Overlays
• Analyze Cost of agents and techniques
'" Adjust Patient Weight from O.05kg to 1500kg
e User controls over program defaults for all settings
'" Expanded Print output options
'" Ideal circuit option
'" Flush agent from breathing circuit
'" Liquid injection in semi-closed circuit
'" effect

Table 15-1.
New features found in Gas Man 2.0/2.l.

15-2
Gas Man® !\r/1J{{llced Fmtllres

ADJUSTABLE SCALES

The heights of each of the scales in the Gas Man Picture can be
adjusted. The default height for each scale is set in the system
and adjustable using the Set Defaults command from the File
menu (see p. 15-5). For a particular simulation, you can change
the scale heights by typing in a value in the box at the upper left
of each scale (DEL, FGF , VA and CO) .

When you change the height of the DEL scale, the height of each
of the body compartments changes accordingly (CKT, ALV, ART,
VRG, MUS, FAT and VEN). In addition, the height of the DEL
scale set in the Picture determines the height of the y-axis of the
compartment tension and DEL portions of the Gas Man Graph.
Similarly, adjusting the height of the FGF, VA and CO scales in
the Picture will change the height of their graphs in the Graph
window.

This feature allows you to make the Graph more useful by choos-
ing a y-axis height that maximizes the visibility of the tension
traces.

VAPORIZATION EFFECT

The Enable Vapor command found under the Special menu

allows you to simulate effective gas flow. Generally, Gas Man is
used without this effect. The Exercises in this Manual all assume
that the total flow into the circuit is determined by the FGF
setting, without including the additional volume of gas provided
by the anesthetic agent added to the fresh gas flcnv.

This new feature in Gas Man allows you to study the effects of
agent vaporization. For instance, it seems logical that enabling
agent vaporization would make an anesthetic administration
more expensive. Actually, because the addition of vapor to the
breathing circuit increases inspired tension, and thereby the level
of anesthesia received by the patient, the anesthesiologist will
naturally adjust the vaporizer downward to main tain desired
tension. The result is that anesthetic cost changes little. You can
design experiments with Gas Man to study this more closely.

15-3
Gas Man® Advanced Features

ADJUSTABLE AGENTS & VALUES

Gas Man comes with the following anesthetic agents identified

and programmed: desflurane, enflurane, halothane, isoflurane,
nitrogen, nitrous oxide and sevoflurane. New agents, other
existing agents, or even user-invented agents can be added to the
Gas Man program by editing or adding to the Gasman.INI file in
the Gas Man directory.

To do so, use a text editor such as Notepad, a standard accessory

included in Windows™ (if you double-click on the INI file from
the Windows File Manager, it will probably open automatically).
Open the Gasman.INI file and study the format and syntax
carefully. To add an agent, simply type in the name in the anes-
thetic list under [Agents], and list its attributes in the same form
as the other agents' attributes are listed.

In examining the INI file you will notice many of the values
which can be adjusted through various Menu Bar commands.
Because Gas Man offers several different ways of adjusting these
values, the following guide may be helpful:

.. Menu Bar commands are used for individual simulation

settings.

The Set Defaults commands are used for a long session of

multiple simulations, or to set and save your personal
settings in the way you like to use Gas Man.

Adjusting the INI file should be reserved for changing

system-level defaults because of new information.

In the Appendix of this Manual, you will find a record of the Gas
Man System Defaults as they are set when the software is shipped.
If you make changes to your INI file and later want to restore its
original settings, refer to this section.

15-4
Gas Man® Advanced FMturcs

etting Program Defaults

An important feature of Gas Man 2.1 is that it enables the user to

make adjustments to the default settings and values the program
uses to run simulations. The Set Defaults command under the
File menu has four dialog boxes, as described below.

--.tile .Edit Anesthesia Qel

New Ctrl+N
Qpen ... Ctrl+O
~Iose
.s.ave Ctrl+S
Save As ...
Run
Run All
erint...
Print Preyiew
Print Setup ...
Print Select...
Set Qefaults Program Settings
View Settings
1 WAKEDES.GAS
Simulation Settings
.f. WAKESEVO.GAS
Patient Settings
J WAKE ISO. GAS
I
E~it I
Figure 15-1a shows the options available for the Set Defaults command.

The first option is Program Settings. A dialog box will appear

when you choose this option enabling you to:

• pick whether or not you wish an audible signal to sound

with each passing minute of a simulation (assuming you
bave a sound card in your computer). You can choose
which of your system sounds to use for this effect.

