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Checketts et al. | Standards of monitoring 2015 Anaesthesia 2015 • Depth of anaesthesia monitoring is recommended during transfer of patients receiving TIVA and neuromuscular blockade, but presents difficulties, because portable battery powered depth of anaesthesia monitors are not widely available. Such devices may come to the market in the future and their efficacy will need to be separately evaluated; • during inhalational anaesthesia, end-tidal anaesthetic vapour monitoring with preset low agent alarms appears a suitable and effective means of estimating depth of anaesthesia; • The isolated forearm technique is another technique to monitor depth of anaesthesia [32]. If used as a ‘depth of anaesthesia monitor’, care should be taken to ensure its safe conduct, especially in relation to avoiding excessive, prolonged cuff inflation. The interpretation of a positive movement to command with isolated forearm technique needs careful interpretation, as does the subsequent management of a patient who has moved in response to spoken command [33]. Appendix 3: Monitoring of neuromuscular blockade during induction, maintenance and termination of anaesthesia A measure of neuromuscular blockade, using a peripheral nerve stimulator, is essential for all stages of anaesthesia when neuromuscular blockade drugs are administered. This is best monitored using an objective, quantitative peripheral nerve stimulator. Ideally the adductor pollicis muscle response to ulnar nerve stimulation at the wrist should be monitored. Where this is not possible, the facial or posterior tibial nerves may be monitored [34]. There is variability in the duration of action of non-depolarising neuromuscular blocking agents. Residual neuromuscular blockade can be detected in up to 40% patients for up to two hours after their administration [35, 36]. Patient harm may result from postoperative hypoxaemia in the post anaesthesia care unit [37, 38] and a risk of AAGA at extubation [13]. The NAP5 project on AAGA reported on the role of neuromuscular blockade in contributing to AAGA, and how patients interpret unintended paralysis in extremely distressing ways. Recommendations: • a peripheral nerve stimulator is mandatory for all patients receiving neuromuscular blockade drugs • peripheral nerve stimulator monitors should be applied and used from induction (to confirm adequate muscle relaxation before endotracheal intubation) until recovery from blockade and return of consciousness; • while a ‘simple’ peripheral nerve stimulator allows a qualitative assessment of the degree of neuromuscular blockade; a more reliable guarantee of return of safe motor function is evidence of a train-of-four ratio > 0.9. • a quantitative peripheral nerve stimulator is required to accurately assess the train of four ratio [34], but other stimulation modalities (e.g. double burst or post tetanic count) can also be used for assessment. Anaesthetic departments are encouraged to replace existing qualitative nerve stimulators with quantitative devices. © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland. 9
Anaesthesia 2016, 71, 1503 Correction doi:10.1111/anae.13691 Following an item of correspondence, the authors of the guidelines [1] agree that the evidence for pH being an important determinant for suitability for peripheral intravenous administration of fluids is equivocal and limited. Therefore, the authors would like to correct the following advice given in the section on peripheral cannulation: Peripheral insertion is inappropriate for infusion of fluid with high osmolality (> 500 mOsm.l high pH (> 9) or intravenous access for more than 2 weeks. 1 ) or low (< 5) or This should read: Peripheral insertion is inappropriate for some fluids and drugs e.g. high osmolality > 500 mOsm.l vasopressors or intravenous access for more than 2 weeks. Check local or national guidance. 1 , potent Reference 1. Bodenham A, Babu S, Bennett J, et al. Association of Anaesthetists of Great Britain and Ireland: Safe vascular access 2016. Anaesthesia 2016; 71: 573–85. © 2016 The Association of Anaesthetists of Great Britain and Ireland 1503
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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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SECTION VIII - EQUIPMENT AND DRUGS
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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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44. Edholm D, Kullberg J, Haenni A,
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75. McKay RE, Malhotra A, Cakmakkay
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Anaesthesia 2015 Barker et al. | Gu
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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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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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egain capacity, and the absence of
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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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Guidelines Immediate post-anaesthes
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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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Domain A: knowledge, skills and per
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Domain B: safety and quality Attrib
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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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Guidelines: Day case and short stay
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