Medical Gases Workbook

U n i v e r s i t y Te a c h i n g Tr u s t
Basic Medical Gas Safety

January 2012
For all clinical and clinical support staff
Patient and Customer Focus Accountability Continuous Improvement Respect

G11102604 Design Services, Salford Royal NHS Foundation Trust, all right reserved 2011. This document MUST NOT be photocopied. Unique identifier: TE1 A (11) Issue: One Review date: January 2014
Learning and Development Department
Checklist
l
This workbook is for all clinical and clinical support staff who work with medical gases see link : http://elearning.hope-academic.org.uk/srht_elearn_dept/
l l
Read through this section of the work book
Familiarise yourself with Trust Policy, legislation and regulation on medical gases, as listed below Familiarise yourself with the gases, gas equipment and gas storage within your working environment Complete the online assessment via e-learning
l l
If further information is required please visit the link at the bottom of this section via the intranet
Page 1
Background
Medical gases are widely used around the hospital and are supplied in cylinders or piped into wards and clinical areas. They are safe if handled correctly, however, misuse or mishandling can have catastrophic consequences. The purpose of this training is to raise awareness of the types of gases commonly used, the risks and hazards associated with their use and handling, and the administration of oxygen to patients. A number of documents including legislation, regulation, policy and procedure apply to working with medical gases. The more important ones for clinical staff are: l Management of Health and Safety at Work Regulations 1999 The Control of Substances Hazardous to Health (COSHH) Regulations l Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1985 (RIDDOR) l Medicines Act (1968) (and the role of The Medicines and Healthcare products Regulatory Agency (MHRA)) l Defect, failure and incident reporting (DATIX) l The Trust Medical Gases Operational Policy l The Trust Oxygen Prescribing and Administration Policy
l
You should familiarise yourself with these. Summaries of these documents, or links to the full texts, can be found on the Medicines Management and Respiratory Medicine pages of the Trust Intranet. (Search keywords: medical gases, gas safety, oxygen administration)
Page 2
An Introduction to Medical Gases

What are medical gases?
l
The Trust Medical Gases Operational Policy denition is
a gas, in any form, intended for administration to a patient; either by inhalation (including ventilation), application, ination of any bodily cavity or by any other means (including cardiopulmonary bypass and extracorporeal ventilation equipment)
l l l
Prescribing of medical gases is not restricted to just doctors The Medicines Act 1968 classies medical gases as medicines
The MHRA controls licensing of medical gas manufacturers, suppliers and their products The European Pharmacopoeia and the Medicines Act dene standards for the manufacturing and composition of medical gases, including any allowable contaminants Special gases (single element or mixtures of gases used for specic purposes such as physiological tests or surgical procedures) must be obtained only from producers with the relevant medical specials manufacturing license In an emergency Oxygen may be administered without a prescription, but in all cases must be recorded in patient notes and used in accordance with relevant policy and procedure New types of medical gases and cylinders, including special gases, must always be ordered through the Pharmacy Department in the rst instance. See Medicines Management pages of the Trust Intranet for further information.
Page 3
Gases and our atmosphere

All medical gases can be found naturally on Earth, in our atmosphere or within the ground. To understand the benets and hazards of medical gases it is helpful to understand the basic composition of the atmosphere, the air we breathe. Air is composed mainly of nitrogen (78%), oxygen (21%) and argon (0.9%), which together make up over 99.9% of the Earths atmosphere. These are often referred to as major gases.
78%
Nitrogen Oxygen
21%
Argon Carbon Dioxide Other gases
0.9% 0.02% 0.04% Of the major gases, oxygen is the most highly reactive. Oxygen itself is not ammable, but it supports combustion and will react with most substances causing them to become highly ammable and to burn vigorously. This balance of major gases is central to the way that materials and life exist and interact with our atmosphere. Altering the concentrations of any gas in our immediate environment, such as a ward or storage area, by even just a few percent can have a dramatic effect on the human body and the materials around us. These effects can be hazardous or fatal and include poisoning, intoxication, anaesthesia, asphyxiation and re or explosion. Extracting them from the air or ground produces most medical gases, but some are produced by means of chemical reaction e.g. nitrous oxide. However produced, they are transported as compressed, cryogenic or liquid gases in cylinders or tanks.
Page 4
Common medical gases used around the hospital

