The advice of the department of anesthesia should also be sought. The operating room conforms to the electrical code and meets the standards for safety in anesthetizing locations and excess anesthetic gas scavenging systems. Medical gas pipeline systems, including low-pressure connecting assemblies, pressure regulators, and terminal units, meet standards for identification, construction, and installation—the piping systems must be certified by a CSA-approved testing agency.
Oxygen concentrators may be an acceptable substitute for bulk oxygen provided that installation and maintenance conform to all applicable CSA standards Appendix 1. The fraction of inspired oxygen FIO 2 delivered by the facility medical oxygen supply may vary from 0. Use of low-flow less than 1 L total fresh gas flow anesthetic techniques may result in the accumulation of inert gas argon and the dilution of nitrous oxide and oxygen in the circuit. There is compliance with all safety regulations with respect to the preparation, storage, identification, and use of medical gases, anesthetic drugs, and related materials.
The anesthetic machine conforms to CSA standards. The machine must be equipped with an oxygen analyzer, vaporizers fitted with keyed filling devices, a ventilator with a low-pressure alarm, an airway pressure monitor, an alternative method of assisted ventilation, a dedicated exhaust gas scavenging system, and a high-vacuum tracheal suction system. The equipment, supplies, and assistance necessary for the safe performance of invasive procedures are available.
Diagnostic equipment, such as nerve stimulators, ultrasound, fluoroscopy, and x-ray should be available to the anesthesiologist as required. A resuscitator, a defibrillator with synchronized electrocardiograph, and drugs and equipment to manage emergencies, including malignant hyperthermia, difficult airways, and failed endotracheal intubation, are immediately available. Facilities that care for children should have specialized pediatric equipment. Wherever obstetric anesthesia is performed, a separate area for newborn assessment and resuscitation, including designated oxygen, suction apparatus, electrical outlets, source of radiant heat, and equipment for neonatal airway management and resuscitation, shall be provided.
Anesthesia providers ensure that potentially infectious materials or agents are not transferred from one patient to another. Special attention in this regard should be given to syringes, infusion pump administration sets, and multidose drug vials. The health care facility must also ensure that all anesthetic and ancillary equipment undergoes regular inspection and maintenance by qualified personnel.
Records indicating conformity to regulations and inspection and maintenance must be retained by the facility administration and the department of anesthesia. Before the introduction of new anesthesia equipment, members of an anesthetic department should receive training sessions on this equipment under the guidance of the chief of the department.
These training sessions should be repeated as necessary for new or established department members. Recirculation of exhaust air shall not be permitted during the hours when operations may be in progress, and it is not recommended at any other time. Wherever an anesthetic delivery system is used, a scavenger shall be provided to capture anesthetic gases that might be released from the anesthetic circuit or ventilator. A maintenance program shall be established in each health care facility to detect and repair leakage from the anesthetic delivery system and to maintain the effectiveness of the scavenging unit.
The health care facility shall be responsible for conducting regular monitoring of exposure to waste anesthetic gases. The monitoring protocol should include individuals and the air flow patterns of the rooms being assessed. When N 2 O is used in the operating room, N 2 O monitoring is a suitable representation for the assessment of adequacy of scavenging. Policies regarding pre-anesthetic assessment should be established by the department of anesthesia.
The primary goal of pre-anesthetic assessment is to obtain the information required to plan anesthetic management. A family history of adverse reactions associated with anesthesia should also be obtained.
Information about the anesthetic that the patient considers relevant should also be documented. The surgeon may request consultation with an anesthesiologist. Medical consultations should be obtained when indicated. Preoperative anesthetic assessment or consultation may take place in an outpatient clinic before admission for the operative procedure. Indications for pre-admission assessment include the presence of significant medical problems co-morbidities , the nature of the proposed diagnostic or therapeutic procedure, and patient request.
All patients should be informed that arrangements will be made if they wish to discuss anesthetic management with an anesthesiologist before admission to the facility. The preoperative assessment clinic should also allow for assessment of the patient by nursing and other health care personnel.
The attending anesthesiologist is responsible for performing a final pre-anesthetic assessment in the immediate preoperative period. Investigations should not be ordered on a routine basis. Fasting policies should vary to take into account age and pre-existing medical conditions and should apply to all forms of anesthesia, including monitored anesthesia care. Emergent or urgent procedures should be undertaken after considering the risk of delaying surgery vs the risk of aspiration of gastric contents.
