1 Medical Gases Storage and Supply (3 24)

CHAPTER 1
Medical Gases: Storage and Supply*

S. Nini Malayaman George Mychaskiw II Jan Ehrenwerth
CHAPTER OUTLINE
OVERVIEW
MEDICAL GAS PIPELINE SYSTEMS
MEDICAL GAS CYLINDERS AND THEIR USE
MEDICAL GAS CENTRAL SUPPLY SYSTEMS
Oxygen Tanks
Nitrous Oxide Tanks
Size
Color Coding
Cylinder Markings
Pressure Relief Valves
Connectors
Oxygen
Oxygen Concentrators
Medical Air
Nitrous Oxide
Helium
Nitric Oxide
Nitrogen
Central Vacuum Systems
GAS CYLINDER SAFETY ISSUES
MEDICAL GAS PIPELINES
CHARACTERISTICS OF GAS CYLINDERS
Prevention of Incorrect Gas Cylinder

Connections
Securing Cylinders Against Breakage
Transfilling
Cylinder Hazards
GUIDELINES FOR USE OF MEDICAL GAS

CYLINDERS
Planning
Additions to Existing Systems
Installation and Testing
HAZARDS OF MEDICAL GAS DELIVERY SYSTEMS

PROCEDURES
Supply
Storage
Transport and Installation
OVERVIEW
Anesthesia providers were once expected to know a great
deal about the storage and supply of medical gases. In
both large and small institutions, anesthesiologists often
had to rely on their own knowledge and skill in this area
to manage the many aspects of medical gases, from purchasing to troubleshooting.
Changes in technology and institutional organization
have relieved the anesthesiologist of the majority of these
responsibilities. However, this should not excuse anesthesia providers from understanding the basic facts and safety
principles associated with the use of medical gases for anesthesia. Invariably, other health care providers and administrators have little knowledge regarding these systems and
look to anesthesia professionals for guidance in the use and
handling of these gases in the hospital or clinic setting.
*Portions of this chapter are reproduced by permission from Eisenkraft
JB: The anesthesia delivery system, part I, vol 3. In Progress in Anesthesiology, San Antonio, TX, 1989, Cannemiller Memorial Education
Foundation.
With few exceptions, the only medical gases encountered by practicing anesthesiologists today are oxygen,
nitrous oxide, and medical air. For safety reasons, flammable agents are rarely, if ever, used in operating rooms (ORs)
today. Nitrogen is used almost exclusively to power gasdriven equipment. Helium, carbon dioxide, and premixed
combinations of oxygen and helium or carbon dioxide are
generally no longer used. In certain uncommon clinical
situations, other gases may be used. Helium is occasionally
used as an adjunct in the ventilation of patients undergoing
laryngeal surgery because of its low density and flowenhancing characteristics. Carbon dioxide is infrequently
used in the management of anesthesia for repair of selected
congenital heart defects. Finally, nitric oxide is currently
available for use as a pulmonary vasodilator. Anesthesiologists who use these gases must be fully versed in their characteristics and safe handling. For detailed information and
numerous references relating to the handling and use of
these and other unusual medical gases, along with a wealth
of general information about medical gas cylinders, the
reader is directed to publications from the Compressed
Gas Association.1,2
3
PART I Gases and Ventilation
Medical gas manufacturers are subject to more stringent government and industry regulations and inspections
than they have been in the past. This has helped markedly
reduce the number of accidents related to medical gases.
For these reasons, anesthesia training programs may not
emphasize instruction in the various aspects of storing and
using medical gases.
In addition, the recent increased concern regarding the
safety of anesthetized patients has helped reduce the number of gas-related injuries. Inspired oxygen monitors with
lower limit alarms provide the anesthesia practitioner with
an early warning when the oxygen supply becomes inadequate or is contaminated with another gas. Mixed-gas
monitoring and analysis is also becoming more common
and provides the practitioner with an important way to
quickly detect contaminants or unusual gas mixtures before
the patient is injured. If the oxygen monitor fails, pulse
oximetry can alert the anesthesiologist to problems with
patient oxygenation related to inadequate oxygen supply.
MEDICAL GAS CYLINDERS

AND THEIR USE
Medical gases are stored either in metal cylinders or in
the reservoirs of bulk gas storage and supply systems. The
cylinders are almost always attached to the anesthesia gas
machine. Bulk supply systems use pipelines and connections to transport medical gases from bulk storage to the
anesthesia machine.
Virtually all facilities in which anesthesia is administered are equipped with central gas supply systems. Anesthesia practice is currently undergoing change in this
regard, and many anesthetics are administered outside the
OR, and even outside the hospital, where a central gas supply system may be unavailable. The current emphasis on
providing care away from the hospitalsuch as in dental
clinics, mobile lithotripsy units, and mobile magnetic resonance imaging facilitieswill only increase the demands
on the anesthesia provider to ensure a safe and continuous
gas supply. E-cylinders are sometimes the only source of
medical gas for anesthesia machines in these settings. If an
anesthetic is being administered using only E-cylinders,
then both the anesthesiologist and related support personnel must first ensure that an adequate supply of reserve
cylinders is available. In addition, the amount of gas in the
cylinders being used must be continually monitored, and
the cylinders must be replaced before they are completely
emptied. The importance of this cannot be overemphasized. Many anesthesia practitioners today have not been
confronted with the possibility of running out of oxygen
and having to change a tank while administering an anestheticbut the evolving nature of anesthesia practice away
from traditional facilities is likely to make this a more
common occurrence. If an anesthesiologist anticipates this
situation, it is imperative that the anesthesia machine be
equipped with two oxygen cylinder yokes so that oxygen
delivery can continue when the empty tank is changed.
Anesthesia practitioners should be familiar with two
sizes of gas cylinders. The cylinder most often used by
anesthesia providers is the E-cylinder, which is approximately 2 feet long and 4 inches in diameter. E-cylinders
are also routinely used as portable oxygen sources, such

as when a patient is transported between the OR and an
intensive care unit (ICU). H-cylinders are larger, approximately 4 feet long and 9 inches in diameter, and are generally used as a source of gas for small or infrequently used
pipeline systems. They may be used as an intermediate or
long-term source of gas at the patients bedside. Almost all
hospitals store H-cylinders of oxygen in bulk as a back-up
source in case the pipeline oxygen fails or is depleted.
H-cylinders of nitrogen are often used to power gas-driven
medical equipment. H-cylinders that contain oxygen,
nitrous oxide, or air have occasionally been used in ORs
and are connected to the anesthesia machine via special
reducing valves and hoses. Such uncommon configurations
are not only potentially hazardous, they also defeat certain
safeguards. Any practitioner who uses such a system must
become thoroughly familiar with it and must be certain it
complies with applicable regulations and guidelines.1-5
Oxygen Tanks
Oxygen (O2) has a molecular weight of 32 and a boiling
point of 183 C at an atmospheric pressure of 760 mm Hg
(14.7 pounds per square inch in absolute pressure [psia]).
The boiling point of a gasthat is, the temperature at
which it changes from liquid to gasis related to ambient
pressure in such a way that as pressure increases, so does the
boiling point. However, a certain critical temperature is
reached, above which it boils into its gaseous form no matter how much pressure is applied in the liquid phase. The
critical temperature for oxygen is 118 C, and the critical
pressure, which must be applied at this temperature to keep
oxygen liquid, is 737 psia. Because room temperature is usually 20 C and therefore in excess of the critical temperature, oxygen can exist only as a gas at room temperature.
E-cylinders of oxygen are filled to approximately 1900
pounds per square inch gauge pressure (psig) at room temperature: 1 atmosphere (atm) is 760 mm Hg, which equals
0 psig or 14.7 psia. At high pressures, psig and psia are virtually the same. When full, the cylinders contain a fixed
number of gas molecules, the so-called fixed mass of that
gas. These gas molecules obey Boyles law, which states
that pressure times volume equals a constant (P1V1 = P2V2),
provided temperature does not change. A full E-cylinder of
oxygen with an internal volume of 5 L (V1) and a pressure
of 1900 psia (P1) will therefore evolve approximately 660 L
(V2) of gaseous oxygen at atmospheric pressure (P2, or 14.7
psia). Thus Boyles law gives the approximate value:
V2 = (P1 V1 ) / P2 = (1900 5) / 14.7 = 660 L
If the oxygen tanks pressure gauge reads 1000 psig,

the tank is approximately 50% full (1000 1900) and will
evolve only 330 L (660 50%) of oxygen (Fig. 1-1). If
such a tank were to be used at an oxygen flow rate of 6 L/
min, it would empty in just under an hour (330 6 = 55
minutes). Likewise, a full (2200 psig) H-cylinder will
evolve 6900 L of oxygen at atmospheric pressure. It is
important to understand these principles when oxygen
tanks are being used to supply the machine or a ventilator
or to transport a patient. Because oxygen exists only as a
gas at room temperature, the tanks pressure gauge can be
1 Medical Gases: Storage and Supply

Volume
Pressure
660 L
330 L
165 L
0L
1900 psig
950 psig
475 psig
0 psig
Volume
Pressure
1590 L
136 L
745 psig
745 psig
745 psig
400 psig
N2O gas
N2O liquid
Full
50% Full
25% Full
Empty
FIGURE 1-1 n Oxygen remains a gas under high pressure. The

pressure falls linearly as the gas flows from the cylinder; thus, in
contrast to nitrous oxide, the pressure remaining always reflects
the amount of gas remaining in the cylinder. (Modified from Bowie
E, Huffman LM: The anesthesia machine: essentials for understanding, 1985. With permission from Datex-Ohmeda, Madison, WI.)
used to determine how much gas remains in the cylinder.

