Guidelines to the Practice of An

Anesthesia is a dynamic speciality of medicine in which many changes have taken place in recent years. Continuous progress is being made to improve standards of anesthetic care for patients having surgical and obstetrical procedures in Canada. To reflect the progress made in the delivery of anesthetic services, this document is reviewed annually and revised periodically.
The following recommendations are aimed at providing basic guidelines to anesthetic practice. They are intended to provide a framework for a reasonable and acceptable standard of patient care and should be so interpreted, allowing for some degree of flexibility to occur in different circumstances. Each section of these guidelines is subject to revision as warranted by the evolution of technology and practice.

Basic Principles

In this document, the term anesthesiologist is used to designate all licensed medical practitioners with privileges to administer anesthetics. An anesthetic is any procedure that is deliberately performed to render a patient temporarily insensitive to pain or the external environment, so that a diagnostic or therapeutic procedure can be performed.

The practice of anesthesia is a specialized field of medicine. As such, certified specialists should practise it. The Canadian Anesthesiologists’ Society acknowledges that remote communities often lack the population base to support a specialist anesthetic practice. In these communities, appropriately trained family physicians may be required to provide anesthesia services. All anesthesiologists are encouraged to continue their education in all aspects of the practice of anesthesia and resuscitation.

These guidelines are intended to apply to all anesthesiologists in Canada.

Organization of Hospital Anesthetic Services

The Department of Anesthesia should be properly organized, directed and integrated with other departments in the hospital.

The Department of Anesthesia should include all hospital staff members who provide anesthetic services to patients for surgical, obstetrical, diagnostic and therapeutic purposes.

The Department should be staffed appropriately, bearing in mind the scope and nature of the services provided, and should strive to ensure that these services are available as required by the health care facility.

The Chief of the Department should be a physician who has obtained certification or appropriate training in anesthesia. This individual should be appointed in the same manner as other chiefs of clinical departments and should be a member of the Medical Advisory body for the hospital.

The responsibilities of the Chief of Anesthesia are:

To maintain an awareness of the current Canadian Anesthesiologists’ Society Guidelines to the Practice of Anesthesia, the requirements of the Canadian Council on Health Facility Accreditation, and the Provincial Licensing Authority’s requirements as they relate to anesthesia.
To ensure that written policies with respect to the practice of anesthesia are established and enforced.
To evaluate the qualifications and abilities of the physicians providing anesthetic care and also of other health professionals providing ancillary care. This includes (but is not restricted to) the recommendations of clinical privileges for physicians with anesthetic responsibilities, and annual review of these privileges.
To monitor systematically the quality of anesthetic care provided throughout the health care facility. This should include chart reviews, internal audits, or more detailed reviews when indicated.
To ensure that records are kept for all anesthetic procedures. These records should allow for evaluation of all anesthetic care in the hospital.
To carry out such other duties as the governing body of the hospital may delegate to ensure safe anesthetic care.

Privileges

All physicians applying for privileges in anaesthesia should demonstrate satisfactory completion of postgraduate training in a Department of Anesthesia which has a residency program approved by the Royal College of Physicians and Surgeons of Canada.

Physicians with anesthetic privileges should possess the knowledge and technical skills necessary for the practice of anesthesia.

These include the ability:

To provide preanesthetic evaluation of the patient and determine appropriate anesthetic management;
To render the patient insensible to pain for the performance of surgical operations and obstetrical procedures;
To monitor and support the vital organ systems in the perioperative period;
To provide immediate postanaesthetic management of the patient;
To provide resuscitation and intensive care when indicated;
To provide relief of acute and chronic pain.

Residents

Residents in anesthesia are registered medical practitioners and may, as part of their training, administer anesthetics without direct supervision.The decision to allow a resident to administer an anesthetic without direct supervision should take into account the nature of the case and the abilities of the resident. The supervising attending anesthesiologist must remain readily available to assist the resident, and should not simultaneously do his or her own slate while supervising a resident.

Ancillary Help

The health care facility must ensure that ancillary personnel are available where appropriate. Anesthesia technicians or other qualified allied health professionals may, with the approval of the governing body of the hospital, render certain ancillary assistance in providing anesthetic, resuscitative, and intensive care services. These personnel must be properly trained, and must have received accreditation by the appropriate authority where applicable. The tasks which they may perform must be clearly defined. An anesthetist must only delegate, or assign to such personnel, tasks for which they have approval or accreditation.

