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## Complete Summary

#### GUIDELINE TITLE

Practice advisory for the prevention and management of operating room
fires.

#### BIBLIOGRAPHIC SOURCE(S)

American Society of Anesthesiologists Task Force on Operating Room
Fires, Caplan RA, Barker SJ, Connis RT, Cowles C, de Richemond AL,
Ehrenwerth J, Nickinovich DG, Pritchard D, Roberson D, Wolf GL. Practice
advisory for the prevention and management of operating room fires.
Anesthesiology 2008 May;108(5):786-801; quiz 971-2. \[93 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=18431114)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Injuries from operating room fires (fires that occur on the patient, in
the airway, or in the breathing circuit)

#### GUIDELINE CATEGORY

Management\
Prevention\
Risk Assessment

#### CLINICAL SPECIALTY

Anesthesiology\
Colon and Rectal Surgery\
Neurological Surgery\
Nursing\
Orthopedic Surgery\
Otolaryngology\
Plastic Surgery\
Surgery\
Thoracic Surgery

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Hospitals\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To identify situations conducive to fire

-   To prevent the occurrence of operating room (OR) fires

-   To reduce adverse outcomes associated with OR fires

-   To identify the elements of a fire response protocol

**Note**: This Advisory does not address fires away from the patient
(e.g., in a trash can), institutional preplanning for fire, or the
responses of fire personnel.

#### TARGET POPULATION

Any patient having surgery in an operating room (OR)

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Prevention**

1.  Fire safety education

    -   Fire prevention/management protocol

2.  Preparation for fires

    -   Operating room (OR) fire drills

    -   Necessary equipment and supplies for extinguishing fires in the
        OR

    -   Assessment of high-risk situation and development and assignment
        of fire management tasks

3.  Intraoperative measures for minimizing risk in presence of an
    ignition source

    -   High-risk procedures

    -   Laser surgery

    -   Airway surgery

    -   Face, head and neck surgery

**Management**

1.  Early warning signs of fire

2.  Airway fire versus nonairway fire

3.  Extinguishing the fire

4.  Management of patient during fire and after fire is extinguished

#### MAJOR OUTCOMES CONSIDERED

-   Incidence of operating room (OR) fires

-   OR fire-related morbidity and injuries

-   OR fire-related mortality

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

For the literature review, potentially relevant studies were identified
via electronic and manual searches of the literature. The literature
search covered a 56-yr period from 1952 through 2007. More than 400
citations were initially identified, yielding a total of 340 articles
that addressed topics related to the evidence linkages and met our
criteria for inclusion. After review of the articles, 240 studies did
not provide direct evidence and were subsequently eliminated.

#### NUMBER OF SOURCE DOCUMENTS

A total of 100 articles contained direct linkage-related evidence.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Scientific Evidence**

Study findings from published scientific literature were aggregated and
are reported in summary form by evidence category.

*Category A: Supportive*: Randomized controlled trials report
statistically significant (*P\<*0.01) differences between clinical
interventions for a specified clinical outcome.

*Level 1*: The literature contains multiple randomized controlled
trials, and the aggregated findings are supported by meta-analysis.§

*Level 2*: The literature contains multiple randomized controlled
trials, but there is an insufficient number of studies to conduct a
viable meta-analysis for the purpose of this Advisory.

*Level 3*: The literature contains a single randomized controlled trial.

§ All meta-analyses are conducted by the ASA methodology group.
Meta-analyses from other sources are reviewed but not included.

*Category B: Suggestive*: Information from observational studies permits
inference of beneficial or harmful relationships among clinical
interventions and clinical outcomes.

*Level 1*: The literature contains observational comparisons (e.g.,
cohort, case-control research designs) of two or more clinical
interventions or conditions and indicates statistically significant
differences between clinical interventions for a specified clinical
outcome.

*Level 2*: The literature contains noncomparative observational studies
with associative (e.g., relative risk, correlation) or descriptive
statistics.

*Level 3*: The literature contains case reports.

*Category C: Equivocal*: The literature cannot determine whether there
are beneficial or harmful relationships among clinical interventions and
clinical outcomes.

*Level 1*: Meta-analysis did not find significant differences among
groups or conditions.

*Level 2*: There is an insufficient number of studies to conduct
meta-analysis and (1) randomized controlled trials have not found
significant differences among groups or conditions or (2) randomized
controlled trials report inconsistent findings.

