Guidelines to the Practice of Anesthesia - Revised Edition 2021

Overview

The Guidelines to the Practice of Anesthesia Revised Edition 2021 (the Guidelines) were prepared by the Canadian Anesthesiologists』 Society (CAS), which reserves the right to determine their publication and distribution. The Guidelines are subject to revision and updated versions are published annually. The Guidelines to the Practice of Anesthesia Revised Edition 2021 supersedes all previously published versions of this document. Although the CAS encourages Canadian anesthesiologists to adhere to its practice guidelines to ensure high-quality patient care, the CAS cannot guarantee any specific patient outcome. Anesthesiologists should exercise their own professional judgement in determining the proper course of action for any patient’s circumstances. The CAS assumes no responsibility or liability for any error or omission arising from the use of any information contained in its Guidelines to the Practice of Anesthesia.

Electronic supplementary material

The online version of this article (10.1007/s12630-020-01842-x) contains supplementary material, which is available to authorized users.

GUIDELINES TO THE PRACTICE OF ANESTHESIA

Revised Edition 2021

Canadian Journal of Anesthesia

Volume 68, number 1

How does this statement differ from the 2020 Guidelines?

Several important content changes have been made and they are highlighted in bold in the text. Some of the more important changes include:

Additional recommendations related to anesthesia medication safety and error prevention, under section 3.1 Responsibilities of the Healthcare Facility, that expand on recommendations introduced in the 2020 Revised Edition that were specific to safety and diversion prevention for controlled medications (e.g., opioids).

The addition of brain natriuretic peptide (BNP/NT-pro BNP) as a preoperative investigation to be considered for patients with, or at risk for, significant cardiovascular disease.

A revision to section 4.2 Fasting Guidelines to clarify the role of H2 receptor blockers in the management of patients presenting for Cesarean delivery (see accompanying editorial).

An entirely new section 5.7 Patient Positioning to address the critical importance of meticulous planning, execution, and rechecking of positioning for patient safety.

A minor but important change related to the requirements for documentation of initial vital signs in PACU necessitated by the expanding implementation of Anesthesia Information Management Systems.

The recommendation that, during patient transport to and in the PACU, if patients with in situ endotracheal tubes require supplemental oxygen, that it should only be administered utilizing devices approved for that application to reduce the risk barotrauma.

Extensive revision to section 9.0, now called Guidelines for Practice of Anesthesia in Remote Locations, addressing the delivery of anesthesia care in remote locations both within and outside of a hospital facility. An important recommendation is that anesthesia staff should have appropriately trained anesthesia support personnel (e.g., an anesthesia assistant) present or immediately available to assist them.

Appendix 1: Canadian Standards Association—Standards for Equipment

Appendix 5: Position Paper on Anesthesia Assistants has been significantly revised in cooperation with the CAS Committee on the Anesthesia Care Team and is available as electronic supplementary material.

GUIDE D』EXERCICE DE L』ANESTHÉSIE DE LA SCA

Édition révisée 2021

Journal canadien d』anesthésie

Volume 68, numéro 1

Comment cet énoncé diffère-t-il des Lignes directrices de 2020?

Plusieurs modifications importantes ont été apportées au contenu; elles sont surlignées en gras dans le texte. Parmi les modifications les plus importantes, citons :

Des recommandations supplémentaires concernant l』innocuité et la prévention des erreurs des médicaments anesthésiques, sous la section 3.1 Responsabilités de l』établissement de santé, qui approfondissent les recommandations introduites dans l』Édition révisée de 2020 spécifiques à l』innocuité et à la prévention du détournement des substances contrôlées (par ex. les opioïdes).

L』ajout du peptide cérébral natriurétique (BNP/NT-pro BNP) parmi les examens préopératoires à envisager chez les patients atteints ou courant un risque d』être atteints de maladie cardiovasculaire significative.

Une révision de la section 4.2 Lignes directrices concernant le jeûne afin de clarifier le rôle des antagonistes des récepteurs H2 dans la prise en charge des patientes devant subir un accouchement par césarienne (voir l』éditorial associé).

Une toute nouvelle section 5.7 Positionnement du patient afin de souligner l』importance cruciale de la planification, de l』exécution et de la vérification méticuleuses du positionnement pour la sécurité des patients.

Une modification mineure mais importante liée aux exigences de documentation des signes vitaux initiaux en salle de réveil nécessaires en raison de l』utilisation toujours plus répandue des Systèmes électroniques de gestion de l』information en anesthésie.

La recommandation selon laquelle, pendant le transfert des patients et dans la salle de réveil, lorsqu』un patient chez qui un tube endotrachéal est installé nécessite de l』oxygène supplémentaire, l』administration ne devrait se faire qu』à l』aide de dispositifs approuvés pour cette application afin de réduire le risque de barotraumatisme.

Une révision approfondie de la section 9.0, désormais intitulée Lignes directrices pour l』exercice de l』anesthésie dans les lieux isolés, abordant la fourniture de soins anesthésiques dans les lieux isolés tant au sein d』un établissement hospitalier que hors d』un milieu hospitalier. Une recommandation importante touche au fait que le personnel d』anesthésie devrait disposer de personnel de soutien en anesthésie ayant reçu une formation adéquate (par ex., un assistant en anesthésie) présent ou immédiatement disponible pour l』assister.

Annexe 1 : Association canadienne de normalisation – Normes concernant le matériel

L』Annexe 5 : Exposé de principe sur les assistants en anesthésie a été révisée de fond en comble en coopération avec le Comité sur les équipes de soin en anesthésie de la SCA et est disponible sous forme de matériel électronique supplémentaire

Contents

Preamble

1. Basic Principles

2 Organization of Anesthetic Services

2.1 Responsibilities of the Chief of Anesthesia

2.2 Privileges in Anesthesia

2.3 Fitness to Practice

2.4 Residents

2.5 Ancillary Personnel

3 Anesthetic Equipment and Anesthetizing Location

3.1 Responsibilities of the Healthcare Facility

3.2 Waste Gases

4 The Preanesthetic Period

4.1 Preoperative Testing

4.2 Fasting Guidelines

4.3 Additional Regulations

5 The Anesthetic Period

5.1 Preparation for Anesthesia

5.2 Airway Management

5.3 Delegation of Patient Care

5.4 Patient Monitoring

5.5 Required Monitoring Equipment

5.6 Perioperative Temperature Management

5.7 Patient Positioning

5.8 Records

6 The Postanesthetic Period

6.1 Recovery Facility

6.2 Discharge of Patients after Day Surgery

7 Guidelines for Obstetric Regional Analgesia

7.1 Initiation of Obstetric Regional Analgesia

7.2 Maintenance of Regional Analgesia During Labour

7.3 Oral Intake During Labour

8 Guidelines for Acute Pain Management Using Neuraxial Analgesia

8.1 Administrative and Educational Policies

8.2 Policies for Drug Administration

8.3 Patient Monitoring and Management of Adverse Events

8.4 Epidurals and Anticoagulation

9 Guidelines for the Practice of Anesthesia in Remote Locations

9.1 Anesthesia Care delivered in a Non-Hospital Medical/Surgical/Dental Facility

9.2 Anesthesia Care delivered outside of an Operating Room within a Hospital or in a Non-Hospital Facility

Appendix 1: Canadian Standards Association—Standards for Equipment

Appendix 2: American Society of Anesthesiologists』 Classification of Physical Status

