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Checketts et al. | Standards of monitoring 2015 Anaesthesia 2015 Introduction The presence of an appropriately trained and experienced anaesthetist is the main determinant of patient safety during anaesthesia. However, human error is inevitable, and many studies have shown that adverse incidents and accidents are frequently attributable, at least in part, to error by anaesthetists [3, 4]. Monitoring will not prevent all adverse incidents or accidents in the peri-operative period. However, there is substantial evidence that it reduces the risks of incidents and accidents both by detecting the consequences of errors, and by giving early warning that the condition of a patient is deteriorating [5–11]. It is appropriate that the AAGBI should define the standards of monitoring for use by anaesthetists in the United Kingdom and Ireland. Newer monitoring modalities such as derived electroencephalogram (EEG) depth of anaesthesia and cardiac output monitors are not established as routine and the Working Party considered their place in contemporary anaesthesia practice in Appendices 1 and 2. The anaesthetist’s presence during anaesthesia An anaesthetist of appropriate experience, or fully trained Physician Assistant (Anaesthesia) PA (A) under the supervision of a consultant anaesthetist, must be present throughout general anaesthesia, including any period of cardiopulmonary bypass. Using both clinical skills and monitoring equipment, the anaesthetist must care for the patient continuously. The same standards must apply when an anaesthetist is responsible for a local/regional anaesthetic or sedative technique for an operative procedure. In certain well-defined circumstances [12], intra-operative patient monitoring can be delegated to a suitably trained non-physician health care worker during certain procedures performed under regional or local anaesthesia. When there is a known potential hazard to the anaesthetist, for example during x-ray imaging, facilities for remotely observing and monitoring the patient must be available. Accurate records of the values determined by monitors must be kept. Minimum monitoring data (heart rate, blood pressure, peripheral oxygen saturation, end-tidal carbon dioxide and anaesthetic vapour concentration, if volatile anaesthetic agents or nitrous oxide are used) must be recorded at least every five minutes, and more frequently if the patient is clinically unstable. It is recognised that contemporaneous records may be difficult to keep in emergency circumstances, but modern patient monitoring devices allow accurate records to be completed or downloaded later from stored data. Automated electronic anaesthetic record systems that can also make hard copies for the medical notes are recommended. Local circumstances may dictate that handing over of responsibility for patient care under anaesthesia to another anaesthetist may be necessary. If so, a detailed handover must be delivered to the incoming anaesthetist and this should be recorded in the anaesthetic record. A handover checklist is useful, and one example of this is the ‘ABCDE’ aide memoir suggested in the NAP5 report [13–15]. When taking over care of a patient (including when returning after relief for a break), the incoming anaesthetist should conduct a check to ensure that all appropriate monitoring is in place with suitable alarm limits (see below). Very occasionally, an anaesthetist working singlehandedly may be called on briefly to assist with or perform a life-saving procedure nearby. Leaving an anaesthetised patient in these circumstances is a matter for individual judgement, but another anaesthetist or trained PA(A) should be sought to continue close observation of the patient. If this is not possible in an emergency situation, a trained anaesthetic assistant must continue observation of the patient and monitoring devices. Any problems should be reported to other available medical staff in the area. Anaesthesia departments should therefore work towards having an additional experienced anaesthetist available (e.g. a ‘Duty Consultant’ or ‘floating registrar’ of appropriate seniority) to provide cover in such situations. Anaesthesia departments should make arrangements to allow anaesthetists working solo during long surgical procedures to be relieved by a colleague or PA (A) for meal and comfort breaks [16]. The 1998 European Working Time Regulation Legislation states that an individual should have an uninterrupted break of not less than 20 minutes if the working day exceeds six hours [17]. To meet this requirement, the presence of an additional experienced anaesthetist in the theatre suite, as described above is desirable. © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland. 3
Anaesthesia 2015 Checketts et al. | Standards of monitoring 2015 Anaesthetic equipment It is the responsibility of the anaesthetist to check all equipment before use, as recommended in the AAGBI guideline Checking Anaesthetic Equipment 2012 [1]. Anaesthetists must ensure that they are familiar with all the equipment they intend to use and that they have followed any specific checking procedures recommended by individual manufacturers. Oxygen supply The use of an oxygen analyser with an audible alarm is essential during anaesthesia. The anaesthetist should check and set appropriate oxygen concentration alarm limits. The analyser must be placed in such a position that the composition of the gas mixture delivered to the patient is monitored continuously. Most modern anaesthetic machines have built-in oxygen analysers that monitor both inspired and expired oxygen concentrations. Breathing systems During spontaneous ventilation, observation of the reservoir bag may reveal a leak, disconnection, high pressure or abnormalities of ventilation. Continuous waveform carbon dioxide concentration monitoring will detect most of these problems, so this is an essential part of routine monitoring during anaesthesia. The 2011 AAGBI position statement on capnography outside the operating theatre recommended that it should be used for all unconscious anaesthetised patients regardless of the airway device used or the location of the patient [18]. There are certain circumstances in which capnography monitoring is not feasible, for example during high frequency jet ventilation. Vapour analyser The use of a vapour analyser is essential during anaesthesia whenever a volatile anaesthetic agent or nitrous oxide is in use. The end-tidal concentration should be documented on the anaesthetic record. Infusion devices When any component of anaesthesia (hypnotic, analgesic, neuromuscular blockade) is administered by infusion, the infusion device must be checked before use. Alarm settings (including infusion pressure alarm levels) and infusion limits must be verified and set to appropriate levels before commencing anaesthesia. It is recommended that the intravenous cannula should be visible throughout the procedure, when this is practical. When not practical, increased vigilance is required and correct functioning of the cannula should be regularly confirmed. It is recommended that infusion devices are connected to mains power whenever possible. When using a total intravenous anaesthesia technique (TIVA) with neuromuscular blockade, a depth of anaesthesia monitor is recommended (see below). Alarms Anaesthetists must ensure that all alarms are set