The most common medical gases around the hospital are:
l l l
Oxygen (O2) Medical air (M.A.)
Medical vacuum (not actually a gas at all, but it is an essential medical gas service) Entonox (50% oxygen and 50% nitrous oxide) Nitrous oxide (N2O)
l l
Other gases used around the hospital include carbon dioxide (CO2), Heliox 21 (a proprietary mixture of 21% oxygen and 79% helium), nitric oxide (NO) and many different special gases. Risks and hazards associated with the most common medical gases will be described later in this training. You must familiarise yourself with the product data sheets for all medical gases you use. Links to data sheets for all standard medical gases used in the Trust can be found on the Medicines Management pages of the Trust Intranet. Manufacturers or suppliers will provide other data sheets as requested. It is recommended that you keep copies of all product and material data sheets in the COSHH section of your departmental Health & Safety documentation.
Acknowledgement: Entonox and Heliox 21 are products and registered trademarks of BOC Medical, a member of the Linde Group of companies.
Page 5
Categories of medical gases and their associated hazards

It is convenient to dene medical gases into three categories:
l
Permanent these remain in a gaseous state under normal temperatures (e.g. medical air, oxygen, Heliox 21) Liqueable these are supplied under normal temperatures but in a liquid state (e.g. carbon dioxide and nitrous oxide) Cryogenic these gases are supplied and stored at extremely low temperatures (e.g. liquid oxygen and liquid nitrogen)
The hazards associated with some medical gases may change depending upon their physical state (e.g. gas or cryogenic liquid) and can present a variety of hazards. They are discussed below.
Hazard: Oxygen enrichment and oxidisation

Oxygen enrichment is when the oxygen level in the air reaches concentrations of more than 21%. In most circumstances, these situations develop undetected because gaseous oxygen is colourless, tasteless and odourless. These properties of oxygen make it particularly hazardous as people are rarely able to detect it without special monitoring equipment. Oxygen enrichment can result from:
l
Leaks from poor connections, damaged or poorly maintained equipment Using excessive ow rates of oxygen or oxidising gases Oxygen equipment left turned on when not required Poor or inadequate ventilation in areas where oxygen or oxidising gases are used or stored
l l l
The main hazards from oxygen-enriched environments are re and explosion. Where oxygen levels are high enough even materials considered as non-ammable and re-retardant can combust and burn vigorously. Some materials may become explosive. An increase in oxygen concentration of only 4% doubles the risk of ignition and rate of combustion for many common items! Ignition can occur from low-energy ignition sources (for example small electrical/static sparks or light friction). At higher oxygen concentrations ignition may require so little heat or energy that combustion and explosion may appear to be spontaneous.
Page 6
If a ward or clinical area is oxygen-enriched, the following common items are particularly vulnerable to combustion:
l l l
Hair and clothing Bed linen, mattresses, pillows and curtains
Dressings, especially if medicated or wet (treated with ointments, liniments, emollients, etc.) Surgical skin disinfectants
l l
Sanitising hand-gels and hand-rubs and any oils, greases, ointments or creams Cardboard and paper items Chemicals and equipment used for cleaning and disinfection Electrical and electronic equipment
l l l
To minimise the risks of oxygen enrichment and oxidation res when using oxygen, nitrous oxide or Entonox (or any oxidising gases; see product data sheet for information):
l
Ensure hands and clothing are clean and free from oil, grease, hand-sanitising gels/rubs or hand creams Use only equipment designed specically for use with oxygen or oxidising gases Ensure owmeters and regulators are within their service date
l Use
the appropriate ow rate of gas according to the method of delivery (mask, nasal specs, etc.) and clinical indication (see the Trusts Oxygen Prescribing and Administration Policy)
l l
Always turn gases off at the outlet source when not in use Store cylinders only in designated gas storage areas.
Explosive atmospheres can develop where ammable materials are stored in the presence of an oxidising gas - NEVER store gas cylinders with linen, chemicals or ammable materials!
Page 7
Hazard: Pressure
It is important to be aware of pressures at which gases are stored and used. Medical gas cylinders are lled to pressures of 127 bar to 300 bar (63 to 150 times that of your car tyre!). Pressure itself is not necessarily dangerous. Hazardous situations occur when pressure is mishandled or improperly contained. In terms of medical gases it is appropriate to consider pressure as a form of stored energy that when released can be deadly. Beware of the following risks when using pressurised medical gases:
l l
Dust and other particles may be forced into eyes or skin
Pressurised gas may force its way between the orbital surface and the eyeball, causing ocular avulsion (trauma whereby the eye leaves the socket) Gas may be forced through the skin into blood vessels and may cause potentially fatal embolism Inadequate regulation of gas supply pressure can result in severe respiratory trauma or equipment failure Rapid release of gas from cylinders may cause their valves or connected equipment to become extremely cold, causing severe coldburn to any areas of skin exposed to them Rapid release of oxidising gases into equipment may cause an intense pressure wave to form within regulators and tubing, causing combustion or possible explosion of any contaminants within the equipment Insecurely connected equipment, either to cylinder or wall outlets, can be ejected with serious consequences
Cylinders subjected to mechanical damage (e.g. dropped or crushed) or re may cause the cylinder to rupture. Resulting explosive release of contents may be extremely destructive and can cause fatal injury Damage to a cylinders neck may cause the cylinder to behave like a torpedo or rocket. This may cause extreme damage to property and fatal injury If a cylinder falls, NEVER try to stop it moving! You may lose a limb! Exploding cylinders are able to travel in excess of 300 metres, while torpedoing or rocketing cylinders may travel even further!
Page 8
Hazard: Temperature
Oxygen and nitrogen are supplied to the hospital in both gaseous and liquid form. The liquid forms (cryogenic liquid gas) are stored at less than -180C. The temperature can drop further, super-cooling as it expands from a liquid to a gas. Liquid gases and their vapours can cause coldburn to exposed parts of the body. These burns are actually caused by the bodys own heat as it is rapidly drawn through the exposed area of skin and tissue by the liquid or vapour! Prolonged exposure can also cause frostbite, possibly leading to loss of bodily extremities such as ngers, toes and nose. Fog can develop around cryogenic delivery vehicles and storage plants. This is caused by moisture condensing out of the air. This fog causes low visibility in the area and high concentrations of the gases being delivered. Fog therefore presents the same risks as high concentrations of those gases in addition to increased risk of accidents such as trips and falls. Special training must be completed by all personnel required to handle and work with cryogenic gases. If you work with these, ensure you complete a relevant training course. When working with cryogenic liquids, such as lling nitrogen asks from Dewars, personnel MUST wear the following Personal Protective Equipment (PPE) designed specically for protection from cryogenic gases:
l
Full-face visor
l Protective gloves l Safety shoes l Apron In addition, all operatives must be suitably clothed for the procedure(s) to be carried out: l Full-length sleeves l Long trousers, no turn-ups or cuffs allowed as these can collect spilled cryogenic gases or their vapours l Trousers must not be tucked in to socks or boots l If wearing a skirt, then a full-length apron of suitable construction must be worn
Page 9
Hazard: Asphyxiation
Asphyxiation may occur where the local environment has become oxygen decient (oxygen concentration below 20%). Nitrogen, nitrous oxide, carbon dioxide and helium can cause this. Other gases may cause asphyxiation but are not commonplace around the hospital. Risk assessments should be carried out and recorded for all situations in which these gases are used, and Standard Operating Procedures should be put in place to minimise risks identied. See the Trust Medical Gases Operational Policy for further information. The following table shows the effects of low concentrations of oxygen in the local environment. Atmospheric Oxygen % 21% to 18% 18% to 11% 11% to 8% 8% to 6% 6% to 0% Effects
No easily discernable symptoms detected. Reduction of physical and intellectual performance. Sufferer not aware of this. At 11%, fainting may occur within a few minutes without prior warning. Death may result below 11% Fainting will occur after a very short time. Successful resuscitation possible if performed immediately. Fainting and deep unconsciousness occurs almost immediately. Successful resuscitation unlikely. Brain damage highly probable even if resuscitation is successful.
Page 10
Asphyxiation and Nitrogen:

