Are Daily Anesthesia Machine Checks Needed?

August 31, 2020 / By Denise E. Smith, RN, MS, CLNC, HACP, Senior Consultant

To provide safe and reliable anesthesia to all patients undergoing surgery it is important to make sure that
the anesthesia machine used is working properly. Anesthesia outcome claims have decreased over the
past two decades to less than 1% of claims according to the American Society of Anesthesiology
(ASAHQ), with the most recent data publicized by ASAHQ which states: “While the overall mortality rate
held steady between 2010 and 2013 at .03 percent, or 3 deaths per 10,000 surgeries or procedures
involving anesthesia, the percentage of adverse events related to anesthesia decreased from 11.8 percent
to 4.8 percent of procedures during that time period. The most common minor complication was
postoperative nausea and vomiting (35.53 percent), while the most common major complication was
medication error (11.71 percent).” Thus, demonstrating that performing anesthesia machine checks daily
and before each procedure had virtually eliminated machine events.

In 1987 the anesthesia professionals proposed to the FDA an anesthesia checklist as the manufacturer’s
operating manuals were too extensive and cumbersome. This checklist was accepted by the FDA and
revised in 1993. In 1993 a pre-anesthesia checklist was developed with the intent to prevent patient injury
or near misses. Prior outcomes in claims from 1990 to 2011 (n = 40) were less severe, with a greater
proportion of awareness (n = 9, 23%) and pneumothorax (n = 7, 18%). The majority, eighty-five percent
(85%), of claims involved provider error with (n = 7) or without (n = 27) equipment failure. Thirty-five
percent of claims were judged as preventable by pre-anesthesia machine check.

Over the years the use of the Pre-Anesthesia Checklist has been associated with a decreased risk of
severe postoperative morbidity and mortality. Though anesthesia machines have evolved with the
availability of new technology, this checklist, updated in 2008, is still recommended today. This checklist
recommends that 15 separate items be checked or verified at the beginning of each day, or whenever a
machine is moved, serviced, or the vaporizers changed (Table 1). Eight of these items should be checked
prior to each procedure (Table 2). Some of these steps may be part of an automated checkout process on
many machines. Following these checklists will typically require <5 minutes at the beginning of the day,
and <2 minutes between cases, but will provide you with the confidence that the machine will be able to
provide all essential life support functions before you begin a case. (Feldman, 2008)

The checklist specifies what should be checked prior to administering anesthesia, and includes the
following:

Reliable delivery of oxygen at any appropriate concentration up to 100%.

Reliable means of positive pressure ventilation.
Backup ventilation equipment available and functioning.
Controlled release of positive pressure in the breathing circuit.
Anesthesia vapor delivery (if intended as part of the anesthetic plan).
Adequate suction.
Means to conform to standards for patient monitoring.

It is important that each facility develop a pre-anesthesia checklist and that all anesthesia providers utilize
the checklist as a means of preventing adverse events related to anesthesia administration. Below is a
sample pre-anesthesia checklist that can be utilized by anesthesia providers.

TABLE 1 – DAILY PRE-ANESTHESIA CHECKLIST

Recommended Essential Steps in a Pre-Anesthesia Checkout Procedure

COMPLETE DAILY AND AFTER A MACHINE IS MOVED OR VAPORIZERS CHANGED

Item Task Responsible Party Completed Y/N

Verify Auxiliary Oxygen Cylinder and Manual

1 Ventilation Device (Ambu Bag) are Available & Provider and Tech
Functioning.

2 Verify patient suction is adequate to clear airway Provider and Tech

Turn on anesthesia delivery system and confirm

3 Provider and Tech
that ac power is available.

Verify availability of required monitors, including

4 Provider and Tech
alarms.

Verify that pressure is adequate on the spare

5 oxygen cylinder mounted on the anesthesia Provider and Tech
machine.

6 Verify that the piped gas pressures are ≥ 50 psig. Provider and Tech

Verify that vaporizers are adequately filled and, if

7 Provider and Tech
applicable, that the filler ports are tightly closed.

Verify that there are no leaks in the gas supply

8 lines between the flowmeters and the common gas Provider and Tech
outlet.

9 Test scavenging system function. Provider and Tech

Calibrate, or verify calibration of, the oxygen

10 Provider and Tech
monitor and check the low oxygen alarm.

Verify carbon dioxide absorbent is fresh and not

11 Provider and Tech
exhausted.

Perform breathing system pressure and leak

12 Provider and Tech
testing.

Verify that gas flows properly through the

13 breathing circuit during both inspiration and Provider and Tech
exhalation.

14 Document completion of checkout procedures. Provider or Tech

TABLE 2 – PRE-ANESTHESIA CHECKLIST FOR EACH PROCEDURE

Recommended Essential Steps in a Pre-Anesthesia Checkout Procedure

TO BE COMPLETED PRIOR TO EACH PROCEDURE

ITEMS IN THE DAILY CHECKLIST TO BE COMPLETED BETWEEN CASES

Item Task Responsible Party Completed Y/N

Verify patient suction is adequate to clear the

2 Provider or Tech
airway.
 Verify availability of required monitors, including
4 Provider or Tech
alarms.

Verify that vaporizers are adequately filled and if

7 Provider
applicable that the filler ports are tightly closed.

11 Verify carbon dioxide absorbent is not exhausted. Provider or Tech

12 Breathing system pressure and leak testing. Provider or Tech

Verify that gas flows properly through the

13 breathing circuit during both inspiration and Provider or Tech
exhalation.

14 Document completion of checkout procedures. Provider or Tech

Confirm ventilator settings and evaluate

15 readiness to deliver anesthesia care. Provider
(ANESTHESIA TIME OUT)

References:

Patient Injuries from Anesthesia Gas Delivery Equipment: A Closed Claims Update

Sonya P. Mehta, M.D., M.H.S.; James B. Eisenkraft, M.D.; Karen L. Posner, Ph.D.; Karen B. Domino, M.D.,
M.P.H., Anesthesiology 10 2013, Vol.119, 788-795. doi:https://doi.org/10.1097/ALN.0b013e3182a10b5e

New Guidelines Available for Pre-Anesthesia Checkout, Jeffrey M. Feldman, MD, MSE; Michael A.
Olympio, MD; Donald Martin, MD; Adam Striker, MD (Anesthesia Patient Safety Foundation Newsletter,
Spring 2008)

OSHA Website: https://www.osha.gov/dts/osta/anestheticgases/index.html#Appendix2