Determination of the risk level of surgery and anesthesia. Physical status of patients according to the ASA (American Society of Anesthesiologists) classification

Physical status of patients according to ASA classification (American Society of Anesthesiologists) is an assessment of the patient's condition before surgical intervention. There are 5 classes of physical status (from a healthy patient to an extremely ill patient) in serious condition): ASA I -healthy patient;ASA II-patient with lung systemic disease;ASA III- patient with severe systemic disease; ASA IV- a patient with a severe systemic disease that poses a constant threat to life and ASA V- dying patient. Operation for life-saving reasons. Additional, sixth grade - ASA VI, is used to determine the death of a patient’s brain and is used in transplantology.

Annually A.S.A. develops for anesthesiologists and resuscitators,

ASA physical status classification system

Classification	Definition		Examples
ASA I	Healthy patient		Healthy, non-smoker, little alcohol drinker.
ASA II	Patient with mild systemic disease		Mild illnesses only without significant functional limitations. Examples include (but are not limited to): smoker, social drinker, pregnant, obese (<30 ИМТ <40), компенсированный сахарный диабет, контролируемая артериальная гипертензия, легкие заболевания дыхательной системы.
ASA III	Patient with severe systemic disease		Significant restrictions on functional activity. Examples include (but are not limited to): poorly controlled hypertension or subcompensated diabetes mellitus, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, mildly reduced cardiac ejection fraction, chronic renal disease insufficiency requiring regularly scheduled hemodialysis. History (more than 3 months) of myocardial infarction, stroke, transient ischemic attack, coronary heart disease or stenting.
ASA IV	Patient with severe systemic disease that is permanently life-threatening		Examples include (but are not limited to): myocardial infarction, stroke, transient ischemic attack, coronary artery disease or stenting, current myocardial ischemia or severe valvular dysfunction, acute reduction in ejection fraction, sepsis, disseminated intravascular coagulation, acute or chronic renal disease insufficiency due to irregular hemodialysis.
ASA V	Dying patient. Operation for life-saving reasons.		Examples include (but are not limited to): ruptured aortic aneurysm, severe polytrauma, intracranial hemorrhage, acute intestinal ischemia with concomitant severe cardiac pathology or multiple organ failure.
ASA VI		Brain death was declared and the organs were removed for donor purposes.
The addition of the letter "E" denotes a surgical emergency. An emergency situation is defined as existing when a delay in treating a patient would result in a significant increase in threat to life. For example: ASA I E, II E, III E or IV E. Class ASA V is usually always ASA V E. Class ASA VI E does not exist.

ASA classification ( American Society of Anesthesiologists) as amended October 15, 2014

The tracheal intubation algorithm (algorithm for intubating a difficult airway) recommended by the ASA:
1. The anesthesiologist must have pre-formulated strategy with difficult tracheal intubation. The anesthesiologist's flow chart shown in is a recommended strategy, which will depend, in part, on the intended surgery, the patient's condition, and the anesthesiologist's skills and preferences.
Recommended Strategy for difficult tracheal intubation:
Occurrence probability assessment six clinical problems , which can be individually or in combination: 1) Difficulty with patient cooperation or compliance 2) difficult mask ventilation 3) upper respiratory tract problem 4) complex laryngoscopy 5) difficult intubation and 6) difficult surgical access to the airways.
Consideration of relative advantages between clinical options for solving the problem: 1) conscious intubation or intubation after induction of anesthesia? 2) non-invasive methods or invasive (ie, surgical or transcutaneous approaches to the airway)? 3) Video laryngoscopy as a primary approach to tracheal intubation? 4) preservation of spontaneous ventilation or its cessation?
Identifying your preferred approach : 1) conscious intubation 2) can be easily ventilated but difficult to intubate 3) a life-threatening situation in which neither ventilation nor intubation is possible.
Search for alternatives , which can be used if the main one does not work or is not feasible.
Uncooperative patient , may limit difficult airway management options, especially those that involve awake tracheal intubation;
Solving difficult airways in patients who refuse to cooperate with the anesthesiologist, a different approach may be required (for example, attempts at intubation after induction of anesthesia), which cannot be considered as the main option for solving the problem.
Performing surgery using local anesthesia or regional anesthesia may be an alternative to tracheal intubation, but this approach does not represent a definitive solution to the problem of a difficult airway and does not eliminate the need for a difficult airway intubation strategy;
Confirmation of tracheal intubation using capnography or expiratory carbon dioxide monitoring.

Tracheal intubation algorithm was developed by the American Society of Anesthesiologists (ASA) in 2013 and recommended for practical use.

ASA STANDARDS FOR ANESTHETIC MONITORING

Approved by the House of Delegates of the American Society of Anesthesiologists (ASA) on October 21, 1986, as amended on October 28, 2015.

apply to all types of anesthesia, although, in emergency circumstances, appropriate life support measures take precedence. These standards may be exceeded at any time based on the decision of the responsible anesthesiologist. They are intended to improve patient safety, but cannot guarantee any specific results. Basic standards for anesthetic monitoring subject to revision from time to time as justified by the development of new technologies and practices. They are applicable for both general and regional anesthesia. This set of standards addresses only issues basic anesthetic monitoring , which is one of the components of anesthesia itself. In some rare or unusual circumstances, any of these monitoring methods may not be clinically practical, and proper use of the monitoring methods described may not detect adverse clinical incidents. Brief interruptions in ongoing monitoring may be unavoidable. These standards are not intended for use in obstetric anesthesiology or pain management.

1. ASA STANDARDI

Qualified anesthesia personnel should be present in the operating room during general anesthesia, regional anesthesia and during monitored anesthesia care.

Task

Because the patient's condition changes rapidly during anesthesia, a physician anesthesiologist and nurse anesthetist must be present at all times to monitor the patient's condition and thereby ensure the safety of anesthesia. If there is a direct danger to medical personnel, such as radiation, remote monitoring of the patient may be required - in this case, all available measures must be used to ensure anesthetic monitoring. In the event that an emergency situation requires the temporary absence of the anesthesiologist responsible for administering anesthesia, the anesthesiologist's decision will depend on comparing the emergency situation with the patient's condition during anesthesia, and if he decides to leave the operating room, he must appoint an anesthesiologist temporarily responsible for administering anesthesia .

1. ASA STANDARD II

During all types of anesthesia, the following parameters must be constantly assessed: oxygenation, ventilation, circulation and the patient's body temperature.
Oxygenation

Task

Ensuring adequate oxygen concentration in the inhaled gas mixture during anesthesia.

Methods

During general anesthesia using an anesthesia-respiratory apparatus, the oxygen concentration in the breathing circuit should be measured using a gas analyzer equipped with an alarm system that is triggered when the oxygen concentration drops to the maximum permissible level.*

During all types of anesthesia, a quantitative method of assessing oxygenation, such as pulse oximetry, should be used.* When using a pulse oximeter, the anesthesiologist should be able to hear pulse tones of varying intensities and desaturation alarms.* Adequate lighting and access to the patient are necessary to assess skin color. *

1. VENTILATION

Task

Ensure proper ventilation during all types of anesthesia.

Methods

During general anesthesia, the adequacy of ventilation must be assessed. Qualitative clinical signs such as chest excursion, observation of the airway bag, and lung auscultation are helpful. Continuous monitoring of exhaled carbon dioxide is considered necessary unless this is inconsistent with the procedure or equipment. Quantitative monitoring of exhaled gas volume is strongly recommended.*

After tracheal intubation or placement of a laryngeal mask airway, their correct position should be verified by clinical assessment as well as assessment of the expiratory carbon dioxide concentration. End-tidal carbon dioxide should be continuously analyzed throughout the anesthesia using a quantitative method (capnography, capnometry or mass spectroscopy).* When capnography or capnometry is used, an alarm should be audible to the anesthesiologist.*

When providing mechanical ventilation, a device must be provided that can detect disconnection of breathing circuit components. The device must give an audible signal if its alarm threshold is exceeded.

