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Year: 2014

Calculation of volatile anaesthetics consumption from agent concentration

and fresh gas flow

Biro, P

Abstract: BACKGROUND The assessment of volatile agents’ consumption can be performed by weighing
vapourisers before and after use. This method is technically demanding and unavailable for retrospective
analysis of anaesthesia records. Therefore, a method based on calculations from fresh gas flow and agent
concentration is presented here. METHODS The presented calculation method herein enables a precise
estimation of volatile agent consumption when average fresh gas flows and volatile agent concentrations
are known. A pre-condition for these calculations is the knowledge of the vapour amount deriving from
1 ml fluid volatile agent. The necessary formulas for these calculations and an example for a sevoflurane
anaesthesia are presented. RESULTS The amount of volatile agent vapour deriving from 1 ml of fluid
agent are for halothane 229 ml, isoflurane 195 ml, sevoflurane 184 m, and desflurane 210 ml. The
constant for sevoflurane is used in a fictitious clinical case to exemplify the calculation of its consumption
in daily routine resulting in a total expenditure of 23.6 ml liquid agent. CONCLUSIONS By application
of the presented specific volatile agent constants and equations, it becomes easy to calculate volatile
agent consumption if the fresh gas flows and the resulting inhaled concentration of the volatile agent are
known. By this method, it is possible to extract data about volatile agent consumption both ways: (1)
retrospectively from sufficiently detailed and accurate anaesthesia recordings, as well as (2) by application
of this method in a prospective setting. Therefore, this method is a valuable contribution to perform
pharmacoeconomical surveys.

DOI: https://doi.org/10.1111/aas.12374

Posted at the Zurich Open Repository and Archive, University of Zurich

ZORA URL: https://doi.org/10.5167/uzh-98532
Journal Article
Accepted Version

Originally published at:

Biro, P (2014). Calculation of volatile anaesthetics consumption from agent concentration and fresh gas
flow. Acta anaesthesiologica Scandinavica, 58(8):968-972.
DOI: https://doi.org/10.1111/aas.12374
Peter Biro, M.D. DESA
Institute of Anaesthesiology
University Hospital Zurich
Raemistrasse 100
CH-8091 Zurich, Switzerland
Email: [email protected]

How to calculate the consumption of volatile anaesthetics from agent concentration

and fresh gas flow

P. BIRO

Senior staff physician, Institute of Anaesthesiology, University Hospital Zurich, CH-8091 Zurich,
Switzerland

Correspondence to: P. Biro

Email: [email protected]

Short Title: Calculation of volatile anaesthetics consumption

Conflict of interests: none.

1
How to calculate the consumption of volatile anaesthetics from agent concentration
and fresh gas flow

Background: The assessment of volatile agents’ consumption is usually performed by weighing

vaporisers before and after use. This method is technically demanding and unavailable for
retrospective analysis of anaesthesia records. Therefore a method based on calculations from fresh
gas flow and agent concentration is presented here.
Methods:. The herein presented calculation method enables a precise estimation of ongoing or past
anaesthesias when average fresh gas flow and average volatile agent concentration throughout the
whole time period of anaesthetic gas delivery is known. Additionally, the vapor amount deriving from 1
ml fluid volatile agent has to be known. The necessary formulas for these calculations are presented
herein for four agents and exemplary calculations simulating clinical dosages are performed.
Results: The calculation of volatile agent vapour deriving from 1 ml of fluid agent is presented:
halothane 229 ml, isoflurane 195 ml, sevoflurane 184 m and desflurane 210 ml. These constants are
used in 4 fictitious clinical cases to exemplify the calculation of volatile agent consumption in daily
routine.
Conclusions: By application of the presented specific volatile agent constants and equations, it
becomes easy to calculate volatile agent consumption if the fresh gas flows and the resulting inhaled
concentration of the volatile agent are known. By this method both is possible, to extract data about
volatile agent consumption both ways: a) retrospectively from sufficiently detailed and accurate
anesthesia recordings, as well as b) by application of this method in a prospective setting. Therefore,
this method is a valuable contribution to perform pharmaco-economical surveys.

