VRAJESH MEHTA, CA-3 MODERATOR: DR. SAHITYA PUTTREDDY ITE keyword review 

Topics  ASA standards for monitoring  - Monitoring during General anesthesia and Monitored Anesthesia Care  PACU monitoring and discharge criteria  Bypassing Stage 1 recovery 

STANDARD 1  Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics, regional anesthetics and monitored anesthesia care.  MAC- Only an anesthesia personnel that is trained to convert from any level of sedation to general anesthesia is appropriate to provide Monitored anesthesia care 

STANDARD II  During all anesthetics, the patient’s oxygenation, ventilation, circulation and temperature shall be continually evaluated. 

OXYGENATION  Inspired gas: During every administration of general anesthesia using an anesthesia machine, the concentration of oxygen in the patient breathing system shall be measured by an oxygen analyzer with a low oxygen concentration limit alarm in use.  Blood oxygenation: During all anesthetics, a quantitative method of assessing oxygenation such as pulse oximetry shall be employed. 

VENTILATION  Qualitative clinical signs such as chest excursion, observation of the reservoir breathing bag and auscultation of breath sounds are useful. Monitoring for the presence of expired carbon dioxide is also required.  CONTINUAL evaluation of ETCO2 VM1 

Slide 6 VM1 Vrajesh Mehta, 1/26/2020 

CIRCULATION  Continuous Electrocardiogram  Every patient receiving anesthesia shall have arterial blood pressure and heart rate determined and evaluated at least every five minutes. 

BODY TEMPERATURE  Every patient receiving anesthesia shall have temperature monitored when clinically significant changes in body temperature are intended, anticipated or suspected. 

PACU bypass  The PACU is traditionally divided into phases 1 and 2. Phase 1 has monitoring and staffing ratios equivalent to the ICU. Phase 2 is a transitional period between intensive observation and either the surgical ward or home. Bypass is typically appropriate for patients who have received either MAC or peripheral regional anesthesia, while phase 1 is typically required for general inhalational anesthesia or neuraxial regional techniques. Ultimately, however, patient co-morbidities, surgical techniques/complications and pharmacological choices also determine the appropriate level of post-operative care on an individual basis.  Additionally, the Aldrete scoring system is commonly used to determine when patients can be safely discharged from phase 1 to phase 2. The scoring basis includes the five parameters: level of activity, respiration, circulation, consciousness and oxygen saturation. 

Discharge from PACU- Aldrete’s modified scoring system  Adapted from Miller: Criteria for Determination of Discharge Score for Release from the Postanesthesia Care Unit  Activity: Able to move four extremities on command: 2 Able to move two extremities on command: 1 Able to move 0 extremities on command: 0  Breathing: Able to breathe deeply and cough freely: 2 Dyspnea: 1 Apnea: 0  Circulation: Systemic blood pressure within 20% of the preanesthetic level: 2 Systemic blood pressure is 20% to 49% of the preanesthetic level: 1 Systemic blood pressure not within 50% of the preanesthetic level: 0  Consciousness: Fully awake: 2 Arousable: 1 Not responding: 0  Oxygen Saturation (Pulse Oximetry): 92% or more while breathing room air: 2 Needs supplemental oxygen to maintain saturation >90%: 1 90% even with supplemental oxygen: 0 

Discharge to Home  Patients who score of 9 or greater and have an appropriate escort are ready to go home  BP Systemic blood pressure and heart rate within 20% of the preanesthetic level: 2 Systemic blood pressure and heart rate 20% to 40% of the preanesthetic level: 1 Systemic blood pressure and heart rate >40% of the preanesthetic level: 0  Activity Level: Steady gait without dizziness or meets the preanesthetic level: 2 Requires assistance: 1 Unable to ambulate: 0  Nausea and Vomiting: None to minimal: 2 Moderate: 1 Severe: 0  Pain: Minimal to no pain, controlled with oral analgesics: 2 (above conditions not met): 1  Surgical Bleeding (consistent with that expected for the surgical procedure): Minimal (does not require dressing change): 2 Moderate (up to two dressing changes required): 1 Severe (more than three dressing changes required): 0 

REFERENCES  https://www.asahq.org/standards-and-guidelines/standards-for- basic-anesthetic-monitoring  Miller, RD et al. Miller’s Anesthesia, 7th edition, Churchill Livingstone: p 2708, 2723-4. 2009, (see in particular Miller Tables 85-14 and 85-15)  J A Aldrete The post-anesthesia recovery score revisited. J Clin Anesth: 1995, 7(1);89-91 

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