What standards and guidelines should be followed for safe anesthetic practice in Canada, particularly for patients with significant medical conditions, according to the Canadian Anesthesiologist Society (CAS) and Workplace Safety Standards?

Canadian Anesthesia Standards and Workplace Safety Guidelines

Core Monitoring Standards

The Canadian Anesthesiologists' Society requires adherence to comprehensive monitoring standards that parallel international best practices, with continuous physiological monitoring being mandatory for all anesthetic procedures. 1, 2, 3

Essential Monitoring Requirements

• Continuous monitoring of inspired and expired oxygen levels with waveform capnography is mandatory for all patients receiving inhaled anesthesia 4
• Pulse oximetry with plethysmograph, non-invasive blood pressure (NIBP), ECG, and temperature monitoring constitute minimum requirements for all anesthetic procedures 4
• When using volatile anesthetics, inspired and end-tidal inhalational anesthetic drug concentration monitoring is required 4
• During mechanical ventilation, airway pressure, tidal volume, and respiratory rate must be continuously monitored 4
• All alarm limits must be set to appropriate values and enabled before beginning procedures, with standardized alarm defaults recommended within departments 4

Pre-Procedure Equipment Verification

All anesthetic equipment must be verified as functioning properly before use, including a systematic "two-bag test" to check breathing system integrity 4

• Verify gas analyzers and monitors are operational before each case 4
• Check breathing system, vaporizers, and ventilator integrity through standardized testing 4
• Ensure gas sampling lines are properly attached and free from obstruction to prevent inaccurate readings 4
• Modern anesthesia workstations must have mandatory hypoxic mixture protection and inspired oxygen measurement features 4

Workplace Safety and Ergonomic Standards

Operating Theatre Environment

Awake tracheal intubation and high-risk procedures should ideally be performed in the operating theatre environment where skilled assistance, drugs, equipment, and space are readily accessible 5

• For high-risk patients with significant airway obstruction, hypoxia, or respiratory failure, the operating theatre provides advantages over anaesthetic rooms including greater space and immediate surgical assistance 5
• When procedures are performed outside the theatre environment (critical care unit or emergency department), the same standards of care must apply 5
• Each ICU bed space should be 25.5 m² to allow room for equipment and five staff members when needed, with equipment ceiling-mounted on swivel mounts for ergonomic positioning 5

Workspace Ergonomics

Workspace ergonomics significantly impact performance and safety and must be optimized before starting procedures 5

• Position patient, operator, and assistants optimally, with monitors in the direct line of sight of the operator 5
• Patients sitting up provides physiological and anatomical advantages for airway procedures 5
• Operating tables and beds must be sufficiently maneuverable and height-adjustable to allow adequate access 5
• For paediatric cases, adjust table height before rendering the child unconscious to achieve comfortable positioning 5
• Preparation trolleys should be positioned on the side of the operator's dominant hand, with ultrasound machines directly opposite and monitors at eye level 5

Team Coordination and Communication

Safety must not be compromised by time pressures; planning and communication with anaesthetic assistants, operating theatre nursing staff, surgeons, and skilled anaesthetic colleagues is essential 5

• Well-trained, competent assistants are critical, as awake tracheal intubation can be associated with the greatest operator-related physical, mental, and psychological stress 5
• A plan for unsuccessful procedures, including possible postponement, front-of-neck access (FONA), or high-risk general anaesthesia, must be discussed explicitly and agreed upon by all team members before beginning 5
• Pre-assigning specific tasks during surgical pauses ensures every team member understands their responsibilities during routine and emergency situations 6
• Immediate access to emergency drugs, staff, and equipment is essential 5

Infection Control and Personal Protective Equipment

Standard Precautions

Hand hygiene with alcohol-based hand rub, surgical mask type II or IIR, and maintaining minimal distance of one meter between staff members when masks cannot be worn are universal safety measures 5

• Healthcare professionals must avoid touching eyes, nose, and mouth 5
• Surfaces and material disinfection protocols must be implemented 5
• Strategies to conserve personal protective equipment should be established in case of present or future shortages 5