Clearly, if a machine is equipped with two E-cylinders of
oxygen, only one should ever be open at any time to
ensure that both tanks are not emptied simultaneously.
Nitrous Oxide Tanks

Nitrous oxide (N2O) has a molecular weight of 44 and a
boiling point of 88 C at 760 mm Hg. Because it has a
critical temperature of 36.5 C and critical pressure of
1054 psig, nitrous oxide can exist as a liquid at room temperature (20 C). E-cylinders of nitrous oxide are filled to
90% to 95% of their capacity with liquid nitrous oxide.
Above the liquid in the tank is nitrous oxide vapor, that is,
gaseous nitrous oxide. Because the liquid nitrous oxide is
in equilibrium with its vapor phase, the pressure exerted
by the nitrous oxide vapor is its saturated vapor pressure
(SVP) at the ambient temperature.
A full E-cylinder of nitrous oxide will evolve approximately 1590 L of gaseous nitrous oxide at 1 atm (14.7 psia).
As long as some liquid nitrous oxide remains in the tank
and temperature remains constant (20 C), the pressure in
the tank will be 745 psig, or the SVP of nitrous oxide at
20C (Fig. 1-2). It should be clear that, unlike oxygen, the
content of a tank of nitrous oxide cannot be determined
from the pressure gauge. It can, however, be determined
by removing the tank, weighing it, and subtracting the
empty weight stamped on each tank (tare weight); the difference is the weight of the contained nitrous oxide. Avogadros formula for volume states that 1 g of molecular
weight of any gas or vapor occupies 22.4 L at standard
temperature and pressure. Thus, 44 g of nitrous oxide
occupies 22.4 L at 0 C and 760 mm Hg pressure. At
20 C this volume increases to 24 L (22.4 293 273);
thus each gram of nitrous oxide is equivalent to 0.55 L of
gas at 20 C.
Only when all the liquid nitrous oxide in the tank has
been used up and the tank contains only gaseous nitrous
Full
FIGURE 1-2 n At ambient temperature (20 C), nitrous oxide liquefies under high pressure, and the pressure of the gas above the
liquid remains constant independent of how much liquid remains
in the cylinder. Only when all the liquid has evaporated does the
pressure start to fall, and then it does so rapidly as the residual
gas flows from the cylinder. (From Bowie E, Huffman LM: The
anesthesia machine: essentials for understanding, 1985. With permission from Datex-Ohmeda, Madison, WI.)
oxide, can Boyles law be applied. In this instance, when

the tank pressure (P1) is 745 psig from gas only and the
internal volume (V1) of the E-cylinder is approximately
5 L, the volume (V2) of nitrous oxide gas that will be
evolved at atmospheric pressure (P2) is represented by the
following equation:
V2 = (P1 V1 ) / P2
(745 5) / 14.7 = 253.4 L
At this point the tank is 16% full (253 1590). A tank

showing a pressure of 400 psig at 20 C will evolve 136 L
[(400 745) 253] of nitrous oxide gas.
While anesthesia is being administered, it is not practical to remove the nitrous oxide cylinder from the anesthesia machine and weigh it accurately enough to
determine how much nitrous oxide is left. When the
nitrous oxide is being used rapidly, the latent heat of
vaporization causes the cylinder itself to become cold. If
humidity is sufficient in the surrounding atmosphere,
some moisture (or even frost) may collect on the outside
surface of the cylinder over the portion that is filled with
liquid nitrous oxide. The moisture line, or frost line,
which may drop as the gas is used, can provide an indication of when the nitrous oxide will run out. A number of
tapes and devices are available to mark the cylinders for
this purpose, but their reliability has not been tested. If
nitrous oxide is to be used as an anesthetic, it is best to
begin with a full cylinder because the length of time the
cylinder will last can be calculated. For example, a full
E-cylinder of nitrous oxide used at a flow rate of 3 L/min
will last about 9 hours (3 60 9 = 1620 L). When the
pressure in the cylinder begins to fall, approximately
250L are left to be evolved, and the tank will soon need
to be replaced.
supplied as bare aluminum, it is important to check the

label and not solely rely on color coding to identify a compressed gas.
CHARACTERISTICS OF GAS CYLINDERS

Size
Table 1-1 gives a list of the sizes, weights, and volumes of
the common cylinders that contain various medical gases.
As noted, the anesthesia provider will most often encounter oxygen and nitrous oxide in E-cylinders and a variety
of gases in H-cylinders. Although other gas cylinders are
found in the ORsuch as those used for gas-powered
equipment, laparoscopy equipment, and lasersthese are
not likely to be in the domain of anesthesia personnel.
Color Coding
Table 1-2 lists the color markings used to identify medical
gas cylinders. Although the internationally accepted color
for oxygen is white, green is used in the United States, primarily for reasons of tradition; in addition, yellow is used
to identify compressed air, which represents another
exception to international standards. Anesthesiologists
working in countries other than the United States should
be aware of these differences. Because nitric oxide (NO)
cylinders are not standardized in color and are frequently
Cylinder Markings
Certain codes are stamped near the neck on all medical
gas cylinders. The U.S. Department of Transportation
(DOT), which has extensive regulations concerning the
marking and shipping of medical gas cylinders, requires
a code to indicate that the cylinder was manufactured
according to its specifications (Fig. 1-3). The service
pressure (in psig) is stamped on each cylinder and should
never be exceeded. Each cylinder is also given its own
serial number and commercial designation; the final
code stamped on the cylinder is usually the date of the
last inspection and the inspectors mark. Medical gas
cylinders must be inspected at least once every 10 years,
at which time they should also be tested for structural
integrity; this is done by filling the cylinder to 1.66
times the normal service pressure. The date of this
inspection is often circled with a black marker to indicate that the cylinder has been checked by the supplier
(Fig. 1-4).
TABLE 1-1 Typical Volume and Weight of Available Contents of Medical Gas Cylinders*
Cylinder
Style and
Dimensions
Nominal
Volume
(in3/L)
B
3.5 13 in
8.89 33 cm
87/1.43
Unit of
Measure
psig
L
lb-oz
kg
D
176/2.88 psig
4.25 17 in
L
10.8 43 cm
lb-oz
kg
E
293/4.80 psig
4.25 26 in
L
10.8 66 cm
lb-oz
kg
M
1337/21.9 psig
7 43 in
L
17.8 109 cm
lb-oz
kg
G
2370/38.8 psig
8.5 51 in
L
17.8 109 cm
lb-oz
kg
H or K
2660/43.6 psig
L
lb-oz
kg
Mixtures
of Oxygen
Air
370
1-8
1900
375
1900
625
1900
2850
1900
5050
2200
6550
CO2
Cyclopropane
838
75
375
1-7.25
0.68
838
940
3-13
1.73
838
1590
6-7
2.92
838
7570
30-10
13.9
838
12300
50-0
22.7
0.66
75
870
3-5.5
1.51
He
1600
300
1600
500
1600
2260
1600
4000
2200
6000
N2
1900
370
1900
610
2200
3200
2200
6400
N2O
745
940
3-13
1.73
745
1590
6-7
2.92
7.45
7570
30-10
13.9
745
13800
56-0
25.4
745
15800
64
29.1
O2
1900
200
1900
400
1900
660
2200
3450
122 cu ft
He
CO2
300
400
500
660
2260
3000
4000
5330
2200
6900
244 cu ft
*Computed contents are based on normal cylinder volumes at 70 F (21.1 C), rounded to no greater than 1% variance.
The pressure and weight of mixed gases vary according to the composition of the mixture.
275 cu ft/7800 L cylinders at 2490 psig are available on request.
Modified from Compressed Gas Association: Characteristics and safe handling of medical gases, publication P-2, ed 7. Arlington, VA, 1989,
Compressed Gas Association.
All medical gas cylinders should come from the supplier

accompanied by a tag with three perforated sections, each
designating a different stage of use: empty, in use, and full.
The portion of the tag marked full should be removed
when a cylinder is put into service. This is not usually critical, however, because it is generally obvious when a cylinder is in use; making use of the tag marker becomes
important when an empty cylinder is removed from the
machine. If the tag is not used correctly at the outset, the
problem is compounded with each successive stage of
TABLE 1-2 C
olor Marking of Compressed Gas
Containers Intended for Medical Use
Gas
U.S. Color
Oxygen
Carbon dioxide
Nitrous oxide
Cyclopropane
Helium
Nitrogen
Air
Mixture other than
oxygen and
nitrogen
Green
White*
Gray
Gray
Blue
Blue
Orange
Orange
Brown
Brown
Black
Black
Yellow*
Black and white
A combination of colors
corresponding to each
component gas
Mixture of Oxygen and Nitrogen

Oxygen 19.5%-23.5% Yellow*
All other oxygen
Black and green
concentrations
Canadian Color
Black and white