Appendix 3: Preanesthetic Checklist

Appendix 4: Guidelines, Standards, and Other Official Statements Available on the Internet

Appendix 5: Position Paper on Anesthesia Assistants: An Official Position Paper of the Canadian Anesthesiologists』 Society

Appendix 6: Procedural sedation: a position paper of the Canadian Anesthesiologists』 Society

Table des matières

Préambule

1 Principes de base

2 Organisation des services d』anesthésie

2.1 Responsabilités du chef du département d』anesthésie

2.2 Privilèges d』exercice en anesthésie

2.3 Aptitude à la pratique

2.4 Résidents

2.5 Personnel de soutien

3 Matériel d』anesthésie et lieux convenant à l』anesthésie

3.1 Responsabilités de l』établissement de santé

3.2 Gaz résiduels

4 La période préanesthésique

4.1 Examens préopératoires

4.2 Lignes directrices concernant le jeuˆne

4.3 Règlementations supplémentaires

5 La période anesthésique

5.1 Préparation à l』anesthésie

5.2 Prise en charge des voies aériennes

5.3 Délégation des soins aux patients

5.4 Monitorage du patient

5.5 Matériel de monitorage requis

5.6 Prise en charge périopératoire de la température

5.7 Positionnement du patient

5.8 Dossiers

6 La période postanesthésique

6.1 La salle de réveil

6.2 Congé des patients après chirurgie d』un jour

7 Lignes directrices pour l』analgésie régionale en obstétrique

7.1 Amorce de l』analgésie régionale en obstétrique

7.2 Maintien de l』anesthésie régionale pendant le travail

7.3 Apport oral pendant le travail

8 Lignes directrices pour la prise en charge de la douleur aiguë à l』aide de l』analgésie neuraxiale

8.1 Politiques administratives et éducatives

8.2 Politiques en matière d』administration de médicaments

8.3 Monitorage des patients et prise en charge des évènements indésirables

8.4 Péridurales et anticoagulation

9 Lignes directrices pour l』exercice de l』anesthésie dans les lieux isolés

9.1 Soins anesthésiques dispensés dans un établissement médical/chirurgical/dentaire non hospitalier

9.2 Soins anesthésiques dispensés hors de la salle d』opération dans un hôpital ou un établissement non hospitalier

Annexe 1: Association canadienne de normalisation – Normes concernant le matériel

Annexe 2: Classification de l』état de santé des patients, selon l』American Society of Anesthesiologists

Annexe 3: Liste de vérification préanesthésique

Annexe 4: Lignes directrices, normes et autres énoncés officiels disponibles sur l』internet

Annexe 5: Exposé de principe sur les assistants en anesthésie : Un exposé de principe officiel de la Société canadienne des anesthésiologistes

Annexe 6: Sédation procédurale : exposé de principe de la Société canadienne des anesthésiologistes

Preamble

Anesthesiology is a dynamic specialty of medicine that fosters continuous improvements in anesthetic care for patients undergoing surgical and obstetric procedures in Canada. This document is reviewed annually and revised periodically.

The following recommendations are aimed at providing basic guidelines to anesthetic practice. They are intended as a framework for reasonable and acceptable patient care and should be interpreted as such to allow for some degree of flexibility in different circumstances. Each section of the Guidelines is subject to revision as warranted by the evolution of technology and practice.

Basic Principles

In this document, the term anesthesiologist is used to designate all licensed medical practitioners with privileges to administer anesthetics. An anesthetic is the deliberate performance of any procedure to render a patient temporarily insensitive to pain or to the external environment so that a diagnostic or therapeutic procedure can be performed.

These Guidelines are intended to apply to all anesthesiologists in Canada. The independent practice of anesthesia is a specialized field of medicine, and as such, it should be practiced by physicians with appropriate training in anesthesia. The only route to specialist recognition in anesthesia in Canada is through the certification process of the Royal College of Physicians and Surgeons of Canada. The Canadian Anesthesiologists』 Society (CAS) acknowledges the fact that remote communities often lack the population base to support a specialist anesthesiology practice. In these communities, appropriately trained family physicians may be required to provide anesthesia services. In communities with the clinical volume to support full-time anesthesiologists, fellowship- certified anesthesiologists should provide these services. All anesthesiologists must continue their education in the practice of anesthesia, pain management, perioperative care, and resuscitation and participate in a structured maintenance of competence program (e.g., Royal College MOC).

Organization of Anesthetic Services

The department of anesthesia should be properly organized, directed, and integrated with other departments in the organization or facility, and it should include all facility staff members who provide anesthetic services to patients for surgical, obstetric, diagnostic, and therapeutic purposes.

The department should be staffed appropriately, bearing in mind the scope and nature of the services it provides, and it should strive to ensure that these services are available as required by the healthcare facility.

The chief of the department should be a physician who has obtained certification or appropriate training in anesthesia. This individual should be appointed in the same manner as other chiefs of clinical departments and should be a member of the senior medical administrative bodies for the facility.

Responsibilities of the Chief of Anesthesia

To be aware of the current CAS Guidelines to the Practice of Anesthesia, the requirements of the Canadian Council on Health Services Accreditation, and the requirements of the provincial licensing authority as they relate to anesthesia;

To ensure that written policies with respect to the practice of anesthesia are established and enforced;

To evaluate the qualifications and abilities of the physicians providing anesthetic care as well as other health professionals providing ancillary care—this includes, but is not restricted to, recommending clinical privileges for physicians with anesthetic responsibilities and annually reviewing these privileges;

To employ a systematic approach for monitoring the quality of anesthetic care provided by members of the department of anesthesia throughout the healthcare facility;

Monitoring quality of care may include, but need not be restricted to, the use of chart audits, clinical indicator and outcome monitoring, adverse event reporting systems, morbidity and mortality conferences, and critical incident case reviews. The extent of quality improvement activities will vary depending on the departmental and health facility resources available to the chief. For effective quality improvement, it is strongly encouraged that all department members should actively participate in any such activities.

To ensure that records are kept for all anesthetic procedures—these records should allow for evaluation of all anesthetic care in the facility;

To carry out such other duties as the governing body of the facility may delegate to ensure safe anesthetic care;

To promote institutional compliance with applicable Canadian Standards Association (CSA) Standards (Appendix 1); and

To coordinate liaison between the departments of anesthesiology, biomedical engineering, and information management services.

Privileges in Anesthesia

All physicians applying for privileges in anesthesia should demonstrate satisfactory completion of specialist postgraduate training in anesthesia or family practice anesthesia training. The standard is training in university programs approved by the Royal College of Physicians and Surgeons of Canada. International medical graduates approved for licensure by provincial regulatory bodies should demonstrate training equivalent to the Canadian standard. Family physicians practicing anesthesia should demonstrate satisfactory completion of an accredited postgraduate program with at least one year of training.

Special areas of anesthetic care may have specific concerns. The department of anesthesia in each institution may determine privileges in pediatric anesthesia according to the pediatric population it serves, the child’s age, the presence of comorbidities, the physician’s specific training and experience in pediatric anesthesia, and the complexity of the procedure involved.

Physicians with anesthetic privileges should possess the knowledge and technical and non-technical skills necessary for the practice of anesthesia.

