Disclaimer: This article represents the personal opinions of the author, Dr John Oyston. They are NOT the official opinions of the Anesthesia Department or the hospital in which he works. The information presented is based on over two years using the machine in a busy community hospital, discussion with other users, and on correspondence and meetings with Siemens employees up to the level of Heidi Hughes, International Product Manager, Anesthesia Systems, Siemens Elema AB, Solna, Sweden. Any errors or omissions are the sole responsibility of the author, Dr John Oyston. The comments refer to the version of the KION machine, marked SC9000XL, currently installed in a Canadian hospital. Later or different versions of the machine may not have all the issues noted. Some similar issues may be associated with the KION Infinity Advantage monitoring system. The author's previous experience was mainly with Datex AS/3 monitors and Drager Narkomed II machines. As a result, this review mainly compares the KION with those machines, which were common in Southern Ontario in the late 1990s. This material is copyright © Dr John Oyston, 2001, 2002. You may print one copy for your personal or departmental use. MANUFACTURERS OF RIVAL PRODUCTS ARE SPECIFICALLY PROHIBITED FROM USING THIS INFORMATION AS " NEGATIVE ADVERTISING ".

INDEX Exterior Noises Knobs and Ventilation Modes Ventilation Settings Vaporizers Pressure Limits Monitor Non-invasive blood pressure Alarms in profusion Default Alarms Trends Duoview Printer KION Web pages Good points about the KION CONCLUSION Responses from Siemens Update, August 2002 Background

Exterior
The first problem is to decide which way around to set up the machine. Siemens says that the "front" is the side with the drawer, shelf and label, as shown in the diagram (above right). The turret, with the CO2 absorber and ventilator is then on your left, and the monitor/control panel swings around the base of the turret. The monitor/control panel is shown twisted round to the user's right, so that it prevents access to the work area behind it. I find it impossible to work with the machine in this position. The monitor/control panel can be rotated around to the left, where it will be near the patient's head. It gets in your assistant's way during intubation, and in the surgeon's way if he/she wants to operate on that area.

I usually rotate the machine so the "front" faces towards the patient, and I am working from the machine's "left" side, as in the photograph on the right. In this position the O2 flush is hidden from my view behind the bellows. Inaccessibility of the O2 flush button was the subject of a case report in the French literature (P. Diemusch et al. A propos de trois problemes. Ann Fr Anesth Reanim 2000;19:140-2). (Siemens says that the flush button is accessible when using the machine in their standard position. A machine which can be used in several configurations could have more than one O2 flush button, just as some cars have four buttons which activate the horn.)

Behind the 02 flush there is a switch which can add 5 litres per minute of oxygen to the fresh gas flow. It is intended as an emergency oxygen supply in the event of a catastrophic or general electrical failure. The extra O2 flow does not show up on the electronic rotameter display. As inadvertently operating this switch could result in unanticipated light anesthesia, it should be more visible, and using it should trigger a warning on the monitor. (Siemens says that the machine will fail its pre-use test if this switch is on. Also, that the FiO2 and other parameters will change in this situation.)

KION Quick Visual Quiz
HOW MUCH OXYGEN IS THERE IN THE FRESH GAS FLOW?
	The virtual flow meter shows a FGF with one liter of oxygen per minute, and 2.5 liters of nitrous oxide, so the percentage oxygen seems to be under 30%
	But the emergency oxygen supply is adding another five litres, for a total of 6 litres oxygen, so the percentage oxygen is actually over 70%. This could result in unintentionally light anesthesia or awareness.

There is one drawer, a small work surface, and a small pull-out shelf. Extra shelving is available as an option. The Drager Narkomeds we used to use had two drawers, two shelves, and space for additional equipment on top of the monitors.

In an attempt to reduce the usual tangle of wires in the OR, the KION bundles the ECG and pulse oximeter wires into a single cable, which ends in a bulky junction box near the patient. Personally, I do not find this an improvement. A truly innovative response to the problem would be to use a wireless link between the patient and the anesthesia machine.(Siemens says it is difficult to use wireless technology in the OR. They suggest hanging the cord from a special hook, rather than winding it up.)

The connector for the pulse oximeter can be inadvertently connected upside down, so the pulse oximeter does not work, even though it seems to be connected. (A letter about this was published in the February 2001 Canadian Journal of Anesthesia, Vol 48 No 2 Page 215. Siemens says that the patient end is a standard Nellcor product, and that an adequately trained person would not make this error).

