Special announcement: Guidelines to the Practice of Anesthesia - Revised Edition 2013

Abstract

In this issue of the Journal, the Canadian Anesthesiologists’ Society (CAS) is pleased to present the latest update to the CAS Guidelines to the Practice of Anesthesia – 2013. Initially developed in 1974 and published in 1975, these Guidelines were published in booklet form throughout the 1990 s and 2000 s and then published as a special article within the Journal since 2010. The Guidelines were developed by the Committee on Standards and approved by the Board of the Canadian Anesthesiologists’ Society. The Committee reviews features of the Guidelines on an ongoing basis and responds to the changing practice of the specialty of anesthesiology with updates to the recommendations presented therein. Some updates are relatively minor or reflect improvements in subtle inconsistencies that previously have escaped notice— for example, since the newer vapourizers do not use traditional ‘‘keyed’’ filling systems, rather than describe an acceptable anesthetic vapourizer as a ‘‘keyed’’ filling device, the description has been reworded to identify a requirement for an ‘‘agent-specific’’ filling system to ensure the vapourizer is filled with the correct agent. Similarly, a small inconsistency edged its way into the use of the Ramsay sedation scale (RSS) to define care: RSS 1 3 would generally be considered ‘‘lighter’’ sedation, and RSS 4 6 would normally be considered ‘‘deeper’’ sedation; a small change was made to apply this terminology consistently. Perhaps the following update has greater impact. We reviewed the guidelines for preoperative laboratory testing, which have not been modified for some years. In general, we recognize that often too much laboratory testing is done without supporting evidence (likely to avoid cancelling or delaying surgery due to ‘‘missing’’ test results). The CAS Guidelines are fairly precise in this regard, but we did recognize that current thought would not consider age alone or isolated (treated) hypertension as specific indications for preoperative electrocardiogram (ECG) testing; therefore, we have removed those items from the diagnoses listed for ECG testing. We recently presented a statement on respiratory monitoring of patients receiving sedative medications. Similar concerns regarding locations outside the operating room (OR) have not previously been addressed, hence the addition of the statement, ‘‘Respiratory monitoring should be considered in non-OR locations (postanesthesia care unit and elsewhere) for sedated patients and those at risk of respiratory depression’’. Lastly, in light of the new CAS Position Paper on Procedural Sedation, we have received several questions about details of the somewhat general statements within that document. In response to those concerns and in recognition that the ECG had been mandated as a monitor of cardiac rhythm prior to the availability of any other high-quality monitor of cardiac function, we have added the statement, ‘‘Electrocardiogram monitoring may be waived in suitable patients when continuous pulse oximetry is used for minor procedures when only RSS 1 3 sedation is employed’’. Those familiar with other guideline statements and other patient safety issues will agree with our concern that more work remains in the ongoing process of revision of our current Guidelines and development of new guideline principles. In particular, the Committee continues to examine issues in the areas of obstetrical anesthesia and analgesia, acute pain management, and clinician fatigue and competence. The CAS Committee on Standards and R. N. Merchant, MD (&) Committee on Standards, Canadian Anesthesiologists’ Society, 1 Eglinton Avenue East, Suite 208, Toronto, ON M4P 3A1, Canada e-mail: richard.merchant@ubc.ca