Anesthetic Equipment & Anesthetising Location

An anesthetic must be given in an appropriate facility. All necessary equipment, drugs and or other supplies must be readily available. Emergency equipment for resuscitation and life support must also be available.

The health care facility is responsible for the design and maintenance of the anesthetising location and for the purchase, maintenance and inspection of anesthetic and ancillary equipment. The Canadian Standards Association (CSA) has provided publications pertaining to anesthetic facilities and to the selection, installation and maintenance of most anesthetic and ancillary equipment (Appendix I). When purchasing new equipment or designing new installations, these standards, as well as specific recommendations arising from provincial legislation, shall be obtained and followed. The advice of the Department of Anesthesia should be sought.

The health care facility must ensure that:

The operating room conforms to the electrical code and meets the standards for safety in anesthetising locations and excess anesthetic gas scavenging systems.
There is compliance with all regulations to minimize the hazards from fire, explosion and electrocution, and that all electrical equipment in the operating room conforms to the standards described in the Canadian Standards Association's current publications.
Medical gas pipeline systems, including low pressure connecting assemblies, pressure regulators and terminal units, meet standards for identification, construction and installation. The piping systems must be certified by a Canadian Standards Association approved testing agency. Oxygen concentrators may be an acceptable substitute for bulk oxygen provided installation and maintenance conform to all applicable CSA standards (Appendix I).

When such concentrators are installed, users must be aware that:

hospital medical oxygen supply may vary between an FIO2 of .93 and .99

oxygen analysers must be calibrated against O2 U.S.P. (FIO2.99) and room air or equivalent (FIO2.21);

use of low-flow (less than one litre total fresh gas flow) anesthetic techniques may result in the accumulation of inert gas (argon) and the dilution of nitrous oxide and oxygen in the circuit.

There is compliance with all safety regulations respecting the preparation, storage, identification and use of medical gases, anesthetic drugs and related materials.
The anesthetic machine conforms to standard Z168.3 or is an electronic, fluidic, or pneumatic controlled machine. The machine must be equipped with an oxygen analyser, vaporisers fitted with keyed filling devices, a ventilator with a low pressure alarm, a dedicated exhaust gas scavenging system and a high vacuum tracheal suction system.
A resuscitator, a defibrillator with synchronised electrocardiograph, and drugs and equipment to manage emergencies (including malignant hyperthermia, difficult airways, and failed endotracheal intubation) must be immediately available. Facilities that care for children should have specialised paediatric equipment. Wherever obstetrical anesthesia is performed, a separate area for newborn assessment and resuscitation including designated oxygen, suction apparatus, electrical outlets and source of radiant heat, and equipment for neonatal airway management and resuscitation shall be provided.
Anesthesia providers must ensure that potentially infectious materials or agents are not transferred from one patient to another. Special attention in this regard should be given to syringes, infusion pump administration sets, and multidose drug vials.

The health care facility must ensure that all anesthetic and ancillary equipment undergo regular inspection and maintenance by qualified personnel. Records indicating both conformity to regulations and inspection and maintenance must be retained by the hospital administration and the Department of Anesthesia.

Before the introduction of new anesthesia equipment, members of an anesthetic department should receive training sessions on this equipment under the guidance of the Chief of the Department. These training sessions should be repeated as necessary for new or established department members.

Recommendations for reducing occupational exposure to waste anesthetic gases:

The dilution ventilation of 20 changes/hour recommended by CSA standard Z317.2 should be provided in all operating rooms.
Recirculation of exhaust air shall not be permitted during the hours when operations may be in progress, and is not recommended at any other time.
Wherever an anesthetic delivery system is used, a scavenger shall be provided to capture anesthetic gases that might be released from the anesthetic circuit or ventilator.
A maintenance program shall be established in each health care facility to detect and repair leakage from the anesthetic delivery system, and to maintain the effectiveness of the scavenging unit.
The health care facility shall be responsible for conducting regular monitoring of exposure to waste anesthetic gases. The monitoring protocol should include individuals and the air flow patterns of the rooms being assessed. When N2O is used in the operating room, N2O monitoring is a suitable representation for the assessment of adequacy of scavenging.

