NURSING GUIDELINES ON THE SETUP AND MANAGEMENT
OF THE AnaConDa DEVICE (ANAESTHETIC CONSERVING DEVICE)
Version Number
V1
Date of Issue
April 2016
Reference Number
SMACD-04-2016-CMCMDBJELODTFJD-V1
Review Interval
3 yearly
Approved By
Signature: Date: April 2016
Name: Fionnuala O’Neill
Title: Nurse Practice Coordinator
Authorised By
Signature:
Date: April 2016
Name: Rachel Kenna
Title: Director of Nursing
Authors
Signature:
Date: April 2016
Name: Dr. Cathy McMahon
Title: Consultant Paediatric Intensivist
Name: Dr. Cathy McMahon & Dr. Martina Healy
Title: Consultant Paediatric Intensivists
Name: Dervilia Beirne, Julie Edwards & Linda O’ Donnell
Title: Clinical Nurse Facilitators, PICU
Author/s
Name: Tony Fitzgerald & Jim Davenport
Title: Clinical Engineer
Name: Moninne Howlett & Diarmaid Semple
Title: Pharmacists (Informatics & PICU)
Location of Copies
On Hospital Intranet and locally in department
Document Review History
Review Date
Reviewed By
Signature
October 2016
Document Change History
Change to Document
Reason for Change
Our Lady’s Children’s Hospital, Crumlin
Document Name: Nursing Guidelines on the Set up and management of the AnaConDa Device
(Anaesthetic Conserving Device)
Reference Number: SMACD-04-2016-CMCMDBJELODTFJD-V1
Version Number: V1
Date of Issue: April 2016
Page 2 of 14
Contents
Page No
1.0
Introduction and Definition
3
2.0
Isoflurane
3
3.0
Indication for AnaConDa
3
4.0
Dose and Prescribing
3
5.0
Patient Exclusion
4
6.0
Equipment
4
7.0
Monitoring
7
8.0
Documentation
7
9.0
Warnings
7
10.0
Procedures
8
10.1
10.2
10.3
10.4
10.5
10.6
10.7
10.8
Filling the syringe
Priming the AnaConDa
Suctioning
Using the nebulisers on AnaConDa
Changing the AnaConDa Device
Changing the syringe
Ending the therapy
Troubleshooting
11.0
Appendix 1
13
12.0
References
14
Our Lady’s Children’s Hospital, Crumlin
Document Name: Nursing Guidelines on the Set up and management of the AnaConDa Device
(Anaesthetic Conserving Device)
Reference Number: SMACD-04-2016-CMCMDBJELODTFJD-V1
Version Number: V1
Date of Issue: April 2016
Page 3 of 14
1.0
Introduction and definition
The AnaConDa is an anaesthetic gas system for use in PICU with the Servo i ventilator to administer
isoflurane/sevoflurane in a safe and controlled manner. It will be set up by clinical engineering and used by
staff trained to administer isoflurane to children. These guidelines are designed to standardize the care of the
child receiving inhaled isoflurane and are not a substitute for training and competency assessment. This
guideline does not currently cover the use of sevoflurane in PICU.
2.0
Isoflurane
Isoflurane is an inhalational anaesthetic agent used for induction and maintenance of general anaesthesia. All
volatile anaesthetic agents share the property of being liquid at room temperature, but evaporating easily for
administration by inhalation.
The AnaConDa device is an anaesthetic delivery system, developed for the administration of isoflurane and
sevoflurane to mechanically ventilated patients.
The AnaConDa is a small device that is inserted at the inspiratory limb of the ventilator circuit. The simple
design of the AnaConDa, incorporates a unique high capacity miniature vaporizer, which allows delivery of
these inhalational anaesthetic agents in a safe and controlled manner.
3.0
Indications for AnaConDa
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Status Epilepticus
Status asthmaticus
As a sedative agent for difficult to sedate patients on multiple agents or to control withdrawal reactions
in those who have been exposed to high doses of conventional agents
For raised Intracranial Pressure (ICP)
Children who require short term ventilation and/or prompt awakening (Head Injury/need investigations
where patient is breathing spontaneously e.g. bronchogram, bronchoscopy or diaphragmatic
screening)
Dose and Prescribing - Please see ‘Appendix 1: Prescribing and Recording of Volatile Liquid
Anaesthetics in PICU’ and the ‘OLCHC Hospital Formulary ‘for full information
4.0
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NOT FOR IV USE
Consultant Prescribing Only
Other sedatives may need to be titrated/ discontinued
Isoflurane is a potent vasodilators, the patient may require a fluid bolus +/_ inotropes
Dose to be titrated to maintain target End Tidal Concentration as specified by Consultant
Normal dose range and adverse effects- please refer to Hospital Formulary
Our Lady’s Children’s Hospital, Crumlin
Document Name: Nursing Guidelines on the Set up and management of the AnaConDa Device
(Anaesthetic Conserving Device)
Reference Number: SMACD-04-2016-CMCMDBJELODTFJD-V1
Version Number: V1
Date of Issue: April 2016
Page 4 of 14
5.0
Patient Exclusion
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6.0
Lots of secretions requiring frequent suctioning
Patient on high frequency ventilation
Caution with patient on inhaled nitric oxide (not tested by the company)
Family history of malignant hyperthermia – (see hospital formulary for further information)
NOTE: To enable treatment of malignant hyperthermia a supply of Intravenous Dantrolene
sufficient to treat the patient must be obtained from pharmacy when commencing Isoflurane
Equipment