Pink
*Historically, vacuum systems have been identified by white in the

United States and yellow in Canada. Therefore it is recommended
that white not be used in the United States and yellow not be
used in Canada as markings to identify containers for use with
any medical gas.
Modified from Compressed Gas Association: Standard color marking
of compressed gas containers intended for medical use, publication
C-9, ed 3. Arlington, VA, 1988, Compressed Gas Association.
FIGURE 1-3 n Some of the cylinder markings on an E-cylinder. DOT

indicates that the cylinder was manufactured according to the
specifications of the United States Department of Transportation
(DOT); 3AL indicates the tank is aluminum. 2015 indicates the
maximum filling pressure of the cylinder in pounds per square
inch gauge pressure (psig), the number to the right is the cylinder
serial number, and ALL GASS is the tank owners name.
thecylinders use, and the final result is storage of an empty

cylinder as a full one. Although a discrepancy in weight
may alert a user to an incorrectly labeled cylinder, this error
may be easily overlooked in an emergency situation.
Pressure Relief Valves

All medical gas cylinders must incorporate a mechanism
to vent the cylinders contents before explosion from
excessive pressure.6 Explosion can result from exposure to
extreme heat, such as in the event of a fire, or from accidental overfilling. These mechanisms are of three basic
typesthe fusible plug, frangible disk assembly, and
safety relief valveand are incorporated into the cylinder;
as such, they cannot be inspected by the user. The fusible
plug, made of a metal alloy with a low melting point, will
melt in a fire and allow the gas to escape. With certain
gases, such as oxygen or nitrous oxide, this can aggravate
the fire because oxygen and nitrous oxide are both strong
oxidizers. The frangible disk assembly contains a metal disk
designed to break when a certain pressure is exceeded and
thereby allow the gas to escape through a discharge vent.
Finally, the safety relief valve is a spring-loaded mechanism
that closes a discharge vent. If the pressure increases, the
valve opens and remains open until the pressure decreases
below the valves opening threshold. Some cylinders have
combination devices that incorporate a fusible metal plug
with one of the other two mechanisms.
Connectors
Figure 1-5 illustrates the tops of typical valves for both
small (E) and large (H) cylinders. As previously mentioned, large cylinders have valve outlets that are coded
and are unique to the gas content of the cylinder. The
coding is based on the threads and diameter of the outlet
port orifice.4 Regulators to reduce and control the pressure of the gas, also specific for each type of gas, are
attached to these threaded valve ports. It is highly
FIGURE 1-4 n An E-cylinder of oxygen. The inspection date,

August 2008, has been painted white to indicate the cylinder
was checked at the time it was delivered to the facility. All cylinders must be checked for leaks and structural integrity with an
overpressure test at least once every 10 years.
unsafe to use a regulator for one type of gas on a valve

port of a cylinder of another type of gas.
Small cylinders have cylindrical ports or holes in their
valves to receive the yoke, either on an anesthesia
machine or free standing, from which the gas will flow. A
washer, usually made of Teflon, is necessary to make this
connection gas tight. Care must be taken to ensure that
On/off valve spindle
the retaining screw that holds the cylinder in the yoke is

not placed into the safety relief device instead of in its
intended location in the conical depression opposite the
valve port (Fig. 1-5, A). The connection between cylinder valve and yoke is made gas specific by the pin index
safety system for small cylinder connections.
GAS CYLINDER SAFETY ISSUES

Prevention of Incorrect Gas Cylinder
Connections
Packing nut
Conical
depression
Safety relief
device
Outlet port
Valve seating
Holes for
pin index system
In the past, cylinders containing the wrong gasfor example, nitrous oxide instead of oxygenwere sometimes connected to anesthesia gas delivery systems, with disastrous
results. This led to the development of systems designed to
help ensure use of the correct cylinder. Most of the gas
tanks used for anesthesia are E-cylinders or other small cylinders, for which the pin index safety system was developed
in 1952. The pin index system4 relies on two 5-mm stainless
steel pins on the cylinder yoke connector just below the fitting for the valve outlet port. Seven different pin positions
are possible depending on the type of gas in the cylinder
(Fig. 1-6). The yoke connector for an oxygen cylinder, for
A
Hand wheel
Nut
Left
Stem
Right
Outlet port
Safety relief
device
1
2
5
3
B
FIGURE 1-5 n Typical cylinder valves. A, A small cylinder packed
valve, such as would be found on an E-cylinder. Note that the
female-type port is not unique to the gas type. B, A large cylinder packed valve, such as would be seen on an H-cylinder. Note
that the male type of outlet port has a unique diameter and
threads as a safety feature intended to help ensure correct connections. (Modified from Davis PD, Parbrook EO, Parbrook GD:
Basic physics and measurement in anesthesia, ed 3. Oxford, UK,
1984, Butterworth-Heinemann.)
FIGURE 1-6 n Pin index safety system pin location is shown, looking at the placement of holes in the tank. Pins are placed precisely
complementary in the tank yoke. Two pins are used to identify
each type of gas. Pin configurations are listed in Table 1-3.
example, has pins at positions 2 and 5 (Fig. 1-7). Pin positions for the various gases are listed in Table 1-3. These pins
fit exactly into the corresponding holes in the cylinder valve
(Fig. 1-8). This system provides an additional safety feature
and, along with color coding, is designed to ensure that the
correct gas is connected to its corresponding cylinder yoke.
Obviously, connectors with either damaged or missing
index pins are unsafe and should not be used under any circumstances. Because a pin can easily be lost or damaged
when a cylinder is handled roughly, the person changing
the cylinder must make certain that both pins are intact.
Securing Cylinders Against Breakage

Gas cylinders should always be secured when placed in an
upright position. If left freestanding, a cylinder can easily
fall over in such a way that it would fracture at the neck
(Fig. 1-9). The cylinders highly pressurized gas would be
suddenly released, and the cylinder would become an
unguided missile of tremendous force; in fact, the cylinder
could generate enough force to penetrate a cinder-block wall
several feet thick. The potential danger of such an occurrence is obvious. Therefore, all gas cylinders must be secured
when they are upright. If that is not possible, the cylinder can
be laid on its side. Individual E-cylinders can be placed in
a broad-based wheeled carriage for support when in use.
Transfilling
Anesthesia personnel should never attempt to refill small
cylinders from larger ones. Even if gas-tight connections
were possible, the risk of explosion from the heat of compression in the small cylinder would still be serious. In
addition, there is always the possibility that the wrong gas
would be placed in the cylinder. The practice of transfilling is also forbidden. Medical gases must be obtained only
from a reputable commercial supplier.
Cylinder Hazards
A study of 14,500 medical gas cylinders consecutively delivered from supposedly reputable suppliers found 120 (0.83%)
with potentially dangerous irregularities.7 Forty cylinders
were delivered either empty or partially filled, 3 were found
to be dangerously overfilled to near-bursting pressures, and
6 cylinders of compressed air were found to be contaminated with volatile hydrocarbons. Thirty cylinders were
unlabeled, and the labels of many others were illegible, having been painted over. Another 4 cylinders were incorrectly
color coded, 5 large cylinders were fitted with incorrect
valve outlet ports (which is especially dangerous because an
oxygen valve on an air cylinder enables air to be fed into an
oxygen outlet), 14 valve assemblies were found to be loose,
and 4 valve assemblies were inoperable. On a large number
of cylinders, the current inspection date was either absent or
had been painted over so as to be illegible. Numerous examples were cited of cylinders being improperly stored or
secured. The results of this study serve to remind anesthesia
practitioners of the danger of assuming that gas supplies are
perfectly safe. All facilities should have an established system to ensure that each cylinder of medical gas is inspected
and tested upon delivery to the facility.
FIGURE 1-7 n A, Cylinder yoke on the anesthesia machine. Note the two pins for the pin index system at the bottom of the yoke (bottom
arrow) and the hole (top arrow; not gas specific) that aligns with the outlet port of the tank. B, Oxygen yoke with the tank removed
and the N2O tank in place.
TABLE 1-3 Pin Index Safety System

Mixtures of Oxygen
Pin positions
Air
Cyclopropane
N2
N2O
O2
He
CO2
1-5
3-6
1-4
3-5
2-5
2-4
1-6
The pin index system relies on two 5-mm stainless steel pins on the cylinder yoke connector just below the fitting for the valve outlet port.
Seven different pin positions are possible depending on the type of gas in the cylinder (the seventh pin position is for a gas not used in
the United States). See Figures 1-6 and 1-7 for pin locations.
10
GUIDELINES FOR USE OF MEDICAL GAS

CYLINDERS
Numerous rules govern the safe handling of cylinders
that contain medical gases.1,2 Summarized below are
practical points that anesthesia practitioners must consider on a routine basis.
Supply
FIGURE 1-8 n Cylinder valve at the top of an E-cylinder shows the

two holes for the pin index system and the outlet port with an
attached washer (arrow).
As noted, medical gases should be purchased only from a

reputable commercial supplier. Outside metropolitan
areas, the only supplier of any type of compressed gas
may be the local welding company. Purchasing medical
gases from such a source can be appropriate once it has
been established that this supplier meets all safety requirements and standards for the manufacture and supply of
medical gases. Such verification should be incorporated
into the system to promote maximum safety.
D
FIGURE 1-9 n A, Gas cylinders must never be left standing upright and unsecured. They are vulnerable to being knocked over easily,
such as by opening a door. Cylinders that fall directly to the floor, and especially cylinders that fall so that the top hits a wall (B),
are at great risk for breaking at the cylinder neck. This creates a dangerous unguided missile, in which the high-pressure gas
escapes out the narrow neck and rockets the cylinder forward with enough force to penetrate a brick wall. C, Oxygen cylinders are
now available with a maximum pressure of 300 psi and a capacity of 1000 L of oxygen. These would present an even greater hazard if ruptured. D, If upright, individual cylinders should be secured in some type of holder, such as a rolling stand for E-sized
cylinders.
11
Storage
Specific regulations and standards govern the storage of
medical gas cylinders.2,3 For example, full cylinders and
empty cylinders must be stored separately, each in its
own tank room if possible. Small cylinders should be
placed in nonflammable racks, and large cylinders should
be chained to a wall. At least one anesthesiologist in each
facility should be aware of these requirements and how
they are being implemented. Anesthesia caregivers should
also assume responsibility for all aspects of medical gas
supplies.
Transport and Installation

