3. ANESTHESIA STANDARDS FOR BASIC INTRAOPERATIVE MONITORING.
Note: Within these standards, "Anesthesia" is defined as all types of anethesia care unless otherwise specified by the text.
These standards apply to all anesthesia care (although, in emergency circumstances, appropriate life support measures take precedence). These standards may be exceeded at any time based on the judgment of the responsible anesthesiologist. These standards are intended to encourage high quality patient care, but observing them may not guarantee any specific patient outcome. They are subject to revision from time to time, as warranted by the evolution of technology and practice. This set of standards addresses only the issue of basic intraoperative monitoring, which is one component of anesthesia care. In certain rare or unusual circumstances, (1) some of these methods of monitoring may be clinically impractical and (2) appropriate use of the described monitoring methods may fail to detect untoward clinical developments. Brief interruptions of continual monitoring may be unavoidable. Under extenuating circumstances, the responsible anesthesiologist may waive the requirements marked with an asterisk W. When this is done, it shall be stated (including the reasons) in a note in the patient's anesthetic record. These standards are not intended for application to the care of the obstetrical patient in labor or in the conduct of pain management.
Note: As used in these protocols, "continual" and "continually" are defined as "repeated, regularly and frequently, in steady, rapid succession," whereas "continuous" means "prolonged, without any interruption at any time."
A. STANDARD: Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics, regional anesthetics and monitored anesthesia care.
OBJECTIVE: Because of the rapid changes in patient status during anesthesia, qualified anesthesia personnel shall be continuously present to monitor the patient and provide anesthesia care. In the event there is a direct known hazard, (e.g., radiation) to the anesthesia personnel which might require intermittent remote observation of the patient, some provision for monitoring the patient must be made. In the event that an emergency requires the temporary absence of the person primarily responsible for the anesthetic, the best judgment of the anesthesiologist will be exercised in comparing the emergency with the anesthetized patient's condition and in the selection of the person left responsible for the anesthetic during the temporary absence.
B. STANDARD: During all anesthetics, the patient's oxygenation, ventilation, and circulation shall be continually evaluated (i.e., repeated, regularly and frequently).
(1) OXYGENATION
OBJECTIVE: To ensure adequate oxygen concentration in the inspired gas of the blood.
METHODS:
(a) Anesthesia machines shall either not be capable of delivering less than 18% oxygen or shall have an alarm, pneumatically or mechanically operated, that shall be activated if the inspired oxygen is less than 18%. This alarm shall be automatically enabled when the anesthesia machine is turned on. An oxygen analyzer is not a substitute for this alarm.
(b) Inspired gas: During every administration of general anesthesia using an anesthesia machine, the concentration of oxygen in the patient breathing system shall be measured by an oxygen analyzer with a low oxygen concentration limit alarm in use.
(c) Blood oxygenation: A quantitative method of assessing oxygenation such as pulse oximetry shall be employed Adequate illumination and exposure of the patient is necessary to assess color.
(2) VENTILATION
OBJECTIVE: To ensure adequate ventilation of the patient.
METHODS:
(a) Every patient receiving general anesthesia shall have the adequacy of ventilation continually evaluated. While qualitative clinical signs such as chest excursion, observation of the reservoir breathing bag and auscultation of breath sounds may be adequate, quantitative monitoring of the C02 content and/or volume of expired gas is encouraged.
(b) When an endotracheal tube is inserted, its correct position in the trachea must be verified by clinical assessment and end-tidal C02 analysis.
(c) ongoing evaluation of mechanical ventilation must be assessed by any or all of the following:
(i) Clinical assessment
(ii) capnometry
(iii) mechanical tidal volume and rate measurement
(d) When ventilation is controlled by a mechanical ventilator, there shall be in continuous use a device that is capable of detecting disconnection of components of the breathing system. The device must give an audible signal when its alarm threshold is exceeded.
(e) During regional anesthesia and monitored anesthesia care, the adequacy of ventilation shall be evaluated, at least, by continual observation of qualitative clinical signs.
(3) CIRCULATION
OBJECTIVE: To ensure the adequacy of the patient's circulatory function during all anesthetics.
METHODS:
(a) Every patient receiving anesthesia shall have the electrocardiogram continuously displayed from the beginning of anesthesia until preparing to leave the anesthetizing location.
(b) Every patient receiving anesthesia shall have arterial blood pressure and heart rate determined and evaluated at least every five minutes.
(c) Every patient receiving general anesthesia shall have, in addition to the above, circulatory function continually evaluated by at least one of the following: palpation of a pulse, auscultation of heart sounds, monitoring of a tracing of intraarterial pressure, ultrasound peripheral pulse monitoring, or pulse plethysmography or oximetry.
(4) DISCRETIONARY PHYSIOLOGIC MONITORS
(a) Body Temperature
OBJECTIVE: to aid in the maintenance of appropriate body temperature during all anesthetics.
METHODS: There shall be readily available a means to continuously measure the patient's temperature. When changes in body temperature are intended, anticipated or suspected, the temperature shall be measured.
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