High-Risk Procedures

For high-risk aerosol-generating procedures, N95 or FFP2 respirators, head caps, fluid-resistant long-sleeved gowns (or surgical gown plus plastic apron), disposable gloves, and face shields are required 5

• During intubation and extubation of COVID-positive or highly suspicious patients, limit the number of staff present in the operating theatre 5
• Avoid ventilating the patient with a face mask during preoxygenation phase 5
• Stop oxygen before removing the bag valve mask 5
• The most experienced senior should intubate using a video laryngoscope 5
• Connect the ventilator only after inflating the intubation tube balloon 5

Medication Safety Practices

Sharing medication vials between patients using new needles and syringes for each patient is acceptable, but reusing needles or syringes between patients is never acceptable 7

• Only 2% of practitioners report reusing needles and 7% report reusing syringes between patients, but this poses significant risk of patient-to-patient infection transmission 7
• Drug-saving anaesthetic strategies should be preferred during resource constraints (for propofol, midazolam, myorelaxants) 5
• Regional anaesthesia should be prioritized whenever possible, with regional analgesia and infiltration techniques also considered 5

Special Populations and Accommodations

Pregnancy

Pregnant anaesthetists require suitable, adjustable seating with sufficient unobstructed space, as well as adjustable equipment, beds, trolleys, and screens 5

• Additional consideration must be given to requirements for standing, manual handling, applying force when operating equipment, and work periods without breaks 5

Disabilities

Employers must make reasonable adjustments to accommodate disability in the workplace, including wheelchair accessibility 5

• Wheelchair users need sufficient clearance under work surfaces (operating tables) to get close enough to patients 5
• An unobstructed floor space of 1.5 m x 1.5 m is required for turning 5
• Shelves should be set no higher than 1.15 m above the floor 5
• Wheelchair users should have access to one regular operating theatre where facilities have been specifically arranged for them 5

Professional Competencies and Responsibilities

Canadian anaesthesiologists must demonstrate competencies across multiple CanMEDS roles, with particular emphasis on leadership in perioperative care coordination 6

• Anaesthesiologists must lead perioperative care coordination across multiple stakeholders, requiring sophisticated management skills to reduce costs while improving outcomes 6
• Communication failures cascade across the perioperative continuum, affecting preoperative shared decision-making, intraoperative team coordination, and postoperative care transitions 6
• Maintaining appropriate conduct, managing fatigue and vigilance, and adhering to ethical standards are essential professional responsibilities 6
• Organizations must implement measures to protect anaesthesiologists from fatigue through adequate breaks and rest facilities, as fatigue degrades vigilance 6

Emergency Management

Anaphylaxis Protocol

Intramuscular epinephrine 0.01 mg/kg (1:1000 concentration) into the anterolateral thigh is the first-line treatment with no absolute contraindications, with maximum doses of 0.5 mg in adults and 0.3 mg in children 8

• Administer 100% oxygen immediately to all patients with respiratory distress 8
• Establish large-bore IV access immediately 8
• Administer rapid IV fluid boluses with normal saline or lactated Ringer's solution 8
• Antihistamines and corticosteroids should not be given before or instead of epinephrine, as they have no role in acute anaphylaxis management due to slow onset of action 8
• Observe patients for at least 4 hours after symptom resolution, extending to 24 hours for severe reactions or those requiring more than one dose of epinephrine 8

Resuscitation Considerations

Rescuers performing cardiopulmonary resuscitation should switch after every second cycle of heart rate assessment to prevent fatigue 5

• The physical demands of cardiopulmonary resuscitation lead to fatigue that compromises effectiveness 5
• Application of human factors principles and team coordination are essential during resuscitation 5

Common Pitfalls and How to Avoid Them

• Gas monitoring lines can cause significant leaks if not properly attached; connections must be checked carefully before each case 4
• Failure to monitor end-tidal anaesthetic concentration can lead to awareness or overdose; continuous monitoring must be maintained throughout the procedure 4
• Time pressures from other staff members must not compromise safety; adequate planning and communication are non-negotiable 5
• Over-sedation during awake tracheal intubation can cause airway obstruction and hypoventilation; continuous end-tidal carbon dioxide monitoring helps detect this complication 5