*Level 3*: Observational studies report inconsistent findings or do
*not* permit inference of beneficial or harmful relationships.

*Category D: Insufficient*: the *lack of scientific evidence* in the
literature is described by the following terms.

*Silent*: No identified studies address the specified relationships
among interventions and outcomes.

*Inadequate*: The available literature cannot be used to assess
relationships among clinical interventions and clinical outcomes. The
literature either does not meet the criteria for content as defined in
the \"Focus\" of the Advisory or it does not permit a clear
interpretation of findings due to methodologic concerns (e.g.,
confounding in study design or implementation).

**Opinion-based Evidence**

Opinion surveys were developed by the Task Force to address each
clinical intervention identified in the document. Identical surveys were
distributed to two groups of respondents: expert consultants and
American Society of Anesthesiologists (ASA) members.

*Category A: Expert Opinion*. Survey responses from Task Force-appointed
expert consultants are reported in summary form in the text. A complete
listing of consultant survey responses is reported in appendix 2 in the
original guideline document.

*Category B: Membership Opinion*. Survey responses from a random sample
of members of the ASA and, when appropriate, responses from members of
other organizations with expertise in the selected topics of interest
are reported in summary form in the text. A complete listing of ASA
member survey responses is reported in appendix 2 in the original
guideline document.

Survey responses are recorded using a five-point scale and summarized
based on median values.

*Strongly Agree*: Median score of 5 (at least 50% of the responses are
5)

*Agree*: Median score of 4 (at least 50% of the responses are 4 or 4 and
5)

*Equivocal*: Median score of 3 (at least 50% of the responses are 3, or
no other response category or combination of similar categories contains
at least 50% of the responses)

*Disagree*: Median score of 2 (at least 50% of responses are 2 or 1 and
2)

*Strongly Disagree*: Median score of 1 (at least 50% of responses are 1)

*Category C: Informal Opinion*. Open-forum testimony, Web-based
comments, letters, and editorials are all informally evaluated and
discussed during the development of the Advisory. When warranted, the
Task Force may add educational information or cautionary notes based on
this information.

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

For this Advisory, a literature review was used in combination with
opinions obtained from experts and other sources (e.g., professional
society members, open forums, Web-based postings) to provide guidance to
practitioners regarding operating room (OR) fire prevention and
management. Both the literature review and opinion data were based on
*evidence linkages*, or statements regarding potential relationships
between fire prevention and management interventions and OR fire
outcomes.

No evidence linkage contained enough studies with well-defined
experimental designs and statistical information to conduct a
quantitative analysis (i.e., meta-analysis).

Interobserver agreement among Task Force members and two methodologists
was established by inter-rater reliability testing. Agreement levels
using a k statistic for two-rater agreement pairs were as follows:

\(1\) type of study design, k = 0.63-- 0.82; (2) type of analysis, k =
0.40--0.87; (3) evidence linkage assignment, k = 0.84 --1.00; and (4)
literature inclusion for database, k = 0.69 --1.00. Three-rater
chance-corrected agreement values were (1) study design, Sav = 0.69, Var
(Sav) = 0.013; (2) type of analysis, Sav = 0.57, Var (Sav) = 0.031; (3)
linkage assignment, Sav = 0.89, Var (Sav) = 0.004; and (4) literature
database inclusion, Sav = 0.79, Var (Sav) = 0.025. These values
represent moderate to high levels of agreement.

*Consensus-based Evidence*

Consensus was obtained from multiple sources, including (1) survey
opinion from consultants who were selected based on their knowledge or
expertise in OR fire prevention and management, (2) survey opinions
solicited from active members of the American Society of
Anesthesiologists (ASA), (3) testimony from attendees of a publicly held
open forum at a national anesthesia meeting, (4) Internet commentary,
and (5) Task Force opinion and interpretation. The survey rate of return
was 52% (n = 38 of 73) for the consultants, and 64 surveys were received
from active ASA members. Results of the surveys are reported in tables 2
and 3 in the original guideline document and in the text of the
Advisory.

