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Recommendations for standards of monitoring during anaesthesia and

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Anaesthesia 2016, 71, 85–93 doi:10.1111/anae.13316

Guidelines
Recommendations for standards of monitoring during anaesthesia
and recovery 2015 : Association of Anaesthetists of Great Britain
and Ireland*
M. R. Checketts,1 R. Alladi,2 K. Ferguson,3 L. Gemmell,4 J. M. Handy,5 A. A. Klein,6 N. J. Love,7
U. Misra,8 C. Morris,9 M. H. Nathanson,10 G. E. Rodney,11 R. Verma12 and J. J. Pandit13

1 Consultant, Department of Anaesthesia, Dundee, UK, and Chair of Working Party, AAGBI
2 Associate Specialist, Department of Anaesthesia, Tameside Hospital, Ashton-under-Lyne, UK and Representative,
Royal College of Anaesthetists
3 Consultant, Aberdeen Royal Infirmary, Aberdeen, UK
4 Consultant, Department of Anaesthesia, North Wales Trust, North Wales, UK
5 Consultant, Department of Anaesthesia and Intensive Care, Chelsea and Westminster Hospital, London, UK
6 Consultant, Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
7 Consultant, Department of Anaesthesia and Intensive Care Medicine, North Devon District Hospital, Barnstaple,
Devon, UK, and Representative, Group of Anaesthetists in Training, AAGBI
8 Consultant, Department of Anaesthesia, Sunderland Royal Hospital, Sunderland, UK
9 Consultant, Department of Anaesthesia and Intensive Care, Royal Derby Hospital, Derby, UK
10 Consultant, Department of Anaesthesia, Nottingham University Hospitals, Nottingham, UK
11 Consultant, Department of Anaesthesia, Ninewells Hospital and Medical School, Dundee, UK
12 Consultant, Department of Anaesthesia, Derby Teaching Hospitals, Derby, UK
13 Consultant, Department of Anaesthesia, Nuffield Department of Anaesthetics, Oxford University Hospitals, Oxford, UK

Summary
This guideline updates and replaces the 4th edition of the AAGBI Standards of Monitoring published in 2007. The
aim of this document is to provide guidance on the minimum standards for physiological monitoring of any patient
undergoing anaesthesia or sedation under the care of an anaesthetist. The recommendations are primarily aimed at
anaesthetists practising in the United Kingdom and Ireland. Minimum standards for monitoring patients during
anaesthesia and in the recovery phase are included. There is also guidance on monitoring patients undergoing seda-
tion and also during transfer of anaesthetised or sedated patients. There are new sections discussing the role of mon-
itoring depth of anaesthesia, neuromuscular blockade and cardiac output. The indications for end-tidal carbon
dioxide monitoring have been updated.
.................................................................................................................................................................

*This is a consensus document produced by members of a Working Party established by the Association of Anaesthetists of
Great Britain and Ireland (AAGBI). It has been seen and approved by the AAGBI Board of Directors. Date of review: 2020.
Accepted: 13 October 2015
This Guidelines is accompanied by an editorial by Lumb and McLure, Anaesthesia, 2016; 71: 3–6.
.................................................................................................................................................................
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs
License, which permits use and distribution in any medium, provided the original work is properly cited, the use is
non-commercial and no modifications or adaptations are made.

© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland. 85
Anaesthesia 2016, 71, 85–93 Checketts et al. | Standards of monitoring 2015