KION Quick Visual Quiz
WHICH WAY UP DOES THE SATURATION PROBE CONNECTOR GO?
	This way?
	..or this way?
	The second way is incorrect. Note that the blue patient end protrudes, and that the blue clamp is elevated at the patient end, when the connector is put in upside down.

Noises
Like may anesthetists, I rely on sounds in the OR to provide auditory patient information no matter where I am in the room, or which direction I am looking in. I want to be able to detect changes in the pulse oximeter tone, or the ventilator's sound, during the course of an anesthetic. Unfortunately, the KION vaporizers make a soft regular hissing sound every few seconds which I find annoying and distracting. Turning off all the vaporizers does not get rid of the sound. It is, apparently, an integral part of the design.

The ventilator is too quiet for my taste. I have to bend down to see the bellows, or check the end-tidal CO2 monitor, to determine that the patient is breathing. Siemens say that in their experience, "clinicians" have complained about ventilators being "too noisy and often distracting", and requested a quieter one. Siemens' advisers "felt that it was adequate enough to be able to see the bellows moving up and down", and that I should rely on the monitors and alarms to be sure that the ventilator is working correctly. In my opinion, the only sound in an operating room which could be considered more important than the sound of the ventilator is the beep of the pulse oximeter.

The KION pulse oximeter has a lower tone to represent 99 - 100% O2 saturation than the Datex. It is a shame the tones could not be standardized. Some users have reported that it is more difficult to detect changes in oxygen saturation with the KION monitor than with the Datex one.

Knobs and Ventilation Modes
There are three main knobs used to set up the ventilator. Setup begins at the bottom right of the control panel and moves up and to the left. Most of us are more used to working down and to the right, like reading a book.

The bottom right knob is "On|Standby|Off" which is pretty straightforward. There is a warning exclamation mark in a triangle by the "On" mark. This "implies that you should not turn the machine "ON" without having read the Operating Instructions" (Siemens).

The next knob seems to give three choices "Circle|Non-rebreathing|Auxiliary fresh gas outlet". The knob can be set to "non-rebreathing", even though this option is not available yet. (UPDATE: Rebreathing is now available.)

The knob cannot be turned to the "Auxiliary gas outlet". That is why there is no "directional line" going to it. The auxiliary gas outlet (for use with a Bain or Ayres T Piece circuit) is actually activated by a little flap lever next to the outlet. This then turns on the little indicator (not warning) light by the knob, which is cunningly disguised as an optional position for the knob. Lifting the flap lever during a case (perhaps in an attempt to release the CO2 absorber) does not trigger an alarm, but does redirect all the FGF away from the circuit in use to the auxiliary gas outlet. A textbook case of designing something in such a way as to obscure its function. I do not think the KION got its design award from anesthesiologists! (Siemens feels that this would not be a problem for an adequately trained person.)

The next knob up has four possible positions, labelled "Manual Ventilation|Volume Control|Pressure Support|Pressure Control". However, Pressure support is not available on our machine and the knob will not stay in this position. There are yellow indicator lights by the two modes which require patient triggering of ventilation.

Once pressure support is available, it may prove useful, for example with patients using a laryngeal mask airway. Some people say pressure control will be useful in pediatric anesthesia. (UPDATE: Pressure support is now available.) Personally I would rather dial the tidal volume and set a pressure limit than risk having changes in compliance result in large changes in tidal volume. (This problem, with a Datex ADU, was the subject of a letter, "Unusual cause of volotrauma", by Wong and Shirzad, CJA, Oct 2000, 47:10;1046.) Incidently, there is no "High Minute Volume" alarm.

KION Quick Visual Quiz
WHERE IS THE FRESH GAS FLOW GOING?
	The knob is pointing to the circle system ..
	..but the auxiliary fresh gas flow is open, so the fresh gas is going there. Note the yellow light is on beside "Auxiliary fresh gas outlet", which is the only easily visible clue.

Ventilation Settings
The KION requires you to set a Fresh Gas Flow, %O2 and choose between O2/Air and O2/N2O mixes. It's nice to have air, but I find this system slightly more confusing than dialing up each gas. However, Siemens's advisers felt this system is more accurate.