During regional anesthesia (without sedation) or local anesthesia (without sedation), the adequacy of ventilation should be assessed by continuous monitoring of qualitative clinical signs. During moderate or deep sedation, the adequacy of ventilation should be assessed by continuous observation of qualitative clinical signs and monitoring of exhaled carbon dioxide, unless inconsistent with the procedure or equipment.

1. CIRCULATION

Task

Ensure adequate blood circulation during anesthesia.

Methods

Each patient should have continuous ECG monitoring from the onset of anesthesia until transport from the operating room*.

During anesthesia, each patient's blood pressure and heart rate should be measured at least every five minutes.*

In addition to the above, at least one of the following methods should be used during general anesthesia: pulse palpation, auscultation of heart sounds, invasive blood pressure monitoring, ultrasound peripheral pulse monitoring, or plethysmography or oximetry.

1. BODY TEMPERATURE

Task

Maintaining appropriate body temperature during anesthesia.

Methods

During anesthesia, constant monitoring of body temperature is necessary. If a change in body temperature is expected, it must be measured.

Note that "periodic" is defined as "repeating regularly, often, in a constant sequence," while "continuous" means "continuously, without any interruption."

* Under extenuating circumstances, the responsible anesthesiologist may waive the requirements marked with an asterisk (*). If this is done, it is recommended that this fact be indicated (including reasons) in a note to the medical documentation.

ASA RECOMMENDATIONS WHEN USING PROPOFOL (Diprivan)

It is not always possible to predict how a particular patient will respond to administration of sedatives . Due to the ability to rapidly and dramatically change the depth of sedation/anesthesia and the lack of antagonists, some drugs such as propofol , require special attention. Although propofol is intended for moderate sedation , when using it, patients should receive care similar to that required for deep sedation .

Members of the American Society of Anesthesiologists (ASA) believe that the best option is participation of an anesthesiologist in observation for each patient during anesthesia. However, when this is not possible, administer propofol Only a highly qualified, experienced physician should be able to save* a patient whose level of sedation has become deeper than originally intended, i.e. entered into a state of anesthesia.**

• The physician responsible for the use sedation/anesthesia , must receive appropriate training to be able to cope with potential complications resulting from the use of sedatives. He must have resuscitation skills and understand the pharmacology of the drugs used. The physician must remain with the patient throughout the entire duration of the sedative drug and remain in a state of immediate availability until the patient fully awakens.
• Doctor practicing administration of propofolA , must be able to identify disorders in the cardiovascular and respiratory systems, which is possible in a patient entering a state of anesthesia, and be able to provide assistance with complications. The doctor must be present with the patient during the entire procedure and engage exclusively in monitoring the patient.
• At administration of propofol The patient's condition must be monitored continuously. This will assess the level of consciousness and also identify early signs of hypotension, bradycardia, apnea, airway obstruction and/or desaturation. Blood oxygen saturation, heart rate and blood pressure should be monitored at regular and short intervals. Monitoring exhaled carbon dioxide is also recommended because chest movement does not reliably detect airway obstruction or apnea.
• In addition to cardiac resuscitation equipment, age-appropriate equipment for maintaining an open airway, oxygenation, and mechanical ventilation should be available.

In the "Warnings" section instructions for use of propofol (Diprivan®, AstraZeneca) states that the administration of propofol for sedation or anesthesia “should only be performed by qualified anesthesiologists who are not involved in the surgical/diagnostic procedure.” The patient must be under constant supervision, and doctors must have equipment for artificial ventilation, oxygen enrichment, and cardiopulmonary resuscitation.

In addition, some US states have separate regulations regarding the administration of propofol. There are different opinions When should propofol be used for sedation? intubated, ventilated patients in critical condition.

Similar problems arise when other intravenous agents, such as methohexital or etomidate, are used for sedation. Administration of a combination of drugs including sedatives and analgesics may increase the likelihood of an adverse outcome.

* Preventing a patient from becoming more sedated than expected requires the intervention of an experienced physician who can establish the airway and perform advanced resuscitation. A trained clinician reverses the negative physiological effects of deep levels of sedation (eg, hypoventilation, hypoxia, and hypotension) and returns the patient to the originally planned level of sedation. Continuing procedures at an unplanned level of sedation is unacceptable.

** The AANA and ASA joint statement regarding the introduction of propofol, dated April 14, 2004, states: “ Whenever propofol is used for sedation/anesthesia, it should only be administered by persons trained in general anesthesia who are not simultaneously participating in surgical or diagnostic procedures. This limitation is consistent with the wording in the instructions for use of propofol. Failure to follow these recommendations may increase the risk of serious injury or death to the patient.».

Approved by the American Society of Anesthesiologists on October 15, 2014

Comment

If the anesthesiologist performs spinal or epidural anesthesia under sterile conditions without any interruption in the process, drugs are prescribed immediately, and everything happens under the direct supervision of a doctor, then marking of sterile syringes is not required.

Rationale

Probability of introduction unintended (unplanned) drug delivery using an unlabeled syringe is extremely low* if the anesthesiologist is performing a continuous procedure and the drug is prepared under sterile conditions immediately prior to use. Markings maybe syringes bring to violation of sterility , contamination of the anesthetic or needles and/or unnecessary delay of the procedure in an emergency. This is not advisable from a patient safety point of view. .

* Comprehensive statistical data analysis (National Anesthesia Clinical Outcomes Registry (four million cases with a clinical outcome reported), anesthesia error claims statistics (10,000 cases over 30 years) and the Anesthesia Incident Reporting Information System (1,500 incident reports since 2011) G.)) did not reveal cases of erroneous administration of the drug due to incorrect marking of the syringe during epidural or spinal anesthesia.

Approved by ASA 10/17/2012

American Society of Anesthesiologists The ASA, as an organization of physicians committed to improving the safety and quality of anesthesia care, believes it is appropriate to express its views on regional anesthesia. This view is based on the premise that the most important objective in the provision of anesthesia care is patient safety.

Anesthesiology in all its forms, including regional anesthesia, is part of medical practice. Regional anesthesia includes a diagnostic assessment, consideration of indications and contraindications, drug selection, and corrective measures and treatment in the event of a complication. Thus, successfully performing regional anesthesia requires both medical and technical competence.

The medical component includes:

• preliminary assessment of the patient's condition;
• development and administration of an anesthesia plan;
• checking the availability of the necessary drug components (including lipid emulsion) and equipment;
• monitoring the course of local anesthetic administration or personal participation in the process when necessary;
• physical accessibility for immediate diagnosis and treatment of complications;
• providing post-anesthesiological monitoring.

Technical requirements for regional anesthesia depend on the procedure to be performed.

The choice of the most suitable anesthesia method for a particular patient is made on the basis of a medical opinion and depends on the competence of the doctors involved in the procedure. Ideally, this should be done by a professional anesthesiologist. The decision to interrupt or cancel a technically complex procedure, recognize complications and make changes in treatment strategy, which must take into account the patient's condition, the procedure required, possible risks, consent issues and the ability to provide appropriate care after the procedure, is the responsibility of the attending physician. Solving issues problems associated with regional anesthesia should ideally be managed by an anesthetist who has the competence and skills necessary to perform the procedure safely and effectively.

ASA GUIDELINES FOR INTRAVASCULAR CATHETERIZATION

Approved by ASA 10/06/13

Some patients undergoing anesthesia for various surgical procedures may requires a more precise and sophisticated level of monitoring conditions of the cardiovascular system than can be obtained using standard non-invasive methods. An arterial catheter, a central venous catheter, and/or a Swan-Ganz catheter may be required to obtain additional and more accurate information needed to provide safe and effective anesthesia and keep the patient alive during the perioperative period.

