These standards1 are recommended for anesthesia professionals throughout the world.
They are intended to provide guidance and assistance to anesthesia professionals,
their professional societies, hospital and facility administrators, and governments
for improving and maintaining the quality and safety of anesthesia care. They were
adopted by the World Federation of Societies of Anaesthesiologists on the 13th June
1992, and revisions were ratified on 5th March 2008 and on 19th March 2010.
For some anesthesia services, groups, and departments these standards will represent
a future goal, while for others they may already have been implemented and be regarded
as mandatory. It is recognized that in some settings facing challenges in resources
and organization, not even those standards regarded as mandatory are met at present.
The provision of anesthesia under such circumstances should be restricted to procedures
which are absolutely essential for the urgent or emergency saving of life or limb,
and every effort should be made by those responsible for the provision of healthcare
in these areas and settings to ensure that the standards are met. Provision of anesthesia
care at standards lower than those outlined as mandatory for anesthesia for elective
surgical procedures simply cannot be construed as safe acceptable practice. The most
important standards relate to individual anesthesia professionals. Monitoring devices
play an important part in safe anesthesia as extensions of human senses and clinical
skills rather than their replacement.
Adopting the standardized language of the World Health Organization, minimum standards
that would be expected in all anesthesia care for elective surgical procedures are
termed “
HIGHLY RECOMMENDED
” and these are the functional equivalent of “mandatory” standards. These
HIGHLY RECOMMENDED
standards, indicated in
bold type
, are applicable throughout any elective procedure, from patient evaluation until
recovery (it is recognized, however, that immediate life-saving measures always take
precedence in an emergency). In the judgement of the WFSA, these are the minimum standards
for anesthesia for a “necessary” procedure (rather than essential and/or emergency)
in settings where resources are extremely limited. This does not imply that these
standards on their own are ideal or even acceptable in more adequately resourced settings.
These HIGHLY RECOMMENDED (functional equivalent of mandatory) standards and (regarding
facilities, equipment, and medications) the parallel prescription for “Level 1” or
“basic” infrastructure are relevant to any healthcare environment anywhere in which
general or regional anesthetics are administered, but not to a setting where superficial
procedures involving local anesthetics only are performed. Additional elements of
the anesthesia standards should be implemented as resources, organization, and training
permit, yielding this paradigm:
Anesthesia standards (in order of adoption)
Setting
Infrastructure
HIGHLY RECOMMENDED
Level 1
Basic
HIGHLY RECOMMENDED + RECOMMENDED
Level 2
Intermediate
HIGHLY RECOMMENDED + RECOMMENDED + Suggested
Level 3
Optimal
See Table 1 for a detailed outline of the integration of the practice standards with
the levels of facilities/infrastructure. The goal always in any setting is to practice
to the highest possible standards, specifically exceeding those prescribed if that
can be accomplished. In spite of some facilities’ limitations, it may be possible
to implement elements of the RECOMMENDED standards even in a “basic” setting and,
likewise, to implement elements of the Suggested standards even in an “intermediate”
setting. The goal is always the best care possible and ongoing improvement by meeting
and exceeding the standards for safe practice of anesthesia, starting with all providers
meeting the HIGHLY RECOMMENDED standards and striving to meet as many of the RECOMMENDED
and Suggested standards as well.
Table 1
Guide to Infrastructure, Supplies and Anesthesia Standards at Three Levels of Health
Care Facility Infrastructure and Supplies
Level 1 (Should meet at least HIGHLY RECOMMENDED anesthesia standards) Small hospital
/ health centre
Level 2 (Should meet at least HIGHLY RECOMMENDED and RECOMMENDED anesthesia standards)
District/provincial hospital
Level 3 (Should meet at least HIGHLY RECOMMENDED, RECOMMENDED and SUGGESTED anesthesia
standards) Referral hospital
Rural hospital or health centre with a small number of beds (or urban location in
an extremely disadvantaged area); sparsely equipped operating room (OR) for “minor”
proceduresProvides emergency measures in the treatment of 90–95% of trauma and obstetrics
cases (excluding cesarean section)Referral of other patients (for example, obstructed
labour, bowel obstruction) for further management at a higher level
District or provincial hospital (e.g. with100–300 beds) and adequately equipped major
and minor operating roomsShort term treatment of 95–99% of the major life threatening
conditions
A referral hospital of 300–1000 or more beds with basic intensive care facilities.
