Additional Information
Book Details
Abstract
First prize winner, Anesthesia Book Category, British Medical Association 2012 Medical Book Competition
- Provides a simple and comprehensive explanation of the function of anaesthetic equipment, ensuring its safe use in clinical practice
- Covers the relevant syllabus required by the FRCA and similar exams taken by trainee anaesthetists
- Clear line diagrams explain the working principles of each piece of equipment
- Chapter on local anaesthesia totally rewritten
- Chapter on error and man-machine interaction will be much more in depth
- New chapter on patient warming
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front cover | cover | ||
| Ward's Anaesthetic Equipment | i | ||
| Copyright page | iv | ||
| Table of Contents | v | ||
| Contributors | vii | ||
| Preface to the Sixth Edition | ix | ||
| Acknowledgments | x | ||
| Dedication | xi | ||
| Abbreviations | xii | ||
| 1 The supply of anaesthetic and other medical gasses | 1 | ||
| Chapter contents | 1 | ||
| Properties of medical gasses | 1 | ||
| Heliox | 3 | ||
| Xenon | 3 | ||
| Nitric oxide | 3 | ||
| Carbon monoxide | 3 | ||
| Medical gas cylinders | 3 | ||
| Cylinder sizes | 3 | ||
| Cylinder filling and maintenance | 3 | ||
| Cylinder identification | 6 | ||
| Cylinder testing | 6 | ||
| Colour coding | 7 | ||
| Cylinder valves | 7 | ||
| Pin index system | 7 | ||
| Bull nose outlet valve | 8 | ||
| Handwheel valves | 9 | ||
| Integral valves | 9 | ||
| Material compatibility | 11 | ||
| Tamper evident seals | 11 | ||
| Storage of medical gas cylinders | 11 | ||
| Cylinder manifolds | 11 | ||
| Safety precautions | 13 | ||
| Bulk oxygen supply systems | 13 | ||
| Cryogenic liquid system (CLS) | 13 | ||
| Siting requirements | 15 | ||
| Sizing | 15 | ||
| Liquid cylinder (LC) installations | 15 | ||
| Oxygen concentrators (PSA plant) | 16 | ||
| Operational process | 16 | ||
| Medical compressed air | 17 | ||
| Synthetic air systems | 18 | ||
| Medical vacuum systems | 19 | ||
| Performance levels and specifications for a medical vacuum service | 20 | ||
| Anaesthetic gas scavenging systems | 20 | ||
| Alarm and indication systems for piped gasses | 20 | ||
| Distribution systems | 21 | ||
| Terminal outlets | 22 | ||
| Flexible pipeline | 23 | ||
| Quick connect probe | 23 | ||
| The flexible hosepipe | 23 | ||
| The non-interchangeable screw thread (NIST) connector | 24 | ||
| Tests and checks for medical gas piped services | 25 | ||
| Further reading | 25 | ||
| 2 Measurement of pressure and gas flow | 27 | ||
| Chapter contents | 27 | ||
| Force, pressure and flow | 27 | ||
| Atmospheric pressure and partial pressure | 28 | ||
| Partial pressure | 28 | ||
| Absolute, differential and gauge pressures | 29 | ||
| Methods of measuring pressure | 30 | ||
| Mechanical methods | 30 | ||
| Bourdon gauge | 30 | ||
| Aneroid gauge | 30 | ||
| Electronic methods | 30 | ||
| Solid-state electronic pressure transducers | 30 | ||
| Measurement of gas flow | 31 | ||
| Differential pressure flowmeters | 31 | ||
| Constant area differential pressure flowmeters | 31 | ||
| Variable-area constant differential pressure flowmeters | 33 | ||
| Constant temperature hot-wire anemometry | 34 | ||
| Mechanical flowmeters | 35 | ||
| The Wright’s respirometer | 35 | ||
| The axial turbine flowmeter | 36 | ||
| Ultrasonic flowmeters | 37 | ||
| The vortex shedding ultrasonic flow transducer | 37 | ||
| The time-of-flight ultrasonic flow transducer | 37 | ||
| Spirometers | 37 | ||
| Peak flowmeters | 37 | ||
| Further reading | 39 | ||
| 3 Vaporizers | 41 | ||
| Chapter contents | 41 | ||
| Laws of vaporization | 41 | ||
| Factors affecting vaporization of a liquid | 41 | ||
| Temperature | 41 | ||
| Volatility | 42 | ||
| The surface area of the liquid | 42 | ||
| Removal of vapour from the vicinity of liquid | 42 | ||
| Vaporizing systems | 42 | ||
| Types of vaporizer | 43 | ||
| Variable bypass vaporizers | 44 | ||
| Design features | 44 | ||
| Surface area of contact between carrier gas and the liquid | 44 | ||
| Temperature | 44 | ||
| Potency of anaesthetic agent | 44 | ||
| Volatility | 45 | ||
| Types of variable bypass vaporizers | 45 | ||
| Draw-over vaporizers | 45 | ||
| Plenum vaporizers | 46 | ||
| Factors affecting vaporizer performance | 46 | ||
| Extremes of temperature | 46 | ||
| Barometric pressure | 46 | ||
| Pumping effect | 47 | ||
| Liquid levels | 47 | ||
| Anaesthetic agents | 48 | ||
| Carrier gas composition | 48 | ||
| Stability | 48 | ||
| Summary of vaporizer performance | 48 | ||
| Calibration of vaporizers | 48 | ||
| Filling of vaporizers | 49 | ||
| Examples of variable bypass vaporizers | 50 | ||
| Temperature-compensated vaporizers | 50 | ||
| TEC 5 (GE Healthcare) | 50 | ||
| TEC 7 series | 50 | ||
| Blease Datum | 52 | ||
| Dräger ‘Vapor’ 2000 series of vaporizers | 53 | ||
| Penlon Sigma Delta vaporizer | 53 | ||
| Plenum vaporizers with electronic control | 56 | ||
| GE Healthcare – Aladin and Aladin 2 vaporizers | 56 | ||
| The cassette | 56 | ||
| The control unit | 56 | ||
| Draw-over vaporizers | 58 | ||
| The Oxford Miniature Vaporizer (OMV) | 59 | ||
| Epstein, Macintosh, Oxford (EMO) ether inhaler | 60 | ||
| Measured flow vaporizers | 60 | ||
