9 Lignes directrices pour l'exercice de l'anesthesie dans les lieux isoles 9.1 Soins anesthesiques dispenses dans un etablissement medical/chirurgical/dentaire non hospitalier 9.2 Soins anesthesiques dispenses hors de la salle d'operation dans un hopital ou un etablissement non hospitalier Annexe 1: Association canadienne de normalisation -Normes concernant le materiel Annexe 2: Classification de l'etat de sante des patients, selon l'American Society of Anesthesiologists Annexe 3: Liste de verification preanesthesique Annexe 4: Lignes directrices, normes et autres enonces officiels disponibles sur l'internet Annexe 5: Expose de principe sur les assistants en anesthesie : Un expose de principe officiel de la Societe canadienne des anesthesiologistes Annexe 6: Sedation procedurale : expose de principe de la Societe canadienne des anesthesiologistes# 
How does this statement differ from the 2020 Guidelines?
- Several important content changes have been made and they are highlighted in bold in the text. Some of the more important changes include:
- Additional recommendations related to anesthesia medication safety and error prevention, under section 3.1 Responsibilities of the Healthcare Facility, that expand on recommendations introduced in the 2020 Revised Edition that were specific to safety and diversion prevention for controlled medications (e.g., opioids).
- The addition of brain natriuretic peptide (BNP/NT-pro BNP) as a preoperative investigation to be considered for patients with, or at risk for, significant cardiovascular disease.
- A revision to section 4.2 Fasting Guidelines to clarify the role of H2 receptor blockers in the management of patients presenting for Cesarean delivery (see accompanying editorial).
- An entirely new section 5.7 Patient Positioning to address the critical importance of meticulous planning, execution, and rechecking of positioning for patient safety.
- A minor but important change related to the requirements for documentation of initial vital signs in PACU necessitated by the expanding implementation of Anesthesia Information Management Systems.
- The recommendation that, during patient transport to and in the PACU, if patients with in situ endotracheal tubes require supplemental oxygen, that it should only be administered utilizing devices approved for that application to reduce the risk barotrauma.
- Extensive revision to section 9.0, now called Guidelines for Practice of Anesthesia in Remote Locations, addressing the delivery of anesthesia care in remote locations both within and outside of a hospital facility. An important recommendation is that anesthesia staff should have appropriately trained anesthesia support personnel (e.g., an anesthesia assistant) present or immediately available to assist them.
- Appendix 1: Canadian Standards Association-Standards for Equipment - Appendix 5: Position Paper on Anesthesia Assistants has been significantly revised in cooperation with the CAS Committee on the Anesthesia Care Team and is available as electronic supplementary material.
Comment cet enonce differe-t-il des Lignes directrices de 2020? Plusieurs modifications importantes ont ete apportees au contenu; elles sont surlignees en gras dans le texte. Parmi les modifications les plus importantes, citons :
- Des recommandations supplementaires concernant l'innocuite et la prevention des erreurs des medicaments anesthesiques, sous la section 3.1 Responsabilite s de l'e tablissement de sante , qui approfondissent les recommandations introduites dans l'E dition revisee de 2020 specifiques a l'innocuite et a la prevention du detournement des substances controlees (par ex. les opioides).
- L'ajout du peptide cerebral natriuretique (BNP/NT-pro BNP) parmi les examens preoperatoires a envisager chez les patients atteints ou courant un risque d'etre atteints de maladie cardiovasculaire significative.
- Une revision de la section 4.2 Lignes directrices concernant le jeune afin de clarifier le role des antagonistes des recepteurs H2 dans la prise en charge des patientes devant subir un accouchement par cesarienne (voir l'editorial associe).
- Une toute nouvelle section 5.7 Positionnement du patient afin de souligner l'importance cruciale de la planification, de l'execution et de la verification meticuleuses du positionnement pour la securite des patients.
- Une modification mineure mais importante liee aux exigences de documentation des signes vitaux initiaux en salle de reveil necessaires en raison de l'utilisation toujours plus repandue des Systemes electroniques de gestion de l'information en anesthesie.
- La recommandation selon laquelle, pendant le transfert des patients et dans la salle de reveil, lorsqu'un patient chez qui un tube endotracheal est installe necessite de l'oxygene supplementaire, l'administration ne devrait se faire qu'a l'aide de dispositifs approuves pour cette application afin de reduire le risque de barotraumatisme.
- Une revision approfondie de la section 9.0, desormais intitulee Lignes directrices pour l'exercice de l'anesthe sie dans les lieux isole s, abordant la fourniture de soins anesthesiques dans les lieux isoles tant au sein d'un etablissement hospitalier que hors d'un milieu hospitalier. Une recommandation importante touche au fait que le personnel d'anesthesie devrait disposer de personnel de soutien en anesthesie ayant recu une formation adequate (par ex., un assistant en anesthesie) present ou immediatement disponible pour l'assister.
- Annexe 1 : Association canadienne de normalisation -Normes concernant le materiel - L'Annexe 5 : Expose de principe sur les assistants en anesthe sie a ete revisee de fond en comble en cooperation avec le Comite sur les equipes de soin en anesthesie de la SCA et est disponible sous forme de materiel electronique supplementaire

# Table des matieres

# Preambule
Overview The Guidelines to the Practice of Anesthesia Revised Edition 2021 (the Guidelines) were prepared by the Canadian Anesthesiologists' Society (CAS), which reserves the right to determine their publication and distribution. The Guidelines are subject to revision and updated versions are published annually. The Guidelines to the Practice of Anesthesia Revised Edition 2021 supersedes all previously published versions of this document. Although the CAS encourages Canadian anesthesiologists to adhere to its practice guidelines to ensure high-quality patient care, the CAS cannot guarantee any specific patient outcome. Anesthesiologists should exercise their own professional judgement in determining the proper course of action for any patient's circumstances. The CAS assumes no responsibility or liability for any error or omission arising from the use of any information contained in its Guidelines to the Practice of Anesthesia.

# Preamble
Anesthesiology is a dynamic specialty of medicine that fosters continuous improvements in anesthetic care for patients undergoing surgical and obstetric procedures in Canada. This document is reviewed annually and revised periodically.
The following recommendations are aimed at providing basic guidelines to anesthetic practice. They are intended as a framework for reasonable and acceptable patient care and should be interpreted as such to allow for some degree of flexibility in different circumstances. Each section of the 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 the deliberate performance of any procedure to render a patient temporarily insensitive to pain or to the external environment so that a diagnostic or therapeutic procedure can be performed.
These Guidelines are intended to apply to all anesthesiologists in Canada. The independent practice of anesthesia is a specialized field of medicine, and as such, it should be practiced by physicians with appropriate training in anesthesia. The only route to specialist recognition in anesthesia in Canada is through the certification process of the Royal College of Physicians and Surgeons of Canada. The Canadian Anesthesiologists' Society (CAS) acknowledges the fact that remote communities often lack the population base to support a specialist Can J Anesth/J Can Anesth (2021) 68:92-129  ? Text approved by CAS Board for 2021 Edition.
Texte approuve par le CA de la SCApour l'edition 2021.
Electronic supplementary material The online version of this article () contains supplementary material, which is available to authorized users. anesthesiology practice.
In these communities, appropriately trained family physicians may be required to provide anesthesia services. In communities with the clinical volume to support full-time anesthesiologists, fellowship-certified anesthesiologists should provide these services. All anesthesiologists must continue their education in the practice of anesthesia, pain management, perioperative care, and resuscitation and participate in a structured maintenance of competence program (e.g., Royal College MOC).

# Organization of Anesthetic Services
The department of anesthesia should be properly organized, directed, and integrated with other departments in the organization or facility, and it should include all facility staff members who provide anesthetic services to patients for surgical, obstetric, diagnostic, and therapeutic purposes.
The department should be staffed appropriately, bearing in mind the scope and nature of the services it provides, and it should strive to ensure that these services are available as required by the healthcare 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 senior medical administrative bodies for the facility.

# Responsibilities of the Chief of Anesthesia
- To be aware of the current CAS Guidelines to the Practice of Anesthesia, the requirements of the Canadian Council on Health Services Accreditation, and the requirements of the provincial licensing authority as they relate to anesthesia; 2. To ensure that written policies with respect to the practice of anesthesia are established and enforced; 3. To evaluate the qualifications and abilities of the physicians providing anesthetic care as well as other health professionals providing ancillary care-this includes, but is not restricted to, recommending clinical privileges for physicians with anesthetic responsibilities and annually reviewing these privileges; 4. To employ a systematic approach for monitoring the quality of anesthetic care provided by members of the department of anesthesia throughout the healthcare facility; Monitoring quality of care may include, but need not be restricted to, the use of chart audits, clinical indicator and outcome monitoring, adverse event reporting systems, morbidity and mortality conferences, and critical incident case reviews. The extent of quality improvement activities will vary depending on the departmental and health facility resources available to the chief. For effective quality improvement, it is strongly encouraged that all department members should actively participate in any such activities. 5. To ensure that records are kept for all anesthetic procedures-these records should allow for evaluation of all anesthetic care in the facility; 6. To carry out such other duties as the governing body of the facility may delegate to ensure safe anesthetic care; 7. To promote institutional compliance with applicable Canadian Standards Association (CSA) Standards (Appendix 1); and 8. To coordinate liaison between the departments of anesthesiology, biomedical engineering, and information management services. Special areas of anesthetic care may have specific concerns. The department of anesthesia in each institution may determine privileges in pediatric anesthesia according to the pediatric population it serves, the child's age, the presence of comorbidities, the physician's specific training and experience in pediatric anesthesia, and the complexity of the procedure involved.

# Privileges in Anesthesia
Physicians with anesthetic privileges should possess the knowledge and technical and non-technical skills necessary for the practice of anesthesia.
Knowledge and technical skills include the ability: - To provide preanesthetic evaluation of the patient and determine the appropriate anesthetic management; - To render the patient insensible to pain for the performance of diagnostic and therapeutic procedures, surgical operations, and obstetric procedures; - To monitor and support the vital organ systems during the perioperative period;
- To provide immediate postanesthetic management of the patient; - To provide resuscitation and intensive care when indicated; and - To provide relief from acute and chronic pain. Nontechnical skills include: - Task management: planning and preparing, prioritizing, providing and maintaining standards, and identifying and utilizing resources; - Teamwork: coordinating activities with team members, exchanging information, using authority and assertiveness, assessing capabilities, supporting others, and supporting the World Health Organization Surgical Safety Checklist; - Situational awareness: anticipating, gathering information, recognizing, and understanding, and;
- Decision-making: identifying options, balancing risks and selecting options, and re-evaluating.

# Fitness to Practice
The provision of anesthesia care requires anesthesiologists to have a high level of expertise, sound judgment, and the ability to recognize and respond to changing clinical situations despite sometimes adverse personal physical circumstances. Anesthesia departments must recognize that fit anesthesia practitioners provide optimal patient care. Anesthesia departments are therefore obligated to develop policies that ensure, as far as possible, that practitioners are healthy and fit to undertake their duties of practice.
A variety of factors impair health and fitness for duty, including adverse physical conditions, mental impairment, and fatigue. All these factors impair fitness and the ability to recognize and respond appropriately to often rapidly changing clinical circumstances. Many studies have shown that fatigue impairs judgement and psychomotor performance in a manner similar to drugs or alcohol. Shifting circadian rhythms, aging, and lack of sleep reinforce such problems; a fatigue-induced lack of recognition of these problems can compound the potential for errors in such circumstances. Physical impairment, illness, and severe stress can have similar detrimental effects on performance.
Anesthesia departments and individual anesthesiologists have a responsibility to organize their working duties such that illness and fatigue do not regularly affect clinical duties. Individual rosters must allow adequate rest between working shifts, and daily rosters should allow appropriate breaks for physiological needs, nutrition, and mental fitness. Operating room scheduling should avoid requiring anesthesiologists to undertake non-emergency procedures during unfavourable hours.
No specific prescription for working shifts and daily rosters can be appropriate for every working situation. Large departments have flexibility to incorporate short shifts and individual leave, while small departments may not have such freedom. Nevertheless, this important area of professional practice must receive ongoing consideration and attention.