Although the position American Society of AnesthesiologyV (ASA) is that the data obtained from these invasive monitoring devices are important for anesthesia, there are several controversial issues regarding the placement of catheters. The ASA developed and continues to refine its Relative Value Guide®, which contains the latest comprehensive descriptors for all types of anesthesia services and is a comprehensive guide to pricing and health insurance issues. Installation of invasive devices for monitoring has not been taken into account in this guide. In fact, the base unit values ​​for many anesthesia codes in which invasive monitoring is currently common were created before the widespread use of invasive devices and were never subsequently changed. In addition, including additional base values ​​to account for invasive monitoring in only some anesthesia codes would make the entire relative scoring system inconsistent.

Consideration of the placement of invasive hemodynamic monitors should be considered as a separate service because not all patients undergoing the same surgical procedure require the same degree of monitoring. Need for invasive monitoring determined more by the patient's condition than by the type of surgical intervention. For example, most patients undergoing bowel surgery do not require invasive monitoring, but patients with significant blood loss during surgery or with underlying cardiovascular disease may require this type of monitoring. Likewise, most carotid endarterectomy patients require an arterial catheter, but some who are healthier than average do not have one.

Use of invasive monitoring devices:

1. Arterial catheter (CPT code 36620). Placing a small catheter (usually in the radial artery) and connecting it to electronic equipment allows continuous monitoring of the patient's blood pressure. This form of monitoring is often necessary for unstable patients undergoing surgery for intra-abdominal pathology or trauma. Patients who have undergone surgery on the heart, blood vessels, spine and brain are susceptible to frequent changes in blood pressure. Continuous monitoring greatly assists the anesthesiologist in working safely with these patients. Arterial catheters also provide a reliable way to obtain arterial blood samples, thereby facilitating proper monitoring of blood gases, blood chemistry, and bleeding disorders.
2. Central venous catheter (CPT code 36555 or 36556). Used for blood pressure control, fluid resuscitation, or drug infusion. A venous catheter allows the anesthesiologist to properly maintain and/or adjust the patient's circulating blood volume. This method is advisable to use for patients who have lost significant amounts of blood or fluid in general during surgery. Additional indications for placement of a central venous catheter are the need to provide a reliable means of rapidly administering large volumes of fluid or blood, to provide access when peripheral venous access is not available, or to administer certain medications that are most effectively and safely administered directly into the central venous circulation.
3. Swan-Ganz pulmonary artery catheter (CPT code 93503). This multichannel catheter is inserted through one of the central veins into the right ventricle of the heart, from where it migrates with the blood flow into the pulmonary artery. A pulmonary artery catheter makes it possible to monitor the functioning of the heart and vascular system. Can be used to measure cardiac output as well as other important cardiovascular parameters. The Swan-Ganz catheter is used for patients whose heart function is or may be impaired before or as a result of a surgical procedure. In addition, some pulmonary artery catheters allow temporary pacing of the heart, which may be necessary for some patients with abnormal heart rhythms.

ANESTHESIOLOGIST FATIGUE FACTOR

From health status and well-being anesthesiologist directly depends on how well he can cope with his professional responsibilities and whether he will expose his patients to unnecessary risk. An important factor in this matter is ensuring optimal performance team of anesthesiologists, which includes (but is not limited to) eliminating the effect of fatigue.

Fatigue can put you at risk How patient safety , and the health and well-being of the doctor. This is a complex issue that depends on the individual physician, the medical staff involved in patient care, and the clinic where the care is provided. Factors that contribute to the accumulation of fatigue include sleep deprivation, the severity of the patient(s), the number of patients per unit of time, working conditions in a given medical institution, personal stress, age, work organization, changes in schedule, number and duration of breaks, opportunity to eat well, etc.

Multiple competing interests typically prevent a physician suffering from fatigue from withdrawing from patient care. Likewise, these interests prevent him from questioning another clinician's ability to act appropriately when he shows signs of fatigue.

Anesthesiology teams should work within their organizational structures to develop and implement policies to combat fatigue, which can negatively impact patient safety. Taking into account the multifactorial nature of fatigue, this policy should be flexible enough to take into account the working conditions of a particular group or facility. Policies should encourage employees to report their own fatigue or suspicions of a colleague's fatigue without fear of reprisal.

Knowledge of the possible negative consequences of fatigue will help increase clinician self-awareness and effectively respond to the situation, both at the individual level and at the level of the group or organization. When developing policies to combat fatigue, it may be helpful to consult recommendations from relevant medical and non-medical sources.

ASA GUIDELINES FOR ENDOSCOPIC EXAMINATIONS

The position of the American Society of Anesthesiologists (ASA) is that “There are no circumstances in which it is acceptable for a person to experience emotional or psychological discomfort or physical pain if it can be safely avoided by medical intervention.”.

Anesthesiology is a separate discipline in medical practice. Its main task consists of assisting patients during surgical, obstetric and other medical procedures by inducing them into a state of narcotic sleep and/or reducing sensitivity to pain and emotional stress.

Therapeutic endoscopic procedures usually carried out without anesthesia . However, there are conditions that make anesthesia necessary even for minor procedures. Examples of such conditions include the presence of a number of concomitant diseases, as well as mental or psychological barriers to cooperation with a doctor. Patients with a personal history of failure with moderate sedation may also require anesthesia.

Prolonged or painful procedures may be the reason for the use of anesthesia. These include polyp biopsy or resection, endoscopic retrograde cholangiopancreatography (ERCP), various biliary tract procedures, bowel dilatation with or without the use of a stent, endoscopic resection, as well as other procedures that have the potential to cause discomfort.

Decision on necessity Anesthesia for a specific patient is determined in the medical report. In this case, all factors must be taken into account, potential risks and benefits, the wishes of the patient himself, the requirements or preferences of the doctor performing the main procedure, and the competence of the specialists involved.

ASA GUIDE TO OUTPATIENT ANESTHESIOLOGY

Developed by the Committee on Ambulatory Surgical Care. Approved by the American Society of Anesthesiologists (ASA) on October 13, 1999, and subsequently amended on October 21, 2009; the final version was approved on October 15, 2014.

This guide is intended for members of the American Society of Anesthesiologists (ASA) who provide anesthesia care in outpatient anesthesia settings (ambulatory anesthesia). These recommendations aimed at increasing quality of anesthesiological care and safety of outpatients . Compliance with these principles cannot guarantee any specific results. These rules are subject to periodic review to keep them in line with changes in federal and state laws and with developments in medical technology and practice.

ASA notes increased demand in private medical practice (primarily we are talking about private clinics providing therapeutic, dental and orthopedic services) for specialists in the field of outpatient anesthesia. Therefore, the ASA's Guidelines for Ambulatory Anesthesia and Surgery should be used in conjunction with other standards and practice guidelines.

There are special issues that ASA members must consider when using anesthesia in the outpatient setting. In contrast to acute care hospitals and licensed ambulatory surgical facilities, there is currently little federal or local government oversight or oversight of private practices. In this regard, private medical practice must carefully study issues that are taken for granted in hospitals or licensed ambulatory surgical facilities - management and organization, staffing, professional training, as well as fire safety, emergency procedures, emergency response. transfer of the patient to another medical institution, recording and monitoring the use of narcotic drugs, etc.

ASA members should be confident that everything possible is done to ensure patient safety and reduce anesthesiologist risk and liability.

Administration

Quality of service provision

• The institution must have chief physician or governing body that sets policy and is responsible for the activities of the institution and its employees. The chief physician (or governing body) is responsible for ensuring that the available equipment and the professional competence of the staff are appropriate for the type of service provided.
• The facility's policies and list of medical services provided must be documented and reviewed annually.
• The Chief Medical Officer (or governing body) must ensure compliance with all local and federal regulations.
• All medical workers (including nurses) must have a valid license or certificate to perform their assigned duties.
• All personnel involved in the provision of medical care must have the qualifications necessary to perform this type of service - the appropriate level of education, professional training and experience.
• The anesthesiologist must work continuouslyb on improving the quality of your professional training.
• The chief physician (or governing body) must know and respect the fundamental rights of his patients. The latter must have access to a written document describing this policy.

