Volume 7, No. 3 • Fall 1992

International Standards for a Safe Practice of Anaesthesia

Adopted by the World Federation of Societies of Anaesthesiologists June 13, 1992

Developed by the International Task Force on Anaesthesia Safety*


These Standards of Care are recommended to anaesthetists throughout the world. Their purpose is to provide guidance and assistance to anaesthetists, professional societies, hospital administrators, and governments in improving the quality and safety of anaesthesia.

For some anaesthetists, these Standards will represent a future goal, while for others they may already have been implemented and be regarded as mandatory. The most important standards relate to the individual anaesthetist. Monitoring devices play an important part in safe anaesthesia as extensions of clinical skills rather than their replacement.

Minimum standards, indicated in bold, are applicable to any preplanned anaesthetic, from patient evaluation to recovery; it is recognized, however, that immediate lifesaving measures always take precedence in an emergency. Further recommendations should be implemented as resources and training permit: highly recommended standards should be implemented first, followed by those which are recommended, and then those that are encouraged. (A Glossary of terms used in this document is given in Appendix A.)

It is anticipated that these standards will need revision as practice and technology evolve.


1. Professional Status

The provision of anaesthesia is a vital component of basic health care and merits an appropriate share of the available resources. It is highly recommended that anaesthetists should be appropriately trained and accredited medical specialists with clinical and administrative autonomy. Where anaesthesia is provided by other personnel, it is highly recommended that the anaesthetist should be appropriately trained and accredited, and directed and supervised by medically qualified specialist anaesthetist.

2. Professional Organizations

Anaesthetists should form appropriate organizations at local, regional, and national levels for the setting of standards of practice, supervision of training and continuing education with appropriate certification and accreditation, and general promotion of anaesthesia as an independent professional specialty. These organizations should form links with appropriate groups within the region or country and internationally.

3. Training, Certification and Accreditation

Adequate time and facilities should be available for professional training, both initial and continuing, to ensure that an adequate standard of knowledge, expertise, and practice is attained and maintained. Formal certification of training and accreditation to practice is recommended.

4. Records and Statistics

A record of the details and course of each anaesthetic should be made and preserved with the patients medical record. This should include details of the pre-operative assessment and the post-operative course. It is recommended that individuals, departments, and regional and national groups collect data to facilitate the progressive enhancement of the safety, efficiency, effectiveness, and appropriateness of anaesthesia.

5. Peer Review

Institutional, regional and/or national mechanisms to provide a continuing review of anaesthetic practice should be instituted. Regular confidential discussion of appropriate topics and cases with professional colleagues should take place. Mechanisms and protocols should be developed to ensure that deficiencies in individual and collective practice are identified and rectified. Anonymous incident reporting is encouraged as a useful mechanism in this respect. Legal safeguards of the confidentiality of the review material may be appropriate and should be sought where they do not already exist.

6. Workload

A sufficient number of trained anaesthetists should be available so that individuals may practice to a high standard. Time should be allocated for professional development, administration, research, and teaching.

7. Personnel

An anaesthetist must be dedicated to each patient and be present throughout each anaesthetic (general, regional, or monitored sedation), and should be responsible for the ,transport of the patient to the post-anaesthesia recovery facility and the transfer of care to appropriately trained personnel. The anaesthetist should retain overall responsibility for the patient during the recovery period and should be readily available for consultation until the patient has made an adequate recovery. The anaesthetist should ensure, if aspects of direct care are delegated before, during, or after an anesthetic, that the person to whom responsibility is delegated is both suitably qualified and conversant with relevant information regarding the anaesthetic and the patient.

Where it is impossible for the above standard to be attained and the surgeon or another individual assumes responsibility for the anaesthetic, it is highly recommended that the practice and cases be reviewed and audited from time to time by an appropriately trained anaesthetist.

8. Facilities and Equipment

Appropriate equipment and facilities, adequate both in quantity and quality, should be present wherever anaesthesia and its recovery is undertaken. A list of recommended equipment and suggestions as to the order in which additions should be made as resources permit is given in Appendix B.

It is highly recommended that anaesthesia equipment conforms to relevant national and international standards.

Formal certification of an individual’s ability to use a specific piece of equipment correctly and safely is encouraged.


The first and most important component of peri-anaesthetic care, including monitoring of the anaesthesia delivery system and the patient, is the continuous presence of a vigilant anaesthetist throughout the operative period.


The patient must be evaluated by an anaesthetist prior to induction of anaesthesia. The anaesthetist must ensure that all necessary equipment is in working order prior to the induction of anaesthesia. The development of protocols to facilitate such verification is encouraged.

The anaesthetist should ensure that assistance is available and that the assistants has been instructed in, or is competent at, the necessary tasks.


A. Oxygenation

(i) Oxygen supply : Supplemental oxygen is highly recommended for all patients undergoing general anaesthesia. The anaesthetist should ensure the integrity of the oxygen supply. When nitrous oxide or other supplemental gases are used, the concentration of oxygen in the inspired gas should be verified, at least at the commencement of each anaesthetic session. It is highly recommended that the inspired oxygen concentration be monitored throughout each anaesthetic with an instrument fitted with a low oxygen concentration alarm. An oxygen supply failure alarm and a device protecting against the delivery of an hypoxic gas mixture are highly recommended. A system should be used to prevent misconnection of gas sources.