Vaporizers
There are three vaporizers slots. Halothane, Isoflurane, and Sevoflurane vaporizer are available.(UPDATE: Desflurane vaporizer is now available.) The vaporizers are colour-coded, which is just as well, as on some models the agent names are only printed on the side, not on the front. Those who have got used to the ability of a Datex AS/3 to measure mixed agents will be disappointed - if you change agents the KION just says "Agent Mix" and does not measure either agent until one has cleared the system, which can take up to thirty minutes at low flow. (Siemens says that 5 minutes at five litres flow is enough to flush the system, and that the agent mix can de determined by looking at the waveform.)

Want to check that you turned all the vaporizers off? You have to rotate the turret so you can see each one in turn. (Seimens suggests attempting to turn on the vaporizer in front of you. If you can do this, all the other vaporizers must be off, because of the interlock system. This is quite an ingenious work-around, if you have complete faith in the interlock system). The turret is a fancy design feature, but I think it decreases useability (but others say it's neat). Personally I think the fact you can turn on a vaporizer, then hide it from view, is dangerous.

KION Quick Visual Quiz
HOW MUCH OF WHICH VOLATILE AGENT IS ENTERING THE FRESH GAS FLOW?
	The Isoflurane vaporizer is off.
	..but the Sevoflurane vaporizer, around the corner, is cranked up to 5%. This would, of course, show up on the agent monitor. However, if called in to assist a colleague with a hypotensive patient, my inclination would be to scan the vaporizers, and if all I could see was one set to zero, assume that the patient was not getting a volatile agent.

Pressure Limits
The APL valve is nice, and has calibrations on it (although the markings are difficult to see when standing by the patient). However, there is also an "Upper pressure limit" control on the control panel as well, so you can have the APL valve screwed down to the 90 mark but still find you can only generate 40 cm water pressure! To adjust this second pressure limit above 40 you have to press a central button and turn the dial. (This is a standard feature of Seimens' ICU ventilators. Also, this situation is not unlike the Norrie blow-off valve used by some pediatric anesthesiologists). Personally, if I am handbagging the patient with a mask I sometimes need high inflation pressures to overcome laryngospasm, and feel the Upper Pressure Limit valve should be disabled during manual ventilation, so there is only one pressure-limiting valve in the circuit at any time.

KION Quick Visual Quiz
WHAT IS THE PRESSURE LIMIT ON THE CIRCUIT?
	The main APL valve is set to 70		..but the Upper Pressure Limit on the control panel is set to 40, so this is the pressure limit on the circuit. To get a higher pressure, you must depress the small, inconspicuous orange button on top of the knob and turn the knob clockwise

Monitor
There are many issues related to the monitor.

Distracting messages

A basic concept of interface design is that flashing information is important information. So what messages are flashing continually during most cases?
"RESP: No parameter box available"
"Vol: No parameter box available"
Even when you understand what this means (that the machine has this information, but has no space to display it), it is still useless information and should not be flashing at you.

Colour Coding of Data

It is not possible to specify what colour each variable is displayed in. The ECG is always green. And the CO2 is yellow, even if it is next to Sevoflurane, which is also yellow. The KION has stepped back to Henry Ford's time. You can have the NIBP displayed in any colour you like, as long as it is white.

White is used for too many of the digit fields. In a typical case I have 22 white numbers, six yellow numbers, two green numbers, and no blue or red numbers on screen. The SpO2, NIBP, and Inspired O2 are all in white, which I find a little confusing. I think each vital sign should have its own distinctive colour, which can be set by the user.

Priority Choices

Instead of deciding what parameter should be in each waveform and digit field, one has to prioritize the data, and select the number of waveforms to be displayed. The monitor then puts the data in order of priority on the screen, displaying as many waveforms as possible, then putting lower priority items in the digit fields at the bottom of the screen. This is awkward and does not work well.

Fixed Keys and "Help"

The Datex AS/3 monitor has six blue keys for various monitoring parameters such as Airway Gases and Non-Invasive BP. Clicking on any key produces an appropriate menu. The equivalent menus on the KION are accessed by rotating the blue knob until the relevant parameter values are highlighted on the screen, then clicking. This adds between one and eight steps to the process.

