Checklist for Anaesthetic Equipment 2012.
In the 2012 guidance, the ‘two-bag check’ was added to the full pre-list check. Firstly, the breathing system, ventilator and vaporizers must be checked individually. Then, a second bag, or ‘test lung’, is added to the patient end of the breathing system. Through this test, the patency and absence of leaks in the whole system is checked. The ‘test lung’ should then be left attached, as this prevents intrusion of foreign bodies into the circuit between the end of the check and attaching the machine to a patient.
Before each case, the two-bag-test, checking of vaporizers, breathing circuits and gas outlet should be repeated. Patient harm has resulted from failure of the latter. This is particularly important when there are small children and larger patients on the same list. Ensure you check the gas outlet selected before every anaesthetic you give.
The ‘manual leak test’, whereby vaporizers are manually put under pressure, is no longer routinely recommended. This test can cause damage to some modern anaesthetic machines, and so you must consult the manufacturer’s guidance before performing this test.
Do not forget:
Self-inflating bag
Trolley/table tilt
Difficult airway equipment
Resuscitation equipment and drugs (availability of dantrolene, sugammadex, lipid emulsion)
Pumps, and infusion equipment
Electrical back-up.
Beware of changes to circuit, or anaesthetist, part way through an operating session. Failure to check for leaks if a vaporizer is changed during use is a common cause of critical incidents. Include confirmation of the machine check in any handover.
Make all of the above part of your routine as you return to work. Just as when we are learning things for the first time, by not cutting corners, we establish foundations of good practice which then continue throughout our careers. This is a great opportunity to ensure you include each important detail of the most recent guidance on equipment checks in your daily practice. Start as you mean to go on, and you will embed this crucial part of safe patient care into your daily practice for good.
Recommendations for standards of monitoring during anaesthesia and recovery[3]
The presence of an anaesthetist, along with minimum monitoring standards, is considered essential from before induction of anaesthesia until after recovery from anaesthetic. This applies regardless of length, type or location of procedure, including patient transfer both within and outside of the hospital. The same standards apply whether for general, regional or local anaesthetic, and for sedation for surgery.
The presence of an anaesthetist is the main determinant of patient safety. A stethoscope must always be available for clinical assessment. Monitoring devices supplement clinical observation, and their correct use reduces the risk of incidents and accidents occurring.
Audible alarm limits should be set appropriately before each case. This includes patient monitoring and equipment alarms (e.g. ventilator and infusion pump alarms). When this is done, alarms give early warning of problems, whether or not they are due to fault or error.
Essential during anaesthesia
Pulse oximetry, blood pressure monitoring, ECG, airway gases (oxygen, carbon dioxide and vapours) and airway pressures where relevant are essential, though more complex cases may require additional monitoring. Temperature measurement for cases >30 minute duration, and a nerve stimulator for anyone who has received a muscle relaxant, must also be immediately available.
Essential during recovery
Pulse oximetry and blood pressure measurement are essential, with ECG, temperature measurement and a nerve stimulator immediately available.
Supplemental advice (2011) on continuous capnography recommends its use in all patients who are:
– anaesthetized
– intubated (excluding tracheostomy without ventilatory support)
– receiving deep sedation
– receiving cardiopulmonary resuscitation, for continuous monitoring of tracheal tube position, and early signalling of return of spontaneous circulation[4].
Depth of anaesthesia monitoring should be chosen on a case-by-case basis, and should be considered in all patients with a high risk of awareness, such as when using a total intravenous anaesthesia (TIVA) technique with neuromuscular blockade[3,5].
Observations from essential monitoring should be recorded every 5 minutes, or more frequently. The AAGBI advocates the use of electronic record keeping systems where available.
Suspected anaphylactic reactions[6]
This 2009 update from the AAGBI is much more than just a guideline for the management of suspected anaphylactic reactions. It forms a good resource for information on many aspects of anaesthetic allergy.
Appendix 1 of the guideline is ‘Frequently Asked Questions’, and is worth reading. Amongst others, it provides a detailed answer to the question ‘What should I do if a patient with a convincing history of cardiovascular collapse during a previous anaesthetic presents for emergency surgery without having been investigated for anaphylaxis?’ It is very useful to know where to access such advice. There is also a discussion of how to manage a case of suspected anaphylaxis in Chapter 8.
A4 sheet Management of a Patient with Suspected Anaphylaxis During Anaesthesia.
Malignant hyperthermia (MH)
This guideline contains three parts. The first outlines the recognition, management and follow-up of MH. The second recommends a team structure for dealing with MH. This list of task allocations is useful because there are many tasks which need to be carried out simultaneously. The third gives the recommended contents of a Malignant Hyperthermia Management kit, so that all necessary equipment is to hand in a crisis[7].
Copies of these should be readily available in areas wherever anaesthetics are given. This also goes for the guidelines on management of suspected anaphylaxis and local anaesthetic toxicity.
You should check where these guidelines are kept as you are introduced to new clinical areas at the start of your return to work. If they are not readily accessible, maybe standardizing the availability of the AAGBI guideline summaries in relevant clinical areas can be your next project!
Management of severe local anaesthetic toxicity
Bear in mind the possible presenting signs and symptoms of local anaesthetic toxicity whenever using large doses of local anaesthetic. These may be delayed, and may or may not include seizures. Any arrhythmia, including bradycardia, tachyarrhythmia or asystole, can be a feature. Remember that arrhythmias in this context may be resistant to normal treatments. The use of 20% lipid emulsion is required in cases of cardiovascular collapse unresponsive to conventional management.
Lipid emulsion (such as IntralipidR) is used to treat toxicity from local anaesthetics, and other lipophilic drugs. Although propofol may sometimes be used in small doses to control convulsions, it is not sufficient management for lipophilic drug toxicity owing to the amount of cardiovascular depression which would ensue.
The AAGBI guidelines give example doses for a 70 kg man. Remember to adjust the dose accordingly. You should use lean body weight in the obese. Always give 5 minutes for a response before giving another bolus or changing the dose.
A blood sample for later analysis from the time of the event is useful. However, this should not delay emergency management. Pancreatitis is a recognized complication of treatment with lipid emulsion. Therefore, it is necessary to check amylase 24 hours following its use.
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