(ii) Oxygenation of the Patient : Tissue oxygenation should be monitored whenever practicable by visual examination. Adequate illumination and exposure of the patient should be ensured whenever practicable unless an appropriate monitor is used. The continuous use of a quantitative monitor of oxygenation such as pulse oximeter is highly recommended.

B. Airway and Ventilation

* The adequacy of the airway and ventilation should be continuously monitored by observation and auscultation whenever practicable.

* Where a breathing circuit is used, movement of the reservoir bag should be observed. Continuous monitoring with a precordial, pretracheal, or oesophageal stethoscope is highly recommended.

* Confirmation of the correct placement of the endotracheal tube and the adequacy of ventilation by continuous measurement and display of the carbon dioxide waveform and concentration is highly recommended.

*When mechanical ventilation is employed, a ‘disconnect alarm’ should be used throughout the period of mechanical ventilation.

* Continuous measurement of the inspired and/or expired gas volumes is recommended.

C. Circulation

(i) Cardiac rate and rhythm

* The circulation should be monitored continuously. Palpation or registration of the pulse and/or auscultation of the heart sounds should be continuous.

* Continuous monitoring and display of the heart rate with a plethysmograph (stand alone or pulse oximeter) or electrocardiograph are highly recommended. The provision of a defibrillator is highly recommended.

(ii) Tissue perfusion

* The adequacy of tissue perfusion should be monitored continually by clinical examination.

* Continuous monitoring with a plethysmograph or capnograph is highly recommended.

(iii) Blood pressure

* Arterial blood pressure should be determined at appropriate intervals (usually at least every five minutes, and more frequently if indicated by clinical circumstances).

* Continual registration of arterial pressure is encouraged in appropriate cases.

D. Temperature

A means of measuring the temperature should be available and should be used at frequent intervals where clinically indicated (e.g. prolonged or complex anaesthetics, young children).

* The continual measurement of temperature in patients in whom a change is anticipated, intended or suspected is highly recommended. The provision and use of continuous electronic temperature measurement is recommended.

E. Depth of Anaesthesia

* The depth of anaesthesia should be regularly assessed by clinical means. The continuous measurement of inspired and expired concentrations of nitrous oxide and volatile agents is encouraged.

F. Neuromuscular Function

* When neuromuscular blocking drugs are given, the use of a peripheral nerve stimulator is recommended.


A. Facilities and Personnel

* All patients who have had an anaesthetic affecting central nervous system function and/or loss of protective reflexes should remain where anaesthetized or be transported to a location specifically designated for post-anaesthesia recovery. See ‘General Standards” (Section 7) above for delegation of responsibilities of the anaesthetist.

B. Monitoring

* All patients should be observed and monitored in a manner appropriate to the state of their nervous system function, vital signs, and medical condition with emphasis on oxygenation, ventilation, and circulation.

* Supplementation of clinical monitoring with quantitative methods described above for intraanaesthetic patient care is recommended. Pulse oximetry is highly recommended.

Appendix A : GLOSSARY

1. “Anonymous incident reporting” mechanism for reporting anaesthesia incidents without identifying the individual administering the anaesthetic

2. “continual” repeated regularly and frequently

3. “continuous” without interruption



1. For anaesthetic administration as available, including intravenous anaesthesia, regional anaesthesia, and inhalational anaesthesia (open techniques or suitable draw-over vaporizer)

2. For patient monitoring

a. stethoscope

b. sphygmomanometer

c. light source

d. thermometer

3. For patient support

a. airway management (airways, masks suction apparatus laryngoscope, endotracheal tubes)

b. ventilatory support (self-inflating bag oxygen supply)

c. circulatory support (needles, syringes, cannulae, infusion fluid)

d. drug therapy (as appropriate for common emergencies and cardiopulmonary resuscitation)


1. For anaesthesia administration

a. compressed gas supply (02, N20)

b. calibrated vaporizer

c. anesthetic circuits

2. For patient monitoring

a. oxygen supply failure alarm

b. oxygen analyzer

c. oximeter

d. capnometer e. ECG

3. For patient support defibrillator


1. For anesthetic administration

a. anaesthesia machine with integrated monitoring of its function

b. neuromuscular blockers

2. For patient monitoring

a. of airway/ventilation (capnograph respiratory volume monitor airway pressure alarm)

b. of circulation (automated blood pressure (oscillometry) invasive hemodynamic pressures c. of administered anaesthetic peripheral nerve simulator respired drug monitoring)

3. For patient support

a. mechanical ventilator

* a disconnect alarm is mandatory if a mechanical ventilator is used (e.g. low pressure, capnograph, expired volume)

+ Members of the International Task Force on Anesthesia Safety

L.H.D.J. Booij (Netherlands), J.M. Desmonts (France), P.G. Duncan (Canada), J.H. Eichhom (U.S.A.) secretary, J.S. Gravenstein (U.S.A.), C.D. Hanning (U.K.), K. Ikeda (Japan), W.B. Runciman (Australia), H. Stoeckel (Germany), T. Tammisto (Finland).