There are several buttons on the right of the monitor, with functions such as "Print Screen". Some are less useful than others. "Code" opens up a stopwatch.
One fixed key is labelled "Help", but, frankly, it does not. To use it:

1. Press "Help"
2. Press blue knob again to select "Fixed Keys". (The other options are "Locked options", which are locked, and "KION status" which just gives access to power source and battery charge information.)
3. Press blue knob again
4. A picture of the monitor appears with the message "Returns to previous menu" on the bottom. This is not easy to understand
5. Rotate the blue knob
6. As each Fixed Key is highlighted, a very brief description of the function of each key appears.

If you could figure out how to use the Help menu, you already knew enough to play with each Fixed Key and find out for yourself what it does.

Zoom button and split screen

A strangely-labelled "Zoom" button allows fast access to commonly needed menu choices, including trends and setting up the split screen, (so that a 10 or 60 minute trend of each waveform, or flow/volume loops are available). To set up this option from the regular menu is possible but requires the following steps:

1. Press Menu
2. Click down three to "Monitor Setup"
3. Press blue knob
4. Press blue knob again to select "Main Screen" (do not go to Trend setup)
5. Scroll down nine stops to "More" as the option you want is not yet listed (a significant design flaw)
6. Press blue knob
7. Scroll to "Split Screen"
8. Press blue knob
9. Rotate knob to select 10 or 60 minute trends, or KION vent (a menu does NOT appear - just scroll with the blue knob until what you want appears - another inconsistency. Hiding the menu choices is also bad design.)
10. Scroll UP to get out of this menu
11. Scroll DOWN to get out of the next menu
12. Scroll UP to get back to the main screen

OK, you could skip the last three steps by pressing "Main Screen" (the grey circular button, not the menu choice with the same name), but even so the system is way too difficult.

Menus

If you are in nested menus you have to go to the bottom of each list to exit from that list, until you get to the first menu when you have to go to the little box at the top to get out. The design should be consistent between menus.

There is a "Main Screen" button which brings you back to the normal monitor interface.

A good interface design should make it obvious what menu choices are available, which menu choice is highlighted, and suggest the likely consequences of selecting the highlighted choice.
These simple concepts are not well implemented on the KION.
Any digit field on the right or bottom of the monitor is actually a potential menu choice. Rotate the blue knob to select, for example, the end-tidal CO2 reading. A menu appears with eight choices:

• A left-pointing arrow, in the header bar
• Scale
• Agent Display
• Sample Flow Rate
• Pressure Comp.
• RRc Apnea Time
• Auto Zero Delay (greyed out)
• et CO2 Alarm

At this stage, the left arrow is the highlighted selection, but this is hard to tell as the highlighted arrow is black on white, the same as all the other non-highlighted choices. The arrow reverts to white on grey if deselected. This choice is accompanied by an explanatory message at the bottom of the screen which reads: "Returns to previous menu". It is not obvious what this message refers to, and few other menu choices are associated with a similar explanation.
Rotating the knob to select any other menu choice causes a black box to appear round the selected item.
Selecting "Scale" highlights the current scale, by making it white on blue, and one can rotate through three options. You have to circle through all possible options to find out what your menu choices are.
Selecting "Agent Display" highlights "On" or "Off" by making it white on black.
Selecting "Sample Flow Rate" displays two possible flow rates in a sub-menu, but then requires you to enter a password to make a change.
Selecting "Pressure Comp." or "RRc Apnea Time" produces a submenu like "Sample Flow Rate", but this time no password is required.
EtCO2 alarm calls up the alarm limits menu.

Eight menu choices, six different user experiences, and five different ways to show which menu item is highlighted.

Non-invasive blood pressure (NIBP)
Most anesthesiologists will want to take the blood pressure every five minutes during the case, and switch it off between cases, so that should be easy to do. There is a "NBP Start/Stop" button, but it only starts and stops, it does not open any menu options. To get into the NIBP options menu you have to rotate the blue knob until the BP reading is highlighted then press it in.

How do you turn off the BP between cases? Highlight the BP box, press, select interval time and set it to off. Then set it to 5 min again! Now, next time you press the NBP Start/Stop button it will go back into a Q5 minute BP mode.

Siemens says that many users quickly get used to this performance.