Safety

• Health care facilities must comply with all federal and local laws, regulations, and policies related to fire safety, building structural integrity, disability accessibility, occupational safety and health, and medical and hazardous waste disposal.
• Health care facilities must comply with laws and regulations regarding the use, storage and accounting of narcotic drugs.

Clinical care

Patient and choice of procedures

• The anesthesiologist must ensure that the procedure to be performed is within the scope of accepted medical practice and within the capabilities of the facility.
• The duration and degree of complexity of the procedure should allow the patient time to recover before being discharged home.
• Patients who are medically or otherwise at high risk for complications should be referred to an appropriate medical facility for the procedure.

Perioperative observation

• The anesthesiologist should adhere to the Core Standards of Preparation, the Standards of Anesthesia Monitoring, the Postoperative Surveillance Guidelines, and the Guidelines for Ambulatory Anesthesiology and Surgery as currently recommended. American Society of Anesthesiologists (ASA) .
• The anesthesiologist must be directly present in the operating room during the operation and be in a state of immediate availability until the patient fully recovers.
• Responsibility for patient discharge is borne by the attending physician (therapist). This decision must be recorded in the medical records.
• Personnel trained in life support (eg, ACLS, PALS) should be immediately available until all patients are discharged home.

Equipment and monitoring

• All facilities must have, at a minimum, a reliable source of oxygen, suction, resuscitation equipment, and emergency medications.
• The operating room must have sufficient space to accommodate all necessary equipment and personnel and provide prompt access to the patient, the anesthesia machine (if available) and all control and measuring instruments.
• All equipment must be inspected and tested in accordance with the manufacturer's specifications.
• Backup energy sources must be available to protect the patient in the event of an emergency.
• Any location where anesthesia is administered should have an appropriate anesthesia machine and equipment that can monitor the patient's condition in accordance with the ASA Standards for Anesthesia Monitoring, as well as documentation of routine preventive maintenance of the equipment in accordance with the manufacturer's recommendations.
• Health care facilities that provide anesthesia services to infants and children must have adequate anesthesia and resuscitation equipment appropriate for small patients. The requirement of compliance also applies to the medicines available here.

Emergency situations and patient transfers

• All facility personnel should be properly trained in emergency procedures and regularly tested on this subject.
• Instructions should be in place for what personnel should do in the event of serious cardiopulmonary complications of a patient's condition, as well as other internal and external emergencies such as fire.
• The health care facility should have the medications, equipment, and written instructions needed when complications arise from the use of anesthesia, such as a malignant hyperthermia crisis (fulminant form).
• The facility must have written instructions for the safe and timely transport of a patient to another health care facility if necessary to save his life and preserve his health.

ASA GUIDE TO MISTRY

The recommendations provided here regarding the use of neuraxial anesthesia in obstetrics are intended to promote improved quality of patient care and cannot guarantee any specific results. They are subject to periodic revision as justified by developments in medical technology and practice.

Standard I

Neuraxial anesthesia can only be used in areas where resuscitation equipment and medications are available to deal with related problems. Resuscitation equipment should include, but not be limited to, oxygen supplies, medical suction, equipment for airway management, tracheal intubation and positive pressure ventilation, as well as drugs and equipment for cardiopulmonary resuscitation.

Standard II

Neuraxial anesthesia must be carried out by a physician with appropriate credentials or under the medical direction of such a person. The authority to perform obstetric anesthesia procedures and manage associated complications is granted to the physician by an institutional credentialing board.

Standard III

Neuraxial anesthetics should not be administered until: 1) the patient has been examined by a qualified specialist; and 2) until an obstetrician with operative delivery privileges (vaginal or cesarean section) who has knowledge of maternal and fetal conditions is available to monitor labor and manage potential complications.

In some cases, qualified personnel can perform an initial gynecological examination. The physician responsible for the patient's obstetric care should be informed of her condition so that he can decide on a management strategy after assessing the risks.

Standard IV

The intravenous infusion should be started before the start of neuraxial anesthesia and maintained throughout the duration of the anesthetic.

Standard V

Neuraxial anesthesia during delivery requires that the mother's vital signs and fetal heart rate be monitored and documented by a qualified professional. Monitoring techniques, frequency of recording, and additional monitoring should be selected based on the clinical status of the mother and fetus and in accordance with institutional policy. When extensive neuraxial blocks are prescribed for complicated labor, basic anesthetic monitoring standards should be applied.

Standard VI

Neuraxial anesthesia , used for cesarean section, requires the application of basic anesthetic monitoring standards and the availability of a physician with obstetric privileges.

Standard VII

Qualified personnel must be available to assume responsibility for neonatal resuscitation. The main task of the anesthesiologist is to provide care for the mother. If an anesthetist is also involved in the care of the newborn, the benefit to the baby must be weighed against the risk to the mother.

Standard VIII

During neuraxial anesthesia Until the patient's post-anesthesia condition is satisfactory and stable, a physician qualified to manage anesthetic complications should be readily available.

Standard IX

All patients after neuraxial anesthesia should receive appropriate post-anesthesia care. Following cesarean section and/or major neuraxial block, basic post-anesthesia care standards should be applied.

Standard X

ASA GUIDELINES FOR POST-ANCOSTIC CARE

Data ASA standards concerning post-anesthesia observation , are intended to improve the quality of patient care, but do not guarantee any specific results. They may be exceeded based on the decision of the responsible anesthesiologist. These standards are subject to periodic review in the light of developments in medical technology and practice.

Standard I

All patients undergoing general and regional anesthesia, as well as after anesthesia during a surgical procedure, should receive appropriate postoperative care.

1. The patient undergoing anesthesia should have access to a recovery room in the intensive care unit or other location where postoperative care will be provided. An exception can only be made by order of the anesthesiologist responsible for the patient.
2. The medical aspects of care in the intensive care unit (or equivalent unit) are governed by regulations that have been reviewed and approved by the US Department of Anesthesiology.
3. The equipment of the intensive care unit and its staffing must meet the requirements of accreditation and licensing bodies.

Standard II

When transporting to the intensive care unit, the patient should be accompanied by a member of the anesthesia team who is knowledgeable about the patient's condition. During transport, the patient's condition must be constantly assessed and maintained.

Standard III

Upon arrival in the intensive care unit, the patient's condition should be reassessed. A member of the anesthesiology team who accompanied the patient during transport provides a verbal report to the head nurse of the department

1. The patient's condition upon arrival in the intensive care unit should be documented.
2. Information about the patient's preoperative condition and surgical/anesthetic procedures performed must be communicated to the head nurse of the intensive care unit.
3. A member of the anesthesiology team must remain in the intensive care unit until the unit nurse assumes responsibility for the patient's care.

Standard IV

The patient's condition should be continuously assessed in the intensive care unit

1. The patient should be continuously monitored using methods appropriate to his condition. Particular attention should be paid to monitoring oxygenation, ventilation, circulation, body temperature and level of consciousness. Quantitative methods for assessing oxygenation, such as pulse oximetry, should be used during the initial phase of patient recovery from anesthesia and until complete recovery. This rule does not apply to maternity ward patients who were given local anesthesia during vaginal delivery.
2. An accurate written record of the patient's stay in the intensive care unit should be maintained. It is recommended that a suitable scoring system be used for each patient - on admission, at regular intervals and at discharge.
3. General medical supervision and coordination of care for patients in the intensive care unit is the responsibility of the anesthesiologist.
4. It is recommended that the facility have a physician available to manage complications and provide cardiopulmonary resuscitation to patients in the intensive care unit.

