Best Practice Guidelines for Checking the Avance CS2 Carestation

Description This document describes the NZATS best practice guidelines for
checking an Avance CS2 Carestation anaesthetic machine.

LEVEL 2 MACHINE CHECK

PRELIMINARY 1. Check bulk gas warning lights / medical gas alarm panel is
CHECKS functioning.
2. Check resuscitation device for leaks; check all valves function
correctly; confirm device has a re-breathing bag and oxygen
tubing attached.
3. Turn patient monitor ON.
4. Turn scavenging on and ensure ball float is in green zone
5. Check machine is plugged into an un-interrupted power supply
and/or that battery is charging.
6. Check machine moves freely.
7. Check service dates on machine and vaporisers
8. Turn ‘systems switch’ ON.
9. Check gas sampling line is clean and free from defects.
10. Check patency of D-Fend water trap if present.
11. Depress condenser drain button to drain condensate.

AVANCE CS2 1. Ensure filter, gas sampling line and correctly assembled circuit is
ELECTRONIC attached to the breathing system.
CHECK 2. In Checkout menu select Full Test
3. Perform the following electronic checks and follow the onscreen
instructions:
 Vent and gas

 Circuit leak

If you have an O2 cell in situ then complete this test

 Circuit O2 cell…wait until O2 stabilizes at 21% +/-1

 then press DONE

Green light indicates the machine is fully functional

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Guidelines for checking Avance CS CarestationNSG – NZATS website - updated September 2014
 4. Note: this set of tests checks the bag/vent switch; driving gas;
ventilator (under high pressure); flow sensors; circuit leaks; circuit
compliance: batteries and electronics

5. Bag/Vent switch back to Bag

HIGH PRESSURE SYSTEM CHECKS

LEAK TEST 1. Disconnect all wall gas supplies.

& ONE GAS TESTS 2. Open ALL gas cylinder valves until pressure is registered in the
Gas Supplies kPa window on the Ventilator Control Panel (VCP)
and then close valves.
Observe that the pressure does not drop confirming that no leak is
present.
3. Select ACGO and attach the filter with the gas sampling line to the
ACGO.
4. Open oxygen cylinder:
5. Select start case – Start Case Now and observe oxygen flow is
6 L/min.
6. Check pressure registers above 5000 kPa and analyse contents.
Gas analysis should confirm 100% oxygen (+/- 3).
Close oxygen cylinder and drain oxygen from machine using
oxygen flush.
7. Check in Alarm Setup on the VCP that the low oxygen alarm is
set to 18% or higher.

If an air cylinder is present:

Open air cylinder.
a. Check contents above 5000 kPa.
b. Select Yes to use Air Only in the O2 Supply Fail menu.
c. The Gases % window on VCP should confirm 21% oxygen
(+/- 3).
d. Close air cylinder and drain machine of air.
If a nitrous oxide cylinder is present:
o Open nitrous oxide cylinder. Ensure nitrous oxide is available by
confirming pressure of nitrous oxide.
Check no nitrous oxide detected in Gases % window on VCP.
o Analyse contents as follows:
a. Turn ON the oxygen cylinder
b. Select Gas Setup on VCP.
c. Select Yes for End Air Only if applicable and re-select
Gas Setup.
d. Select N2O and O2% 50 and then Close.
e. Set oxygen and nitrous oxide flows to 2 L.
Analyse gas observing for 50% oxygen: 50% nitrous oxide
reading on VCP (+/- 3).
f. Turn OFF nitrous oxide cylinder and drain.
g. Select O2 and turn up to 100%
h. Turn OFF oxygen cylinder and drain.
o If only one cylinder key available – leave on the oxygen cylinder.

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 LOW PRESSURE SYSTEM CHECKS

ONE GAS TESTING

1. Plug oxygen probe into wall supply and tug test.
2. Confirm oxygen supply reads approximately 410 kPa
3. Confirm 100% oxygen (+/- 3) on VCP.
4. Check auxiliary oxygen supply – test flowmeter to maximum
flows.
5. Disconnect oxygen wall supply and drain machine using oxygen
flush.
6. Plug medical air probe into the wall supply and tug test.
7. Confirm medical air supply reads approximately 410 kPa.
8. Select Yes to use air only
9. Confirm 21% oxygen (+/- 3) on VCP.
10. Disconnect medical air probe at wall and drain machine of gas.
11. Plug nitrous oxide probe into wall supply and tug test.
12. Confirm nitrous oxide supply reads approximately 410 kPa.
13. Check no nitrous oxide detected in Gases % window on VCP.
14. Re-connect oxygen wall supply, select Gas Setup and select Yes
for End air only.
15. Re-select Gas Setup and select N2O and then Close.
16. Set oxygen to 50% (at 2 L/min gas flow). Confirm a 50% oxygen /
50% Nitrous Oxide mix on the VCP and patient monitor ( +/- 3 %).

ANTI-HYPOXIC 1. Change oxygen to 25%.

DEVICE TEST 2. Confirm with gas analysis on the VCP and patient monitor that no
less than 25% oxygen can be delivered.

