With precedent-setting resolve the American Society of Anesthesiologists’ House of Delegates at the ASA annual meeting in October adopted formal standards of practice for intra-operative monitoring. “Standards for Basic Intra-Operative Monitoring” (see page 3) represents the first set of detailed specifications of the minute-to-minute conduct of anesthesia practice published by the ASA.
The ASA Ad Hoc Committee on Standards of Care reported “. . . this should have a major impact in reducing unexpected deaths related to anesthesia due to human error. The judgment of the anesthesiologist in assessing the patient’s condition has been acknowledged and preserved as an integral part of the success of any venture which is directed at improving patient safety and optimizing cam We believe that the Standards combine the art of medicine with the reasonable application of technology.”
The standards mandate the presence of qualified anesthesia personnel in the room throughout all anesthetics and the continual evaluation of the patients’ oxygenation, ventilation, circulation, and temperature. Monitoring of end-tidal C02 (capnography) for ventilation and use of pulse oximetry for oxygenation are cited as quantitative evaluations (rather than the traditional qualitative methods) and are “encouraged”.
The standards are practical and realistic, as shown by the notation of the possibility of brief interruptions and various exceptions. There is elaboration of the methodology to be employed to help ensure adequate oxygen availability, ventilation, circulatory function, and maintenance of temperature. Provisions are made for future revision of the standards, as warranted by the evolution of technology and practice.
In the process of developing the standards, the ASA Committee on Standards of Care focused on the potential preventability of anesthesia morbidity and mortality. The committee reviewed the literature and also case files from the Harvard associated malpractice insurer, the State of Washington, and the ASA dosed claims study This review led to the conclusion that improved intraoperative monitoring could make the greatest impact and should be the first area of attention.
Burton S. Epstein, M.D., chairman of the committee, suggests that the development of these monitoring standards and other standards to be proposed in the future should “significantly improve” the chances of a successful outcome of an anesthetic. He noted that the standards constitute an ASA attempt to clearly delineate methods by which anesthesia accidents due to human error can be reduced.
The ASA committee debated whether to include capnography and pulse oximetry as the “standard of care’ ‘At that time, it was felt impractical to mandate very specific (and very expensive) high tech equipment when the greatest focus of the effort was the general extension of the vigilance of the anesthesiologist. The committee also considered the questions of the consistency of performance of these two instruments and the availability at that time relative to the potential demand. However, E. C. (“Jeep7’) Pierce, M.D., committee member and past president of the ASA, now states, “Capnography and oximetry are becoming so widespread that they will he functional standards. Projecting current trends, it is likely that by the end of 1988, enough oximeters will have been sold for there to be one available for every operating room in the country”.
Dr. Eichhorn, Harvard Medical School, is a member of the ASA Committee on Standards of Cam and Editor, APSF News Letter.