# Residents
Residents in anesthesia are registered medical practitioners who participate in the provision of anesthesia services both inside and outside the operating room as part of their training. The Royal College of Physicians and Surgeons of Canada and provincial and local regulatory authorities require that a responsible attending staff anesthesiologist must supervise all resident activities. The degree of this supervision must consider the condition of each patient, the nature of the anesthetic service, and the experience and capabilities of the resident (increasing professional responsibility). At the discretion of the supervising staff anesthesiologist, residents may provide a range of anesthetic care with minimal supervision. In all cases, the supervising attending anesthesiologist must remain readily available to give advice or assist the resident with urgent or routine patient care. Whether supervision is direct or indirect, close communication between the resident and the responsible supervising staff anesthesiologist is essential for safe patient care. Each anesthesia department teaching anesthesia residents should have policies regarding the activities and supervision of residents.

# Ancillary Personnel
The healthcare facility must ensure that ancillary personnel are available as assistants to the anesthesiologist. Such assistants must be available at all times and places where anesthetic services are provided. Ancillary personnel should have the competencies to meet the specific needs of subspecialty areas of anesthesia, reflecting on the need for specific skills in areas such as specialty pediatric anesthesia.
It is recommended that facilities have a formally designated anesthesia assistant with specific training in anesthesia assistance. The department of anesthesia and the appropriate administrative bodies must approve the scope of practice for anesthesia assistants working in a specific institution. Furthermore, anesthesia assistants like other employed health professionals, must be covered by the facility's liability insurance. Duties and tasks delegated to anesthesia assistants must be consistent with existing governmental regulations, the policies and guidelines established by professional regulatory agencies, and the policies of the local facility.
An institution without formal anesthesia assistants must provide other paramedical personnel to assist the anesthesiologist. The tasks that these assistants may perform must be clearly defined. An anesthesiologist must only delegate or assign those tasks for which such personnel have approval or accreditation.

# Anesthetic Equipment and Anesthetizing Location
An anesthetic must be administered in an appropriate facility. All necessary equipment, including emergency equipment, life support systems, medications, and supplies must be readily available. It is strongly recommended that a cognitive aid manual be made available at all anesthetizing locations in support of the management of critical perioperative emergencies. The contents of the manual should be regularly reviewed, updated as required, and periodically practiced as a team.
The healthcare facility, in consultation with the department of anesthesia, is responsible for the design and maintenance of preoperative, postoperative, and anesthetizing locations, as well as the purchase, maintenance, and disposal of anesthetic and ancillary equipment and supplies. The Canadian Standards Association (CSA) and other standards development organizations have published standards and guidance documents for the design, construction, and renovation of healthcare facilities and for the risk management, basic safety, and essential performance of medical equipment (Appendix 1).

# Responsibilities of the Healthcare Facility
The healthcare facility must ensure that: 1. The operating rooms, anesthetizing locations, and perioperative care locations comply with at least the minimum design and construction requirements of the national, provincial, and local building, plumbing, electrical, HVAC (heating, ventilation, and air conditioning), fire, and security codes at the time of construction or renovation. 2. Medical gas and vacuum systems, waste anesthetic gas scavenging systems, terminal units, head walls, low pressure connecting assemblies, and pressure regulators meet the requirements of the CSA and are certified by a CSA-approved testing agency. 3. Oxygen concentrators that comply with CSA requirements are an acceptable substitute for bulk oxygen supply systems. When such concentrators are installed, users must be aware that:
a. The facility medical oxygen supply may deliver a fraction of inspired oxygen (FiO 2 ) that varies from 0.93 to 0.99; b. Oxygen analyzers must be calibrated against 100% O 2 (FiO 2 0.99) and room air or equivalent (FiO 2 0.21); c. The 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 and best practice with respect to the storage, preparation, identification, labelling, disposal, and use of medical gases, medications, and related materials.
a. General medication safety recommendations include, but need not be restricted to:
- Identifying an anesthesia department lead designated to cooperate with pharmacy to promote medication safety best practice. In recognition of the increased risk of medication errors related to medication brand substitutions and look-alike packaging, departments and pharmacies should consider strategies to reduce this risk.
- Requesting that pharmacy staff notify anesthesia staff, with as much notice as possible, of upcoming medication supplier, packaging, or concentration changes such that anesthesia staff can be alerted. - Standardization of drug trays across all locations and during product transitions. Medications with different supplier brands and packaging for a medication should not be mixed in the same anesthesia cart. - Medication substitutions, particularly of a different concentration, should be labelled with highly visible warning labels when any new medication is introduced. - Look-alike medications should be physically separated in the anesthesia carts as much as is possible and identified with warning labels. - Cautioning physicians and technical support staff that replacement of unopened medications back into anesthesia carts is risky because medication may be put in the incorrect location.
- Reporting any medication-related adverse events through local adverse event reporting systems or CAIRS or both.
b. Through cooperation between the departments of anesthesia and pharmacy, there are policies developed and enforced for the safe handling, storage, and disposal of controlled medications (e.g., opioids) in the operating rooms and postanesthesia care unit (PACU) that are consistent with the law, with any regulatory authority requirements, and established best practice principles. The goals of such policies should be to limit access of unauthorized personnel to controlled medications to minimize the risk of controlled medication diversion, and to establish robust documentation procedures that can be audited, while also protecting patient safety by still permitting anesthesia providers immediate access to any medications required for patient care.
Best practice principles support a variety of specific strategies to achieve these goals. The CAS does not endorse any one specific strategy or policy but strongly recommends that all available options be considered. Robust systems and procedures must be implemented. Due consideration should be given to any limitation in resources available to implement specific security systems and procedures within a facility, particularly for smaller facilities.
Recommendations include, but need not be restricted to: - Storing controlled substances in a secure lockable safe or locked drawer when the OR is unattended by anesthesia personnel (e.g., between cases). - Never leaving controlled substances (including those drawn up into syringes or bags) unattended in any location. - Emptying the contents of syringes and bags containing controlled substances before disposal. - Adopting disposal and/or destruction systems to dispose of controlled substance waste. - Consideration of a requirement that controlled substance waste be returned to the pharmacy and be subjected to random analysis. - Periodic audits of a healthcare provider's controlled substance utilization records and their anesthesia records. - Consideration of the implementation of automated anesthesia cabinets or automated medication dispensing cabinets (e.g. PyxisTM)
The operating room, labour and delivery, postanesthesia care unit (PACU), and regional block areas, for example, should all be recognized as high risk areas for controlled medication diversion and therefore must be subject to heightened security, surveillance, and auditing.
- If general anesthesia is provided using an electronic anesthetic system (gas machine), it must comply with CAN/CSA-C22. 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 multi-dose drug vials.
Training on the safe use of all anesthesia equipment should be provided to all anesthesia department members prior to use. Attendance at these sessions should be documented. These training sessions should be repeated as necessary for new or established department members. 

# Waste Gases

# The Preanesthetic Period
The department of anesthesia should establish policies regarding preanesthetic assessment.
The primary goal of preanesthetic assessment is to obtain the information required to plan anesthetic management. Accordingly, a physician who is knowledgeable about anesthetic management for the proposed diagnostic or therapeutic procedure should document all aspects of the patient's medical and surgical history, findings on physical examination, and laboratory investigations that are relevant to anesthetic management. The patient's history should include past and current medical problems, current and recent drug therapy, unusual reactions or responses to drugs, and any problems or complications associated with previous anesthetics. A family history of adverse reactions associated with anesthesia should also be obtained. Information about the anesthetic that the patient considers relevant should also be documented. An American Society of Anesthesiologists physical status classification (Appendix 2) should be recorded for each patient.
In appropriate cases, the availability of an ''Advance Care Plan'' (representation agreement, advanced directive, ''living will'', ''do not resuscitate'' directive, etc.) should be ascertained, and its applicability to the proposed intervention should be determined and documented on the anesthetic assessment record.
The surgeon may request consultation with an anesthesiologist. Medical consultations should be obtained when indicated.
Preoperative anesthetic assessment or consultation may take place in an outpatient clinic before admission for the operative procedure. Indications for pre-admission assessment include the presence of significant medical problems (comorbidities), the nature of the proposed diagnostic or therapeutic procedure, and patient request. A parent/guardian must be present if the patient is a child or not competent to provide informed consent. All patients should be informed that arrangements will be made to meet with an anesthesiologist if they wish to discuss anesthetic management before admission to the facility. The preoperative assessment clinic should also allow nursing and other healthcare personnel to assess the patient. The attending anesthesiologist is responsible for performing a final preanesthetic assessment in the immediate preoperative period.

# Preoperative Testing
Laboratory testing should not be performed on a routine basis but should be obtained only when results will change perioperative management. Laboratory investigations should be performed when indicated by the patient's medical status, drug therapy, and the nature of the proposed procedure.
Routine 

# Partial thromboplastin time/ international normalized ratio
May be considered:
- with conditions or medications associated with impaired coagulation (e.g., liver disease, malnutrition), history of excessive bleeding, or a family history of heritable coagulopathies
- for patients on oral or parenteral anticoagulant therapy.

# TEST INDICATIONS
Electrolytes May be considered:
- with known or compelling findings in favour of hypertension, congestive heart failure, chronic renal failure, complicated diabetes, liver disease, pituitary-adrenal disease, malnutrition
- for patients taking diuretics, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and other therapy affecting electrolytes.
Creatinine and estimated glomerular filtration rate (eGFR) May be considered:
- as above for electrolytes, also with advanced age and for patients taking medications potentially affecting renal function
- for patients receiving direct oral anticoagulants
- as required for calculating perioperative risk indices
- eGFR is recommended to assist with renal outcome prediction.
Fasting glucose level May be considered:
- for diabetics, preoperatively on day of surgery to guide glycemic control
- for patients on glucocorticoid therapy
- as screening for body mass index [ 40 or a very high risk of diabetes based on signs and symptoms.

# Hemoglobin A1c
- May be considered for known diabetics as early as possible before surgery (ideally at time of surgical referral) if results would change management.

# Pregnancy testing Based on specific institutional guidelines
- Should be offered to women of childbearing age based on any reasonable likelihood of pregnancy, on the reliability of menstrual history, and if the results will cancel or change the procedure or the anesthetic management.
- Point of care urine or blood testing capability is ideal and is therefore recommended.

# Electrocardiography
- May be considered for patients with known or suspected coronary heart disease, significant arrhythmia, peripheral vascular disease, or other significant structural heart disease.
- May be considered in the absence of symptoms or known cardiovascular disease in patients having high-risk surgery in the presence of clinical risk factors (e.g., Revised Cardiac Risk Index (RCRI) or American College of Surgeons (ACS) Surgical Risk Calculator).
Brain natriuretic peptide (BNP or NT-pro BNP)
May be considered if:
- age  65 yr,
- age 45-65 yr with significant cardiac disease,
- Revised Cardiac Risk Index score  1. 

# Chest radiograph
- Not recommended for asymptomatic patients in routine preoperative assessment unless part of a surgical or oncological workup unrelated to perioperative risk assessment.
- May be considered for patients with acute or chronic cardiopulmonary disease based on history and physical exam if it will change management.