Philips bedside monitor
Servo I ventilator +patient appropriate circuit
AnaConDa device +red cap [keep for safe disposal of the device]
Our Lady’s Children’s Hospital, Crumlin
Document Name: Nursing Guidelines on the Set up and management of the AnaConDa Device
(Anaesthetic Conserving Device)
Reference Number: SMACD-04-2016-CMCMDBJELODTFJD-V1
Version Number: V1
Date of Issue: April 2016
Page 5 of 14

Infusion pump [B Braun perfusor FM syringe driver]

Gas scavenging unit Maquet EVAC 180

DraegerGas Monitor +gas monitoring line +water trap
Our Lady’s Children’s Hospital, Crumlin
Document Name: Nursing Guidelines on the Set up and management of the AnaConDa Device
(Anaesthetic Conserving Device)
Reference Number: SMACD-04-2016-CMCMDBJELODTFJD-V1
Version Number: V1
Date of Issue: April 2016
Page 6 of 14

Cerebral Function Monitor

Test Lung
Consumables
 Drager sample line
 Drager water trap
 Drager airway adaptor
 Bottle of Isoflurane with Sedana filling adaptor attached
Our Lady’s Children’s Hospital, Crumlin
Document Name: Nursing Guidelines on the Set up and management of the AnaConDa Device
(Anaesthetic Conserving Device)
Reference Number: SMACD-04-2016-CMCMDBJELODTFJD-V1
Version Number: V1
Date of Issue: April 2016
Page 7 of 14

Provided syringe extension and labels

Safety equipment - gloves goggles apron
7.0
Monitoring
Monitoring in addition to routinely recorded parameters
Once set up the bedside monitor (Drager Gas Monitor) will display three additional values
 Inspiratory concentration of the anesthetic agent
 Expiratory concentration of the anesthetic agent
 EtCO2
8.0
Documentation
Nursing staff should follow PICU policy for documenting information relating to nursing care vital signs and are
reminded that they are not only responsible for what they include, but also what they omit. See Appendix 1 for
further information on documenting on ICCA.
However, with regard to the AnaConDa device, the following values should be recorded hourly on ICCA:





Concentration of the anaesthetic agent (End Tidal concentration), based on direct measurement
The rate of infusion of the anaesthetic agent- see Appendix 1
The remaining syringe level
End Tidal CO2 displayed
Pupil Reaction
This is in addition to the parameters below, which should be routinely recorded:
 HR / RR / BP / ETCO2 / Saturations / Temperature
 Ventilator parameters
 Blood gases
 Intracranial Pressure (if being monitored)
 Inotropes
9.0
Warnings


Not for IV use
Must be prescribed by a Consultant as per Appendix 1
Our Lady’s Children’s Hospital, Crumlin
Document Name: Nursing Guidelines on the Set up and management of the AnaConDa Device
(Anaesthetic Conserving Device)
Reference Number: SMACD-04-2016-CMCMDBJELODTFJD-V1
Version Number: V1
Date of Issue: April 2016
Page 8 of 14
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10.0
10.1
1.
2.
3.
4.
5.
Anaesthetic agents are potent vasodilators – monitor blood pressure, child may require a fluid bolus
and may also require inotropic support.
Other sedatives may need to be titrated/ discontinued
To be delivered using syringe drivers labelled ‘AnaConDa – stored in Clinical Engineering Department.
Do not use the bolus function on the syringe driver
Can only be used with the Servo I in OLCHC
Humidifier must be turned on
AnaConDa device placed in the inspiratory limb. Monitor from the patient end of the short patient
module using a green connector with green port (in nitric oxide aisle)
Always put syringe driver on hold before disconnecting AnaConDa to avoid unnecessary exposure to
anaesthetic agent
Disconnect from the ventilator first, then from child. Attach to child first, then to ventilator. Attach test
lung to ventilator. This is to prevent unnecessary exposure to anaesthetic agent
Do not use desflurane: AnaConDa device and syringe are only compatible with isoflurane
Do not reconnect AnaConDa device that has been disconnected and idle for greater than 8 hours.
Always use a new device.
Replace the AnaConDa every 24 hours
Set the pressure alarms on the syringe driver to maximum.
Save the red cap for when disposing of AnaConDa: store in plastic bag on top of ventilator
AnaConDa has not been tested with nitric oxide
In this appliance the only relevant value for ISO is the ET value
Procedures
Filling and syringe
PROCEDURE
RATIONALE and EVIDENCE
Ensure the anaesthetic agent; dose and route are In accordance with Medicines Management
clearly prescribed. To be checked with two nurses, Policy
To maintain patient safety
one of which has received AnaConDa training.
Personal protective equipment: gloves; apron; face To maintain personal safety
visor to be worn
If not already done, attach the filling adaptor. Only To ensure safe and easy filling of the syringe
use the syringe red cap supplied with the Anaconda with the anesthetic agent
system since others may not be suited for
isoflurane
Fill the syringe with air (approx. 15mls) and firmly To equalize the pressure and prevent spray
connect to the filling adaptor on the anesthetic effect when removing the syringe from the
agent bottle. Push the air into the bottle, invert the bottle.
bottle and allow the anesthetic agent to fill the
syringe. Once the syringe stops filling push the
remaining air back into the bottle and again allow
the anaesthetic agent to fill the syringe as before.
The syringe must not be filled above 50mls.
With the syringe still connected to the inverted To prevent exposure to the anesthetic agent