Knowledge and technical skills include the ability:

To provide preanesthetic evaluation of the patient and determine the appropriate anesthetic management;

To render the patient insensible to pain for the performance of diagnostic and therapeutic procedures, surgical operations, and obstetric procedures;

To monitor and support the vital organ systems during the perioperative period;

To provide immediate postanesthetic management of the patient;

To provide resuscitation and intensive care when indicated; and

To provide relief from acute and chronic pain. Non-technical skills include:

Task management: planning and preparing, prioritizing, providing and maintaining standards, and identifying and utilizing resources;

Teamwork: coordinating activities with team members, exchanging information, using authority and assertiveness, assessing capabilities, supporting others, and supporting the World Health Organization Surgical Safety Checklist;

Situational awareness: anticipating, gathering information, recognizing, and understanding, and;

Decision-making: identifying options, balancing risks and selecting options, and re-evaluating.

Fitness to Practice

The provision of anesthesia care requires anesthesiologists to have a high level of expertise, sound judgment, and the ability to recognize and respond to changing clinical situations despite sometimes adverse personal physical circumstances. Anesthesia departments must recognize that fit anesthesia practitioners provide optimal patient care. Anesthesia departments are therefore obligated to develop policies that ensure, as far as possible, that practitioners are healthy and fit to undertake their duties of practice.

A variety of factors impair health and fitness for duty, including adverse physical conditions, mental impairment, and fatigue. All these factors impair fitness and the ability to recognize and respond appropriately to often rapidly changing clinical circumstances. Many studies have shown that fatigue impairs judgement and psychomotor performance in a manner similar to drugs or alcohol. Shifting circadian rhythms, aging, and lack of sleep reinforce such problems; a fatigue-induced lack of recognition of these problems can compound the potential for errors in such circumstances. Physical impairment, illness, and severe stress can have similar detrimental effects on performance.

Anesthesia departments and individual anesthesiologists have a responsibility to organize their working duties such that illness and fatigue do not regularly affect clinical duties. Individual rosters must allow adequate rest between working shifts, and daily rosters should allow appropriate breaks for physiological needs, nutrition, and mental fitness. Operating room scheduling should avoid requiring anesthesiologists to undertake non-emergency procedures during unfavourable hours.

No specific prescription for working shifts and daily rosters can be appropriate for every working situation. Large departments have flexibility to incorporate short shifts and individual leave, while small departments may not have such freedom. Nevertheless, this important area of professional practice must receive ongoing consideration and attention.

Residents

Residents in anesthesia are registered medical practitioners who participate in the provision of anesthesia services both inside and outside the operating room as part of their training. The Royal College of Physicians and Surgeons of Canada and provincial and local regulatory authorities require that a responsible attending staff anesthesiologist must supervise all resident activities. The degree of this supervision must consider the condition of each patient, the nature of the anesthetic service, and the experience and capabilities of the resident (increasing professional responsibility). At the discretion of the supervising staff anesthesiologist, residents may provide a range of anesthetic care with minimal supervision. In all cases, the supervising attending anesthesiologist must remain readily available to give advice or assist the resident with urgent or routine patient care. Whether supervision is direct or indirect, close communication between the resident and the responsible supervising staff anesthesiologist is essential for safe patient care. Each anesthesia department teaching anesthesia residents should have policies regarding the activities and supervision of residents.

Ancillary Personnel

The healthcare facility must ensure that ancillary personnel are available as assistants to the anesthesiologist. Such assistants must be available at all times and places where anesthetic services are provided. Ancillary personnel should have the competencies to meet the specific needs of subspecialty areas of anesthesia, reflecting on the need for specific skills in areas such as specialty pediatric anesthesia.

It is recommended that facilities have a formally designated anesthesia assistant with specific training in anesthesia assistance. The department of anesthesia and the appropriate administrative bodies must approve the scope of practice for anesthesia assistants working in a specific institution. Furthermore, anesthesia assistants like other employed health professionals, must be covered by the facility’s liability insurance. Duties and tasks delegated to anesthesia assistants must be consistent with existing governmental regulations, the policies and guidelines established by professional regulatory agencies, and the policies of the local facility.

An institution without formal anesthesia assistants must provide other paramedical personnel to assist the anesthesiologist. The tasks that these assistants may perform must be clearly defined. An anesthesiologist must only delegate or assign those tasks for which such personnel have approval or accreditation.

Anesthetic Equipment and Anesthetizing Location

An anesthetic must be administered in an appropriate facility. All necessary equipment, including emergency equipment, life support systems, medications, and supplies must be readily available. It is strongly recommended that a cognitive aid manual be made available at all anesthetizing locations in support of the management of critical perioperative emergencies. The contents of the manual should be regularly reviewed, updated as required, and periodically practiced as a team.

The healthcare facility, in consultation with the department of anesthesia, is responsible for the design and maintenance of preoperative, postoperative, and anesthetizing locations, as well as the purchase, maintenance, and disposal of anesthetic and ancillary equipment and supplies. The Canadian Standards Association (CSA) and other standards development organizations have published standards and guidance documents for the design, construction, and renovation of healthcare facilities and for the risk management, basic safety, and essential performance of medical equipment (Appendix 1).

Responsibilities of the Healthcare Facility

The healthcare facility must ensure that:

The operating rooms, anesthetizing locations, and perioperative care locations comply with at least the minimum design and construction requirements of the national, provincial, and local building, plumbing, electrical, HVAC (heating, ventilation, and air conditioning), fire, and security codes at the time of construction or renovation.

Medical gas and vacuum systems, waste anesthetic gas scavenging systems, terminal units, head walls, low pressure connecting assemblies, and pressure regulators meet the requirements of the CSA and are certified by a CSA-approved testing agency.

Oxygen concentrators that comply with CSA requirements are an acceptable substitute for bulk oxygen supply systems. When such concentrators are installed, users must be aware that:

The facility medical oxygen supply may deliver a fraction of inspired oxygen (FiO2) that varies from 0.93 to 0.99;

Oxygen analyzers must be calibrated against 100% O2 (FiO2 0.99) and room air or equivalent (FiO2 0.21);

The use of low-flow (less than one litre total fresh gas flow) anesthetic techniques may result in the accumulation of inert gas (argon) and the dilution of nitrous oxide and oxygen in the circuit.

There is compliance with all safety regulations and best practice with respect to the storage, preparation, identification, labelling, disposal, and use of medical gases, medications, and related materials.

Identifying an anesthesia department lead designated to cooperate with pharmacy to promote medication safety best practice. In recognition of the increased risk of medication errors related to medication brand substitutions and look-alike packaging, departments and pharmacies should consider strategies to reduce this risk.

Requesting that pharmacy staff notify anesthesia staff, with as much notice as possible, of upcoming medication supplier, packaging, or concentration changes such that anesthesia staff can be alerted.

Standardization of drug trays across all locations and during product transitions. Medications with different supplier brands and packaging for a medication should not be mixed in the same anesthesia cart.

Medication substitutions, particularly of a different concentration, should be labelled with highly visible warning labels when any new medication is introduced.

Look-alike medications should be physically separated in the anesthesia carts as much as is possible and identified with warning labels.

Cautioning physicians and technical support staff that replacement of unopened medications back into anesthesia carts is risky because medication may be put in the incorrect location.

Reporting any medication-related adverse events through local adverse event reporting systems or CAIRS or both.

