Guidelines to the Practice of Anesthesia - 2008

Appendix III: Pre-anesthetic Checklist

A. Gas pipelines

[ ] Secure connections between terminal units (outlets) and anesthetic machine

B. Anesthetic machine

1. [ ] Turn on machine master switch and all other necessary electrical equipment [ ] Line oxygen (40-60 psi or 275-415 KPa)
   [ ] Line nitrous oxide (40-60 psi or 275-415 KPa)
   [ ] Adequate reserve cylinder oxygen pressure
   [ ] Adequate reserve cylinder nitrous oxide content
   [ ] Check for leaks and turn off cylinders
   [ ] Flow meter function of oxygen and nitrous oxide over the working range
   
2. [ ] Vaporizer filled
   [ ] Filling ports pin-indexed and closed
   [ ] Ensure "on/off" function and turn off
   
3. [ ] Functioning oxygen bypass (flush)
4. [ ] Functioning oxygen fail-safe device
5. [ ] Oxygen analyzer calibrated and turned on functioning mixer (where available)
   [ ] Attempt to create a hypoxic O2/N2O mixture and verify correct changes in flow and/or alarm
   
6. [ ] Functioning common fresh gas outlet
7. [ ] Ventilator function verified
8. [ ] Backup ventilation equipment available and functioning

If an anesthesiologist uses the same machine in successive cases, departmental policy may permit performing an abbreviated checklist between cases.

C. Breathing circuit

1. [ ] Correct assembly of circuit to be used
2. [ ] Patient circuit connected to common fresh gas outlet
3. [ ] Oxygen flow meter turned on
4. [ ] Check for exit of fresh gas at face mask
   [ ] Pressurize. Check for leaks, and integrity of circuit (eg, Pethick test for co-axial)
   
5. [ ] Functioning high-pressure relief valve
6. [ ] Unidirectional valves and soda lime
7. [ ] Functioning adjustable pressure relief valve

D. Vacuum system

[ ] Suction adequate

E. Scavenging system

[ ] Correctly connected to patient circuit and functioning

F. Routine equipment

1. [ ] Airway Management:
   [ ] Functioning laryngoscope (back-up available)
   [ ] Appropriate tracheal tubes: patency of lumen and integrity of cuff
   [ ] Appropriate oropharyngeal airways
   [ ] Stylet
2. [ ] Intravenous supplies
3. [ ] Blood pressure cuff of appropriate size
4. [ ] Stethoscope
5. [ ] ECG monitor
6. [ ] Pulse oximeter
7. [ ] Capnograph
8. [ ] Temperature monitor
9. [ ] Functioning low- and high-pressure alarm

G. Drugs

[ ] Adequate supply of frequently used drugs and intravenous solutions
[ ] Appropriate doses of drugs in labeled syringes

H. Location of special equipment in each anesthetising location

[ ] Defibrillator
[ ] Emergency drugs
[ ] Difficult intubation kit

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