NURSING GUIDELINES ON THE SETUP AND … · Our Lady’s Children’s Hospital, Crumlin Document Name: Nursing Guidelines on the Set up and management of the AnaConDa Device (Anaesthetic

NURSING GUIDELINES ON THE SETUP AND MANAGEMENT

OF THE AnaConDa DEVICE (ANAESTHETIC CONSERVING DEVICE)

Version Number V1

Date of Issue April 2016

Reference Number SMACD-04-2016-CMCMDBJELODTFJD-V1

Review Interval 3 yearly

Approved By

Name: Fionnuala O’Neill

Title: Nurse Practice Coordinator

Signature: Date: April 2016

Authorised By

Name: Rachel Kenna

Title: Director of Nursing


Authors

Name: Dr. Cathy McMahon

Title: Consultant Paediatric Intensivist


Author/s

Name: Dr. Cathy McMahon & Dr. Martina Healy

Title: Consultant Paediatric Intensivists

Name: Dervilia Beirne, Julie Edwards & Linda O’ Donnell

Title: Clinical Nurse Facilitators, PICU

Name: Tony Fitzgerald & Jim Davenport

Title: Clinical Engineer

Name: Moninne Howlett & Diarmaid Semple

Title: Pharmacists (Informatics & PICU)

Location of Copies On Hospital Intranet and locally in department

Document Review History

Review Date Reviewed By Signature

October 2016

Document Change History

Change to Document Reason for Change

Our Lady’s Children’s Hospital, Crumlin

Document Name: Nursing Guidelines on the Set up and management of the AnaConDa Device (Anaesthetic Conserving Device) Reference Number: SMACD-04-2016-CMCMDBJELODTFJD-V1 Version Number: V1

Date of Issue: April 2016 Page 2 of 14

Contents

Page No

1.0 Introduction and Definition 3

2.0 Isoflurane 3

3.0 Indication for AnaConDa 3

4.0 Dose and Prescribing 3

5.0 Patient Exclusion 4

6.0 Equipment 4

7.0 Monitoring 7

8.0 Documentation 7

9.0 Warnings 7

10.0 Procedures 8

10.1 Filling the syringe

10.2 Priming the AnaConDa

10.3 Suctioning

10.4 Using the nebulisers on AnaConDa

10.5 Changing the AnaConDa Device

10.6 Changing the syringe

10.7 Ending the therapy

10.8 Troubleshooting

11.0 Appendix 1 13

12.0 References 14




1.0 Introduction and definition

The AnaConDa is an anaesthetic gas system for use in PICU with the Servo i ventilator to administer

isoflurane/sevoflurane in a safe and controlled manner. It will be set up by clinical engineering and used by

staff trained to administer isoflurane to children. These guidelines are designed to standardize the care of the

child receiving inhaled isoflurane and are not a substitute for training and competency assessment. This

guideline does not currently cover the use of sevoflurane in PICU.

2.0 Isoflurane

Isoflurane is an inhalational anaesthetic agent used for induction and maintenance of general anaesthesia. All

volatile anaesthetic agents share the property of being liquid at room temperature, but evaporating easily for

administration by inhalation.

The AnaConDa device is an anaesthetic delivery system, developed for the administration of isoflurane and

sevoflurane to mechanically ventilated patients.

The AnaConDa is a small device that is inserted at the inspiratory limb of the ventilator circuit. The simple

design of the AnaConDa, incorporates a unique high capacity miniature vaporizer, which allows delivery of

these inhalational anaesthetic agents in a safe and controlled manner.