General medication safety recommendations include, but need not be restricted to:

Through cooperation between the departments of anesthesia and pharmacy, there are policies developed and enforced for the safe handling, storage, and disposal of controlled medications (e.g., opioids) in the operating rooms and postanesthesia care unit (PACU) that are consistent with the law, with any regulatory authority requirements, and established best practice principles. The goals of such policies should be to limit access of unauthorized personnel to controlled medications to minimize the risk of controlled medication diversion, and to establish robust documentation procedures that can be audited, while also protecting patient safety by still permitting anesthesia providers immediate access to any medications required for patient care.

Best practice principles support a variety of specific strategies to achieve these goals. The CAS does not endorse any one specific strategy or policy but strongly recommends that all available options be considered. Robust systems and procedures must be implemented. Due consideration should be given to any limitation in resources available to implement specific security systems and procedures within a facility, particularly for smaller facilities.

Recommendations include, but need not be restricted to:

Storing controlled substances in a secure lockable safe or locked drawer when the OR is unattended by anesthesia personnel (e.g., between cases).

Never leaving controlled substances (including those drawn up into syringes or bags) unattended in any location.

Emptying the contents of syringes and bags containing controlled substances before disposal.

Adopting disposal and/or destruction systems to dispose of controlled substance waste.

Consideration of a requirement that controlled substance waste be returned to the pharmacy and be subjected to random analysis.

Periodic audits of a healthcare provider’s controlled substance utilization records and their anesthesia records.

Consideration of the implementation of automated anesthesia cabinets or automated medication dispensing cabinets (e.g. PyxisTM)

The operating room, labour and delivery, postanesthesia care unit (PACU), and regional block areas, for example, should all be recognized as high risk areas for controlled medication diversion and therefore must be subject to heightened security, surveillance, and auditing.

5.

If general anesthesia is provided using an electronic anesthetic system (gas machine), it must comply with CAN/CSA- C22.2 No. 60601-2-13. An alternate means of ventilation (e.g., manual bag and mask resuscitator) must be immediately available with each

6.

The equipment, supplies, and appropriate assistance necessary for the safe performance of invasive procedures are provided. Diagnostic equipment, such as, but not limited to nerve stimulators, ultrasound, image intensifiers, and x-ray, should be available to the anesthesiologist as required. For the placement of central venous and arterial catheters, dedicated ultrasound capability must be provided by the facility. The use of real-time ultrasound guidance for elective internal jugular central venous catheter placement is strongly recommended when the anesthesia provider has training and experience with the technique.

7.

A cardiac arrest cart containing emergency resuscitation equipment including a manual resuscitator, a defibrillator complying with current Canadian Heart and Stroke Association Guidelines, and appropriate medications and intravenous equipment is immediately available.

Equipment appropriate for resuscitating infants and children must be immediately available in any location where sedation or anesthesia involving children is performed. It should also be available in any location receiving pediatric patients who might require resuscitation, such as the emergency department. This equipment must be able to support bag-mask ventilation, endotracheal intubation, fluid administration, temperature monitoring, and advanced cardiac life support. A length-based pediatric emergency tape kit (e.g., BroselowTM) may facilitate the conduct of resuscitation for providers who infrequently manage pediatric resuscitations.

8.

If Malignant Hyperthermia triggering agents are used, a 『『Malignant Hyperthermia Kit』』 complying with the recommendations of the Malignant Hyperthermia Association of the United States must be immediately available (Appendix 4).

9.

A 『『Difficult Airway Kit』』 for difficult or failed airway management is immediately available. Facilities that care for children must have specialized pediatric airway equipment immediately available.

10.

Facilities that care for children should have specialized pediatric equipment. Wherever obstetric anesthesia is performed, a separate area for newborn assessment and resuscitation must be provided. This area must include designated oxygen, suction apparatus, electrical outlets, a source of radiant heat, and equipment for neonatal airway management and resuscitation.

11.

Personal protection devices, including N95 masks, face masks, and means of disposal of hazardous and infectious wastes and sharps are provided. Surgical, diagnostic, therapeutic, and esthetic settings must have plume scavenging systems complying with CSA Z305.13-09.

12.

Infusion pump systems with a drug library, appropriate soft and hard limits for each medication, and enabled alarms for the delivery of medications by continuous intravenous infusion are available as required.

13.

Oxygen supplies for transport of perioperative patients must be provided. The use of transport oxygen cylinders capable of providing an audible low-pressure alarm is strongly recommended.

14.

Qualified personnel conduct regular inspections and maintenance of all anesthetic and ancillary equipment. The facility administration and the department of anesthesia must retain records indicating conformity to regulations and inspection and maintenance.

Anesthesia providers must ensure that potentially infectious materials or agents are not transferred from one patient to another. Special attention in this regard should be given to syringes, infusion pump administration sets, and multi-dose drug vials.

Training on the safe use of all anesthesia equipment should be provided to all anesthesia department members prior to use. Attendance at these sessions should be documented. These training sessions should be repeated as necessary for new or established department members.

Waste Gases

Recommendations for reducing occupational exposure to waste anesthetic gases:

Dilution ventilation at the rate of 20 exchanges per hour must be provided in all anesthetizing locations where volatile anesthetic gases or nitrous oxide (N2O) are used.

Recirculation of exhaust air must not be permitted during the hours when operations may be in progress, and it is not recommended at any other time.

Wherever an anesthetic delivery system is used, a scavenger must be provided to capture anesthetic gases that might be released from the anesthetic circuit or ventilator.

A maintenance program must be established in each healthcare facility to detect and repair leakage from the anesthetic delivery system and to maintain the effectiveness of the waste anesthetic scavenging unit.

The healthcare facility must be responsible for conducting regular monitoring of exposure to waste anesthetic gases. The monitoring protocol should include individuals and the air flow patterns of the rooms being assessed. When N2O is used in the operating room, N2O monitoring is a suitable representation for the assessment of adequacy of scavenging.

The Preanesthetic Period

The department of anesthesia should establish policies regarding preanesthetic assessment.

The primary goal of preanesthetic assessment is to obtain the information required to plan anesthetic management. Accordingly, a physician who is knowledgeable about anesthetic management for the proposed diagnostic or therapeutic procedure should document all aspects of the patient’s medical and surgical history, findings on physical examination, and laboratory investigations that are relevant to anesthetic management. The patient’s history should include past and current medical problems, current and recent drug therapy, unusual reactions or responses to drugs, and any problems or complications associated with previous anesthetics. A family history of adverse reactions associated with anesthesia should also be obtained. Information about the anesthetic that the patient considers relevant should also be documented. An American Society of Anesthesiologists physical status classification (Appendix 2) should be recorded for each patient.

In appropriate cases, the availability of an 『『Advance Care Plan』』 (representation agreement, advanced directive, 『『living will』』, 『『do not resuscitate』』 directive, etc.) should be ascertained, and its applicability to the proposed intervention should be determined and documented on the anesthetic assessment record.

The surgeon may request consultation with an anesthesiologist. Medical consultations should be obtained when indicated.

Preoperative anesthetic assessment or consultation may take place in an outpatient clinic before admission for the operative procedure. Indications for pre-admission assessment include the presence of significant medical problems (comorbidities), the nature of the proposed diagnostic or therapeutic procedure, and patient request. A parent/guardian must be present if the patient is a child or not competent to provide informed consent. All patients should be informed that arrangements will be made to meet with an anesthesiologist if they wish to discuss anesthetic management before admission to the facility. The preoperative assessment clinic should also allow nursing and other healthcare personnel to assess the patient. The attending anesthesiologist is responsible for performing a final preanesthetic assessment in the immediate preoperative period.

