Procedure for Intra-Operative Monitoring, Post-Anesthesia Status, and Documentation

1. Purpose

The purpose of this document is to outline the procedure for intra-operative monitoring, post-
anesthesia status, and documentation during anesthesia administration in order to ensure patient
safety, effective anesthetic management, and accurate clinical records throughout the perioperative
period.

2. Scope

This procedure applies to all patients undergoing anesthesia in the operating theatre (OT), including
those receiving general anesthesia, regional anesthesia, local anesthesia, or sedation. The procedure
is intended for use by anesthesia providers (e.g., anesthesiologists, anesthesia nurses, anesthesia
technicians) and surgical teams involved in the patient's care.

3. Intra-Operative Monitoring Procedure

3.1. Monitoring Parameters

Intra-operative monitoring ensures that vital signs and other clinical indicators are closely observed
to detect potential complications early. The following parameters must be monitored and
documented continuously during the anesthesia period:

1. Vital Signs:

o Heart Rate: Continuous monitoring, documenting every minute.

o Blood Pressure: Continuous or frequent measurement (every 5 minutes) using non-

invasive or invasive methods (e.g., arterial line).

o Oxygen Saturation (SpO2): Continuous monitoring via pulse oximetry.

o End-Tidal Carbon Dioxide (ETCO2): Continuous measurement to assess ventilation

and anesthetic depth, especially with general anesthesia.

o Temperature: Core temperature monitoring, especially in lengthy procedures or if

the patient is at risk for hypothermia.

2. Airway and Respiratory Monitoring:

o Airway Management: Continuous assessment for airway patency (e.g., use of

endotracheal tubes, laryngeal mask airway, or other devices).

o Ventilation: Monitor ventilation parameters (e.g., tidal volume, respiratory rate) and
adequacy of ventilation.

o Arterial Blood Gases (ABG): If indicated, monitor arterial blood gases to assess
oxygenation, ventilation, and acid-base balance.

3. Cardiac Monitoring:
 o Electrocardiogram (ECG): Continuous monitoring to detect arrhythmias, ischemia, or
other cardiac abnormalities.

o Hemodynamic Monitoring: Use of invasive monitoring (e.g., arterial line, central

venous pressure [CVP]) if required based on the patient’s condition and the surgery
type.

o Oxygenation: Continuous pulse oximetry to ensure adequate oxygen saturation

levels (typically > 95%).

4. Neurological Monitoring (if applicable):

o Bispectral Index (BIS) Monitoring: If used, to monitor depth of anesthesia and avoid
over-sedation.

o Motor Evoked Potentials (MEPs) or Somatosensory Evoked Potentials (SSEPs): In

high-risk neurosurgeries to monitor neurological function.

5. Blood Loss and Fluid Management:

o Intraoperative Blood Loss: Document estimated blood loss (EBL) regularly,

particularly for high-risk procedures.

o Fluid Management: Document the type and volume of fluids administered (e.g.,
crystalloids, colloids, blood products).

6. Medications and Anesthetic Agents:

o Anesthetic Agents: Document the doses and types of anesthetic drugs used,
including induction agents, maintenance agents, and muscle relaxants.

o Adjunct Medications: Record the use of other drugs, including analgesics,

antiemetics, or vasopressors.

3.2. Emergency Monitoring and Alerts

 Be prepared for emergency situations such as malignant hyperthermia, anaphylaxis, or

cardiac arrest.

 Malignant Hyperthermia: Continuous temperature monitoring for early detection.

Immediate access to dantrolene and the hyperthermia protocol.

 Anaphylaxis: Continuous monitoring for signs of allergic reactions. Immediate access to

epinephrine, antihistamines, and other emergency treatments.

 Cardiac Arrest: Continuous ECG monitoring to detect arrhythmias, and preparation for
immediate resuscitation measures.

4. Post-Anesthesia Status

After the surgical procedure is completed, the patient will be transferred to the recovery room (post-
anesthesia care unit, PACU) for post-anesthesia monitoring and management. The post-anesthesia
status includes the following:

4.1. Initial Recovery Phase

 1. Airway and Respiratory Status:

o Airway Patency: Ensure the airway is open, and the patient is adequately ventilating
(e.g., monitor respiratory rate, SpO2).

o Oxygen Therapy: Administer supplemental oxygen as needed to maintain oxygen

saturation above 94-95%.

o Ventilation Assistance: If needed, assist with ventilation using bag-valve-mask (BVM)

or reintubation.