to appropriate values. The default alarm settings incorporated by the manufacturer are often inappropriate. During the checking procedure, the anaesthetist must review and reset the upper and lower limits as necessary. It is recommended that anaesthetic departments agree consensus-based alarm limits for their monitors and ask their medical physics technicians to set these up. Audible alarms must be enabled before anaesthesia commences. When intermittent positive pressure ventilation is used during anaesthesia, airway pressure alarms must also be used to detect high pressure within the airway and to give warning of disconnection or leaks. Provision, maintenance, calibration and renewal of equipment are the responsibilities of the institution in which anaesthesia is delivered. Institutions should take into account (e.g., through suitably constituted equipment committees) the views of the anaesthetic department on matters relating to acquisition and maintenance of equipment. Monitor displays Care should be taken to configure the display setup, with attention to both the size and arrangement of onscreen data with regular updating of displayed values. An appropriate automatic non-invasive blood pressure (NIBP) recording interval should be set; NIBP monitors should not continue to display readings for longer than 5 minutes to reduce the risk of an older reading being mistaken for a recent one. 4 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland.
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Recommendations for the Safe Transf
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CONTENTS Section I Summary and Reco
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SECTION II - BACKGROUND In 1996 the
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SECTION IV - ORGANISATION AND COMMU
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SECTION V - STAFFING REQUIREMENTS A
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Guidelines Peri-operative managemen
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Recommendations 1 Every hospital sh
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35 30 25 Prevalance (%) 20 15 10 5
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is an increased incidence of prolon
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Figure 2 Relationship between total
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techniques, and when used with neur
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Table 5 The STOP-BANG screening que
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Intra-operative care Preparation of
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Figure 3 Ramping position for obese
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eturn of airway reflexes with desfl
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Table 6 Dosing schedule for thrombo
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A review and meta-analysis by the S
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numbers of staff are needed to roll
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Table 7 Equipment for managing obes
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11. Schneider HJ, Glaesmer H, Klots
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Out of Hours Activity (Anaesthesia)
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Considerations for anaesthetists Th
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OAA / AAGBI Guidelines for Obstetri
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Contents 1. Key recommendations 2 2
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2. Introduction This is the third v
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Recommendations Medical staff The t
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appointed directly from other count
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Peripartum care Pre-operative asses
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Intravenous patient-controlled opio
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depression. In the absence of contr
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of clinical deterioration, as recom
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5. Training and education Each obst
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• Skills and drills training: ana
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• The midwife caring for a woman
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7. Support services, equipment, fac
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Equipment for PCA must be available
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8. The future The delivery of healt
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The following national guidelines s
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19. Obstetric Anaesthetists’ Asso
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At the first meeting held on 9 th M
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Methods to estimate/establish publi
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Recommendations The WP recommends:
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Anaesthesia, 2007, 62, pages 1199-1
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Anaesthesia, 2007, 62, pages 1199-1
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OPTION 3 - PRESUMED CONSENT. ‘Pre
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Power of Attorney) while requiring
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Needle-stick injury and HIV testing
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treatment if it was understood that
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Management of hypertension before e
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AAGBI Safety Guideline Management o
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Malignant Hyperthermia Crisis Task
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MEMBERSHIP OF THE WORKING PARTY Dr
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Section 1 Recommendations 1. Transf
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Section 3 Introduction In 1997 it w
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This process may require many telep
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Section 6 Accompanying the patient
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Section 7 Monitoring, drugs and equ
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heavily congested areas, but not al
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APPENDIX 1 Departure checklist Do a
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Membership of the Working Party Dr
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AAGBI SAFETY GUIDELINE Immediate Po
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The Royal College of Anaesthetists
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Contents ❚ Foreword 4 Introductio
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Introduction ❚ The Good Anaesthet
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Related guidelines and sources of i
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Day Case and Short Stay Surgery 2 P
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GUIDELINES Day case and short stay
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