# Fasting Policies
Fasting policies should vary to account for age and preexisting medical conditions and should apply to all forms of anesthesia, including procedural sedation (see Appendix 6). 1 Emergent or urgent procedures should be undertaken after considering the risk of delaying surgery vs the risk of aspiration of gastric contents. The type and amount of food ingested should be considered in determining the duration of fasting. Before elective procedures, the minimum duration of fasting should be:
- Eight hours after a large meal of solids particularly containing protein (e.g., meat) or fatty foods - Six hours after a light meal (e.g., non-fatty meal such as toast) - Six hours after ingestion of infant formula, non-human milk, or expressed breast milk fortified with additions - Four hours after ingestion of breast milk - Two hours after ingestion of clear fluids for adults - One hour after ingestion of clear fluids for infants and children Unless contraindicated, adults and children should be encouraged to drink clear fluids (including water, pulp-free juice, complex carbohydrate beverages, and black tea or coffee up to two hours before elective surgery. Pediatric patients should also be encouraged to consume clear fluids, as defined, up to one hour before elective procedures.
Conditions that delay gastric emptying require individual patient assessment. These guidelines may be modified at the discretion of the physician.
Premedication, when indicated, should be ordered by the anesthesiologist. Orders should be specific as to dose, time, and route of administration.
An H2 receptor antagonist (oral or intravenous) is recommended for all women presenting for Cesarean delivery.
Thirty mL of oral sodium citrate (0.3 molar) is recommended prior to an emergent Cesarean delivery if general anesthesia is planned. See Section 7.3 for fasting guidelines specific to patients in active labour.

# Additional Regulations
Provincial legislation or facility bylaws may dictate additional regulations governing the conduct of anesthesia.

# The Anesthetic Period

# Preparation for Anesthesia
Before beginning anesthesia, the anesthesiologist must ensure that 1. An explanation of the planned anesthetic procedure, including recognized risks and alternative techniques, has been provided and documented; 2. An adequate review of the patient's condition has been performed; 3. All equipment that is expected to be required is available and in working order, including the equipment required for supporting core temperature management (patient core temperature 36-37C); 4. A reserve source of oxygen under pressure is available; 5. All drugs and agents that are expected to be required are correctly identified-user-applied drug labels should conform to the CSA Standard CAN/CSA-Z264.3-98 (R2005) (Appendix 1); 6. If Luer neuraxial connectors are used, both sides of all Luer connections must be labelled. Consideration should be given to the use of neuraxial connectors complying with ISO 80369-6:2016-small bore connectors for neuraxial application (e.g., NRFitO connectors) subject to availability from equipment suppliers; and 7. The manufacturers' recommendations concerning the use, handling, and disposal of anesthetic equipment and supplies have been considered.

# Airway Management
Airway management, particularly of the difficult airway, contributes to a significant proportion of anesthesia related morbidity and mortality.
The appropriate management of those patients who have a predicted, or an unanticipated difficult intubation, a failed airway, where bag-mask ventilation or supraglottic device placement may be difficult, or who require a surgical airway is critical for patient safety. This includes, but need not be restricted to, adequate airway assessment, equipment (e.g., difficult airway carts, videolaryngoscopes, bronchoscopes), training and simulation, support personnel and the use of protocols and cognitive aids to optimize difficult airway management. The CAS does not endorse any one specific protocol, algorithm, or cognitive aid for difficult and failed airway management but strongly recommends that readers refer to Appendix 4 for up to date publications related to this topic.

# Delegation of Patient Care
The anesthesiologist's primary responsibility is to the patient receiving care. The anesthesiologist or an anesthesia assistant supervised by the anesthesiologist must remain with the patient at all times throughout the conduct of all general and major regional, anesthetics and for procedural sedation until the patient is transferred to the care of personnel in an appropriate care unit.
If the attending anesthesiologist leaves the operating room temporarily, he/she must delegate care of the patient to another anesthesiologist, a resident in anesthesia, or an anesthesia assistant. When the attending anesthesiologist delegates care to a resident in anesthesia or an anesthesia assistant, the attending anesthesiologist remains responsible for the anesthetic management of the patient. Before delegating care of the patient to an anesthesia assistant, the anesthesiologist must ensure that the patient's condition is stable and that the anesthesia assistant is familiar with the operative procedure and the operating room environment and equipment. The attending anesthesiologist must remain immediately available when care is delegated to an anesthesia assistant.
An anesthesiologist may briefly delegate routine care of a stable patient to a competent person who is not an anesthesia assistant only under the most exceptional circumstances, e.g., to provide life-saving emergency care to another patient. That person's only responsibility would be to monitor the patient during the anesthesiologist's absence and to keep the anesthesiologist informed until he/ she returns. In this situation, the anesthesiologist remains responsible for the care of the patient and must inform the operating room team.
An intraoperative handover of care between two anesthesiologists should be documented in the anesthesia record and follow a structured protocol.
It is unacceptable for one anesthesiologist to simultaneously administer general anesthesia, major regional anesthesia (spinal, epidural, or other), or deep procedural sedation (see Appendix 6) 1 for concurrent diagnostic or therapeutic procedures on more than one patient. Nevertheless, it may be appropriate in specific circumstances for one anesthesiologist to supervise more than one patient where only minimal to moderate sedation is administered, provided an appropriately trained, qualified, and accredited individual approved by the department of anesthesiology, and the healthcare institution is in constant attendance with each patient receiving care. In an obstetric unit, however, it is acceptable to supervise more than one patient receiving regional analgesia for labour. Due care must be taken to ensure that a suitably trained person adequately observes each patient following an established protocol. When an anesthesiologist is providing anesthetic care for an obstetric delivery, a second appropriately trained person should be available to provide neonatal resuscitation.
It is unacceptable for a single physician to administer an anesthetic, including deep procedural sedation, and simultaneously perform a diagnostic or therapeutic procedure, except for procedures done with only infiltration of local anesthetic and/or minimal sedation.

# Patient Monitoring
The only indispensable monitor is the presence, at all times, of a physician or an anesthesia assistant who is under the immediate supervision of an anesthesiologist and has appropriate training and experience. 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. Monitoring equipment must be used as intended by the manufacturer and approved by Health Canada for the specific application.
The healthcare 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 healthcare facility regarding 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 for ensuring that appropriate monitoring equipment is available and working correctly. A preanesthetic checklist (Appendix 3 or equivalent) must be completed prior to initiation of anesthesia.
Cautious dosing, vigilant monitoring, and the appropriate reversal of neuromuscular blocking drugs are all essential for patient safety. Neuromuscular monitoring must be utilized when neuromuscular blocking agents are administered.
Monitoring guidelines for standard patient care apply to all patients receiving general anesthesia, regional anesthesia, or procedural sedation.

# Required Monitoring Equipment
Monitoring equipment is classified as follows:
- 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 used with no delay. - Immediately available: These monitors must be available to facilitate their use without undue delay.
The following monitoring equipment is required: - Pulse oximeter;
- Apparatus to measure blood pressure, either directly or noninvasively; - Electrocardiography; - Neuromuscular blockade monitor when neuromuscular blocking drugs are used; - Capnography for general anesthesia and to assess the adequacy of ventilation for moderate or deep procedural sedation; and - Agent-specific anesthetic gas monitor, when inhalational anesthetic agents are used.
The following monitoring equipment must be exclusively available for each patient:
- Apparatus to measure temperature; - Stethoscope; - Appropriate lighting to visualize an exposed portion of the patient.
The following monitoring equipment must be immediately available: - Spirometer to measure tidal volume; - Manometer to measure endotracheal tube cuff pressure.
- Equipment for invasive hemodynamic monitoring if indicated (e.g., arterial, central venous).
The anesthesiologist must remain constantly vigilant, understanding that brief interruptions in continuous monitoring may be unavoidable and there are certain circumstances in which a monitor may fail.
Audible and visual alarms for oximetry and capnography should not be indefinitely disabled during the conduct of an anesthetic except during unusual circumstances. The variable pitch, pulse tone, and lowthreshold alarm of the pulse oximeter and the capnograph apnea alarm must give an audible and visual warning.

# Perioperative Temperature Management
Monitoring patient core temperature is strongly recommended during cases of general and neuraxial regional anesthesia lasting 30 min or longer. In the absence of surgical or patient indications for intraoperative hypothermia, active patient warming systems, control of the operating room ambient temperature, and other methods, should be used to target a central core temperature of 36-37C.

# Patient Positioning
Patient positioning for procedures requiring anesthesia is an operating room team responsibility and demands a high level of attention to avoid complications. It is recognized, however, that positioning-related complications can still occur despite best practice and vigilance. Risks related to patient positioning will vary and depend on the type and duration of surgery, the specific position utilized, and patient factors such as BMI and other comorbidities. Therefore, the considerations and planning for positioning best practice should be discussed by the surgical team ideally before anesthesia induction, for example during part 1 of the Surgical Safety Checklist. All members of the team, including the anesthesiologist, should be encouraged to voice concerns related to any aspect of positioning (e.g., specific risk factors and availability, condition and appropriateness of OR tables and other positioning equipment), and strategies to mitigate these risks should be considered. Patient positioning should be documented and also rechecked regularly by the anesthesiologist to be sure positioning conditions remain ideal. Patients should be informed preoperatively of any specific risks that may be associated with the position planned for their procedure.

# Records
All monitored physiologic 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 must be monitored continuously and should be recorded at frequent intervals, at a minimum of every five minutes, for all patients. End-tidal carbon dioxide concentration must be monitored continuously and recorded at frequent intervals if the trachea is intubated or a supraglottic device is in situ. 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 intravenous fluids should be recorded. All other relevant intraoperative anesthesia care and events, including unexpected or adverse events, should also be recorded.
The patient health record should include the patient's level of consciousness, heart rate, blood pressure, oxygen saturation, and respiratory rate as first determined in the PACU. These recommendations apply to both manually created (handwritten) and electronic anesthesia information management system (AIMS) created anesthesia records. At present, there are no practice standards for what additional data (e.g., gas analysis, ventilator, and respiratory data) that can potentially be collected by an AIMS charting system should become part of a patient's permanent health record.
AIMS have been shown to have potential benefits over handwritten records in several key areas, including improved legibility, precision and reliability of anesthesia records, providing searchable data for quality improvement, outcome and performance reporting and translational research, enhanced medication safety and tracking and real-time clinical decision support for users. The anesthesia patient safety literature supports the use of AIMS. Importantly, AIMS maintain a longitudinal patient database so historical patient encounters should be easily retrievable for review and this should be considered an important feature of any system. The CAS does not promote or endorse any one specific vendor or product but acknowledges that there may be potential benefits of a well designed and implemented AIMS over manually charted records where facility and anesthesia department resources permit the consideration of an AIMS. Ideally it should be implemented and supported in cooperation with the facility information technology department including communication with other facility electronic patient databases wherever possible.
6 The Postanesthetic Period

# Recovery Facility
A PACU must be available in any facility that provides anesthetic services. Administrative policies to coordinate medical and nursing care responsibilities must be enforced in accordance with facility bylaws.
The department of anesthesia should have overall medical administrative responsibility for the PACU. There should be a PACU policy manual approved by appropriate medical, nursing, and administrative authorities.
The anesthesiologist should accompany the patient to the PACU, communicate necessary information to the PACU nurse(s) as part of a structured handover of care protocol, and write appropriate orders. Continuous monitoring of patients is recommended during the perioperative period appropriate to the clinical situation. If clinically indicated, supplemental oxygen, portable pulse oximetry, and other appropriate monitoring devices should be applied during transport to the PACU or intensive care unit. If supplemental oxygen is applied during transport or in PACU to patients who are intubated it is strongly recommended that it only be provided using devices approved for that specific application to minimize any risk of barotrauma. The anesthesiologist should delegate care to the PACU nurse only when assured that nursing staff may safely observe and care for the patient. The anesthesiologist or designated alternate is responsible for providing anesthetic-related care in the PACU. Discharge from the PACU is the responsibility of the anesthesiologist; this responsibility may be delegated in accordance with facility policy.
Supplemental oxygen and suction must be available for every patient in the PACU. Emergency equipment for airway management, resuscitation, and life support must be available in the PACU. Equipment for management of the difficult airway must be immediately available to the PACU. The monitoring used in the PACU should be appropriate to the patient's condition, and a full range of monitoring devices should be available. Monitor alarms should be enabled with alarm settings appropriate to the condition and age of the patient. The use of continuous pulse oximetry is required in the initial phase of recovery. Capnography is required for intubated and deeply sedated patients and is recommended for unconscious patients with in situ supraglottic airway devices. An apnea monitor is recommended for preterm infants with a gestational age of less than 50 weeks.
An accurate record of the immediate recovery period must be maintained. This must include a record of vital signs together with other aspects of treatment and observation. The recovery record must 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.
In some circumstances, it may be considered acceptable to transfer a patient directly to other care units or to bypass the PACU if the appropriate level of care is available in another unit in the facility and the suitability of the patient for this transfer is documented on the anesthetic record.