The Preanesthetic Period

Basic preanesthetic requirements should be established in a written policy statement of the Department of Anesthesia. These should include documentation of a current history and physical examination, and a review of appropriate laboratory determinations. The patients medical record should document a pre-anesthetic evaluation by a physician who has knowledge of the proposed anesthetic procedure.

Ideally, preanesthetic evaluation should be conducted by the anesthesiologist who is scheduled to provide services for the patient, but in practice this is not always possible. At the time of the preoperative visit, the anesthetist should take such history and carry out such physical examinations as are necessary for the planning of anesthesia. This history should include enquiry as to drug therapy, unusual reactions or responses to drugs and previous anesthetics, including problems and complications. Information about the anesthetic that the patient considers relevant should be discussed. An American Society of Anesthesiologists physical status classification (Appendix II) should be recorded for each patient. Details of the preoperative assessment should be documented on the patients chart.

Laboratory investigations indicated by the history and physical examination should be carried out. These should take into consideration the physical condition of the patient and the proposed operation.

The surgeon and attending physician have a responsibility to inform the anesthesiologist of any problems known to them that may affect the safe administration of an anesthetic. Pertinent medical consultations should be requested and obtained when indicated.

Any difference of opinion between the operating surgeon and the anesthesiologist with regard to the care of the patient should be resolved before the time of the operation.

Fasting policies should vary to take into account age and preexisting medical conditions, and should apply to all forms of anesthesia, including monitored anesthesia care. Emergent or urgent procedures should be undertaken after considering the risk of delaying surgery versus the risk of aspiration of gastric contents. The type and amount of food ingested should be considered in determining the duration of fasting. Prior to elective procedures, the minimum duration of fasting should be:

Eight hours after a meal that includes meat, fried or fatty foods;

Six hours after a light meal (such as toast and a clear fluid), or after ingestion of infant formula or nonhuman milk;

Four hours after ingestion of breast milk, and

Two hours after clear fluids.

Premedication, when indicated, should be ordered by the anesthesiologist. Orders should be specific as to dose, time and route of administration.

There may be additional regulations governing the conduct of anesthesia that are dictated by provincial legislation or hospital by-laws.

The Anesthetic Period

Before beginning an anesthetic the anesthesiologist must ensure that:

An explanation of the planned anesthetic procedure has been given;
An adequate review of the patient's condition has been performed;
All equipment items that are expected to be required are available and in working order;
A reserve source of oxygen under pressure is available;
All drugs and agents that are expected to be required are correctly identified;
Until a specific connection system is devised for neuraxial use, both sides of all Luer connections should be labelled.
The manufacturers' recommendations concerning the use, handling and disposal of anesthetic equipment and supplies have been considered.

The anesthesiologist's primary responsibility is to the patient receiving care. The anesthesiologist must remain with the patient at all times throughout the conduct of all general, major regional, and monitored intravenous anesthetics. The anesthesiologist should leave only when the patient has been transferred to the care of the postanesthesia recovery room (PAR) or ICU personnel. Under exceptional circumstances, for example to provide life-saving emergency care to another patient, an anesthesiologist may elect to delegate routine care of the patient to a competent person whose only responsibility is to monitor that patient during the anesthesiologist's absence. In this situation the anesthesiologist must inform the surgeon.

Simultaneous administration of general, spinal, epidural, or other major regional anesthesia by one anesthesiologist for concurrent diagnostic or therapeutic procedures on more than one patient is unacceptable. However, in an obstetrical unit it is acceptable to supervise more than one patient receiving regional analgesia for labour. Due care must be taken to ensure that each patient is adequately observed by a suitably trained person following an established protocol. When an anesthesiologist is providing anesthetic care for an obstetrical delivery, a second individual, appropriately trained, should be available to provide neonatal resuscitation.

Simultaneous administration of an anesthetic and performance of a diagnostic or therapeutic procedure by a single physician is unacceptable, except for procedures done with only infiltration of local anesthetic.