Medical gas cylinders must be handled with care. As previously mentioned, a broken cylinder can have serious
consequences, as can valve assemblies damaged by rough
handling. Cylinders should undergo a final inspection
just before they are used. If questions arise concerning
the safety or content of a cylinder, it should not be used;
instead, an investigation should be undertaken before
returning the cylinder to the supplier. Before a small
E-cylinder is installed in the hanger yoke, the plastic
wrapping surrounding the cylinder valve outlet must be
completely removed. If this is not done, the plastic wrapper will prevent the gas from entering the inlet in the
hanger yoke. All cylinders should be opened slightly, or
cracked, immediately before installation to clean any
residual oil, grease, or debris from the valve outlet port
that would otherwise be released into the anesthetizing
apparatus. Furthermore, cylinders should always be
opened slowly to prevent dramatic heating of the suddenly
pressurized piping. If an abnormal odor is detected when
the cylinder is opened, gas should be collected from the
tank and analyzed by gas chromatography to detect
hydrocarbon contamination.8 Once a problem is confirmed, the cylinder in question should be sequestered,
not returned to the supplier, and the appropriate local
and federal authorities contacted.
Connections between gas cylinders and anesthesia
machines must be tight. Figure 1-10 illustrates the
proper method for balancing the tank when securing it
to or removing it from the yoke. Washers are necessary
for small cylinder yokes and occasionally need replacement; the old washer must be removed before placing a
new washer. Having two washers in place simultaneously will create a leak and may defeat the pin index system. If a hissing noise is heard when a cylinder is opened,
a leak is present. Tightness can always be checked by
dripping soapy water onto the connection and inspecting it for bubbles. A connection should never be overtightened in an attempt to compensate for a leak; doing
so may damage or even crack the cylinder valve. As in all
aspects of anesthesia practice, brute force is almost never
appropriate.
Once a new cylinder is in place, the pressure must be
checked on the applicable gauge. Correct pressures for
full cylinders are listed in Table 1-1. Overpressurized cylinders are dangerous and must be removed at once and
reported to the supplier.
FIGURE 1-10 n Proper method for attaching an E-cylinder to the

yoke of an anesthesia machine. The tank is first supported on the
anesthesiologists foot while the holes on the tank are aligned
with the pins in the yoke. The tank is then slid into place on the
yoke, and the T-handle is tightened to make a gas-tight seal.
MEDICAL GAS PIPELINE SYSTEMS

Medical gas pipeline systems consist of three main components: 1) a central supply of gas, 2) pipelines to transport gases to points of use, and 3) connectors at these
points that connect to the equipment that delivers the
medical gas. Anesthesia caregivers are primarily concerned
with piped oxygen and nitrous oxide; however, ORs may
have two other medical gas supply pipelines: one for compressed air and another for nitrogen to power gas-driven
equipment.
Detailed standards and guidelines exist for the use
of medical gas delivery systems. In North America,
these are published by the American National Standards Institute (ANSI), the American Society of
Mechanical Engineers (ASME), the Compressed Gas
Association (CGA), the National Fire Protection Association (NFPA), the Canadian Standards Association
(CSA), and the American Hospital Association (AHA).9
In the United States, a hospital must meet the NFPA
standards to be accredited by The Joint Commission
(TJC) and often to obtain insurance coverage. The
construction of a medical facility is governed by standards, and the procedures required for operating a
medical gas system must be followed by the plant engineering and maintenance departments. Problems in
the construction of gas pipelines have led to anesthesia
deaths; anesthesia providers should therefore be aware
of these standards and the gas delivery system at their
facility.10
MEDICAL GAS CENTRAL SUPPLY

SYSTEMS
The central supply (bulk storage) system is the source of
medical gases distributed throughout the pipeline system.
For oxygen, the central supply can be a series of standard
cylinders connected by a manifold system or, for larger
12

Line
pressure
regulator
Relief
valve
Emergency
alarm switch
Vent to outside
of building
Piping system
Main shut-off valve
Vent to outside
of building
Relief
valve
Operating
alarm switch
Operating
pressure
regulator
High-pressure header
Operating
pressure
regulator
Check valve
Shut-off valve
High-pressure header
Check valve
Cylinder valve
Safety relief device
Cylinders
(bank 1)
Cylinders
(bank 2)
FIGURE 1-11 n Typical cylinder (H size) supply system, as would be seen in a small hospital or a freestanding facility. There is no reserve
supply. (From CSA Standard Z305.1-1975, Nonflammable medical-gas piping systems. Toronto, 1975, Canadian Standards Association.)
installations, pressure vessels of liquid oxygen with accompanying vaporizers. For medical air, the supply can be cylinders of compressed air, cylinders of oxygen and nitrogen
with the gases mixed by a regulator, or air compressors. In
general, for nitrous oxide or nitrogen, a series of cylinders,
or liquid Dewar tanks, with a manifold system is used.
Oxygen
Central supply systems that carry oxygen are both the
most common and the most important supply systems; as
such, they have received considerable attention. Standards for bulk systems that involve the storage of oxygen
as a liquid are contained in NFPA Publication 55.11 Oxygen systems are extensively covered in NFPA Publication
9912 and in the CSA Standard Z305.1.13
Very small systems have a total storage capacity of less
than 2000 cubic feet (cu ft) of gas (a single H-cylinder of
oxygen contains 244 cu ft, or 6900 L) and have additional
standards when based in nonhospital facilities. Systems in
very small hospitals may store oxygen in a series of standard
H-cylinders connected by a manifold or high-pressure

header system. These systems typically do not have
reserve supplies. In Figures 1-11 and 1-12, note that there
are two banks of cylinders; all central supply systems for
medical gases must be present in duplicate, with two
identical sources able to provide the needed medical gas
interchangeably. These are often referred to as the primary and secondary supplies (not to be confused with the
entirely separate reserve system).
The larger the oxygen demand of the facility, the more
complex the supply system. Most hospitals store their bulk
oxygen in liquid form (Fig. 1-13), which enables the hospital to maintain a large reservoir of oxygen in a relatively
small space. One cubic foot of oxygen stored at a temperature of 297 F (183 C) expands to 860 cu ft of oxygen
at 70 F (21 C).14 Because 1 cu ft is equal to 28.3 L, this
amount of liquid oxygen provides 24,338 L at room temperature and pressure, the equivalent of 3.5 H-cylinders
of oxygen.
Liquid oxygen is stored in a special container and kept
under pressure. This container has an inner and outer
13
To pipeline
2200 psig
50 psig
2200 psig
Primary
Secondary
Changeover
valve
FIGURE 1-12 n A simplified version of Figure 1-11. The oxygen is supplied in H-cylinders from both a primary and a secondary supply.
The tanks are connected by a manifold; when the tanks are full, the pressure is 2200 psig. A changeover valve automatically switches
to the secondary supply once the primary supply has been exhausted. A reducing valve decreases the pressure to 50 psig before the
oxygen enters the hospital pipeline. (Modified from Davis PD, Parbrook EO, Parbrook GD: Basic physics and measurement in anesthesia,
ed 3. Oxford, UK, 1984, Butterworth Heinemann.)
FIGURE 1-13 n A typical bulk-storage vessel for liquid oxygen.
layer separated by layers of insulation and a near vacuum.

This construction is similar to that of a thermos bottle
and keeps the liquid oxygen cold by inhibiting the entry
of external heat (Fig. 1-14).
Liquid oxygen systems must be in constant use to be
cost effective. If the system goes unused for a period of
time, the pressure increases as some of the liquid oxygen
boils. The oxygen is then vented to the atmosphere. The
liquid oxygen system contains vaporizers that heat the
liquid and convert it to a gas before it is piped into the

hospital. Environmental and mechanical heat sources can
be used to aid in vaporization.
Liquid oxygen can be extremely hazardous, and fires
are an ever-present danger. In addition, personnel can
receive severe burns if they come in contact with liquid
oxygen or an uninsulated pipe carrying liquid oxygen.
Small hospitals typically require central supply systems
that store oxygen in replaceable liquid oxygen cylinders
and a reserve of oxygen stored in high-pressure H-cylinders.
The reserve system is automatically activated when the
main supply, with its component primary and secondary
storage, fails or is depleted (Fig. 1-15). Hospitals of average size may store liquid oxygen in bulk pressure vessels
rather than in liquid oxygen cylinders. The storage vessel
is filled from a liquid oxygen supply truck through a cryogenic hose designed to function at extremely low temperatures. In such a system, the size of the reserve system
depends on the rate of oxygen use because the reserve
must constitute at least an average supply for 1 day, but
preferably 2 to 3 days. This supply may be stored in a
series of high-pressure H-cylinders. However, large hospitals are required to have a second liquid oxygen storage
vessel as the reserve system because of the impracticality
of storing and connecting enough cylinders to provide an
average days reserve supply of oxygen (Fig. 1-16).
Built into all these central supply systems for oxygen
are a variety of mandatory safety devices. Pressure relief
valves are designed to open if pressure in the system
exceeds the normal level by 50%. This prevents the rupture of vessels or pipes from the excessive pressure generated by a frozen valve or a malfunctioning pressure
regulator. Alarm systems indicate when the supply in the
main storage vessel is low and when the reserve supply has
been accessed. An oxygen alarm should activate a rehearsed
protocol within the hospital that results in contact with the
oxygen supplier and subsequent verification that an oxygen delivery is on the way.15 Pressure alarms built into the
14