Treatment aims are the same as for Level 2, with the addition of: Ventilation in OR
and ICUProlonged endotracheal intubationThoracic trauma careHemodynamic and inotropic
treatmentComplex neurological and cardiac surgeryBasic ICU patient management and
monitoring for up to 1 week : all types of cases, but possibly with limited provision
for: Multi-organ system failureHemodialysisProlonged respiratory failureMetabolic
care or monitoring
Essential Procedures
Essential Procedures
Essential Procedures
Normal deliveryUterine evacuationCircumcisionHydrocele reduction, incision and drainageWound
suturingControl of hemorrhage with pressure dressingsDebridement and dressing of woundsTemporary
reduction of fracturesCleaning or stabilization of open and closed fracturesChest
drainage (possibly) Abscess drainage
Same as Level 1 with the following additions: Cesarean sectionLaparotomy (usually
not for bowel obstruction)AmputationHernia repairTubal ligationClosed fracture treatment
and application of plaster of ParisAcute open orthopedic surgery: e.g internal fixation
of fracturesEye operations, including cataract extractionRemoval of foreign bodies:
e.g. in the airwayEmergency ventilation and airway management for referred patients
such as those with chest and head injuries
Same as Level 2 with the following additions:Facial and intracranial surgeryBowel
surgeryPediatric and neonatal surgeryThoracic surgeryMajor eye surgeryMajor gynecological
surgery, e.g. vesico-vaginal repair
Personnel
Personnel
Personnel
Paramedical staff/anesthetic officer (including on-the-job training) who may have
other duties as wellNurse-midwife
One or more trained anesthesia professionalsDistrict medical officers, senior clinical
officers, nurses, midwivesVisiting specialists or resident surgeon and/or obstetrician/
gynecologist
Clinical officers and specialists in anesthesia and surgery
Drugs
Drugs
Drugs
Ketamine 50 mg/ml injectionLidocaine 1% or 2%Diazepam 5 mg/ml injection, 2 ml or midazolam
1 mg/ml injection, 5 mlPethidine 50 mg/ml injection, 2 mlMorphine 10 mg/ml, 1 mlEpinephrine
(Adrenaline) 1 mgAtropine 0.6 mg/mlAppropriate inhalation anesthetic if vaporizer
available
Same as Level 1, but also:Thiopental 500 mg/1 g powder or propofol.Suxamethonium bromide
500 mg powderPancuroniumNeostigmine 2.5 mg injectionEther, halothane or other inhalation
anestheticsLidocaine 5% heavy spinal solution, 2 mlBupivacaine 0.5% heavy or plain,
4 mlHydralazine 20 mg injection
Same as Level 2 with these additions:PropofolNitrous oxideVarious modern neuromuscular
blocking agentsVarious modern inhalation anestheticsVarious inotropic agentsVarious
intravenous antiarrhythmic agentsNitroglycerine for infusionCalcium chloride 10% 10
im injection
Furosemide 20 mg injectionDextrose 50% 20 ml injectionAminophylline 250 mg injectionEphedrine
30/50 mg ampoulesHydrocortisone(?) Nitrous oxide
Potassium chloride 20% 10 ml injection for infusion
Equipment: capital outlay
Equipment: capital outlay
Equipment: capital outlay
Adult and pediatric self-inflating breathing bags with masksFoot-powered suctionStethoscope,
sphygmomanometer, thermometerPulse oximeterOxygen concentrator or tank oxygen and
a draw-over vaporizer with hoses
Complete anesthesia, resuscitation and airway management systems including: Reliable
oxygen sourcesVaporizer(s)Hoses and valvesBellows or bag to inflate lungsFace masks
(sizes 00–5)Work surface and storagePediatric anesthesia systemOxygen supply failure
alarm; oxygen analyzer
Same as Level 2 with these additions (per operating room or per ICU bed, except where
stated):ECG (electrocardiograph) monitor*Anesthesia ventilator, reliable electric
power source with manual overrideInfusion pumps (2 per bed)Pressure bag for IV infusionElectric
or pneumatic suctionOxygen analyzer*
Laryngoscopes, bougies
Adult and pediatric resuscitator setsPulse oximeter, spare probes, adult and pediatric*Capnograph*Defibrillator
(one per O.R. suite / ICU)*ECG (electrocardiograph) monitor*Laryngoscope, Macintosh
blades 1-3(4)Oxygen concentrator[s] [cylinder]Foot or electric suctionIV pressure
infusor bagAdult and pediatric resuscitator setsMagill forceps (adult and child),
intubation stylet and/or bougieSpinal needles 25GNerve stimulatorAutomatic non-invasive
blood pressure monitor
Thermometer [temperature probe*]Electric warming blanketElectric overhead heaterInfant
incubatorLaryngeal mask airways sizes 2, 3, 4 (3 sets per O.R)Intubating bougies,
adult and child (1 set per O.R)Anesthetic agent (gas and vapour) analyserDepth of
anesthesia monitors are being increasingly recommended for cases at high risk of awareness
but are not standard monitoring in many countries.