# Discharge of Patients After Day Surgery
Discharge of patients after day surgery must utilize a formal care plan approved by the institution and be documented in the patient care notes. Patients should meet the facility discharge to home criteria using a validated assessment tool. (e.g., Post Anesthetic Discharge Scoring System). Specific written instructions should include management of pain and postoperative complications, and both routine and emergency follow-up. The patient should be advised regarding the additive effects of alcohol and other sedative drugs, the danger of driving or operating other hazardous machinery during the postoperative period (most commonly 24 hr postoperatively), and the necessity for attention by a competent adult during the postoperative period (most commonly 24 hr postoperatively).
7 Guidelines for Obstetric Regional Analgesia Anesthesia services for parturients include obstetric analgesia for labour-for both uncomplicated and complicated deliveries-or for operative deliveries. All guidelines regarding provision of anesthesia for other diagnostic or therapeutic procedures also apply to the provision of obstetric anesthesia. The guidelines in this section pertain to epidural and spinal analgesia during labour. The term ''regional analgesia'' includes epidural, spinal, and combined spinal-epidural analgesia.
These guidelines are reviewed annually by the Obstetric Anesthesia Section of CAS and updated as indicated. Each facility may choose to develop additional guidelines or policies for specific situations in which obstetric regional analgesia is provided.
Under the direction of an anesthesiologist, some aspects of monitoring and management of obstetric regional analgesia may be delegated to other healthcare personnel. Each facility should ensure that such other personnel receive the same training, certification, continuing education, and recertification in obstetric regional analgesia.

# Initiation of Obstetric Regional Analgesia
Before introducing obstetric regional analgesia, the facility 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 indicate whom to contact if assistance is required.
- Obstetric regional analgesia should be provided only by physicians with training, facility privileges, and licence to provide these services. This includes trainees with appropriate supervision. 2. Regional analgesia should be initiated and maintained only in locations where appropriate resuscitation equipment and drugs are immediately available. 3. Informed consent should be obtained and documented in the medical record. 4. Intravenous access must be established before initiating regional analgesia, and it should be maintained throughout the administration of regional analgesia. 5. The anesthesiologist should be immediately available until analgesia is established and the patient's vital signs are stable. When initial and top-up bolus epidural local anesthetics are administered, the anesthesiologist must be immediately available to intervene appropriately recognizing that these techniques can cause immediate life-threatening complications.
Individual departments of anesthesiology should establish their own policies regarding the appropriate availability of an anesthesiologist to manage the potential complications of regional analgesia for labour and delivery.
Safety systems must be in place to secure epidural local anesthetic mixtures and supplies containing controlled substances (e.g., opioids) to minimize the risk of diversion.

# Oral Intake During Labour
Gastric emptying of solids is delayed during labour and opioid analgesics may further delay gastric emptying.
Therefore, parturients should generally be discouraged from ingesting solid foods when in active labour. In contrast to solid food, clear fluids are emptied relatively rapidly from the stomach during labour. Therefore, in general, women should be permitted clear fluids as desired during active labour. Individual facilities should develop protocols regarding the intake of solids and clear fluids by women in active labour.

# Guidelines for Acute Pain Management Using Neuraxial Analgesia
When neuraxial analgesia is managed by anesthesiologists, the incidence of side effects is no higher than when alternative techniques of pain management are used. Accordingly, when its use is appropriate, neuraxial analgesia should be managed by anesthesiologists.
For the purposes of these guidelines, neuraxial analgesia is defined as intrathecal or epidural administration of opioids and/or local anesthetics for treatment of postoperative pain or other acute pain problems. These guidelines are to provide anesthesiologists with the principles of management to maximize the benefit-risk ratio of providing neuraxial analgesia.

# Administrative and Educational Policies
The department of anesthesia should establish an acute pain service that is responsible for: 1. Developing policies and procedures for neuraxial analgesia. - Assessment and management of hypotension in patients receiving neuraxial analgesia; and - Signs and symptoms of the rare but catastrophic complications of epidural hematoma or abscess.

# Policies for Drug Administration
Each facility should use a limited number of standard solutions. A preprinted order sheet listing the standard solutions for the facility is strongly recommended. Before any solution that is not standard in the facility is dispensed, the anesthesiologist should verify the order with nursing and pharmacy personnel and discuss its indications and all concerns relating to its use with the nurses responsible for administering the drug and monitoring the patient.
The risk of errors due to incorrect route of drug injection must be minimized. For continuous infusions or PCEA, the use of unique tamper-proof pumps that are distinct from the pumps used for intravenous fluid or drug administration is strongly recommended. The tubing between neuraxial analgesia infusion pumps and catheters should not have ports that could permit unintentional injection of intravenous drugs (see section 5.1-6).
Preparation of solutions should follow a standardized procedure. All analgesic drug solutions should be labeled with the composition of the solution (opioid, local anesthetic, or both) and its intended route of administration. For epidural administration, this should include the date and time of preparation and the name of the individual who prepared it.

# Patient Monitoring and Management of Adverse Events
Patients receiving neuraxial analgesia should be in a room equipped with oxygen and suction. Resuscitation drugs and equipment must be immediately available. Before initiating neuraxial analgesia, intravenous access must be secured, and after discontinuing neuraxial analgesia, intravenous access must be maintained for the expected duration of drug effects. Epidural catheter dressings should permit examination for catheter movement and daily inspection of the catheter entry site for any signs of infection.
Standardized policies for patient management should be established. The parameters to be assessed, frequency of assessments, documentation, and procedures for management of complications should be specified. Adequate nursing personnel must be available to assess and manage patients receiving neuraxial analgesia. Monitoring should continue after discontinuation of neuraxial analgesia until its effects have dissipated.
An anesthesiologist must be readily available to advise nursing personnel on such issues as dose titration and management of adverse effects. Each facility with an acute pain service should ensure that an anesthesiologist is available to attend directly to patients receiving neuraxial analgesia within an appropriate time depending on the clinical situation. Each facility should also specify procedures for emergent management of any lifethreatening complications.
Other drugs, particularly benzodiazepines or parenteral opioids, may cause severe respiratory depression in patients receiving neuraxial analgesia. For this reason, other physicians should not order sedatives or analgesics for any patient receiving neuraxial analgesia. The acute pain service should direct analgesic and sedative therapy until the effects of neuraxial analgesia have dissipated.

# Epidurals and Anticoagulation
Patients with epidural catheters may receive prophylactic low-dose anticoagulant therapy if appropriate precautions are taken:
- To minimize the risk of epidural hematoma, catheter insertion and removal and the timing of anticoagulant administration must be coordinated so that no clinically significant anticoagulant effect is present at these times. - Use of nonsteroidal anti-inflammatory drugs in patients receiving neuraxial analgesia is appropriate, but concurrent administration of these drugs or other antiplatelet medication and an anticoagulant may increase the risk of epidural hematoma.
- Where neuraxial analgesia is used for prolonged postoperative pain management, every effort should be made to avoid lower extremity motor blockade. - Nursing staff should be aware of the signs and symptoms of epidural hematoma. Any change in neurologic status or new-onset back pain must be investigated immediately.
If full anticoagulation is indicated in a patient with an epidural catheter, the anesthesiologist should be consulted so that catheter removal and initiation of alternative analgesic management are accomplished before anticoagulation.

# Guidelines for the Practice of Anesthesia in Remote Locations
The basic principles, training requirements, techniques, equipment, and medications used for the practice of anesthesia in remote locations are as outlined in other sections of these Guidelines. They apply equally to anesthesia care, including procedural sedation (see Appendix 6) delivered by anesthesiologists in any operating room or out-of-operating room locations both within a hospital facility and outside of a hospital facility (e.g., offices, clinics).
9.1 Anesthesia Care delivered in a Non-Hospital Medical/Surgical/Dental Facility

# Patient Selection
The physical status of patients should be classified using the American Society of Anesthesiologists physical status (ASA) score. Typically, only patients with ASA classifications of I and II should be considered for procedures. Patients with ASA III classification may be accepted under certain circumstances but only at the discretion of the attending anesthesiologist. Caution should be exercised when booking patients with a known difficult airway.

# Preoperative Considerations
The patient must have had a recent and documented health history, physical examination including an airway examination, and any appropriate laboratory investigations. This may be carried out by another physician (e.g., proceduralist) but it is strongly recommended that there be a screening process that is developed and supported by the anesthesia leadershipproviding services. The duration of fasting should be consistent with section 4.2 Fasting Guidelines.

# Conduct of Anesthesia
The anesthetic and recovery facilities must conform to facility standards established by the CSA (see Appendix 1) and all CAS guidelines established for patient care. The patient should be discharged home from the facility using a validated scoring system for fitness to discharge (e.g., Post Anesthetic Discharge Scoring System).
Patients should be provided with written instructions for the preoperative and postoperative periods. The demand for the delivery of anesthesia care services outside of an operating room (e.g., endoscopy, interventional radiology, cardiac catheterization) is growing because of technological advances and the growth in the availability of less invasive, yet potentially painful, procedures. The delivery of anesthesia care in these remote procedural units can present unique challenges to the anesthesia care team (e.g., patients may have an ASA status of III-IV and have significant comorbidities) and they may be some distance from the operating rooms and support staff or outside of a hospital facility. Procedural units where anesthesiologists have been asked to provide care should comply with the same CSA standards (Appendix 1), equipment guidelines (see section 3.0), and general CAS guidelines as an operating room to the greatest extent possible. This includes, but need not be restricted to, patient selection and assessment, preprocedural testing, fasting guidelines, equipment and electrical outlets, oxygen and suction, ventilation and scavenging if inhalational agents will be utilized, medications and equipment required for resuscitation, patient monitoring, the recovery facility and anesthesia support personnel. Any location outside of an operating room where anesthesiologists provide care must be approved by the anesthesia leadership of the facility. Appropriately trained and experienced anesthesia support personnel, for example an Anesthesia Assistant (see section 2.5) or other staff with experience supporting anesthesia should be present or immediately available to assist the anesthesiologist in remote locations. It is not appropriate to rely solely on procedural unit staff to support anesthesia unless they have had training and experience in the direct support of the delivery of anesthesia care and are approved by anesthesia leadership. There must be reliable two-way communication available to call for assistance and support of the anesthesia provider as it may be required. Les recommandations suivantes ont pour objectif de proposer des lignes directrices de base touchant l'exercice de l'anesthesie. Leur but est de constituer un cadre pour la prestation de soins aux patients qui soient raisonnables et acceptables, et c'est ainsi qu'elles devraient etre interpretees, ce qui permet une certaine flexibilite selon les circonstances. Chaque partie du Guide peut faire l'objet de revision au besoin, selon l'evolution de la technologie et de la pratique.