The consultants were asked to indicate which, if any, of the evidence
linkages would change their clinical practices if the Advisory was
instituted. The rate of return was 18% (n = 13 of 73). The percent of
responding consultants expecting a change in their practice associated
with each linkage topic was as follows: (1) education, 77%; (2) OR fire
drills, 69%; (3) team discussion of fire strategy, 69%; (4) minimizing
or avoiding an oxidizer-enriched atmosphere near the surgical site, 38%;
(5) managing ignition sources, 38%; (6) managing fuels, 31%; (7)
identification of a high-risk procedure, 85%; (8) management of a
high-risk procedure, 31%; and (9) OR fire management, 77%. Eighty-five
percent of the respondents indicated that the Advisory would have *no
effect* on the amount of time spent on a typical case, and 15% indicated
that there would be an increase of 1 to 5 min in the amount of time
spent on a typical case with the implementation of this Advisory.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The American Society of Anesthesiologists (ASA) appointed a Task Force
of nine members. These individuals included four anesthesiologists in
private and academic practice from various geographic areas of the
United States, an otolaryngologist, a perioperative registered nurse, a
professional engineer/fire investigator, and two consulting
methodologists from the ASA Committee on Standards and Practice
Parameters. Two Task Force members are former firefighters.

The Task Force developed the Advisory by means of a seven-step process.
First, they reached consensus on the criteria for evidence. Second, a
systematic review and evaluation was performed on original, published,
peer-reviewed and other research studies related to operating room (OR)
fires. Third, a panel of expert consultants was asked to (1) participate
in opinion surveys on the effectiveness of various strategies for fire
prevention, detection, and management and (2) review and comment on a
draft of the Advisory developed by the Task Force. Fourth, opinions
about the Advisory were solicited from a random sample of active members
of the ASA. Fifth, the Task Force held an open forum at a major national
meeting to solicit input on its draft recommendations. Sixth, the
consultants were surveyed to assess their opinions on the feasibility of
implementing this Advisory. Seventh, all available information was used
to build consensus within the Task Force to formulate the advisory
statements (See Appendix 1 in the original guideline document).

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The panel of expert consultants was asked to review and comment on draft
reports. The Task Force held an open forum at a major national
anesthesia meeting to solicit input from attendees on a draft of the
Guidelines.

This Practice Advisory has been endorsed by the American Academy of
Otolaryngology--Head and Neck Surgery.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

I.  **Education**

    -   All anesthesiologists should have fire safety education,
        specifically for operating room (OR) fires, with emphasis on the
        risk created by an oxidizer-enriched atmosphere.

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II. **OR Fire Drills**

    -   Anesthesiologists should periodically participate in OR fire
        drills, with the entire OR team. This formal rehearsal should
        take place during dedicated educational time, not during patient
        care.

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III. **Preparation**

     -   For every case, the anesthesiologist should participate with
         the entire OR team (e.g., during the surgical pause) in
         assessing and determining whether a high-risk situation exists.

     -   If a high-risk situation exists, all team members---including
         the anesthesiologist---should take a joint and active role in
         agreeing on how a fire will be prevented and managed.

     -   Each team member should be assigned a specific fire management
         task to perform in the event of a fire (e.g., removing the
         tracheal tube, turning off the airway gases).

     -   Each team member should understand that his or her preassigned
         task should be performed immediately if a fire occurs, without
         waiting for another team member to take action.

     -   When a team member has completed a preassigned task, he or she
         should help other team members perform tasks that are not yet
         complete.

     -   In every OR and procedure area where a fire triad can exist
         (i.e., an oxidizer-enriched atmosphere, an ignition source, and
         fuel), an easily visible protocol for the prevention and
         management of fires should be displayed.

     -   Equipment for managing a fire should be readily available in
         every procedural location where a fire triad may exist.

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IV. **Prevention**

    -   The anesthesiologist should collaborate with all members of the
        procedure team *throughout the procedure* to minimize the
        presence of an oxidizer-enriched atmosphere in proximity to an
        ignition source.

    -   For all procedures:

        -   Surgical drapes should be configured to minimize the
            accumulation of oxidizers (oxygen and nitrous oxide) under
            the drapes and from flowing into the surgical site.

        -   Flammable skin prepping solutions should be dry before
            draping.

        -   Gauze and sponges should be moistened before use in
            proximity to an ignition source.

    -   For high-risk procedures:

        -   The anesthesiologist should notify the surgeon whenever
            there is a potential for an ignition source to be in
            proximity to an oxidizer-enriched atmosphere or when there
            is an increase in oxidizer concentration at the surgical
            site.

        -   Any reduction in supplied oxygen to the patient should be
            assessed by monitoring (1) pulse oximetry and, if
            feasible, (2) inspired, exhaled, and/or delivered oxygen
            concentration.