bottle, expel all air.
Our Lady’s Children’s Hospital, Crumlin
Document Name: Nursing Guidelines on the Set up and management of the AnaConDa Device
(Anaesthetic Conserving Device)
Reference Number: SMACD-04-2016-CMCMDBJELODTFJD-V1
Version Number: V1
Date of Issue: April 2016
Page 9 of 14
6. Turn the bottle the right way up, remove the syringe To prevent exposure to the anesthetic agent
and immediately replace the red cap.
In accordance with Medicines Management
7. Label the syringe and sign as appropriate.
8. Place the syringe into the syringe driver with the red To prevent exposure to the anaesthetic agent
cap in place.
9. Empty bottles can be disposed of in glass recycling To ensure safe and appropriate management of
bin in sluice room. Any bottles with remaining medicinal waste as per Waste Management
product should be returned to pharmacy for Policy in OLCHC (available on intranet)
disposal in purple lidded clinical rigid bins fitted with
absorbent material (UN3291).
10.2
Priming the Anaconda
PROCEDURE
RATIONALE and EVIDENCE
1. Important: Priming must be done before To maintain patient safety: isoflurane is a potent
vasodilator.
connecting to the patient; do not purge.
To prevent exposure to anaesthetic agents.
2. Increase pressure limits on dedicated Braun To enable priming to be completed safely before
connecting to the patient.
pump to maximum
3. Set the rate of infusion
To maintain patient safety
4. Set appropriate alarm limits on vital signs
10.3
Suctioning
PROCEDURE
Closed suctioning can be used with this device
Closed suctioning as per guidelines.
In the event of the patient requiring
Open suctioning
PROCEDURE
1. Consider bolus of sedation
2. Stop syringe driver
RATIONALE
To minimize exposure to the Isoflurane
To limit fluctuations in gas delivery
RATIONALE
Anaesthetic agent has short duration of action
3. Disconnect the ventilator
To prevent exposure to anaesthetic agent.
To prevent exposure to anaesthetic agent.
4. Immediately place on test lung
5. Put ventilator on standby
6. Hand ventilate directly via ETT and
perform
suction as per guidelines
7. Connect ventilator to patient
8. Start syringe driver – double check infusion rate
and sign on ICCA
In accordance with OLCHC Medication Policy
Our Lady’s Children’s Hospital, Crumlin
Document Name: Nursing Guidelines on the Set up and management of the AnaConDa Device
(Anaesthetic Conserving Device)
Reference Number: SMACD-04-2016-CMCMDBJELODTFJD-V1
Version Number: V1
Date of Issue: April 2016
Page 10 of 14
10.4
Using Nebulisers on Anaconda
PROCEDURE
1. Connect the nebuliser in the routine position on
RATIONALE
To enable use of nebuliser
the inspiratory limb.
2. Discontinue nebulisation if problems arise
3. Always consider dead space when adding any
extra items
10.5
To prevent complications
To ensure appropriate delivery of inhaled
anaesthetic agent.
Changing the Anaconda device
PROCEDURE
1. The device is to be changed every 24 hours
RATIONALE
2. Obtain new Anaconda pack containing syringe,
Anaconda device and giving set
3. Fill new syringe (see item 1), remove old syringe
from syringe driver and replace red cap and
place new syringe in syringe driver
4. Label AnaConDa with date and time (using field In accordance with OLCHC Medication Policy
on label for ‘Bed’). Both nurses should initial the
label for syringe preparation
5. Connect AnaConDa giving set to syringe