Recommendations 9 All patient monitoring equipment should be

The Association of Anaesthetists of Great Britain & Ire- checked before use in accordance with the AAGBI
land regards it as essential that minimum standards of guideline Checking Anaesthetic Equipment 2012 [1].
monitoring are adhered to whenever a patient is anaes-
thetised. These minimum standards should be uniform
regardless of duration, location or mode of anaesthesia. *In hospitals employing Physician Assistants (Anaes-
thesia) [PA(A)s], this responsibility may be delegated
1 The anaesthetist must be present and care for the to a PA(A), supervised by a consultant anaesthetist in
patient throughout the conduct of an anaesthetic.* accordance with guidelines published by the Royal
2 Minimum monitoring devices (as defined in the College of Anaesthetists [2].
recommendations) must be attached before induc- **In certain specific well defined circumstances, intra-
tion of anaesthesia and their use continued until operative patient monitoring can be delegated to a
the patient has recovered from the effects of suitably trained non-physician health care worker dur-
anaesthesia. The same standards of monitoring ing certain procedures performed under regional or
apply when the anaesthetist is responsible for local anaesthesia.
local/regional anaesthesia or sedative techniques.** • What other guideline statements are available on
3 A summary of information provided by all moni- this topic?
toring devices should be recorded on the anaes- The European Board of Anaesthesiology (2012),
thetic record. Automated electronic anaesthetic the American Society of Anesthesiologists (2011)
record systems that also provide a printed copy and the Australian and New Zealand College of
are recommended. Anaesthetists (2013) have published guidelines on
4 The anaesthetist must ensure that all anaesthetic standards of clinical monitoring. Lessons learned
equipment, including relevant monitoring equip- from the 2014 joint Association of Anaesthetists of
ment, has been checked before use. Alarm limits Great Britain and Ireland’s and Royal College of
for all equipment must be set appropriately before Anaesthetists’ 5th National Anaesthetic Project on
use. The appropriate audible alarms should be accidental awareness during general anaesthesia
enabled during anaesthesia. were considered by the working party when updat-
5 These recommendations state the monitoring ing this guideline.
devices that are essential (‘minimum’ monitoring) • Why were these guidelines developed? th
and those that must be immediately available dur- It was necessary to update the 2007 4 edition of
ing anaesthesia. If it is absolutely necessary to con- the guideline to include new guidance on monitor-
tinue anaesthesia without an essential monitor, the ing neuromuscular blockade, depth of anaesthesia
anaesthetist should note the reasons in the anaes- and cardiac output.
thetic record. • How and why does this statement differ from exist-
6 Additional monitoring may be necessary as judged ing guidelines?
appropriate by the anaesthetist. Capnography monitoring is essential at all times in
7 Minimum monitoring should be used during the patients with endotracheal tubes, supraglottic air-
transfer of anaesthetised patients. way devices and those who are deeply sedated. A
8 Provision, maintenance, calibration and renewal of peripheral nerve stimulator must be used whenever
equipment are the responsibilities of the institu- neuromuscular blocking drugs are given. A quanti-
tion in which anaesthesia is delivered. The institu- tative peripheral nerve stimulator is recommended.
tion should have processes for taking advice from Depth of anaesthesia monitoring is recommended
departments of anaesthesia in matters of equip- when using total intravenous anaesthesia with neu-
ment procurement and maintenance. romuscular blockade.

86 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland.
Checketts et al. | Standards of monitoring 2015 Anaesthesia 2016, 71, 85–93