Liquid nitrogen poses a particular risk of oxygen deciency as it can evolve rapidly into gaseous nitrogen, displacing oxygen within the local atmosphere. Spilled liquid nitrogen produces over 690 times its own volume in nitrogen gas. Therefore, oxygen deciency monitors must be used in all enclosed spaces where liquid nitrogen is used and stored. This is particularly relevant to any area where decanting from larger to smaller containers is carried out, due to the increased risk of a spill occurring. Local policy must be in place and must dene standard operating procedures, emergency actions and safety precautions.
Asphyxiation and Nitrous oxide:

Nitrous oxide is a potent analgesic and anaesthetic, but does not support respiration and must always be mixed with oxygen. In concentrations greater than 79% it is an asphyxiant. The increased danger comes from the mixture of these two properties; a person could become intoxicated and drowsy from inhaling the gas, falling into unconsciousness and then becoming asphyxiated whilst asleep. There have been a number of recorded incidents where this has happened through either misuse or mishandling of nitrous oxide.
Asphyxiation and Carbon dioxide:

At Salford Royal Hospitals carbon dioxide is piped only into laparoscopy theatres where it is used for the ination of body cavities to enable laparoscopic or abdominal key hole surgery. It is supplied to other areas such as Gastrointestinal Investigations Unit (Endoscopy) and Theatres in small cylinders where it is used to achieve a better view of the lumen walls or abdominal cavity. The only preparations containing carbon dioxide gas for inhalations are carbon dioxide 5%/oxygen 95% (known in past times as Carbogen), and a few specialist mixtures of varying concentrations for physiological testing of cardio-respiratory function. Special care should be taken when using and storing carbon dioxide, and risk assessments should be performed and recorded. It should be noted that in enclosed spaces the exhalation of carbon dioxide can further increase hazardous levels.
Page 11
The following table shows the effects of increased concentrations of carbon dioxide in the local environment.
Atmospheric Carbon Dioxide % 2 % to 4% 5% 5% to 9 % 9% to 12%
Effects
May feel a little asphyxiated. Breathing rate increases. After around 30 minutes exposure headaches, dizziness and sweating can occur. Judgement impaired. Breathing laboured. Fatal in exposures of around 4 hours.
Asphyxiation and Helium:

At Salford Royal Hospitals helium is used rarely and then only for specialist applications. It is mostly used in the form of Heliox 21, a mixture of 21% helium and 79% oxygen. Extra care should be taken regarding ventilation where pure medical helium is used and stored.
Supply and storage of medical gases

Medical gases are supplied in compressed gas cylinders or piped to wards and clinical areas through complex systems collectively known as the Medical Gas Pipeline Services (MGPS). Where possible the piped gas services should always be used in preference to cylinders. The availability of piped medical gas services varies between wards and clinical areas. You should familiarise yourself with the piped services available in your work area and understand local policy and procedure for when and how cylinders should be used.
Page 12
Compressed gas cylinders

