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Checketts et al. | Standards of monitoring 2015 Anaesthesia 2015 4. Webb RK, Currie M, Morgan CA, et al. The Australian Incident Monitoring Study: an analysis of 2000 incident reports. Anaesthesia and Intensive Care 1993; 21: 520–8. 5. Keenan RL, Boyan CP. Decreasing frequency of anesthetic cardiac arrests. Journal of Clinical Anesthesia 1991; 3: 354–7. 6. Eichhorn JH, Cooper JB, Cullen DJ, Maier WR, Philip JH, Seeman RG. Standards for patient monitoring during anesthesia at Harvard Medical School. Journal of the American Medical Association 1986; 256: 1017–20. 7. Webb RK, Van der Walt JH, Runciman WB, et al. Which monitor? An analysis of 2000 incident reports. Anaesthesia and Intensive Care 1993; 21: 529–42. 8. McKay WP, Noble WH. Critical incidents detected by pulse oximetry during anaesthesia. Canadian Journal of Anaesthesia 1988; 35: 265–9. 9. Cullen DJ, Nemaskal JR, Cooper JB, Zaslavsky A, Dwyer MJ. 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The Working Time Regulations 1998. http://www.legislation. gov.uk/uksi/1998/1833/made (accessed 07/07/2015). 18. Association of Anaesthetists of Great Britain & Ireland. The use of Capnography Outside the Operating Theatre. AAGBI Safety Statement. London, 2011. http://www.aagbi.org/sit es/default/files/Capnographyaagbi090711AJH%5B1%5D_1.pdf (accessed 24/04/15). 19. Bick E, Bailes I, Patel A, Brain AIJ. Fewer sore throats and a better seal: why routine manometry for laryngeal mask airways must become the standard of care. Anaesthesia 2014; 69: 1304–8. 20. Sessler DI. Temperature monitoring and perioperative thermoregulation. Anesthesiology 2008; 109: 318–38. 21. Association of Anaesthetists of Great Britain & Ireland. Immediate Post-anaesthesia Recovery 2013. AAGBI Safety Guideline. London, 2013. http://www.aagbi.org/sites/default/files/immediate_post-anaesthesia_recovery_2013.pdf (accessed 10/05/15). 22. American Society of Anesthesiologists Task Force on Intraoperative Awareness. 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Anaesthesia 2013; 68: 677–81. 33. Pandit JJ, Russell IF, Wang M. Interpretations of responses using the isolated forearm technique in general anaesthesia: a debate. British Journal of Anaesthesia 2015; 115(Suppl. 1): i32–i45. 34. Hemmerling TN, Le N. Brief review: neuromuscular monitoring: an update for the clinician. Canadian Journal of Anaesthesia 2007; 54: 58–72. 35. Debaene B, Plaud B, Dilly M-P, Donati F. Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action. Anesthesiology 2003; 98: 1042–8. 36. Naguib M, Kopman AF, Ensor JE. Neuromuscular monitoring and postoperative residual curarisation: a meta-analysis. British Journal of Anaesthesia 2007; 98: 302–16. 37. Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS. Residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit. Anesthesia and Analgesia 2008; 107: 130–7. 38. 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Anaesthesia 2015 Checketts et al. | Standards of monitoring 2015 Appendix 1: Cardiac output monitors There are a range of cardiac output monitors available – such as those estimating cardiac output from pulse pressure, carbon dioxide rebreathing, lithium dilution or oesophageal Doppler measurements – however, their routine use is uncommon. Although the literature base is large, there is little evidence that one type of monitor is consistently superior to another. Training in the use of the technique adopted is essential. Invasive methods, such as those requiring a pulmonary artery catheter, are more accurate but, because of the small risk of serious complications associated with the use of the pulmonary artery catheter, their routine use outside of cardiac surgical centres cannot be recommended. There are concerns about accuracy and reliability with many cardiac output monitors. The percentage error of pulse contour analysis, oesophageal Doppler, partial carbon dioxide rebreathing, and transthoracic bio-impedance has been shown to be greater than 30%, a widely accepted cut-off [25]. The use of cardiac output monitoring for assessment of fluid responsiveness has been shown to be more accurate, but interpatient variability and dynamic changes in stroke volume may be significant [26]. The cardiac output monitors currently available all have advantages and disadvantages associated with their use, and the AAGBI Working Party cannot recommend one type over another. In summary: • the pulmonary artery catheter is the most accurate, but less invasive monitoring has superseded its routine use outside of cardiac surgery [27]; • there is conflicting evidence about whether the use of cardiac output monitoring improves patient outcomes, and this is an area of ongoing research; • echocardiography can be used to estimate cardiac output and allows cardiac function and filling status to be directly observed - however, training and experience in its use is required [28, 29]; • there remains doubt about the accuracy of all cardiac output monitoring devices currently available, and data are mostly confined to patients whose lungs are mechanically ventilated; • the use of cardiac output monitors to assess fluid responsiveness has some evidence base. Appendix 2: Depth of anaesthesia monitors EEG-based depth of anaesthesia monitors have been variously recommended as an option in patients at greater risk of awareness or those likely to suffer the adverse effects of excessively deep anaesthesia, and also in patients receiving TIVA [30]. Data on the efficacy of these devices in correctly predicting accidental awareness during general anaesthesia (AAGA) or correctly predicting an adequate level of anaesthesia, remains inconsistent and debated [31]. However, data from these monitors may provide an additional source of information on the patient’s condition. The NAP5 project published in 2014 made a number of recommendations on risk factors for AAGA and the place of depth of anaesthesia monitoring [13], which can be summarised as: • the incidence of reports of AAGA was 1 in 8000 when neuromuscular blocking drugs were used (as high as 1:670 in caesarean section) and 1 in 136 000 when they were not (i.e., implying a focus should specifically be on paralysed patients); • about half of the reports of AAGA occurred around the time of induction of anaesthesia and transfer from anaesthetic room to the operating theatre. • almost 20% of AAGA reports occurred at the time of emergence from general anaesthesia and were commonly if not universally related to inadequate reversal of neuromuscular blockade Building on these recommendations, the AAGBI Working Party makes the following recommendations: • Depth of anaesthesia monitoring is recommended when neuromuscular blockade is used in combination with TIVA; • Depth of anaesthesia monitoring should logically commence from induction of anaesthesia and be continued at least until the completion of surgical and anaesthetic interventions (i.e., up to the point where it is intended to awaken the patient); 8 © 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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SECTION VII - THE TRANSFER The tran
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Figure 2 Relationship between total
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Table 5 The STOP-BANG screening que
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Intra-operative care Preparation of
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A review and meta-analysis by the S
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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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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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depression. In the absence of contr
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of clinical deterioration, as recom
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Equipment for PCA must be available
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The following national guidelines s
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Methods to estimate/establish publi
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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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Management of hypertension before e
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AAGBI Safety Guideline Management o
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MEMBERSHIP OF THE WORKING PARTY Dr
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Section 1 Recommendations 1. Transf
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heavily congested areas, but not al
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Introduction ❚ The Good Anaesthet
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Related guidelines and sources of i
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