| TEC 6 (Plus) (Desflurane) | 60 | ||
| Dräger D Vapor | 62 | ||
| The Dräger DIVA | 63 | ||
| Further reading | 63 | ||
| Pumping effect | 63 | ||
| Thymol and halothane | 63 | ||
| Vapour output | 63 | ||
| Filling devices | 64 | ||
| Individual vaporizers | 64 | ||
| Vaporizers in circle systems | 64 | ||
| Hazards | 64 | ||
| 4 The anaesthetic workstation | 65 | ||
| Chapter contents | 65 | ||
| Functions of the modern workstation | 67 | ||
| Development of the anaesthetic workstation | 67 | ||
| Integrated and modular designs | 67 | ||
| Patient and machine monitoring | 68 | ||
| Electronics: monitoring or control? | 68 | ||
| The anaesthetic delivery system | 68 | ||
| Machine framework | 69 | ||
| The compressed gas attachments | 69 | ||
| Cylinders | 69 | ||
| Pipelines | 70 | ||
| Pressure (contents) gauges | 70 | ||
| Single-block manifold | 70 | ||
| Pressure regulators (reducing valves) | 70 | ||
| Working principles | 71 | ||
| The accuracy of regulators | 72 | ||
| Interchangeability of regulators | 73 | ||
| Common faults in regulators | 73 | ||
| Relief valves on regulators | 73 | ||
| Primary pressure regulators | 73 | ||
| Secondary pressure regulators | 73 | ||
| Flow restrictors | 74 | ||
| Gas-tight connections within the machine | 75 | ||
| Joints in metal tubing | 75 | ||
| Other detachable joints | 76 | ||
| Valve glands | 76 | ||
| ‘O’-rings | 77 | ||
| Flowmeters (rotameters) | 77 | ||
| The flowmeter block | 78 | ||
| Carbon dioxide flowmeters | 79 | ||
| Anti-hypoxia devices | 79 | ||
| Mechanical devices | 79 | ||
| Pneumatic devices, e.g. Pneupac ratio system | 80 | ||
| Electronically controlled anti-hypoxia devices (Penlon Ltd) | 81 | ||
| The back bar | 81 | ||
| The Ohmeda ‘Selectatec’ System | 83 | ||
| Dräger Interlock 2 | 83 | ||
| Problems with detachable vaporizer systems | 83 | ||
| Back bar working pressures | 83 | ||
| Additional safety features | 84 | ||
| Emergency oxygen | 84 | ||
| Oxygen failure warning devices | 85 | ||
| The Ritchie whistle | 85 | ||
| Current oxygen failure warning devices | 86 | ||
| Common gas outlet | 87 | ||
| Auxiliary gas sockets | 87 | ||
| Ventilators | 87 | ||
| Proportional flow valves | 87 | ||
| Integral breathing systems | 89 | ||
| Ergonomics | 90 | ||
| Standards | 91 | ||
| The critical incident (see also Chapter 29) | 91 | ||
| Alarms | 92 | ||
| Pre-use check | 93 | ||
| Specific machines | 94 | ||
| (Datex-Ohmeda) Aestiva/5, GE Healthcare | 95 | ||
| (Datex-Ohmeda) ADU, GE Healthcare | 97 | ||
| Dräger Primus | 97 | ||
| Dräger Zeus | 98 | ||
| GE Healthcare, Aisys | 103 | ||
| References | 105 | ||
| Further reading | 105 | ||
| 5 Breathing systems and their components | 107 | ||
| Chapter contents | 107 | ||
| Introduction | 107 | ||
| Definitions | 107 | ||
| Classification of breathing systems | 107 | ||
| Non-rebreathing systems | 108 | ||
| Systems where rebreathing is possible | 108 | ||
| Mapleson’s classification of breathing systems | 109 | ||
| Working principles of breathing systems | 109 | ||
| Mapleson A breathing system | 109 | ||
| Mapleson A system and controlled ventilation | 110 | ||
| Other Mapleson A breathing systems | 111 | ||
| The Lack co-axial breathing system (Fig. 5.7A) | 111 | ||
| Lack parallel breathing system (Fig. 5.7B) | 111 | ||
| Mapleson B and C systems | 112 | ||
| Mapleson D system | 112 | ||
| The Mapleson D system with spontaneous respiration | 112 | ||
| Mapleson D system with controlled or assisted ventilation | 113 | ||
| The Bain system | 115 | ||
| Hybrid systems | 115 | ||
| Mapleson E and F systems | 117 | ||
| The T-piece system | 117 | ||
| Controlled ventilation with the T-piece | 117 | ||
| The Rees T-piece (Mapleson F system) | 118 | ||
| Alternative classification for Mapleson type systems | 118 | ||
| Non-rebreathing systems utilizing carbon dioxide absorption and recirculation of gasses | 118 | ||
| Carbon dioxide absorption | 118 | ||
| Chemical composition of absorbents | 119 | ||
| Sodium/potassium | 119 | ||
| Barium | 119 | ||
| Water content | 119 | ||
| Other constituents | 119 | ||
| Zeolite | 119 | ||
| Silica | 119 | ||
| Calcium chloride | 119 | ||
| Granule size | 120 | ||
| Production | 120 | ||
| Absorptive capacity | 120 | ||
| The exothermic reaction | 120 | ||
| Classification of breathing systems utilizing carbon dioxide absorption | 121 | ||
| ’To-and-fro’ absorption systems | 121 | ||
| The Waters’ canister (Fig. 5.16) | 121 | ||
| Circle absorption systems | 122 | ||
| Apparatus dead space | 123 | ||
| Flow resistance | 124 | ||
| Efficiency of absorbers | 124 | ||
| Absorber switch | 124 | ||
| Ventilator switch | 125 | ||
| The use of ventilators with circle systems | 125 | ||
| ‘Bag squeezer’ | 125 | ||
| ‘Pneumatic piston’ | 125 | ||
| Turbine | 125 | ||
| Mechanical ventilation in circle systems | 125 | ||
| Control of minute ventilation | 125 | ||
| Maintenance of circle absorber systems | 126 | ||
| Gas and vapour concentration in a circle system | 127 | ||
| First stage | 127 | ||
| Second stage | 127 | ||
| Third stage | 127 | ||
| Oxygen concentrations in circle systems at low fresh gas flows | 127 | ||
| The use of volatile agents in the circle system | 128 | ||
| Vaporizer outside circle | 128 | ||
| Vaporizer in circle | 128 | ||