3.0 Indications for AnaConDa

Status Epilepticus

Status asthmaticus

As a sedative agent for difficult to sedate patients on multiple agents or to control withdrawal reactions

in those who have been exposed to high doses of conventional agents

For raised Intracranial Pressure (ICP)

Children who require short term ventilation and/or prompt awakening (Head Injury/need investigations

where patient is breathing spontaneously e.g. bronchogram, bronchoscopy or diaphragmatic

screening)

4.0 Dose and Prescribing - Please see ‘Appendix 1: Prescribing and Recording of Volatile Liquid

Anaesthetics in PICU’ and the ‘OLCHC Hospital Formulary ‘for full information

NOT FOR IV USE

Consultant Prescribing Only

Other sedatives may need to be titrated/ discontinued

Isoflurane is a potent vasodilators, the patient may require a fluid bolus +/_ inotropes

Dose to be titrated to maintain target End Tidal Concentration as specified by Consultant

Normal dose range and adverse effects- please refer to Hospital Formulary




5.0 Patient Exclusion

Lots of secretions requiring frequent suctioning

Patient on high frequency ventilation

Caution with patient on inhaled nitric oxide (not tested by the company)

Family history of malignant hyperthermia – (see hospital formulary for further information)

NOTE: To enable treatment of malignant hyperthermia a supply of Intravenous Dantrolene

sufficient to treat the patient must be obtained from pharmacy when commencing Isoflurane

6.0 Equipment

Philips bedside monitor

Servo I ventilator +patient appropriate circuit

AnaConDa device +red cap [keep for safe disposal of the device]




Infusion pump [B Braun perfusor FM syringe driver]

Gas scavenging unit Maquet EVAC 180

DraegerGas Monitor +gas monitoring line +water trap




Cerebral Function Monitor

Test Lung

Consumables

Drager sample line

Drager water trap

Drager airway adaptor

Bottle of Isoflurane with Sedana filling adaptor attached




Provided syringe extension and labels

Safety equipment - gloves goggles apron

7.0 Monitoring

Monitoring in addition to routinely recorded parameters

Once set up the bedside monitor (Drager Gas Monitor) will display three additional values

Inspiratory concentration of the anesthetic agent

Expiratory concentration of the anesthetic agent

EtCO2

8.0 Documentation

Nursing staff should follow PICU policy for documenting information relating to nursing care vital signs and are

reminded that they are not only responsible for what they include, but also what they omit. See Appendix 1 for

further information on documenting on ICCA.

However, with regard to the AnaConDa device, the following values should be recorded hourly on ICCA:

Concentration of the anaesthetic agent (End Tidal concentration), based on direct measurement

The rate of infusion of the anaesthetic agent- see Appendix 1

The remaining syringe level

End Tidal CO2 displayed

Pupil Reaction

This is in addition to the parameters below, which should be routinely recorded:

HR / RR / BP / ETCO2 / Saturations / Temperature

Ventilator parameters

Blood gases

Intracranial Pressure (if being monitored)

Inotropes

9.0 Warnings

Not for IV use

Must be prescribed by a Consultant as per Appendix 1




Anaesthetic agents are potent vasodilators – monitor blood pressure, child may require a fluid bolus

and may also require inotropic support.

Other sedatives may need to be titrated/ discontinued

To be delivered using syringe drivers labelled ‘AnaConDa – stored in Clinical Engineering Department.

Do not use the bolus function on the syringe driver

Can only be used with the Servo I in OLCHC

Humidifier must be turned on

AnaConDa device placed in the inspiratory limb. Monitor from the patient end of the short patient

module using a green connector with green port (in nitric oxide aisle)

Always put syringe driver on hold before disconnecting AnaConDa to avoid unnecessary exposure to

anaesthetic agent

Disconnect from the ventilator first, then from child. Attach to child first, then to ventilator. Attach test

lung to ventilator. This is to prevent unnecessary exposure to anaesthetic agent

Do not use desflurane: AnaConDa device and syringe are only compatible with isoflurane

Do not reconnect AnaConDa device that has been disconnected and idle for greater than 8 hours.

Always use a new device.

Replace the AnaConDa every 24 hours

Set the pressure alarms on the syringe driver to maximum.