    -   For laser procedures:

        -   A laser-resistant tracheal tube should be used.

            -   The laser-resistant tracheal tube used should be chosen
                to be resistant to the laser used for the procedure
                (e.g., carbon dioxide \[CO~2~\], neodymium-doped yttrium
                aluminium garnet \[Nd:YAG\], Ar, erbium-doped yttrium
                aluminium garnet \[Er:YAG\], potassium titanyl phosphate
                \[KTP\]).

        -   The tracheal cuff of the laser tube should be filled with
            saline and colored with an indicator dye such as methylene
            blue.

        -   Before activating a laser:

            -   The surgeon should give the anesthesiologist adequate
                notice that the laser is about to be activated.

            -   The anesthesiologist should:

                -   *Reduce* the delivered oxygen concentration to the
                    minimum required to avoid hypoxia.

                -   *Stop* the use of nitrous oxide.

                -   *Wait* a few minutes after reducing the
                    oxidizer-enriched atmosphere before approving
                    activation of the laser.

    -   For cases involving an ignition source and surgery inside the
        airway:

        -   Cuffed tracheal tubes should be used when clinically
            appropriate.

        -   The anesthesiologist should advise the surgeon against
            entering the trachea with an ignition source (e.g.,
            electrosurgery unit).

        -   *Before* activating an ignition source inside the airway:

            -   The surgeon should give the anesthesiologist adequate
                notice that the ignition source is about to be
                activated.

            -   The anesthesiologist should:

                -   *Reduce* the delivered oxygen concentration to the
                    minimum required to avoid hypoxia.

                -   *Stop* the use of nitrous oxide.

                -   *Wait* a few minutes after reducing the
                    oxidizer-enriched atmosphere before approving the
                    activation of the ignition source.

        -   In some cases (e.g., surgery in the oropharynx), scavenging
            with suction may be used to reduce oxidizer enrichment in
            the operative field.

    -   For cases involving moderate or deep sedation, an ignition
        source, and surgery around the face, head, or neck:

        -   The anesthesiologist and surgeon should develop a plan that
            accounts for the level of sedation and the patient\'s need
            for supplemental oxygen.

            -   If moderate or deep sedation is required or used, or if
                the patient exhibits oxygen dependence, the
                anesthesiologist and surgeon should consider a sealed
                gas delivery device (e.g., cuffed tracheal tube or
                laryngeal mask).

            -   If moderate or deep sedation is not required, and the
                patient does not exhibit oxygen dependence, an open gas
                delivery device (e.g., facemask or nasal cannula) may be
                considered.

        -   Before activating an ignition source around the face, head,
            or neck:

            -   The surgeon should give the anesthesiologist adequate
                notice that the ignition source is about to be
                activated.

            -   The anesthesiologist should:

                -   *Stop* the delivery of supplemental oxygen or reduce
                    the delivered oxygen concentration to the minimum
                    required to avoid hypoxia.

                -   *Wait* a few minutes after reducing the
                    oxidizer-enriched atmosphere before approving the
                    activation of the ignition source.

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V.  **Management of OR Fires**

    -   When an early warning sign is noted, halt the procedure and call
        for an evaluation of fire.

    -   When a fire is definitely present, immediately announce the
        fire, halt the procedure, and initiate fire management tasks.

    -   Team members should perform their preassigned fire management
        tasks as quickly as possible.

        -   Before the procedure, the team may identify a predetermined
            order for performing the tasks.

        -   If a team member cannot rapidly perform his or her task in
            the predetermined order, other team members should perform
            their tasks without waiting.

        -   When a team member has completed a preassigned task, he or
            she should help other members perform tasks that are not yet
            complete.

    -   For a fire in the airway or breathing circuit, as fast as
        possible:

        -   Remove the tracheal tube.

        -   Stop the flow of all airway gases.

        -   Remove all flammable and burning materials from the airway.

        -   Pour saline or water into the patient\'s airway.

    -   For a fire elsewhere on or in the patient, as fast as possible:

        -   Stop the flow of all airway gases.

        -   Remove all drapes, flammable, and burning materials from the
            patient.

        -   Extinguish all burning materials in, on, and around the
            patient (e.g., with saline, water, or smothering).

    -   If the airway or breathing circuit fire is extinguished:

        -   Reestablish ventilation by mask, avoiding supplemental
            oxygen and nitrous oxide, if possible.