Records

All monitored physiological variables should be charted at intervals appropriate to the clinical circumstances. Heart rate and blood pressure should be recorded at least every five minutes. Oxygen saturation should be continuously monitored and recorded at frequent intervals. Every patient receiving inhalational, major regional, or monitored intravenous anesthesia should have oxygen saturation and, if the trachea is intubated, end tidal carbon dioxide concentration monitored continuously. Reasons for deviation from these charting guidelines should be documented in the anesthetic record. Monitors, equipment and techniques, as well as time, dose and route of all drugs and fluids should be recorded. Intraoperative care should be recorded.

The anesthesia record should include the recording of the patient's level of consciousness, heart rate, blood pressure, oxygen concentration, and respiratory rate as first determined in the postanesthesia recovery (PAR) Room.

Patient Monitoring

The only indispensable monitor is the presence, at all times, of an appropriately trained and experienced physician. Mechanical and electronic monitors are, at best, aids to vigilance. Such devices assist the anesthesiologist to ensure the integrity of the vital organs, and in particular, the adequacy of tissue perfusion and oxygenation.

The health care facility is responsible for the provision and maintenance of monitoring equipment that meets current published equipment standards.

The Chief of Anesthesia is responsible for advising the health care facility on the procurement of monitoring equipment, and for establishing policies for monitoring to help ensure patient safety.

The anesthesiologist is responsible for monitoring the patient receiving care and must ensure that appropriate monitoring equipment is available and working correctly. A preanesthetic checklist (Appendix III or equivalent) shall be completed prior to initiation of anesthesia.

Monitoring guidelines for standard patient care apply to all patients receiving general anesthesia, regional anesthesia or intravenous sedation.

Monitoring equipment is classified either as:

Required: These monitors must be in continuous use throughout the administration of all anesthetics.

Exclusively available for each patient: These monitors must be available at each anesthetic work station, so that they can be applied without any delay.

Immediately available: These monitors must be available such that they can be applied without undue delay.

The following are required:

Pulse oximeter;

Apparatus to measure blood pressure, either directly or noninvasively;

Electrocardiography;

Capnography, when endotracheal tubes or laryngeal masks are inserted.

The following shall be exclusively available for each patient:

Apparatus to measure temperature;

Peripheral nerve stimulator, when neuromuscular blocking drugs are used;

Stethoscope - either precordial, oesophageal or paratracheal;

Appropriate lighting to visualize an exposed portion of the patient.

The following shall be immediately available:

Spirometer for measurement of tidal volume.

It is recognised that brief interruptions of continuous monitoring may be unavoidable. Furthermore, there are certain circumstances where a monitor may fail and therefore continuous vigilance by the anesthesiologist is essential. The use of agent-specific anesthetic gas monitors is encouraged.

Alarms for oximetry and capnography should not be indefinitely disabled during the conduct of an anesthetic except during unusual circumstances.

The Postanesthetic Period

Recovery Facility

In any hospital providing anesthetic services, a postanesthesia recovery (PAR) room must be available. Administrative policies in accordance with hospital by-laws shall be enforced to co-ordinate medical and nursing care responsibilities.

The Department of Anesthesia should have overall medical administrative responsibility of the PAR room. There should be a policy manual for the PAR room, which has been approved by medical, nursing and administrative authorities.

The anesthesiologist should accompany the patient to the PAR room, communicate necessary information, and write appropriate orders. If clinically indicated, supplemental oxygen and appropriate monitoring devices should be applied during transport. Care should not be delegated to the PAR room nurse until the anesthesiologist is assured that the patient may be safely observed and cared for by the nursing staff. The anesthesiologist or designated alternate is responsible for providing anesthetic-related care in the PAR room. Discharge from the PAR room is the responsibility of the anesthesiologist. This responsibility may be delegated in accordance with hospital policy.

Supplemental oxygen and suction must be available for every patient in the PAR room. Emergency equipment for resuscitation and life support must be available in the PAR room. The monitoring used in the PAR room should be appropriate to the patient's condition and a full range of monitoring devices should be available. The use of pulse oximetry in the initial phase of recovery is required (as of July 1, 1995).

An accurate record of the immediate recovery period shall be maintained. This must include a record of vital signs together with other aspects of treatment and observation. It shall form a part of the permanent medical record. Any complications that bear any relation to the anesthetic should be recorded, either on the recovery record or on the progress notes on the patient's chart.