| Breathing systems with assisted circulation | 128 | ||
| Inspiratory assistance | 129 | ||
| Procedures for checking breathing systems | 129 | ||
| The components of a breathing system | 129 | ||
| Rebreathing and reservoir bags | 129 | ||
| Adjustable pressure limiting (APL) valves | 130 | ||
| The Humphrey APL valve | 131 | ||
| APL valves with in-built overpressure safety devices | 131 | ||
| Alternative APL valve design | 132 | ||
| Breathing hoses | 132 | ||
| Tapered connections (adapters) | 134 | ||
| Problems with tapered connections | 136 | ||
| Reuse of breathing system components | 136 | ||
| Further reading | 136 | ||
| Breathing systems | 136 | ||
| Classification of breathing systems | 136 | ||
| Mapleson A systems | 136 | ||
| Mapleson D, E and F systems | 136 | ||
| Rebreathing with Mapleson systems | 136 | ||
| Resistance to flow with Mapleson systems | 136 | ||
| Hybrid systems | 136 | ||
| Carbon dioxide absorption | 137 | ||
| Circle systems | 137 | ||
| Levels of anaesthetic agents in circle systems | 137 | ||
| Absorbers and absorbents | 137 | ||
| Carbon monoxide and compound A formation | 137 | ||
| Abnormal heat generation in circle systems | 137 | ||
| Apparatus | 138 | ||
| 6 Airway management equipment | 139 | ||
| Chapter contents | 139 | ||
| Fundamentals | 140 | ||
| Materials used in airway devices | 140 | ||
| Rubber | 140 | ||
| Plastics | 140 | ||
| Artificial airways | 140 | ||
| Terminology | 140 | ||
| Simple airway adjuncts | 141 | ||
| Oropharyngeal airway | 141 | ||
| Inserting the airway | 142 | ||
| Complications | 142 | ||
| Oropharyngeal airways for flexible endoscopic oral intubation | 142 | ||
| Nasopharyngeal airway | 143 | ||
| Complications | 144 | ||
| Facemasks | 144 | ||
| Specialized face masks | 146 | ||
| Flexible endoscopic intubation | 146 | ||
| Monitoring ventilation | 146 | ||
| Supraglottic airways | 146 | ||
| History | 146 | ||
| Features | 146 | ||
| Terminology | 146 | ||
| Pharyngeal seal and efficacy vs oesophageal seal and safety | 147 | ||
| First-generation SADs | 147 | ||
| The laryngeal mask airways | 147 | ||
| The LMA Classic | 147 | ||
| cLMA dimensions relevant for its use as a conduit | 148 | ||
| Inserting the LMA | 148 | ||
| Pre-use checks | 148 | ||
| Standard insertion | 148 | ||
| Alternative methods of insertion | 149 | ||
| Confirmation of correct placement | 149 | ||
| Indications for using the LMA: | 149 | ||
| Contraindications | 150 | ||
| LMA Flexible | 150 | ||
| Other ‘laryngeal masks’ | 151 | ||
| Cuff pressure monitoring | 151 | ||
| Intubating LMA | 152 | ||
| Other first-generation SADs | 152 | ||
| Laryngeal tube | 153 | ||
| CobraPLA | 153 | ||
| Second-generation SADs | 154 | ||
| LMA ProSeal | 154 | ||
| LMA Supreme | 155 | ||
| i-gel | 156 | ||
| Combitube | 156 | ||
| The Laryngeal Tube Suction mark II | 157 | ||
| SLIPA | 157 | ||
| Sads summary | 158 | ||
| Tracheal tubes | 158 | ||
| History | 158 | ||
| Design | 159 | ||
| Construction materials | 160 | ||
| Size | 161 | ||
| Adults | 161 | ||
| Children | 161 | ||
| Tracheal tube cuffs | 162 | ||
| High-pressure cuffs | 162 | ||
| Medium-pressure cuffs | 163 | ||
| Low-pressure or high-volume cuffs | 163 | ||
| Nitrous oxide and tracheal tube cuffs | 164 | ||
| Nasotracheal intubation | 165 | ||
| Common problems with the use of tracheal tubes | 165 | ||
| ISO connectors, angle pieces and catheter mounts | 167 | ||
| ISO connectors | 167 | ||
| Connectors and angle pieces | 167 | ||
| Catheter mounts | 167 | ||
| Tracheal tubes for special purposes | 168 | ||
| RAE preformed tubes | 168 | ||
| Reinforced tubes | 169 | ||
| Polar tubes | 169 | ||
| Microlaryngeal tube | 170 | ||
| Carden tube | 170 | ||
| Tubes for laser surgery | 170 | ||
| Mallinckrodt ‘Laser-Flex’ tracheal tubes | 170 | ||
| Foil wrapped | 171 | ||
| Jet ventilation | 171 | ||
| Tubes and catheters for ‘jet ventilation’ (high-pressure source ventilation) | 171 | ||
| Supraglottic ventilation | 171 | ||
| Transglottic ventilation – Hunsaker tube | 171 | ||
| Subglottic ventilation: transtracheal catheters | 172 | ||
| Laryngectomy tube | 172 | ||
| Tubes for thoracic surgery (including bronchial blockers) | 172 | ||
| (Endo) bronchial tubes | 172 | ||
| Tubes with bronchial blockers | 173 | ||
| Double lumen tubes | 173 | ||
| Sizes | 173 | ||
| Insertion | 174 | ||
| Tubes to assist intubation | 174 | ||
| Tubes with additional ports/lumens | 175 | ||
| LITA tube | 175 | ||
| Tubes for non-operative jet ventilation (e.g. intensive care) | 175 | ||
| Developments in tracheal tube and cuff technology for intensive care | 175 | ||
| Subglottic devices | 176 | ||
| Tracheostomy tubes | 176 | ||
| Percutaneous tracheostomy kits | 177 | ||
| Devices for cricothyroidotomy | 178 | ||
| Manujet ‘injector’ (VBM Medizintechnik) | 178 | ||
| Ravussin catheter | 178 | ||
| Melker cricothyroidotomy kits | 179 | ||
| Quicktrach | 179 | ||
| The Mini-Trach | 179 | ||
| Portex Cricothyroidotomy Kit (PCK) | 179 | ||
| Laryngoscopes | 179 | ||
| History | 180 | ||
| Retractor type laryngoscopes | 180 | ||
| Features of modern laryngoscopes | 181 | ||
| Single-use and reusable laryngoscope blades | 181 | ||
| Direct laryngoscopy | 182 | ||
| Polio laryngoscope | 183 | ||
| McCoy blade | 183 | ||
