Recommendations for the Monitoring of Patients During Anaesthesia (France)

With the aim of contributing to the optimum safety of anaesthetized patients, the French Society for Anaesthesiology and Intensive Care (SFAR) recommends monitoring principles set out in this document. Monitoring should be employed whenever general anaesthesia, regional analgesia, or sedation is performed for a therapeutic or diagnostic procedure. Monitoring during obstetric analgesia will be the subject of specific recommendations. The recommendations apply to staffing and to monitoring of both patient and anaesthetic apparatus. To this basic clinical and instrumental monitoring may be added further measures depending on the condition of the patient, the nature of the procedure and the anaesthetic requirements. In an emergency it may not be possible to implement these recommendations in full. Monitoring by competent personnel is also necessary during transfer of a patient to recovery ward, dependency unit, or intensive care unit. Monitoring in the recovery ward will be the subject of specific recommendations.

1. Staffing

General anaesthesia, regional analgesia and intravenous sedation must be performed by, or in the presence of a qualified anaesthesiologist This may be a doctor who has completed specialist training in anaesthesiology, or one undergoing such training provided his or her competence is appropriate to the procedure being performed. In certain situations (particular operation and/or patient at high risk) other doctors may need to be present.

The anaesthesiologist may be helped by a doctor undergoing specialist training and/or an anaesthetic nurse. These assistants are not entitled to perform anaesthesia in the absence of an anaesthesiologist. Their roles are confined to those of surveillance and assistance.

The anaesthesiologist may have to leave the operating mom for a brief period and entrust the monitoring of patient and apparatus to a trainee and/or anaesthetic nurse. Nevertheless the anaesthesiologist remains responsible for the procedure unless handover has been made to someone suitably qualified.

2. Monitoring of Patient and Anaesthetic Apparatus

During anaesthesia, oxygenation, ventilation, and the circulation are monitored continuously and relevant data are noted in the anaesthetic record.

When the anesthesiologist has to be remote from the patient (particular procedure ionizing radiation, MRI) adequate instrumental monitoring substitutes for close clinical observation.

2. 1. Oxygenation

Monitoring of oxygenation includes: a) continuous measurement of oxygen concentration in the administered gas mixture b) observation of the patient, c) continuous measurement of blood oxygen saturation, or equivalent.

2.2. Ventilation

Monitoring of ventilation is based on clinical observation (rate, amplitude and symmetry of thoracic expansion, movements of reservoir bag, auscultation) and measuring devices (expired volume and airway pressure). If expired gas can be collected, the measurement of expired CO2 is recommended.

After tracheal intubation and after every change in the patient’s position, correct placement of the tracheal tube is checked.

2.3. Circulation

Monitoring of the circulation comprises assessment of heart beats, heart rate, arterial pressure, peripheral circulation, and ECG.

Heart beats are monitored by palpation of the pulse and/or at least one of the following measures: auscultation of the heart, continuous measurement of arterial blood pressure and pulse oximetry or equivalent technique. The values of head rate and blood pressure are noted at intervals which should not exceed five minutes. ECG monitoring should be saw before induction and continued until recovery.

2.4. Additional Monitoring

During anaesthesia a careful watch is kept on the patient’s position, with particular attention to pressure points and areas where risk of nerve damage is high. A further check is made whenever the patient’s position is changed.

Central temperature should be measured whenever a significant change occurs or is expected; this measurement is particularly indicated in small children. Monitoring of urine output is indicated during certain types of operation (long duration, following transfusion) and if problems occur with the circulation.

3. Monitoring Equipment

The anaesthesiologist must have available equipment with which he or she is familiar, and whose correct functioning has been confirmed using a check list.

3. 1. Monitoring the Patient:

Every site where anaesthesia is performed should be equipped as follows:

3. 1. 1. Mandatory Equipment:

ECG monitor Device for automatic blood pressure measurement

Pulse oximeter

3.1.2. Recommended Equipment:

Capnograph

3.2. Monitoring the Anaesthetic Machine:

Every anaesthetic machine should be equipped with the following devices:

An oxygen supply pressure gauge situated on the machine or pipeline

An oxygen analyzer connected to the anaesthetic breathing system giving audible warning of low concentration; the presence of safety linkage between N2O and O2 flow controls does not allow this requirement to be waved

During mechanical ventilation, the ventilator must be fitted with warning devices indicating

a) disconnection or leak,

b) excessive airway pressure,

c) ventilator arrest.

3.3. Supplementary Equipment

Other monitoring devices may be indicated depending on the state of the patient, the type of procedure and anaesthetic requirements. They include monitors of temperature, neuromuscular block, and intravascular pressures, anaesthetic gas analyser, and ECG recorder.

At present, the lack of staff and/or equipment in some hospitals may prevent the full implementation of these recommendations. In this case SFAR recommends that anaesthesiologists should draw up with the hospital administration a plan naming a date (no later than 1 st January 1993) by which the necessary staff and equipment will be available