Preoperative Testing

Laboratory testing should not be performed on a routine basis but should be obtained only when results will change perioperative management. Laboratory investigations should be performed when indicated by the patient’s medical status, drug therapy, and the nature of the proposed procedure. Routine laboratory blood testing, electrocardiograms, and chest radiographs are not recommended for asymptomatic patients having low-risk surgery. Examples of low-risk surgery include, but are not restricted to, cataract surgery, minor breast surgery, superficial procedures, and many minor ambulatory procedures. For more detailed definitions of low-risk surgery and for other recommendations related to preoperative testing, visit Choosing Wisely on the CAS website and the associated Internet links.

Test Indications

TESTINDICATIONSComplete blood count• May be considered based on the potential for significant blood loss, extremes of age (i.e., \ one year), liver or hematological disease, history of anemia or malignancy.Sickle cell screen• Should be offered with counselling to patients of high risk ethnicity.Partial thromboplastin time/ international normalized ratio

May be considered:

• with conditions or medications associated with impaired coagulation (e.g., liver disease, malnutrition), history of excessive bleeding, or a family history of heritable coagulopathies

• for patients on oral or parenteral anticoagulant therapy.

Electrolytes

May be considered:

• with known or compelling findings in favour of hypertension, congestive heart failure, chronic renal failure, complicated diabetes, liver disease, pituitary- adrenal disease, malnutrition

• for patients taking diuretics, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and other therapy affecting electrolytes.

Creatinine and estimated glomerular filtration rate (eGFR)

May be considered:

• as above for electrolytes, also with advanced age and for patients taking medications potentially affecting renal function

• for patients receiving direct oral anticoagulants

• as required for calculating perioperative risk indices

• eGFR is recommended to assist with renal outcome prediction.

Fasting glucose level

May be considered:

• for diabetics, preoperatively on day of surgery to guide glycemic control

• for patients on glucocorticoid therapy

• as screening for body mass index > 40 or a very high risk of diabetes based on signs and symptoms.

Hemoglobin A1c• May be considered for known diabetics as early as possible before surgery (ideally at time of surgical referral) if results would change management.Pregnancy testing

Based on specific institutional guidelines

• Should be offered to women of childbearing age based on any reasonable likelihood of pregnancy, on the reliability of menstrual history, and if the results will cancel or change the procedure or the anesthetic management.

• Point of care urine or blood testing capability is ideal and is therefore recommended.

Electrocardiography

• May be considered for patients

with known or suspected coronary heart disease, significant arrhythmia, peripheral vascular disease, or other significant structural heart disease.

• May be considered in the absence of symptoms or known cardiovascular disease in patients having high-risk surgery in the presence of clinical risk factors (e.g., Revised Cardiac Risk Index (RCRI) or American College of Surgeons (ACS) Surgical Risk Calculator).

Brain natriuretic peptide (BNP or NT-pro BNP)

May be considered if:

• age ≥ 65 yr,

• age 45–65 yr with significant cardiac disease,

• Revised Cardiac Risk Index score ≥ 1.

Resting echocardiography

• May be considered if clinical

assessment suggests undiagnosed severe obstructive intra-cardiac

abnormality, cardiomyopathy, or

severe pulmonary hypertension.

Chest radiograph

• Not recommended for asymptomatic patients in routine preoperative assessment unless part of a surgical or oncological workup unrelated to perioperative risk assessment.

• May be considered for patients with acute or chronic cardiopulmonary disease based on history and physical exam if it will change management.

Fasting Policies

Fasting policies should vary to account for age and preexisting medical conditions and should apply to all forms of anesthesia, including procedural sedation (see Appendix 6).1 Emergent or urgent procedures should be undertaken after considering the risk of delaying surgery vs the risk of aspiration of gastric contents. The type and amount of food ingested should be considered in determining the duration of fasting.

Before elective procedures, the minimum duration of fasting should be:

Eight hours after a large meal of solids particularly containing protein (e.g., meat) or fatty foods

Six hours after a light meal (e.g., non-fatty meal such as toast)

Six hours after ingestion of infant formula, non- human milk, or expressed breast milk fortified with additions

Four hours after ingestion of breast milk

Two hours after ingestion of clear fluids for adults

One hour after ingestion of clear fluids for infants and children

Unless contraindicated, adults and children should be encouraged to drink clear fluids (including water, pulp-free juice, complex carbohydrate beverages, and black tea or coffee up to two hours before elective surgery. Pediatric patients should also be encouraged to consume clear fluids, as defined, up to one hour before elective procedures.

Conditions that delay gastric emptying require individual patient assessment. These guidelines may be modified at the discretion of the physician.

Premedication, when indicated, should be ordered by the anesthesiologist. Orders should be specific as to dose, time, and route of administration.

An H2 receptor antagonist (oral or intravenous) is recommended for all women presenting for Cesarean delivery.

Thirty mL of oral sodium citrate (0.3 molar) is recommended prior to an emergent Cesarean delivery if general anesthesia is planned.

See Section 7.3 for fasting guidelines specific to patients in active labour.

Additional Regulations

Provincial legislation or facility bylaws may dictate additional regulations governing the conduct of anesthesia.

The Anesthetic PeriodPreparation for Anesthesia

Before beginning anesthesia, the anesthesiologist must ensure that

An explanation of the planned anesthetic procedure, including recognized risks and alternative techniques, has been provided and documented;

An adequate review of the patient’s condition has been performed;

All equipment that is expected to be required is available and in working order, including the equipment required for supporting core temperature management (patient core temperature 36–37°C);

A reserve source of oxygen under pressure is available;

All drugs and agents that are expected to be required are correctly identified—user-applied drug labels should conform to the CSA Standard CAN/CSA- Z264.3-98 (R2005) (Appendix 1);

If Luer neuraxial connectors are used, both sides of all Luer connections must be labelled. Consideration should be given to the use of neuraxial connectors complying with ISO 80369-6:2016-small bore connectors for neuraxial application (e.g., NRFit® connectors) subject to availability from equipment suppliers; and

The manufacturers』 recommendations concerning the use, handling, and disposal of anesthetic equipment and supplies have been considered.

Airway Management

Airway management, particularly of the difficult airway, contributes to a significant proportion of anesthesia related morbidity and mortality.

The appropriate management of those patients who have a predicted, or an unanticipated difficult intubation, a failed airway, where bag-mask ventilation or supraglottic device placement may be difficult, or who require a surgical airway is critical for patient safety. This includes, but need not be restricted to, adequate airway assessment, equipment (e.g., difficult airway carts, videolaryngoscopes, bronchoscopes), training and simulation, support personnel and the use of protocols and cognitive aids to optimize difficult airway management. The CAS does not endorse any one specific protocol, algorithm, or cognitive aid for difficult and failed airway management but strongly recommends that readers refer to Appendix 4 for up to date publications related to this topic.

Delegation of Patient Care

The anesthesiologist’s primary responsibility is to the patient receiving care. The anesthesiologist or an anesthesia assistant supervised by the anesthesiologist must remain with the patient at all times throughout the conduct of all general and major regional, anesthetics and for procedural sedation until the patient is transferred to the care of personnel in an appropriate care unit.