15-5
Gas Man® ;ldvallced Fpa/ures

@l.Q.!'f! o System 1 o System 3

o Beep o System 2 o System 4
[".raPh line 1..abels .
@Off OOn o Auto
I
ro",aph (jne _.ThiCkness
One @Two o Three
I
GraPh Jump Eercent· Use
o .!iraph I . . .J}.tS......... I
rL=!'~,--·._._---'I=""-J_~Lt~ ·67 Paper
L. . £il~~.~I.~.1
Figure 15-1b shows the Program Settings dialog box.

set \vhether line labels OIl the Graph (1 for inspired, A for
alveolar, etc.) never appear (Off), always appear (On) or
automatically appear (Auto) when there is room or when
you are using a monochrome monitor.

set the th ickness of the Graph lines (the Figures in this

Manual are all done with a thickness of two).

determine how far to the left the Graph will 'Jump" when
you are scrolling through a simulation whose View setting
is shorter than the total simulation length. A setting of
67% means that in a 15-minute view, each movement of
the scroll bar will jump the view 10 minutes (67% of 15
minutes) to the left.

turn Graph Paper on, which puts a gray shading behind

the Graph display. This may be helpful to viewing the
graphs on certain monitors or projectors.

The View Settings dialog enables you to set defaults for how the
Picture and Graph will appear in each new simulation you open.
You can set defaults for:

15-6
Gas Man® Adv(mccd Features

Figure 15-1c shows the View Settings dialog box.

e the height of the scales for FGF, VA and CO

e the length of the simulation View
e whether Show Cost or Show Volume is enabled
• whether Graph scrolling is enabled (this command is also
available under the Special menu).

The Simulation Settings dialog box enables you to set the de-
faults which will be active each time a new simulation file is
opened:

the fresh gas flow for a semi-closed circuit

the circuit volume
the simulation speed
the circuit type
the anesthetic agent.

Figure 15-1d shows the Simulation Settings dialog box.

15-7
Gas Man® Advanad Fm/ures

Figure 15-1 e shows the Patient Settings dialog box.

The Patient Settings dialog box enables you to make detailed

adjustments in key characteristics of the patient:

e patient weight (and whether the display will be in kilo-

grams or pounds)
compartment volumes for each compartment (to change
the values which are set automatically by the program
according to weight)
flow percentages (distribution of vapor absorption by the
vessel-rich group, muscle and fat)
• patient metabolism (alveolar ventilation and cardiac
output - again giving you the option to alter automatic
settings) .

15-8
Gas Man® Advanced Features

sing Overlays

The most powerful and useful new feature of Gas Man 2.0 is the
Overlay function. The Gas Man Overlay allows you to instantly
compare single variables across multiple simulations, and ratios
of any two simulation parameters for one or multiple simula-
tions, using an intuitive, graphical interface. Several of the Exer-
cises in earlier chapters of this Manual used Overlays to analyze
the results.

The Overlay window consists of a graphical display area and two

columns of radio buttons. The graphical display uses the value
or the ratio as its y-axis, and time as its x-axis. For overlaying
multiple simulations or views, Overlay will assign different colors
to each simulation's trace. The legend underneath tells you
which line corresponds to which simulation.

The View time view in the Overlay window matches that set in the
Graph of the active simulation. This is important to remember to
ensure you achieve the visual display you seek. If you are com-
paring two simulations with different View times, Overlay will use
the View time from the simulation currently selected. If that is
not the time view you want in the Overlay, adjust the View time of
the active simulation accordingly.

The two columns of radio buttons construct display commands in

the "show X over Y' syntax. That is, to show alveolar over inspired
(the A/I ratio), you select the radio button to the left of ALV (in
the Show column) and the button to the right of CKT (in the
Over column).

Overlays cannot be saved or printed from ·within Gas Man, but

they are easily repeated and instantly displayed. To save an Over-
lay image, use the Print Screen command from your PC keyboard
and paste the image into a presentation or graphics program.

15-9
Gas Man® Advanced Features

To get
c familiar \'\Iith the Overlav, function, run a standard simula-
tion (such as 2% isoflurane for 15 minutes). Click on the Overlay
icon in the Toolbar or select Overlay from the View menu.

First, select "DEL over One". You \Nill see a straight line running
across the full 15 minutes at the level of DEL=2.

Next, choose "DEL over MAC". You will see the straight line
running at a value just below 2. It is in fact at 1.73, since the
MAC ofisoflurane is 1.15, and 2 divided by 1.15 equals 1.73.