To enable priming to be completed safely before
to connecting to the patient
6. Prime new AnaConDa with approx 1.2mls of
anaesthetic agent before connecting
patient
7. Disconnect ventilator tubing from old Anaconda, To prevent exposure to the anaesthetic agent
then disconnect Anaconda from patient end and To prevent flushing of the anaesthetic agent from
insert red cap into Anaconda
the Anaconda device
8. Connect new Anaconda to patient end first and
To prevent flushing of the anaesthetic agent from
then connect to ventilator tubing. Retain red cap the Anaconda device
To seal the Anaconda when therapy discontinued
9. Start syringe driver and monitor patient and
anaesthetic agent concentration. Record new
MEI number
For audit trail purposes
10. Discard old Anaconda and syringe as clinical
waste
To prevent exposure to the anaesthetic agent
Our Lady’s Children’s Hospital, Crumlin
Document Name: Nursing Guidelines on the Set up and management of the AnaConDa Device
(Anaesthetic Conserving Device)
Reference Number: SMACD-04-2016-CMCMDBJELODTFJD-V1
Version Number: V1
Date of Issue: April 2016
Page 11 of 14
10.6
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.7
Changing the syringe
PROCEDURE
Personal protective equipment: gloves; apron;
face visor to be worn
Stop syringe driver and remove empty syringe,
still connected to supply line
Place new syringe in driver with red cap in place
Disconnect supply line from empty syringe and
immediately connect supply line to new syringe
Connect red cap onto empty syringe
Start syringe driver, observing child’s vital signs
and anaesthetic agent concentration
Refill empty syringe with anaesthetic agent for
next use. Connect red cap to end of syringe.
Write 2nd use on label.
Re-use syringe for a maximum of 2 times.
Discard used syringe as clinical waste
RATIONALE
To maintain personal safety
To prevent exposure to the anaesthetic agent
To prevent exposure to the anaesthetic agent
To prevent exposure to the anaesthetic agent
To prevent exposure to the anaesthetic agent
To prevent exposure to the anaesthetic agent
To be prepared for next syringe change.
To prevent exposure to anaesthetic agent.
To conserve current limited supply of syringes
To prevent exposure to the anaesthetic agent
Ending the therapy
PROCEDURE
RATIONALE
1. Stop syringe driver. Monitor child’s condition
and record end time
2. Disconnect Anaconda from ventilator circuit
For audit purposes
To prevent exposure to the anaesthetic agent
first then from the patient end
3. Connect red cap to patient end of
AnaConDa
4. Remove syringe from driver. Leave
To seal the old Anaconda and prevent exposure to
the anaesthetic agent
To prevent exposure to the anaesthetic agent
connected to supply line
5. Discard AnaConDa, syringe, monitoring line,
To prevent exposure to the anaesthetic agent
water trap and scavenging filter as clinical
waste
6. Clean syringe drivers, gas monitoring bench
In accordance with local policy
and scales
7. Document on ICCA and in the patient case
notes
In accordance with local policy
Our Lady’s Children’s Hospital, Crumlin
Document Name: Nursing Guidelines on the Set up and management of the AnaConDa Device
(Anaesthetic Conserving Device)
Reference Number: SMACD-04-2016-CMCMDBJELODTFJD-V1
Version Number: V1
Date of Issue: April 2016
Page 12 of 14
10.8
Troubleshooting
PROBLEM
1. Gas concentration does not increase
although more than 2mls has been
delivered by syringe driver
SOLUTION