Alarms in profusion
The machine has an extensive automated pre-use check. If there is even a small leak (usually from the CO2 absorber,) the result is a "Fail" message, rather than just a notification of a small leak. This causes me a problem, as I am not prepared to use a machine which has failed its pre-use test, even if the leak is so small as to be clinically insignificant.

Turn the machine on and it immediately greets you with an alarm! "Cylinder pressure low" comes on, unless you are silly enough to have the backup cylinders turned on. Press one of the "Alarm Silence" button on the monitor or on the machine interface, which in this case is also the alarm override. The alarm does not then come back on.

It seems to me that the NORMAL situation is that the machine is connected to the pipeline and has standby cylinders present but not open. This situation should NOT generate an alarm. Missing backup cylinders, backup cylinders turned on despite an adequate pipeline pressure, or an absence of adequate pipeline pressure, should be the alarm conditions.

On the KION anything except turning all the alarms off during the most critical phases of anesthesia results in a distracting cacophony of alarms. Colleagues now calmly advise each other that the correct thing to do is to turn off all the alarms during induction and emergence, which is "OK because you are watching the patient".

How do you turn the alarms back on? By pressing the "All Alarms Off" button, of course! To be fair, I guess this is no more perverse than having to press the "Start" button on a Windows PC to turn the computer off, and look at how rich Bill Gates got selling that system.

Default Alarms
You want to set the alarm limits back to their default values? DO NOT press the "Alarm Limits" button - you CANNOT get to the "restore defaults" option from there! Instead, go to the MENU button and select "Restore Setups" Select "Restore setup" again (it's a little confusing, as this is a menu with only one choice, but you have to highlight it and select it anyway) and then choose which setup you wish to restore. Note that this resets the display options as well as the alarm values. It is not currently possible to just reset the alarm limits. The "Auto Set" option DOES NOT RESTORE DEFAULTS - it sets the new limits as a percentage above and below the current actual values.

It is unfortunate that restoring the defaults is not easier, as when one arrives in the OR and the machine is already turned on, the alarm values may still be set to the preferences of the previous anesthetist who worked with that machine.

The alarm limits can be shown in small figures beside each alarm. This is a nice touch, but it does make the screen busy. There is an option not to display the alarm limits.

Trends
Anesthesiologists need trend data to assess the patient's progress and to assist in completing the anesthetic chart. The Datex AS/3 has a "Display Trends" key, while the KION requires one to select "Zoom" and choose "Display Trends" from the menu. As I review the trends at least once per case (when entering the induction vitals onto the chart), this added step is a nuisance.The KION provides both graphical and numerical trend data. But good luck navigating back and forth in time! As you attempt to scroll, all the data disappears, so you have to guess where you want to look. Using the double arrows at each end of the time scale box moves you back or forward one page at a time, which is the least inconvenient way of finding the data you need. Navigating through the menu choices in this screen makes me dizzy: The highlight is first on the scroll bar to move up and down the list of variables, then moves to the right to change the scales, then goes along the bottom of the graph to scroll through time, then back to the left and along the bottom list of options, such as the horizontal scale and the cursor.

Duoview
The "Duoview" is an optional extra monitor panel, for use in more difficult cases where multiple invasive monitoring waveforms need to be displayed. Unfortunately, in the version we used, the top of the usual monitor was taken up with respiratory waveform data, put where the ECG and oxygen saturation waveforms would normally be, and it was not possible to move or delete this data, which was of minimal value, and which took up valuable screen "real estate". As a result, in the most difficult cases, it was more difficult than usual to find important information in a quick glance at the monitor.

Printer
It is possible to print trend data to a laser printer, either locally or via a network. There is also a rhythm strip recorder available. To print trends, go into the graphical trend display and rotate the blue knob nine clicks to the right to highlight "Report" and press.

KION Web pages
If I were Siemens, selling a technology based product to computer-savvy professionals around the world, I'd have a great Web site, full of information about the wonders of the product. So far I have found almost nothing about the KION on the net, one reason for creating this page. A few sites I did find include:

• Siemens USA Home Page This gives an idea of how large Siemens is, and how insignificant anesthesia machines are in the overall scope of Siemens' business.
• A brief overview of the KION machine from Siemens.
• A New Concept In Anesthesia Machines, by Heidi R. Hughes, RN, ICRN Product Manager - Anesthesia Systems, Siemens Elema AB.
• Anestesiapparat / Anesthesia apparatus "Kion" Swedish Design Award for KION.