Now show each of the compartments over MAC, one by one. You
will see the time course of anesthetic tension in each compart-
ment as it approached 1 NlAC in the simulation. As you move
from "CKT over MAC" down to "FAT over MAC", you will note
similar curves, but the vertical axis scales get lower in heigh t as
you go through the compartments.

Show Over
ODEL 0
<!>. CKT 0
OALV 0
OVRGO
o MUSO
····0 FAT 0
OVEN 0
MAC@
One. 0
o Cost
H!IE",~~J
1,~~;J~9~~~~~. . J

Figure 15-2a shows the Overlay of CKr/MAC in a simulation of 2 %

isojlurane for 15 minutes.

15-10
Gas Man® Advanced Features

Choosing "Cost over One" will show you the progress of anes-
thetic cost through the simulation.

Next, look at the relationship between compartments. Selecting

"ALV over CKT" will produce the A/I ratio. "VRG over CKT"
shows the slower rise in the vessel-rich group. "CKT over ALV"
displays the overpressure ratio.

Overlays are particularly useful for comparing agents. Many of

the Exercises in this book have used this feature. A simple ex-
ample would be as follows. Run two simulations in open circuit,
one with 5% halothane and the other with 8% sevoflurane.
Create an Overlay of "ALV over DEL". You will see from the
display that sevoflurane is a much less soluble drug than
halothane (for more information, see Chapters 5 and 6).

Figure 15-2b shows the Overlay comparing ALV/DELfor 5%

halothane and 8% sevoflurane in open circuits.

15-11
Gas Man® Advanced Features

rinting & Export Options

Gas Man has a number of printing and output options that are
particularly useful in recording, sharing and presenting your
findings developed ,vith the program.

Any screen image can be copied using the Copy Selection com-
mand (Ctrl+X) and pasted into your presentation or word pro-
cessing files. These images can be edited (cropped, annotated,
re-colored) in most presentation and graphics software, and
translate well across the PC and Macintosh platforms.

The data from Gas Man simulations can be output to a spread-

sheet program, as described in the next section.

o PRINTING
A full record of a Gas Man simulation can be printed on your
laser printer. There are four commands under the File menu
related to printing. Start with Print Setup, which brings up the
usual vVindows dialog box that allows you to set your default
printer, choose a new one, set paper size and orientation, and
other options.

The Print Select command allows you to choose which tables

and figures you wish to print:

e Printout, which produces a tabular record of the currently

active simulation. The table includes the name of the
siumulation file, date and time of the printout, agent and
circuit used, patient weight, amount of liquid injected (if
any), and the values for the parameters DEL, FGF, VA,
CO. The printout lists all changes made to these settings
during the course of the simulation, and when the
changes were made.

Graphs, which records on a full page the time course of all

15-12
Gas Man® Ar/r l (lIIccd Fm/ures

four parameters (DEL, FGF, VA, CO), a graph withjust

CKT, ALV and VRG, and a graph with all five compart-
ment tensions (thus displaying more than the Gas Man
Graph screen display). Note that the view time of this
printout will match the current Vie'IV of the open simula-
tion when the Print command is invoked.

Screen Image, which prints out a bitmapped image of

both the Gas Man Picture and Graph on one page. Note
that some printers may not be able to handle the complex
data in this image, in which case you can use the keyboard
Print Screen function to paste an image on your screen
into a presentation or graphics package.

Whatever you select through this dialog box will remain selected
for all subsequent simulations until you close the program.

Print Preview will display on the screen the pages you have
selected to prin t (Printout, Graphs and/ or Screen Image). You
can zoom in and out, view them one page at a time, and go
directly to the Print dialog box from Preview mode.

If you know what you want to print without needing to usc Print
Select or Preview, go directly to the Print command. Check to see
if the correct printer is identified, select which pages you wish to
print, and the number of copies. Note that you can reach the
Print Setup window through this dialog box if you need to make
setup changes.

o DATA EXPORT
Another important feature of Gas Man that assists you in analyz-
ing your experiments is the ability to export data into other
software programs. The data contained in a Gas Man simulation
can be exported to a spreadsheet program, like Microsoft®
ExceFM or Lotus 1-2-3®, by using the Copy Data (Ctrl+C) com-
mand from the Edit menu. Once the data is in a spreadsheet, you
can create your own custom tables, reports and graphs that may
meet your needs better than the Overlay and Print functions
which Gas Man provides.