Equipment: disposable
Equipment: disposable
Equipment: disposable
Examination glovesIV infusion/drug injection equipment
ECG electrodesIV equipment (minimum fluids: normal saline, Ringer’s lactate and dextrose
5%)
Same as Level 2 with these additions:Ventilator circuits
Suction catheters size 16 FG
Pediatric giving sets
Yankauer suckers
Airway support equipment, including airways and tracheal tubes
Suction catheters size 16 FGSterile gloves sizes 6–8
Giving sets for IV infusion pumpsDisposables for suction machines
Oral and nasal airways
Nasogastric tubes sizes 10–16 FGOral airways sizes 000–4Tracheal tubes sizes 3–8.5 mmSpinal
needles sizes 22 G and 25GBatteries size C
Disposables for capnography, oxygen analyzer, in accordance with manufacturers’ specifications:Sampling
linesWater trapsConnectorsFilters – Fuel cells
* It is preferable to combine these modalities all in one unit
Note: drug concentrations and quantities are indicative only. All equipment should
be appropriate for patients’ age and size
It is anticipated that these standards and the setting/infrastructure specifications
will be revised as practice and technology evolve.
International Standards for a Safe Practice of Anesthesia 2010
General standards
1. Professional status
Anesthesia services are a vital component of basic healthcare requiring appropriate
resources. The WFSA views anesthesia as a medical practice. Medically trained anesthesia
specialists should be trained and accredited with clinical and administrative autonomy.
When anesthesia is provided by non-medical personnel, these providers should be appropriately
trained and accredited as well as directed and supervised by medically qualified specialist
anesthesia professionals.
2. Professional organizations
Anesthesia professionals should form appropriate organizations at local, regional,
and national levels for the setting of standards of practice, supervision of training
and continuing education/continuing professional development with appropriate certification
and accreditation, and general promotion of anesthesia as an independent professional
specialty. These organizations should form links with appropriate groups within the
region and/or country and internationally.
3. Training, certification, and accreditation
Adequate time, facilities, and financial support should be available for professional
training, both initial and continuing, to ensure that an adequate standard of knowledge,
expertise, and practice is attained and maintained. Formal certification of training
and accreditation to practice is RECOMMENDED.
4. Records and statistics
A record of the details of each anesthetic should be made and preserved with the patient’s
medical record. This should include details of the pre-operative assessment and the
post-operative course. It is RECOMMENDED that individuals, departments, and regional
and national groups collect cumulative data to facilitate the progressive enhancement
of the safety, efficiency, effectiveness, and appropriateness of anesthesia care.
5. Peer review and incident reporting
Institutional, regional, and/or national mechanisms to provide a continuing review
of anesthetic practice should be instituted. Regular confidential discussion of appropriate
topics and cases with multidisciplinary professional colleagues should take place.
Protocols should be developed to ensure that deficiencies in individual and collective
practice are identified and rectified. An anonymous incident reporting system with
case analysis and resulting suggested remedies is RECOMMENDED.
6. Workload
A sufficient number of trained anesthesia professionals should be available so that
individuals may practice to a high standard without undue fatigue or physical demands.
Time should be allocated for education, professional development, administration,
research, and teaching.