The type and amount of food ingested should be considered in determining the duration of fasting. Before elective procedures, the minimum duration of fasting should be. Premedication, when indicated , should be ordered by the anesthesiologist.
Orders should be specific as to dose, time, and route of administration. Additional regulations governing the conduct of anesthesia may be dictated by provincial legislation or facility by-laws. Until a specific connection system is devised for neuraxial use, both sides of all Luer connections are labelled; and. The anesthesiologist or an anesthesia assistant supervised by the anesthesiologist shall remain with the patient at all times throughout the conduct of all general, major regional, and monitored intravenous anesthetics until the patient is transferred to the care of personnel in an appropriate care unit.
When the attending anesthesiologist delegates care to a resident in anesthesia or an anesthesia assistant, the attending anesthesiologist remains responsible for the anesthetic management of the patient. When care is delegated to an anesthesia assistant, the attending anesthesiologist must remain immediately available.
Only under the most exceptional circumstances, e. In this situation, the anesthesiologist remains responsible for the care of the patient and must inform the operating team. Simultaneous administration of general, spinal, epidural, or other major regional anesthesia by one anesthesiologist for concurrent diagnostic or therapeutic procedures on more than one patient is unacceptable. However, in an obstetric unit, it is acceptable to supervise more than one patient receiving regional analgesia for labour.
Due care must be taken to ensure that each patient is adequately observed by a suitably trained person following an established protocol. When an anesthesiologist is providing anesthetic care for an obstetric delivery, a second appropriately trained person should be available to provide neonatal resuscitation. Simultaneous administration of an anesthetic and performance of a diagnostic or therapeutic procedure by a single physician is unacceptable, except for procedures done with only infiltration of local anesthetic.
All monitored physiologic variables should be charted at intervals appropriate to the clinical circumstances. Heart rate and blood pressure should be recorded at least every 5 min. Oxygen saturation should be monitored continuously and recorded at frequent intervals. For every patient receiving inhalational, major regional, or monitored intravenous anesthesia, oxygen saturation should be monitored continuously, and end-tidal carbon dioxide concentration should be monitored continuously if the trachea is intubated.
Reasons for deviation from these charting guidelines should be documented in the anesthetic record. Monitors, equipment, and techniques, as well as time, dose, and route of all drugs and fluids should be recorded. Intraoperative care should be recorded.
The only indispensable monitor is the presence, at all times, of a physician or an anesthesia assistant who is under the immediate supervision of an anesthesiologist and has appropriate training and experience. Mechanical and electronic monitors are, at best, aids to vigilance. Such devices assist the anesthesiologist to ensure the integrity of the vital organs and, in particular, the adequacy of tissue perfusion and oxygenation.
The health care facility is responsible for the provision and maintenance of monitoring equipment that meets current published equipment standards. The chief of anesthesia is responsible for advising the health care facility on the procurement of monitoring equipment and for establishing policies for monitoring to help ensure patient safety.
The anesthesiologist is responsible for monitoring the patient receiving care and ensuring that appropriate monitoring equipment is available and working correctly. A pre-anesthetic checklist Appendix 3 or equivalent shall be completed prior to initiation of anesthesia. Monitoring guidelines for standard patient care apply to all patients receiving general anesthesia, regional anesthesia, or intravenous sedation. Required : These monitors must be in continuous use throughout the administration of all anesthetics.
Exclusively available for each patient : These monitors must be available at each anesthetic work station so that they can be applied without any delay.
Immediately available : These monitors must be available so that they can be applied without undue delay. It is recognized that brief interruptions of continuous monitoring may be unavoidable. Furthermore, there are certain circumstances in which a monitor may fail and, therefore, continuous vigilance by the anesthesiologist is essential. Audible and visual alarms for oximetry and capnography should not be indefinitely disabled during the conduct of an anesthetic except during unusual circumstances.
The variable pitch, pulse tone, and low-threshold alarm of the pulse oximeter and the capnograph apnea alarm must give an audible and visual warning. In any facility providing anesthetic services, a PACU must be available. Administrative policies in accordance with facility by-laws shall be enforced to coordinate medical and nursing care responsibilities. The department of anesthesia should have overall medical administrative responsibility for the PACU.
There should be a policy manual for the PACU, which has been approved by medical, nursing, and administrative authorities. The anesthesiologist should accompany the patient to the PACU, communicate necessary information, and write appropriate orders. If clinically indicated, supplemental oxygen and appropriate monitoring devices should be applied during transport. Care should not be delegated to the PACU nurse until the anesthesiologist is assured that the patient may be safely observed and cared for by the nursing staff.
