The Urgency of Redifining Minimum Monitoring Standards in Anesthesia

Anesthesiology
The Urgency of Redifining Minimum Monitoring

Standards in Anesthesia
LD Mishra*, Ankit Agarwal**
Abstract
Anesthesiology is an intense discipline, which entails unexpected, often life threatening complications, requiring immediate
recognition and prompt intervention. It is essential to have uniform standards of monitoring irrespective of location, duration
and type of anesthesia.The Indian Society of Anesthesiologists (ISA) in 1998 started preparing guidelines suited for indian
conditions and presented these in 1999. The 1999 ISA guidelines have outlived and there is an urgent need to update the
currently applicable guidelines. These guidelines of ISA are under revision since April 2007. Keeping in view of developments
in the field, medically complex patients, training methods of present day trainees and CPA needs, updated guidelines should
include additional monitoring techniques and precautions.
Keywords: Anesthesiology, standard of monitoring, guidelines, ECG monitor, defibrillator, pulse oxymetry
I
t has been almost a decade since minimum availability of infrastructure and the cost involved
monitoring standards for anesthesiologists in India had been a hindrance. The Indian Society of
came into force. In this decade, medicine and its Anesthesiologists (ISA) took lead in 1998 and started
practice has changed a lot. With changing trends preparing guidelines suited for Indian conditions and
in medicine, there is an urgent need for revision in presented these in 1999 w.e.f. 31/12, mostly based
guidelines for anesthesiologists too. The practice of on 1992 WFSA guidelines.3 These were adopted as
anesthesiology is not a wait and watch approach. It is National Monitoring Standards being applicable to
indeed an intense discipline which entails unexpected, anesthesia practice in the entire country.
often life threatening complications, requiring
immediate recognition and prompt intervention. Details of 1999 ISA Guidelines for Minimum
Most perioperative complications are preventable, Monitoring Standards
if properly monitored. Executing at least a core
A hospital in an Indian setup cannot boast of the
monitoring standard is important for patient safety
as well as for anesthetists safety. It is essential to luxury of meeting all standards set internationally.
have uniform standards of monitoring irrespective of To comply with the vital standards and to have others
location, duration and type of anesthesia.1 whenever possible, these standards were divided into:
i) Prerequisites, ii) basic standards and iii) desirable
The first worldwide attempt to establish monitoring
standards.
standards was by the American Society of
Anesthesiologists (ASA) in the year 1986.2 Thereafter, Prerequisites
the World Federation of Society of Anesthesiologists
(WFSA), in 1992 endorsed these recommendations of These are the facilities whose availability should be a
ASA with few changes. Subsequently, the ASA (and must to every anesthetist, and must be ensured before
also the WFSA) has been updating its guidelines every starting any anesthetic procedure, whether elective or
few years. emergency. The prerequisites imply to, not just the
material availability of certain equipments, but also to
There was an impending need for preparing and
following such guidelines in India too. But lack of the anesthetist, the medical fraternity involved and the
management of the organization responsible.
*Head, Dept. of Anesthesiology Physician

Division of Neuroanesthesiology
**Dept. of Anesthesiology
A medically qualified anesthesiologist only can
Banaras Hindu University, Varanasi, Uttar Pradesh administer anesthesia.
122 Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013
Anesthesiology
Facilities and Equipments be equipped with failure warning facility. Pulse

