SECTION and BOARD OF
EUROPEAN UNION OF MEDICAL
identified standards of monitoring must be employed whenever
a patient undergoes Monitored Anaesthetic Care, Local, or
General Anaesthesia for an operative procedure. These are minimum
standards, irrespective of the duration or location of anaesthesia.
- Provision, maintenance,
calibration and renewal of equipment is an institutional
- Qualified anaesthetic
personnel must be present during the perioperative period.
- The anaesthetist must ensure
that all equipment has been checked before use. Alarm limits for all
equipment must be set appropriately before use. Audible alarms must
be enabled during anaesthesia
- Core monitoring devices must
be attached before induction of anaesthesia, and their use continued
until the patient has recovered from the effects of anaesthesia.
Additional monitoring may be necessary as deemed appropriate by the
- A brief interruption of
monitoring is only acceptable if the recovery area is immediately
adjacent to the operating theatre. Monitoring should be continued
during transfer to the same degree as any other intra- or
- A summary of
information, either manual or electronic, provided by monitoring
devices must be recorded on the anaesthetic record.
maintenance, calibration and renewal of equipment is an institutional
institution is responsible for the provision and maintenance of the
anaesthetising location and for the provision, maintenance and
renewal of anaesthetic and monitoring equipment that meets current
published equipment standards.
department of anesthesia is responsible for advising the institution
on the procurement of monitoring equipment and for establishing
policies for monitoring to help ensure patient safety.
institution must also ensure that all anaesthetic and monitoring
equipment undergoes regular inspection and maintenance by qualified
anaesthetic personnel must be present during the perioperative period
changes in patient status occur during the perioperative period, both
due to the operative procedure, and as a consequence of
anaesthetic agents. Due care must be taken to ensure that each
patient is adequately observed by a suitably trained person
following an established protocol.
anaesthesia personnel, of appropriate experience, should be
continuously present during the perioperative period.
the event there is a direct known hazard, e. g., radiation,
to the anesthesia personnel that might require intermittent remote
observation of the patient, provision for remote monitoring of the
patient must be made available.
circumstances may dictate that handing over of responsibility for
patient care under anaesthetic may be necessary. If so, hand-over
time must be sufficient to appraise the incoming anaesthetist of all
information concerning the patient’s condition. The time and
details of the hand-over must be noted in the anaesthetic record.
the event that an emergency requires the temporary absence of the
person primarily responsible for the anesthetic, the best judgment of
the anaesthetist must be exercised in comparing the emergency with
the anesthetized patient’s condition, and in the selection of the
person left responsible for the anaesthetic during the temporary
absence. If the anaesthetist leaves the operating room temporarily,
he must delegate care of the patient to another member of the
Anaesthetic Department, of appropriate experience. Before delegating
care, the primary anesthetist must ensure that the anesthesia
assistant is familiar with the operative procedure, the operating
room environment and equipment, and that the patient’s condition is
anaesthetist must ensure that all equipment has been checked before
use. Alarm limits for all equipment must be set appropriately before
use. Audible alarms must be enabled during anaesthesia
is the responsibility of the anaesthetist to check all equipment
before use. Anaesthetists must ensure that they are familiar with all
equipment that they intend to use and that they have followed any
specific checking procedure recommended by individual manufacturers.
More complex equipment will require more formal induction and
training in its use.
must ensure that all alarms are set at appropriate values. The
default alarm settings incorporated by the manufacturer are often
inappropriate and during the checking procedure the anaesthetist must
review and reset the upper and lower limits as necessary. Audible
alarms must be enabled when anaesthesia commences.
for oximetry and capnography should not be disabled during the
conduct of an anaesthetic except during unusual circumstances. The
low-threshold alarm of the pulse oximeter and the capnograph apnoea
alarm must give an audible signal. Audible alarms for oximetry and
capnography should not be indefinitely disabled during the conduct of
intermittent positive pressure ventilation is used during
anaesthesia, airway pressure alarms must also be used to detect
excessive pressure within the airway and also to give warning of
disconnection or leaks. The upper and lower alarm limits must be
reviewed, and set appropriately before anaesthesia commences.
administering solutions using an infusion pump, alarm settings and
infusion limits must be verified and set to appropriate levels before
monitoring devices must be attached before induction of anaesthesia
and their use continued until the patient has recovered from the
effects of anaesthesia. Additional monitoring may be necessary as
deemed appropriate by the anaesthetist.
only indispensable monitor is the presence, at all times, of an
anaesthetist or an anaesthesia assistant, under immediate
supervision. Mechanical and electronic monitors are, at best, aids to
vigilance. Such devices assist the anaesthetist to ensure the
integrity of the vital organs and, in particular, the adequacy of
tissue perfusion and oxygenation.
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 should 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.
use of an oxygen analyser with an audible alarm is essential during
anaesthesia. It must be placed in such a position that the
composition of the gas mixture delivered to the patient is monitored
continuously. The positioning of the sampling port will depend on the
breathing system in use.
oximetry is the non-invasive measurement of the ratio of
oxyhaemoglobin to deoxyhaemoglobin, measured by optical
plethysmography and spectroscopy. It is obtained by transilluminating
pulsatile capillary beds. The pulse oximeter should be the first
monitor placed on the patient, and the last one removed.