Key Words: consumption, volatile anaesthestics; pharmacoeconomics

Introduction

The knowledge about the consumption of volatile agents during anaesthesia and its
1,2
pharmacoeconomical implications gains increasing relevance and attention. The easiest way to
assess the consumption of volatile anaesthetics is to weigh the vaporiser before and after anaesthesia
and to take the difference (plus the eventually added refilled volumes during the ongoing anaesthesia)
as the consumed amount. This method has been widely used for various drug consumption and
3,4
pharmaco-economic investigations. A certain technical problem derives from the necessity for a
very precise balance that has a wide range of measurement. Usually the larger the measurement
range, the less is the resolution for small differences between the measured objects. A vaporiser
weighs up to 5 kg, while the differences produced by the prevailing levels of its volatile anaesthetic
content remains in the range of a few grams. Besides this technical limitation, this method can be only
adopted if the assessment is planned in advance and one has the opportunity and necessary time to

2
perform pre- and post-anaesthesia measurements. Due to the limited availability of the mentioned
equipment as well as the necessity to plan the measurements individually in advance, this weighing
method remains limited to a reduced number of cases.

However, since roughly two decades we have a reliable method for the assessment of volatile agents
consumption that can be applied if a few basic data of the already carried out such as the settings for
both, the fresh gas flow (FGF) and the volatile agent concentration in the fresh gas, as well as the time
5,6
course of these parameters. Additional concomitant conditions that have to be taken into
consideration are the average temperature of the vaporiser during the procedure, and the specific
amount of anaesthetic vapor that can be maximally drawn from 1 ml of fluid agent; the calculation of
the latter for 4 volatile agents under standard conditions is presented further down. The vaporiser
temperature can be approximated to be roughly 2°C below the prevailing room temperature, while the
amount of anaesthetic vapor at complete saturation of the fresh gas is a constant that can be obtain
by a few preparatory calculations. In the following, the calculation of volatile anaesthetic consumption
from anaesthesia records is demonstrated.

Methods

As being an investigation based on physical principles and calculations without involvement of patients
and/or personnel, there is no need for approval by an Ethical Committee. The herein presented
assessment of volatile anaesthetic consumption relies on the assumption, that if the amount of fresh
gas and its content of volatile anaesthetic is known, one can calculate how much of the volatile
anaesthetic in its original fluid form has been drawn from the vaporiser. The first step is to determine
the amount of anaesthetic vapor at complete saturation for each specific volatile agent. For this
purpose, this equation has to be applied:

𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑤𝑒𝑖𝑔ℎ𝑡 1 ∙ 𝐴𝑣𝑜𝑔𝑎𝑑𝑟𝑜 ′ 𝑠 𝑔𝑎𝑠 𝑐𝑜𝑛𝑠𝑡𝑎𝑛𝑡 2 ∙ (273 + 𝑡𝑒𝑚𝑝𝑒𝑟𝑎𝑡𝑢𝑟𝑒)3

𝐹𝑙𝑢𝑖𝑑 𝑉𝐴 (𝑚𝑙) =
𝑚𝑜𝑙𝑒𝑐𝑢𝑙𝑎𝑟 𝑤𝑒𝑖𝑔ℎ𝑡 4 ∙ 273

1
Specific weight for volatile anaesthetics in g/ml is as follows: halothane 1.87, isoflurane 1.49,
7,8
sevoflurane 1.53, and desflurane 1.47.

2
Avogadro’s gas constant states that at a standard atmospheric pressure of 760 mmHg (at sea level)
23
and at a temperature of 0°C = 273 °K one mole of any gas consists of 6.023 x 10 molecules which in
turn occupy a volume of 22’400 ml. This is the same for all gases at STPD conditions, and also in the
case of all volatile anaesthetics. STPD means “standard temperature, standard pressure, dry”, which
is given for a volume of gas at 0° C and 760 torr, and that contains no water vapor.

3
The temperature of the vaporiser is close to room temperature. Due to the loss of energy during
evaporation there is a tendency of cooling of the vaporiser, which is counteracted by its inbuilt high

3
temperature conductibility. It’s reasonable to subtract 2°C from the prevailing room temperature
(personal experience), then the result is to be added to 273°K.

4
Molecular weights for volatile anaesthetics are as follows: halothane 197, isoflurane 184, sevoflurane
7,8
200, and desflurane 168.