Introduction oxide are used) must be recorded at least every five

The presence of an appropriately trained and experi- minutes, and more frequently if the patient is clinically
enced anaesthetist is the main determinant of patient unstable. It is recognised that contemporaneous
safety during anaesthesia. However, human error is records may be difficult to keep in emergency circum-
inevitable, and many studies have shown that adverse stances, but modern patient monitoring devices allow
incidents and accidents are frequently attributable, at accurate records to be completed or downloaded later
least in part, to error by anaesthetists [3, 4]. from stored data. Automated electronic anaesthetic
Monitoring will not prevent all adverse incidents record systems that can also make hard copies for the
or accidents in the peri-operative period. However, medical notes are recommended.
there is substantial evidence that it reduces the risks of Local circumstances may dictate that handing over
incidents and accidents both by detecting the conse- of responsibility for patient care under anaesthesia to
quences of errors, and by giving early warning that the another anaesthetist may be necessary. If so, a detailed
condition of a patient is deteriorating [5–11]. handover must be delivered to the incoming anaes-
It is appropriate that the AAGBI should define the thetist and this should be recorded in the anaesthetic
standards of monitoring for use by anaesthetists in the record. A handover checklist is useful, and one exam-
United Kingdom and Ireland. Newer monitoring ple of this is the ‘ABCDE’ aide memoir suggested in
modalities such as derived electroencephalogram the NAP5 report [13–15]. When taking over care of a
(EEG) depth of anaesthesia and cardiac output moni- patient (including when returning after relief for a
tors are not established as routine and the Working break), the incoming anaesthetist should conduct a
Party considered their place in contemporary anaesthe- check to ensure that all appropriate monitoring is in
sia practice in Appendices 1 and 2. place with suitable alarm limits (see below).
Very occasionally, an anaesthetist working single-
The anaesthetist’s presence during handedly may be called on briefly to assist with or
anaesthesia perform a life-saving procedure nearby. Leaving an
An anaesthetist of appropriate experience, or fully anaesthetised patient in these circumstances is a matter
trained Physician Assistant (Anaesthesia) PA (A) under for individual judgement, but another anaesthetist or
the supervision of a consultant anaesthetist, must be trained PA(A) should be sought to continue close
present throughout general anaesthesia, including any observation of the patient. If this is not possible in an
period of cardiopulmonary bypass. Using both clinical emergency situation, a trained anaesthetic assistant
skills and monitoring equipment, the anaesthetist must must continue observation of the patient and monitor-
care for the patient continuously. The same standards ing devices. Any problems should be reported to other
must apply when an anaesthetist is responsible for a available medical staff in the area. Anaesthesia depart-
local/regional anaesthetic or sedative technique for an ments should therefore work towards having an addi-
operative procedure. In certain well-defined circum- tional experienced anaesthetist available (e.g. a ‘Duty
stances [12], intra-operative patient monitoring can be Consultant’ or ‘floating registrar’ of appropriate senior-
delegated to a suitably trained non-physician health ity) to provide cover in such situations.
care worker during certain procedures performed under Anaesthesia departments should make arrange-
regional or local anaesthesia. When there is a known ments to allow anaesthetists working solo during long
potential hazard to the anaesthetist, for example during surgical procedures to be relieved by a colleague or PA
x-ray imaging, facilities for remotely observing and (A) for meal and comfort breaks [16]. The 1998 Euro-
monitoring the patient must be available. pean Working Time Regulation Legislation states that
Accurate records of the values determined by an individual should have an uninterrupted break of
monitors must be kept. Minimum monitoring data not less than 20 minutes if the working day exceeds
(heart rate, blood pressure, peripheral oxygen satura- six hours [17]. To meet this requirement, the presence
tion, end-tidal carbon dioxide and anaesthetic vapour of an additional experienced anaesthetist in the theatre
concentration, if volatile anaesthetic agents or nitrous suite, as described above is desirable.

© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland. 87
Anaesthesia 2016, 71, 85–93 Checketts et al. | Standards of monitoring 2015

Anaesthetic equipment use. Alarm settings (including infusion pressure alarm

It is the responsibility of the anaesthetist to check all levels) and infusion limits must be verified and set to
equipment before use, as recommended in the AAGBI appropriate levels before commencing anaesthesia. It is
guideline Checking Anaesthetic Equipment 2012 [1]. recommended that the intravenous cannula should be
Anaesthetists must ensure that they are familiar with visible throughout the procedure, when this is practi-
all the equipment they intend to use and that they cal. When not practical, increased vigilance is required
have followed any specific checking procedures recom- and correct functioning of the cannula should be regu-
mended by individual manufacturers. larly confirmed. It is recommended that infusion
devices are connected to mains power whenever possi-
Oxygen supply ble. When using a total intravenous anaesthesia tech-
The use of an oxygen analyser with an audible alarm nique (TIVA) with neuromuscular blockade, a depth
is essential during anaesthesia. The anaesthetist should of anaesthesia monitor is recommended (see below).
check and set appropriate oxygen concentration alarm
limits. The analyser must be placed in such a position Alarms
that the composition of the gas mixture delivered to Anaesthetists must ensure that all alarms are set to
the patient is monitored continuously. Most modern appropriate values. The default alarm settings incorpo-
anaesthetic machines have built-in oxygen analysers rated by the manufacturer are often inappropriate.
that monitor both inspired and expired oxygen con- During the checking procedure, the anaesthetist must
centrations. review and reset the upper and lower limits as neces-
sary. It is recommended that anaesthetic departments
Breathing systems agree consensus-based alarm limits for their monitors
During spontaneous ventilation, observation of the and ask their medical physics technicians to set these
reservoir bag may reveal a leak, disconnection, high up. Audible alarms must be enabled before anaesthesia
pressure or abnormalities of ventilation. Continuous commences.
waveform carbon dioxide concentration monitoring When intermittent positive pressure ventilation is
will detect most of these problems, so this is an essen- used during anaesthesia, airway pressure alarms must
tial part of routine monitoring during anaesthesia. The also be used to detect high pressure within the airway
2011 AAGBI position statement on capnography out- and to give warning of disconnection or leaks.
side the operating theatre recommended that it should Provision, maintenance, calibration and renewal of
be used for all unconscious anaesthetised patients equipment are the responsibilities of the institution in
regardless of the airway device used or the location of which anaesthesia is delivered. Institutions should take
the patient [18]. There are certain circumstances in into account (e.g., through suitably constituted equip-
which capnography monitoring is not feasible, for ment committees) the views of the anaesthetic depart-
example during high frequency jet ventilation. ment on matters relating to acquisition and
maintenance of equipment.
Vapour analyser
The use of a vapour analyser is essential during anaes- Monitor displays
thesia whenever a volatile anaesthetic agent or nitrous Care should be taken to configure the display setup,
oxide is in use. The end-tidal concentration should be with attention to both the size and arrangement of on-
documented on the anaesthetic record. screen data with regular updating of displayed values.
An appropriate automatic non-invasive blood pressure
Infusion devices (NIBP) recording interval should be set; NIBP moni-
When any component of anaesthesia (hypnotic, anal- tors should not continue to display readings for longer
gesic, neuromuscular blockade) is administered by than 5 minutes to reduce the risk of an older reading
infusion, the infusion device must be checked before being mistaken for a recent one.