Blood Pressure Monitoring
pressure monitoring is fundamental to determine the effects of
anaesthetic agents on the patient’s cardiovascular system. Blood
pressure is monitored non-invasively either manually (auscultatory
method) or with an automated device (oscillometric method).
ECG is a surface recording of the electrical activity of the
myocardium, and is created by connecting various electrodes through
which electrical potentials are measured. Although the three-lead
system is adequate, a five lead system is preferable. By
monitoring lead II and lead V5 simultaneously, optimum information
can be obtained.
end-tidal carbon dioxide analysis using capnography should be used
from the time of endotracheal tube/laryngeal mask placement, until
extubation/removal or transfer to a postoperative care location.
use of an agent-specific vapour analyser is essential during whenever
a volatile anaesthetic agent is in use.
airway pressure monitor should alarm if the measured pressure in the
anaesthetic circuit fails to reach a predetermined level. The
alarm limits should be set appropriately for each patient.
any compound (hypnotic, analgesic, muscle relaxant) is administered
by infusion, the infusion device unit must be checked before use. The
infusion site should be secure and preferably visible, to verify that
these drugs are delivered to the patient.
MONITORING IN THE PERIOPERATIVE PERIOD
following is the core monitoring essential to the safe provision of
anaesthesia. If it is necessary to continue anaesthesia without
a particular device, the anaesthetist must clearly record the
reasons for this in the anaesthetic record.
and Maintenance of General Anaesthesia
- Pulse oximeter
- Non-invasive blood pressure
- Airway gases: oxygen, carbon
dioxide and vapour
- Airway pressure
The following must also be
A nerve stimulator
whenever a muscle relaxant is used.
- A means of measuring the
induction of anaesthesia in children and in uncooperative adults it
may not be possible to attach all monitoring before induction. In
these circumstances monitoring must be attached as soon as possible
and the reasons for delay recorded in the patient’s notes.
Techniques & Sedation for Operative Procedures
must have appropriate monitoring, including a minimum of the
- Pulse oximeter
- Non-invasive blood pressure monitor
regional anesthesia and monitored anesthesia care, the adequacy of
ventilation must be evaluated by continual observation of qualitative
clinical signs and/or monitoring for the presence of exhaled carbon
standard of monitoring should be maintained until the patient is
fully recovered from anaesthesia.
Care Unit (PACU), or an area which provides equivalent care, should
be available to receive patients after surgery and anesthesia. All
patients who receive general anesthesia, sedation and/or major
regional anaesthesia should be admitted to the PACU or equivalent
following core monitoring devices must supplement clinical
- Pulse oximetry
- Non-invasive blood pressure monitoring
following must also be immediately available:
- Nerve stimulator
- Means of measuring temperature
decision to apply additional monitoring should be made by the
anaesthetist on a case-by-case basis, depending on the
individual patient, and the nature of the procedure. Some patients
will require additional, mainly invasive, monitoring, e. g.
vascular or intracranial pressures, cardiac output, or biochemical
blood pressure monitoring is indicated when there may be rapid
changes in blood pressure, large fluid shifts, when arterial blood
gas analysis will be required, or where the patient’s condition
venous pressure monitoring is used as a guide for fluid
management as a guide to right ventricular preload. A central
venous catheter can also facilitate insertion of a pulmonary
artery catheter. This will facilitate measurement of Pulmonary
Arterial Pressure, as well as intermittent measurement of Pulmonary
Capillary Wedge Pressure. Cardiac Output as well as other
haemodynamic variables can be calculated.
use of devices designed to reduce the frequency of intra-operative
awareness or to monitor depth of anaesthesia using adaptations of
either surface EEG monitoring or auditory evoked potentials, is not
yet considered as part of our recommended core monitoring standards.
The decision to use a brain function monitor should be made on
a case-by- -case basis by the individual practitioner for
interruption of monitoring is only acceptable if the recovery area is
immediately adjacent to the operating theatre. Monitoring should be
continued during transfer to the same degree as any other intra- or
anaesthetist is responsible for ensuring that this transfer is
the recovery area is not immediately adjacent to the operating
theatre, or if the patient’s general condition is poor, adequate
mobile monitoring of the above parameters will be needed during
is essential that the standard of care and monitoring during transfer
is as high as that applied in the controlled operating theatre
environment and that personnel with adequate knowledge and experience
accompany the patient. The patient should be physiologically as
stable as possible prior to departure.
to transfer, appropriate monitoring must be commenced. Oxygen
saturation and non-invasive blood pressure should be monitored in all
patients and an ECG must be attached. Intravascular or intracranial
pressure monitoring may be necessary in special cases. A monitored
oxygen supply of known content sufficient to last the maximum
duration of the transfer is essential for all patients. If the
patient’s lungs are mechanically ventilated, expired carbon dioxide
should be monitored continuously. Airway pressure, tidal volume and
respiratory rate must also be monitored when the lungs are
of information, either manual or electronic, provided by monitoring
devices must be recorded on the anaesthetic record.
checklist should be completed prior to initiation of anesthesia.
records of the measurements provided by monitors must be kept. It has
become accepted that core
data (heart rate, BP
and peripheral oxygen saturation) should be recorded at intervals no
longer than 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. Electronic
record keeping systems are now becoming more widely available.
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