Discharge of Patients after Day Surgery

The patient must be discharged from the facility under the care of a responsible adult only when fully conscious and ambulatory. The patient should be advised not to drive an automobile or to operate hazardous machinery for at least 24 hours. The patient should also be advised about the additive effects of alcoholic beverages and sedative drugs.

Guidelines for Obstetrical Regional Analgesia

Anesthesia services to parturients include obstetric analgesia for labour and uncomplicated deliveries, obstetric anesthesia for complicated or operative deliveries. All guidelines regarding provision of anesthesia for other diagnostic or therapeutic procedures also apply to provision of obstetric anesthesia. These Guidelines for Obstetrical Regional Analgesia pertain to epidural and spinal analgesia during labour. The term “regional analgesia” includes epidural, spinal, and combined spinal-epidural analgesia.

These guidelines will be reviewed by the Section of Obstetric Anesthesia every three years and updated as indicated. Each hospital may wish to develop additional guidelines or policies for specific situations where obstetrical regional analgesia is provided.

Initiation of Obstetrical Regional Analgesia

Prior to introducing obstetrical regional analgesia, individual hospitals should have appropriate monitoring protocols in place. These protocols should outline the types of monitoring required and the frequency of monitoring. In addition, they should clearly state how to manage common problems and emergencies, and who to contact if assistance is required.
Obstetric regional analgesia should only be provided by physicians with training, hospital privileges and license to provide these services. This includes trainees with appropriate supervision.
Regional analgesia should only be initiated and maintained in locations in which appropriate resuscitation equipment and drugs are immediately available.
Informed consent should be obtained and documented in the medical record.
Intravenous access must be established prior to initiating regional analgesia. The intravenous access should be maintained as long as regional analgesia is utilized.
The anesthesiologist should be immediately available until analgesia is established and the patient’s vital signs are stable.

Maintenance of Regional Labour Analgesia

Continuous infusions of low dose (diluted) epidural local anesthetics with or without other adjuncts are associated with a very low incidence of significant complications. Consequently, it is not necessary for an anesthesiologist to remain physically present or immediately available during maintenance of continuous epidural infusion analgesia provided that:

there are appropriate protocols for management of patients receiving epidural analgesia;

the anesthesiologist can be contacted for the purpose of advice and direction.

The safety of patient-controlled epidural analgesia (PCEA) using low-dose (diluted) local anesthetics with or without other adjuncts is comparable to low-dose continuous infusion epidural analgesia. Consequently, it is not necessary for an anesthesiologist to remain physically present or immediately available during maintenance of PCEA provided that:

there are appropriate protocols for management of patients receiving PCEA;

the anesthesiologist can be contacted for the purpose of advice and direction.

Bolus dose of local anesthetics through the epidural catheter, or through a catheter or needle presumed to be in the epidural space, can cause immediate, life threatening complications. For this reason, when a bolus dose of local anesthetic is injected through the epidural catheter (except PCEA), an anesthesiologist must be available to intervene appropriately should any complications occur. The intent of the phrase available to intervene appropriately is that individual Departments of Anesthesiology should establish their own policies regarding the availability of an anesthesiologist to manage any complications of regional analgesia. Each Department should consider the possible risk of bolus injection of local anesthetics and the methods of dealing with emergency situations in developing these policies.

Oral Intake During Labour

Gastric emptying of solids is delayed during labour. Opioid analgesics may further delay gastric emptying. Therefore, parturients should not eat solid foods once they are in established labour. In contrast to solid food, clear liquids are relatively rapidly emptied from the stomach and absorbed in the proximal small bowel, including during labour. Therefore, individual hospitals should develop protocols regarding the intake of clear liquids for women in established labour.

Guidelines for the Practice of Anesthesia Outside a Hospital

The basic principles, training requirements, techniques, equipment and drugs used for the practice of anesthesia are noted in other sections of the guidelines. The following are guidelines for certain aspects particular to anesthetic practice outside a hospital.

Patient Selection

Patients should be classified as to physical status in a manner similar to that in use by the American Society of Anesthesiologists. Usually, only patients in the ASA Classifications I and II should be considered for an anesthetic outside a hospital. Patients in Classification III may be accepted under certain circumstances.