If the attending anesthesiologist leaves the operating room temporarily, he/she must delegate care of the patient to another anesthesiologist, a resident in anesthesia, or an anesthesia assistant. When the attending anesthesiologist delegates care to a resident in anesthesia or an anesthesia assistant, the attending anesthesiologist remains responsible for the anesthetic management of the patient. Before delegating care of the patient to an anesthesia assistant, the anesthesiologist must ensure that the patient’s condition is stable and that the anesthesia assistant is familiar with the operative procedure and the operating room environment and equipment. The attending anesthesiologist must remain immediately available when care is delegated to an anesthesia assistant.

An anesthesiologist may briefly delegate routine care of a stable patient to a competent person who is not an anesthesia assistant only under the most exceptional circumstances, e.g., to provide life-saving emergency care to another patient. That person’s only responsibility would be to monitor the patient during the anesthesiologist’s absence and to keep the anesthesiologist informed until he/ she returns. In this situation, the anesthesiologist remains responsible for the care of the patient and must inform the operating room team.

An intraoperative handover of care between two anesthesiologists should be documented in the anesthesia record and follow a structured protocol.

It is unacceptable for one anesthesiologist to simultaneously administer general anesthesia, major regional anesthesia (spinal, epidural, or other), or deep procedural sedation (see Appendix 6)1 for concurrent diagnostic or therapeutic procedures on more than one patient. Nevertheless, it may be appropriate in specific circumstances for one anesthesiologist to supervise more than one patient where only minimal to moderate sedation is administered, provided an appropriately trained, qualified, and accredited individual approved by the department of anesthesiology, and the healthcare institution is in constant attendance with each patient receiving care. In an obstetric unit, however, it is acceptable to supervise more than one patient receiving regional analgesia for labour. Due care must be taken to ensure that a suitably trained person adequately observes each patient following an established protocol. When an anesthesiologist is providing anesthetic care for an obstetric delivery, a second appropriately trained person should be available to provide neonatal resuscitation.

It is unacceptable for a single physician to administer an anesthetic, including deep procedural sedation, and simultaneously perform a diagnostic or therapeutic procedure, except for procedures done with only infiltration of local anesthetic and/or minimal sedation.

Patient Monitoring

The only indispensable monitor is the presence, at all times, of a physician or an anesthesia assistant who is under the immediate supervision of an anesthesiologist and has appropriate training and experience. Mechanical and electronic monitors are, at best, aids to vigilance. Such devices assist the anesthesiologist to ensure the integrity of the vital organs and, in particular, the adequacy of tissue perfusion and oxygenation. Monitoring equipment must be used as intended by the manufacturer and approved by Health Canada for the specific application.

The healthcare facility is responsible for the provision and maintenance of monitoring equipment that meets current published equipment standards.

The chief of anesthesia is responsible for advising the healthcare facility regarding the procurement of monitoring equipment and for establishing policies for monitoring to help ensure patient safety.

The anesthesiologist is responsible for monitoring the patient receiving care and for ensuring that appropriate monitoring equipment is available and working correctly. A preanesthetic checklist (Appendix 3 or equivalent) must be completed prior to initiation of anesthesia.

Cautious dosing, vigilant monitoring, and the appropriate reversal of neuromuscular blocking drugs are all essential for patient safety. Neuromuscular monitoring must be utilized when neuromuscular blocking agents are administered.

Monitoring guidelines for standard patient care apply to all patients receiving general anesthesia, regional anesthesia, or procedural sedation.

Required Monitoring Equipment

Monitoring equipment is classified as follows:

Required: These monitors must be in continuous use throughout the administration of all anesthetics.

Exclusively available for each patient: These monitors must be available at each anesthetic work station so that they can be used with no delay.

Immediately available: These monitors must be available to facilitate their use without undue delay.

The following monitoring equipment is required:

Pulse oximeter;

Apparatus to measure blood pressure, either directly or noninvasively;

Electrocardiography;

Neuromuscular blockade monitor when neuromuscular blocking drugs are used;

Capnography for general anesthesia and to assess the adequacy of ventilation for moderate or deep procedural sedation; and

Agent-specific anesthetic gas monitor, when inhalational anesthetic agents are used.

The following monitoring equipment must be exclusively available for each patient:

The following monitoring equipment must be immediately available:

Spirometer to measure tidal volume;

Manometer to measure endotracheal tube cuff pressure.

Equipment for invasive hemodynamic monitoring if indicated (e.g., arterial, central venous).

The anesthesiologist must remain constantly vigilant, understanding that brief interruptions in continuous monitoring may be unavoidable and there are certain circumstances in which a monitor may fail.

Audible and visual alarms for oximetry and capnography should not be indefinitely disabled during the conduct of an anesthetic except during unusual circumstances. The variable pitch, pulse tone, and low- threshold alarm of the pulse oximeter and the capnograph apnea alarm must give an audible and visual warning.

Perioperative Temperature Management

Monitoring patient core temperature is strongly recommended during cases of general and neuraxial regional anesthesia lasting 30 min or longer. In the absence of surgical or patient indications for intraoperative hypothermia, active patient warming systems, control of the operating room ambient temperature, and other methods, should be used to target a central core temperature of 36–37°C.

Patient Positioning

Patient positioning for procedures requiring anesthesia is an operating room team responsibility and demands a high level of attention to avoid complications. It is recognized, however, that positioning-related complications can still occur despite best practice and vigilance. Risks related to patient positioning will vary and depend on the type and duration of surgery, the specific position utilized, and patient factors such as BMI and other comorbidities. Therefore, the considerations and planning for positioning best practice should be discussed by the surgical team ideally before anesthesia induction, for example during part 1 of the Surgical Safety Checklist. All members of the team, including the anesthesiologist, should be encouraged to voice concerns related to any aspect of positioning (e.g., specific risk factors and availability, condition and appropriateness of OR tables and other positioning equipment), and strategies to mitigate these risks should be considered. Patient positioning should be documented and also rechecked regularly by the anesthesiologist to be sure positioning conditions remain ideal. Patients should be informed preoperatively of any specific risks that may be associated with the position planned for their procedure.

Records

All monitored physiologic variables should be charted at intervals appropriate to the clinical circumstances. Heart rate and blood pressure should be recorded at least every five minutes. Oxygen saturation must be monitored continuously and should be recorded at frequent intervals, at a minimum of every five minutes, for all patients. End-tidal carbon dioxide concentration must be monitored continuously and recorded at frequent intervals if the trachea is intubated or a supraglottic device is

in situ. Reasons for deviation from these charting guidelines should be documented in the anesthetic record. Monitors, equipment, and techniques, as well as time, dose, and route of all drugs and intravenous fluids should be recorded. All other relevant intraoperative anesthesia care and events, including unexpected or adverse events, should also be recorded.

The patient health record should include the patient’s level of consciousness, heart rate, blood pressure, oxygen saturation, and respiratory rate as first determined in the PACU. These recommendations apply to both manually created (handwritten) and electronic anesthesia information management system (AIMS) created anesthesia records. At present, there are no practice standards for what additional data (e.g., gas analysis, ventilator, and respiratory data) that can potentially be collected by an AIMS charting system should become part of a patient’s permanent health record.