Compressed gas supplied in cylinders is a convenient way to deliver medical gases to patients in situations where piped services are unavailable or impractical, such as patient transfers, self-ambulatory patients and crash trolleys. Cylinders are available in many different sizes, with a variety of valve types and can supply a variety of medical gases. For ease of reference, suppliers of compressed medical gases assign different letter codes to all their cylinders depending on size, construction and valve type. Please take a few moments to read the document Medical Gas Cylinders used at SRFT and familiarise yourself with the sizes and types of cylinders available for each medical gas used onsite. Most cylinders require the tting of a pressure-regulating device, known simply as a regulator, before they can be used. However, newer lighter-weight cylinders with integral valve systems are available for some gases. These newer cylinders come ready equipped with a regulator and owmeter built in, and have two outlets (except for Entonox which has only an integral regulator and Schrader valve). Some of the most common cylinders used at Salford Royal Hospitals are pictured below:
Figure 1: Oxygen CD cylinders in multicylinder trolley
Figure 2: Oxygen F cylinders in multicylinder trolley
Figure 3: Oxygen ZX cylinder integrated valve (showing collar, handwheel and gauge)
Figure 4: Oxygen ZX cylinder integrated valve (showing collar and batch information)
Page 13
Pressure regulators
Pressure regulators reduce the pressure of the gas leaving the cylinder (typically around 127bar) to a safer usable pressure (4bar) suitable for administration equipment. If the gas is being used for inhalation by a patient, a ow meter is tted to the output of the regulator. A typical ow meter further reduces the ow of gas to between 1L/min and 15L/min, although meters providing other ow rates are available. As some valve types can allow any medical gas regulator to be tted to the cylinder, care must be taken to check that the gas and regulator match. Even with pin-index valves, sufcient brute force and ignorance makes it possible for the incorrect regulator type to be tted to a cylinder! ALWAYS check externally tted regulators before using a medical gas cylinder. See picture and checklist overleaf.
Gauge
Needle
Gas identifier (type)
Page 14
Follow this checklist before using a cylinder and regulator for the rst time:
l l
Regulator is for the correct gas being used Check for leaks
o Ensure owmeter and regulator are off o Close cylinder main valve o Vent pressure by gently turning regulator on then the ow meter o Regulator gauge should fall to zero o Turn off owmeter and regulator o Open cylinder main valve gently and slowly o Turn regulator on to full then dial back a half-turn. Gauge should rise to show cylinder contents o Turn regulator off and observe gauge. If gauge holds steady there are no leaks and the cylinder/regulator assembly is ready for use. If gauge falls this indicates either a leak between regulator and cylinder valve, or a faulty regulator. If this is observed you must turn off the cylinder main valve and report the regulator to Medical Physics for servicing immediately. This checklist should be repeated from time to time, especially if the cylinder is moved around a lot or has been in storage without use for any time. For oxygen cylinders on resuscitation or crash trolleys, please refer to the documentation relating to your trolley. NEVER:
l l
Tamper with any tting on a cylinder
Attempt to t or remove any owmeter or regulator from a gas cylinder Tighten or adjust regulator or owmeter seals
A qualied Designated Porter or medical equipment technician must be called upon to change this equipment.
Page 15
Handling cylinders
Medical gas cylinders can pose many hazards to health and safety if misused or mishandled, with possibly fatal consequences. It is important that all personnel working with cylinders understand these hazards and know how to minimise the risks. In addition to the following points, the usual principles of safe moving and handling practice must be applied. It is assumed that personnel completing this medical gas training module have received the Trust training on Moving & Handling. Whilst some smaller cylinders may be carried singularly by hand (or two if CD or ED), multiples of cylinders must always be transported in designated medical gas cylinder trolleys. If you are unsure of any aspect of moving and handling medical gas cylinders please seek further advice. Sizes C, D and E are all steel bodied cylinders with standard brass valves. Sizes C and D may be carried manually one at a time supported by the cylinder body, never by the valve. Size E must always be transported in a trolley. If dropped the valve and cylinder neck are vulnerable to catastrophic damage leading to pressure containment failure, possibly causing torpedoing or rocketing of the cylinder. Size F and HX cylinders are the largest cylinders permitted in wards and clinical areas. They are steel bodied with standard brass valves (HX have integral valve systems), and must be transported in medical gas cylinder trolleys at all times. Due to their weight they pose increased crushing and blunt trauma hazards. As with all brass valve cylinders, the neck and valve assembly are vulnerable to damage if dropped or allowed to fall. Size CD and ED cylinders are small lighter-weight cylinders with integral valve systems. They have an integrated carry handle and up to two can be carried manually at a time.
Page 16
G size cylinders, and larger, weigh between 34kg and 105kg when full and pose increased risk of the following health and safety hazards due to their size, weight and instability:
l l l l
Moving and handling injuries such as back and muscle strain Crush injuries Serious or fatal blunt trauma