Preoperative Considerations

The patient must have had a recent and recorded history, physical examination and appropriate laboratory investigations. This may be carried out by another physician or anesthesiologist. The duration of fasting before anesthesia should conform to the previously stated guidelines. The patient should be given an information sheet with pre and postanesthetic instructions.

Conduct of Anesthesia

The anesthetic and recovery facilities shall conform to hospital standards published by the Canadian Standards Association as defined in other sections. The standards of care and monitoring shall be the same in all anesthetising locations.

Appendix I: Published Standards for Equipment

* new edition

Z5361 Tracheal Tubes

Z7228 Tracheal Tube Connectors

Z168.3 Anaesthetic Machines for Medical Use

Z5360 Anaesthetic Vaporizers - Agent Specific Filling Systems

Z168.5.1 Anaesthesia Ventilators

Z168.5.2 Critical Care Ventilators

Z168.5.3 Neonatal Ventilators

Z168.5.6 Expired Air Pulmonary Resuscitators

Z8382 Resuscitators Intended for Use with Humans

Z168.8 Anaesthetic Gas Scavenging Systems

Z168.9 Breathing Systems for Use in Anaesthesia

Z168.11 Vacuum Devices Used for Suction and Drainage

Z168.13 Gas Specific Connections: Ancillary Devices for Medical Air

Z305.1 Non-flammable Medical Gas Piping Systems

Z305.2 Low-pressure Connecting Assemblies for Medical Gas Systems

Z305.3 Pressure Regulators, Gauges, and Flow Metering Devices for Medical Gases

Z305.5 Medical Gas Terminal Units

Z305.6 Medical Oxygen Concentrator Central Supply System For Use with Non-flammable Medical Gas Piping Systems

*Z317.5 Illumination Systems in Health Care Facilities

Z318.6 Commissioning of Medical Gas Systems in Health Care Facilities

Z264.3 Standard for User-Applied Drug Labels in Anaesthesia and Critical Care

Z364.3 Blood-Gas Oxygenators

Z8836 Suction Catheters for Use in the Respiratory Tract

*7767-98 Oxygen Monitors for Monitoring the Patient breathing Mixtures - Safety Requirements

9703.1 Anaesthesia and Respiratory Care Alarm Signals Part 1: Visual Alarm Signals

9703.2 Anaesthesia and Respiratory Care Alarm Signals Part 2: Auditory Alarm Signals

Z9918 Capnometers for Use with Humans - Requirements

Z9919 Pulse Oximeters for Medical Use - Requirements

Z10651.2 Lung Ventilators for Medical Use - Part 2: Particular Requirements for Home Care Ventilator

Z10651.3 Lung Ventilators for Medical Use - Part 3: Particular Requirements for Emergency and Transport Ventilators

Z11196 Anaesthetic Gas Monitors

Z32 Electrical Safety and Essential Electrical Systems in Health Care Facilities

Z32.2 Electrical Safety in Patient Care Areas

Z32.4 Essential Electrical Systems for Hospitals

C22.1 Canadian Electrical Code Part I (Section 24, Patient Care Areas)

*C22.2 No. 601.1 Medical Electrical Equipment, Part 1: General Requirements for Safety

C22.2 No. 601.1S1 Supplement to No. 1-94 C22.2 No.601.1

C22.2 No. 601.1.1 Medical Electrical Equipment - Part I: General Requirements for Safety - 1. Collateral Standard: Safety Requirements for Medical Electrical Systems

C22.2 No 601.1B Amendment to C22.2 No.601.1

C22.2 No. 601.1.2 Medical Electrical Equipment, Part 1: General Requirements for Safety - 2. Collateral Standard: Electromagnetic Compatability Requirements and Tests

C22.2 No. 601.2.4 Medical Electrical Equipment, Part 2: Particular Requirements for the Safety of Cardiac Defibrillators and Cardiac Defibrillator-Monitors

C22.2 No. 601.2.12 Medical Electrical Equipment, Part 2: Particular Requirements for the Safety of Lung Ventilators for Medical Use

C22.2 No. 601.2.13 Medical Electrical Equipment, Part 2: Particular Requirements for the Safety of Anaesthetic Machines

C22.2 No. 601.2.22 Particular Requirements for the Safety of Diagnostic and Therapeutic Laser Equipment