15-13
Gas Man® Adv([lIr:ed Features

To practice data export, follow these steps:

1 Open a spreadsheet program with a blank file.

2 Open a Gas Man simulation and run it for 15 minutes.

3 Type Ctrl+C, or use the Copy Data command.

4 Switch to the spreadsheet, highlight the leftmost cell where you

want the data from Gas Man to begin, and type Ctrl+V or use the
program's Paste command or toolbar icon. A line of data will
appear in a single row running to the right.

5 Switch back to Gas Man and run the simulation for a few more
minutes. Pause, copy the data, switch to the spreadsheet, select
the row underneath the first row, and paste again. A second row
of data will appear. Repeat this a few more times. Your spread-
sheet 'williook similar to that pictured in Figure 15-3.

Now that the data is in the spreadsheet, you can select subsets of
the data (for instance, time, DEL, and Uptake $), or plot new
data relationships using the spreadsheet's graphics tools.

F""i"Note: Gas Man does not export the header information along with the
data. You should note what the headers are and save them in a
spreadsheet file for future use. From left to right, the headers
are: Minutes, DEL, CKT, ALV, VRG, MUS, FAT, YEN, Uptake in
liters, Delivered in liters, Uptake in dollars, Delivered in dollars.

A
1 Minutes IILV MUS FAT Y£M Uptake L
2 0:15:00 2.900 2.521 1.718 1.695 0.152 0.008 1.316 0.519 3.480 2.08 13.92
3 0:25:00 2.900 2.56"3 1.893 1.871 0.281 0.015 1.473 0.803 5.800 3.21 23.20
4 0:45:00 2.900 2.592 1.919 1.971 0.523 0.030 1.594 1.325 10.44 5.30 41.16
5 0:55:00 2.900 2.603 2.012 2.004 0.635 0.031 1.639 1.512 12.76 6.29 51.04
6

Figure 15-3 shows a spreadsheet constructed from a series of data

readings exported from a Gas Man simulation using Copy Data.

15-14
 /~~
I \

Appendix \~'----~
/\
U
o
volution of the Understanding, Modeling & Simulation of
Anesthesia Uptake & Distribution
--------"---,--"-----,---,-,

The simulation of anesthesia uptake and distribution has been developed

over the last forty-five years, and has paralleled the development of our
understanding of the subject as well as the capabilities of computer hard-
ware and software. This section describes this development and annotates
the bibliography included in this book.

In 1950 19 and 19512°, Kety presented a physical and mathematical represen-

tation of the dvnamics of anesthetic tension equilibration in the body. He
I ,

suggested that the body be modeled as several compartments, whose anes-

thetic partial pressures tended toward equality. The effects of volumes,
anesthetic solubilities, and flows between compartments were clearly
explained. In 1963, Eger9 , MacKrelJ25, and Mapleson 2G , each wrote descrip-
tive computer simulations of anesthetic uptake and distribution at constant
inspired concentration, using large computers. In 1963, Eger and
Guadagnil4 developed a model for anesthesia administration at constant
alveolar concentration. In the same year, Eger described the concentration
effect lO • In 1964, Epstein, et a1. 16 described the second gas effect. In 1965,
Eger, Saidman, and Brandstater 15 established minimum alveolar concentra-
tion (NIAC) as the standard of anesthetic potency.

Numerous investigators have added further sophistication to computer

simulations by considering various physiologic effects. In 1967, Munson and
Bowers28 simulated the effect of hyperventilation on the rate of cerebral
anesthetic equilibration. In 1968, Munson, Eger, and Bowers29 simulated
the effects of changes in cardiac output and distribution on the rate of
cerebral anesthetic equilibration. In 1970, Ashman, Blesser and Epstein I
used a nonlinear model for halothane uptake in humans. Zwart, Smith,
and Beneken 44 used a multiple model approach to study the interaction of
circulation effects and anesthetic uptake in 1972. In 1973, Munson, Eger

A-I
Gas Man® AjJjmld ix

and Bowers:\(} studied and simulated the effects of anesthesia-depressed

ventilation and cardiac output on anesthetic uptake. In that seune year,
Mapleson~7 integrated circulation time into his digital computer simulation.