• Do It By Design, an introduction to human factors design in medical devices such as anesthesia machines, from the FDA.
• The Future of the Anesthesia Machine, my own thoughts about the direction anesthesia machines should be going in.

Good points about the KION

So as not to be wholly negative, I should point out I like the supplemental O2 outlet (for use with nasal prongs, etc) on the front of the machine, and that the little light is cute.

"Smart cards" are available, which are supposed to enable users to set their own preferences on the machine, and carry those preferences with them on a the card from room to room. This sounds interesting.

The ability to switch between manual or spontaneous ventilation and controlled ventilation with a single knob is nice. However, it is important to remember that, when using the older machines, you have to go back to turning the ventilator on and moving the lever to redirect the gas flow.

There are times when the ability to rotate the monitor to point in an unusual direction is useful. For example, if one is needed on the phone, or needs to talk to a colleague, the monitor can be more readily kept in view.

I am impressed that I can literally pull the plug on the machine and all it does is let out a little squeak and go on to batteries, which apparently last for over half an hour.

If you need a pediatric or ICU ventilator in your OR, you may like the KION. The ventilator is said to be excellent.

There is a "Pick and Go" system, which allows you to use the KION monitor as a transport monitor, without having to change over all the leads and connections. In some circumstances, this could be very useful.

The KION monitoring system can be networked and connected to the PICIS information management system.

If you have not used an integrated monitoring system, but still have a collection of separate monitors, the KION system will probably be an improvement.

All the new generation of electronic anesthesia machines have the potential to fail, and just give the patient oxygen. So far, our KIONs have not done this.

CONCLUSION

It is possible to give a good, safe anesthetic with the current version. However, if the user is tired, distracted, or stressed by an emergency situation, I feel that the design and interface issues may impair the users ability to respond appropriately.

It is possible to put up with an awkwardly designed VCR or phone, but medical equipment should be designed to a higher standard, so that the requirement for training, experience and thought are minimized. An anesthesia machine should be sufficiently intuitive in its interface that, even if you have not used it for a couple of weeks, you can be woken up at 3.00 am to anesthetize a sick child and be able to work out everything you need to know to give a safe anesthetic.

Siemens makes great ventilators, and acceptable ICU monitors. When they moved into the anesthesia machine market with the KION, I feel they failed to appreciate the difference between the ICU and the operating room.

Difference	ICU	OR
Patient turnover	Patient stays on monitor for several days	New patient every 15 minutes in some rooms
Monitoring person	Nurse. Several nurses monitor same patient over course of day	Physician anesthesiologist monitors many patients in course of one day
Monitor requirements	Standardization to protocols set by management. Changes rarely	Variable according to personal preferences and case mix. Changes frequently

They also failed to realize that the competing monitors, such as the AS/3, are very advanced and user friendly.

Common task	AS/3	KION	Other monitor
Reviewing trends data	One click of "Trend" button	Zoom. Scroll down three to trend. Press
Turn on and off q5min BP	One click of "NIBP On/Off" button	Scroll down to BP display. Scroll to Interval Time. Set to off. Set to five minutes. Press "NBP start".
Putting a specific variable in the second data area at the bottom of the screen	Select "Numerical variables". Select variable for desired location.	Select Monitor Setup - Main Screen- Parameter Priority. Juggle with priority order of variables until desired data appears in correct box.
Resetting the alarm limits to default	Select "Alarm Limits". Press "Restore Defaults".	Select Monitor Setup - Restore Defaults- Restore Defaults - KION General.

New technology should only be used if it is better for the users than the old technology. The new generation of electronic anesthesia machines is a stepping stone to an integrated system, which would take patient data from the hospital network and automatically generate an anesthesia record. These machines will likely have many advantages, but at present we are bringing problems associated with computers into the operating room without gaining a great deal of advantage.