# Principes de base
Dans le present document, le mot anesthesiologiste est utilise pour designer toute personne qui a un permis d'exercer la medecine avec privilege d'administrer l'anesthesie. L'anesthesie est la realisation deliberee de toute intervention visant a rendre un patient temporairement insensible a la douleur ou a l'environnement externe dans le but d'executer une intervention diagnostique ou therapeutique.
Le present Guide s'adresse a tous les anesthesiologistes du Canada. L'exercice independant de l'anesthesie est une specialite medicale et, a ce titre, elle doit etre exercee par des medecins ayant une formation appropriee en anesthesie. Le processus de certification du College royal des medecins et chirurgiens du Canada constitue la seule voie de reconnaissance comme specialiste en anesthesie au Canada.
La Societe canadienne des anesthesiologistes (SCA) reconnat que la population dans les collectivites eloignees n'est souvent pas suffisamment nombreuse pour justifier une pratique d'anesthesiologie specialisee. Dans ces collectivites, des medecins de famille ayant recu une formation adequate pourraient etre appeles a dispenser les services d'anesthesie. Dans les communautes ou' le volume clinique est suffisamment important pour justifier l'emploi d'anesthesiologistes a temps plein, des anesthesiologistes ayant complete leur specialisation devraient offrir ces services. Tous les anesthesiologistes doivent poursuivre une formation continue dans la pratique de l'anesthesie, de la prise en charge de la douleur, des soins perioperatoires et de la reanimation, et participer a un programme structure de maintien des competences (par ex., MDC du College royal).

# Organisation des services d'anesthesie
Le departement d'anesthesie devrait etre organise, dirige et integre de facon appropriee aux autres departements de l'organisme ou de l'etablissement, et devrait regrouper tous les membres du personnel de l'etablissement qui assurent des soins anesthesiques aux patients, aussi bien a des fins chirurgicales, obstetricales, diagnostiques ou therapeutiques.
Compte tenu de l'ampleur et de la nature des services offerts, le departement devrait comporter le personnel necessaire et s'efforcer d'assurer que ces services soient disponibles comme l'etablissement de soins de sante le requiert.
Le chef du departement devrait etre un medecin certifie en anesthesie ou encore possedant une formation adequate en anesthesie. Cette personne devrait etre nommee de la meme maniere que les autres chefs de departements cliniques et devrait faire partie des entites administratives medicales superieures de l'etablissement. Aucune recommandation specifique concernant les quarts de travail et la liste de garde quotidienne ne peut etre adaptee a toutes les situations de travail. Les grands departements disposent de la flexibilite necessaire a integrer des quarts de travail courts et des conges personnels, alors que les departements plus petits pourraient ne pas jouir de cette liberte. Toutefois, ce domaine important de l'exercice professionnel doit faire l'objet d'une attention et d'une consideration constantes.

# Residents
Les residents en anesthesie sont des medecins autorises qui participent a la prestation des soins anesthesiques tant en salle d'operation qu'a l'exterieur de celle-ci dans le cadre de leur formation. Le College royal des medecins et chirurgiens du Canada et les organismes de reglementation provinciaux et locaux exigent qu'un anesthesiologiste responsable supervise toutes les activites des residents. Le degre de supervision doit prendre en consideration l'etat de chaque patient, la nature des soins anesthesiques, ainsi que l'experience et les capacites du resident (responsabilite professionnelle croissante). A' la discretion de l'anesthesiologiste superviseur, les residents peuvent fournir une gamme de soins anesthesiques sous un minimum de supervision. Dans tous les cas, l'anesthesiologiste superviseur doit demeurer promptement disponible afin de prodiguer des conseils ou d'assister le resident lors de soins urgents ou de routine. Que la supervision soit directe ou indirecte, une communication etroite entre le resident et l'anesthesiologiste superviseur est essentielle pour garantir des soins securitaires aux patients. Chaque departement d'anesthesie qui enseigne aux residents en anesthesie doit avoir des politiques en place concernant les activites et la supervision des residents. 2.7 Personnel de soutien L'etablissement de soins de sante doit s'assurer de la disponibilite de personnel de soutien pour remplir un role d'assistance aupres de l'anesthesiologiste. Cette assistance doit etre disponible en tout temps et en tout lieu ou' des services d'anesthesie sont offerts. Le personnel de soutien doit posseder les competences necessaires a repondre aux besoins specifiques des domaines de surspecialite de l'anesthesie, ce qui se repercute sur le besoin de competences specifiques dans des domaines tels que l'anesthesie specialisee en pediatrie.
On recommande aux etablissements de disposer d'un assistant en anesthesie formellement designe qui aura recu une formation specifique en assistance en anesthesie. Le departement d'anesthesie et les autorites administratives competentes doivent approuver l'etendue des taches des assistants en anesthesie travaillant dans un etablissement en particulier. En outre, les assistants en anesthesie, tout comme les autres professionnels de la sante employes par l'etablissement, doivent etre proteges par l'assuranceresponsabilite de l'etablissement. Les responsabilites et les taches deleguees aux assistants en anesthesie doivent etre conformes aux reglements gouvernementaux en vigueur, aux politiques et lignes directrices edictees par les organismes de reglementation de la profession, et aux politiques de l'etablissement local.
Un etablissement ne disposant pas d'assistants en anesthesie en bonne et due forme doit mettre a disposition de l'anesthesiologiste du personnel paramedical afin de l'assister. Les taches incombant a ces assistants doivent etre clairement definies. Un anesthesiologiste ne doit leur deleguer ou impartir que les taches pour lesquelles ils ont ete autorises ou approuves.
3 Materiel d'anesthesie et lieux convenant a l'anesthesie L'anesthesie doit se pratiquer dans un etablissement adapte. Tout le materiel necessaire, y compris le materiel d'urgence, les systemes de soutien des fonctions vitales, les medicaments et les autres fournitures, doit etre a portee de main. Il est fortement recommande qu'un manuel de listes de controle et d'aides cognitives soit disponible dans tous les lieux ou l'anesthesie est pratiquee afin de soutenir la prise en charge des urgences perioperatoires critiques. Le contenu de ce manuel devrait etre revise et mis a jour regulierement selon les besoins et repete de facon periodique en equipe.
L'etablissement de soins de sante, en consultation avec le departement d'anesthesie, est responsable de l'amenagement et de l'entretien des lieux servant aux soins preoperatoires, postoperatoires et anesthesiques, ainsi que de l'achat, de l'entretien et du traitement apres utilisation du materiel et des fournitures servant a l'anesthesie et aux autres fonctions connexes. L'Association canadienne de normalisation (CSA) et d'autres organismes d'elaboration de normes ont publie des normes et des recommandations se rapportant a la conception, la construction et la renovation des etablissements de sante, ainsi que concernant la gestion du risque, la securite de base et les performances essentielles du materiel medical (Annexe 1).

# Responsabilites de l'etablissement de sante
Il incombe a l'etablissement de soins de sante de veiller a l'application des mesures suivantes : 

# La periode preanesthesique
Le departement d'anesthesie devrait formuler les politiques concernant l'evaluation preanesthesique. Le principal objet de l'evaluation preanesthesique est d'obtenir les renseignements requis pour planifier la prise en charge anesthesique. Par consequent, un medecin bien informe quant a la prise en charge anesthesique pour la procedure diagnostique ou therapeutique proposee devrait documenter tous les aspects des antecedents medicochirurgicaux du patient, le bilan de l'examen physique et les resultats des analyses de laboratoire pertinents a la prise en charge anesthesique. Les antecedents du patient devraient inclure les problemes medicaux passes et actuels, la prise de medicaments recente et actuelle, les reactions ou reponses inhabituelles aux medicaments et tous les problemes et complications associes aux anesthesies administrees anterieurement. Il y a lieu de connatre egalement les antecedents familiaux de reactions indesirables associees a l'anesthesie. Tout renseignement concernant l'anesthesie que le patient juge pertinent de signaler devrait egalement etre note. Il convient enfin d'inscrire au dossier medical de chaque patient le code de classification de l'American Society of Anesthesiologists (Annexe 2).
Dans les cas adaptes, la disponibilite d'un  Plan de soins avances  (accord de representation, directive prealable,  testament biologique , directive  ne pas reanimer , etc.) doit etre verifiee et son applicabilite a l'intervention proposee determinee et documentee au dossier d'evaluation anesthesique.
Le chirurgien peut solliciter une consultation avec un anesthesiologiste. Les consultations medicales devraient etre obtenues lorsque cela est indique.
Le bilan ou la consultation anesthesique preoperatoire peut avoir lieu en clinique externe avant l'admission pour l'operation. Les indications concernant l'evaluation prealable a l'admission comprennent l'existence de problemes medicaux importants (comorbidites), la nature de la procedure diagnostique ou therapeutique proposee, et la demande du patient. La presence d'un parent/tuteur legal est necessaire si le patient est un enfant ou n'est pas apte a fournir un consentement eclaire. Tous les patients devraient etre informes que des dispositions seront prises pour rencontrer un anesthesiologiste s'ils souhaitent s'entretenir de leur prise en charge anesthesique avant leur admission a l'etablissement. La clinique d'evaluation preoperatoire devrait egalement permettre au personnel infirmier et aux autres membres du personnel de sante d'evaluer le patient. L'anesthesiologiste en charge du patient est responsable de l'evaluation preanesthesique finale durant la periode preoperatoire immediate.

# Examens preoperatoires
Les examens de laboratoire ne devraient pas etre realises sur une base reguliere mais uniquement lorsque les resultats modifieront la prise en charge perioperatoire. Les analyses de laboratoire devraient etre realisees lorsque l'etat du patient, le traitement medicamenteux et la nature de l'intervention proposee les justifient. Les tests sanguins de laboratoire, les electrocardiogrammes et les radiographies du poumon de routine ne sont pas recommandes chez les patients asymptomatiques subissant une chirurgie a faible risque. 

# Depistage d'hematies falciformes avec
- Devrait etre propose consultation aux patients presentant un risque eleve en raison de leur origine ethnique.

# Temps de thromboplastine partielle/rapport international normalise
Peut etre envisage :
- Avec les affections ou medicaments associes a une alteration de la coagulation (p. ex., maladies hepatiques, malnutrition), antecedents de saignements excessifs, ou antecedents familiaux de coagulopathies transmissibles.
- Pour les patients recevant un traitement anticoagulant par voie orale ou parenterale.

# Taux d'electrolytes
Peut etre envisage :
- Si connu pour ou avec des constatations connues ou convaincantes en faveur des pathologies suivantes : hypertension, insuffisance cardiaque congestive, insuffisance renale chronique, diabete avec complications, maladie hepatique, trouble hypophysaire, atteinte de l'axe hypophyso-adrenalien, malnutrition.
- chez des patients recevant des diuretiques, des inhibiteurs de l'enzyme de conversion de l'angiotensine, des bloqueurs du recepteur de l'angiotensine et d'autres traitements affectant les electrolytes.
Creatinine et debit de filtration glomerulaire estime (DFGe/ eGFR)
Peut etre envisage :
- Comme ci-dessus pour les electrolytes, egalement avec un age avance et chez les patients prenant des medicaments affectant potentiellement la fonction renale.
- Pour les patients recevant des anticoagulants directs par voie orale.
- Si necessaire pour calculer les indices de risque perioperatoire.
- Le DFGe est recommande pour contribuer a la prediction de l'evolution de la fonction renale.