Closed-circuit simulations have been performed. Nonlinear models con-

tinue to be used. The ability to maintain anesthesia depth with automated
anesthetic vaporizer control has been demonstrated.

o THE Gas Man® APPROACH

In 1973, Cowles, Borgsteclt and Gillies 7 reassessed the evolution of computer
simulations in anesthesia and simplified the model to four patient compart-
ments. The mathematics of the Gas Man program follow an approach
similar to that of Cowles, et al. The Gas Man program was specifically
written as an educational tool to teach the fundamentals of anesthesia
uptake and distribution:;". Unlike most other simulation programs, a Jarge
computer is not required. It stresses partial pressure difference as the
driving force for equilibration. It has an advantage over physical hydraulic
models, since it is easily transported in the form of a computer disk. It is
more versatile since it graphs results and has special educational features
(optional removal of anesthetic from venous blood, optional concentration
effect, and optional vaporization effect).

In Gas Man, the patient is modeled as four compartments: the lung, vessel-
rich group, muscle, and fat; the breathing circuit is a fifth. The simulation
uses Euler's method of solution for the simultaneous differential equa-
tions 37 .38 , with linear coefficients that govern the five-compartment system.
For each compartment, the change in anesthetic tension is proportional to
the difference between entering and exiting anesthetic quantity, and in-
versely proportional to compartment capacity; that is, mass is conserved.
The volume of the functional residual capacity of the lung is held constant
by increasing inspired or expired alveolar ventilation. If anesthetic tension
in any compartment were to change more than 20% during a single time
slice at which tensions are computed, the interval time is split in half, allow-
ing the simulation's graphs to be smooth.

The uptake and distribution of inhalation anesthetics depends upon nu-

merous parameters and variables. The model embodied in the Gas Man
program utilizes standard values for organ volumes, anesthetic solubilities,
and regional blood flows, as shown in Table A-I. In actuality, the value of

A-2
 Gas Man®

each of these parameters is at best an estimate for any patient, but they are
representative enough for teaching and exploring anesthesia concepts.

Model Parameters in Gas Man 2.1

Tissue/Gas partition co£jjicients

MAC 110 1.1 1.7 0.8 6.0 2.1 200.0

Delivered
Circuit 8.0
Alveoli 2.5
Blood 5.00 0.47 1.30 1.90 2.47 0.42 0.65 0.014
VRG 6.0 3.80 0.76 0.42 2.10 2.80 4.80 0.54 1.10 0.010
Muscle 33.0 0.90 0.18 0.54 4.50 4.60 9.90 0.97 2.40 0.014
Fat 14.5 0.30 0.06 1.08 70.00 63.00 150.00 13.00 34.00 0.070

Tissue/Blood partition
. -
co£jjicients (calculated)

Blood/Gas 0.47 1.30 1.90 2.47 0.42 0.65 0.014

Brain/Blood 0.89 1.11 1.47 1.94 1.29 1.69 0.714
Muscle/Blood 1.15 2.37 2.42 4.01 2.31 3.69 1.000
Fat/Blood 2.30 36.84 33.16 60.73 30.95 53.21 5.000

Notes:
Values for volume, flow and relative flow are taken from Lowe and Ernst, 1981 2:1•
Values for nitrous oxide and enflurane are taken from Eger, 198112.
Values for isoflurane, halothane, desflurane and sevoflurane are taken from Yasuda, Targ
and Eger 45 .
Values for nitrogen al-e taken from Weathersby and Homer, 1980.14 •
Values for sevoflurane are taken from the package insert and Abbott data.

Table A-I.
Model Parameters for Gas Man as set in Version 2.1. Users of earlier ver-
sions of Gas Man should note that the values of some of these parameters
are slightly different.

A-3
Gas Man® AjJjJelulix

urther Considerations on the Use of Gas Man®

Some advanced features of anesthesia uptake and distribution have been

added in Versions 2.0 and 2.1. The ability to change tissue volumes and
their relative flows allows the user to simulate several interesting clinical
phenomena, such as: cachexia and its effect on tissue volumes; the altered
perfusion which accompanies hyperventilation and excitement; and the
depressed cardiac output and alveolar ventilation secondary to deep
anesthesia.

Gas Man is necessarily a limited simulation model- limited by computer

resources, by the natural variations in clinical settings, and by the need to
presene Gas Man's educational simplicity. Gas Man does not include the
effects of shunts and dead space, intertissue diffusion, incomplete tissue
mixing, drug metabolism, or nonpulmonary drug excretion.

ORGAN VOLUMES

In certain chronic conditions, tissue volumes can deviate markedly from

those in the standard default Gas Man model. Obesity, cachexia, and
muscularity obviously affect compartment volumes. Similarly, tissue and
blood solubility variations are possible. These can be simulated in Version
2.1 of Gas Man.

ORGAN BLOOD FLOWS

Blood flow to organs is known to change in certain clinical situations.