~85 psig
Safety
relief valve
~50 psig
Pressure
regulator
To pipeline
Temperature
approximately
256 F
(160 C)
Superheater
Vacuum
Control
valve
Vaporizer
FIGURE 1-14 n Diagram of a liquid oxygen supply system. The vessel resembles a giant vacuum bottle. The liquid oxygen is at approximately 256 F (160 C). Pressure inside the vessel is maintained at approximately 85 psig. When oxygen is used from the top of the
vessel, it first passes through a superheater and then through the pressure regulator to keep the pipeline pressure at 50 psig. During
times of rapid use, the temperature in the tank may fall, along with the vapor pressure. The control valve causes liquid oxygen to pass
through the vaporizer, which adds heat and thus maintains the pressure in the tank. (Modified from Davis PD, Parbrook EO, Parbrook
GD: Basic physics and measurement in anesthesia, ed 3. Oxford, UK, 1984, Butterworth-Heinemann.)
Relief
valve
Reserve supply
operating alarm switch
Vent to outside
of building
Piping system
Check
valve
Operating
control unit
Check
valve
Secondary
bank pressure
regulator
Operating supply
pressure regulator
Bleeder valve
Operating selector
Secondary supply
operating alarm
switch
Shut-off valve
Reserve
pressure
regulator
Shut-off
valve
Relief
valve
Cylinder valves
Line pressure
regulator
Safety relief
device
Primary supply
(liquid cylinders)
Secondary supply
(liquid cylinders)
Main shut-off valve

Vent to outside
of building
Check valves
Pressure
relief
device
Emergency
alarm switch
Reserve supply
(high-pressure cylinders)
Operating supply may

consist of one or more
supply units on each bank.
FIGURE 1-15 n Typical cryogenic cylinder supply system for liquid oxygen with a high-pressure cylinder reserve supply, as would be
seen in a small hospital. The redundant primary and secondary liquid cylinders are intended to be the continuous oxygen source;
there is an automatic switchover to the other bank when one is depleted and ready for replacement. The reserve supply is automatically activated when both banks of cylinders are depleted or fail. (From CSA Standard Z305.192, Nonflammable medical gas piping systems. Toronto, 1992, Canadian Standards Association.)
15
B
3
24
19
20
23
24
23
5
6
17
10
8
9
18
9
13
12
10
14
15
11b
16
11a
11b
11
21
22
To hospital
FIGURE 1-16 n Typical bulk supply system for oxygen, as would be seen in a large hospital. Very large hospitals may require more than
one system of this magnitude. A, Main liquid oxygen reservoir. B, reserve liquid oxygen reservoir. 1, Connection to supply vehicle; 2,
top and bottom fill lines; 3, reservoir pressure relief valves; 4, economizer circuit; 5, gas regulator in pressure-building circuit; 6,
pressure-building vaporizer; 7, liquid regulator in pressure-building circuit; 8, cryogenic liquid-control valves; 9, liquid vaporizers; 10,
downstream valves for isolation of vaporizers; 11, primary line pressure regulator; 11a, secondary line pressure regulator; 11b, valves
to isolate regulators for repair; 12, pressure relief valve for main pipeline; 13, reserve system liquid vaporizer; 14, reserve system line
pressure regulator; 15, gas flow check valves; 16, reserve system economizer line; 17, reserve system fill line; 18, valve controlling
flow to reserve system from main cylinder; 19, low liquid level alarm; 20, reserve in use alarm; 21, main line pressure alarm; 22, main
shut-off valve and T-fitting; 23, liquid level indicators; 24, vapor or head pressure gauges. In normal operation, liquid oxygen flows
from the lower left of the main vessel (A) via a cryogenic pipe through valves (8) and to the vaporizer (9), where the liquid becomes
gaseous oxygen. It then flows through pressure regulators (11) and hence into the supply pipeline to the hospital. (From Bancroft ML,
du Moulin GC, Hedley-Whyte J: Hazards of bulk oxygen delivery systems. Anesthesiology 1980;52:504-510.)
main supply line sound when the line pressure varies by

20% in either direction from the normal operating pressure of approximately 55 psig. Pressure alarms should also
be located in various areas in the pipeline to detect oxygen
supply problems beyond the main connection (Fig. 1-17).
All these alarm systems must sound in two different

locations: the hospital maintenance or plant engineering
department and an area occupied 24 hours a day, such as
the telephone switchboard. These alarms should be periodically tested as part of a regular maintenance program
16
FIGURE 1-17 n A, Bank of pressure gauges that monitor the gases in one zone of the operating room. These gauges are for oxygen, air,
and vacuum. Note that the rooms being monitored are identified on the top of the panel. B, A second gas monitoring panel for N2O,
nitrogen, CO2, and waste gases. Note that colored lights indicate whether the line pressures are in the normal range; alarms are triggered for high or low pressures.
because failure of such alarms has led to crisis situations.

Testing the various alarms can be difficult but is possible
if the system is properly designed.
Another critical safety feature is the T-fitting located
at the point where the central supply system joins the
hospital piping system. This fitting allows delivery of an
emergency supply of oxygen from a mobile source in the
event of extended failure, extensive repair, or modification of the hospitals central supply.
The location and housing of oxygen central supply
systems are governed by strict standards.11 A bulk oxygen
storage unit should be located away from public areas and
flammable materials.
Oxygen Concentrators
The use of oxygen concentrators to deliver oxygen to the
anesthesia circuit has gained attention recently. Oxygen is
generated by the selective adsorption of the components of
air with molecular sieve technology. These sieves consist
of rigid structures of silica and aluminum, with additional
calcium or sodium as cations.16 Air is forced through the
sieves under pressure, and oxygen and nitrogen are generated. The oxygen is then used clinically, and the nitrogen
is vented to the atmosphere. The maximum oxygen concentration produced by concentrators is approximately
90% to 96%, with the balance made up mostly of argon.17,18
Oxygen concentrators are commonly used in remote
locations and developing countries, but in some cases they
have been configured to supplement a hospitals existing
liquid oxygen system as a reserve or a secondary supply.17
Oxygen concentration may vary with gas flow, and concentrators are most effective at delivering oxygen at flows of
less than 4 L/min to anesthesia machines.18 Accumulation
of argon may occur, however, in low-flow conditions, so
the use of an oxygen monitor is essential.19 As the current
emphasis on cost cutting in medical care continues, along
with cost increases of supplied liquid and gaseous oxygen,
oxygen concentrators are likely to come into wider use.
Medical Air
The central supply of medical air can come from three
sources: 1) cylinders of compressed air that have been
cleaned to medical quality by filtration distillation; 2) a
proportioning system (relatively uncommon) that receives
oxygen and nitrogen from central sources, mixes them in
a proportion of 21% oxygen to 79% nitrogen, and delivers this mixture to the medical air pipeline (these systems
usually have compressed air cylinders or an air compressor as a reserve system); and 3) air compressors (Fig. 1-18),
the most common source of medical air in hospitals. The
compressor works by compressing ambient air and then
delivering the pressurized air to a reservoir or holding
tank.14 The medical air is then fed to the pressure regulator and travels from there to the hospital piping system.
Air compressor systems are subject to rigorous standards.12,13 As with other systems (i.e., vacuum or electrical generators), redundancy is important. Duplicate
compressors are necessary, each with the capacity to
meet the entire hospitals medical air needs if the other
fails. The system must be used only for the medical air
pipeline and not for the purpose of powering equipment. If air is to be used for powering equipment, a
separate instrument air system must be installed. (The
requirements for this system are specified in NFPA99.) The compression pumps must not add contaminants to the gas, and the air intake must be located away
from any street or other exhaust. It is particularly
important that the pumps be located away from the
hospitals vacuum system exhaust. The air must first be
thoroughly dried to remove water vapor and then filtered to remove dirt, oil, and other contaminants. The
condensed water is then properly disposed of to eliminate potential breeding grounds for bacteria, such as
those that cause Legionnaires disease. Valves, pressure
regulators, and alarms analogous to those in oxygen
supply systems are needed. In addition, the piping
should not be exposed to subfreezing temperatures.
17
Pipeline distribution system