For Information

Note: Z168.3 is directed primarily at pneumatically operated anaesthetic machines.The CSA Technical Commitee on Anaesthetic Equipment, respiratory Technology and Critical Care Equipment is currently developing a standard for integrated anaesthetic workstations, and this is expected to be completed in late 2000. in the interim, some manufacturers are submitting their workstation for approval under Z168.3. For the purpose of these 1999 guidelines, the essential requirements for these systems is compliance with C22.2 Electrical Standards.
DIR003-1997 List of CSA Certified Health Care Products and Services
Z441 Terminology and Definitions Used in CSA Health Care Technology Standards
C22.2 No. 601.2.10 Medical Equipment, Part 2: Particular Requirements for the Safety of Nerve and Muscle Stimulators
No. 601.2.18 Particular Requirements for the Safety of Endoscopic Equipment
No. 601.2.19 Particular Requirements for the Safety of Baby Incubators
No. 601.2.20 Particular Requirements for the Safety of Transport Incubators
No. 601.2.25 Particular Requirements for the Safety of Electrocardiographs

Copies of standards may be obtained by writing to:
Canadian Standards Association
178 Rexdale Boulevard, Rexdale, Ontario, M9W 1R3

Appendix II: Physical Status Classification

I - Normal healthy patient
II - A patient with mild systemic disease
III - A patient with severe systemic disease limiting activity but not incapacitating
IV - A patient with incapacitating systemic disease that is a constant threat to life
V - Moribund patients not expected to live 24 hours with or without operation

(Emergency operation designated by "E" after appropriate classification.)

Appendix III: Preanesthetic Checklist

A. Gas Pipelines

[ ] Secure connections between terminal units (outlets) and anesthetic machine.

B. Anesthetic Machine

[ ] Turn on machine master switch and all other necessary electrical equipment
[ ] Line Oxygen (40-60psi) (275-415 KPa)
[ ] Line Nitrous Oxide (40-60 psi) (275-415KPa)
[ ] Adequate reserve cylinder Oxygen pressure
[ ] Adequate reserve cylinder Nitrous Oxide content
[ ] Check for leaks and turn off cylinders
[ ] Flow meter function of Oxygen and Nitrous Oxide over the working range
[ ] Vaporiser filled
[ ] Filling ports pin-indexed and closed
[ ] Ensure "on/off" function and turn off
[ ] Functioning Oxygen bypass (flush)
[ ] Functioning Oxygen fail-safe device
[ ] Oxygen analyser calibrated and turned on Functioning mixer (where available)
[ ] Attempt to create a hypoxic O2/N2O mixture and verify correct changes in flow and/or alarm
[ ] Functioning common fresh gas outlet
[ ] Ventilator function verified
[ ] Backup ventilation equipment available and functioning

If an anesthesiologist uses the same machine in successive cases, departmental policy may permit performing an abbreviated checklist between cases.

C. Breathing Circuit

[ ] Correct assembly of circuit to be used
[ ] Patient circuit connected to common fresh gas outlet
[ ] Oxygen flow meter turned on
[ ] Check for exit of fresh gas at face mask
[ ] Pressurize. Check for leaks, and integrity of circuit (e.g. Pethick test for co-axial)
[ ] Functioning high pressure relief valve
[ ] Unidirectional valves and soda lime
[ ] Functioning adjustable pressure relief valve

D. Vacuum System

[ ] Suction adequate

E. Scavenging System

[ ] Correctly connected to patient circuit and functioning

F. Routine Equipment

[ ] Airway
[ ] Functioning laryngoscope (back-up available)
[ ] Appropriate tracheal tubes: patency of lumen and integrity of cuff
[ ] Appropriate oropharyngeal airways
[ ] Stylet
[ ] Magill forceps
[ ] I.V. supplies
[ ] B.P. cuff of appropriate size
[ ] Stethoscope
[ ] E.C.G. monitor
[ ] Pulse oximeter
[ ] Capnograph
[ ] Temperature monitor
[ ] Functioning low and high pressure alarm

G. Drugs

[ ] Adequate supply of frequently used drugs and intravenous solutions
[ ] Appropriate doses of drugs in labeled syringes

H. Location of Special Equipment in Each Anesthetising Location

[ ] Defibrillators
[ ] Emergency Drugs
[ ] Difficult Intubation Kit