Specifically, hyperventilation causes cerebral vasoconstriction and hence
slowed anesthetic transfer from blood to brain. Excitement (stage II
anesthesia) increases muscle blood flow and changes the time course of
induction as well.

A-4
Gas Man® ilfJ pen di x

During deep anesthesia, cardiac output decreases with most agents.

Anesthetic depth also changes alveolar ventilation during spontaneous
breathing. Some of these effects have been programmed to occur auto-
matically in other simulation programs. Gas Man allows the user to adjust
cardiac output, relative blood flows and alveolar ventilation to observe these
effects.

BREATHING CIRCUIT

The semiclosed circuit simulated in the Gas Man program assumes perfect
gas mixing and instant vaporization of injected anesthetic liquid. In a real
breathing circuit, because the fresh gas flow enters near the inspiratory
valve, gases administered to the patient are typically incompletely mixed
and contain a preponderance of fresh gas early in each breath. Completely
unmixed gas in the breathing circuit has been simulated as the Ideal cir-
cuit. Clinical circuits act as if they fall between the ideal and semi-closed
circuits that are simulated with Gas Man. Adding a mixing device makes a
real breathing circuit function more like the ideal circuit modeled. When
anesthetizing large animals, a larger breathing circuit and resevoir bag are
often used. This can be simulated in Gas Man by changing circuit volume
by using the Simulation Settings dialog under the Set Defaults command.

SHUNTS AND DEAD SPACE

Within the lungs, intrapulmonary shunts may allow the delivery of venous
blood to the arterial system without equilibrating with alveolar gas. These
shunts slow anesthesia induction with blood-insoluble agents. Dead space
affects anesthetic induction, decreasing effective ventilation to the alveolar
space. In the Gas Man model, dead space has been taken into account by
allowing selection of alveolar ventilation rather than total lung minute
ventilation.
INTER-TISSUE DIFFUSION

il-5
Gas Man®

Inter-tissue diffusion may occur between fat and muscle; this effect has
been ignored in the Gas Man model. Instead, it is assumed that complete
mixing- occurs in each oro-an,
L. b
and that anesthetic tension evervwhere within
I

each organ is equal to anesthetic tension in the outt1owing venous blood

whose volume is a part of the organ volume. Although this is not exactly
true clinically, it is a close approximation. Further, the quantity of anes-
thetic taken up by the arterial blood volume has not been included in Gas
Man's calculation of uptake. Circulation times between sequential compart-
ments are all 0.1 minutes.

o SUMMARY
The Gas Man theory and program are a natural outgrowth of the work
done in the last forty-five years on the computer simulation of anesthesia
uptake and distribution. It builds on the foundation of earlier models and
has important advantages, but also has its limitations. Gas Man does not
account for all the phenomena known to affect anesthesia uptake and
distribution. Many physiologic subtleties have been ignored to preserve the
simple educational value of the program. This program should never be
used to govern patient care; instead, it is a powerful tool for educational
simulation.

A-6
Gas Man® AjJjJendix

as Man System Defaults

The following is a listing of the data in the file GAS.MAN.INI, found in the
Gas Man directory, as it is configured on the Gas Man program disk when
you first receive it. Use this listing for reference, and for restoring any
defaults you may change using the Set Defaults command or directly in the
INI file itself. The data for the first agent is annotated.

Agents=Desflurane,Enflurane,Halothane,Isoflurane,Nitrous Oxide,
Sevoflurane,Nitrogen

[Desflurane]
Lambda=OA2 Blood/Gas Partilion CoeJJicienl
VRG=0.54 VRG/Gas Parlilion Coefficienl
MUS=0.97 l\IIU';/Gas Partition Coefficienl
FAT=13 FAT/Gas Partition Coefficient
Max=90 A1aximwn value jbr vajJorizer tOj)
High=18 High end of vaj)orizer scale
Default=9 Default vaj)orizer setting
DefU ni tDose= 1 Unit dose of liquid injected
Volatility=209 Vapor/Liqu,id volume ratio (2(I'C)
MAC=6.0 ALAC value
BottleCost=70 Bottle cosl in $US
Bo ttleSize=2 40 Bottle volume in mL

[Enflurane] [Halothane] [Iso flurane]