Emergency
alarm sensor
(abnormal)
Main service isolation

shut-off valve
Line pressure
gauge
Emergency
alarm sensor
(dew point)
Filter*
muffler
intake
Filter*
muffler
intake
Line
pressure
regulators
Emergency
alarm sensor
(high water
level)
Main service
isolation
shut-off valve,
alternate location
Emergency
alarm sensor
(reserve low)
Reserve
pressure
regulator
Compressor 1
Compressor 2
Service
water
supply*
Emergency alarm
sensor (low water
pressure)*
Emergency
alarm sensor
(reserve
in use)
Drain
Operating
devices for
initiating
alternator,
lag
compressor,
and alarm
Dryer
Drain
Dryer
Reserve
supply
Drain
FIGURE 1-18 n A typical duplex medical air compressor system. Compressors (lower left) draw in ambient air and send high-pressure
air to a holding tank. It is critical that these air intakes not be located near any source of air pollution, such as a garage or the exhaust
from the facilitys vacuum system. The air from the holding tank is dried and filtered on its way to pressure regulators, which deliver
gas at about 55 psig into the pipeline system. *Where required. (From Standard Z305.192, Nonflammable medical gas piping systems.
Toronto, 1992, Canadian Standards Association.)
Nitrous Oxide
Helium
Specific standards exist for nitrous oxide systems, and

certain portions of the more general standards of the
NFPA and CSA are applicable as well.20 A nitrous oxide
central supply system may be warranted, depending on
the expected daily use of the gas. If demand is sufficient,
such a system could be cost effective compared with
attaching small cylinders to each anesthesia machine.
Even though anesthesiologists are the only people
who use the nitrous oxide system, they must delegate
the responsibility for the operation and maintenance of
the central nitrous oxide system to other hospital
personnel.
Nitrous oxide central supply systems are usually of the
cylinder-manifold type, as shown in Figure 1-11. Again,
it is necessary to have two separate banks of cylinders
with an automatic crossover; however, large institutions
may need a bulk liquid storage system similar to the one
used for oxygen, shown in Figure 1-16. In this case, the
storage of liquid nitrous oxide requires an insulated container similar to that used for liquid oxygen.
Helium is commonly supplied in an E-size cylinder with

a flowmeter that delivers it into the fresh-gas flow, but
H-size cylinders are also used. Anesthesia machines are
available that incorporate a helium flowmeter on the
manifold, usually in place of medical air (see Fig. 1-18,
A). Although this design incorporates some of the anesthesia machines safety features, care must be taken to
avoid delivering hypoxic gas mixtures. On new machines,
helium tanks are supplied premixed with oxygen as a 3:1
He/O2 mixture. This prevents the risk of hypoxia that
occurs when 100% helium tanks are used on the machine.
Nitric Oxide
Inhaled nitric oxide is approved and regulated by the U.S.
Food and Drug Administration as a pharmaceutical product, not as a medical gas. It is provided as 800 ppm nitric
oxide diluted in nitrogen and available in D cylinders
(353 L at 2000 psig) or the larger 88 cylinders (1963 L at
2000 psig). The selected concentration of inhaled nitric
18
oxide is delivered into the inspiratory limb of the breathing system. A monitoring device to measure the concentrations of oxygen, nitric oxide, and nitrogen dioxide (a
toxic byproduct) is placed downstream of the nitric oxide
inlet. Ikaria, Inc. (Hampton, NJ) produces the INOmax
DS delivery system, which electronically controls the
amount of nitric oxide injected into the circuit, monitors
delivered concentrations, and adjusts nitric oxide to
maintain a constant concentration despite variations in
fresh gas flow (Fig. 1-19).
Nitrogen
Even though a nitrogen central supply system is designed
to supply gas only for powering OR equipment, it is still
subject to the same standards outlined above. Nitrogen
supply systems are frequently smaller than those for
nitrous oxide but are of essentially the same design, in
which a series of H-cylinders are connected by a manifold (pressure header) system that feeds a pressure regulator. A typical nitrogen control panel is illustrated in
Figure 1-20. Again, because this system services the OR,
it is important to delegate responsibility for maintenance. Although relatively uncommon, some systems
are designed to mix central nitrogen with oxygen to create medical air. It is also possible to store nitrogen as a
liquid for a centrally supplied system.
FIGURE 1-19 n Ikaria INOmax DS delivery system delivers a constant, operator-determined concentration of nitric oxide with
sensors to detect oxygen, nitric oxide, and nitrogen dioxide.
(Courtesy Ikaria, Hampton, NJ.)
Central Vacuum Systems

Although not a source of medical gas, the central vacuum
system is no less important and demands the same attention to detail as a medical gas system. Inadequate or failed
suction can be disastrous in the face of a surgical or anesthetic crisis.
Certain standards exist for the central vacuum source
and vacuum piping system; the Canadian standards are
considered the most complete and current.13 Larger ORs
must have enough suction to remove 99 L/min of air.
Factors such as normal wall suction (7 psig), total flow of
the system, and the length of the longest run of pipe must
be considered to maintain adequate suction. Two independent vacuum pumps must be present, each one capable of handling the peak load alone. An automatic
switching device distributes the load under normal conditions and automatically shifts if one unit fails. Emergency
power connections are essential, and the pumps must be
located away from oxygen and nitrous oxide storage.
There must be traps to collect and safely dispose of any
solid or liquid contaminants introduced into the system,
and the system piping must not be exposed to low temperatures to prevent condensation. The type and location
of the vacuum system exhaust is specified and must not be
near the intake for the medical air compressor.
MEDICAL GAS PIPELINES

Medical gas must travel through a pipeline to reach its
designated point of use. The potential for serious injury
to a patient from a medical gas pipeline mishap has led to
the development of detailed standards.12,13
FIGURE 1-20 n An operating room control panel for nitrogen. The

outlet pressure of nitrogen can be controlled by the variable
pressure regulator. In this manner, the exact pressure can be set
to meet the demands of the piece of equipment being powered.
Planning
In any new construction, physicians must provide architects and engineers with the number and desired locations of any gas outlets. Anesthesiologists need to decide
whether they want one or two sets of outlets for anesthesia gases in each OR and whether they want wall and/or
ceiling-mounted distribution of the gases. Representatives from all the departments that will use the system
should be involved in planning the location of the outlets.
A basic layout for a portion of a piping system is illustrated in Figure 1-21. Extensive planning is necessary for

Note: Single service valves are shown, but multiple zones can branch off a single service valve.
Area alarm
switch/sensor*
Future valve
19
Service valve
Service valve
D.C.
Outlet(s)/inlet(s)
Outlet(s)/inlet(s)
Zone valve Zone valve
Critical areas (such as intensive care)
Noncritical areas (such as general patient rooms)

Riser
Master alarm
switch/sensor
D.C.
D.C.
Line pressure
indicator
Area alarm
switch/sensor
Riser valve(s)
D.C.
Main line
Source or
main valve
Service valve
Indicates a valve that must be secured
Zone valve
Outlet(s)/inlet(s)
Anesthetizing areas
FIGURE 1-21 n A representative portion of the pipeline system for oxygen in a hospital. Note that separate similar designs are needed
for the other medical gases. The schematic is representational, demonstrating a possible arrangement of required components. It
is not intended to imply a method, materials of construction, or more than one of many possible and equally compliant arrangements. Alternative arrangements are permitted. *Area alarms are required in critical care locations (e.g., intensive care units, coronary care units, angiography laboratories, cardiac catheterization laboratories, postanesthesia recovery rooms, and emergency
rooms) and anesthetizing locations (e.g., operating rooms and delivery rooms). Locations for switches/sensors are not affected by
the presence of service or inline valves. (From NFPA 99-2012. Health care facilities. Copyright 2011, National Fire Protection Association.
Quincy, MA, 02269.)
Detailed standards must be followed with respect to the

specific type of pipe used, typically seamless copper tubing,
as well as the cleaning, soldering, and supporting of the
pipe within the walls.8,12,13 In addition, pipelines must be
protected, such as by enclosure in conduits, especially when
they run underground. Pipes located inside risers and walls
must be labeled in a specific way and at given intervals.
Once drafted, the plans must be examined to verify
that all standards have been met. Given the fact that the
construction of medical gas pipelines is relatively uncommon, it is possible that a given engineering, architectural, or building firm has never constructed one before.
Any changes made in the plans should be recorded in the
as-built drawings to enable hospital personnel to discern
the exact location of the pipes if problems arise.
FIGURE 1-22 n Typical shut-off valves for the gases supplied in
operating rooms (ORs). Each gas must have its own shut-off
valve, and a separate set of valves must be present for each OR.
each separate medical gas pipeline, and anesthesiologists

must be aware of all appropriate requirements. For example, each anesthetizing location must have a separate
shut-off valve (Fig. 1-22), and other areas such as the
postanesthesia care unit (PACU) require zone shut-off
valves.
Additions to Existing Systems

Even more difficult than planning a new medical gas pipeline system is adding to an existing system. In addition to
all the planning outlined above, the interaction between
the old facility and the new one must be considered. The
central supply system may need to be expanded to include
new pipeline systems, which may necessitate the difficult
task of shutting down the existing pipeline system.
Extreme precision is required for such an operation, and
procedural standards exist both for modifying or adding
to existing systems.13
20
Installation and Testing