OXYGEN FAILURE 1. Set oxygen flow to 8 L/min

ALARM TEST 2. Disconnect oxygen wall supply.
3. Confirm nitrous oxide supply is cut off and that audible oxygen
failure alarm is sounding.
4. Confirm VCP displays “O2 supply pressure low”.
5. Re-connect wall supplies of all gases and tug test pipeline
connections – including scavenging and suction.
6. Re-confirm pressure display registers gas supply.

ALTERNATIVE 1. Turn on alternative flow and set oxygen flow meter to 6 L/min,
OXYGEN CHECK confirm gas analyser reads 100% +/- 3% on VCP and patient
monitor.
2. Select End Case – End Case Now.
3. Select Checkout button.
EMERGENCY 1. Attach 2 L reservoir bag to the ACGO.
OXYGEN FLUSH 2. Using the oxygen flush fill the reservoir bag and observe that it
fills within 4 seconds indicating a 35-70 L/min delivery of oxygen.
3. Remove the reservoir bag.

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VAPORISER & BACK 1. Check vaporisers are correctly seated and locked in position
BAR TESTS 2. Check contents of each vaporiser.
3. Check filling ports closed.
4. Select start case Set the oxygen flow to 6 L and check
vaporisers for obstructions. Turn the 1st vaporiser on to 1% slowly
whilst observing that oxygen bobbin does not fall more than
1L/min flow rate. Repeat on 2nd vaporiser.
5. Check dial turns to maximum setting for each vaporiser.
6. Test interlock system for each vaporiser.
7. Select End Case – End Case Now.
8. Select Checkout and then Low P Leak and follow the onscreen
instructions.
For the Tec 6 and Tec 6 plus vaporiser a setting of 12% should be
used instead of the suggested 1%.
9. Select Pass or Fail whichever appropriate and then select Back.
10. Switch AGCO to circle.

CIRCUIT AND Absorber checks

ABSORBER TESTS
1. Check colour of soda lime.
2. Take the absorber ‘out of circuit’.

Circuit checks

1. Connect circuit and attach breathing filter to distal end. Connect

reservoir bag to filter.
2. Extend circuit tubing out and ensure it is clean and correctly
connected to machine.
3. Select Start Case – Start case Now, then End Case – End Case
Now to observe circuit pressure gauge on VCP.
4. Close APL valve. Pressurise the circuit using the ‘oxygen flush’
until the airway pressure gauge reads just above 30 cm H2O.
Allow pressure to settle and confirm pressure holds for at least 5
seconds.
5. Replace absorber canister “in circuit”, ensuring it is seated
correctly.
6. Re-pressurise circuit as in 5. and confirm pressure holds for at
least 5 seconds.
7. Open APL valve. Observe passive spilling of the reservoir bags
but ensure bags do not empty completely confirming that
scavenging is patent but not overactive.
8. Close APL valve. Squeeze both bags alternately ensuring free
movement of the uni-directional valves and ensure that no
resistance detected in the circuit.
9. Open APL valve and squeeze both reservoir bags simultaneously
ensuring even and easy gas spill.

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VENTILATOR TESTS 1. Set the Bag/Vent switch to Vent
2. Fill the bellows using the oxygen flush.
3. Observe bellows do not drop for 10 seconds.
4. Select Start Case – Start Case Now
5. Scroll to set oxygen flow at basal rate.
6. Set the ventilator settings as follows (or as per hospital protocol)

Mode: Volume control

Tidal volume: 500 mls
Rate: 12 / min
I:E ratio: 1:2
P limit: 40 cms H2O
PEEP: Off

7. Set the Bag/Vent switch to ‘Bag’ and then reset back to ‘Vent’ to
start the ventilator cycling.
8. Ensure:
o The bellows cycle during mechanical ventilation
o End tidal volume Vte reaches set tidal volume Vt
(+/- 10%) within 6-8 breaths. (to see Vte select the
Spirometry button)

High pressure alarm

1. Squeeze reservoir bag to simulate high airway pressure. Confirm
that ‘Ppeak high’ (high airway pressure) appears on VCP and that
an audible alarm sounds.
2. Re-fill bellows using oxygen flush and cycle ventilator for 2-3
breaths to ensure bellows not unseated.

Low pressure alarm

1. As ventilator cycles, remove reservoir bag from circuit. Confirm
‘Unable to drive bellows’ appears on the VCP and that an audible
alarm sounds. Ensure VCP then displays ‘Ppeak low. Leak?’’ and
that the audible alarm recommences.

o Return Bag/Vent switch to Bag.

o Select End case – End Case Now.
o Select Checkout to display COMPLETED CHECKS
o Attach appropriate face mask.
o Confirm APL valve open.