Other users can, according to Siemens, adapt to a monitor which requires more steps to do routine tasks than would be necessary in a better-designed system. However, having studied Web site design and useability, I am concerned by badly designed user interfaces. Having read the FDA's Web site about Human Factors Engineering, I am aware that if there is a way a medical device can conceivably be mis-used by poorly-trained, tired, or stressed individuals, then eventually that mis-use will occur, and patients may be harmed. Designers should not rely on the assumption that an anesthesia machine will only be used by people who are alert, well-trained and able to remember what they have been taught. Designers have the luxury of time and a quiet, comfortable working environment, and can spend months designing and trouble-shooting the equipment, but the anesthesiologist, who is tired and stressed, may only have three minutes to review all possible causes for a critical problem, and find and effect a solution, before the patient suffers permanent brain damage. As Dr Charles McLesky said (about infusion pumps, in the APSF Newsletter, Winter 2000-1), "Should we be using a device that is designed by idiots that takes a genius to operate? Wouldn't it be better if geniuses designed the device and even an idiot could operate it?".

I think that if the designers were adequately educated about the real needs of the users, there would be much less need to teach the users the peculiarities of the machine. I can accept that modes of ventilation which are new to the OR will need additional training, but I can see no reason why the use of standard modes of ventilation should be more difficult on an electronic machine than on an older mechanical model.

Responses from Siemens

• Siemens recognizes that some of the monitoring issues are valid. They plan to "aggressively persue additional improvements to our monitoring software so as to address the needs as they have been identified".
• Siemens feels that the days when a new staff member or locum could be given a five minute demonstration of an unfamiliar anesthesia machine and be left to get on with the list are over, and that all the new electronic machines, by their nature, require more training than the old mechanical machines. "It is the recommendation of both myself and my monitoring colleagues that training be mandatory for all users to ensure that the Hospital gets the full benefits of both the currently available capabilities as well as the new ones".
• "The KION system has been available for nearly three years now and with over two thousand of them in use world-wide, we have received extremely favourable responses from many customers". Apparently, many of the ergonomic issues I complain about are hailed as advantages in some quarters. (I gather most people were pretty happy with the "Titanic" until it actually sank.)
• "Unfortunately we also realize that, like any manufacturer, we cannot please all of the customers all of the time".

Update August 19th 2002

• A desflurane vaporizer.
• Pressure support.
• Non-rebreathing (so the FGF equals the minute ventilation and the carbon dioxide absorber is not used).
• A new ventilator which is NOT a minute volume divider, so changes to the rate do not change the tidal volume.
• Smart alarms, which reduce the number of nuisance alarms, especially if set up in the "OR" mode and carefully tweaked.

• The basic unit is unchanged, there is no redesign of the exterior.
• It is still difficult to choose what data appears where on the screen.
• Colours cannot be specified.
• The trend data is still not visible as one scrolls through the timeline.

• Once the respiratory rate was set at 11, but the KION delivered 15 breaths per minute. The patient was paralysed, and not making any respiratory effort.
• In another case the end tidal carbon dioxide and gas monitoring stopped working. After much hassle it turned out to be a recognized "software glitch" which required the monitor to be turned off and restarted. As luck would have it, this happened during surgery on an 8 week old infant. Computer users are used to programs being sold before they have been thoroughly debugged, but crucial medical equipment should not be released for general use with recognized but unresolved bugs.

We eventually sold our KIONs to Datex, and equipped all our ORs at both sites with Datex machines.

They are much more user friendly. At the Grace site, there were some problems, apparently related to electric power surges, which were resolved by adding surge protectors. (It would seem reasonable to build in surge protectors to critical equipment which will malfunction when supplied with "dirty" electricity.) Since then they have proven to be reliable.

There were NO KIONs at the 2003 ASA meeting. Siemens has apparently sold off its anesthesia machine division. Drager has bought the monitoring part, and a Swedish company has bought the ventilator part. Drager is continuing to maintain Morth American KIONs for the time being. The future of the machine seems uncertain.

Background
The author, Dr. John Oyston, works as an anesthesiologist in a community hospital in the eastern suburbs of Toronto. The hospital has replaced three Drager Narkomed 2 anesthesia machines (equipped with Datex AS/3 monitors) with KION machines and their integrated monitors. This article represents the personal opinion of the author, and not the official policy of his department or hospital. The author has not received funding from any equipment manufacturer.

This page is by no means the last word on KION. I am sure the machine will change and improve with time, and hope that this page may put some small amount of pressure on Siemens to make changes sooner rather than later. I am happy to correct any errors and update it as necessary.
I would appreciate information about other users' experience with the KION and other electronic anesthesia machines. Comments to John Oyston at please.