Save the red cap for when disposing of AnaConDa: store in plastic bag on top of ventilator

AnaConDa has not been tested with nitric oxide

In this appliance the only relevant value for ISO is the ET value

10.0 Procedures

10.1 Filling and syringe

PROCEDURE RATIONALE and EVIDENCE

1. Ensure the anaesthetic agent; dose and route are

clearly prescribed. To be checked with two nurses,

one of which has received AnaConDa training.

In accordance with Medicines Management

Policy

To maintain patient safety

2. Personal protective equipment: gloves; apron; face

visor to be worn

To maintain personal safety

3. If not already done, attach the filling adaptor. Only

use the syringe red cap supplied with the Anaconda

system since others may not be suited for

isoflurane

To ensure safe and easy filling of the syringe

with the anesthetic agent

4. Fill the syringe with air (approx. 15mls) and firmly

connect to the filling adaptor on the anesthetic

agent bottle. Push the air into the bottle, invert the

bottle and allow the anesthetic agent to fill the

syringe. Once the syringe stops filling push the

remaining air back into the bottle and again allow

the anaesthetic agent to fill the syringe as before.

The syringe must not be filled above 50mls.

To equalize the pressure and prevent spray

effect when removing the syringe from the

bottle.

5. With the syringe still connected to the inverted

bottle, expel all air.

To prevent exposure to the anesthetic agent




6. Turn the bottle the right way up, remove the syringe

and immediately replace the red cap.

To prevent exposure to the anesthetic agent

7. Label the syringe and sign as appropriate. In accordance with Medicines Management

8. Place the syringe into the syringe driver with the red

cap in place.

9. Empty bottles can be disposed of in glass recycling

bin in sluice room. Any bottles with remaining

product should be returned to pharmacy for

disposal in purple lidded clinical rigid bins fitted with

absorbent material (UN3291).

To prevent exposure to the anaesthetic agent

To ensure safe and appropriate management of

medicinal waste as per Waste Management

Policy in OLCHC (available on intranet)

10.2 Priming the Anaconda

PROCEDURE RATIONALE and EVIDENCE

1. Important: Priming must be done before

connecting to the patient; do not purge.

To maintain patient safety: isoflurane is a potent

vasodilator.

To prevent exposure to anaesthetic agents.

2. Increase pressure limits on dedicated Braun

pump to maximum

3. Set the rate of infusion

To enable priming to be completed safely before

connecting to the patient.

4. Set appropriate alarm limits on vital signs To maintain patient safety

10.3 Suctioning

PROCEDURE RATIONALE

Closed suctioning can be used with this device

Closed suctioning as per guidelines.

To minimize exposure to the Isoflurane

To limit fluctuations in gas delivery

In the event of the patient requiring

Open suctioning

PROCEDURE RATIONALE

1. Consider bolus of sedation Anaesthetic agent has short duration of action

2. Stop syringe driver

3. Disconnect the ventilator To prevent exposure to anaesthetic agent.

4. Immediately place on test lung To prevent exposure to anaesthetic agent.

5. Put ventilator on standby

6. Hand ventilate directly via ETT and perform

suction as per guidelines

7. Connect ventilator to patient

8. Start syringe driver – double check infusion rate

and sign on ICCA

In accordance with OLCHC Medication Policy




10.4 Using Nebulisers on Anaconda

PROCEDURE RATIONALE

1. Connect the nebuliser in the routine position on

the inspiratory limb.

To enable use of nebuliser

2. Discontinue nebulisation if problems arise To prevent complications

3. Always consider dead space when adding any

extra items

To ensure appropriate delivery of inhaled

anaesthetic agent.