Lambda=1.9 Lambda=2A7 Lambda=1.3
VRG=2.8 VRG=4.8 VRG=2.1
MUS=4.6 MUS=9.9 MUS=4.5
FAT=63 FAT=150 FAT=70
DefUnitDose=1 DefUnitDose=O.5 DefUnitDose=0.5
Volatility=198 Volatility=240 Volatility= 196
Max=33 Max=25 Max=25
High=7 High=5 High=5
Default=5.7 Default=3.3 Default=2.9
MAC=1.7 MAC=0.8 MAC=1.1
Bo ttleCost= 122 BottleCost=15 BottleCost=72
BottleSize=240 BottleSize=240 BottleSize= 100

i\.-7
Gas Man® ;l jJjJe n d Lx-

[Sevoflurane] [Nitrous Oxide] [Nitrogen]

Lambda=0.65 Lambda=0.47 Lambda=0.014
VRG=l.l VRG=0.42 VRG=O.OlO
MUS=2.4 MUS=0.54 MUS=0.014
FAT=34 FAT=l.OS FAT=0.070
MAC=2.1 lIlAC=110 MAC=200
DefU nitDose= 1 DefUnitDose=l.O
Volatility=lS3 Volatility=2S7 Ambient=SO
Max=33 Max=150 Max=SOO
High=S High=lOO High=400
Default=3.S Default=70
BottleCost=lSO Bottleeost=.57
Bo ttleSize=250 Bottlesize= 1000

[Ratio of Flows] [Defaults]

VRG=76 VA=4.00
MUS=lS CO=5.00
FAT =6 Speed=AFAP
Agen t=Isoflurane
[Volumes of Compartments] Cireui t=Semi-closed
CKT=S.O seroll=O
ALV=2.5 linewidth=2
VRG=6 linelabels=2
FAT=14.5 serollpereent=67
MUS=33.0 graphminutes=15
VEN=l OverlayShow=Alv
OverlayOver=Ckt
Showeost=O
Weight=70

[Settings]
PreviewPages=2

A-8
Gas Man i' Bibliogmphy

1. Ashman MN, Blesser vVB, Epstein RM: A nonlinear model for the
uptake and distribution of halothane in man. Anesthesiology 33:
419, 1970.

2. Barton F, NunnJF: Totally closed circuit nitrous oxide/oxygen

anaesthesia. BrJ Anaesth 47: 350, 1975.

3. Brandom BvV, Brandom RB, Cook DR: Uptake and distribution of

halothane in infants: In vivo measurements and computer
simulations. Anesth Analg 62: 404, 1983.

4. Brody S: Bioenergetics and Growth. New York: Reinhold, 1945.

5. Brown RE: Compartmental system analysis: State of the art. IEEE

Trans Biomed Eng 27: I, 1980.

6. Chilcoat RT: Computer assistance in the control of depth of anaes-

thesia. Ph.D. thesis, \l\Telsh National School of Medicine, University
of Wales, 1982.

7. Cowles AL, Borgsteclt HH, Gillies AJ: A simplified digital method for
prediciting anesthetic uptake and distribution. Com put BioI Med 3:
385,1973.

8. Edsall D\I\T: Economy is not a major benefit of closed-system

anesthesia. Anesthesiology 54: 258, 1981.

9. Eger EI II: A mathematical model of uptake and distribution. In:

Papper EM, Kitz RJ, eds: Uptake and Distribution of Anesthetic
Agents, New York: McGravv-Hill, 1963, p. 72.

10. Eger EI II: Effect of inspired anesthetic concen tration on the rate of
rise of alveolar concentration. Anesthesiology 24: 153, 1963.

B-1
Gas Man i; Bi/JIiop:mp/iy

11. Eger El II: Anesthetic uptake and action. Baltimore: Williams &
Wilkins, 1974.

12. Eger E1 II: lsoflurane (Forane')<)): A Compendiurn and Reference.

Madison, ,NI: Airco, 1981.

13. Eger EI II, Bahlman SH: Is the end-tidal anesthetic partial pressure
an accurate measure of the arterial anesthetic partial pressure?
Anesthesiolog"v 35: 301, 1971.
UI

14. Eger EI II, Guadagni NP: Halothane uptake in man at constant

alveolar concentration. Anesthesiology 24: 299, 1963.

15. Eger EI II, Saidman q, Brandstater B: Minimum alveolar

anesthetic concentration: A standard of anesthetic potency.
Anesthesiolog-y 26: 756, 1965.

16. Epstein RM, Rackow H, Salanitre E, Wolf GL: Influence of the

concentration effect on the uptake of anesthetic mixtures: The
second gas effect. Anesthesiology 25: 364, 1964.