Check monitor and gas bench connections

Check monitoring line is free from kinks and
attached to water trap on gas bench
Check AnaConDa has black part facing
upwards

2. Gas concentration levels drop, although
syringe driver rate is unchanged
3. Water in scavenging port
4. After a while, the child’s tidal volumes
decrease (pressure control mode of
ventilation)
OR
After a while, the child’s peak inspired
pressures increase (volume control mode
of ventilation)


Check for air bubbles in syringe
Increase syringe pump rate by increments of
0.5mls every 10 minutes until waveform and
concentration is displayed, observing child’s
condition carefully


Check monitor connections and for leakage
Check AnaConDa has black part facing
upwards
Check for water in scavenging port
Check for leak around ETT, re-inflate cuff
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Stop syringe driver.
Wear apron, gloves and face visor,
Remove scavenging.
Empty water into sharps bin.
Reconnect scavenging
Assess child
Check if child needs a suction
Check Anaconda has black part facing
upwards
Check for water in scavenging (see point 3)
Our Lady’s Children’s Hospital, Crumlin
Document Name: Nursing Guidelines on the Set up and management of the AnaConDa Device
(Anaesthetic Conserving Device)
Reference Number: SMACD-04-2016-CMCMDBJELODTFJD-V1
Version Number: V1
Date of Issue: April 2016
Page 13 of 14
11.0
1.
Appendix 1: Prescribing and Recording of Volatile Liquid Anaesthetics in PICU
PRESCRIBING ON ICCA: (Consultant Prescribing only )
Prescribe as a ‘free-form medication infusion’ choosing the appropriate standard order from the drop
down menu. E.g. ‘isoflurane inhalational continuous’
NB: The ‘Target End Tidal Concentration’ 0.5-1% should be specified in the ‘order instructions’ field.
All other fields will auto-fill but should be reviewed before the order is confirmed by pressing OK.
2.
RECORDING OF ADMINISTRATION:
The following values should be recorded hourly: (See Image 1&2 below):
Location
Intake/Infusions
Flowsheet
Parameter
Rate
Administered
Syringe Level
Ventilation
Flowsheet
End Tidal
Concentration
Comment
To maintain accurate fluid intake volumes
DO NOT enter Volume Administered on
flowsheet (this field refers to IV/SC
Infusions only).
'ET ConcIso' will need to be added using
‘Add Row’ in Ventilation
The hourly checks do not require counter signing. The syringe preparation does require 2
nurses counter signing
Our Lady’s Children’s Hospital, Crumlin
Document Name: Nursing Guidelines on the Set up and management of the AnaConDa Device
(Anaesthetic Conserving Device)
Reference Number: SMACD-04-2016-CMCMDBJELODTFJD-V1
Version Number: V1
Date of Issue: April 2016
Page 14 of 14
12.0
References
Berton J, Sargentini C, Nguyen J, Belii A & Beydon L (2007) AnaConDa Reflection Filter: Bench and Patient
Evaluation of Safety and Volatile Anesthetic Conservation. International Anesthesia Research Society Vol.
104(1) 130-134
Eifinger F et al (2013) Observations on the Effects of Inhaled Isoflurane on Long-term Sedation of Critically Ill
Children using a Modified Anaconda System. Online Source 12/04/2016
L’Her E, Dy L, Pili R, Prat G, Tonnelier JM, Lefevre M, Renault A, Boles JM (2008) Feasibility and potential
cost/benefit of routine isoflurane sedation using an Anesthetic-Conserving Device: a prospective observational
study. Respiratory Care. Vol. 53(10), 1295-1303
Meiser A & Laubenthal H (2005) Inhalation anaesthetics in the ICU: theory and practice of inhalational sedation
in the ICU, economics, risk-benefit. Best Practice & Research Clinical Anaesthesiology. Vol. 19, No. 3, 523538
Playfor S, Macarthur A (2010) Guidelines for the use of the AnaConDa device. Royal Manchester Children’s
Hospital guidelines
Röhm KD, Wolf MW, Schöllhorn T, Schellhaass A, Boldt J, Piper SN (2008) Short-term sevoflurane sedation
using the Anaesthetic Conserving Device after cardiothoracic surgery. Intensive Care Medicine. Vol. 34, 16831689
Sackey PV, Roland-Martling CR, Radell PJ (2005) ,Three cases of PICU sedation with isoflurane delivered by
the AnaConDa. Pediatric Anesthesia. Vol. 15, 879-885
Sackey PV, Roland-Martling C, Carlswärd C, Sundin O, Radell PJ (2008) Short and long-term follow-up of
intensive care patients after sedation with isoflurane and midazolam – A pilot study. Critical Care Medicine.
Vol. 36, 801-806
Sheerin M (2015) Clinical Procedures: Setup and Management of the AnaConDa Device (Anaesthetic
Conserving Device). Temple Street University Hospital
‘The Waste Management Policy’ in OLCHC. This policy is available on the OLCHC intranet under ‘Policies,
Guideline and SOPs’, ‘Policies A-Z’.
Forane® (Isoflurane) Summary of Product Characteristics. Available at:
http://www.medicines.ie/medicine/3787/SPC/Forane++99.9++w+w%2c+inhalation+vapour%2c+liquid/
Sedan Medical - Instruction for Use -http://www.sedanamedical.com/files/IFU_Anaconda26000_English_151101.pdf
Sedan Medical - Training manual - http://www.sedanamedical.com/files/TM_Anaconda26000_English.pdf
Disclaimer 2016, Our Lady’s Children’s Hospital Crumlin, Dublin 12. All rights reserved. No part of this publication may be reproduced, stored in a
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