Administration of Anesthesia to the Surgical Patient

Anesthesia services shall be provided by anesthesia providers with appropriate medical staff privileges.  
The owner of any anesthesia equipment will certify that such equipment meets the minimum specifications outlined below and that such equipment has been tested and tagged by a biomedical engineer, consistent with the recommendations of the manufacturer.

The type of anesthesia is determined by the staff member performing the procedure; the decision is based upon many  factors including the physical condition of the patient and the type of surgical procedure to be performed. Anesthesia 
available within the office surgery unit includes general, local, regional, block or conscious sedation; a description 
of the various levels of anesthesia is appended to this policy.
Patients undergoing a major procedure and/or any patient known or suspected to be a medical risk will have a history 
and physical examination performed not more than one month prior to surgery.  These documents will be placed in the 
medical record before the anesthesia evaluation at the time of the surgery.  In addition to the actual administration of 
anesthesia, the anesthesia provider is responsible for:

1.  Pre-operative physical examination and evaluation of the patient indexed to the level of anesthesia anticipated
    for the patient, and for the timely documentation of these findings.
2.  Ordering of pre-operative medications;
3.  Checking pre-operative medications out of the lockbox and overseeing wastage of any residual medication at the end
    of each patient's procedure;
4.  Utilizing appropriate equipment for patient care during the anesthesia episode of care. 
5.  Post-operative evaluation of the patient prior to discharge; and
6.  Cancellation of surgery on any patient who is not a candidate for surgery in the outpatient setting.

The American Society of Anesthesiologists, House of Delegates, effective date July 1, 2011 state that during moderate or 
deep sedation the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs and 
monitoring for the presence of exhaled carbon dioxide unless precluded or invalidated by the nature of the patient, procedure, or equipment.  Our organization has evaluated this carefully. Discussion between the Medical Director and the anesthesiologist has determined that capnography is not needed in our organization. The type of patients, procedures and the time under anesthesia is such that it will not be helpful to monitor exhaled CO2. The nature of our patient population invalidates the use of capnography.


Description of Various Levels of Anesthesia :
LOCAL: Not used in our organization.
BLOCK: Not used in our organization
Minimal Sedation (Anxiolysis): is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected. 

Moderate Sedation/Analgesia ('Conscious Sedation'): is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. 
Deep Sedation/Analgesia: is a drug-induced depression of consciousness during which patients cannot be easily aroused 
but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. 

General Anesthesia: is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often 
require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. 
Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation 
becomes deeper than initially intended. Individuals administering Moderate Sedation/Analgesia ('Conscious Sedation') should be able to rescue patients who enter a state of Deep Sedation/Analgesia, while those administering Deep Sedation/Analgesia should be able to rescue patients who enter a state of general anesthesia.
* Monitored Anesthesia Care does not describe the continuum of depth of sedation, rather it describes 'a specific 
anesthesia service in which an anesthesia provider has been requested to participate in the care of a patient undergoing 
a diagnostic or therapeutic procedure.'
*Reflex withdrawal from a painful stimulus is NOT considered a purposeful response. 
Personnel qualified to provide anesthsia or personnel qualified in Advanced resuscitative techniques (e.g. ACLS or 
PALS) are present until the patient has been discharged from the facility.

Approved By Governing Board    
Control #38.3
Gupta Gastro