88 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland.
Checketts et al. | Standards of monitoring 2015 Anaesthesia 2016, 71, 85–93

Monitoring the devices

Many devices used in anaesthetic practice need their
• Temperature for any procedure > 30 min duration
[20].
own checks and monitoring. This includes monitoring
the cuff pressure of tracheal tubes and cuffed supra- Monitoring must continue until the patient has
glottic airway devices. Cuff pressure manometers recovered from anaesthesia. Anaesthesia departments
should be used to avoid exceeding manufacturers’ rec- must work towards providing capnography monitoring
ommended intracuff pressures which can be associated throughout the whole period of anaesthesia from
with increased patient morbidity. When using devices induction to full recovery of consciousness as recom-
where manufacturers do not specify or recommended mended by the AAGBI guideline Immediate Post-
a maximum cuff pressure, there may still be benefit in anaesthesia Recovery 2013 [21].
avoiding high pressure inflation, as this is associated During induction of anaesthesia in children and in
with reduced morbidity and improved device perfor- uncooperative adults, it may not be feasible to attach
mance [19]. all monitoring before induction. In these circum-
stances, monitoring must be attached as soon as possi-
Monitoring the patient ble and the reasons for delay recorded.
During anaesthesia, the patient’s physiological state
and adequacy of anaesthesia need continual assess- Recovery from anaesthesia
ment. Monitoring devices supplement clinical observa- Minimum monitoring should be maintained until the
tion in order to achieve this. Appropriate clinical patient has recovered fully from anaesthesia. In this
observations may include mucosal colour, pupil size, context, ‘recovered fully’ means that the patient no
response to surgical stimuli and movements of the longer needs any form of airway support, is breathing
chest wall and/or the reservoir bag. The anaesthetist spontaneously, alert, responding to commands and
may undertake palpation of the pulse, auscultation of speaking. Until this point, monitoring must be main-
breath sounds and, where appropriate, measurement of tained to enable rapid detection of airway, ventilatory
urine output and blood loss. A stethoscope must and cardiovascular disturbance. The period of transfer
always be available. from theatre to recovery can be a time of increased
risk depending on the local geography of the theatre
Monitoring devices complex and the status of the patient. Departments
The monitoring devices described above are essential should work towards providing full monitoring,
to the safe conduct of anaesthesia. If it is necessary to including capnography, in patients with a tracheal tube
continue anaesthesia without a particular device, the or supraglottic airway in situ, for these transfers and
anaesthetist must record the reasons for this in the in the recovery area. Supplemental oxygen should rou-
anaesthetic record and only proceed where the benefits tinely be given to patients during transfer to the recov-
or clinical urgency outweigh the risks. The following ery room and in the recovery room until at least after
are considered minimum monitoring for anaesthesia: full recovery.
In summary, the minimum monitoring for recov-
• Pulse oximeter ery from anaesthesia [21] includes:
• NIBP
• ECG • Pulse oximeter
• Inspired and expired oxygen, carbon dioxide, • NIBP
nitrous oxide and volatile anaesthetic agent if used • ECG
(see below) • Capnography if the patient has a tracheal tube,
• Airway pressure supraglottic airway device in situ or is deeply
• Peripheral nerve stimulator if neuromuscular block- sedated [17]
ing drugs used (see Appendix 3) • Temperature

© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland. 89
Anaesthesia 2016, 71, 85–93 Checketts et al. | Standards of monitoring 2015