Catastrophic rocketing or torpedoing behaviour caused by cylinder neck/valve damage Due to serious health and safety concerns, at SRFT it is policy that all cylinders larger than F are banned from wards and clinical areas. There are only two exceptions to this policy ruling; larger cylinders may be used in Cardio-Respiratory Investigations where specialist gases are required and can not be piped in to the area, and in the event of MGPS failure or planned shut-downs for engineering work whereby the responsible ofcer from Estates may use G or J oxygen and medical air cylinders to supply gases to affected wards and clinical areas. In any event, these larger cylinders must always be secured to a stable anchor point, even when in a trolley. If cylinders are unattended in public areas, the securing mechanism must be tamper-proof. See the Trust Medical Gases Operational Policy for further information.
Storage of cylinders:
HTM 02-01 denes how medical gas cylinders must be stored. These requirements are reected in the Trust Medical Gas Operational Policy.
l
There are two main medical gas cylinder stores at SRFT. Access to these stores is restricted to Porters and other suitably qualied personnel. Storage of cylinders in wards and clinical areas should be strictly limited to a supply of no more than 24 hours of normal demand. All cylinders must be secured in appropriate holders, which must be xed to a wall or other substantially stable structure (e.g. crash trolleys, anaesthetic machines). This includes cylinders in trolleys. Cylinder stock levels in wards and clinics should be checked daily.
Page 17
Storage of cylinders:
HTM 02-01 denes how medical gas cylinders must be stored. These requirements are reected in the Trust Medical Gas Operational Policy.
l
There are two main medical gas cylinder stores at SRFT. Access to these stores is restricted to Porters and other suitably qualied personnel. Storage of cylinders in wards and clinical areas should be strictly limited to a supply of no more than 24 hours of normal demand. All cylinders must be secured in appropriate holders, which must be xed to a wall or other substantially stable structure (e.g. crash trolleys, anaesthetic machines). This includes cylinders in trolleys. Cylinder stock levels in wards and clinics should be checked daily. Excess or empty cylinders must be returned immediately to the main cylinder stores. With the exception of crash or resuscitation trolleys, cylinder valves must be turned off for storage. Cylinders must NEVER be stored:
l l
Free-standing even in trolleys. Cylinders laid on their sides are considered also to be free-standing unless in a rack specically designed for the purpose In poorly ventilated rooms or conned spaces In strong direct sunlight or any heat source
l l l
Concealed from sight i.e. within cupboards or drawers, under desks, etc. (except where mounted on or within medical gas equipment) With solvents or chemicals With linen or any other combustible materials With the cylinder valve turned on Attached to equipment in long-term storage
l l l l
Page 18
Piped gases:
Supplying medical gases to wards and clinical areas through a medical gas pipeline service is safe, efcient and convenient. It is the preferred method of supply where high volumes and high ow rates are required. The Estates Department are responsible for the provision and maintenance of these systems up to the outlets on the wall or pendant. All devices attached to these outlets are the responsibility of Medical Physics. These gases are supplied by various plant equipment located throughout the entire site. The status of each system is monitored from central switchboard through the use of master alarm panels, with local alarm panels located in each ward and department that is served by them (usually in close vicinity to the nurses station). You should familiarise yourself with the piped gas services and their alarm panel in your work area.
A typical local medical gas alarm panel
Page 19
The alarm panel should always show green lights when everything is operating normally. Absence of green lights, or the presence of amber or red ones, indicates a fault and should be reported to switchboard immediately. See table below for alarm panel indications and action to be taken: Alarm Indication Normal Action ( Telephonist to inform ) ONWH: Inform boilerman\engineer on call ONWH: Inform boilerman\engineer on call
No Action to be taken
Plant Faults NWH: Inform Estates Plant Emergency NWH: Inform Estates Reserve Low Anytime: porters Change cylinders Anytime: porters Change cylinders Anytime: porters immediately NWH: Inform Estates Rell liquid (Main VIE)
AND inform Estates: ONWH: Inform boilerman\engineer on call
No Action to be taken
Rell liquid NWH: Inform Estates ONWH: Inform boilerman\engineer immediately on call (Main VIE) (If this alarm shows it may indicate a fault. BOC should already be aware via remote telemetry and should have called to advise us. If not Estates need to inform BOC.) Pressure fault NWH: Inform Estates Power On No Action to be taken ONWH: Inform boilerman\engineer on call System Fault NWH: Inform Estates Abbreviations: ONWH: Inform boilerman\engineer on call
NWH = Normal Working hours ONWH = Outside Normal Working Hours
Page 20
Depending on location within the hospital, you will nd the following piped medical gas services available:
l l l l l l
Oxygen (O2) Medical Air 4bar (M.A.4) Medical Air 7bar (M.A.7, also referred to as Surgical Air) Vacuum (Vac.) Nitrous oxide (N2O) Carbon dioxide (CO2)
CAUTION! Medical Air 7bar must NEVER be administered to a patient. It is for surgical tool use only. Connection to these piped gases is by means of wall outlets, known as self-sealing-valves (SSVs). Each valve is specic to the gas supplied through it and only probes designed for those gases can be connected. In addition they are clearly marked and colour coded, as are the hoses and equipment used to connect into them:
Oxygen (O2)
Nitrous Oxide (N2O)
Medical Air 4bar (MA4)
Medical Vacuum
Anaesthetic Gas Scavenger System (AGSS)
Page 21
Blanking caps inserted in the outlet valves will identify any medical gas outlet that is not in service:
Flow meters can be attached which allow regulation of the ow of gases for administration to a patient:
The outlets also allow equipment such as ventilators, anaesthetic machines, surgical tools and vacuum apparatus to be attached directly.
Page 22
Connecting to medical gas outlets:

Wall outlets or cylinder Schrader valves:
l
Ensure hands and equipment probe are clean and free from oil, grease or hand creams Identify correct outlet for the gas required Check that hose or ow meter to be attached is correct for the gas required Ensure any gas ow controls on the equipment to be inserted are turned to off or zero Standing just off-centre to the outlet (if possible) and holding the owmeter or hose probe rmly, offer it up to the opening ensuring it is square-on to the outlet Using a smooth assertive motion insert the probe fully into the valve until you feel it catch (you may also hear an audible click) do not let go yet! Check full and proper insertion by gently pulling probe away from outlet Once you are certain the probe is properly in place you may let go Check gas is owing through equipment
l l
l l
To disconnect:
l l
Ensure ow through equipment is off or zero
If disconnecting from a cylinder ensure cylinder main valve is turned to off Hold the probe rmly with one hand With your free hand push the collar of the valve inwards to the wall (if cylinder Schrader valve, turn collar in direction of arrows) Remove probe completely from outlet It is perfectly normal to hear a short hiss or pop as the residual pressure within the hose or equipment is released. In the case of wall outlets, if the hiss continues once the probe is completely removed you must notify switchboard and request immediate assistance. If this happens with a cylinder, check main valve is fully closed. If problem continues try to remove the cylinder to outdoors or a well-ventilated area and report problem to Pharmacy immediately
l l
l l
Page 23
Flowmeters:
l l
Ensure hands are clean and free from oil, grease or hand creams
Select appropriate tubing and giving set (for oxygen use, ensure the tubing is oxygen-safe) Ensure ow is set to zero Holding with ow meter in one hand and the tubing in the other, rmly push open end of tubing over the owmeter outlet (usually a rtree connection) Removal is reverse of the above
l l
Area Valve Service Units (AVSUs) and emergency isolation of medical gas supplies:
Valves contained in locked boxes (AVSUs) are mounted in or around wards and clinical areas. These can be used to turn off the medical gas supply to the area.
In some situations it may be necessary to operate these valves to terminate ow of gases to the area, such as serious damage to a medical gas pipe or outlet, or the outbreak of re.
Page 24
The procedure for emergency isolation of medical gas supplies is as follows:
Fire:
l l
Follow standard Trust and local procedure
Ensure your area Designated Nursing Ofcer (DNO-MGPS) is aware of the situation and follow any instruction and advice given
Alternative supplies from cylinders should be obtained (Porters or Estates will deliver to area)
l l
Once certain that no patient will be harmed by turning off the medical gas supply, operate the AVSU(s) as below to isolate the supply
Damaged medical gas pipes or outlets:

l
Contact switchboard and tell them of the problem. They will contact your area Designated Nursing Ofcer (DNO-MGPS) and Estates & Facilities If oxygen is owing freely from the damaged pipe or outlet, evacuate immediate area and open doors and windows (where available) If nitrous oxide or carbon dioxide is owing freely from the damaged pipe or outlet, evacuate area immediately and close all doors into the area. Do not re-enter area until DNO-MGPS or Estates & Facilities say it is safe to do so DNO-MGPS or Estates & Facilities will co-ordinate further action. Do not isolate gas supply unless instructed to do so by DNO-MGPS or Estates & Facilities.
l l
Operating the AVSU(s):

l l l l
Notify other personnel of the action you are about to take Break glass to access valve Turn valve in direction indicated by arrows
Notify switchboard and instruct them to notify DNO-MGPS and Estates & Facilities of the action you have taken Do not reinstate supply of gas until instructed to do so by DNO- MGPS or Estates & Facilities
Page 25
Part three: Administration of oxygen

The administration of supplemental oxygen is an essential element of appropriate management for a wide range of clinical conditions; however oxygen is a drug and therefore requires prescribing in all but emergency situations. Failure to administer oxygen appropriately can result in serious harm to the patient. The safe implementation of oxygen therapy with appropriate monitoring is an integral component of the Healthcare Professionals role. All patients who require supplementary oxygen therapy should receive therapy that is appropriate to their clinical condition and in line with national guidance and Trust policy (BTS Guideline; Thorax, 2008) (Policy for the Prescription and Administration of Oxygen in adults; SRFT, 2010).
Oxygen prescription
Oxygen will be prescribed according to a target saturation range. This system of prescribing target saturation aims to achieve a specied outcome, rather than specifying the oxygen delivery method alone. The target saturation will be prescribed on the electronic EPR prescription, or in some cases may be prescribed via other written order e.g. post operative pathway (see Trust policy for specialist areas). Once a target saturation range has been prescribed on the EPR prescription this can be transcribed across onto the bedside observation chart. The qualied nurse must sign the EPR prescription at every drug round. This ensures that the target SPO2 and delivery device/ ow rate have been checked by the nurse to ensure that the patient is receiving appropriate treatment, if the patient is not receiving oxygen therapy at that time, ON AIR can be selected.
Emergency situations
In the emergency situation an oxygen prescription is not required. Oxygen should be given to the patient immediately without a formal prescription until the patient is stabilised and immediate senior medical assessment has been made. This must then be documented in the patients record.
Page 26
Cautions
In patients with chronic CO2 (carbon dioxide) retention, oxygen administration may cause further increases in carbon dioxide and respiratory acidosis. This may occur in patients with COPD, neuromuscular disorders, morbid obesity or musculoskeletal disorders.
Oxygen administration
The prescription incorporates a suggested starting ow rate and/or device to achieve target saturation. The oxygen delivery device and oxygen ow rate should be recorded alongside the oxygen saturation on the bedside observation chart. Those who administer oxygen therapy will monitor the patient and keep within the target saturation range, via regular pulse oximetry measurements. The frequency of these measurements will depend on the condition being treated and the stability of the patient. Saturation higher than target specied or >98% for an extended period of time. Step down oxygen therapy incrementally (see Trust O2 policy for guidance) Consider discontinuation of oxygen therapy. Saturation lower than target specied Check all elements of oxygen delivery system for faults or errors. Step up oxygen therapy incrementally (see Trust O2 policy for guidance) and inform medical team, any sudden fall in oxygen saturation should lead to clinical evaluation and in most cases measurement of blood gases. Monitor Early Warning Score for further clinical signs of deterioration. Saturation within target specied Continue with oxygen therapy, and monitor patient to identify appropriate time for stepping down therapy, once clinical condition allows.
Page 27
Oxygen Therapy Delivery Devices
Device
Nasal Cannulae
Description
Nasal cannulae consist of pair of tubes about 2cm long, each projecting into the nostril and stemming from a tube which passes over the ears and which is thus selfretaining.
Purpose And Practical Issues