# TEST INDICATIONS
Glycemie a jeun Peut etre envisage :
- Chez les diabetiques, en preoperatoire, le jour de la chirurgie pour guider le controle glycemique.
- Pour les patients recevant un traitement avec glucocorticodes.
- A' titre de depistage chez les patients ayant un IMC [ 40 ou un risque tres eleve de diabete en fonction de signes et symptomes.

# Hemoglobine A1c
- Peut etre envisage chez les diabetiques connus, le plus tot possible avant la chirurgie (de preference, sitot le patient adresse au chirurgien) si les resultats sont susceptibles de modifier la prise en charge du patient.
Test de grossesse En fonction des lignes directrices propres a l'etablissement
- Devrait etre propose aux femmes en age de procreer en fonction de la probabilite raisonnable de grossesse, de la fiabilite de l'historique des menstruations et si le resultat est susceptible d'annuler ou modifier la procedure ou la prise en charge de l'anesthesie.
- La possibilite d'effectuer un test urinaire ou sanguin au point de service est l'ideal et donc recommandee.

# E lectrocardiogramme
- Peut etre envisage chez les patients avec une coronaropathie, une arythmie significative, une maladie vasculaire peripherique ou toute autre cardiopathie importante connue ou soupconnee.
- Peut etre envisage en l'absence de symptomes ou de maladie cardiovasculaire connue chez les patients devant subir une chirurgie a risque intermediaire ou elevee en presence de facteurs de risque cliniques (par ex. Index de risque cardiaque revise (RCRI), ou Calculateur de risque chirurgical de l'American College of Surgeons).
Le peptide cerebral natriuretique (BNP ou NT-pro BNP) peut etre envisage si :
- le patient est age  65 ans,
- le patient est age de 45-65 ans et a une condition cardiaque significative,
- le patient a un score a l'Index cardiaque de risque revise  1.
E chocardiographie au repos - Peut etre envisagee si l'evaluation clinique suggere une anomalie intracardiaque obstructive severe et non diagnostiquee, une cardiomyopathie ou une hypertension pulmonaire severe.

# TEST INDICATIONS
Radiographie pulmonaire - Non recommandee chez les patients asymptomatiques dans le cadre de l'evaluation preoperatoire de routine, a moins que cet examen ne fasse partie d'un bilan chirurgical ou oncologique non lie a l'evaluation du risque perioperatoire.
- Peut etre envisagee chez les patients souffrant de maladie cardiopulmonaire aigue ou chronique en fonction de leurs antecedents et de l'examen physique, si cela modifiera la prise en charge.

# Lignes directrices concernant le jeune
Les regles concernant le jeune devraient varier en fonction de l'age du patient et de ses antecedents medicaux et s'appliquer a toutes les formes d'anesthesie, incluant la sedation procedurale (voir Annexe 6). 1 Les interventions tres urgentes ou urgentes doivent etre realisees apres avoir examine les risques qu'entranerait leur report comparativement au risque d'aspiration du contenu de l'estomac. Le type et la quantite de nourriture absorbee doivent etre pris en consideration pour determiner la duree du jeune. Avant une intervention non urgente, la duree minimale du jeune devait etre de :
- Huit heures apres un repas copieux comportant des aliments solides, particulierement s'il contenait des proteines (par ex. de la viande) ou des aliments gras; - Six heures apres un repas leger (par ex. repas faible en gras tel une tartine); - Six heures apres l'ingestion de lait maternise, de lait non humain ou de lait maternel tire et fortifie avec des adjuvants; - Quatre heures apres l'ingestion de lait maternel;
- Deux heures apres l'ingestion de liquides clairs pour un adulte; - Une heure apres l'ingestion de liquides clairs pour les nourrissons ou les enfants.
Sauf contre-indication, il convient d'encourager les adultes et les enfants a boire des liquides clairs (eau, jus sans pulpe, boissons a base de sucres complexes et the ou cafe noir) jusqu'a deux heures avant une chirurgie non urgente. Les patients pediatriques devraient egalement etre encourages a boire des liquides clairs, tels que definis, jusqu'a une heure avant une chirurgie non urgente.
Les conditions retardant la vidange gastrique necessitent une evaluation au cas par cas du patient. Ces recommandations peuvent etre modifiees a la discretion du medecin.
Lorsqu'elle est indiquee, la premedication devrait etre ordonnee par l'anesthesiologiste. Les ordonnances doivent specifier la dose, le moment et la voie d'administration.
Un antagoniste des recepteurs H2 (par voie orale ou intraveineuse) est recommande pour toutes les femmes devant subir un accouchement par cesarienne.
Trente (30) mL de citrate de sodium (0,3 molaire) sont recommandes avant un accouchement par cesarienne urgent si l'on planifie une anesthesie generale.
Voir la Section 7.3 pour les recommandations de jeune specifiques aux patientes en travail actif.

# Reglementations supplementaires
Des lois provinciales ou la reglementation de l'etablissement pourraient prescrire d'autres directives regissant l'administration de l'anesthesie.
5 La periode anesthesique

# Preparation a l'anesthesie
Avant le debut de l'anesthesie, l'anesthesiologiste doit s'assurer que 1. La procedure anesthesique prevue a ete expliquee au patient, y compris les risques reconnus et les techniques alternatives, et on a documente cette explication; 2. Une evaluation adaptee de l'etat du patient a ete realisee; 3. Tout le materiel qu'on prevoit necessaire est accessible et en bon etat de fonctionnement, y compris le materiel necessaire au maintien de la temperature centrale (temperature centrale du patient 36-37C); 4. On a acces a une source de reserve d'oxygene sous pression; 5. Tous les medicaments et agents qu'on prevoit necessaires sont correctement identifies -les etiquettes de medicament apposees par l'usager doivent etre conformes a la norme de la CSA CAN/ CSA -Z264.3-98 (R2005) (Annexe 1); 6. Si des connecteurs Luer neuraxiaux sont utilises, les deux cotes des raccords Luer doivent etre etiquetes. Il faut envisager l'utilisation de connecteurs neuraxiaux conformes a la norme ISO 80369-6:2016connecteurs de petit diametre interne pour application neuraxiale (raccords NRFitO) en fonction des disponibilites des fournisseurs de materiel; et 7. On a tenu compte des indications du fabricant quant a l'utilisation, a la manipulation et a la disposition de l'equipement et du materiel d'anesthesie.

# Prise en charge des voies aeriennes
La prise en charge des voies aeriennes, particulierement en cas de voies aeriennes difficiles, contribue significativement a la morbidite et a la mortalite liees a l'anesthesie.
Une prise en charge adaptee des patients dont l'intubation est difficile, de maniere prevue ou imprevue, chez lesquels l'intubation a echoue, lorsqu'une ventilation au masque ou le positionnement d'un dispositif supraglottique pourrait etre difficile, ou qui necessitent des voies aeriennes chirurgicales, est essentielle a la securite des patients. Cette prise en charge comprend, sans necessairement s'y limiter, une evaluation adaptee des voies aeriennes, du materiel (par ex. chariots pour les voies aeriennes difficiles, videolaryngoscopes, bronchoscopes), une formation et des exercices de simulation appropries, du personnel de soutien et le recours aux protocoles et listes de controle adequats afin de prendre en charge au mieux des voies aeriennes difficiles. La SCA ne recommande pas un protocole, un algorithme ou une liste de controle en particulier pour la prise en charge des voies aeriennes difficiles ou lors d'un echec d'intubation, mais elle encourage fortement les lecteurs a se referer a l'Annexe 4 pour acceder aux publications les plus recentes sur le sujet.

# Delegation des soins aux patients
L'anesthesiologiste est avant tout responsable du patient qu'il a sous ses soins. L'anesthesiologiste ou un assistant en anesthesie supervise par l'anesthesiologiste doit demeurer constamment aux cotes du patient pour toute la duree d'une anesthesie generale, regionale majeure et intraveineuse monitoree, jusqu'a ce que le patient ait ete confie aux soins du personnel de l'unite de soins competente.
Si l'anesthesiologiste traitant quitte temporairement la salle d'operation, il doit confier les soins du patient a un autre anesthesiologiste, a un resident en anesthesie ou a un assistant en anesthesie. Lorsque l'anesthesiologiste traitant delegue les soins a un resident en anesthesie ou a un assistant en anesthesie, il demeure responsable de la prise en charge anesthesique du patient. Avant de deleguer les soins du patient a un assistant en anesthesie, l'anesthesiologiste doit s'assurer que l'etat du patient est stable et que l'assistant en anesthesie est familier avec l'intervention chirurgicale ainsi qu'avec l'environnement et le materiel de la salle d'operation. L'anesthesiologiste traitant doit demeurer immediatement disponible lorsque les soins sont delegues a un assistant en anesthesie.
Un anesthesiologiste peut brievement confier les soins courants d'un patient dont l'etat est stable a une personne competente qui n'est pas un assistant en anesthesie qu'en cas de circonstances particulierement exceptionnelles, pour se porter par exemple au secours d'un autre patient dont la vie est en danger. L'unique responsabilite de cette personne devrait etre de surveiller le patient en l'absence de l'anesthesiologiste et de tenir l'anesthesiologiste informe jusqu'a son retour. Dans de telles circonstances, l'anesthesiologiste demeure responsable des soins prodigues au patient et se doit de tenir l'equipe de la salle d'operation au courant.
Le transfert peroperatoire des soins entre deux anesthesiologistes doit etre note au dossier d'anesthesie et se conformer a un protocole structure.
Il est inacceptable qu'un anesthesiologiste administre simultanement une anesthesie generale, une anesthesie regionale majeure (rachidienne, peridurale ou autre) ou une sedation procedurale profonde (voir Annexe 6) 1 pour des interventions diagnostiques ou therapeutiques concomitantes pratiquees sur plus d'un patient a la fois. Toutefois, il peut etre admis, dans des circonstances particulieres, qu'un anesthesiologiste supervise plus d'un patient chez lequel une sedation minime a moderee est administree, a condition qu'un individu ayant recu une formation adequate, qualifie, accredite et approuve par le service d'anesthesiologie et l'etablissement de sante, soit constamment present aupres de chaque patient recevant des soins. Il sera par contre admis, dans un service d'obstetrique, de surveiller simultanement plus d'une patiente a laquelle est administree une analgesie regionale pour le travail. Chaque parturiente devra cependant etre surveillee adequatement par une personne competente, suivant un protocole etabli. Lorsqu'un anesthesiologiste dispense des soins anesthesiques en vue d'un accouchement, une deuxieme personne dument formee doit se tenir prete a intervenir pour pratiquer la reanimation neonatale.
Il est inacceptable qu'un seul medecin administre une anesthesie y compris la sedation procedurale profonde simultanement a la realisation d'une procedure diagnostique ou therapeutique, exception faite des interventions realisees par seule infiltration d'anesthesiques locaux et/ou une sedation minimale.