Additional monitoring Monitoring depth of anaesthesia is desirable when

Some patients will require additional monitoring, for transferring anaesthetised patients who have received
example intravascular pressures, cardiac output neuromuscular blocking drugs (TIVA is invariably
(Appendix 1), or biochemical or haematological vari- used in these circumstances), but will remain difficult
ables depending on patient and surgical factors. The to provide until portable, battery-powered depth of
use of additional monitoring is at the discretion of the anaesthesia monitors become widely available.
anaesthetist.
Use of depth of anaesthesia monitors, for example Anaesthesia in locations outside the
processed EEG monitoring, is recommended when operating suite
patients are anaesthetised with total intravenous tech- The standards of monitoring used during general and
niques and neuromuscular blocking drugs, to reduce regional anaesthesia or sedation administered by an
the risk of accidental awareness during general anaes- anaesthetist should be the same in all locations.
thesia (see Appendix 2). However, there is no com- When anaesthetists are called to administer gen-
pelling evidence that routine use of depth of eral or regional anaesthesia and/or sedation in loca-
anaesthesia monitoring for volatile agent-based general tions outwith the operating theatre (for example
anaesthetics reduces the incidence of accidental aware- emergency department, cardiac catheter lab, radiology,
ness when end-tidal agent monitoring is vigilantly department electroconvulsive therapy suite, endoscopy,
monitored and appropriate low agent alarms are set pain clinic, community dental clinic critical care, deliv-
[13, 22]. ery suite), the same minimum essential standards of
monitoring already outlined in this document should
Regional techniques and sedation for operative apply:
procedures
Patients must have appropriate monitoring, including • Pulse oximeter

[23]: pulse oximeter, NIBP, ECG and end-tidal carbon • NIBP

dioxide monitor if the patient is sedated. • ECG

• Inspired and expired oxygen, carbon dioxide,
nitrous oxide and volatile anaesthetic agent if used
Monitoring during transfer within the
hospital • Airway pressure

It is essential that the standard of care and monitoring • Peripheral nerve stimulator when neuromuscular
blocking drugs used (see Appendix 3)
during transfer of patients who are anaesthetised or
sedated is equivalent to that applied in the operating • Temperature in procedures > 30 min duration.

theatre, and that personnel with adequate knowledge

Competing interests
and experience accompany the patient [24].
No external funding and no competing interests
The patient should be physiologically as stable as
declared.
possible for transfer. Before transfer, appropriate moni-
toring must be commenced. Use of a pre-transfer
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Anaesthesia 2016, 71, 85–93 Checketts et al. | Standards of monitoring 2015

Appendix 1: Cardiac output monitors

• the use of cardiac output monitors to assess fluid
There are a range of cardiac output monitors available responsiveness has some evidence base.
– such as those estimating cardiac output from pulse
pressure, carbon dioxide rebreathing, lithium dilution Appendix 2: Depth of anaesthesia
or oesophageal Doppler measurements – however, monitors
their routine use is uncommon. Although the literature EEG-based depth of anaesthesia monitors have been
base is large, there is little evidence that one type of variously recommended as an option in patients at
monitor is consistently superior to another. Training greater risk of awareness or those likely to suffer the
in the use of the technique adopted is essential. Inva- adverse effects of excessively deep anaesthesia, and also
sive methods, such as those requiring a pulmonary in patients receiving TIVA [30]. Data on the efficacy
artery catheter, are more accurate but, because of the of these devices in correctly predicting accidental
small risk of serious complications associated with the awareness during general anaesthesia (AAGA) or cor-
use of the pulmonary artery catheter, their routine use rectly predicting an adequate level of anaesthesia,
outside of cardiac surgical centres cannot be recom- remains inconsistent and debated [31]. However, data
mended. from these monitors may provide an additional source
There are concerns about accuracy and reliability of information on the patient’s condition.
with many cardiac output monitors. The percentage The NAP5 project published in 2014 made a num-
error of pulse contour analysis, oesophageal Doppler, ber of recommendations on risk factors for AAGA and
partial carbon dioxide rebreathing, and transthoracic the place of depth of anaesthesia monitoring [13],
bio-impedance has been shown to be greater than which can be summarised as:
30%, a widely accepted cut-off [25]. The use of cardiac
output monitoring for assessment of fluid responsive- • the incidence of reports of AAGA was 1 in 8000
ness has been shown to be more accurate, but inter- when neuromuscular blocking drugs were used (as
patient variability and dynamic changes in stroke vol- high as 1:670 in caesarean section) and 1 in
ume may be significant [26]. 136 000 when they were not (i.e., implying a focus
The cardiac output monitors currently available all should specifically be on paralysed patients);
have advantages and disadvantages associated with • about half of the reports of AAGA occurred
their use, and the AAGBI Working Party cannot rec- around the time of induction of anaesthesia and
ommend one type over another. transfer from anaesthetic room to the operating
In summary: theatre.
• almost 20% of AAGA reports occurred at the time
• the pulmonary artery catheter is the most accurate, of emergence from general anaesthesia and were
but less invasive monitoring has superseded its rou- commonly if not universally related to inadequate
tine use outside of cardiac surgery [27]; reversal of neuromuscular blockade
• there is conflicting evidence about whether the use
of cardiac output monitoring improves patient out- Building on these recommendations, the AAGBI
comes, and this is an area of ongoing research; Working Party makes the following recommendations:
• echocardiography can be used to estimate cardiac
• Depth of anaesthesia monitoring is recommended
output and allows cardiac function and filling sta- when neuromuscular blockade is used in combina-
tus to be directly observed - however, training and tion with TIVA;
experience in its use is required [28, 29];
• Depth of anaesthesia monitoring should logically
• there remains doubt about the accuracy of all car- commence from induction of anaesthesia and be
diac output monitoring devices currently available, continued at least until the completion of surgical
and data are mostly confined to patients whose and anaesthetic interventions (i.e., up to the point
lungs are mechanically ventilated; where it is intended to awaken the patient);