Ensure machine
ready for use

SUCTION CHECKS 1. Check suction tubing is clean and is approximately 2-3 M long.
2. Check suction unit is assembled correctly.
3. Turn suction on to ‘max’ setting and listen to flow to confirm
system patent from suction tip to suction gauge. After 3 seconds
occlude suction tubing and ensure a negative pressure of
approximately -60 kPa is achieved within 10 seconds.
4. Check regulator is functioning correctly on ‘min’ setting by
ensuring suction pressure can be regulated from minimum to
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Guidelines for checking Avance CS CarestationNSG – NZATS website - updated September 2014
 maximum pressures.
Confirm regulator is set to maximum

1. Pulse oximetry present and functioning

MONITORING 2. ECG leads present
EQUIPMENT 3. Blood pressure cuff present – appropriate size for patient
CHECKS 4. Temperature probe and cable available
5. Stethoscope present
6. Nerve stimulator available
7. Pressure cables available

All equipment must be clean.

AIRWAY 1. Check for the presence and function of 2 laryngoscopes blades –

EQUIPMENT sizes appropriate to patient.
CHECKS 2. Check availability of following essential items:
a) Bougies & stylets
b) Selection of oropharyngeal airways
c) Syringe
d) Selection of LMA sizes
e) Selection of endotracheal tube sizes
f) Magill’s forceps

EMERGENCY 1. Check suxamethonium available and date check as per hospital

DRUGS protocol
CHECK 2. Check emergency drugs well stocked – including adrenaline,
amiodarone, atropine.

1. Check intravenous cannulation and infusion equipment available

2. Check infusion pumps available and check service dates
ANCILLARY 3. Check warming equipment available and check service dates
EQUIPMENT
CHECKS
DOCUMENTATION Sign / date machine checklist as per hospital policy
1. Clean machine as per hospital protocol.
PROCEDURE FOR 2. Turn machine OFF
END DAY 3. Turn scavenging OFF (if this function available)

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 LEVEL 3 MACHINE CHECK
This check is to be completed immediately before commencement
of each anaesthetic.

CIRCUIT CHECKS Check any changed or new items in the breathing circuit: filters,
angle pieces, catheter mounts etc

Circuit checks

1. Attach new breathing filter to distal end of circuit and connect

reservoir bag to filter.
2. Extend circuit tubing out and ensure it is clean and correctly
connected to machine.
3. Select Start Case – Start Case Now, then End Case – End
Case Now if circuit pressure gauge is not visible on VCP.
4. Close APL valve. Pressurise the circuit using the ‘oxygen flush’
until the airway pressure gauge reads just above 30 cm H2O.
Allow pressure to settle and confirm pressure holds for at least 5
seconds.
5. Open APL valve. Observe passive spilling of the reservoir bags
but ensure bags do not empty completely confirming that
scavenging is patent but not overactive.
6. Close APL valve. Squeeze both bags alternately ensuring free
movement of the uni-directional valves and ensure that no
resistance detected in the circuit.
7. Open APL valve and squeeze both reservoir bags simultaneously
ensuring even and easy gas spill
If a vaporiser is changed between cases, perform the following checks as
VAPORISER per Level 2 guidelines.

1. Check vaporisers are correctly seated and locked in position

2. Check contents of each vaporiser.
3. Check filling ports closed.
4. Select Start Case—Start Case Now Set the oxygen flow to 6 L and
check vaporisers for obstructions. Turn the 1st vaporiser on to 1%
slowly whilst observing that oxygen bobbin does not fall more than
1 L/min flow rate. Repeat on 2nd vaporiser.
5. Check dial turns to maximum setting for each vaporiser.
6. Test interlock system for each vaporiser.

SUCTION TESTS Replace used suction items: yankauer sucker, suction catheter,
suction tubing, suction liner and re-check as follows;

1. Check suction tubing clean and is approximately 2-3 M in length.

2. Check suction unit is assembled correctly.
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 3. Turn suction on to ‘Max’ setting and listen to flow to confirm
system patent from suction tip to suction gauge. After 3 seconds
occlude suction tubing and ensure a negative pressure of
approximately -60 kPa (500 mmHg) is achieved within 10
seconds.

MONITORING Ensure all monitoring is cleaned between patients as per hospital

protocol.

1. Check Pulse oximetry present and functioning

2. ECG leads present
3. Blood pressure cuff present – appropriate size for patient
4. Temperature probe and cable available
5. Stethoscope present
6. Nerve stimulator available
7. Pressure cables available

AIRWAY Replace all soiled/disposable airway equipment and perform the following
EQUIPMENT checks as per the Level 2 guidelines:

1. Check for the presence and function of 2 laryngoscopes blades –

sizes appropriate to patient.
2. Check availability of following essential items:
a) Bougies & stylets
b) Selection of oropharyngeal airways
c) Syringe
d) Selection of LMA sizes
e) Selection of endotracheal tube sizes
f) Magill’s forceps

DRUGS Check suxamethonium and emergency drug levels adequate. Ensure

adequate stock of all other drugs.

OTHER o Re-confirm resuscitation device present.

o Trainee will be expected to demonstrate appropriate hand

hygiene during Level 2 & 3 checks.

These guidelines have been written by the NZATS for NZATS Approved
Training Hospitals throughout New Zealand. They detail the minimum
standard expected in the conduct of Level 2 and Level 3 machine checks
before and during an anaesthesia session.

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Guidelines for checking Avance CS CarestationNSG – NZATS website - updated September 2014