AIMS have been shown to have potential benefits over handwritten records in several key areas, including improved legibility, precision and reliability of anesthesia records, providing searchable data for quality improvement, outcome and performance reporting and translational research, enhanced medication safety and tracking and real-time clinical decision support for users. The anesthesia patient safety literature supports the use of AIMS. Importantly, AIMS maintain a longitudinal patient database so historical patient encounters should be easily retrievable for review and this should be considered an important feature of any system. The CAS does not promote or endorse any one specific vendor or product but acknowledges that there may be potential benefits of a well designed and implemented AIMS over manually charted records where facility and anesthesia department resources permit the consideration of an AIMS. Ideally it should be implemented and supported in cooperation with the facility information technology department including communication with other facility electronic patient databases wherever possible.

The Postanesthetic PeriodRecovery Facility

A PACU must be available in any facility that provides anesthetic services. Administrative policies to coordinate medical and nursing care responsibilities must be enforced in accordance with facility bylaws.

The department of anesthesia should have overall medical administrative responsibility for the PACU. There should be a PACU policy manual approved by appropriate medical, nursing, and administrative authorities.

The anesthesiologist should accompany the patient to the PACU, communicate necessary information to the PACU nurse(s) as part of a structured handover of care protocol, and write appropriate orders. Continuous monitoring of patients is recommended during the perioperative period appropriate to the clinical situation. If clinically indicated, supplemental oxygen, portable pulse oximetry, and other appropriate monitoring devices should be applied during transport to the PACU or intensive care unit. If supplemental oxygen is applied during transport or in PACU to patients who are intubated it is strongly recommended that it only be provided using devices approved for that specific application to minimize any risk of barotrauma. The anesthesiologist should delegate care to the PACU nurse only when assured that nursing staff may safely observe and care for the patient. The anesthesiologist or designated alternate is responsible for providing anesthetic-related care in the PACU. Discharge from the PACU is the responsibility of the anesthesiologist; this responsibility may be delegated in accordance with facility policy.

Supplemental oxygen and suction must be available for every patient in the PACU. Emergency equipment for airway management, resuscitation, and life support must be available in the PACU. Equipment for management of the difficult airway must be immediately available to the PACU. The monitoring used in the PACU should be appropriate to the patient’s condition, and a full range of monitoring devices should be available. Monitor alarms should be enabled with alarm settings appropriate to the condition and age of the patient. The use of continuous pulse oximetry is required in the initial phase of recovery. Capnography is required for intubated and deeply sedated patients and is recommended for unconscious patients with in situ supraglottic airway devices. An apnea monitor is recommended for preterm infants with a gestational age of less than 50 weeks.

An accurate record of the immediate recovery period must be maintained. This must include a record of vital signs together with other aspects of treatment and observation. The recovery record must form a part of the permanent medical record. Any complications that bear any relation to the anesthetic should be recorded either on the recovery record or on the progress notes on the patient’s chart.

In some circumstances, it may be considered acceptable to transfer a patient directly to other care units or to bypass the PACU if the appropriate level of care is available in another unit in the facility and the suitability of the patient for this transfer is documented on the anesthetic record.

Discharge of Patients After Day Surgery

Discharge of patients after day surgery must utilize a formal care plan approved by the institution and be documented in the patient care notes. Patients should meet the facility discharge to home criteria using a validated assessment tool. (e.g., Post Anesthetic Discharge Scoring System). Specific written instructions should include management of pain and postoperative complications, and both routine and emergency follow-up. The patient should be advised regarding the additive effects of alcohol and other sedative drugs, the danger of driving or operating other hazardous machinery during the postoperative period (most commonly 24 hr postoperatively), and the necessity for attention by a competent adult during the postoperative period (most commonly 24 hr postoperatively).

Guidelines for Obstetric Regional Analgesia

Anesthesia services for parturients include obstetric analgesia for labour—for both uncomplicated and complicated deliveries—or for operative deliveries. All guidelines regarding provision of anesthesia for other diagnostic or therapeutic procedures also apply to the provision of obstetric anesthesia. The guidelines in this section pertain to epidural and spinal analgesia during labour. The term 『『regional analgesia』』 includes epidural, spinal, and combined spinal-epidural analgesia.

These guidelines are reviewed annually by the Obstetric Anesthesia Section of CAS and updated as indicated. Each facility may choose to develop additional guidelines or policies for specific situations in which obstetric regional analgesia is provided.

Under the direction of an anesthesiologist, some aspects of monitoring and management of obstetric regional analgesia may be delegated to other healthcare personnel. Each facility should ensure that such other personnel receive the same training, certification, continuing education, and recertification in obstetric regional analgesia.

Initiation of Obstetric Regional Analgesia

Before introducing obstetric regional analgesia, the facility should have appropriate monitoring protocols in place. These protocols should outline the types of monitoring required and the frequency of monitoring. In addition, they should clearly state how to manage common problems and emergencies and indicate whom to contact if assistance is required.

Obstetric regional analgesia should be provided only by physicians with training, facility privileges, and licence to provide these services. This includes trainees with appropriate supervision.

Regional analgesia should be initiated and maintained only in locations where appropriate resuscitation equipment and drugs are immediately available.

Informed consent should be obtained and documented in the medical record.

Intravenous access must be established before initiating regional analgesia, and it should be maintained throughout the administration of regional analgesia.

The anesthesiologist should be immediately available until analgesia is established and the patient’s vital signs are stable.

Maintenance of Regional Anesthesia During Labour

Continuous Epidural Infusions (CEI), Programmed Intermittent Epidural Bolus (PIEB), and Patient- Controlled Epidural Analgesia (PCEA) of low dose diluted epidural local anesthetics (e.g., bupivacaine £ 0.125% or ropivacaine £ 0.16%) with or without adjuncts (e.g., opioids) are associated with a very low incidence of significant complications. Consequently, it is not necessary for an anesthesiologist to remain present or immediately available during maintenance of CEI or PIEB with or without PCEA provided that:

there are appropriate protocols for management of patients receiving CEI, PIEB, and PCEA; and

the anesthesiologist can be contacted for the purpose of obtaining advice and direction.

When initial and top-up bolus epidural local anesthetics are administered, the anesthesiologist must be immediately available to intervene appropriately recognizing that these techniques can cause immediate life-threatening complications.

Individual departments of anesthesiology should establish their own policies regarding the appropriate availability of an anesthesiologist to manage the potential complications of regional analgesia for labour and delivery.

Safety systems must be in place to secure epidural local anesthetic mixtures and supplies containing controlled substances (e.g., opioids) to minimize the risk of diversion.

Oral Intake During Labour

Gastric emptying of solids is delayed during labour and opioid analgesics may further delay gastric emptying. Therefore, parturients should generally be discouraged from ingesting solid foods when in active labour. In contrast to solid food, clear fluids are emptied relatively rapidly from the stomach during labour. Therefore, in general, women should be permitted clear fluids as desired during active labour. Individual facilities should develop protocols regarding the intake of solids and clear fluids by women in active labour.

Guidelines for Acute Pain Management Using Neuraxial Analgesia

When neuraxial analgesia is managed by anesthesiologists, the incidence of side effects is no higher than when alternative techniques of pain management are used. Accordingly, when its use is appropriate, neuraxial analgesia should be managed by anesthesiologists.

For the purposes of these guidelines, neuraxial analgesia is defined as intrathecal or epidural administration of opioids and/or local anesthetics for treatment of postoperative pain or other acute pain problems. These guidelines are to provide anesthesiologists with the principles of management to maximize the benefit–risk ratio of providing neuraxial analgesia.