Standard V

The physician is responsible for discharging the patient from the intensive care unit

1. The criteria by which a patient can be considered fit for discharge from the department must be approved by the Department of Anesthesiology and the medical staff of the hospital. These may vary depending on whether the patient is transferred to a regular hospital ward, to a short-stay hospital, or to home.
2. In the absence of the discharge physician, the ICU nurse determines that the patient meets discharge criteria. The name of the physician accepting responsibility for discharge must be recorded in the medical record.

Minimal sedation (anxiolysis)- This is a medicinal state in which the patient responds normally to voice commands. Cognitive functions and motor coordination may be impaired, but respiratory and hemodynamic parameters remain unchanged.

Moderate sedation/analgesia– depression of consciousness caused by the action of pharmacological agents, in which the patient purposefully** responds to voice commands or voice commands accompanied by mild tactile stimulation. Adequate functioning of the cardiovascular system and spontaneous breathing are maintained.

Deep sedation/analgesia- drug-induced depression of consciousness in which the patient cannot be easily awakened, but still responds purposefully** to repeated or painful stimulation. The airway may be compromised, resulting in insufficient spontaneous breathing. The functioning of the cardiovascular system, as a rule, remains normal.

General anesthesia– a condition caused by the action of pharmacological drugs, characterized by complete loss of consciousness. The patient in this state does not respond even to painful stimulation. The ability to breathe independently is often impaired. Due to respiratory depression, the patient may require artificial ventilation. The functioning of the cardiovascular system may also be impaired.

Changing the depth of sedation occurs continuously and evenly, so it is not always possible to predict the reaction of a particular patient to a particular drug. It follows that a physician planning to achieve a given level of sedation in his patient should be able to save*** him if the level of sedation becomes deeper than originally intended. For example, a physician administering moderate sedation/analgesia should be able to save*** a patient who is entering a state of deep sedation/analgesia, and one scheduling deep sedation/analgesia should be able to save*** a patient entering a state of general anesthesia .

* Anesthesia monitoring does not describe the depth of sedation, but rather “a specific anesthesia service in which an anesthesiologist is involved in the care of a patient undergoing a diagnostic or therapeutic procedure.”

*A reflex response to painful stimulation is not considered a goal-directed response.

*** A physician experienced in airway management and advanced life support can help prevent a deeper level of sedation than expected. A skilled physician is able to correct the negative physiological effects of a deeper level of sedation than originally intended (eg, hypoventilation, hypoxia, and hypotension) and return the patient to the originally planned level of sedation. Continuing the procedure at an unintended level of sedation is unacceptable.

Currently, risk assessment according to the classification of the American Association of Anesthesiologists (ASA) has become widespread, the use of which allows for a standard assessment of the risk level of anesthesiological care. In case of emergency surgical interventions, an index is added to the corresponding class « E» (emergency). This classification evaluates the physical condition of the patient, but it should be borne in mind that although there is a relationship between the risk of general anesthesia and the physical condition of the patient, they are not the same thing. The risk of general anesthesia assesses the ability of a particular patient to tolerate a specific anesthetic under specific conditions.

On an outpatient basis, general anesthesia with risk levels I and II can be performed. Starting from risk degree III, therapeutic manipulations should be carried out in a hospital setting.

In clinical practice, another classification is also used, which is based on the principle of assessing the general condition of patients, taking into account the degree emotional stress, nature and severity of concomitant diseases, age of patients. It reflects 5 degrees of risk of anesthesia (Table).

Table

Classification of the risk level of general anesthesia according to asa

Class	Definition	Mortality after anesthesia benefits (%)
	Practically healthy patients
	Patients with minor systemic pathology without dysfunction
	Patients with systemic pathology and dysfunction that can be compensated by treatment
	Patients with severe pathology that threatens life and leads to failure of functions, requiring constant use of medications
	Patients with severe diseases leading to death within 24 hours without surgical intervention

Classification of degrees of anesthetic risk during outpatient dental surgery

The following are subject to general anesthesia:

I. Healthy people aged 16 to 60 years without pronounced psycho-emotional stress.

II. Practically healthy people of all ages (including children) with an unbalanced psyche and severe psycho-emotional stress (anxiety, tendency to faint) before the intervention.

III. Patients with concomitant diseases, with minor functional and organic changes in various organs and systems of the body.

IV  . Patients with concomitant diseases in the presence of pronounced functional and organic changes in various organs and systems of the body in the compensation stage.

V.  Patients with gross organic changes in various organs and systems of the body in the stage of decompensation.

Assessing the patient’s condition should begin with a thorough, targeted history taking in order to identify concomitant general somatic diseases and clarify the characteristics of their course, the therapy used by the patient (medicines and their dosages). History taking should be standardized.

An assessment of the patient’s psychophysiological state is carried out to establish:

1) psychological status (personality type, attitude towards the upcoming intervention, fear of intervention, anxiety).

A correct assessment of the patient’s psychological status guides the doctor in the need for drug correction of the identified characteristics and, partly, in choosing the type of pain relief necessary for the patient. Fear and anxiety are determined not only by the status of the patient, but also by the personality of the doctor and the degree of trust in him;

2) general condition :

the patient's appearance (skin color). Particular attention should be paid to the color of the lips (cyanosis, anemia);

features of the oral mucosa, tongue, salivation, etc.;

metabolism (body weight, height, body temperature) taking into account physiological norms, age-related changes, and the influence of concomitant pathology;

breathing (frequency and rhythm of breathing, audible breathing sounds, cough, activity of accessory respiratory muscles), shortness of breath;

blood circulation (pulse, blood pressure, blood circulation in the capillaries - a symptom of a white spot, the presence of edema, venous congestion) taking into account the norm data, as well as changes associated with age or the presence of concomitant pathology;

the ratio of indicators of respiratory and circulatory functions is normal (the ratio of the duration of inhalation and exhalation is 1:2) and in the presence of concomitant pathology (shortness of breath, etc.).

André Gottschalk, Hugo Van Aken, Michael Zenz, Thomas Standl

Translation into Russian: M. Nasekin

The first head of the department of anesthesiology in Europe, Sir Robert Mackintosh, uttered insightful words about 60 years ago that anesthesia is always dangerous and therefore requires special training (1). A study carried out between 1948 and 1952 at 10 university hospitals confirmed the risk assessment of anesthesia in Mackintosh's time. In a study of 599,500, the anesthetic mortality rate was 64 per 100,000 procedures. In population terms, this is 3.3 per 100,000. In subsequent decades, new anesthesia techniques and monitoring options have been developed, and anesthetists receive more advanced training, so mortality has decreased. In the early 1940s, anesthetic mortality was 1 in 1000, and remained high in the 1960s (about 0.8 per 1000), with a tenfold decline to 10-30 per 100,000 in the 1970s and early 1980s. Data , obtained for the period 1965-1969, showed a strong increase in perioperative mortality in emergency patients and people with serious comorbidities.

Following the introduction of enhanced safety standards, such as pulse oximetry and capnography, further significant reductions in anesthetic mortality were observed. By the late 1980s, anesthetic mortality was 0.4 per 100,000 procedures.

Anesthesia and mortality today

According to World Health Organization (WHO) estimates based on data from 56 WHO member countries, approximately 230 million major surgical procedures are performed annually worldwide (3). In industrialized countries, the incidence of perioperative complications ranges from 3 to 16%, with 0.4 to 0.8% of anesthetic procedures resulting in severe permanent injury or death. Two studies examined the role of anesthetic mortality.

An epidemiological study was conducted in the United States of America based on ICD-10 codes (related to complications of anesthesia) and large statistical material (death certificates issued from 1999 to 2005) (4). 105.7 million surgical cases were processed and 2211 anesthesia-related deaths were identified, a rate of 8.2 per 1,000,000 hospital discharges. Of these deaths, 867 occurred in the hospital, 258 after discharge, and 349 in hospice. The remaining cases are not described in detail.