17. Foldes FF, Cerayolo AJ, Carpenter SL: The administration of

nitrous oxide-oxygen anesthesia in closed systems. Annals Surgery
136: 978, 1952.

18. Goldberg IS, MostertJvV, LanzI EF, Lowe HJ: A pharmacokinetic

model of closed-circuit inhalation anesthesia. Ann Biomed Eng 6:
231,1978.

19. Kety SS: The physiological and physical factors governing the
uptake of anesthetic gases by the body. Anesthesiology 11: 517, 1950.

20. Kety SS: The theory and applications of the exchange of inert gas
at the lungs and tissues. Pharmacol Rev 3: 1, 1951.

21. Latta WE, Snider MT: Uptake and distribution: Hydraulic

simulation designed for resident teaching. Scientific Exhibits,
Annual Meeting, American Society of Anesthesiologists,
San Francisco, CA, 1976.

B-2
Gas Manti Bibliography

22. Lowe H.J: Dose-Regulated Pentlll'ane';; IVlethoxyf1urane Anesthesia.

Abbott Laboratories, 1972.

23. Lowe HJ, Ernst EA: The Quantitative Practice of Anesthesia: Use of
Closed Circuit. Baltimore: Williams & \I\rilkins, 1981.

24. Lowe Hj, MacKrell TN, Mostert]\"', Hagler rq: Quantitative closed
circuit anesthesia. Anesthesiology Review, August 1974, p. 16.

25. MacKrell TN: An electrical teaching model. In: Papper EM, Kitz
Rj, eds: Uptake and Distribution of Anesthetic Agents, New York:
McGraw-Hill, 1963, p. 215.

26. Mapleson W'''': An electrical analogue for the uptake and exchange
of inert gases and other agents. J Appl Physiol18: 197,1963.

27. Mapleson WVV: Circulation-time models of the uptake of inhaled

anaesthetics and data for quantifying them. BrJ Anaesth 45: 319,
1973.

28. Munson ES, Bowers DL: Effects of hyperventilation on the rate of

cerebral anesthetic equilibration. Anesthesiology 28: 377, 1967.

29. Munson ES, Eger E1 II, Bowers DL: The effects of changes in
cardiac output and distribution on the rate of cerebral anesthetic
equilibration. Anesthesiology 29: 533, 1968.

30. Munson ES, Eger E1 II, Bowers DL: Effects of anesthetic-depressed

ventilation and cardiac output on anesthetic uptake: A computer
nonlinear simulation. Anesthesiology 38: 251, 1973.

3l. Patel A, Milliken RA: Costs of delivery of anesthetic gases re-

examined. 1. Anesthesiology 55: 710, 1981.

32. Perl W, Rackow H, Salanitre E, ",rolf GL, Epstein RM: 1ntertissue

diffusion effect for inert fat-soluble gases. J Appl Physiol 20: 621,
1965.

B-3
Gas ManE Bibfiop:mjJhv

Philip ]H: CAS MAN pictorial and graphical simulation for

teaching anesthesia uptake and distribution. Anesthesiology 59:
A471,1983.

34. Philip ]H, Cooper]B, Newbower RS: The Boston Anesthesia

System. Abstract, presented at: Low Flow and Closed Circuit
Anesthesia Symposium, Denver, CO, April 1978.

35. Philip ]H: Cas Man'Jc - An example of goal oriented computer-

assisted teaching which results in learning. IntI] Clin Monitoring
& Computing 3: 165, 1986.

36. Severinghaus ]W: The rate of uptake of nitrous oxide in man.

] Clin Invest 33: 1183, 1954.

37. Soong TT: Pharmacokinetics with uncertainties in the rate

constants. Mathematical Biosciences, 1971.

38. Soong TT: Random Differential Equations in Science and

Engineering. New York: Academic Press, 1979.

39. Spain]A: Cost of delivery of anesthetic gases reexamined. III.

Anesthesiology 55: 711, 1981.

40. Stoeling RK, Longnecker DE: The effect of right-to-left shunt on

the rate of increase of arterial anesthetic concentration.
Anesthesiology 36: 352, 1972.

41. Virtue RW: Low flow anesthesia: Advantage in its clinical applica-
tion, cost, and ecology. In: Aldrete ]A, Lowe H], Virtue RW, eds:
Low flow and closed system anesthesia, New York: Crune and
Stratton, 1979.

42. Virtue R\I\T, Aldrete]A: Costs of delivery of anesthetic gases re-

examined. II. Anesthesiology 55: 711, 1981.

B-4