The anesthesiologist or designated alternate is responsible for providing anesthetic-related care in the PACU. Discharge from the PACU is the responsibility of the anesthesiologist. This responsibility may be delegated in accordance with facility policy. Supplemental oxygen and suction must be available for every patient in the PACU.
Emergency equipment for resuscitation and life support must be available in the PACU. The use of pulse oximetry in the initial phase of recovery is required. An accurate record of the immediate recovery period shall be maintained. This must include a record of vital signs together with other aspects of treatment and observation. The recovery record shall form a part of the permanent medical record. In some circumstances, it may be considered acceptable to transfer a patient directly to other care units or to bypass the PACU if the appropriate level of care is available in another unit in the facility and the suitability of the patient for this transfer is documented on the anesthetic record.
Discharge of patients after day surgery must be through the application of a formal care plan approved by the institution and documented in the patient care notes. Specific written instructions should include management of pain, postoperative complications, and routine and emergency follow up. The patient should be advised regarding the additive effects of alcohol and other sedative drugs, the danger of driving or the operation of other hazardous machinery during the postoperative period most commonly 24 hr postoperatively , and the necessity for attention by a competent adult for the postoperative period most commonly 24 hr postoperatively.
Anesthesia services to parturients include obstetric analgesia for labour, for both uncomplicated and complicated deliveries, or for operative deliveries. All guidelines regarding provision of anesthesia for other diagnostic or therapeutic procedures also apply to provision of obstetric anesthesia. The guidelines in this section pertain to epidural and spinal analgesia during labour. Each facility may wish to develop additional guidelines or policies for specific situations in which obstetric regional analgesia is provided.
Under the direction of an anesthesiologist, some aspects of monitoring and management of obstetric regional analgesia may be delegated to other health care personnel.
Each facility should ensure that these personnel receive the same training, certification, continuing education, and recertification in obstetric regional analgesia. Before introducing obstetric regional analgesia, the facility should have appropriate monitoring protocols in place.
These protocols should outline the types of monitoring required and the frequency of monitoring. In addition, they should clearly state how to manage common problems and emergencies and indicate who to contact if assistance is required. Obstetric regional analgesia should only be provided by physicians with training, facility privileges, and licence to provide these services. This includes trainees with appropriate supervision.
An anesthetic must be administered in an appropriate The workstations shall at least be equipped with an facility. All necessary equipment, including emergency oxygen analyser, an airway pressure monitor, waste equipment and life support systems, medications and sup- anesthetic gas scavenging system and a high vacuum plies must be readily available.
If vapourizers are used, they must use a documented. These training sessions should be repeated as keyed filling device to ensure filling with the correct necessary for new or established department members. If a ventilator is provided, it shall have a low- Recommendations for reducing occupational exposure pressure or disconnect alarm. The equipment, supplies, and appropriate assistance 1. Diagnostic equipment, such volatile anesthetic gases or N2O are used. Recirculation of exhaust air shall not be permitted image intensifiers, and x-ray should be available to during the hours when operations may be in progress, the anesthesiologist as required.
For the placement of and it is not recommended at any other time. Wherever an anesthetic delivery system is used, a bility must be provided.
A maintenance program shall be established in each Association Guidelines, and appropriate medications and health care facility to detect and repair leakage from intravenous equipment shall be immediately available. The health care facility shall be responsible for tions of the Malignant Hyperthermia Association of conducting regular monitoring of exposure to waste the United States shall be immediately available anesthetic gases.
The monitoring protocol should Appendix 4. When N2O is used in the Facilities that care for children should have special- operating room, N2O monitoring is a suitable repre- ized pediatric equipment. Wherever obstetric sentation for the assessment of adequacy of anesthesia is performed, a separate area for newborn scavenging. Personal protection devices, including N95 masks, Policies regarding pre-anesthetic assessment should be facemasks and means of disposal of hazardous and established by the department of anesthesia.
Plume The primary goal of pre-anesthetic assessment is to scavenging systems complying with CSA Z All anesthetic and ancillary equipment undergoes laboratory investigations that are relevant to anesthetic regular inspection and maintenance by qualified management should be documented by a physician who is personnel.
Records indicating conformity to regula- knowledgeable about anesthetic management for the pro- tions and inspection and maintenance must be posed diagnostic or therapeutic procedure.
A family history of another. Special attention in this regard should be given to adverse reactions associated with anesthesia should also be syringes, infusion pump administration sets, and multidose obtained.