The distribution by cause of death is as follows:

• 46.6% of all cases involve overdose of drugs used for anesthesia
• 42.5% - with side effects of anesthetics administered in therapeutic doses
• 3.6% of cases are associated with pregnancy or obstetric care.

Among the remaining complications (7.3%), 1% were death due to malignant hyperthermia and 2.3% due to problematic intubation. Complications of anesthesia as the cause of death were noted only in 241 cases (2.2 per 1,000,000).

A European study published in 2006 used different methodological approaches (5). The researchers analyzed 537,459 death certificates issued since 1999. A list of codes related to anesthesia and anesthetic complications was compiled based on ICD-9. In addition, the study also included codes related to complications after surgical, gynecological and any medical procedures. Then, based on this list, an analysis of death certificates was carried out. After identifying 1,491 deaths, the researchers queried the certifiers to better understand the role of anesthesia. Among deaths that were solely attributable to anesthesia, the mortality rate was 0.69 per 100,000, and among deaths partially attributable to anesthesia, the mortality rate was 4.7 per 100,000. In addition, the results of the study showed a close relationship between mortality and the patient's age or grade. according to ASA (Table 2).

Another study, conducted in a US hospital, examined all perioperative mortality (within 24 hours after surgery) over a 10-year period (6). Of the 72,595 anesthetics, 144 resulted in cardiac arrest. The risk increased with increasing ASA score. Of these 144 episodes, 15 were classified as being caused by anesthesia, with seven patients dying. The causes of death were problems in ensuring airway patency, the effects of medications and myocardial infarction. The anesthetic mortality rate in this study was 5.5 per 100,000.

A German case-control study examined risk factors in anesthesia management that may influence postoperative 24-hour morbidity and mortality (7). A previously published study by the same authors analyzed 24-hour postoperative mortality in 869,483 patients and identified 807 deaths, 119 of which were related to the course of anesthesia (8). To identify risk factors during anesthesia, these 807 deaths were compared with another 883 cases, and the authors found a significant reduction in risk under the following conditions:

• detailed testing of equipment according to the list (correlation index [IC] 0.64)
• recording test results in documents (IC 0.61)
• another anesthesiologist in close proximity (IR 0.46)
• the anesthesiologist does not change during the operation (IR 0.44)
• constant presence of a nurse anesthetist (IR 0.41)
• two anesthesiologists during emergency anesthesia (IR 0.69)
• use of antagonists for muscle relaxants and/or opioids (IC 0.1 and 0.29).

When comparing opioid postoperative analgesia (IC 0.16), postoperative analgesia with local anesthetics (IC 0.06) or a combination of local anesthetics and opioids (IC 0.325) with a postoperative period without analgesia at all, a decrease in mortality was noted in the first case.

Thus, anesthetic mortality in patients without significant systemic diseases remains low - 0.4 per 100,000 procedures. Although there is a significant increase in the risk of death in patients with serious comorbidities (ASA III: 27 per 100,000 and ASA IV: 55 per 100,000). The overall mortality rate is 0.69 per 100,000 anesthesia events. According to data from the German Federal Statistical Office, the proportion of patients over 65 years of age among all patients admitted for surgery increased from 38.8% (4.7 million operations) in 2005 to 40.9% (5.9 million operations) in 2005. 2009 (total number of transactions in 2005: n = 12.1 million, 2009: n = 14.4 million) (www.gbe-bund.de).

In purely numerical terms, anesthetic mortality has increased again. However, the reason for this increase is not a decrease in the quality of anesthesiology services, but an increase in the proportion of patients undergoing surgery who are older or have multiple concomitant diseases.

There are several reasons:

Today, surgical interventions in such patients are quite typical; although in the past, many comorbidities often became an insurmountable obstacle.

The number of extremely invasive surgical interventions has increased, previously unimaginable

Complications of general anesthesia

The risk of aspiration during general anesthesia has remained unchanged for decades, ranging from 1 in 2000 to 1 in 3000 procedures; Pregnant women after the second trimester have a slightly greater risk, approximately 1 in 1000 (9,10). Although recent studies have shown a decrease in the incidence of aspiration in pregnant women (8). Fortunately, the mortality rate from bronchopulmonary aspiration is low and the dreaded acid-associated pneumonitis (Mendelssohn syndrome - chemical pneumonitis, massive bronchospasm, significant impairment of gas exchange, approximately 8% of all aspirations, mortality approximately 3%) is quite rare.

It appears that pressing on the cricoid cartilage, as we have been taught so far, does not prevent aspiration. not likely to prevent aspiration. Although the administration of antacids, H 2 -antagonists and proton pump blockers reduces the risk of aspiration of gastric contents with pH<2,5. Однако это не улучшает исход после аспирации (9).

Current evidence suggests that a small exception to the “nothing by mouth” rule (avoiding everything, even clean water, 2 hours before the start of anesthesia) does not increase the risk of aspiration (11).

Many patients fear intraoperative awakening: if the patient remembers events that occurred during surgery, this can lead to chronic psychological problems (10). The risk of awakening is 0.1-0.15%, it increases in young girls, as well as cardiac and obstetric patients, amounting to 0.26% (12,13). The risk of developing long-term neuropsychological disorders as a result of intraoperative awakening ranges from 10 to 33% (11). It is believed that the phenomenon of awakening is not so dangerous if it is not accompanied by pain (11). Sufficient depth of anesthesia and use of muscle relaxants may help avoid awakening.

Muscle relaxants are an independent element of anesthesiological practice. They facilitate tracheal intubation and improve the surgeon's working conditions during abdominal and endoprosthetic operations, especially in emergency surgery. Arbous et al (7) statistically estimated that the use of muscle relaxant antagonists at the end of surgery may help reduce mortality. This allows us to draw an indirect conclusion that Residual Curarization in the postoperative period negatively affects the outcome of the intervention.

The risk of postoperative pulmonary complications is associated with:

Increasing age

Increasing the duration of the operation

Operations on the abdominal organs

Using the long-release muscle relaxant pancuronium

Deep muscle relaxation (12).

Complications of regional anesthesia

In recent years, regional anesthesia has become a very important part of anesthesia. The use of regional anesthesia for intraoperative analgesia and postoperative pain relief has played a huge role since prolonged regional blockade has been proven to provide the most effective analgesia after surgery (13, 14).

But, despite this, when determining indications for regional anesthesia procedures, it is necessary to remember possible complications: nerve damage and paraplegia after central blocks, as well as infectious complications. In addition, many surgical interventions cannot be performed using only the regional component, and general anesthesia is necessary.

The most severe complication associated with central (neuraxial) blockade is permanent paraplegia. The incidence estimated from retrospective studies is 1 in 150,000 to 220,000 procedures, which is slightly lower than recent studies (15,16). A study of more than 1.7 million patients found that the risk of developing an epidural hematoma is 1 in 200,000 procedures in obstetric practice, and 1 in 3600 in orthopedic surgeries in women. The average risk is 1 in 10,300 procedures (14). Another single-site study of 14,228 epidurals found a risk of hematoma of 1 in 4,741 procedures, with epidural hematomas occurring only after lumbar puncture. Although none of the patients showed permanent neurological damage (13). A 2009 publication estimated the risk of long-term paraplegia or death from neuraxial blockade to be 0.7 to 1.8 per 100,000 procedures. Two thirds of paraplegia are transient (15). Prolonged epidural anesthesia requires constant neurological monitoring, as early diagnosis and immediate intervention (laminectomy) can prevent long-term neurological damage. A large review of 32 studies performed from 1995 to 2005 analyzed neurological complications after regional anesthesia (16). The review cited the risk of neuropathy after spinal anesthesia as 3.8 per 10,000 procedures, and for epidural anesthesia 2.19 per 10,000. Moreover, for spinal anesthesia, the risk of permanent neurological problems according to various studies ranges from 0 to 4.2 per 10,000 procedures, and for epidural anesthesia from 0 to 7.7 per 10,000.