| Flexiblade | 183 | ||
| Rigid optical laryngoscopes | 183 | ||
| Bladed rigid optical laryngoscoscopes | 185 | ||
| Bullard laryngoscope | 185 | ||
| McGrath Series 5 | 185 | ||
| GlideScope | 185 | ||
| C-Mac | 186 | ||
| Conduit rigid optical laryngoscopes | 186 | ||
| Upsherscope | 186 | ||
| Pentax AWS | 186 | ||
| Airtraq | 187 | ||
| LMA CTrach | 188 | ||
| Optical stylets | 188 | ||
| Bonfils intubating fibrescope | 189 | ||
| The Shikani Optical Stylet and Levitan FPS (First Pass Success) | 189 | ||
| SensaScope | 189 | ||
| Further developments | 189 | ||
| Flexible endoscopes | 190 | ||
| Flexible fibreoptic laryngoscopes | 190 | ||
| Principles and design | 190 | ||
| Use | 191 | ||
| Video technology | 191 | ||
| Ambu aScope | 193 | ||
| Care of the flexible endoscope | 194 | ||
| Flexible endoscopic (‘fibreoptic’) intubation | 194 | ||
| Technique | 194 | ||
| Training | 195 | ||
| Associated equipment | 195 | ||
| Tracheal tubes | 195 | ||
| Bite blocks | 195 | ||
| Conduit oropharyngeal airways | 195 | ||
| Tongue forceps | 195 | ||
| Ventilation/intubation masks | 195 | ||
| Aintree Intubation Catheter (AIC) | 195 | ||
| Aids for intubation/ tube exchange | 196 | ||
| Bougies and stylets | 196 | ||
| Light wand | 197 | ||
| Trachlight | 198 | ||
| Airway Exchange Catheter (AEC) | 198 | ||
| Retrograde intubation | 198 | ||
| Miscellany | 199 | ||
| Magill’s forceps | 199 | ||
| Drug Delivery Systems | 199 | ||
| References | 201 | ||
| Further reading | 205 | ||
| 7 Equipment for the inhalation of oxygen and other gasses | 207 | ||
| Chapter contents | 207 | ||
| Introduction | 207 | ||
| Normobaric oxygen therapy | 207 | ||
| Low dependency systems | 207 | ||
| Variable performance devices | 208 | ||
| No capacity oxygen delivery devices | 209 | ||
| Low capacity oxygen delivery devices (capacity <100 ml) | 210 | ||
| Medium capacity oxygen delivery devices (capacity 100–250 ml) | 210 | ||
| High capacity oxygen delivery devices (capacity 250–2500 ml) | 210 | ||
| Very high capacity oxygen delivery devices (capacity >2500 ml) | 212 | ||
| Fixed performance devices | 213 | ||
| The Bernoulli effect and the Venturi principle | 213 | ||
| Medium dependency systems | 215 | ||
| High-dependency systems | 217 | ||
| Metered sources of oxygen and air | 217 | ||
| The administration of oxygen in a mixture of gasses | 217 | ||
| Entonox | 217 | ||
| The BOC Entonox valve | 217 | ||
| The Pneupac Entonox valve | 217 | ||
| Heliox | 217 | ||
| Oxygen delivery at high or low atmospheric pressures | 220 | ||
| Hyperbaric medicine | 220 | ||
| Diving | 220 | ||
| Mountaineering | 223 | ||
| References | 223 | ||
| 8 Manual resuscitators | 225 | ||
| Chapter contents | 225 | ||
| Components | 225 | ||
| The self-inflating bag | 225 | ||
| The respirable gas inlet | 225 | ||
| The non-rebreathing valve | 226 | ||
| Ambu single shutter valve (Figs 8.4A, B and C) | 226 | ||
| Laerdal pattern valve | 228 | ||
| Safety features incorporated into manual resuscitators | 229 | ||
| Other uses for manual resuscitators | 229 | ||
| Further reading | 230 | ||
| 9 Automatic ventilators | 231 | ||
| Chapter contents | 231 | ||
| Positive pressure ventilators | 231 | ||
| Methods of pressure generation | 232 | ||
| Classification of ventilators | 232 | ||
| Power | 232 | ||
| Low-powered ventilators | 232 | ||
| 10 Ventilation in the intensive care unit | 253 | ||
| Chapter contents | 253 | ||
| Introduction | 253 | ||
| Ideal requirements | 253 | ||
| Differences between ventilators for anaesthesia and intensive care | 254 | ||
| Driving mechanisms | 254 | ||
| Microprocessor electronic control | 255 | ||
| Information display | 255 | ||
| Inspiratory flow valve | 256 | ||
| Flow sensors | 257 | ||
| Patient triggering | 257 | ||
| Pressure triggering | 258 | ||
| Flow triggering | 258 | ||
| Neurally adjusted ventilatory assist (NAVA) | 258 | ||
| Expiratory pressure generation | 258 | ||
| Exhalation valves | 258 | ||
| Constriction type (scissor valves) | 258 | ||
| Diaphragm type – mechanically operated | 259 | ||
| Diaphragm type – pressure operated | 259 | ||
| Overpressure valves | 259 | ||
| Ambient air inlet | 260 | ||
| Nebulizer port | 260 | ||
| Battery back-up | 260 | ||
| Flow pattern generation/ventilation modes | 260 | ||
| Control and phase variables | 261 | ||
| Volume pre-set control mode | 261 | ||
| Pressure pre-set control mode | 261 | ||
| Other ventilator modes | 262 | ||
| Conditional variables | 262 | ||
| Controlled mandatory ventilation (CMV) | 262 | ||
| Intermittent mandatory ventilation (IMV) | 262 | ||
| Synchronous intermittent mandatory ventilation (SIMV) | 262 | ||
| Pressure support mode/spontaneous assist | 262 | ||
| Closed loop controlled ventilatory modes | 265 | ||
| Dual control mode | 265 | ||
| Volume support (VS) | 266 | ||
| Automode | 266 | ||
| Autoflow | 266 | ||
| Adaptive support ventilation (ASV) | 266 | ||
| Automatic tube compensation (ATC) | 266 | ||
| SmartCare | 266 | ||
| Individual ventilators | 266 | ||
| 900C | 266 | ||
| Servo-i and Servo 300 | 267 | ||
| Dräger Evita series (2 Dura, 4, XL) | 268 | ||
| Pneumatics (Fig 10.22B) | 268 | ||
| Non-invasive ventilation | 268 | ||
| High frequency oscillators | 270 | ||
| Summary | 272 | ||
