While chatting with the patient about to undergo a laparoscopic cholecystectomy, you administer an induction dose of propofol and an intubating dose of a muscle relaxant. The patient loses consciousness and spontaneous respiration ceases. You adjust the mask on the patient’s face to establish a secure fit and squeeze the reservoir bag, only to find that you are unable to deliver a positive pressure breath. A quick visual inspection of the breathing circuit does not reveal the cause of the problem. Are you confident in your ability to ventilate this patient before she becomes hypoxic? Is an alternative method of ventilation readily available and functioning? Is there a reliable source of oxygen? Furthermore, you are using a relatively new anesthesia machine that performs an automated checkout procedure. What functions of the anesthesia machine did the automated checkout actually evaluate? Did you perform a thorough check of the machine before use that should have detected the source of this problem?

ailure to check anesthesia equipment prior to use can lead to patient injury or “near misses.”¹ Checking equipment also has been associated with a decreased risk of severe postoperative morbidity and mortality.² Indeed a preuse anesthesia apparatus checkout recommendation (AACR) was developed many years ago and was widely accepted to be an important step in the process of preparing to deliver anesthesia care.³ Despite the accepted importance of the AACR, available evidence suggests that the current version is not well-understood and not reliably utilized by anesthesia providers.^4,5 Furthermore, anesthesia delivery systems have evolved to the point that one checkout procedure is not broadly applicable to all anesthesia delivery systems currently on the market. For these reasons, a new approach to the preuse AACR is being developed. The primary goal of this effort is to develop an approach that is applicable to all anesthesia delivery systems and will be reliably performed.

The effort to revise the AACR was initiated by the Committee on Equipment and Facilities at the ASA 2003 Annual Meeting. A task force was established consisting of representatives from major anesthesia delivery system manufacturers, American Association of Nurse Anesthetists, the American Society of Anesthesia Technologists and Technicians, the anesthesia technician organization and ASA.* The task force met for the first time at the ASA 2004 Annual Meeting but has been working continuously via e-mail since 2003.
Early on in the process, the task force recognized that a single checkout recommendation would not be applicable to all modern anesthesia delivery systems. Not only are there different designs, but some of the systems automate only a portion of the checkout process. As a result, the task force is developing a guideline describing the items that should be checked prior to use rather than an actual checklist procedure. The actual checklist one would use will be based upon the guideline but tailored to the equipment and resources available at a specific anesthetizing location. Once the guideline is established, the task force members intend to develop actual checklists, evaluate them in different departments and, ultimately, make the updated checklists available for reference.

The task force also recognized that complexity is an obstacle to completing the checkout procedure. Much debate has ensued to differentiate the items that must be checked by the clinician from those items that could be checked by appropriately trained anesthesia technicians or clinical engineers. Departments that benefit from skilled technician and engineering support may be able to develop checkout procedures that utilize these individuals, thereby reducing the burden on the clinician and increasing compliance with checkout procedures. Certain critical steps in the checkout process will benefit from being checked by more than one individual to reduce the likelihood that human error will fail to recognize an important equipment fault.

Once checkout procedures are developed, it is essential that clinicians be trained to utilize these procedures effectively. This is especially true when a new anesthesia delivery system design is put into service. New designs have significant differences from legacy systems. For that reason, the members of the task force have been very involved with the process of developing the new guideline along with effective training programs.

A number of resources have been utilized by the task force in the process of developing the checkout guideline. Literature on the existing guideline, information from manufacturers and checkout recommendations from other countries have all proven useful. In the past year, a Web-based survey tool has been developed to assess experience with the current AACR. Preliminary results indicate that 29 percent of responders rated their understanding of the existing checklist as poor. Only 20 percent indicated that they perform the preuse check before every case, with the majority (52 percent) performing a preuse check for the first case of the day only.

ASA members are encouraged to take a few minutes to complete the survey anonymously at the University of Florida’s Virtual Anesthesia Machine Web site <vam.anest.ufl.edu/logincheck.html>. To access the survey, you need to register as a Virtual Anesthesia Machine user, which is free. After completion of the anonymous survey, you will be provided access to preview a free Web simulation of the 1993 Food and Drug Administration Anesthesia Apparatus Checkout Recommendations, whose development is funded by the Anesthesia Patient Safety Foundation. The information from the survey is proving invaluable to the process of developing the next checkout recommendation.

The members of the task force will meet at the upcoming ASA Annual Meeting in Atlanta. The goals of that meeting are to complete a draft of the checkout guideline, review recommendations for a departmental policy on equipment checkout procedures and discuss with manufacturers the process of training clinicians to perform an adequate checkout. In the upcoming year, we hope to publish the checkout guideline for wider commentary and to develop and test checkout procedures on a variety of equipment in different departments. Final recommendations from the task force are expected by the 2006 ASA Annual Meeting.

Jeffrey M. Feldman, M.D., is Associate Professor of Clinical Anesthesia, University of Pennsylvania School of Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania. He is President of the Society for Technology in Anesthesia.