The following risk factors for the formation of epidural hematoma were also identified:

Taking anticoagulants

Coagulopathies

Female

Age > 50 years

Orthopedic surgeries

Ankylosing spondylitis

Kidney failure

Large number of punctures and catheter movements (17).

To reduce the risk of epidural hematoma formation, it is recommended to adhere to strict anticoagulant guidelines in regional anesthesia practice (18).

Transient neurological deficit after peripheral nerve blocks occurs in 2.84 cases per 100 procedures (interscalene block), 1.48 per 100 (axillary block) and 0.34 per 100 (femoral nerve block) (16). In 16 studies examining neurological complications after peripheral blocks, only one case of permanent neuropathy was reported.

Infectious complications are another risk inherent in prolonged catheter-based regional anesthesia techniques. Severity ranges from mild local infection to epidural abscess. The German Society for Safe Regional Anesthesia, formed by the German Society of Anesthesiologists and Resuscitators, as well as the German Professional Association of Anesthesiologists, based on uniform standardized documentation, calculated the risk of infectious complications of catheter techniques. A total of 8,781 catheter procedures (22,112 catheter days) were studied (19). Of these, 5057 are neuraxial techniques and 3724 are peripheral catheter techniques. A total of 4 severe, 15 moderate and 128 mild infectious complications were registered. Neuraxial techniques were found to be associated with a higher risk of infection compared to peripheral techniques (2.7% vs 1.3%).

In addition, risk factors are:

Multiple skin punctures instead of one (4.1% vs 1.6%)

Length of time the catheter is in place

Poor general condition of the patient.

Perioperative antibiotic use or diabetes mellitus were not associated with an increased incidence of infectious complications.

Anesthesia and outcome

Although we have shown that anesthetic mortality is still very low, a study of 1064 patients showed that overall perioperative mortality during the first year is very high (20). Researchers have found that 5.5% of patients die within the first year after surgery performed under general anesthesia, and among patients over 65 years of age, the percentage rises to 10.3%. Death within the first year after surgery is in most cases associated with existing concomitant diseases, but joint deep anesthesia and low intraoperative systolic pressure (less than 80 mmHg) are independent factors that significantly increase mortality. Already in 2003, the development of the concept of “conveyor” surgery (fast-track surgery) drew attention to the fact that anesthesia plays a significant role in the postoperative recovery of the patient (21).

Anesthetic measures that can reduce the intensity of postoperative treatment are:

Normothermia during surgery

Adequate fluid therapy

Analgesia

Reducing post-traumatic stress factors

Early mobilization

Reduction of postoperative intestinal paresis

Reduced postoperative nausea and vomiting

All of these goals can be achieved using thoracic epidural anesthesia as part of general anesthesia. A retrospective analysis of 12,817 patients (Medicare) showed that this approach significantly reduces morbidity and mortality after colectomy. Without epidural anesthesia, the 7-day mortality rate was 26.79 per 1000 operations, and with the introduction of an epidural component in the anesthesia - only 9.3 per 1000 (IC 0.35, confidence interval 0.21-0.59) (22).

Ways to increase the safety of anesthesia

Hardman and Moppett, in their article “To err is human,” wrote: “Errors are an inevitable part of anesthesia. An anesthesiologist is a person, and humans make mistakes” (17). This is why, despite the continued decline in anesthetic mortality, there is still a need to improve patient safety during anesthesia. The adoption of the Helsinki Declaration of Patient Safety in Anesthesiology by the European Board of Anaesthesiology and the European Society of Anesthesiology is only one step in the right direction (23). This declaration obliges all medical centers that provide anesthesia care to take prescribed measures to improve patient safety during anesthesia.

One of the main points of development is the optimization of the education and training of anesthesiologists (18). Moreover, they should include not only the development of individual specialized skills, but also the simulation of full-fledged clinical situations (19,20). In addition, we consider it necessary to remind our readers of the minimum requirements established by the German Federal Court, for example, they established that anesthesia must be performed by an anesthesiologist, i.e. a specialist who has undergone special training. It is acceptable for anesthesia to be performed by a doctor of another specialty if there is no other option, and the anesthesiologist is available, albeit at the level of verbal contact (24).

Conclusion

In recent years, optimization of perioperative processes, in which anesthesiology plays a key role, has become an extremely important task. Recent studies have shown that anesthesia can have a significant impact on outcomes. Anesthesia may also have significant effects on the immune system (25). Further studies, especially prospective studies with larger numbers of participants, are needed to establish this role more fully.

In addition, we can state that anesthetic mortality in patients without serious comorbidities remains very low. However, now the increase in the number of older patients undergoing surgery and patients with severe comorbidities in whom surgery was previously considered unthinkable, as well as the performance of new types of operations that were impossible in the past, has led to an increase in anesthetic mortality in numerical terms.

Bibliography

Macintosh RR: Deaths under anaesthetics. Br J Anaesth 1949; 21:107-36.

Eichhorn JH: Prevention of intraoperative anesthesia accidents and related severe injury through safety monitoring. Anesthesiology. 1989; 70: 572-7.

Weiser TG, Regenbogen SE, Thompson KD, et al.: An estimation of the global volume of surgery: a modeling strategy based on available data. Lancet 2008; 372: 139-44.

Li G, Warner M, Lang BH, Huang L, Sun LS: Epidemiology of anesthesia-related mortality in the United States, 1999-2005. Anesthesiology 2009; 110: 759-65.

Lienhart A, Auroy Y, Pequignot F, et al.: Survey of anesthesia-related mortality in France. Anesthesiology 2006; 105: 1087-97.

Newland MC, Ellis SJ, Lydiatt CA, et al.: Anesthetic-related cardiac arrest and its mortality: a report covering 72,959 anesthetics over 10 years from a US teaching hospital. Anesthesiology 2002; 97:108-15.

Arbous MS, Meursing AE, van Kleef JW, et al.: Impact of anesthesia management characteristics on severe morbidity and mortality. Anesthesiology 2005; 102: 257-68; quiz 491-2.

McDonnell NJ, Paech MJ, Clavisi OM, Scott KL: Difficult and failed intubation in obstetric anaesthesia: an observational study of airway management and complications associated with general anaesthesia for caesarean section. Int J Obstet Anesth 2008; 17: 292-7.

Paranjothy S, Griffiths JD, Gyte GM: Interventions at caesarean section for reducing the risk of aspiration pneumonitis. Cochrane Database Syst Rev. 2010: Jan 20; (1): CD004943.

Ghoneim MM, Block RI, Haffarnan M, Mathews MJ: Awareness during anesthesia: risk factors, causes and sequelae: a review of reported cases in the literature. Anesth Analg 2009; 108: 527-35.

Bischoff P, Rundshagen I: Awareness during general anesthesia. Dtsch Arztebl Int 2011; 108(1-2): 1-7.

Berg H, Roed J, Viby-Mogensen J, et al.: Residual neuromuscular block is a risk factor for postoperative pulmonary complications. A prospective, randomized, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium. Acta Anaesthesiol Scand. 1997; 41: 1095-103.

Popping DM, Zahn PK, Van Aken HK, Dasch B, Boche R, Pogatzki-Zahn EM: Effectiveness and safety of postoperative pain management: a survey of 18,925 consecutive patients between 1998 and 2006 (2nd revision): a database analysis of prospectively raised data. Br J Anaesth 2008; 101:832-40.

Moen V, Dahlgren N, Irestedt L: Severe neurological complications after central neuraxial blockades in Sweden 1990-1999. Anesthesiology 2004; 101: 950-9.

Cook TM, Counsell D, Wildsmith JA: Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth 2009; 102: 179-90.

