This document provides guidelines for anaesthesia safety standards and pre-operative fasting. It outlines principles of anaesthesia care including constant monitoring of patients and designation of qualified staff. Intra-operative monitoring of vital signs, ventilation, oxygenation and temperature is recommended. Regional anaesthesia and monitored sedation also require standards and oversight. Pre-anaesthetic consultation and assessment of patients is important to optimize health status prior to surgery. Guidelines provide fasting timeframes for solids, liquids and breastmilk based on aspiration risk reduction. Rapid induction techniques and emergency equipment are advised to prevent aspiration complications during intubation.
Guidelines for Safe Anaesthesia and Pre-Op Fasting
1. Recommendation for Safety Standards and
Monitoring during Anaesthesia and
Recovery Revised 2008
& Guideline for Pre Operative Fasting
2008
Dr. Nor Hidayah Zainool Abidin
International Islamic University of Malaysia
Anor Hidayah
2. Outlines
1. Principle of Anaesthesia care
2. Intra operative monitoring of the patient
3. Recovery from anaesthesia
4. Regional anaesthesia
5. Monitored anaesthesia care/ monitored
sedation
6. Pre-Anaesthetic consultation
7. Pre Operative fasting
Anor Hidayah
3. Principle of Anaesthesia Care
ANAESTHETIST Medical Officer / trainee
Under adequate
supervision of
Who administer Specialist
Qualified specialist
anaesthetic
anaesthetist
Must be contantly present from
induction/monitoring until safe Shall be responsible for the overall
transfer to PACU/ ICU anaesthetic care of patient
In acceptional circumstances, deligate temporarily to an appropriately qualified person
competent of the task
SKILLED • Assist anaesthetist
• Must be available all the times of conduct of anaesthesia
ASSISTANT • Should not have any other duty
Anor Hidayah
4. Principle of Anaesthesia Care
• Every patient must have pre-anaesthetic
assessment
• Adequate and legible records of anaesthesia &
must be part of patients medical record
• Anaesthetist responsibility to make sure all
equipments corrects and functioning
Transfer/ • Minimum 3 person
positioning of • Anaesthetist responsible to take
patient care of airway, head and neck
Anor Hidayah
5. Clinical INTRAOPERATIVE
Monitoring
observation
equipments MONITORING
of VS
Oxygenation Ventilation Temperature
• Colour of mucous membrane • Excursion of chest wall • Neonatal / paediatric patient
• Colour of operative site • Movement of reservoir beg
• Spo2 with variable pulse tone & • Ascultation of breathing
low alarm limit • Tidal volume monitoring
• Neurovascular
• Capnograph • Peripheral nerve stimulator
• Circulation • Quantitative assessment of
• BP ventilation • Anaesthetist effect
• Detection of adverse clinical
• Pulse rate
event (PE/ air embolism) on brain
• Indication of correct placement • MAC
of ETT/ LMA • BIS
Anor Hidayah
6. Regional Anaesthesia
• Major RA should received equivalent standard
and care as general anaesthesia
• Examples:
– Spinal anaesthesia
– Epidural anaesthesia
– Plexus block
Anor Hidayah
7. Recovery from Anaesthesia
• Designated area (PACU) – medical staff should be
immediately available for emergency
• Standard equipments in PACU
– Oxygen supply
– Appropriate delivering equipments means for
ventilation (ETT, Laryngoscope, LMA)
– Equipments, drugs for resuscitation
– Easy access to monitoring equipments
– Suction apparatus
– Pt warming devices(forsced air warmer, radiant
heater), temp monitoring devices
Anor Hidayah
8. Monitored anaesthesia care/ monitored
sedation
Objective of • Produce degree of amnesia
• Anxiolysis
sedation • Maintain cooperation of patient
• Requirements
– Patient should be assessed
– The medical practitioner should know
• basic knowledge of action of drugs
• detect and manage complications
– Recorded time and dosage given and vital signs
– IV access
– Location with cardiopulmonary resuscitation
Anor Hidayah
9. Pre Anaesthetic Consultation
• To assess and ensure patient is optimised
before surgery
Preferable to be given by anaesthetist who
is to administer the anaesthetics
• Medical history, medicines and
allergy, laboratory & radiological
• Other investigation
• Anaesthetic consent Discussion of the
nature of procedure, details of anaesthesia.