Installation of a pipeline should be overseen by a representative from the medical facility, and the testing should
actively involve several individuals who will use the system. Prior to installation, the copper tubing used for the
medical gas pipeline must be clean and free of contamination. The lengths of pipe must be stored with both ends
sealed with rubber or plastic caps to prevent contamination. After the pipelines have been installed, but before the
outlet valves are installed at each gas outlet location, highpressure gas must be used to blow the pipeline free of any
particulate matter.
The pipeline system involves pressure regulators that
function to maintain normal outlet pressure (e.g., 55 psig
for oxygen). Also, there must be pressure relief devices
that automatically vent the gas if the pressure increases by
50% above the normal operating pressure. High- and
low-pressure alarms and shut-off valves are required at
various locations throughout the system. The locations of
all these should be marked on a map of the institution.
The pipeline terminates at various locations within the
hospital. A connector is installed at these termination
points to allow the interface of various pieces of medical
equipment, such as the anesthesia machine or ventilator.
The connectors installed at each outlet of the pipeline are
subject to detailed requirements.12,13 Two basic types of
connectors are used: one is the quick coupler, which is
made by several manufacturers and allows rapid connection and disconnection of fittings and hoses (Figs. 1-23
and 1-24). The other is a noninterchangeable thread system called the diameter index safety system (Fig. 1-25).5
Both systems have gas-specific fittings to prevent incorrect connections. Improper use of a gas outlet or use of an
incorrect fitting essentially defeats the purpose of the
built-in safeguards of the system. Accordingly, the station
outlets must have back-up automatic shut-off valves in
case the quick coupler is damaged or removed. All outlets, hoses, and quick couplers should be properly labeled
and color coded.
Gas outlets in the OR may be located in either the wall
or the ceiling. If the gas hoses are run along the floor, they
must be made of noncompressible materials to prevent
obstruction in case the hose is run over by a piece of heavy
equipment. Outlets may be suspended from the ceiling in
columns or as freestanding hose drops (Fig. 1-26), or they
may be integrated into a multiservice gas boom (Fig. 1-27).
These gas booms can be configured with all the anesthetic
gases as well as vacuum systems, electrical outlets, monitor
connections, and even data and telephone lines. They can
be rotated to several different positions and can be raised
or lowered as necessary.
Testing of the pipeline begins after the couplers have
been installed. Before the walls are closed, the pipeline is
subjected to 150 psig, and each joint is examined for leaks.
The system then undergoes a 24-hour standing pressure
test, in which the system is filled with gas to at least 150
psig, disconnected from the gas source, and closed. If the
pressure is the same after 24 hours, no leaks are present.
Cross-connection testing involves pressurizing each
pipeline system separately with test gas and verifying that
only the outlets of that particular systemfor example,
FIGURE 1-23 n Common types of quick couplers used in hospitals.

Note that each has a specific pin configuration for the individual
gas. The quick coupler and the attached hose should be color
coded for the specific gas.
FIGURE 1-24 n Wall connections for oxygen, air, and nitrous oxide
in a safety-keyed quick-connect system. The GE Healthcare
(Waukesha, WI) quick-connect system is shown, in which each
gas is assigned two specific pins with corresponding inlet holes
within the circumference of the circle. In this manner, the connection is made gas specific.
compressed airare pressurized. This is particularly

important when additions or modifications are made to
existing pipeline systems.
After the correct connections have been verified,
each pipeline is connected to its own central supply of
gas, and the pipelines are purged with their own gases.
The content of gas from every station outlet must then
be analyzed. An oxygen analyzer can be used for the
oxygen (100%) and medical air (21%) outlets. The concentrations of nitrous oxide and nitrogen must be 100%
according to chromatography or other appropriate
analysis.
All the gas systems must be properly verified. According to NFPA-99, testing shall be conducted by a party
technically competent and experienced in the field of
medical gas and vacuum pipeline testing and meeting the
21
FIGURE 1-25 n A, Examples of hoses with the diameter index safety system (DISS). These are threaded connections in which the diameters of the threads are specific for each of the gases. B and C, Connections made to DISS fittings on the anesthesia machine.
D, DISS fittings on an anesthesia machine.
FIGURE 1-26 n Freestanding ceiling hose drops in an operating

room. Note the proximal ends of the hoses (nearest to the ceiling) have diameter index safety system connections. The distal
ends (nearest to the anesthesia machine) have quick-coupler
connections (see Fig. 1-23).
requirements of ASSE 6030, Professional Qualifications

Standard for Medical Gas Systems Verifiers. Once the
testing has been completed, the facility can accept responsibility for the gas system from the contractor. Anesthesiologists should certainly be involved in verifying the
correctness of the gas supplies. Major problems with new
systems have been identified by anesthesiologists after the
system was certified safe for use.21 Australia has a rigorous permit to work system modeled after a similar system in the United Kingdom, with specific steps that must
be followed before gas supplies can be used.22,23
Contamination of medical gas pipelines has become a
concern,8 and rigorous standards have been developed to
prevent contamination. Gas samples should be taken at the
same time from both the source of the system and the most
distant station outlet. If analysis by gas chromatography
demonstrates contaminants present above the maximum
allowable level, the system should be purged and retested.
If purging the system fails to solve the problem, extensive
troubleshooting may be necessary. Detailed records of all
testing must be maintained and should be available for
inspection by TJC. Once the testing has been satisfactorily
completed, the system is ready for use.
22
C
FIGURE 1-27 n A to C, The distribution head for an articulating
multiservice gas boom. Compressed gases, vacuum, waste
anesthesia gas, computer/Internet, and electrical connections
can all be integrated at one location. The articulated arm can be
raised, lowered, or rotated in a wide arc.
HAZARDS OF MEDICAL GAS DELIVERY

SYSTEMS
A number of deaths have occurred as a result of incorrect
installation or malfunction of medical gas delivery systems. The exact number is not known, however, because
the medical literature contains few publications on medical gas delivery systems. Physicians and administrators
may be reluctant to discuss or publish details of accidents
that occur at their facilities. Often, only personnel within
the medical facility are aware of an accident. If the accident is either serious or results in litigation, it may be
reported in the media. However, it is likely that many, if
not most, accidents that involve medical gas delivery systems are not reported, which may prevent the dissemination of valuable information that could help prevent
future accidents. One attempt was made to learn about
problems with bulk gas delivery systems by conducting a
survey of hospitals with anesthesia residency training
programs.24 One third of the hospitals responding
reported problems, three of which were deaths. In this
survey, 76 malfunctions in medical gas delivery systems
were reported by 59 institutions. Half of these involved
insufficient oxygen pressure, crossed pipelines, depletion
of central supply gas, failure of alarms, pipeline leaks,
and freezing of gas regulators. Insufficient oxygen pressure was most frequently reported from pipelines damaged during unrelated hospital construction projects,
such as resurfacing a parking lot above a buried pipeline.
Another frequent problem was debris or other material
in pipelines, which could be eliminated by adhering to
the prescribed procedures for testing newly installed gas
piping systems.
Between 1964 and 1973 in the United Kingdom, 29
deaths or permanent complications were reported to the
Medical Defense Union, a malpractice insurance company. These resulted from problems in the gas supply or
anesthetic apparatus.25 Three cases were the result of
either an error or failure in piped oxygen supplies, and
two were caused by contaminated nitrous oxide. More
recently, 45 deaths resulted from 26 pipeline incidents in
the United States from 1972 through 1993.26 A substantially higher number of near misses also occurred during this period, and patient death was prevented by
prompt discovery of improper oxygen supply and treatment of exposed patients.26
Errors on the part of commercial suppliers when filling liquid oxygen bulk reservoirs have endangered
patients and, in at least one instance, have harmed a
patient. A supplier succeeded in filling a liquid oxygen
reservoir with liquid nitrogen by bypassing the indexed,
noninterchangeable safety valve connection designed to
prevent such an occurrence.27 A hypoxic gas mixture was
thus delivered to anesthetized patients. Fortunately, however, the ensuing problems were quickly recognized and
catastrophe averted by a switch to tank oxygen supply. In
another more recent episode, two patients received a
hypoxic gas mixture that led to the death of one of the
patients.28 In this case a 100-L container of liquid oxygen was delivered and connected to the hospitals gas
pipeline approximately 1 hour before patients were anesthetized. This container actually contained almost pure
nitrogen. It is interesting to note that no inspired oxygen
analyzer was in use at the time of the accident.
Several other problems with bulk oxygen delivery systems have been reported. In one case, the delivery of a
large volume of liquid oxygen caused a sudden drop in the
temperature of the system, which resulted in a regulator
freezing in a low-pressure mode.29 Insufficient oxygen