Information about the anesthetic that the patient drug vials. Attendance at these sessions should be patient. The surgeon may request consultation with an anesthe- Test Indications siologist. Medical consultations should be obtained when indicated. All patients should be informed that arrangements will be made if they wish to discuss anesthetic management with an anesthesi- ologist before admission to the facility.
The preoperative Fasting policies should vary to take into account age and assessment clinic should also allow for assessment of the pre-existing medical conditions and should apply to all patient by nursing and other health care personnel. The forms of anesthesia, including monitored anesthesia care. Before elective procedures, the minimum the nature of the proposed procedure. Investigations should duration of fasting should be not be ordered on a routine basis.
Orders should be specific as to dose, time, pulmonary, renal, or hepatic and route of administration. A reserve source of oxygen under pressure is available; electrolytes 5. Until a specific connection system is devised for following an established protocol.
When an anesthesiolo- neuraxial use, both sides of all Luer connections are gist is providing anesthetic care for an obstetric delivery, a labelled; and second appropriately trained person should be available to 7. The anesthesiologist or an anes- thesia assistant supervised by the anesthesiologist shall remain with the patient at all times throughout the conduct of all general, major regional, and monitored intravenous Records anesthetics until the patient is transferred to the care of personnel in an appropriate care unit.
All monitored physiologic variables should be charted at If the attending anesthesiologist leaves the operating intervals appropriate to the clinical circumstances. Oxygen saturation should be monitored continu- anesthesia assistant. When the attending anesthesiologist ously and recorded at frequent intervals.
For every patient delegates care to a resident in anesthesia or an anesthesia receiving inhalational, major regional, or monitored intra- assistant, the attending anesthesiologist remains responsi- venous anesthesia, oxygen saturation should be monitored ble for the anesthetic management of the patient.
Reasons for deviation from these charting guidelines stable and that the anesthesia assistant is familiar with the should be documented in the anesthetic record. Monitors, operative procedure and the operating room environment equipment, and techniques, as well as time, dose, and route and equipment. When care is delegated to an anesthesia of all drugs and fluids should be recorded.
Intraoperative assistant, the attending anesthesiologist must remain care should be recorded. In this situation, the anesthesiologist remains responsible for the care of the patient and must inform the The only indispensable monitor is the presence, at all operating team. Mechan- Ramsay Sedation Scale, see Appendix 6 , by one anes- ical and electronic monitors are, at best, aids to thesiologist for concurrent diagnostic or therapeutic vigilance.
Such devices assist the anesthesiologist to procedures on more than one patient is unacceptable. The Post-anesthetic Period A pre-anesthetic checklist Appendix 3 or equivalent shall be completed prior to initiation of anesthesia. Recovery Facility Monitoring guidelines for standard patient care apply to all patients receiving general anesthesia, regional anesthe- In any facility providing anesthetic services, a PACU must sia, or intravenous sedation.
Administrative policies in accordance with Monitoring equipment is classified as one of the facility by-laws shall be enforced to coordinate medical following: and nursing care responsibilities. There should be throughout the administration of all anesthetics. If clinically indicated, supplemental available so that they can be applied without undue oxygen and appropriate monitoring devices should be delay. Emergency equipment for anesthetic agents are used.
Any complications that bear any relation to the the patient. Furthermore, there are another unit in the facility and the suitability of the patient certain circumstances in which a monitor may fail and, for this transfer is documented on the anesthetic record.
Discharge of Patients After Day Surgery Audible and visual alarms for oximetry and capnogra- phy should not be indefinitely disabled during the conduct Discharge of patients after day surgery must be through the of an anesthetic except during unusual circumstances.
The application of a formal care plan approved by the institu- variable pitch, pulse tone, and low-threshold alarm of the tion and documented in the patient care notes. Specific pulse oximeter and the capnograph apnea alarm must give written instructions should include management of pain, an audible and visual warning. The patient should be advised regarding the 5. Intravenous access must be established before initiat- additive effects of alcohol and other sedative drugs, the ing regional analgesia.
The intravenous access should danger of driving or the operation of other hazardous be maintained as long as regional analgesia is machinery during the postoperative period most com- administered. Maintenance of Regional Analgesia During Labour Guidelines for Obstetric Regional Analgesia Continuous infusions of low-dose diluted epidural local Anesthesia services to parturients include obstetric anal- anesthetics, with or without other adjuncts, are associated gesia for labour, for both uncomplicated and complicated with a very low incidence of significant complications.