Having these four items (and assuming a room temperature of 22°C and a vaporiser temperature of
20°C), we obtain the saturated vapor volumes from the evaporation of 1 ml fluid volatile anaesthetics:

1.87 ∙ 22′ 400 ∙ (273 + 20)

𝐻𝑎𝑙𝑜𝑡ℎ𝑎𝑛𝑒 𝑣𝑎𝑝𝑜𝑟 𝑣𝑜𝑙𝑢𝑚𝑒 = = 229 𝑚𝑙
197 ∙ 273

1.49 ∙ 22′ 400 ∙ (273 + 20)

𝐼𝑠𝑜𝑓𝑙𝑢𝑟𝑎𝑛𝑒 𝑣𝑎𝑝𝑜𝑟 𝑣𝑜𝑙𝑢𝑚𝑒 = = 195 𝑚𝑙
184 ∙ 273

1.53 ∙ 22′ 400 ∙ (273 + 20)

𝑆𝑒𝑣𝑜𝑓𝑙𝑢𝑟𝑎𝑛𝑒 𝑣𝑎𝑝𝑜𝑟 𝑣𝑜𝑙𝑢𝑚𝑒 = = 184 𝑚𝑙
200 ∙ 273

1.47 ∙ 22′ 400 ∙ (273 + 20)

𝐷𝑒𝑠𝑓𝑙𝑢𝑟𝑎𝑛𝑒 𝑣𝑎𝑝𝑜𝑟 𝑣𝑜𝑙𝑢𝑚𝑒 = = 210 𝑚𝑙
168 ∙ 273

After obtaining these constants, the next step is to include these values into a formula that considers
the settings for the FGF, as well as for the volatile agent concentrations that have been used
throughout the course of the investigated anaesthesia. For volatile agent concentrations, measured
9
values are to be preferred , but if these are unavailable, the vaporiser settings can be used as well,
albeit with a lesser degree of precision, since usually the output of vaporisers is lower than the set
10
level . Finally, for our calculations we need average FGF and anaesthetic agent concentrations.
Usually, during an anaesthesia, both, FGF and even more so the volatile agent concentrations are
subjected to multiple changes, which may happen independently of each other. Therefore, first the
whole anaesthesia time duration has to be broken down into segments with constant settings, and
their resulting products must be cumulated to obtain the average values of the entire anaesthesia. To
illustrate this measure, here come 4 examples of fictitious (but realistic) inhaled anaesthesia
applications which in the “Results” section will be used to exemplify the calculation of the ensuing
volatile agent consumptions:

Case A.
A halothane anaesthesia of 40 minutes duration. The FGF settings (in L/min) and their durations
(in min) were: 12 for 15 min, and 6 for 25 min. The concentration changes (in Vol%) were: 2 for
10 min, 1.2 for 20 min, 0.8 for 10 min.

4
 Case B.
An isoflurane anaesthesia of 60 minutes duration. The FGF settings (in L/min) and their durations
(in min) were: 6 for 5 min, 3 for 20 min, 6 for 5 min, and 2 for 30 min. The concentration changes
(in Vol%) were: 2.8 for 10 min, 1.6 for 15 min, and 2 for 35 min.

Case C.
A sevoflurane anaesthesia of 90 minutes duration. The FGF settings (in L/min) and their
durations (in min) were: 10 for 10 min, 3 for 20 min, 4 for 10 min, and 1.5 for 50 min. The
concentration changes (in Vol%) were: 2.5 for 5 min, 1.8 for 15 min, 1.2 for 50 min, and 0.9 for 20
min.

Case D.
A desflurane anaesthesia of 120 minutes duration. The FGF settings (in L/min) and their
durations (in min) were: 7 for 10 min, and 0.5 for 110 min. The concentration changes (in Vol%)
were: 8 for 5 min, 6 for 100 min, and 1 for 15 min.

The usual high FGF settings at the end of anaesthesia with the scope of rapid removal of the residual
volatile agent from the body are here ignored since during this measure no volatile agent consumption
from the otherwise closed vaporiser occurs anymore. The hereby removed agent has already been
included into the consumption calculation while it was delivered into the circuit. The time courses of
the FGF and volatile agent setting examples are illustrated in Fig. 1.

Fig. 1. Visual display of the time courses for fresh gas flows (FGF) and volatile agent concentrations in
four different examples as they usually appear in anaesthesia records. Such displays are sufficient to

5
extract the necessary data for the calculation of mean FGF and volatile agent concentrations. On the
right margin the resulting average values are included.