pressure resulted, and attempts to correct the problem
quickly revealed that a low-pressure alarm had been disconnected during a recent modification of the system. In
an attempt to restore regulator function, several maneuvers were performed that worsened the situation by
allowing excessive pressure (100 psig) into the hospital
pipeline. This caused reducing valves on anesthesia
machines to rupture. In this case, injury to patients was
avoided by the quick thinking of the anesthesiologists in
the OR. A more tragic incident involved a child who sustained cardiac arrest and subsequent brain damage when
an oxygen pipeline valve was simply turned off.30 Another
case of a hypoxic mixture coming from oxygen outlets
involved a problem with the regulator in the oxygen
pipeline; the regulator failed, causing a decreased oxygen
pressure that allowed high-pressure compressed air to
enter the oxygen system through an air-oxygen blender
connected to both outlets in the neonatal intensive
care unit.31
Accidental cross-connecting of pipelines represents a
clearly recognized threat to patients.32-34 Exposure of
patients to incorrect gases proves the inadequacy of the
testing of that pipeline. An additional source of error may
arise when the pipeline is connected to the anesthesia
machine. According to one report, several deaths were
caused by the connection of a nitrous oxide pipeline to
the oxygen inlet on the anesthesia machine with the corresponding connection of the oxygen pipeline to the
nitrous oxide inlet.35 In other instances, repair of the
hoses that run from the outlet to the machine led to
the interchange of the oxygen and nitrous oxide quick
coupler female adapters. As a result, the nitrous oxide
pipeline was connected to the oxygen inlet, causing the
death of one patient, among other catastrophes.36,37
One published report of contamination of gas pipeline
systems involved a newly constructed hospital building.8
During cross-connection testing of the gas pipelines, a distinct organic chemical odor was detected. Gas chromatography revealed the presence of a volatile hydrocarbon
at a concentration of 10 ppm. Four days of purging
reduced this contaminant to 0.1 ppm in the oxygen pipeline and 0.4 ppm in the medical air pipelines. The original
outlet tests also showed a fine, black powder being expelled
from gas outlets. Subsequent investigation revealed that
during installation, the ends of the pipe segment were
color coded with spray paint. Later, when the pipe ends
were being prepared for soldering, they were sanded
down, and the paint particles settled inside the pipeline.
This particulate contamination was eliminated by the
purging process.
Contamination of a hospital oxygen pipeline system by
other chemicals was also reported when the solution used
to clean the oxygen supply tubing between the supply
tank and the hospital pipeline had not been flushed out.38
In this case, all the hospital outlets had to be shut down,
and patients were switched to tank supplies while the
problem was identified and the pipeline system flushed
with fresh oxygen.
A commercial firm that conducts tests of new hospital
gas pipelines conducted a study of 10 hospitals in which a
total of 1668 gas outlets were examined. At seven hospitals,
23
all outlets failed the gas purity tests. Of the 1668 outlets,
331 (20%) failed for a variety of reasons, such as unacceptably high moisture, volatile hydrocarbons, halogenated
hydrocarbon solvents, unidentified odors, and particulate
matter such as solder flux. Contamination of new medical
gas pipelines appears to be a common problem that merits
close attention. A report in the 2012 fall newsletter of the
Anesthesia Patient Safety Foundation further emphasizes
this problem. During a construction project, a new oxygen
line was built and was leak tested with nitrogen. Subsequently, the nitrogen was not fully purged from the line
and entered the main hospital oxygen supply. The inspired
oxygen concentration decreased to 2% to 3% in 8 to 9
operating rooms.39
Another frequently reported cause of mishaps in oxygen supply is a problem with oxygen blending devices,
such as those found on ventilators to decrease the inspired
oxygen percentage.40,41 These devices are subjected to
heavy use and are exposed to multiple mechanical stresses
as ventilators are moved about. Again, the importance of
monitoring the delivered oxygen concentration cannot
be overemphasized.
Although the potential hazards of using medical gas
delivery systems are many, such mishaps are largely preventable with close attention to the applicable standards.
PROCEDURES
When a new medical gas delivery system is constructed,
both the medical staff and the plant engineering department must be involved in all stages of the process to prevent building inadequacies or inconveniences into the
system that might otherwise limit its value or even create
a hazard. The medical facility must clearly designate the
lines of responsibility for the medical gas delivery system
among the hospital staff members. One suggestion is for
institutions to have four departmentsplant engineering, maintenance, anesthesia, and respiratory therapy
delegate responsibility for the gas delivery systems to one
or more members of each department. Each member of
the group should possess a thorough understanding of
the institutions systems, and each person must be able to
manage any problem that might occur. Consideration
should be given to use of an outside contractor who specializes in the construction of new and refurbished medical pipeline systems.
Excellent communication must be established with the
company that supplies the bulk gas. The gas supplier
should supply the hospital with a list of emergency contacts and should notify the institution whenever a bulk
gas delivery is scheduled. In this way, the delivery can be
overseen by the appropriate committee member. Had
this been done in certain situations, several of the problems cited above could have been avoided.
Communication between the supplier and the hospitals representatives is important when the gas delivery
system undergoes any work. In addition, representatives
from both the institution and the supplier should be
aware of any construction that might affect the gas system. In one case, such precautions could have prevented
crushing of the underground pipes of an oxygen bulk
24
supply system during the resurfacing of a hospital parking lot.24 Hospitals need to develop protocols and designate a responsible person to respond to medical gas
alarms, including a complete failure of the oxygen system. The necessity of such plans is illustrated by a situation in which a tornado destroyed a hospitals central
bulk oxygen supply.42
Interdepartmental communication is also critical. All
affected departments must be notified when the gas supply system is to be shut off for repair or periodic maintenance. A near-crisis situation arose when an engineering
department shut down piped oxygen supplies during the
operating schedule without notifying anyone else in the
hospital.24 Although this incident occurred many years
ago, such incidents still occur but often go unreported,
especially if no patients are injured. After repair or maintenance, a qualified person should inspect the system
before it is put back into service. The patient death that
resulted from the interchanged quick couplers could
have been prevented had this procedure been followed.
Anesthesia providers are often complacent about their
gas supply until either a problem or a catastrophe occurs.
Almost all injuries to patients and problems related to
medical gases are preventable, even those caused by natural disasters. Building and maintaining a safe medical gas
system requires a great deal of effort on the part of many
individuals but is vital to the integrity of health care
facilities.
REFERENCES
1. Safe handling of compressed gas in containers: Publication P1, ed 11,
Arlington, VA, 2008, Compressed Gas Association.
2. Characteristics and safe handling of medical gases:Publication P2,
ed9, Arlington, VA, 2006, Compressed Gas Association.
3. Dorsch JA, Dorsch SE: Medical gas cylinders and containers. In
Understanding anesthesia equipment, ed 5, Baltimore, 2008, Lippincott Williams & Wilkins, pp 1215.
4. American National, Canadian, and Compressed Gas Association standard
for compressed gas cylinder valve outlet and inlet connections:Publication
V1 ed 12, Arlington, VA, 2005, Compressed Gas Association.
5. Diameter index safety system:Publication V5, ed 6, Arlington, VA,
2008, Compressed Gas Association.
6. Pressure relief device standards: Part 1. Cylinders for compressed gases:
Publication S1.1, ed 13, Arlington, VA, 2007, Compressed Gas
Association.
7. Feeley TW, Bancroft ML, Brooks RA, etal: Potential hazards of
compressed gas cylinders: a review, Anesthesiology 48:7274, 1978.
8. Eichhorn JH, Bancroft ML, Laasberg H, etal: Contamination of
medical gas and water pipelines in a new hospital building, Anesthesiology 46:286289, 1977.
9. Slack GD: Medical gas and vacuum systems, Chicago, 1989, American
Hospital Association.
10. Eichhorn JH: Medical gas delivery systems, Int Anesthesiol Clin
19(2):126, 1981.
11. Compressed gases and cryogenic fluids code, NFPA 55, Quincy, MA,
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12. Gas and vacuum systems. In Health care facilities code, NFPA-99.
Quincy, MA, 2012, National Fire Protection Association,
pp25-73.
13. Nonflammable medical gas pipeline systems, Z305.1-92, Toronto,

1992, Canadian Standards Association.
14. Dorsch JA, Dorsch SE: Medical gas piping systems. In Understanding anesthesia equipment, ed 2, Baltimore, 1984, Williams & Wilkins,
pp 1637.
15. Bancroft ML, duMoulin GC, Hedley-Whyte J: Hazards of hospital bulk oxygen delivery systems, Anesthesiology 52:504510, 1980.
16. Penny M: Physical and chemical properties of molecular sieves:
the pressure absorption cycle, Health Service Estate (HSE) 61:4449,
1987.
17. Friesen RM: Oxygen concentrators and the practice of anesthesia,
Can J Anaesth 39:R80R84, 1992.
18. Rathgeber J, Zuchner K, Kietzmann D, Kraus E: Efficiency of a
mobile oxygen concentrator for mechanical ventilation in anesthesia: studies with a metabolic lung model and early clinical results,
Anaesthesist 44:643650, 1995.
19. Wilson IH, vanHeerden PV: Domiciliary oxygen concentrators in
anaesthesia: preoxygenation techniques and inspired oxygen concentrations, Br J Anaesth 65:342345, 1990.
20. Standard for nitrous oxide systems at consumer sites: Publication G-8.1,
ed 4, Arlington, VA, 2007, Compressed Gas Association.
21. Krenis LJ, Berkowitz DA: Errors in installation of a new gas delivery
system found after certification, Anesthesiology 62:677678, 1985.
22. Seed RF: The permit to work system, Anaesth Intensive Care
10:353358, 1982.
23. Howell RSC: Piped medical gas and vacuum systems, Anaesthesia
35:679698, 1980.
24. Feeley TW, Hedley-Whyte J: Bulk oxygen and nitrous oxide delivery systems: design and dangers, Anesthesiology 44:301305, 1976.
25. Wylie WD: There, but for the grace of God, Ann R Coll Surg Engl
56:171180, 1975.
26. Petty WC: Medical gases, hospital pipelines, and medical gas
cylinders: how safe are they? AANA Journal 63:307324, 1995.
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1975.
28. Holland R: Wrong gas disaster in Hong Kong, Anesthesia Patient
Safety Foundation Newsletter 4(3):26, 1989.
29. Feeley TW, McClelland KJ, Malhotra IV: The hazards of bulk
oxygen delivery systems, Lancet 1:14161418, 1975.
30. Epstein RM, Rackow H, Lee AA, et al: Prevention of accidental
breathing of anoxic gas mixtures during anesthesia, Anesthesiology
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35. McCormick JM: National fire protection codes1968, Anesth
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CHAPTER 1

Medical Gases: Storage and Supply*

MEDICAL GAS PIPELINE SYSTEMS

MEDICAL GAS CYLINDERS AND THEIR USE

MEDICAL GAS CENTRAL SUPPLY SYSTEMS

GAS CYLINDER SAFETY ISSUES

MEDICAL GAS PIPELINES

CHARACTERISTICS OF GAS CYLINDERS

Prevention of Incorrect Gas Cylinder

GUIDELINES FOR USE OF MEDICAL GAS

HAZARDS OF MEDICAL GAS DELIVERY SYSTEMS

PART I Gases and Ventilation

MEDICAL GAS CYLINDERS

are also routinely used as portable oxygen sources, such

If the oxygen tanks pressure gauge reads 1000 psig,