| References | 272 | ||
| 11 Breathing filters, humidifiers and nebulizers | 275 | ||
| Chapter contents | 275 | ||
| Breathing system filters | 275 | ||
| Filtration and mechanisms of filtration | 275 | ||
| Mechanisms of filtration of gas-borne particles | 275 | ||
| a. Interception | 275 | ||
| b. Inertial impaction | 275 | ||
| c. Gravitational settling | 276 | ||
| d. Diffusion | 276 | ||
| e. Electrostatic attraction | 276 | ||
| Most penetrating particle size | 276 | ||
| Types of filter | 276 | ||
| Glass fibre filters | 276 | ||
| Electrostatic filters | 277 | ||
| 1. Tribocharged filters | 277 | ||
| 2. Fibrillated coronal-charged filters | 277 | ||
| Measuring the performance of breathing system filters | 277 | ||
| Humidifiers | 277 | ||
| Humidity | 277 | ||
| Humidification requirements | 278 | ||
| Humidification equipment | 278 | ||
| Passive humidification systems | 278 | ||
| 1. Heat and moisture exchangers (HMEs) | 278 | ||
| Classification of filters and heat and moisture exchangers | 280 | ||
| 2. Circle breathing systems | 280 | ||
| Active humidification systems | 282 | ||
| 1. Bottle humidifier | 282 | ||
| 2. Active heat and moisture exchanger | 283 | ||
| 3. Heated humidifiers | 283 | ||
| Nebulizers | 283 | ||
| 1. Gas-driven nebulizers | 284 | ||
| 2. Ultrasonic nebulizer | 284 | ||
| Deposition in the airways | 284 | ||
| Problems with filters, humidifiers and nebulizers | 286 | ||
| References | 286 | ||
| Further reading | 287 | ||
| 12 Equipment for paediatric anaesthesia | 289 | ||
| Chapter contents | 289 | ||
| Anatomical and physiological differences between adults and children | 289 | ||
| Anatomical differences in the airway between adults and children | 289 | ||
| Physiological differences in breathing between adults and children | 289 | ||
| Equipment | 290 | ||
| The anaesthetic machine | 290 | ||
| Transmission of infection | 290 | ||
| Regulation of equipment manufacture | 291 | ||
| Equipment for management of the airway | 291 | ||
| Facemasks | 291 | ||
| Tracheal tubes | 292 | ||
| Laryngeal Masks | 295 | ||
| Other supraglottic airway devices | 296 | ||
| Airway adjuncts | 296 | ||
| Tracheostomy tubes | 296 | ||
| Gaining access to the airway | 296 | ||
| The laryngoscope | 296 | ||
| The fibreoptic bronchoscope | 297 | ||
| Trans-illumination techniques | 298 | ||
| Alternative approach to the difficult airway | 298 | ||
| Anaesthetic breathing systems | 298 | ||
| Ideal airway and breathing equipment for paediatric anaesthesia | 300 | ||
| Breathing systems in use | 300 | ||
| Mapleson A | 300 | ||
| T-piece (Mapleson E and F) | 300 | ||
| Mapleson D | 301 | ||
| Humphrey ADE | 301 | ||
| Circle system | 301 | ||
| Breathing system humidification and filtration | 302 | ||
| Ventilators for use during paediatric anaesthesia | 302 | ||
| Mechanical thumbs | 303 | ||
| Bag squeezers | 303 | ||
| Hybrid systems: the Newton valve | 303 | ||
| Access to the circulatory system | 305 | ||
| Positioning, environmental control and temperature monitoring | 305 | ||
| Transfer of the critically ill child | 306 | ||
| Monitoring | 307 | ||
| Finally | 307 | ||
| Acknowledgements | 307 | ||
| References | 308 | ||
| Further reading | 309 | ||
| 13 Equipment for regional anaesthesia | 311 | ||
| Chapter contents | 311 | ||
| Nerve location devices | 311 | ||
| Ultrasound | 311 | ||
| Device specifics | 311 | ||
| Imaging modes used in ultrasound-guided regional anaesthesia | 312 | ||
| Controls | 312 | ||
| Transducers | 313 | ||
| Features | 314 | ||
| Image processing software | 314 | ||
| Image recording and remote viewing capability | 314 | ||
| On screen tutorials | 314 | ||
| Needle visibility | 314 | ||
| Adjuncts | 314 | ||
| Introduction of ultrasound imaging into clinical practice | 315 | ||
| Nerve stimulators | 315 | ||
| Needles and catheters | 316 | ||
| General considerations | 316 | ||
| Needle tip design | 316 | ||
| Stimulating needles | 316 | ||
| Catheters | 317 | ||
| Insertion | 317 | ||
| Design | 317 | ||
| Needle diameter and length | 317 | ||
| Spinal anaesthesia | 318 | ||
| Microspinal catheters | 319 | ||
| Epidural anaesthesia | 319 | ||
| Equipment for combined spinal/epidural (CSE) techniques | 320 | ||
| Ambulatory continuous infusions of local anaesthetic | 321 | ||
| Non-luer connectors | 321 | ||
| References | 321 | ||
| 14 Physiological monitoring: | 323 | ||
| Chapter contents | 323 | ||
| Introduction | 323 | ||
| Classification of monitoring equipment | 323 | ||
| Monitoring biological electrical potentials | 324 | ||
| The electrocardiograph (ECG) | 327 | ||
| Neuromuscular monitoring | 328 | ||
| Blood pressure monitoring | 329 | ||
| Non-invasive arterial blood pressure (NIBP) measurement | 329 | ||
| The sphygmomanometer | 330 | ||
| The oscillotonometer | 330 | ||
| Oscillometry | 331 | ||
| Peñaz volume clamp technique | 331 | ||
| Pulse oximetry | 332 | ||
| Principles | 332 | ||
| Limitations | 333 | ||
| Body temperature monitoring | 334 | ||
| References | 335 | ||
| 15 Physiological monitoring: gasses | 337 | ||
| Chapter contents | 337 | ||
| Respiratory gas sampling | 337 | ||
| Gas concentration monitoring | 338 | ||
| Refractometry | 338 | ||
| Infrared absorption spectroscopy | 339 | ||
| Mass spectrometry | 341 | ||