7. Personnel
An anesthesia professional should be dedicated to each patient and be immediately
present throughout each anesthetic (general, regional, or monitored sedation), and
should be responsible for the transport of the patient to the post-anesthesia recovery
facility and the transfer of care to appropriately trained personnel. An anesthesia
professional should retain overall responsibility for the patient during the recovery
period and should be readily available for consultation until the patient has made
an adequate recovery. If responsibility for care is transferred from one anesthesia
professional to another, a “handover protocol” should be followed, during which all
relevant information about the patient’s history, medical condition, anesthetic status,
and plan should be communicated. An anesthesia professional should ensure, if aspects
of direct care are delegated before, during, or after an anesthetic, that the person
to whom responsibility is delegated is both suitably qualified and conversant with
relevant information regarding the anesthetic and the patient. Where it is impossible
for this standard to be attained and the surgeon or other individual assumes responsibility
for the anesthetic, these arrangements should be reviewed and audited by an appropriately
trained anesthesia professional.
8. Facilities, equipment, and medications
Appropriate equipment and facilities, adequate both in quantity and quality, should
be present wherever anesthesia and recovery from it is undertaken, including outside
traditional hospital operating room suites, such as procedure or imaging suites and
outpatient facilities or offices. In-service training and verification of an individual’s
ability to use a specific piece of equipment correctly and safely is required. Formal
certification as documentation of this process is Suggested. A list of facilities,
infrastructure elements and supplies at the three levels and suggestions as to the
order in which additions should be made when possible as resources permit is presented
in Table 1. Anesthesia equipment should conform to relevant national and international
standards. Appropriate anesthetic, resuscitative, and adjuvant medications are required
at each level.
9. World Health Organization 2009 Safe Surgery Checklist
The 2009 Safe Surgery Checklist (http://www.who.int/patientsafety/information_centre/documents/en/index.html)
consists of evidence based vital checks in 3 phases: before starting anesthesia, before
starting surgery and at the end of surgery. The use of the checklist (locally modified
if appropriate) in anesthesia care is HIGHLY RECOMMENDED.
Peri-anesthetic care and monitoring standards
The first and most important component of peri-anesthetic care, including monitoring
of the anesthesia delivery system and the patient, is the continuous presence of a
vigilant anesthesia professional during anesthesia. In addition to use of monitoring
technology, careful continuous clinical observation is required because equipment
may not detect clinical deterioration as rapidly as the skilled professional. If an
emergency requires the brief temporary absence of the primary anesthesia professional,
judgment must be exercised comparing the emergency with the anesthetized patient’s
condition and in the selection of the person left responsible for the anesthetic during
the temporary absence.
1. Pre-anesthetic care
The patient must be evaluated by an anesthesia professional prior to administration
of anesthesia and an appropriate anesthetic plan formulated. The anesthesia professional
must ensure that all necessary equipment is present and functions correctly prior
to initiation of anesthesia care. The anesthesia professional should ensure that assistance
is available as needed and that the assistant is competent at, or has been instructed
in, the necessary tasks. The development of protocols and check-lists to facilitate
such verification is RECOMMENDED.
2. Pre-anesthesia checks
An appropriate “pre-list check,” which has been established in each health care institution
providing anesthesia services, of the anesthesia system, facilities, equipment, and
supplies should be performed prior to the start of each operating list.
The relevant components of the World Health Organization Safe Surgery Checklist should
be performed.
An appropriate “pre-patient check” (such as presented in the attached Pre-anesthetic
check list) which has been established in each health care institution providing anesthesia
services, of the anesthesia system and anesthetizing location should be executed prior
to each anesthetic.
*The integrity of a circle system and its valves should be checked by placing one
breathing bag in the correct place for ventilating a patient and another breathing
bag on the patient limb of the Y-piece (i.e. in place of the patient) and ventilating
the system manually using an appropriate fresh gas flow and squeezing the primary
and secondary bags alternatively, so that gas passes around the circle from one to
the other. Inflation and deflation of the breathing bag, movement of any visible unidirectional
valves, and the resistance and compliance of the system should all be assessed as
“normal”. The function of the adjustable pressure limiting valve should also be checked
by spilling some of the gas when both bags are compressed. This “two bag check” is
a reliable way of detecting expiratory limb obstruction which is readily missed when
less systematic checks of the integrity of the circuit are carried out.
3. Monitoring during anesthesia
A. Oxygenation
(i) Oxygen supply
Supplemental oxygen is HIGHLY RECOMMENDED for all patients undergoing general anesthesia.