Cannulae are preferred to masks by most patients. They have the advantage of not interfering with eating and speech. Flow rates can be adjusted from 2 4 l/ min, but may vary from 1 6 l/min in some circumstances. This is a variable performance device.
Device
Simple face mask
Description
Mask has a soft plastic face piece, vent holes are provided to allow air to escape. Maximum 50%-60% at 15ltrs/minute ow. Not to be used for patients with CO2 retention

This is a variable performance device. The oxygen concentration delivered will be inuenced by: a. b. the oxygen ow rate (litres per minute) used, leakage between the mask and face; the patients tidal volume and breathing rate
Page 28

In non re-breathing systems the oxygen may be stored in the reservoir bag during exhalation by means of a oneway valve. High concentrations of oxygen 80-90% can be achieved at relatively low ow rates.
Device
Reservoir mask (Non-rebreathe mask)
Description
Mask has a soft plastic face piece with apvalve exhalation ports. There is also a one-way valve between the face mask and reservoir bag. NOT to be used for patients with CO2 retention EXCEPT in life-threatening emergencies such as cardiac arrest or major trauma.
Device
Venturi mask
Description
This is a high performance oxygen mask designed to deliver a specied oxygen concentration regardless of breathing rate or tidal volume (xed performance device) Oxygen is forced out through a small hole causing a Venturi effect, which enables air to mix with oxygen. This is the most appropriate device to use in patients with CO2 retention

Venturi devices come in different colours for % Blue = 24% White = 28% Yellow = 35% Red = 40% Green = 60% The minimum oxygen ow rate is indicated on the mask or packet. This minimum ow rate should be doubled if the patient has a respiratory rate >30 per minute, as higher ows are required for patients with rapid respiration and high inspiratory ow rates. This will not effect the concentration (% O2 delivered to the patient), but allows the gas ow to match the patients breathing pattern.
Page 29

To ensure that the patient receives the correct amount of oxygen.
Device
Description
Device to allow the patient to receive an accurate ow of oxygen, usually between 2 and 15 litres per minute. May be wall-mounted or on a cylinder. Take special care when using twin oxygen outlets or if there are air outlets which may be mistaken for oxygen outlets. The CENTRE of the ball shows the correct ow rate. The diagrams shows the correct setting to deliver 2 l/ min.
Correct Setting for 2 l/min
Page 30

G11102604 Design Services, Salford Royal NHS Foundation Trust, all right reserved 2011. This document MUST NOT be photocopied. Unique identifier: TE1A (11) Issue: One Review date: January 2014

Medical Gases Workbook

Caricato da

Informazioni sul documento

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Medical Gases Workbook

Caricato da

Copyright:

Formati disponibili

U n i v e r s i t y Te a c h i n g Tr u s t

Basic Medical Gas Safety

For all clinical and clinical support staff

Patient and Customer Focus Accountability Continuous Improvement Respect

Learning and Development Department

Basic Medical Gas Safety

Read through this section of the work book

Learning and Development Department

Basic Medical Gas Safety

Learning and Development Department

Basic Medical Gas Safety

An Introduction to Medical Gases

The Trust Medical Gases Operational Policy denition is

Learning and Development Department

Basic Medical Gas Safety

Gases and our atmosphere

Argon Carbon Dioxide Other gases

Learning and Development Department

Basic Medical Gas Safety

Common medical gases used around the hospital

Oxygen (O2) Medical air (M.A.)

Learning and Development Department

Basic Medical Gas Safety

Categories of medical gases and their associated hazards

Hazard: Oxygen enrichment and oxidisation

Learning and Development Department

Basic Medical Gas Safety

Hair and clothing Bed linen, mattresses, pillows and curtains

Learning and Development Department

Basic Medical Gas Safety

Dust and other particles may be forced into eyes or skin

Learning and Development Department

Basic Medical Gas Safety

Learning and Development Department

Basic Medical Gas Safety

Learning and Development Department

Basic Medical Gas Safety

Asphyxiation and Nitrogen:

Asphyxiation and Nitrous oxide:

Asphyxiation and Carbon dioxide:

Learning and Development Department

Basic Medical Gas Safety

Atmospheric Carbon Dioxide % 2 % to 4% 5% 5% to 9 % 9% to 12%

Asphyxiation and Helium:

Supply and storage of medical gases

Learning and Development Department

Basic Medical Gas Safety

Compressed gas cylinders

Figure 1: Oxygen CD cylinders in multicylinder trolley

Figure 2: Oxygen F cylinders in multicylinder trolley

Learning and Development Department

Basic Medical Gas Safety

Gas identifier (type)

Learning and Development Department

Basic Medical Gas Safety

Tamper with any tting on a cylinder

Learning and Development Department

Basic Medical Gas Safety

Learning and Development Department

Basic Medical Gas Safety

Learning and Development Department

Basic Medical Gas Safety

Learning and Development Department

Basic Medical Gas Safety