Administrative and Educational Policies

The department of anesthesia should establish an acute pain service that is responsible for:

Developing policies and procedures for neuraxial analgesia. Participation of other departments (e.g., nursing, pharmacy, surgery, and materials management) should be sought as needed.

Liaison with the surgical departments. Surgeons need to understand the criteria for patient selection, the effects of neuraxial analgesia on the normal postoperative course and on the presentation of postoperative complications, and the implications of other therapies, such as prophylactic anticoagulation, on neuraxial analgesia.

Education and certification of nurses. A standardized educational program—with initial training, certification, and ongoing maintenance of competence—should be established for nurses caring for patients receiving neuraxial analgesia.

Nursing personnel should understand:

The risk of respiratory depression, including delayed respiratory depression when hydrophilic opioids are used;

Assessment and management of respiratory depression;

Assessment of motor and sensory blockade;

Assessment and management of hypotension in patients receiving neuraxial analgesia; and

Signs and symptoms of the rare but catastrophic complications of epidural hematoma or abscess.

Policies for Drug Administration

Each facility should use a limited number of standard solutions. A preprinted order sheet listing the standard solutions for the facility is strongly recommended. Before any solution that is not standard in the facility is dispensed, the anesthesiologist should verify the order with nursing and pharmacy personnel and discuss its indications and all concerns relating to its use with the nurses responsible for administering the drug and monitoring the patient.

The risk of errors due to incorrect route of drug injection must be minimized. For continuous infusions or PCEA, the use of unique tamper-proof pumps that are distinct from the pumps used for intravenous fluid or drug administration is strongly recommended. The tubing between neuraxial analgesia infusion pumps and catheters should not have ports that could permit unintentional injection of intravenous drugs (see section 5.1-6).

Preparation of solutions should follow a standardized procedure. All analgesic drug solutions should be labeled with the composition of the solution (opioid, local anesthetic, or both) and its intended route of administration. For epidural administration, this should include the date and time of preparation and the name of the individual who prepared it.

Patient Monitoring and Management of Adverse Events

Patients receiving neuraxial analgesia should be in a room equipped with oxygen and suction. Resuscitation drugs and equipment must be immediately available. Before initiating neuraxial analgesia, intravenous access must be secured, and after discontinuing neuraxial analgesia, intravenous access must be maintained for the expected duration of drug effects.

Epidural catheter dressings should permit examination for catheter movement and daily inspection of the catheter entry site for any signs of infection.

Standardized policies for patient management should be established. The parameters to be assessed, frequency of assessments, documentation, and procedures for management of complications should be specified. Adequate nursing personnel must be available to assess and manage patients receiving neuraxial analgesia. Monitoring should continue after discontinuation of neuraxial analgesia until its effects have dissipated.

An anesthesiologist must be readily available to advise nursing personnel on such issues as dose titration and management of adverse effects. Each facility with an acute pain service should ensure that an anesthesiologist is available to attend directly to patients receiving neuraxial analgesia within an appropriate time depending on the clinical situation. Each facility should also specify procedures for emergent management of any life- threatening complications.

Other drugs, particularly benzodiazepines or parenteral opioids, may cause severe respiratory depression in patients receiving neuraxial analgesia. For this reason, other physicians should not order sedatives or analgesics for any patient receiving neuraxial analgesia. The acute pain service should direct analgesic and sedative therapy until the effects of neuraxial analgesia have dissipated.

Epidurals and Anticoagulation

Patients with epidural catheters may receive prophylactic low-dose anticoagulant therapy if appropriate precautions are taken:

To minimize the risk of epidural hematoma, catheter insertion and removal and the timing of anticoagulant administration must be coordinated so that no clinically significant anticoagulant effect is present at these times.

Use of nonsteroidal anti-inflammatory drugs in patients receiving neuraxial analgesia is appropriate, but concurrent administration of these drugs or other antiplatelet medication and an anticoagulant may increase the risk of epidural hematoma.

Where neuraxial analgesia is used for prolonged postoperative pain management, every effort should be made to avoid lower extremity motor blockade.

Nursing staff should be aware of the signs and symptoms of epidural hematoma. Any change in neurologic status or new-onset back pain must be investigated immediately.

If full anticoagulation is indicated in a patient with an epidural catheter, the anesthesiologist should be consulted so that catheter removal and initiation of alternative analgesic management are accomplished before anticoagulation.

Guidelines for the Practice of Anesthesia in Remote Locations

The basic principles, training requirements, techniques, equipment, and medications used for the practice of anesthesia in remote locations are as outlined in other sections of these Guidelines. They apply equally to anesthesia care, including procedural sedation (see Appendix 6 ) delivered by anesthesiologists in any operating room or out-of-operating room locations both within a hospital facility and outside of a hospital facility (e.g., offices, clinics).

Anesthesia Care delivered in a Non-Hospital Medical/Surgical/Dental FacilityPatient Selection

The physical status of patients should be classified using the American Society of Anesthesiologists physical status (ASA) score. Typically, only patients with ASA classifications of I and II should be considered for procedures. Patients with ASA III classification may be accepted under certain circumstances but only at the discretion of the attending anesthesiologist. Caution should be exercised when booking patients with a known difficult airway.

Preoperative Considerations

The patient must have had a recent and documented health history, physical examination including an airway examination, and any appropriate laboratory investigations. This may be carried out by another physician (e.g., proceduralist) but it is strongly recommended that there be a screening process that is developed and supported by the anesthesia leadership-providing services. The duration of fasting should be consistent with section 4.2 Fasting Guidelines.

Conduct of Anesthesia

The anesthetic and recovery facilities must conform to facility standards established by the CSA (see Appendix 1 ) and all CAS guidelines established for patient care. The patient should be discharged home from the facility using a validated scoring system for fitness to discharge (e.g., Post Anesthetic Discharge Scoring System). Patients should be provided with written instructions for the preoperative and postoperative periods.

Anesthesia Care delivered Outside of an Operating Room within a Hospital or in a Non-Hospital Facility

The demand for the delivery of anesthesia care services outside of an operating room (e.g., endoscopy, interventional radiology, cardiac catheterization) is growing because of technological advances and the growth in the availability of less invasive, yet potentially painful, procedures. The delivery of anesthesia care in these remote procedural units can present unique challenges to the anesthesia care team (e.g., patients may have an ASA status of III–IV and have significant comorbidities) and they may be some distance from the operating rooms and support staff or outside of a hospital facility. Procedural units where anesthesiologists have been asked to provide care should comply with the same CSA standards (Appendix 1 ), equipment guidelines (see section 3.0), and general CAS guidelines as an operating room to the greatest extent possible. This includes, but need not be restricted to, patient selection and assessment, pre-procedural testing, fasting guidelines, equipment and electrical outlets, oxygen and suction, ventilation and scavenging if inhalational agents will be utilized, medications and equipment required for resuscitation, patient monitoring, the recovery facility and anesthesia support personnel. Any location outside of an operating room where anesthesiologists provide care must be approved by the anesthesia leadership of the facility. Appropriately trained and experienced anesthesia support personnel, for example an Anesthesia Assistant (see section 2.5) or other staff with experience supporting anesthesia should be present or immediately available to assist the anesthesiologist in remote locations. It is not appropriate to rely solely on procedural unit staff to support anesthesia unless they have had training and experience in the direct support of the delivery of anesthesia care and are approved by anesthesia leadership. There must be reliable two-way communication available to call for assistance and support of the anesthesia provider as it may be required.

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