10.5 Changing the Anaconda device

PROCEDURE RATIONALE

1. The device is to be changed every 24 hours

2. Obtain new Anaconda pack containing syringe,

Anaconda device and giving set

3. Fill new syringe (see item 1), remove old syringe

from syringe driver and replace red cap and

place new syringe in syringe driver

4. Label AnaConDa with date and time (using field

on label for ‘Bed’). Both nurses should initial the

label for syringe preparation

In accordance with OLCHC Medication Policy

5. Connect AnaConDa giving set to syringe

6. Prime new AnaConDa with approx 1.2mls of

anaesthetic agent before connecting to

patient

To enable priming to be completed safely before

connecting to the patient

7. Disconnect ventilator tubing from old Anaconda,

then disconnect Anaconda from patient end and

insert red cap into Anaconda


To prevent flushing of the anaesthetic agent from

the Anaconda device

8. Connect new Anaconda to patient end first and

then connect to ventilator tubing. Retain red cap

To prevent flushing of the anaesthetic agent from

the Anaconda device

To seal the Anaconda when therapy discontinued

9. Start syringe driver and monitor patient and

anaesthetic agent concentration. Record new

MEI number

For audit trail purposes

10. Discard old Anaconda and syringe as clinical

waste





10.6 Changing the syringe

PROCEDURE RATIONALE

1. Personal protective equipment: gloves; apron;

face visor to be worn

To maintain personal safety

2. Stop syringe driver and remove empty syringe,

still connected to supply line


3. Place new syringe in driver with red cap in place To prevent exposure to the anaesthetic agent

4. Disconnect supply line from empty syringe and

immediately connect supply line to new syringe


5. Connect red cap onto empty syringe To prevent exposure to the anaesthetic agent

6. Start syringe driver, observing child’s vital signs

and anaesthetic agent concentration


7. Refill empty syringe with anaesthetic agent for

next use. Connect red cap to end of syringe.

Write 2nd use on label.

To be prepared for next syringe change.

To prevent exposure to anaesthetic agent.

8. Re-use syringe for a maximum of 2 times. To conserve current limited supply of syringes

9. Discard used syringe as clinical waste To prevent exposure to the anaesthetic agent

10.7 Ending the therapy

PROCEDURE RATIONALE

1. Stop syringe driver. Monitor child’s condition

and record end time

For audit purposes

2. Disconnect Anaconda from ventilator circuit

first then from the patient end


3. Connect red cap to patient end of

AnaConDa

To seal the old Anaconda and prevent exposure to

the anaesthetic agent

4. Remove syringe from driver. Leave

connected to supply line


5. Discard AnaConDa, syringe, monitoring line,

water trap and scavenging filter as clinical

waste


6. Clean syringe drivers, gas monitoring bench

and scales

In accordance with local policy

7. Document on ICCA and in the patient case

notes

In accordance with local policy




10.8 Troubleshooting

PROBLEM SOLUTION

1. Gas concentration does not increase

although more than 2mls has been

delivered by syringe driver

Check monitor and gas bench connections

Check monitoring line is free from kinks and

attached to water trap on gas bench

Check AnaConDa has black part facing

upwards

Check for air bubbles in syringe

Increase syringe pump rate by increments of

0.5mls every 10 minutes until waveform and

concentration is displayed, observing child’s

condition carefully

2. Gas concentration levels drop, although

syringe driver rate is unchanged Check monitor connections and for leakage

Check AnaConDa has black part facing

upwards

Check for water in scavenging port

Check for leak around ETT, re-inflate cuff

3. Water in scavenging port Stop syringe driver.

Wear apron, gloves and face visor,

Remove scavenging.

Empty water into sharps bin.

Reconnect scavenging

4. After a while, the child’s tidal volumes

decrease (pressure control mode of

ventilation)

OR

After a while, the child’s peak inspired

pressures increase (volume control mode

of ventilation)

Assess child

Check if child needs a suction

Check Anaconda has black part facing

upwards

Check for water in scavenging (see point 3)




11.0 Appendix 1: Prescribing and Recording of Volatile Liquid Anaesthetics in PICU

1. PRESCRIBING ON ICCA: (Consultant Prescribing only ) Prescribe as a ‘free-form medication infusion’ choosing the appropriate standard order from the drop down menu. E.g. ‘isoflurane inhalational continuous’

NB: The ‘Target End Tidal Concentration’ 0.5-1% should be specified in the ‘order instructions’ field. All other fields will auto-fill but should be reviewed before the order is confirmed by pressing OK. 2. RECORDING OF ADMINISTRATION: The following values should be recorded hourly: (See Image 1&2 below):

Location Parameter Comment Intake/Infusions

Flowsheet Rate

Administered Syringe Level

To maintain accurate fluid intake volumes DO NOT enter Volume Administered on flowsheet (this field refers to IV/SC Infusions only).