| Raman spectroscopy | 343 | ||
| The piezoelectric (Engstrom Emma) gas analyzer | 344 | ||
| The paramagnetic gas analyzer | 344 | ||
| Dräger PATO | 345 | ||
| Fuel cells and polarographic cells | 345 | ||
| Nitric oxide measurement | 346 | ||
| Measurement of respiratory volumes | 346 | ||
| Blood gas analysis | 346 | ||
| pH electrode | 347 | ||
| The Severinghaus pCO2 electrode | 348 | ||
| Derived variables from a blood gas machine | 348 | ||
| Temperature and blood gas analysis | 348 | ||
| Other ion-selective electrodes | 348 | ||
| Transcutaneous blood gas analyzers | 349 | ||
| Intravascular blood gas analyzers | 349 | ||
| The co-oximeter | 349 | ||
| References | 350 | ||
| Further reading | 350 | ||
| 16 Cardiac output monitoring | 351 | ||
| Chapter contents | 351 | ||
| Pulmonary artery catheter | 351 | ||
| Cardiac output (CO) with PAC | 353 | ||
| Modified pulmonary artery catheters | 353 | ||
| Limitations | 354 | ||
| Oesophageal doppler method for measurement of cardiac output | 354 | ||
| Doppler effect | 354 | ||
| CardioQ-ODM (Deltex Medical) | 354 | ||
| Aortic flow signal | 354 | ||
| The nomogram | 355 | ||
| Doppler probe | 355 | ||
| Probe insertion | 356 | ||
| Limitations | 356 | ||
| The CardioQ-ODM parameters | 356 | ||
| Corrected flow time (FTc) | 356 | ||
| Peak velocity (PV) | 356 | ||
| Mean acceleration (MA) | 358 | ||
| HemoSonic 100, Arrow Critical Care Products, USA | 358 | ||
| Arterial pressure waveform analysis | 358 | ||
| PiCCO2 (Pulsion Medical Systems) | 359 | ||
| Transpulmonary thermodilution | 359 | ||
| Additional variables | 359 | ||
| LiDCOplus and LiDCOrapid | 360 | ||
| Lithium dilution cardiac ouput | 361 | ||
| PulseCO continuous cardiac output | 361 | ||
| LiDCOrapid | 363 | ||
| FloTrac-Vigileo (Edwards Lifesciences, USA) | 364 | ||
| FloTrac algorithm | 364 | ||
| The NICOM | 364 | ||
| References | 366 | ||
| Further reading | 367 | ||
| 17 Depth of anaesthesia and neurophysiological monitoring | 369 | ||
| Chapter contents | 369 | ||
| Nerve stimulators | 369 | ||
| Assessment of neuromuscular blockade | 369 | ||
| Accelerometry/acceleromyography | 370 | ||
| Piezoelectric methods (‘Kinemyography’) | 370 | ||
| Other methods | 371 | ||
| Nerve stimulators for regional anaesthesia | 371 | ||
| Assessment of neural integrity | 371 | ||
| Peripheral/cranial nerves | 371 | ||
| Spinal cord/nerve roots | 371 | ||
| Somatosensory evoked potentials | 371 | ||
| Motor-evoked potentials (MEPs) | 372 | ||
| Monitoring ‘depth of anaesthesia’ | 372 | ||
| EEG | 373 | ||
| General principles, signal processing and artefact rejection | 373 | ||
| Time and frequency domain analysis and data presentation | 373 | ||
| Bispectral analysis and the EEG bispectral index | 374 | ||
| Other spontaneous EEG processing devices | 376 | ||
| Entropy | 377 | ||
| Auditory evoked potentials | 377 | ||
| aepEX monitor | 378 | ||
| Clinical use of depth of anaesthesia monitoring | 378 | ||
| Limitations | 379 | ||
| Pain measurement | 379 | ||
| Assessment of cerebral blood flow | 380 | ||
| Stump pressure | 380 | ||
| Transcranial Doppler technique (TCD) | 380 | ||
| SSEPs | 381 | ||
| EEG | 381 | ||
| Jugular bulb oximetry | 381 | ||
| Cerebral oximetry | 381 | ||
| References | 381 | ||
| Further Reading | 383 | ||
| 18 Atmospheric pollution | 385 | ||
| Chapter contents | 385 | ||
| Effects on the environment | 385 | ||
| Effects on individuals | 387 | ||
| Legislation | 387 | ||
| Control of pollution | 389 | ||
| The extent of pollution | 389 | ||
| Anaesthetic gasses and vapours | 389 | ||
| The employment of a scavenging system and its efficiency | 389 | ||
| Leakage | 390 | ||
| The efficiency of the air-conditioning system | 390 | ||
| The size of the premises | 390 | ||
| Measurement of pollution | 390 | ||
| Operating theatres | 390 | ||
| Theatre personnel | 390 | ||
| Scavenging systems | 391 | ||
| The collecting system | 391 | ||
| The transfer system | 392 | ||
| The receiving system | 392 | ||
| The disposal system | 392 | ||
| Active disposal systems | 392 | ||
| Passive disposal systems | 395 | ||
| Absorption systems | 395 | ||
| Other devices | 395 | ||
| References | 397 | ||
| Further Reading | 398 | ||
| 19 Infusion equipment and intravenous anaesthesia | 399 | ||
| Chapter contents | 399 | ||
| Evolution of infusion systems | 399 | ||
| Microprocessor controlled/ software driven | 400 | ||
| Simple infusion systems | 401 | ||
| Rapid infusion | 402 | ||
| Principles of infusion devices | 402 | ||
| The stepper motor | 402 | ||
| Infusion pumps | 403 | ||
| Cassette type | 403 | ||
| Peristaltic pumps | 403 | ||
| Syringe drivers | 404 | ||
| Rechargeable batteries | 404 | ||
| Safety | 405 | ||
| Error traps and drug libraries | 407 | ||
| Drug libraries (Fig. 19.12) | 407 | ||
| Bar code scanners | 407 | ||
| Line pressure limits | 408 | ||
| Electromagnetic interference | 408 | ||
| Target-controlled infusion (tci) | 408 | ||
| Key components | 409 | ||
| Diprifusor | 409 | ||
| Accuracy | 411 | ||
| Open label TCI | 412 | ||
| Other pharmacokinetic models | 413 | ||
| Future developments | 413 | ||
| Open TCI initiative | 413 | ||
| Experimental systems | 414 | ||
| Patient-controlled analgesia (pca) | 414 | ||
| Elastomeric pumps | 415 | ||
