Anesthesia Assistants: Patient Management during General Anesthesia & Procedural Sedation/Analgesia

Medical Directive ID: 
Lead Contact Person: 
Kevin Tiggeloven, Coordinator Respiratory Therapy, LHSC
Physician/Nurse Lead: 
Dr. Jim Watson, Anesthesiologist
Anesthesia & Perioperative Medicine
Approval By: 
Medical Advisory Committee
Original Effective Date: 
Tuesday, April 1, 2008
Revised Date: 
Thursday, December 11, 2014
To Be Reviewed Date: 
Sunday, December 11, 2016
This Medical Directive Applies to the following sites: 
St. Joseph’s
This Medical Directive Applies to the following patient population: 

This medical directive is to guide the provision and monitoring of local, regional, general and neuraxial anesthesia in stable adult (greater than16 years of age) patients by Advanced Practice Anesthesia Assistants (AA) in the operating room and throughout the hospital where procedural sedations are done under the direction of anesthesia in accordance with the hospital standards: Preoperative, intraoperative and postoperative procedure FOR ASSISTANCE in providing anesthesia by an Advanced Practice Anesthesia Assistant (AA).  It directs patient monitoring, oxygenation and mechanical ventilation, IV initiation, crystalloid fluid administration, arterial line initiation, thermoregulation, laboratory investigations, maintenance of inhalational anesthesia, maintenance/reversal of neuromuscular blockade and emergency treatment of bradycardia, hypotension, hypertension and hypoxemia.

The Anesthesia Assistant must continuously monitor the patient and inform the anesthesiologist if:

  • There is any change in the clinical or surgical situation which they are concerned about or if any other significant signs, symptoms or complications arise
  • Systolic blood pressure falls below 80 mmHg or rises above 130 mmHg unless instructed otherwise by the responsible anesthesiologist
  • Heart Rate falls below 50 bpm or rises above 100 bpm unless instructed otherwise by the responsible anesthesiologist
  • ECG changes consistent with arrhythmia, ischemia or infarction appear
  • Greater than 50% FiO2 is required to maintain oxygen saturation greater than or equal to 93% unless instructed otherwise by the responsible anesthesiologist
  • End-tidal CO2 rises above 45 mmHg or if RR greater than14 is required to maintain normocarbia in a mechanically ventilated patient or end-tidal CO2 rises above 50 mmHg in a spontaneously breathing patient unless instructed otherwise by the responsible anesthesiologist
  • Urine output is less than 0.5 mL/kg/h unless instructed otherwise by the anesthesiologist
  • Temperature is less than 35.5°C or greater than 37.5°C unless instructed otherwise by the responsible anesthesiologist
  • There is unexpected surgical blood loss
  • Surgery is 20 min. from ending unless instructed otherwise by the responsible anesthesiologist
  • Surgery is finished

The specific patient interventions and orders are described fully in Appendix A and Appendix B, attached.

This medical directive does not include the delegation of a controlled act/procedure.


Appendix A – Intervention Tree for the Management of Bradycardia, Hypotension and Hypoxemia

Appendix B – Intervention / Diagnostic Test / Drug Table

Appendix C – American Society of Anesthesiologists (ASA) Definitions

Appendix D – Medication Review

Click the link to view the entire medical directive in detail: 


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