All resuscitation equipments must be available in oxymetry, should be used in every procedure.
operating room (OR) area. Availability of resuscitation In addition major procedures will require noninvasive
equipments, uninterrupted oxygen supply, anesthesia BP (NIBP), oxygen analyser, airway pressure
machine and other equipments should be confirmed alarm, respiratory volume monitor, capnography, NM
and checked before starting procedure. There should monitor, etc.
be a reliable suction and an uninterrupted light source.
The urgent need of updated guidelines
Personnel and Workload
The 1999 ISA guidelines have outlived, as many, even
Adequate number of anesthetists must be available as very basic monitorings have been left out. Thus, there
per workload. Each anesthesiologist should be assisted is an urgent need to update the currently applicable
with a fully dedicated personnel/technician. Sharing guidelines.
of manpower, may sometimes, in the event of an
untoward emergency, be disastrous. These guidelines of ISA are under revision since April
2007. Now, India is emerging as an economically sound
Anesthesia team is responsible for transport of patient
country, and more sophisticated surgeries and other
to recovery room (RR) unit and availability for later
treatments are being undertaken. Keeping in view of
consultation, if needed. Transport of patients must not
developments in the field, medically complex patients,
be leftover to other staff, as the anesthetist, who was
training methods of present day trainees and CPA
with the patient throughout the procedure best knows
needs, addition in these guidelines is needed. Thus,
about conditions such as drugs administered, possible
updated guidelines should include following additional
interactions and thus can most efficiently manage an
monitoring techniques and precautions:
emergency.
An anesthesiologist should start a case only when
Records Keeping
prerequisites and basic monitoring facilities are
Details of each anesthesia procedure must be available and functional.
entered into patients medical record with outcome/ ECG, NIBP, SaO2 (with PR and waveform) and
complications, if any.
core temperature monitoring should be a must for
Professional Organization Membership every case.
Appropriate anesthesia forums must be active with Most standards from desirable should now be
regular organizational and scientific meetings to keep shifted to Basic monitoring standards.
up-to-date with recent advances in this field. All All machines and equipments should have O2
anesthesiologits must attend regular CMEs, updates failure warning facility.4
and conferences (local, state, national and international).
Anesthetic specific vaporizer should be available.
Basic Standards There should be availability of central gas supply
This includes requirements that are essential in and suction.
all situations. These include: Often undermined, Availability of a flexible fiberoptic bronchoscope
preanesthetic evaluation and adherence to a proxy would ease difficult airways and to a large extent
autoconfiguration (PAC) protocol. Pulse, precordial will reduce complications.5
stethoscope, BP and temperature monitoring should Access to modern equipments as fiberoptic
be routinely done. The skin color, pulse and blood laryngoscopes and C-LMAs would greatly
pressure (BP) should be noted every five minutes.
increase patient safety, at the same time easing the
In addition, an ECG monitor with a defibrillator
anesthetist. These must be labeled as desirable.
capable of displaying rate and wave pattern should be
available. In place of a routine defibrillator, an automated
external defibrillator (AED) would be beneficial
Desirable Standards as it can automatically sense rhythm and act
Each operation theater (OT) should have at accordingly.
least one anesthesia machine with an anesthetic Ready availability of portable ultrasound machine,
specific vaporizer, and all equipments should Doppler, etc. with the anesthetist, providing point
Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013 123
Anesthesiology
of care facility would ease and make procedures as Additional Points to be Included in Final Proposals
central venous catheterization safer.
Anesthesiologists must give sufficient time and
Major procedures will also require oxygen analyzer, information to his reliever if handover is required
airway pressure alarm, respiratory volume monitor, and this should not be taken lightly. If called for a life
capnography, NM monitor, etc.6 saving procedure in an adjacent room, it is the individual
Airway pressure EtCO2 monitor should be a must for decision whether to leave patient unattended or not. If
laparoscopic surgeries. he/she decides to leave; the surgeons must agree and
stop surgery until return. Finally, an informed and
Provision, maintenance, calibration and renewal of alert anesthesiologist is the best monitor, provided
equipments should be an institutional responsibility.7 guidelines too are followed.
Another important aspect to be incorporated in
the proposed guidelines will be the duration of References
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124 Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

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Anesthesiology

The Urgency of Redifining Minimum Monitoring

*Head, Dept. of Anesthesiology Physician

Facilities and Equipments be equipped with failure warning facility. Pulse

CPAP Reverses White matter Changes in Sleep Apnea

Malignant Melanoma Risk 4-fold Higher in Parkinsons

Post-Traumatic Stress Disorder

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