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Checketts et al. | Standards of monitoring 2015 Anaesthesia 2015 Monitoring the devices Many devices used in anaesthetic practice need their own checks and monitoring. This includes monitoring the cuff pressure of tracheal tubes and cuffed supraglottic airway devices. Cuff pressure manometers should be used to avoid exceeding manufacturers’ recommended intracuff pressures which can be associated with increased patient morbidity. When using devices where manufacturers do not specify or recommended a maximum cuff pressure, there may still be benefit in avoiding high pressure inflation, as this is associated with reduced morbidity and improved device performance [19]. Monitoring the patient During anaesthesia, the patient’s physiological state and adequacy of anaesthesia need continual assessment. Monitoring devices supplement clinical observation in order to achieve this. Appropriate clinical observations may include mucosal colour, pupil size, response to surgical stimuli and movements of the chest wall and/or the reservoir bag. The anaesthetist may undertake palpation of the pulse, auscultation of breath sounds and, where appropriate, measurement of urine output and blood loss. A stethoscope must always be available. Monitoring devices The monitoring devices described above are essential to the safe conduct of anaesthesia. If it is necessary to continue anaesthesia without a particular device, the anaesthetist must record the reasons for this in the anaesthetic record and only proceed where the benefits or clinical urgency outweigh the risks. The following are considered minimum monitoring for anaesthesia: • Pulse oximeter • NIBP • ECG • Inspired and expired oxygen, carbon dioxide, nitrous oxide and volatile anaesthetic agent if used (see below) • Airway pressure • Peripheral nerve stimulator if neuromuscular blocking drugs used (see Appendix 3) • Temperature for any procedure > 30 min duration [20]. Monitoring must continue until the patient has recovered from anaesthesia. Anaesthesia departments must work towards providing capnography monitoring throughout the whole period of anaesthesia from induction to full recovery of consciousness as recommended by the AAGBI guideline Immediate Postanaesthesia Recovery 2013 [21]. During induction of anaesthesia in children and in uncooperative adults, it may not be feasible to attach all monitoring before induction. In these circumstances, monitoring must be attached as soon as possible and the reasons for delay recorded. Recovery from anaesthesia Minimum monitoring should be maintained until the patient has recovered fully from anaesthesia. In this context, ‘recovered fully’ means that the patient no longer needs any form of airway support, is breathing spontaneously, alert, responding to commands and speaking. Until this point, monitoring must be maintained to enable rapid detection of airway, ventilatory and cardiovascular disturbance. The period of transfer from theatre to recovery can be a time of increased risk depending on the local geography of the theatre complex and the status of the patient. Departments should work towards providing full monitoring, including capnography, in patients with a tracheal tube or supraglottic airway in situ, for these transfers and in the recovery area. Supplemental oxygen should routinely be given to patients during transfer to the recovery room and in the recovery room until at least after full recovery. In summary, the minimum monitoring for recovery from anaesthesia [21] includes: • Pulse oximeter • NIBP • ECG • Capnography if the patient has a tracheal tube, supraglottic airway device in situ or is deeply sedated [17] • Temperature © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland. 5
Anaesthesia 2015 Checketts et al. | Standards of monitoring 2015 Additional monitoring Some patients will require additional monitoring, for example intravascular pressures, cardiac output (Appendix 1), or biochemical or haematological variables depending on patient and surgical factors. The use of additional monitoring is at the discretion of the anaesthetist. Use of depth of anaesthesia monitors, for example processed EEG monitoring, is recommended when patients are anaesthetised with total intravenous techniques and neuromuscular blocking drugs, to reduce the risk of accidental awareness during general anaesthesia (see Appendix 2). However, there is no compelling evidence that routine use of depth of anaesthesia monitoring for volatile agent-based general anaesthetics reduces the incidence of accidental awareness when end-tidal agent monitoring is vigilantly monitored and appropriate low agent alarms are set [13, 22]. Regional techniques and sedation for operative procedures Patients must have appropriate monitoring, including [23]: pulse oximeter, NIBP, ECG and end-tidal carbon dioxide monitor if the patient is sedated. Monitoring during transfer within the hospital It is essential that the standard of care and monitoring during transfer of patients who are anaesthetised or sedated is equivalent to that applied in the operating theatre, and that personnel with adequate knowledge and experience accompany the patient [24]. The patient should be physiologically as stable as possible for transfer. Before transfer, appropriate monitoring must be commenced. Use of a pre-transfer checklist is recommended [13]. Oxygen saturation, ECG and NIBP should be monitored in all patients. Intravascular or other monitoring may be necessary in special cases. An oxygen supply sufficient to last the duration of the transfer is essential for all patients. If the patient has a tracheal tube or supraglottic airway in situ, end-tidal carbon dioxide should be monitored continuously. Airway pressure, tidal volume and respiratory rate must also be monitored when the lungs are mechanically ventilated. Monitoring depth of anaesthesia is desirable when transferring anaesthetised patients who have received neuromuscular blocking drugs (TIVA is invariably used in these circumstances), but will remain difficult to provide until portable, battery-powered depth of anaesthesia monitors become widely available. Anaesthesia in locations outside the operating suite The standards of monitoring used during general and regional anaesthesia or sedation administered by an anaesthetist should be the same in all locations. When anaesthetists are called to administer general or regional anaesthesia and/or sedation in locations outwith the operating theatre (for example emergency department, cardiac catheter lab, radiology, department electroconvulsive therapy suite, endoscopy, pain clinic, community dental clinic critical care, delivery suite), the same minimum essential standards of monitoring already outlined in this document should apply: • Pulse oximeter • NIBP • ECG • Inspired and expired oxygen, carbon dioxide, nitrous oxide and volatile anaesthetic agent if used • Airway pressure • Peripheral nerve stimulator when neuromuscular blocking drugs used (see Appendix 3) • Temperature in procedures > 30 min duration. Competing interests No external funding and no competing interests declared. References 1. Association of Anaesthetists of Great Britain & Ireland. Checking Anaesthetic Equipment 2012. AAGBI Safety Guideline. London, 2012. http://www.aagbi.org/sites/default/files/ checking_anaesthetic_equipment_2012.pdf (accessed 07/07/ 2015). 2. Royal College of Anaesthetists. PA (A) supervision and limitation of scope of practice (May 2011 revision). London, 2011. http://www.rcoa.ac.uk/news-and-bulletin/rcoa-news-and-sta tements/paa-supervision-and-limitation-of-scope-of-practice-may (accessed 24/05/15). 3. Buck N, Devlin HB, Lunn JN. The Report of a Confidential Enquiry into Perioperative Deaths. London: Nuffield Provincial Hospitals Trust, The Kings Fund Publishing House, 1987. 6 © 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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A p p ropriate re s p i ra t o ry s
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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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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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• The midwife caring for a woman
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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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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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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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Introduction ❚ The Good Anaesthet
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Related guidelines and sources of i
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