| Other non-electrically powered infusion devices | 416 | ||
| Autotransfusion | 416 | ||
| Related equipment | 416 | ||
| Filtration | 416 | ||
| Infusion lines | 417 | ||
| TIVAtrainer© | 418 | ||
| References | 419 | ||
| Further Reading | 420 | ||
| 20 Medical suction apparatus | 421 | ||
| Chapter contents | 421 | ||
| Main components | 421 | ||
| Energy source | 421 | ||
| Vacuum source | 421 | ||
| Pump types | 421 | ||
| Internal connections | 423 | ||
| Filter | 423 | ||
| Collection vessel | 423 | ||
| Suction tubing to disposal | 424 | ||
| Efficiency | 424 | ||
| Other components of suction apparatus | 425 | ||
| Vacuum control valve or regulator | 425 | ||
| Vacuum gauge | 425 | ||
| Cut-off over-flow valve | 425 | ||
| Foam prevention | 425 | ||
| Multiple collection vessels | 425 | ||
| The suction nozzle, catheter or hand-piece | 425 | ||
| Local vacuum units | 426 | ||
| Choice of suction apparatus | 426 | ||
| Standards and testing | 427 | ||
| Further Reading | 428 | ||
| 21 Cleaning, disinfection and sterilization | 429 | ||
| Chapter contents | 429 | ||
| Introduction | 429 | ||
| Risk assessment and the decontamination process | 429 | ||
| Terminology | 430 | ||
| Decontamination | 430 | ||
| Bioburden | 430 | ||
| Cleaning | 430 | ||
| Disinfection | 430 | ||
| Sterilization | 431 | ||
| Sterilant | 431 | ||
| Dry saturated steam | 431 | ||
| Infection control strategies | 431 | ||
| Factors to be considered | 431 | ||
| Single-use versus reusable anaesthetic equipment | 431 | ||
| Disinfection or sterilization | 432 | ||
| Centralization of decontamination services | 433 | ||
| Heat-labile instruments | 433 | ||
| Endoscope processing | 433 | ||
| Automated decontamination | 433 | ||
| Drying cabinets | 433 | ||
| Standard precautions | 435 | ||
| Tracking of reusable anaesthetic equipment | 435 | ||
| Damage caused by the decontamination process | 435 | ||
| Bacterial/viral filters and anaesthetic breathing systems | 436 | ||
| Prion disease | 436 | ||
| References | 437 | ||
| 22 Information technology and the anaesthetic workstation | 439 | ||
| Chapter contents | 439 | ||
| Record keeping | 439 | ||
| Functions of the anaesthetic record | 439 | ||
| Clinical communication | 439 | ||
| Audit | 439 | ||
| Education | 440 | ||
| Medicolegal | 440 | ||
| Research | 440 | ||
| Computerized anaesthetic records | 440 | ||
| Automatic data capture | 441 | ||
| Data entry | 441 | ||
| Other information and communication systems | 445 | ||
| Electronic prescribing | 445 | ||
| Decision support | 445 | ||
| Pharmacology display systems | 445 | ||
| Communication | 445 | ||
| References | 446 | ||
| 23 Electrical hazards and their prevention | 447 | ||
| Chapter contents | 447 | ||
| mains electricity supply | 447 | ||
| Pathophysiological effects of electricity | 448 | ||
| Accidents associated with the mains electricity supply | 449 | ||
| Electrocution | 450 | ||
| Microshock | 450 | ||
| Shock protection | 451 | ||
| Classification of electromedical equipment to ensure electrical safety | 452 | ||
| Class I equipment | 452 | ||
| Class II equipment (Fig. 23.10A) | 453 | ||
| Class III equipment | 453 | ||
| Type B equipment (Fig. 23.10B) | 453 | ||
| Type BF equipment (Fig. 23.10C) | 453 | ||
| Type CF equipment (Fig. 23.10D) | 454 | ||
| Burns | 454 | ||
| Sparks and static electricity | 454 | ||
| Fire and explosion | 455 | ||
| High oxygen partial pressure | 455 | ||
| Volatile anaesthetic agents and flammable solvents | 455 | ||
| Other causes of fire | 455 | ||
| Zone of risk | 455 | ||
| Classification of anaesthetic equipment and zone of risk (Fig. 23.11) | 456 | ||
| Anaesthetic-proof equipment (AP) | 456 | ||
| Anaesthetic-proof category G (APG) equipment | 456 | ||
| References | 456 | ||
| Further Reading | 457 | ||
| 24 Surgical diathermy | 459 | ||
| Chapter contents | 459 | ||
| Physical principles | 459 | ||
| Current density | 459 | ||
| Accidents due to diathermy | 461 | ||
| Electrical burns | 461 | ||
| Diathermy and laparoscopic surgery | 463 | ||
| Diathermy and pacemakers | 463 | ||
| Fires and explosions | 463 | ||
| References | 463 | ||
| Further reading | 463 | ||
| 25 Pacemakers and defibrillators | 465 | ||
| Chapter contents | 465 | ||
| Summary | 465 | ||
| Basic cardiac electrophysiology | 465 | ||
| Pacemakers | 466 | ||
| Introduction | 466 | ||
| The NASPE/BPEG code | 466 | ||
| Pacing terminology | 467 | ||
| Temporary pacing | 467 | ||
| Transvenous pacing | 467 | ||
| Transoesophageal and transgastric pacing | 468 | ||
| Transcutaneous pacing | 468 | ||
| Permanent pacing | 469 | ||
| Hardware | 469 | ||
| Software | 470 | ||
| Future directions | 470 | ||
| Vagal nerve stimulators | 470 | ||
| Defibrillators | 471 | ||
| Introduction | 471 | ||
| External defibrillation | 472 | ||
| The implantable cardioverter defibrillator | 472 | ||
| Hardware | 472 | ||
| Software | 473 | ||
| Future directions | 473 | ||
| Electromagnetic interference | 473 | ||
| References | 474 | ||
| further reading | 474 | ||
| 26 Lasers | 475 | ||
| Chapter contents | 475 | ||
| Principles | 475 | ||
| Clinical applications | 476 | ||
| Safety aspects | 477 | ||
| Anaesthetic-related risks | 478 | ||
| Safety codes | 478 | ||
| References | 478 | ||
