Volume 6, No. 1 • Spring 1991

ASA Standards Amended : C02 Seen After Intubation Now the ‘Standard of Care’

John H. Eichhorn, M.D.

Further “fine tuning” of the American Society of Anesthesiology published standards of care occurred at the ASA meeting in October. Previewed in the Fall 1990 issue of the APSF Newsletter were the proposed amendments to the Standards for Basic lntraoperative Monitoring and the Standards for Postanesthesia Cam These were adopted with minimal alteration and one comment.

An unplanned procedural development involved debate over the Standards for Conduction Anesthesia in Obstetrics. No consensus could be finally achieved regarding the many proposed alterations in those standards in time for consideration by the ASA House of Delegates. Therefore, the substance of this set of standards was left temporarily intact and the document was retitled “Guidelines” instead of “Standards” with the anticipation that a newly revised set of guidelines would be offered for approval in 1991. The Committee on Standards of Care and the Committee on Obstetric Anesthesia were charged with generating the new document and both are actively seeking input from all interested anesthesia providers. Specific analysis of the saw implications of these guidelines in their various forms will be forthcoming in a future Newsletter issue

The proposal to modify the intraoperative monitoring standards was adopted as offered and has direct relevance to patient safety. In the “Ventilation” section, the second point now reads: “When an endotracheal tube is inserted, its correct positioning in the trachea must be verified by clinical assessment and by identification of carbon dioxide in the expired gas. End-tidal C02 analysis, in use from the time of endotracheal tube placement, is encouraged.”

Some Misplaced ET Tubes Stiff Going Unrecognized

This change was inspired by the fact that the ASA Closed Claims Study organizers have noted that unrecognized esophageal intubation was the single cause of anesthesia related catastrophe apparently least affected by all the patient safety efforts to date. The modification of the formal published standard (effective January 1, 199 1) stops short of mandating capnography in all cases when physically practical but a comment was generated in the ASA annual report that there was significant testimony at the Reference Committee that the Committee on Standards of Care should consider continuous end-tidal C02 monitoring as a future standard.

PACU Oximetry

The pulse oximeter amendment to the standards for Postanesthesia Care was modified slightly in the review process and targeted to cover patients “in the initial phase of recovery” with mandatory pulse oximetry. Further, an exception was added with the wording “This is not intended for application during the recovery of the obstetrical patient in whom regional anesthesia was used for labor and vaginal delivery.” The effective date is January 1, 1 992. At that time, it will be the formal published standard that, with the noted routine obstetrical exception, all patients who have received an anesthetic must be monitored at least in the initial phases of recovery with pulse oximetry.

Focus Shifted from OR

The impetus for the comparatively expansive scope of the PACU mandate was the recognition that in the last several years, there appeared to be far fewer intraoperative hypoxic incidents while, at the same time, hypoxic accidents in the PACU received much more attention, either because there were more of them or they simply stood out more as the OR accidents decreased dramatically The patient safety implications are clear. The drafters are hoping to optimize PACU outcome with pulse oximetry as one key component of a comprehensive safety program in a manner analogous to what many people believe has happened in the operating room. Also, in 1991, there likely will be an acceleration of the trend to equip PACUs with a significant, and therefore sufficient, number of pulse oximeters to meet this newly mandated level of care.

In the current year, in addition to the further work on the obstetrical guidelines, attention will be given via the ASA mechanism to the issues surrounding the JCAHO-required role for anesthesiologists to participate in the formulation of policy and procedure for non-anesthetists to use intravenous sedation outside the operating room. Again, the patient safety implications of such considerations are obvious and will be reported here as completed proposals are brought forth.

Dr. Eichhorn, of the University of Mississippi Medical Center is Editor of APSF Newsletter and a member of the ASA Committee on Standards of Care.