the monitoring of patients in the immediate post-anaesthesia recovery period , 13 and this includes monitoring :
• Pulse oximeter
• NIBP
• ECG
• Capnography if an airway device is in situ or deeply sedated
• Temperature monitoring .
Additional monitoring Cardiac output monitoring The most accurate cardiac output monitor is the pulmonary artery catheter , but the AAGBI no longer recommends the routine use of this device anywhere but specialist cardiac surgical centres . A plethora of less invasive devices is now available , but the accuracy of most devices is debatable and no single device can be recommended over another . However , cardiac output monitors may have a role to play in assessing fluid responsiveness , with some evidence supporting their application for this purpose . The use of echocardiography is also recognised as an alternative for estimating cardiac function and fluid status . Whichever device or technique is used , training of anaesthetists using them is imperative .
Depth of anaesthesia monitoring Although there are limited data demonstrating a reduction of accidental awareness during general anaesthesia ( AAGA ), depth of anaesthesia monitors may supplement clinical information . The incidence of AAGA is highest when
By implementing the recommendations made in the guideline , anaesthetists and departments are best positioned to deliver safe anaesthesia irrespective of location
neuromuscular blocking drugs are used with total intravenous anaesthesia ( TIVA ), 8 therefore the AAGBI recommend using these monitoring devices in this clinical setting in particular . When used , depth of anaesthesia monitoring should commence at induction of anaesthesia until the end of surgery and anaesthesia . When maintaining anaesthesia with inhalation anaesthetic agents , end-tidal anaesthetic vapour monitoring is recommended with low agent alarms set . The isolated forearm technique may also be used , 14 but care interpretation and management must be taken .
Neuromuscular blockade monitoring The use of neuromuscular blocking drugs mandates monitoring from induction through to full recovery of blockade and consciousness . Older , qualitative peripheral nerve stimulators are less reliable and the AAGBI encourages replacing these older devices with more objective quantitative monitoring devices . Ideally , quantitative monitoring using train-of-four assessment , with a ratio of > 0.9 representing a return of motor function , should be used . Stimulation of the ulnar nerve in particular is ideal , however the facial or posterior tibial nerves are alternatives . The importance of neuromuscular blockade monitoring can be appreciated by the finding of residual neuromuscular blockade in up to 40 % two hours after administration , and the high risk of both AAGA8 and postoperative pulmonary complications associated with their use .
Regional anaesthesia and sedation for operative procedures As a minimum , the AAGBI recommends that patients having regional anaesthesia procedures require pulse oximeter , NIBP , ECG and , if sedated , end-tidal carbon dioxide monitoring . The AAGBI recommends that patients be monitored with capnography whenever an anaesthetist administers sedation , in any situation or location that this may occur .
Monitoring during intra-hospital transfer As previously noted , any anaesthetised or sedated patient should have the same standard of monitoring throughout transfer , be it within hospital or without . 15 Before transfer , physiological status should be optimised , a sufficient oxygen supply to last the entire duration of transfer should be checked , and a pre-transfer checklist 8 should be used . Monitors must include pulse oximetry , NIBP and ECG for all patients , as well as end-tidal carbon dioxide , airway pressure , tidal volumes and respiratory rate in anaesthetised and ventilated patients . Although portable depth of anaesthesia monitors are not broadly available yet , the AAGBI suggests that if available they should also be applied as a standard of monitoring for patient transfers when TIVA is being used .
Anaesthesia outside the operating theatre Irrespective of location , the AAGBI recommends the same minimum standards of monitoring depending on whether general anaesthesia , regional anaesthesia or sedation .
Conclusions The 2015 standards of monitoring during anaesthesia and recovery is a landmark guideline that builds upon previous recommendations . The use of capnography in all areas of anaesthetic care , from sedation , to intra-hospital transfer , and during recovery / waking up from anaesthesia or sedation , is a progressive development in response to a number of studies demonstrating the utility of this monitor . The data from NAP58 has stimulated encouragement for the use of both depth of anaesthesia monitors and a more continuous use of neuromuscular blockade monitors . The recommendations also outline a minimum standard of monitoring in a wide range of clinical scenarios ( Table 1 ), and describes the value of cardiac output monitors in the assessment of fluid responsiveness . By implementing the recommendations made in this safety guideline , anaesthetists and departments are best positioned to deliver safe anaesthesia irrespective of location .
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