Volume 4, No. 3 • Fall 1989

Monitoring for All Phases of Care

Anthony P. Adams

The AAGBI document addresses the provision of standards of monitoring in the anesthetic room, the operating room, the recovery room, and during transfer of patients under the care of the anesthesiologist within the hospital and between hospitals. The concept of monitoring from before induction until after recovery from anesthesia is stressed. This has caused many anesthesiologists to reconsider the use of the traditional British anesthetic room as an induction room because of the need for reduplication of equipment and the problem of transferring patients into the operating room while maintaining full monitoring. Opinion is divided on this point but the anesthetic room can always be retained as the anesthesiologist’s “base” for reception of patients, establishment of venous access and application of monitoring sensors. The document recognizes that standards for patient monitoring have been promulgated in several countries, notably at Harvard Medical School (1986) and at other institutions in the U.S.A., which lead on to adoption by the A.S.A. The Netherlands adopted standards as far back as 1978.

The increase in malpractice insurance premiums by 7 1 % in 1987 and by 88% in 1988 in the U.K., plus the publicity given by several legal cases has also focused attention on safety; further rises in premiums are due this year and there is a real prospect that differential subscriptions according to specialty will be introduced, something hitherto unknown in the U.K.

The AAGBI document emphasizes the need for the continuous presence of the anesthesiologist throughout the conduct of the anesthetic so the patient can be observed constantly and an adequate record kept; ” also applies to any local or regional anesthetic or sedation involving a risk of unconsciousness, or cardiovascular or respiratory complications either from the technique employed or from systemic toxicity of the local anesthetic agent or sedative drugs.

The document also addresses the monitoring of the anesthetic machine and the monitoring of the patient as separate but intimately related functions. The emphasis is always on clinical observations first, with a back up constant supply of information coming in to the anesthesiologist’s senses from monitoring instruments. The recommendations also apply to operations or procedures of brief duration including those outside the operating room (dental extraction or conservation, endoscopy, cardioversion, electroconvulsive therapy, etc). The use of routine pulse oximetry, and capnography with a tracing display of the C02 waveform, is strongly recommended.

Summary of Main Recommendations

(The full recommendations are not reproduced here for reasons of space but are available from the AAGBI at 9 Bedford Square, London WCIB 3RA, England.)

a. The anaesthetist should be present throughout the conduct of the whole anesthetic and should ensure that an adequate record of the procedure is made

b. Monitoring should be commenced before induction of anaesthesia and continued until the patient has recovered from the anesthetic.

c. Monitoring of anesthetic machine function should include an oxygen analyzer (with alarms) and devices which enable leaks, disconnections, rebreathing or overpressure of the breathing system to be detected.

d. Continuous monitoring of ventilation and circulation is essential. This may be performed using the human senses augmented, where appropriate, by the use of monitoring equipment. Clinical observations include the patient’s color, responses to the surgical stimulus, movements of the chest wall and reservoir bag, palpation of the pulse and auscultation of the breath and heart sounds. Continuous monitoring devices include the pulse plethysmograph, the pulse oximeter, the electrocardiograph, the capnograph, and devices for measuring vascular pressures and body temperature

e Where intermittent non-invasive methods are used to measure arterial pressure and heart rate the frequency of measurement should be appropriate to the clinical state of the patient.

f. A peripheral nerve stimulator should be readily available when neuromuscular blocking drugs are employed.

g. Additional monitoring may be required for long or complicated operations and for patients with co-existing medical disease.

h. Adequate monitoring is needed during brief anesthetics or when using local anesthetic or sedation techniques which may lead to loss of consciousness or to cardiovascular or respiratory complications.

i. Appropriate monitoring should be used during transport of the patient whilst under the care of the anaesthetist.

j. Anaesthetists should issue clear instructions concerning monitoring during postoperative care when handing over the patient to recovery ward staff. Appropriate monitoring facilities should be available in the recovery ward.

The College of Anaesthetists held a Symposium of Safety and Standards of Anaesthesia in November last yen; one speaker, a prominent lawyer, thought the AAGBI recommendations were excellent and sorely needed the only problem he felt was that many words such as ‘should’ really ought to be ,must’. This was particularly interesting as many anesthesiologists are now of the same opinion. It must be admitted that the original document produced by the AAGBI working party was somewhat watered down before publication because some members of Council had strongly objected to too many words such as “must”! Indeed the word “appropriate” (in [e] and [i]) has met with justified criticism. However, from the outset, this document has been regarded as an important step in patient safety as well as to advise and support our members, and we anticipate that revisions will be required from time to time to take account of changes in clinical practice and the evolution of technology.

A very important point remains which is the training of anesthesiologists in the use of monitoring equipment. It is often amazing that many practitioners still do not know the default alarm settings of monitors or bother to set the alarm limits appropriate to the patient concerned.

Anthony P. Adams, M.B., B.S., Ph.D., FFARCS, FFARACS, is Chairman of Association of Anaesthetists of Great Britain & Ireland Working Party on Safe Monitoring, Chairman of AAGBI Safety Committee, and from the Department of Anaesthetics, United Medical & Dental Schools, Guy’s Hospital, London, England.