2. Circulatory and Hemodynamic Status:

o Vital Signs: Measure and record heart rate, blood pressure, and oxygen saturation at
regular intervals (e.g., every 5-15 minutes).

o Fluid Balance: Monitor fluid intake and output, and administer fluids if necessary to
maintain adequate perfusion and blood pressure.

o Pain Management: Assess pain levels and administer analgesics (e.g., opioids,
NSAIDs, or local anesthesia) as appropriate.

3. Neurological and Sensory Status:

o Consciousness Level: Monitor the patient’s level of consciousness using a

standardized scale (e.g., Glasgow Coma Scale).

o Pupillary Reaction: Assess for proper pupillary response to light.

o Postoperative Nausea and Vomiting (PONV): Monitor for nausea or vomiting and
administer antiemetics as required.

4. Postoperative Nausea and Vomiting (PONV):

o Monitor the patient for symptoms of nausea or vomiting after emergence from
anesthesia.

o Administer antiemetic medications (e.g., ondansetron, dexamethasone) as needed.

4.2. Discharge Criteria from PACU

 Stable Vital Signs: Ensure that the patient’s heart rate, blood pressure, and oxygen
saturation are stable and within acceptable limits.

 Adequate Respiratory Function: Ensure that the patient is breathing adequately and does
not require supplemental oxygen.

 Pain Control: Ensure that the patient’s pain is well-managed and within acceptable limits.

 Consciousness: The patient should be alert and responsive to verbal commands or stimuli.

 No Significant Complications: The patient should not exhibit any signs of anesthesia
complications such as respiratory depression, excessive bleeding, or cardiovascular
instability.

4.3. Hand-off Communication

  Communicate the patient’s status clearly during transfer to the recovery room staff.

 Provide a detailed report of intraoperative events, anesthesia management, and any

complications or concerns for postoperative care.

5. Documentation of Intraoperative and Post-Anesthesia Care

5.1. Intraoperative Documentation

The following information should be documented during the intraoperative period:

 Patient Information: Name, age, ASA classification, surgical procedure, and anesthetic plan.

 Induction: Time of induction, drugs used, and any issues encountered during intubation or
airway management.

 Intraoperative Monitoring: Continuous documentation of vital signs, airway status,

anesthesia drugs administered, and any significant intraoperative events (e.g., blood loss,
complications).

 Emergency Interventions: Document any emergencies or adverse events and how they were
managed.

 End of Surgery: Document the time the procedure ended, the patient’s condition at the end
of surgery, and any immediate postoperative interventions.

5.2. Post-Anesthesia Documentation

Post-anesthesia documentation should include:

 Postoperative Assessment: Record the patient’s vital signs, consciousness level, and pain
level at regular intervals after surgery.

 Complications: Document any complications observed during recovery, such as

nausea/vomiting, respiratory issues, or excessive bleeding.

 Pain Management: Document analgesics administered, including the dose and time.

 Discharge Criteria: Document when the patient meets the discharge criteria and is
transferred from the PACU to the inpatient or outpatient ward.

6. Review and Follow-up

 Ensure that all intraoperative and post-anesthesia monitoring data are thoroughly reviewed
by the anesthesia team before patient discharge from the PACU.

 Post-operative Follow-up: Monitor the patient for any delayed anesthesia complications or
symptoms that may arise in the postoperative period (e.g., respiratory depression, pain
control, nausea).

 Regular audits should be performed to ensure adherence to protocols and continuous

improvement in the anesthesia care process.
7. Conclusion

Intraoperative monitoring and documentation, along with post-anesthesia status assessment, are
critical components of safe anesthesia management. Accurate and continuous monitoring during
surgery ensures the timely detection of complications, while thorough documentation supports
effective communication and improves patient care outcomes. Post-anesthesia care and the timely
documentation of recovery milestones are essential for identifying any emerging complications and
ensuring patient safety in the recovery process.