Brull R, McCartney CJ, Chan VW, El-Beheiry H: Neurological complications after regional anesthesia: contemporary estimates of risk. Anesth Analg 2007; 104:965-74.

Pogatzki-Zahn EM, Wenk M, Wassmann H, Heindel WL, Van Aken H: Complications of regional anesthesia: diagnostic and management. Anasthesiol Intensivmed Notfallmed Schmerzther 2007; 42: 42-52.

Gogarten W, Vandermeulen E, Van Aken H, Kozek S, Llau J, Samama C: Regional Anesthesia and Antithrombotic/Antiplatelet Drugs Recommendations of the European Society of Anaesthesiology. Eur J Anaesthesiol 2010; 12: 999-1015.

Volk T, Engelhardt L, Spies C, et al.: Incidence of infection from catheter procedures for regional anesthesia: first results from the network of DGAI and BDA. Anaesthesist 2009; 58: 1107-12.

Monk TG, Saini V, Weldon BC, Sigl JC: Anesthetic management and one-year mortality after noncardiac surgery. Anesth Analg 2005; 100: 4-10.

Kehlet H, Dahl JB: Anaesthesia, surgery, and challenges in post-operative recovery. Lancet 2003; 362:1921-8.

Wu CL, Rowlingson AJ, Herbert R, Richman JM, Andrews RA, Fleisher LA: Correlation of postoperative epidural analgesia on morbidity and mortality after colectomy in Medicare patients. J Clinical Anesthesia 2006; 18: 594-9.

Mellin-Olsen J, Staender S, Whitaker DK, Smith AF: The Helsinki Declaration on Patient Safety in Anesthesiology. Eur J Anaesthesiol 2010; 27: 592-7.

Münsteraner Erklärung: Gemeinsame Stellungnahme des BDA und der DGAI zur Parallelnarkose. Anaesth Intensivmed 2005; 46: 32-4.

Gottschalk A, Sharma S, Ford J, Durieux ME, Tiouririne M: Review article: the role of the perioperative period in recurrence after cancer surgery. Anesth Analg 2010; 110: 1636-43.

Please enable JavaScript to view the

The most widely known and used classification of preoperative physical status is the American Society of America (ASA) classification. Although its correlations with perioperative risk have some limitations, it provides a general assessment and its use is widely advocated.

As would be expected, as the ASA anesthesia risk score increases, postoperative mortality and complication rates increase. The feasibility of extensive surgical intervention in patients with an ASA score of 4 requires an objective assessment of the degree of risk and the planned effect, since in such patients surgical interventions are accompanied by a particularly high risk of complications and mortality.

Preoperative testing aims to predict the outcome of a specific surgical procedure given specific measurable preoperative and operative parameters in order to improve patient selection. Many attempts have been made to improve the reliability and sensitivity of preoperative risk assessment; the ASA risk score is considered one of the best.

All researchers agree that concomitant diseases, a large volume of abdominal or thoracic surgery, as well as the age of patients carry a risk of increased postoperative mortality and complication rates, increasing the anesthetic risk according to ASA.

What is assessed to determine ASA risk?

By carefully examining the patient's condition, it is possible to quantify the perioperative risk. Already during the collection of anamnesis, it is necessary to identify diseases that can affect the perioperative period. Patients undergoing major elective surgery of the upper gastrointestinal tract and in whom the functions of at least one organ system are impaired are at a relatively higher risk of postoperative complications and mortality. It has been established that patients requiring esophagectomy are more likely to have disorders of the cardiac and respiratory systems. Coronary heart disease, poorly controlled hypertension, and pulmonary dysfunction are associated with an increased incidence of postoperative complications.

During the initial history and physical examination to assess ASA risk, special attention should be paid to identifying heart disease, in particular congestive heart failure and clinically significant. The patient should be asked if he has pain in the chest or upper extremities, palpitations, shortness of breath on exertion, nocturnal paroxysmal shortness of breath, syncope, fainting, intermittent claudication, cough, wheezing, and sputum production. If concomitant diseases are identified, it is necessary to establish the degree of their severity, the stability of the course and the effectiveness of the treatment currently being carried out.

When assessing ASA risk, it is necessary to quantify the patient's tolerance to exercise. All patients are advised to monitor blood pressure, regular physical examinations of the cardiovascular and respiratory systems to identify signs of cardiomegaly, dilatation of the jugular veins, ventricular failure, pathological changes in heart sounds and cardiac murmurs, inadequacy of respiratory excursions of the chest and inhalation. You should also pay attention to such signs of vertebrobasilar insufficiency as dizziness, transient episodes of ischemia and murmurs over the carotid arteries.

Previous thoracic surgery may prevent collapse of the lung on the side of the operation during thoracotomy due to pleural adhesions. In addition, in a patient who has previously undergone lung resection on the side opposite the planned operation, the possibility of one-lung ventilation is excluded, which limits the possibilities. The same obstacle to one-lung ventilation can be a history of occupational or inflammatory lung disease.

Various systemic diseases can reduce perioperative cardiorespiratory reserves and increase ASA risk. During the examination, it is necessary to pay attention to symptoms of impaired renal and liver function, to exclude endocrine pathology, especially dysfunction of the thyroid gland and diabetes mellitus. It is necessary to pay attention to the presence of thromboembolic complications in the anamnesis.

Some diseases of the nervous and musculoskeletal systems can affect the perioperative course and ASA risk, especially when respiratory function and ventilatory reserves are compromised as a result of thoracotomy. In patients with ankylosing spondylitis, separate intubation can be very difficult. Such patients require especially careful examination. Neurological disease, spinal disease or injury, and clinically significant disease in the back require special attention if perioperative epidural anesthesia is planned.

POSSUM Risk Score

In an attempt to refine the ASA risk score and improve the reliability of predicting surgical outcomes, Copeland proposed the Physiological and Surgical Severity Score for Quantifying Mortality and Complications (POSSUM). The POSSUM scale combines an assessment of physiological status in points with an assessment of the severity of surgical intervention in points to determine the risk of mortality and the incidence of complications. This scale takes into account signs, symptoms and examination findings of the cardiac and respiratory systems, biochemical, hematological and operative factors. The severity of the operation is determined based on the technical complexity of the surgical procedure, the expected blood loss and the presence or absence of malignant disease.

The advantage of such a system is that it takes into account the values ​​of both the physiological parameters of the patient and the volume of surgical intervention to predict the outcome of the latter. Due to the overestimation of postoperative mortality, a modification of this system was proposed - P-POSSUM. It is not surprising that POSSUM, like most scoring systems, correctly identifies the patient's pre-existing conditions as the main determinants of surgical outcome. In patients undergoing surgery on the upper gastrointestinal tract, concomitant diseases of the vascular and respiratory systems have the greatest impact on the outcome of the operation.

To improve mortality prediction, an attempt was made to develop a specific composite scoring system based on objective preoperative physiological parameters. The authors claim that by taking into account the patient's general condition, tumor stage, and selected measured parameters of lung, liver, kidney, heart, and endocrine function, they have developed a system for improving patient selection. Three preoperative parameters correlated best with postoperative mortality: cardiac dysfunction; a decrease in the vital capacity of the lungs compared to the proper one in combination with a reduced oxygen tension in the arterial blood (paO2); cirrhosis of the liver.

In addition, it is important to clarify the details of previous anesthetic treatments, if any. There may have been difficulties with tracheal intubation, reactions, perioperative cardiovascular instability, or bronchospasm.

A family history of malignant hyperthermia and pseudocholinesterase deficiency, although extremely rare, must be excluded. Malignant hyperthermia is associated with significant mortality, requiring special precautions during anesthesia. In those rare cases when a patient is diagnosed with both of these conditions, the anesthesiological team must be involved in the examination and preparation of the patient at the earliest stages.

The article was prepared and edited by: surgeon