Results
The calculation of mean FGF and volatile anaesthetic concentrations for each case follows here. First
the product of FGF (in Liters) and its time segment (in minutes) is obtained.

Case A (stepwise calculation as example):

Total FGF: (12 x 15) + (6 x 35) = 330 L; Divided by the total duration of 40 min, we obtain a
mean FGF by having 330 : 40 = 8.25 L/min

This is followed by the product of agent concentrations (in Vol%) and their time segment (in minutes):

Total Vol%: (2 x 10) + (1.2 x 20) + (0.8 x 10) = 52. Mean Vol% results from 52 : 40 = 1.3 Vol%.

Analog calculations for the other three agents result in:

Case B
Mean FGF = 3 L/min
Mean Vol% = 2.03 Vol%

Case C
Mean FGF = 3.06 L/min
Mean Vol% = 1.31 Vol%

Case D
Mean FGF = 1.05 L/min
Mean Vol% = 5.46 Vol%

These mean values for FGF have to be converted into milliliters/min, and inserted together with the
mean volatile agent concentrations (Fig. 1), the duration of anaesthetic gas delivery (min) and the
specific constants for saturated gas for each volatile anaesthetic into this equation:

𝑚𝑒𝑎𝑛 𝐹𝐺𝐹 (𝑚𝑙 ⁄min) ∙ 𝑚𝑒𝑎𝑛 𝑎𝑔𝑒𝑛𝑡 𝑐𝑜𝑛𝑐. (𝑉𝑜𝑙%) ∙ 𝐴𝑛𝑎𝑒𝑠𝑡ℎ. 𝑑𝑢𝑟𝑎𝑡𝑖𝑜𝑛 (min)
𝐹𝑙𝑢𝑖𝑑 𝑣𝑜𝑙𝑎𝑡𝑖𝑙𝑒 𝑎𝑔𝑒𝑛𝑡 = = 𝑚𝑙
𝑆𝑎𝑡𝑢𝑟𝑎𝑑𝑒𝑑 𝑔𝑎𝑠 𝑣𝑜𝑙𝑢𝑚𝑒 (𝑚𝑙) ∙ 100 (𝑉𝑜𝑙%)

This is presented for all four exemplary cases:

Case A

6
 8250 𝑚𝑙 ⁄min ∙ 1.3 𝑉𝑜𝑙% ∙ 40 min
𝐻𝑎𝑙𝑜𝑡𝑎𝑛𝑒 𝑓𝑙𝑢𝑖𝑑 𝑐𝑜𝑛𝑠𝑢𝑚𝑝𝑡𝑖𝑜𝑛 = = 18.7 𝑚𝑙
229 𝑚𝑙 ∙ 100 𝑉𝑜𝑙%

Case B
3000 𝑚𝑙 ⁄min ∙ 2.03 𝑉𝑜𝑙% ∙ 60 min
𝐼𝑠𝑜𝑓𝑙𝑢𝑟𝑎𝑛𝑒 𝑓𝑙𝑢𝑖𝑑 𝑐𝑜𝑛𝑠𝑢𝑚𝑝𝑡𝑖𝑜𝑛 = = 18.8 𝑚𝑙
195 𝑚𝑙 ∙ 100 𝑉𝑜𝑙%

Case C
3060 𝑚𝑙 ⁄min ∙ 1.31 𝑉𝑜𝑙% ∙ 90 min
𝑆𝑒𝑣𝑜𝑓𝑙𝑢𝑟𝑎𝑛𝑒 𝑓𝑙𝑢𝑖𝑑 𝑐𝑜𝑛𝑠𝑢𝑚𝑝𝑡𝑖𝑜𝑛 = = 19.6 𝑚𝑙
184 𝑚𝑙 ∙ 100 𝑉𝑜𝑙%

Case D
1050 𝑚𝑙 ⁄min ∙ 5.46 𝑉𝑜𝑙% ∙ 120 min
𝐷𝑒𝑠𝑓𝑙𝑢𝑟𝑎𝑛𝑒 𝑓𝑙𝑢𝑖𝑑 𝑐𝑜𝑛𝑠𝑢𝑚𝑝𝑡𝑖𝑜𝑛 = = 32.7 𝑚𝑙
210 𝑚𝑙 ∙ 100 𝑉𝑜𝑙%

Having the consumed fluid volatile anaesthetic volumes, it’s easy to calculate the costs. In contrast to
i.v. anaesthetics where the unused remnant has to be discarded, the residual content of vaporisers is
no waste and can be used for the next patient. We only need to know the expenditure and price of the
evaporated agent. In Table 1 the volatile agent market prices for Switzerland (as obtained from the
hospital’s pharmacy in November 2013) are included and the resulting costs of the four examples are
displayed.