The anesthesia professional should verify the integrity of the oxygen supply. It is
RECOMMENDED that the inspired oxygen concentration be monitored throughout each anesthetic
with an instrument fitted with a low oxygen concentration alarm. An oxygen supply
failure alarm and a device protecting against the delivery of an hypoxic gas mixture
are RECOMMENDED. Systems with interlocks (tank yokes, hose connections, etc.) should
be used to prevent misconnection of gas sources.
(ii) Oxygenation of the patient
Tissue oxygenation should be monitored continuously. For visual examination, adequate
illumination and exposure of the patient should be ensured whenever practicable. Continuous
use of pulse oximetry is HIGHLY RECOMMENDED.
B. Airway and ventilation
The adequacy of the airway and ventilation should be continuously monitored at least
by observation and auscultation whenever practicable.
Where a breathing circuit is used, the reservoir bag should be observed. Continuous
monitoring with a precordial, pretracheal, or oesophageal stethoscope is RECOMMENDED.
Confirmation of the correct placement of an endotracheal tube and also the adequacy
of ventilation by continuous measurement and display of the expired carbon dioxide
waveform and concentration (capnography) is RECOMMENDED
. When mechanical ventilation is employed, a “disconnect alarm” should be used throughout
the period of mechanical ventilation. Continuous measurement of the inspiratory and/or
expired gas volumes, and of the concentration of volatile agents, is Suggested.
C. Circulation
(i) Cardiac rate and rhythm
The circulation should be monitored continuously. Palpation or display of the pulse
and/or auscultation of the heart sounds should be continuous. Continuous monitoring
and display of the heart rate with a pulse oximeter is HIGHLY RECOMMENDED; an electrocardiograph
is RECOMMENDED. The availability of a defibrillator is RECOMMENDED.
(ii) Tissue perfusion
The adequacy of tissue perfusion should be monitored continually by clinical examination.
Continuous monitoring with a pulse oximeter is HIGHLY RECOMMENDED; continuous monitoring
with a capnograph is RECOMMENDED.
(iii) Blood pressure
Arterial blood pressure should be determined at appropriate intervals (usually at
least every 5 minutes and more frequently if indicated by clinical circumstances).
Automated non-invasive blood pressure measurements have many advantages in anesthesia;
continuous measurement and display of arterial pressure is Suggested in appropriate
cases.
D. Temperature
A means of measuring the temperature should be available and should be used at frequent
intervals where clinically indicated (e.g. prolonged or complex anesthetics, young
children). The continual measurement of temperature in patients in whom a change is
anticipated, intended, or suspected is RECOMMENDED. The availability and use of continuous
electronic temperature measurement is Recommended.
E. Neuromuscular function
When neuromuscular blocking drugs are given, the use of a peripheral nerve stimulator
is RECOMMENDED.
F. Depth of anesthesia
The depth of anesthesia (degree of unconsciousness) should be regularly assessed by
clinical observation. The continuous measurement of inspired and expired concentrations
of anesthetic gases and volatile agents is Suggested. The application of an electronic
device intended to measure brain function (consciousness), while controversial and
not universally recommended, should be considered, particularly in cases with high
risk of awareness under general anesthesia.
G. Audible signals and alarms
Available audible signals (such as the variable pitch pulse tone of the pulse oximeter)
and audible alarms (with appropriately set limit values) should be activated at all
times and loud enough to be heard throughout the operating room.
4. Post-anesthesia care
A. Facilities and personnel
All patients who have had an anesthetic affecting central nervous system function
and/or a loss of protective reflexes should remain where anesthetized until recovered
or be transported safely (with care and monitoring as indicated) to a specifically
designated recovery location for post-anesthesia recovery. See General Standards,
Section 7, for delegation of responsibilities to dedicated qualified recovery personnel.
B. Monitoring
All patients should be observed and monitored in a manner appropriate to the state
of their nervous system function, vital signs, and medical condition with emphasis
on the adequacy of oxygenation, ventilation, circulation, and temperature. Supplementation
of clinical monitoring with quantitative methods analogous to intra-anesthetic patient
care described above is RECOMMENDED. Specifically, pulse oximetry is HIGHLY RECOMMENDED
until consciousness has recovered (i.e. the patient is no longer anesthetized).
C. Pain relief
All patients are entitled to appropriate efforts to prevent and alleviate postoperative
pain employing available appropriate medications and modalities; these efforts are
therefore HIGHLY RECOMMENDED. Usually, the involved anesthesia professional assumes
initial responsibility for this.