To provide safe and reliable anesthesia to all patients undergoing surgery it is important to make sure that the anesthesia machine used is working properly. Anesthesia outcome claims have decreased over the past two decades to less than 1% of claims according to the American Society of Anesthesiology (ASAHQ), with the most recent data publicized by ASAHQ which states: “While the overall mortality rate held steady between 2010 and 2013 at .03 percent, or 3 deaths per 10,000 surgeries or procedures involving anesthesia, the percentage of adverse events related to anesthesia decreased from 11.8 percent to 4.8 percent of procedures during that time period. The most common minor complication was postoperative nausea and vomiting (35.53 percent), while the most common major complication was medication error (11.71 percent).” Thus, demonstrating that performing anesthesia machine checks daily and before each procedure had virtually eliminated machine events.
In 1987 the anesthesia professionals proposed to the FDA an anesthesia checklist as the manufacturer’s operating manuals were too extensive and cumbersome. This checklist was accepted by the FDA and revised in 1993. In 1993 a pre-anesthesia checklist was developed with the intent to prevent patient injury or near misses. Prior outcomes in claims from 1990 to 2011 (n = 40) were less severe, with a greater proportion of awareness (n = 9, 23%) and pneumothorax (n = 7, 18%). The majority, eighty-five percent (85%), of claims involved provider error with (n = 7) or without (n = 27) equipment failure. Thirty-five percent of claims were judged as preventable by pre-anesthesia machine check.
Over the years the use of the Pre-Anesthesia Checklist has been associated with a decreased risk of severe postoperative morbidity and mortality. Though anesthesia machines have evolved with the availability of new technology, this checklist, updated in 2008, is still recommended today. This checklist recommends that 15 separate items be checked or verified at the beginning of each day, or whenever a machine is moved, serviced, or the vaporizers changed (Table 1). Eight of these items should be checked prior to each procedure (Table 2). Some of these steps may be part of an automated checkout process on many machines. Following these checklists will typically require <5 minutes at the beginning of the day, and <2 minutes between cases, but will provide you with the confidence that the machine will be able to provide all essential life support functions before you begin a case. (Feldman, 2008)
The checklist specifies what should be checked prior to administering anesthesia, and includes the following:
- Reliable delivery of oxygen at any appropriate concentration up to 100%.
- Reliable means of positive pressure ventilation.
- Backup ventilation equipment available and functioning.
- Controlled release of positive pressure in the breathing circuit.
- Anesthesia vapor delivery (if intended as part of the anesthetic plan).
- Adequate suction.
- Means to conform to standards for patient monitoring.
It is important that each facility develop a pre-anesthesia checklist and that all anesthesia providers utilize the checklist as a means of preventing adverse events related to anesthesia administration. Below is a sample pre-anesthesia checklist that can be utilized by anesthesia providers.
TABLE 1 – DAILY PRE-ANESTHESIA CHECKLIST
Recommended Essential Steps in a Pre-Anesthesia Checkout Procedure
COMPLETE DAILY AND AFTER A MACHINE IS MOVED OR VAPORIZERS CHANGED
| Item | Task | Responsible Party | Completed Y/N |
| 1 | Verify Auxiliary Oxygen Cylinder and Manual Ventilation Device (Ambu Bag) are Available & Functioning. | Provider and Tech | |
| 2 | Verify patient suction is adequate to clear airway | Provider and Tech | |
| 3 | Turn on anesthesia delivery system and confirm that ac power is available. | Provider and Tech | |
| 4 | Verify availability of required monitors, including alarms. | Provider and Tech | |
| 5 | Verify that pressure is adequate on the spare oxygen cylinder mounted on the anesthesia machine. | Provider and Tech | |
| 6 | Verify that the piped gas pressures are ≥ 50 psig. | Provider and Tech | |
| 7 | Verify that vaporizers are adequately filled and, if applicable, that the filler ports are tightly closed. | Provider and Tech | |
| 8 | Verify that there are no leaks in the gas supply lines between the flowmeters and the common gas outlet. | Provider and Tech | |
| 9 | Test scavenging system function. | Provider and Tech | |
| 10 | Calibrate, or verify calibration of, the oxygen monitor and check the low oxygen alarm. | Provider and Tech | |
| 11 | Verify carbon dioxide absorbent is fresh and not exhausted. | Provider and Tech | |
| 12 | Perform breathing system pressure and leak testing. | Provider and Tech | |
| 13 | Verify that gas flows properly through the breathing circuit during both inspiration and exhalation. | Provider and Tech | |
| 14 | Document completion of checkout procedures. | Provider or Tech |
TABLE 2 – PRE-ANESTHESIA CHECKLIST FOR EACH PROCEDURE
Recommended Essential Steps in a Pre-Anesthesia Checkout Procedure
TO BE COMPLETED PRIOR TO EACH PROCEDURE
ITEMS IN THE DAILY CHECKLIST TO BE COMPLETED BETWEEN CASES
| Item | Task | Responsible Party | Completed Y/N |
| 2 | Verify patient suction is adequate to clear the airway. | Provider or Tech | |
| 4 | Verify availability of required monitors, including alarms. | Provider or Tech | |
| 7 | Verify that vaporizers are adequately filled and if applicable that the filler ports are tightly closed. | Provider | |
| 11 | Verify carbon dioxide absorbent is not exhausted. | Provider or Tech | |
| 12 | Breathing system pressure and leak testing. | Provider or Tech | |
| 13 | Verify that gas flows properly through the breathing circuit during both inspiration and exhalation. | Provider or Tech | |
| 14 | Document completion of checkout procedures. | Provider or Tech | |
| 15 | Confirm ventilator settings and evaluate readiness to deliver anesthesia care. (ANESTHESIA TIME OUT) | Provider |
References:
Patient Injuries from Anesthesia Gas Delivery Equipment: A Closed Claims Update
Sonya P. Mehta, M.D., M.H.S.; James B. Eisenkraft, M.D.; Karen L. Posner, Ph.D.; Karen B. Domino, M.D., M.P.H., Anesthesiology 10 2013, Vol.119, 788-795. doi:https://doi.org/10.1097/ALN.0b013e3182a10b5e
New Guidelines Available for Pre-Anesthesia Checkout, Jeffrey M. Feldman, MD, MSE; Michael A. Olympio, MD; Donald Martin, MD; Adam Striker, MD (Anesthesia Patient Safety Foundation Newsletter, Spring 2008)
OSHA Website: https://www.osha.gov/dts/osta/anestheticgases/index.html#Appendix2