        -   Extinguish and examine the tracheal tube to assess whether
            fragments were left in the airway.

            -   Consider bronchoscopy (preferably rigid) to look for
                tracheal tube fragments, assess injury, and remove
                residual debris.

        -   Assess the patient\'s status and devise a plan for ongoing
            care.

    -   If the fire elsewhere on or in the patient is extinguished:

        -   Assess the patient\'s status and devise a plan for ongoing
            care of the patient.

        -   Assess for smoke inhalation injury if the patient was not
            intubated.

    -   If the fire is *not* extinguished after the first attempt (e.g.,
        after performing the preassigned tasks):

        -   Use a CO~2~ fire extinguisher in, on, or around the patient.

        -   If the fire persists after use of the CO~2~ fire
            extinguisher:

            -   Activate the fire alarm.

            -   Evacuate the patient if feasible, following
                institutional protocols.

            -   Close the door to the room to contain the fire and do
                not reopen it or attempt to reenter the room.

            -   Turn off the medical gas supply to the room.

    -   Follow local regulatory reporting requirements (e.g., report
        fires to your local fire department and state department of
        health).

    -   Treat every fire as an adverse event, following your
        institutional protocol.

#### CLINICAL ALGORITHM(S)

A clinical algorithm for operating room fires is provided in the
original guideline document.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

Evidence was obtained from two principal sources: scientific evidence
and opinion-based evidence.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Prevent the occurrence of operating room (OR) fires

-   Reduce adverse outcomes associated with OR fires

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   Advisories developed by the American Society of Anesthesiologists
    (ASA) are not intended as standards, guidelines, or absolute
    requirements. They may be adopted, modified, or rejected according
    to clinical needs and constraints.

-   The use of practice advisories cannot guarantee any specific
    outcome. Practice advisories summarize the state of the literature
    and report opinions obtained from expert consultants and ASA
    members. Practice advisories are not supported by scientific
    literature to the same degree as standards or guidelines because of
    the lack of sufficient numbers of adequately controlled studies.
    Practice advisories are subject to periodic revision as warranted by
    the evolution of medical knowledge, technology, and practice.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Staff Training/Competency Material

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness\
Safety\
Timeliness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

American Society of Anesthesiologists Task Force on Operating Room
Fires, Caplan RA, Barker SJ, Connis RT, Cowles C, de Richemond AL,
Ehrenwerth J, Nickinovich DG, Pritchard D, Roberson D, Wolf GL. Practice
advisory for the prevention and management of operating room fires.
Anesthesiology 2008 May;108(5):786-801; quiz 971-2. \[93 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=18431114)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2008 May

#### GUIDELINE DEVELOPER(S)

American Society of Anesthesiologists - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American Society of Anesthesiologists

#### GUIDELINE COMMITTEE

Task Force on Operating Room Fires

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Task Force Members*: Robert A. Caplan, M.D. (Chair), Seattle,
Washington; Steven J. Barker, Ph.D., M.D., Tucson, Arizona; Richard T.
Connis, Ph.D., Woodinville, Washington; Charles Cowles, M.D., Deer Park,
Texas; Albert L. de Richemond, M.S., P.E., Plymouth Meeting,
Pennsylvania; Jan Ehrenwerth, M.D., Madison, Connecticut; David G.
Nickinovich, Ph.D., Bellevue, Washington; Donna Pritchard, R.N.,
Brooklyn, New York; David Roberson, M.D., Boston, Massachusetts; Gerald
L. Wolf, M.D. (Honorary), Brooklyn, New York

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### ENDORSER(S)

American Academy of Otolaryngology - Head and Neck Surgery - Medical
Specialty Society

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Anesthesiology Journal Web
site](http://www.anesthesiology.org/pt/re/anes/asapractice.htm;jsessionid=L2BH21hrr2JpZ9Q96cP9RK5rT8wGvQjh1n6Lhjyd88NhyVnn5mTp!195308708!181195628!8091!-1).

Print copies: Available from the American Society for Anesthesiologists,
520 North Northwest Highway, Park Ridge, IL 60068-2573.

#### AVAILABILITY OF COMPANION DOCUMENTS

A continuing medical education (CME) activity is available from the
[Anesthesiology Journal Web
site](http://www2.asahq.org/journal-cme/web/).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI Institute on July 9, 2008. The
information was verified by the guideline developer on July 23, 2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline that is copyrighted
by the American Society of Anesthesiologists.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008