Time 1 2 3 4 5 6 7
segment
Duration 5 5 10 10 10 30 20
GF flow 10’000 10’000 3’000 3’000 4’000 1’500 1’500
(ml/min)
VA conc. 2.5 1.8 1.8 1.2 1.2 1.2 1.2
(Vol%)
VA 6.8 4.9 2.9 2.0 2.6 2.9 2.0
consumption

Table 1. Results from the costs calculations considering the actual volatile anaesthetic prices and their
application on the presented cases A to D (as given in November 2013 in Switzerland. Currency
conversion rates were at the same time: 1.00 CHF = 1.10 US$ = 0.81 EUR).

Discussion

The consumption of volatile anaesthetics can be precisely estimated from anaesthesia records if these
essential data are available: a) the choice of the volatile anaesthetic, b) the applied FGF (with
knowledge about the durations of its setting variations), and finally c) the applied concentration of the
7
chosen volatile anaesthetic - again with knowledge about the durations of each concentration setting.
The total anaesthesia time is identical with the sum of the recorded FGF or volatile agent
concentration time segments. Considerations of uptake of the volatiles into the body or losses through
leaks in the breathing circuit are irrelevant for this kind of cost calculations since what counts in this
respect is only the extracted amount from the vaporizer, which is the composition and amount of the
FGF.

The herein presented approach by calculation from FGF and (preferably) from measured exhaled
volatile agent concentrations has the big advantage to be applicable without the necessity to have
sophisticated equipment such as a very precise balance with a large measurement range. Additionally,
one can assess volatile agent consumptions retrospectively, provided that the recordings are accurate
and detailed enough. By this it’s theoretically possible to extract data from an unlimited number of
cases resp. from archived records.

A certain disadvantage of this calculation based method is the initially laborious assessment of the
mean FGF and agent concentrations by summing up their individual time segments. However, this
work can be considerably facilitated by using a suitable matrix in a spreadsheet (e.g. in Excel,
Microsoft, Seattle USA) where one only has to enter the relevant numbers into the matching cells. To
illustrate such a table, a screenshot from the calculation for the case D is included in Fig. 2.

Fig. 2. Example for a calculation matrix for case C (sevoflurane anaesthesia) as used in Excel
(Microsoft, Seattle, USA) to obtain the mean fresh gas flow (FGF) and mean volatile agent
concentration over the total anaesthesia time. In the bottom row are calculated the consumption per
min and the total consumed volume of the volatile agent.

Another – thanks to this work by now not anymore existing – handicap is to obtain the constants for
the specific amounts of the most familiar volatile agents indicating the gas volume that result from
evaporation of 1 ml of each agent. These values have been obtained from known physical attributes
such as the molecular as well the specific weight of these compounds, and finally by applying
8
Avogadro’s universal gas laws. The resulting constants for the four most widespread volatiles are here
available: halothane 229 ml, isoflurane 195 ml, sevoflurane 184 m and desflurane 210 ml. However,
for the sake of accuracy is to be stated, that these constants are valid for “low lands” only (which for
practical reasons may be acceptable for locations up to 500 m above sea level). For anaesthesia
practiced at higher altitudes, the figures have to be calculated with altered parameters.

Conclusions

The professional audience has been offered a suitable tool to make precise and relevant
pharmacoeconomical calculations in their daily business. The hereby presented method is also well
suitable to estimate the impact of various FGF settings in order to optimise the consumption
3
parameters for the involved inhaled anaesthetics and of related equipment. An interesting and useful
expansion of the here stated method would be the simultaneous measurement of inhaled and exhaled
volatile anaesthetics and to compare the obtained uptake with the calculated delivered amount of that
2,11
agent. By comparing these parameters, one can deduct the magnitude of unused anaesthetic gas
and will be able to take measures for minimizing waste and pollution.

Conflicts of interests
None.

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