# Monitorage du patient
Le seul moniteur indispensable est la presence, a tous les instants, d'un medecin ou d'un assistant en anesthesie place sous la supervision immediate d'un anesthesiologiste et detenant la formation et l'experience appropriees. Les moniteurs mecaniques et electroniques ne sont, au mieux, que des aides a la vigilance. Ces appareils aident l'anesthesiologiste a s'assurer de l'integrite des organes vitaux et, en particulier, de la perfusion et de l'oxygenation satisfaisantes des tissus. Le materiel de monitorage doit etre utilise comme prevu par le fabricant et approuve par Sante Canada pour l'application specifique.
Il incombe a l'etablissement de soins de sante de fournir et d'entretenir un equipement de monitorage qui respecte les normes en vigueur.
Il incombe au chef du departement d'anesthesie de conseiller l'etablissement de soins de sante au sujet de l'acquisition de l'equipement de monitorage et d'etablir les normes de monitorage qui aideront a assurer la securite du patient.
Il incombe a l'anesthesiologiste de monitorer le patient qui est sous ses soins et de s'assurer que l'equipement de monitorage approprie soit disponible et fonctionne correctement. Une feuille de verification preanesthesique (Annexe 3 ou equivalent) doit etre remplie avant l'amorce de l'anesthesie.
Une posologie prudente, un monitorage vigilant et la neutralisation adequate des bloqueurs neuromusculaires sont des elements essentiels a la securite des patients. Un monitorage neuromusculaire doit etre utilise lors de l'administration de bloqueurs neuromusculaires. Les directives de monitorage pour les soins standard aux patients s'appliquent a tous les patients recevant une anesthesie generale, une anesthesie regionale ou une sedation intraveineuse.

# Materiel de monitorage requis
Le materiel de monitorage est categorise comme suit : - Requis : Ces moniteurs doivent etre utilises sans interruption pendant toute la duree de l'administration de toute anesthesie. - Accessible en exclusivite pour chaque patient : Ces moniteurs doivent etre accessibles a chaque poste de travail d'anesthesie, de sorte qu'ils puissent etre utilises sans delai. - A portee immediate : Ces moniteurs doivent etre accessibles afin de faciliter leur utilisation sans delai indu.
Le materiel de monitorage suivant est requis : - Un saturometre; - Un appareil permettant de mesurer la tension arterielle, directement ou sans effraction; - Un electrocardiographe; - Un moniteur de bloc neuromusculaire lors de l'utilisation de bloqueurs neuromusculaires;
- Un capnographe, pour l'anesthesie generale et pour evaluer le caractere adequat de la ventilation pour une sedation moderee ou une sedation procedurale profonde; et - Un moniteur de gaz anesthesiques specifique a l'agent, lorsque des agents anesthesiques par inhalation sont utilises.
Le materiel de monitorage suivant doit etre accessible en exclusivite pour chaque patient :
- Un appareil pour mesurer la temperature;
- Un stimulateur des nerfs peripheriques, lors de l'utilisation de bloqueurs neuromusculaires; - Un stethoscope -precordial, oesophagien ou paratracheal; et - Un eclairage suffisant pour visualiser une partie exposee du patient.
Le materiel de monitorage suivant sera a portee immediate :
- Un spirometre pour mesurer le volume respiratoire;
- Un manometre pour mesurer la pression du ballonnet du tube endotracheal. - Le materiel pour un monitorage hemodynamique invasif si indique (p. ex., ligne arterielle, catheter veineux central).
L'anesthesiologiste doit demeurer vigilant en tout temps, etant conscient que de breves interruptions du monitorage continu peuvent etre inevitables et que, dans certaines circonstances, un moniteur pourrait faire defaut. Les alarmes audibles et visuelles du saturometre et du capnographe ne devraient pas etre desactivees indefiniment pendant le deroulement d'une anesthesie, sauf en cas de circonstances inhabituelles. L'alarme a tonalite variable, celle des pulsations cardiaques et l'alarme de seuil inferieur du saturometre ainsi que l'alarme d'apnee du capnographe doivent emettre un signal audible et visible. 

# Dossiers
Toutes les variables physiologiques monitorees doivent etre enregistrees a intervalles reguliers en fonction des circonstances cliniques. La frequence cardiaque et la tension arterielle doivent etre enregistrees au minimum toutes les cinq minutes. La saturation en oxygene doit etre monitoree en continu et devrait etre enregistree a intervalles frequents, au minimum toutes les cinq minutes, chez tous les patients. La concentration en dioxyde de carbone (PCO2) tele-expiratoire doit etre monitoree en continu et enregistree a intervalles frequents en cas d'intubation tracheale ou si un dispositif supraglottique est en place. On doit documenter au dossier anesthesique toute raison pour laquelle on deroge a ces directives de tenue de dossier. Les types de moniteurs, le materiel et les techniques, ainsi que l'heure, la posologie et la voie d'administration de tout medicament et liquide devraient etre notes. Tous les autres soins et evenements anesthesiques peroperatoires pertinents, y compris les evenements imprevus ou indesirables, devraient egalement etre enregistres.
Le dossier de sante du patient doit inclure le niveau de conscience du patient, sa frequence cardiaque, sa tension arterielle, sa saturation en oxygene et sa frequence respiratoire tels que mesures a l'arrivee en salle de reveil. Ces recommandations s'appliquent tant aux dossiers anesthesiques manuscrits qu'a ceux crees via des systemes electroniques de gestion de l'information en anesthesie (SGIA). A l'heure actuelle, il n'existe aucune norme de pratique indiquant quelles donnees supplementaires (par ex. donnees d'analyse de gaz, de ventilation et respiratoires) potentiellement recoltees par un systeme de dossier de SGIA devraient faire partie du dossier de sante permanent d'un patient.
Il a ete demontre que les SGIA pouvaient avoir des avantages potentiels par rapport aux dossiers rediges a la main dans plusieurs domaines cles, notamment en augmentant la lisibilite, la precision et la fiabilite des dossiers anesthesiques, en creant des donnees interrogeables favorisant l'amelioration de la qualite, la communication des resultats et de la performance, la recherche translationnelle, une meilleure innocuite et un meilleur suivi des medicaments, ainsi qu'un suivi et un soutien a la decision clinique en temps reel pour les utilisateurs. La litterature sur la securite des patients en anesthesie appuie l'utilisation des SGIA. Il est important de mentionner que les SGIA permettent de creer une base de donnees de patients longitudinale, de telle maniere que les antecedents anesthesiques importants des patients soient facilement trouvables si l'on veut les passer en revue, ce qui devrait etre considere comme une propriete importante pour tout systeme. La SCA ne promeut ni n'endosse un fournisseur ou un produit en particulier, mais elle reconnat les avantages potentiels d'un SGIA bien concu et mis en oeuvre par rapport a des dossiers completes manuellement la ou' les ressources institutionnelles et du departement d'anesthesie permettent d'envisager l'implantation d'un SGIA. Dans l'ideal, ce systeme devrait etre mis en oeuvre et gere en cooperation avec le departement des technologies de l'information de l'etablissement, et devrait permettre la communication avec les autres bases de donnees electroniques de patients de l'etablissement dans la mesure du possible.
6 La periode postanesthesique 6.1 La salle de reveil Une salle de reveil doit etre disponible dans tout etablissement offrant des services anesthesiques. Des politiques administratives conformes aux reglements de l'etablissement devront etre appliquees de facon a coordonner les responsabilites des soins medicaux et infirmiers.
Le departement d'anesthesie devrait endosser l'ensemble de la responsabilite administrative medicale pour la salle de reveil. Il devrait exister un manuel des politiques de la salle de reveil approuve par les autorites medicales, infirmieres et administratives competentes.
L'anesthesiologiste devrait accompagner le patient en salle de reveil, transmettre les renseignements necessaires au personnel infirmier de la salle de reveil dans le cadre d'un transfert structure du protocole de soins, et rediger les ordonnances necessaires. Le monitorage continu des patients est recommande pendant la phase perioperatoire en fonction de la situation clinique. Si cliniquement indique, de l'oxygene supplementaire, une oxymetrie de pouls portable et d'autres dispositifs de monitorage adaptes doivent etre utilises pendant le transfert vers la salle de reveil ou l'USI. Si de l'oxygene supplementaire est administre a des patients intubes pendant le transport ou en salle de reveil, afin de minimiser tout risque de barotraumatisme, il est fortement recommande de ne le fournir qu'avec des dispositifs approuves pour cette application specifique. L'anesthesiologiste ne devrait deleguer les soins du patient a l'infirmier ou l'infirmiere de la salle de reveil que lorsqu'il est assure que le personnel infirmier pourra adequatement observer et prendre soin du patient. L'anesthesiologiste ou un anesthesiologiste remplacant designe est responsable des soins postanesthesiques en salle de reveil. Le conge de la salle de reveil est sous la responsabilite de l'anesthesiologiste; cette responsabilite peut etre deleguee en accord avec les politiques de l'etablissement.
Une source d'oxygene d'appoint et une succion doivent etre disponibles pour chaque patient en salle de reveil. Le materiel d'urgence necessaire a la prise en charge des voies aeriennes, la reanimation et au support vital doit etre disponible en salle de reveil. Le materiel pour la prise en charge de voies aeriennes difficiles doit etre a portee immediate en salle de reveil. Le monitorage utilise en salle de reveil doit etre adapte a l'etat du patient et un eventail complet d'appareils de monitorage doit etre disponible. Les alarmes des moniteurs doivent etre en fonction, avec des parametres d'alarme adaptes a l'etat et a l'age du patient. L'utilisation continue d'un saturometre est requise pendant la phase initiale de recuperation. Un capnographe est requis pour les patients intubes ou sous sedation profonde et est recommande pour les patients inconscients ayant des dispositifs supraglottiques in situ dans les voies aeriennes. Un moniteur d'apnee est recommande chez les nourrissons prematures et ayant un age gestationnel de moins de 50 semaines.
Un dossier detaille de la periode immediate de reveil doit etre tenu. Celui-ci doit inclure un enregistrement des signes vitaux ainsi que des autres aspects du traitement et de l'observation. Cette feuille d'observation fait partie du dossier medical permanent. Toute complication ayant un lien avec l'anesthesie doit etre notee sur la feuille de la salle de reveil ou dans les notes d'evolution du dossier du patient. Dans certaines situations, il peut etre acceptable de transferer un patient directement vers d'autres unites de soins ou de passer outre la salle de reveil si un niveau de soins adapte est disponible dans une autre unite de l'etablissement et s'il est note au dossier anesthesique que le patient est juge apte a ce transfert.

# Conge des patients apres chirurgie d'un jour
Le conge des patients apres une chirurgie ambulatoire doit se faire en utilisant un plan formel de soins approuve par l'institution et documente dans les notes de soins prodigues aux patients. Les patients doivent satisfaire les criteres de conge au domicile en utilisant un outil d'evaluation valide (p. ex., le systeme de cotation de conge post-anesthesie ). La prise en charge de la douleur et des complications postoperatoires, ainsi que le suivi de routine et d'urgence, doivent tous faire l'objet d'instructions ecrites specifiques. Le patient doit etre averti au sujet des synergies additives qu'il existe entre l'alcool et d'autres sedatifs, du danger de conduire ou d'utiliser des machines dangereuses dans la periode postoperatoire (dans la plupart des cas durant les 24 heures suivant l'operation), et de la necessite d'attention de la part d'un adulte competent dans la periode postoperatoire (dans la plupart des cas durant les 24 heures suivant l'operation).