92 © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland.
 Checketts et al. | Standards of monitoring 2015 Anaesthesia 2016, 71, 85–93

• Depth of anaesthesia monitoring is recommended this is not possible, the facial or posterior tibial nerves
may be monitored [34].
during transfer of patients receiving TIVA and
neuromuscular blockade, but presents difficulties, There is variability in the duration of action of
because portable battery powered depth of anaes- non-depolarising neuromuscular blocking agents.
thesia monitors are not widely available. Such Residual neuromuscular blockade can be detected in up
devices may come to the market in the future and to 40% patients for up to two hours after their adminis-
their efficacy will need to be separately evaluated; tration [35, 36]. Patient harm may result from postop-

• during inhalational anaesthesia, end-tidal anaes- erative hypoxaemia in the post anaesthesia care unit
[37, 38] and a risk of AAGA at extubation [13].
thetic vapour monitoring with preset low agent
alarms appears a suitable and effective means of The NAP5 project on AAGA reported on the role
estimating depth of anaesthesia; of neuromuscular blockade in contributing to AAGA,

• The isolated forearm technique is another tech- and how patients interpret unintended paralysis in
extremely distressing ways.
nique to monitor depth of anaesthesia [32]. If used
as a ‘depth of anaesthesia monitor’, care should be Recommendations:
taken to ensure its safe conduct, especially in rela-
• a peripheral nerve stimulator is mandatory for all
tion to avoiding excessive, prolonged cuff inflation. patients receiving neuromuscular blockade drugs
The interpretation of a positive movement to com-
• peripheral nerve stimulator monitors should be
mand with isolated forearm technique needs careful applied and used from induction (to confirm ade-
interpretation, as does the subsequent management quate muscle relaxation before endotracheal intuba-
of a patient who has moved in response to spoken tion) until recovery from blockade and return of
command [33]. consciousness;
• while a ‘simple’ peripheral nerve stimulator allows
Appendix 3: Monitoring of a qualitative assessment of the degree of neuromus-
neuromuscular blockade during cular blockade; a more reliable guarantee of return
induction, maintenance and of safe motor function is evidence of a train-of-four
termination of anaesthesia ratio > 0.9.
A measure of neuromuscular blockade, using a periph- • a quantitative peripheral nerve stimulator is
eral nerve stimulator, is essential for all stages of required to accurately assess the train of four ratio
anaesthesia when neuromuscular blockade drugs are [34], but other stimulation modalities (e.g. double
administered. This is best monitored using an objec- burst or post tetanic count) can also be used for
tive, quantitative peripheral nerve stimulator. Ideally assessment. Anaesthetic departments are encour-
the adductor pollicis muscle response to ulnar nerve aged to replace existing qualitative nerve stimula-
stimulation at the wrist should be monitored. Where tors with quantitative devices.

© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland. 93

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