Ventilation Flowsheet

End Tidal Concentration

'ET ConcIso' will need to be added using ‘Add Row’ in Ventilation

The hourly checks do not require counter signing. The syringe preparation does require 2 nurses counter signing




12.0 References Berton J, Sargentini C, Nguyen J, Belii A & Beydon L (2007) AnaConDa Reflection Filter: Bench and Patient

Evaluation of Safety and Volatile Anesthetic Conservation. International Anesthesia Research Society Vol.

104(1) 130-134

Eifinger F et al (2013) Observations on the Effects of Inhaled Isoflurane on Long-term Sedation of Critically Ill

Children using a Modified Anaconda System. Online Source 12/04/2016

L’Her E, Dy L, Pili R, Prat G, Tonnelier JM, Lefevre M, Renault A, Boles JM (2008) Feasibility and potential

cost/benefit of routine isoflurane sedation using an Anesthetic-Conserving Device: a prospective observational

study. Respiratory Care. Vol. 53(10), 1295-1303

Meiser A & Laubenthal H (2005) Inhalation anaesthetics in the ICU: theory and practice of inhalational sedation

in the ICU, economics, risk-benefit. Best Practice & Research Clinical Anaesthesiology. Vol. 19, No. 3, 523-

538

Playfor S, Macarthur A (2010) Guidelines for the use of the AnaConDa device. Royal Manchester Children’s

Hospital guidelines

Röhm KD, Wolf MW, Schöllhorn T, Schellhaass A, Boldt J, Piper SN (2008) Short-term sevoflurane sedation

using the Anaesthetic Conserving Device after cardiothoracic surgery. Intensive Care Medicine. Vol. 34, 1683-

1689

Sackey PV, Roland-Martling CR, Radell PJ (2005) ,Three cases of PICU sedation with isoflurane delivered by

the AnaConDa. Pediatric Anesthesia. Vol. 15, 879-885

Sackey PV, Roland-Martling C, Carlswärd C, Sundin O, Radell PJ (2008) Short and long-term follow-up of

intensive care patients after sedation with isoflurane and midazolam – A pilot study. Critical Care Medicine.

Vol. 36, 801-806

Sheerin M (2015) Clinical Procedures: Setup and Management of the AnaConDa Device (Anaesthetic

Conserving Device). Temple Street University Hospital

‘The Waste Management Policy’ in OLCHC. This policy is available on the OLCHC intranet under ‘Policies,

Guideline and SOPs’, ‘Policies A-Z’.

Forane® (Isoflurane) Summary of Product Characteristics. Available at:

http://www.medicines.ie/medicine/3787/SPC/Forane++99.9++w+w%2c+inhalation+vapour%2c+liquid/

Sedan Medical - Instruction for Use -http://www.sedanamedical.com/files/IFU_Anaconda26000_English_151101.pdf

Sedan Medical - Training manual - http://www.sedanamedical.com/files/TM_Anaconda26000_English.pdf

Disclaimer 2016, Our Lady’s Children’s Hospital Crumlin, Dublin 12. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means without the prior written permission of the copyright holder. Every effort has been made to ensure that the information provided is accurate and in accord with standards accepted at the time of printing.

http://www.sedanamedical.com/files/IFU_Anaconda26000_English_151101.pdf

http://www.sedanamedical.com/files/TM_Anaconda26000_English.pdf

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NURSING GUIDELINES ON THE SETUP AND … · Our Lady’s Children’s Hospital, Crumlin Document Name: Nursing Guidelines on the Set up and management of the AnaConDa Device (Anaesthetic