| 27 Provision of anaesthesia in difficult situations and the developing world | 479 | ||
| Chapter contents | 479 | ||
| Difficult situations within hospitals | 480 | ||
| Radiology departments | 480 | ||
| Radiotherapy units | 480 | ||
| Magnetic resonance imaging (MRI) | 480 | ||
| Remote anaesthesia | 480 | ||
| Interhospital transfers | 481 | ||
| Developing countries | 481 | ||
| ‘District hospital’-based anaesthesia | 481 | ||
| Draw-over anaesthesia | 482 | ||
| Draw-over apparatus | 482 | ||
| Supplemental oxygen | 485 | ||
| Ventilators suitable for developing countries | 485 | ||
| Manley Multivent ventilator | 485 | ||
| Combination anaesthetic equipment | 485 | ||
| Universal Anaesthesia Machine (UAM) | 486 | ||
| Major accidents and disasters | 486 | ||
| The battlefield | 487 | ||
| Triservice apparatus | 488 | ||
| Pneupac compPac ventilator | 488 | ||
| Nuclear biological chemical (NBC) capability | 489 | ||
| Equipment for other battlefield anaesthetic techniques | 489 | ||
| Abnormal ambient pressures | 489 | ||
| Altitude | 489 | ||
| Hyperbaric chamber and anaesthetic equipment | 490 | ||
| Monitoring | 490 | ||
| Essential equipment to pack | 491 | ||
| References | 491 | ||
| Further reading | 491 | ||
| 28 The anaesthetist and the Medicines and Healthcare products Regulatory Agency | 493 | ||
| Chapter contents | 493 | ||
| Standards | 493 | ||
| Interrelationship of standards | 495 | ||
| CE marking | 495 | ||
| Competent authorities and notified bodies | 495 | ||
| Limitations of CE marking | 496 | ||
| Global harmonization | 497 | ||
| UK consumer advisory role | 497 | ||
| Adverse incident reportage | 497 | ||
| Safety advice | 498 | ||
| Other MHRA publications | 499 | ||
| One liners | 499 | ||
| Evaluation reports | 499 | ||
| Device bulletins | 499 | ||
| Annual adverse incident report | 499 | ||
| The anaesthetist’s role | 499 | ||
| Acknowledgements | 500 | ||
| Appendix 1 | 500 | ||
| Glossary | 500 | ||
| Appendix 2 | 501 | ||
| Adverse incident reporting | 501 | ||
| References | 501 | ||
| Further reading | 502 | ||
| 29 Error, Man and Machine | 503 | ||
| Chapter contents | 503 | ||
| Human factors in aviation | 503 | ||
| Understanding error | 504 | ||
| Root causes of adverse events | 505 | ||
| An example from aviation | 505 | ||
| Decision-making | 506 | ||
| Situational awareness | 506 | ||
| Fatigue, vigilance and arousal | 507 | ||
| Communication styles | 508 | ||
| The Shiva factor | 508 | ||
| Volant diagram | 509 | ||
| Error management | 509 | ||
| Barriers for safety | 510 | ||
| Checklists | 510 | ||
| An example from aviation | 510 | ||
| An example from anaesthesia | 511 | ||
| Conclusions | 511 | ||
| Appendix 1 | 511 | ||
| Glossary | 511 | ||
| References | 512 | ||
| Further reading | 512 | ||
| 30 Warming devices | 513 | ||
| Chapter contents | 513 | ||
| Background | 513 | ||
| Physical principles | 513 | ||
| Heat generation | 513 | ||
| Heat transfer | 514 | ||
| Conduction | 514 | ||
| Convection | 514 | ||
| Radiation | 514 | ||
| Evaporation | 514 | ||
| Thermal capacity | 514 | ||
| Insulation | 514 | ||
| Devices used to prevent perioperative hypothermia | 514 | ||
| Passive devices | 514 | ||
| Active devices | 515 | ||
| Circulating water devices | 515 | ||
| Carbon fibre and polymer devices | 515 | ||
| Forced-air warming blankets | 516 | ||
| Radiant heaters | 517 | ||
| Other devices | 518 | ||
| Locally applied warm water and pulsating negative pressure | 518 | ||
| Devices used to warm intravenous fluids | 518 | ||
| Forced-air/coil warmers | 519 | ||
| Plate warmers | 519 | ||
| Counter-current warmers | 519 | ||
| Infrared flow compensated fluid warmers | 521 | ||
| High-flow fluid warmers | 521 | ||
| References | 523 | ||
| Further Reading | 523 | ||
| 31 Physics and technology of ultrasound | 525 | ||
| Chapter contents | 525 | ||
| What is ultrasound? | 525 | ||
| Pulse echo principle | 526 | ||
| The ultrasound transducer | 527 | ||
| Image formation | 527 | ||
| The ultrasound journey | 529 | ||
| Speckle | 530 | ||
| Attenuation | 530 | ||
| Time gain compensation | 530 | ||
| Poor visualization | 532 | ||
| Resolution | 532 | ||
| Electronic focusing | 533 | ||
| Slice thickness | 533 | ||
| Artefacts | 534 | ||
| Shadowing (Fig. 31.15) | 534 | ||
| Post cystic enhancement (Fig. 31.15) | 534 | ||
| Reverberation (Fig. 31.15) | 535 | ||
| Mirror artefact (Fig. 31.17) | 535 | ||
| Slice thickness artefact (Fig 31.18) | 535 | ||
| Refraction (Fig. 31.19) | 535 | ||
| Viewing anatomical structures | 536 | ||
| Compound mode | 536 | ||
| Harmonic imaging | 537 | ||
| Colour Doppler ultrasound | 538 | ||
| Colour power Doppler | 539 | ||
| Further reading | 539 | ||
| Appendix SI units and conversion tables | 541 | ||
| SI units | 541 | ||
| Conversion tables | 544 | ||
| French/Gauge | 544 | ||
| Further Reading | 545 | ||
| Index | 547 | ||
| A | 547 | ||
| B | 549 | ||
| C | 550 | ||
| D | 552 | ||
| E | 554 | ||
| F | 555 | ||
| G | 556 | ||
| H | 557 | ||
| I | 558 | ||
| J | 560 | ||
| K | 560 | ||
| L | 560 | ||
| M | 561 | ||
| N | 562 | ||
| O | 564 | ||
| P | 564 | ||
| Q | 568 | ||
| R | 568 | ||
| S | 569 | ||
| T | 571 | ||
| U | 572 | ||
| V | 573 | ||
| W | 574 | ||
| X | 574 | ||
| Y | 574 | ||
| Z | 574 |