Anor Hidayah
10. History
5 solid and all
1946 66 cases of aspiration of died
Landmark stomach content into Lungs
paper by In 45 cases aspirated
Mandelson materials recorded 40 liquids
Similar vomitus liquids injected into rabits Positive CXR changes – no
lungs – simlar CXR changes death
Neutralized vomitus liquids no CXR
changes
MORTALITY 3-70%
MORBIDITY –
bronchospam, hypoxia,
• No oral feeding during labour pneumonitis, lungs
• IVD should be given abscess
Conclusions • Wider use of regional Anaesthesia
• Careful administration of GA with full appreciation of
the danger of aspiration during induction and recovery
Anor Hidayah
11. Patient at risk
• Residual gastrics fluid volume > 0.4ml/kg with pH < 2.5
at the time of aspiration
• >0.8ml/kg needed to produce pneumonia resulting in
mortality
• Amount of fluid instilled into the lung (not fluid
contained in stomach)
• to prevent complication – Pre operative fasting
allow sufficient time for gastric emptying
Anor Hidayah
12. Recommendation
Water, glucose drink,
• Clear Fluid cordial drink, Ribena,
2 hours black tea
• Breast milk
4 hours less hungry
Less thirsty
• Milk Less irritable
Less likelyhood of
6 hours • Solids dehydration and
hypotension
• Fatty food Less stress
8 hours • Large amount of food intake
Anor Hidayah
13. Recommendations base of cases
• No solid food from 12MN
• Breast milk up to 4 hours before surgery in infant
Am List • Oral pre med 1-2hrs before surgery up to 150ml of water
• Light breakfast at 7 am
• CF until 2-3 hrs before schedule time
Pm List
• If operation is Semi-Emergency, to follow the above
• Regional anaesthetic should be considered
• To be careful in “adequately” fasted duration . (Delayed gastric
Emergency emptying in trauma and labour patient.
List
• Extreme care in gastric outlet obstruction/ bowel obstruction
however long the fasting duration
Anor Hidayah
14. Recommendations
• Majority of aspiration occur during
laryngoscope and intubation
• Rapid sequence induction technique with
functioning suckers
• In case of fail intubation, Pro seal LMA should
be at hand
Anor Hidayah
15. Role of Cricoid pressure
• to prevent regurgitation
• to assist with visualisation of the glottis
• Prevention of gas insufflation
COMPLICATIONS
• Nausea / vomiting
•Esophageal rupture
• Difficult tracheal and mask intubation (pressure > 40N
may compromise patency)
Anor Hidayah
Guidelines are made to for guide medical practitioner for high quality of anaesthesiapractise and safety of patient under our careAnaesthetist clinical judgement and observation remain the cornerstone of safe anaesthesia practiceAnd the vigilence of anaesthetist while administering anaesthetics cannot be overemphasized
Sedative side effect – depression of protective reflexes, respiration, CVAWide variation in individual response to variety drugs especially in elderly and sick
Bear in mind even adequately fasted patient can have residual gastric volume >0.4ml/kg/hr that pH< 2.5Fasted patient (reduce the risk of aspiration)Higher risk for aspirationDelayed gastric emptying trauma patient, ingestion of fatty food, certain medicationsHiatus hernia, GERD, bowel obstruction, pregnant lady, morbidly obese, bulbar palsy
In Chochrane Review75% of infant entered fasting state after 3 hrs of fasting17% in formula milkFlexible fasting policy
The initial article by Sellick was based on a small sample size at a time when high tidal volumes, head-down positioning, and barbiturate anesthesia were the rule.[