# Lignes directrices pour l'analgesie regionale en obstetrique
Les services d'anesthesie destines aux parturientes comprennent l'analgesie obstetricale pour le travailpour l'accouchement avec ou sans complication -ou pour les cesariennes. Toutes les directives visant l'anesthesie administree pour toute autre intervention diagnostique ou therapeutique s'appliquent egalement a l'anesthesie obstetricale. Les directives de la presente section portent sur l'analgesie peridurale et la rachianesthesie pendant le travail. L'expression  analgesie regionale  designe l'analgesie peridurale, la rachianesthesie et la combinaison des deux.
Ces directives sont passees en revue chaque annee par la Section d'anesthesie obstetricale de la SCA et mises a jour au besoin. Chaque etablissement peut decider d'elaborer des directives ou politiques supplementaires pour des situations specifiques dans lesquelles une analgesie regionale obstetricale est dispensee.
Sous la direction d'un anesthesiologiste, certains aspects du monitorage et de la prise en charge de l'analgesie regionale obstetricale peuvent etre delegues a d'autres membres du personnel de sante. Chaque etablissement doit s'assurer que ces personnes recoivent les memes formation, certification, formation continue et recertification en analgesie regionale en obstetrique. Chaque departement d'anesthesiologie devrait etablir ses propres politiques concernant la disponibilite jugee adaptee d'un anesthesiologiste pour prendre en charge les complications potentielles liees a l'analgesie regionale pour le travail obstetrical et l'accouchement.
Des systemes de securite doivent exister pour proteger les melanges d'anesthesiques locaux periduraux contenant des substances controlees (par ex. des opiodes) de facon a minimiser les risques de detournement.

# Absorption orale pendant le travail
La vidange gastrique des aliments solides est retardee pendant le travail, et les analgesiques opiodes peuvent la retarder encore davantage. Par consequent, on devrait generalement decourager les parturientes d'ingerer des aliments solides pendant le travail actif. Contrairement aux aliments solides, les liquides clairs sont elimines relativement rapidement de l'estomac pendant le travail. Ainsi, en regle generale, on devrait permettre aux parturientes d'ingerer des liquides clairs comme elles le souhaitent pendant le travail actif. Chaque etablissement devrait elaborer des protocoles concernant l'absorption d'aliments solides et de liquides clairs par les femmes en travail actif.
8 Lignes directrices pour la prise en charge de la douleur aigue a l'aide de l'analgesie neuraxiale Lorsque l'analgesie neuraxiale est prise en charge par des anesthesiologistes, l'incidence d'effets secondaires n'est pas plus elevee que lorsque des techniques alternatives de prise en charge de la douleur sont utilisees. En consequence, lorsque son utilisation est indiquee, l'analgesie neuraxiale devrait etre prise en charge par les anesthesiologistes.
Aux fins de ce guide, l'analgesie neuraxiale se definit comme l'administration intrathecale ou peridurale d'opiodes et/ou d'anesthesiques locaux en vue du traitement de la douleur postoperatoire ou d'autres problemes de douleur aigue. Ce guide vise a fournir aux anesthesiologistes les principes de prise en charge afin que l'analgesie neuraxiale soit pratiquee de maniere a en maximiser les avantages et en minimiser les risques. Le risque d'erreurs attribuables a une voie impropre d'injection du medicament doit etre minimise. Pour des perfusions continues ou une APCP, l'emploi de pompes inviolables distinctes de celles utilisees pour l'administration de solutes ou de medicaments est vivement recommande. La tubulure entre les pompes de perfusion de l'analgesie neuraxiale et les catheters ne devrait comporter aucun orifice susceptible de permettre une injection non intentionnelle de medicaments intraveineux.
La preparation des solutions devrait suivre une procedure standardisee. Toutes les solutions analgesiques devraient porter une etiquette indiquant la composition de la solution (opiode, anesthesique local, ou les deux) ainsi que la voie d'administration appropriee. Dans le cas d'une administration peridurale, cela doit inclure la date et l'heure de la preparation ainsi que le nom de la personne l'ayant preparee.

# Monitorage des patients et prise en charge des evenements indesirables
Les patients auxquels est administree une analgesie neuraxiale devraient etre places dans une chambre equipee d'oxygene et de succion. Des medicaments et du materiel de reanimation doivent etre a portee immediate. L'acces intraveineux doit etre etabli avant d'amorcer l'analgesie neuraxiale et, apres cessation de l'analgesie neuraxiale, maintenu pendant toute la duree prevue des effets medicamenteux.
Le pansement qui maintient en place le catheter peridural doit permettre l'examen du catheter pour detecter tout mouvement et permettre l'inspection quotidienne du point d'entree afin de deceler tout signe d'infection.
L'adoption de politiques standardisees au chapitre de la prise en charge des patients est preconisee. Les parametres qu'il convient d'evaluer, la frequence des evaluations, la documentation et les procedures de prise en charge des complications devraient etre precises. Un personnel de soins infirmiers en nombre suffisant doit etre present pour evaluer et prendre en charge les patients recevant une analgesie neuraxiale. Le monitorage devrait se poursuivre apres cessation de l'analgesie neuraxiale jusqu'a ce que ses effets se soient dissipes.
Un anesthesiologiste doit etre immediatement disponible afin de conseiller le personnel infirmier sur des aspects tels que le titrage de la dose et la prise en charge des effets indesirables. Chaque etablissement dote d'un service de traitement de la douleur aigue doit veiller a ce qu'un anesthesiologiste soit disponible pour s'occuper directement des patients recevant une analgesie neuraxiale dans un delai approprie en fonction de la situation clinique. Chaque etablissement devrait egalement determiner les procedures en vue d'une prise en charge urgente de toute complication menacant le pronostic vital. D'autres medicaments, notamment les benzodiazepines ou les opiodes parenteraux, peuvent causer une depression respiratoire majeure chez les patients recevant une analgesie neuraxiale. Pour cette raison, les autres medecins ne devraient pas prescrire de sedatifs ou d'analgesiques a tout patient recevant une analgesie neuraxiale. Le service de traitement de la douleur aigue devrait demeurer en charge de la therapeutique analgesique et sedative jusqu'a dissipation des effets de l'analgesie neuraxiale. 9 Lignes directrices pour l'exercice de l'anesthesie dans les lieux isoles Les principes fondamentaux, les exigences de formation, les techniques, le materiel et les medicaments utilises pour la pratique de l'anesthesie dans les lieux isoles ont ete documentes dans d'autres sections de ce Guide. Ils s'appliquent egalement aux soins anesthesiques, notamment a la sedation consciente (voir Annexe 6) dispensee par un anesthesiologiste dans toute salle d'operation ou emplacement hors de la salle d'operation, tant a l'interieur d'un etablissement hospitalier qu'a l'exterieur (par ex. bureaux, cliniques). 9.1 Soins anesthesiques dispenses dans un etablissement medical/chirurgical/dentaire non hospitalier

# Se lection des patients
Le statut physique des patients devrait etre categorise selon le score de l'American Society of Anesthesiologists (ASA). D'une maniere generale, seuls les patients des classes ASA I et II devraient etre retenus pour subir une intervention. Les patients de statut ASA III pourraient etre acceptes sous certaines conditions, mais seulement a la discretion de l'anesthesiologiste en charge. Il faut faire preuve de prudence lors de la selection de patients presentant des voies aeriennes difficiles connues.

# Conside rations pre ope ratoires
Une histoire de cas et un examen physique recents, incluant un examen des voies aeriennes, devraient paraitre au dossier du patient, ainsi que les resultats des examens de laboratoire appropries. Ces examens peuvent etre executes par un autre medecin (par ex. un 'proceduraliste', soit un medecin/chirurgien competent pour realiser des interventions diagnostiques ou therapeutiques), mais l'existence d'un processus de selection mis au point et endosse par les services anesthesiques est fortement recommandee. La duree du jeu ne devrait etre conforme a la section 4.2 Lignes directrices concernant le jeune.

# Conduite de l'anesthe sie
Les installations des salles d'anesthesie et de reveil doivent etre conformes aux normes hospitalieres etablies par la CSA (voir Annexe 1) et a toutes les lignes directrices de la SCA etablies pour les soins aux patients. Le patient devrait recevoir son conge de l'hopital pour rentrer a la maison en utilisant un systeme de notation valide evaluant son aptitude au conge (par. ex. Systeme de cotation de conge postanesthesique). Les patients devraient recevoir des instructions ecrites concernant les periodes preoperatoire et postoperatoire. 9.2 Soins anesthesiques dispenses hors de la salle d'operation dans un hopital ou un etablissement non hospitalier En raison des avancees technologiques et de la plus grande disponibilite d'interventions moins invasives mais potentiellement douloureuses, la demande pour la fourniture de soins anesthesiques a l'exterieur de la salle d'operation (par ex., endoscopie, radiologie interventionnelle, catheterisation cardiaque) croit. La fourniture de soins anesthesiques dans ces unites interventionnelles eloignees peut s'accompagner de defis particuliers pour l'equipe de soins anesthesiques (p. ex., les patients pourraient avoir un statut ASA III-IV et d'importantes comorbidites), et ces unites pourraient se trouver a une certaine distance des salles d'operation et du personnel de soutien, voire a l'exterieur d'un etablissement hospitalier. Les unites d'intervention dans lesquelles les anesthesiologistes sont appeles a fournir des soins devraient se conformer, dans la mesure du possible, aux memes normes de la CSA (Annexe 1), lignes directrices concernant le materiel d'anesthesie (voir section 3.0), et lignes directrices generales de la SCA qu'une salle d'operation. Cela comprend, sans s'y limiter, la selection et l'evaluation des patients, les examens pre-proceduraux, les lignes directrices concernant le jeu ne, le materiel et les prises electriques, l'oxygene et la succion, la ventilation et l'evacuation des agents volatils si utilises, les medicaments et le materiel necessaires a la reanimation, le monitorage du patient, les installations de retablissement et le personnel de soutien en anesthesie. Tout lieu ou des anesthesiologistes fournissent des soins en dehors d'une salle d'operation doit etre approuve par la direction de l'anesthesie dans l'etablissement. Du personnel de soutien en anesthesie adequatement forme et experimente, par exemple un assistant en anesthesie (voir section 2.5) ou d'autres personnes ayant de l'experience dans le soutien en anesthesie, devrait etre present ou immediatement disponible pour assister l'anesthesiologiste dans les lieux isoles. Il ne convient pas de dependre exclusivement du personnel de l'unite chirurgicale pour soutenir l'anesthesie, a moins que ce personnel ne soit forme et ait de l'experience dans le soutien direct de la fourniture de soins anesthesiques et qu'il ait recu l'aval de la direction de l'anesthesie. Une communication bidirectionnelle fiable doit etre disponible pour que le prestataire d'anesthesie ait acces a de l'aide et du soutien si necessaire.
Remerciements Nous tenons a remercier les anciens membres du Comite des normes de pratique de l'anesthesie qui ont apporte leurs contributions a des versions anterieures de ce Guide. Le Comite tient a remercier since'rement le Dr Hilary P. Grocott pour son aide majeure pendant son mandat en tant que redacteur en chef du JCA.
Conflits d'interets Tous les auteurs de cet article font partie du Comite des normes de la Societe canadienne des anesthesiologistes (SCA). Aucun des auteurs n'a un quelconque interet financier ou commercial lie aux societes ou fabricants d'appareils medicaux dont il est fait mention dans cet article ou dans les annexes associees. Dr Gregory Dobson est president du Comite des normes de la SCA. Annexe 4: Lignes directrices, normes et autres enonces officiels disponibles sur l'internet L'Annexe 4 (disponible au : / Guide-d-exercice) offre une liste non exhaustive de sites contenant des declarations officielles promulguees par d'autres associations medicales au Canada et ailleurs dans le monde. Cette liste est fournie aux membres de la SCA uniquement a des fins pratiques. La SCA n'est pas responsable de l'exactitude, de la mise a jour ou de la fiabilite du contenu de ces sites. La SCA n'offre aucune garantie a cet effet. Elle se degage de toute responsabilite concernant l'information trouvee par le biais de ces liens et n'endosse pas necessairement ces sites ou leur contenu. Cette liste contient l'adresse de sites qui sera mise a jour de facon periodique.