All guidelines Consequently, it is not necessary for an anesthesiologist to regarding provision of anesthesia for other diagnostic or remain present or immediately available during mainte- therapeutic procedures also apply to provision of obstetric nance of continuous epidural infusion analgesia provided anesthesia.
The guidelines in this section pertain to epi- that dural and spinal analgesia during labour. Each facility of obtaining advice and direction. For this reason, an anesthesiologist must be of monitoring and management of obstetric regional anal- available to intervene appropriately should any complica- gesia may be delegated to other health care personnel. Each tions occur when a bolus dose of local anesthetic is injected facility should ensure that these personnel receive the same through the epidural catheter except PCEA.
In developing these policies, each department 1. Before introducing obstetric regional analgesia, the should consider the possible risk of bolus injection of local facility should have appropriate monitoring protocols anesthetics and the methods of dealing with emergency in place.
These protocols should outline the types of situations. In addition, they should clearly state how to manage common problems and emergencies and indicate who Oral Intake During Labour to contact if assistance is required.
Obstetric regional analgesia should only be provided Gastric emptying of solids is delayed during labour. Opioid by physicians with training, facility privileges, and analgesics may further delay gastric emptying. Therefore, licence to provide these services. This includes train- parturients should not eat solid foods once they are in ees with appropriate supervision. In contrast to solid food, clear liquids 3.
Regional analgesia should only be initiated and are relatively rapidly emptied from the stomach and maintained in locations where appropriate resuscita- absorbed in the proximal small bowel, including during tion equipment and drugs are immediately available.
Therefore, individual facilities should develop 4. Informed consent should be obtained and documented protocols regarding the intake of clear liquids by women in in the medical record.
Guidelines for Acute Pain Management Using any solution that is not standard in the facility, the anes- Neuraxial Analgesia thesiologist should verify the order with nursing and pharmacy personnel and discuss its indications and all When neuraxial analgesia is managed by anesthesiologists, concerns relating to its use with the nurses responsible for the incidence of side effects is no higher than when alter- administering the drug and monitoring the patient.
The risk of errors due to incorrect route of drug injection Accordingly, when its use is appropriate, neuraxial anal- must be minimized. For continuous infusions or PCEA, the gesia should be managed by anesthesiologists. The purpose of these ports that could permit unintentional injection of intrave- guidelines is to provide principles of management for nous drugs.
All analgesic drug solutions should be labelled with the composition of the solution opioid, local anes- Administrative and Educational Policies thetic, or both and its intended route of administration epidural or intravenous. The department of anesthesia should establish an acute pain service that is responsible for Patient Monitoring and Management of Adverse Events 1.
Developing policies and procedures for neuraxial Patients receiving neuraxial analgesia should be in a room analgesia. Participation of other departments, such as equipped with oxygen and suction. Resuscitation drugs and nursing, pharmacy, surgery, and materials manage- equipment must be immediately available. Before initiating ment should be sought as needed. Liaison with the surgical departments. Surgeons and after discontinuing neuraxial analgesia, intravenous need to understand the criteria for patient selection, the access must be maintained for the expected duration of effects of neuraxial analgesia on the normal postoper- drug effects.
Standardized policies for patient management should be 3. Education and certification of nurses. A standard- established. The parameters to be assessed, frequency of ized educational program that includes initial training, assessments, documentation, and procedures for manage- certification, and ongoing maintenance of competence ment of complications should be specified. Adequate should be established for nurses caring for patients nursing personnel must be available to assess and manage receiving neuraxial analgesia.
Nursing personnel patients receiving neuraxial analgesia. Each facility should also specify proce- complications of epidural hematoma or abscess. Policies for Drug Administration Other drugs, particularly benzodiazepines or parenteral opioids, may cause severe respiratory depression in Each facility should use a limited number of standard patients receiving neuraxial analgesia. For this reason, solutions. Preprinted order sheets listing the standard other physicians should not order sedatives or analgesics solutions are strongly recommended.
Before dispensing for any patient receiving neuraxial analgesia. Patients with epidural catheters may receive prophy- Patients should be classified as to physical status in a lactic low-dose anticoagulant therapy if appropriate manner similar to that in use by the American Society of precautions are taken. Anesthesiologists Appendix 2. Patients in classifi- insertion and removal and the timing of anticoagulant cation III may be accepted under certain circumstances.
The duration of fasting before anesthesia postoperative pain management, every effort should should conform to the previously stated guidelines. The be made to avoid lower extremity motor blockade. Any change in neurologic status or new-onset back pain must be Conduct of Anesthesia investigated immediately.
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