Anaesthesia Equipment and Anaesthetising Facilities: Equipment
Anaesthesia equipment Anaesthesia mixture components Breathing circuits Ancillary equipment per theatre Monitors Recovery room equipment Equipment and drugs Routines for checking, cleaning, servicing and storage of equipment Every item on the list of essential equipment should be available at every site where anaesthesia is provided, even if anaesthesia is only provided occasionally. Essen
Anaesthesia mixture components
Ancillary equipment per theatre
Routines for checking, cleaning, servicing and storage of equipment
- Every item on the list of essential equipment should be available at every site where anaesthesia is provided, even if anaesthesia is only provided occasionally.
- Essential items are equivalent to a mandatory standard of care.
- Recommended/desirable items should be available where resources allow and if appropriate for the surgical/anaesthesia services delivered.
- Private facilities will generally be equipped at the level of regional (level 2) hospitals, except where these facilities provide specialised services (e.g., cardiothoracic surgery, shoulder surgery, etc.) where they will need to meet the requirements for tertiary/central (level 3/level 4) hospitals.
- Day surgery and office-based facilities are discussed in the relevant portion of the practice guidelines (Appendix E).
- It remains the duty of the anaesthesia provider to ensure that all relevant anaesthesia equipment required in the perioperative period is available, in working order and appropriate for the case being performed.
Anaesthesia equipment
- Essential anaesthesia equipment requirements will differ between institutions depending on the nature of the surgery undertaken and the surgical services offered. The availability of maintenance and repair services is also a key consideration when procuring anaesthesia equipment. Referral hospitals are usually in large centres and must meet higher standards.
- Regional (Level 2) hospital requirements will include most of the recommended equipment.
- Tertiary (Level 3) and central/specialised hospital requirements must include all items listed as “Recommended”.
Anaesthesia mixture components
No anaesthetic machine must be capable of delivering a hypoxic mixture of gases under any circumstance.
Essential items
Gas sources exclusively from cylinders must have:
- Pin-index yokes with pressure-reducing valves for both oxygen, air and nitrous oxide. These should be marked with the name or the chemical symbol of the gas and colour-coded in accordance with international standards.
- Pressure indicators for all cylinders must be available.
- One nitrous oxide cylinder and one full spare per machine, or one medical air cylinder and one full medical air cylinder spare per machine.
- Two oxygen cylinders and two full spares per machine.
- A suitable spanner or key must be available to open and close gas cylinders, even if the cylinders have finger-control knobs. The spanner should be attached to the anaesthesia machine.
Gas sources from pipelines with backup cylinders must have:
- SASA recommends that all new facilities be provided with piped medical air and oxygen and nitrous oxide.
- Non-interchangeable wall points and connectors for nitrous oxide, oxygen and any other gases, conforming to national standards.
- Colour-coded pipeline hoses capable of withstanding pressures of up to 1 000 kPa affixed to anaesthesia machines by non-interchangeable fittings. Colour-coding according to international standards: oxygen (white), nitrous oxide (blue) and medical air (black).
- Pressure indicators for each line, either outside the operating theatre, or in the gas pipeline before the anaesthesia machine. (South African National Standards [SANS] 7396-1:2009 Medical gas pipeline system).
- Non-return valves fitted at the machine connection point of the pipeline.
- One backup cylinder with pin-index yoke for oxygen attached to the anaesthesia machine.
- One spare oxygen cylinder, in addition to the spare on the machine’s yoke.
- A suitable spanner or key must be available to open and close gas cylinders, even if the cylinders have finger-control knobs. This should be attached to the anaesthesia machine.
- Medical air pipelines should be fitted with a water trap between the wall supply and the anaesthesia machine.
An oxygen-failure device with an audible alarm, preferably continuous, must be fitted to the anaesthesia machine. Appropriate flow controllers for all available gases:
- The flow meter for oxygen must be accurate to 100 ml/minute or less for flows up to 1 l/minute and accurate to 500 ml/ minute for higher oxygen flows.
- Where there is a sequence of gas control knobs, oxygen must be positioned on the right, as seen from a position facing the machine.
- Oxygen must always be the final gas delivered to the common gas pathway.
- Machines with electronic flow controllers must have a manual device for oxygen delivery, independent of electrical supply.
One volatile delivery system that can deliver accurate, controllable partial pressures of volatile anaesthesia agents at varying fresh gas flows, and under the full range of normal clinical conditions. The graduations of the control should not exceed 0.5 minimum alveolar concentration (MAC) and should provide at least three times the MAC of the selected agent.
The breathing system pressure relief valve should be set to 6 kPa/60 cm H2O.
An oxygen flush system, delivering at least 35 l/minute of oxygen to the machine outflow and controlled by a prominent, recessed, non-lockable button.
Outflow point connector of 22 mm International Organization for Standardization (ISO) standard male taper.
These components must be mounted on a rigid frame that maintains the flow meters in a vertical position and the volatile delivery system in a level position.
The mounting frame for a mobile anaesthesia machine must be sufficiently stable to prevent it from being accidentally tipped over. All ancillary monitoring equipment should be mounted on a suitable horizontal surface, or securely attached to the machine.
Oxygen analyser with an audible low-concentration warning device which should be adjustable, but with a minimum of 18%.
Where a potentially hypoxic gas mixture could be delivered, a hypoxic guard must be fitted to ensure a minimum oxygen concentration of 25%.
High-pressure gas supply master/slave switches, whereby low oxygen pipeline or cylinder pressure cuts off hypoxic gas sources (fail-safe device).
All major theatres must have a pipeline supply of medical air.
SASA recommends a medical air supply for all new operating theatres, including theatres for minor procedures/occasional use.
Appropriate delivery system for the supply of compressed air.
Gas delivery systems capable of delivering accurately proportioned fresh gas mixtures at flow rates down to 250 ml/minute. It should be noted that low flow anaesthesia using a fresh gas flow less than the patient’s minute ventilation, mandates the use of real-time capnography and anaesthetic agent analysis (AA). SASA recommends anaesthetic AA at all sites.
Breathing circuits
| Essential Items |
| - Suitable breathing system for adult patients fitted at all junctions with ISO-standard tapered fittings. |
| - Paediatric anaesthetic breathing systems must be available in institutions where children might be anaesthetised. |
| - One set of face masks per machine in a suitable range of sizes appropriate for the patient population. |
| - Ready availability of sufficient stock of single-use, Guedel-type oral airways, available in every size, for all patients to be anaesthetised on any given day in each operating theatre. |
| - Complete set of supraglottic/laryngeal mask airways per theatre complex, as appropriate for the caseload (e.g., full range of adult sizes (3–5) for adults or paediatric sizes (1 - 2½) for children. |
| - An appropriate range of different endotracheal tube sizes with standard connectors which are immediately available. |
| - Breathing circuit pressure gauge. |
| - A self-inflating resuscitation bag (Ambu® or similar), with reservoir bag and adaptors/oxygen cylinder for administering supplementary oxygen. |
| - A ventilator suitable for the cases anaesthetised at that location. |
| Recommended Items |
| - Anaesthesia workstation with central processing unit controlling electronic flow meters, electronic vaporisers, and integrated multi-mode anaesthesia ventilator, e.g., rising bellow or piston-driven, with integrated patient monitoring and a circle breathing circuit with a carbon dioxide absorber. |
| - Venturi® injector for airway inflation within the theatre complex. |
Ancillary equipment per theatre
Essential items
Laryngoscopes (preferably with fibre-optic light carrier and light-emitting diode light source)
Two functional handles with:
- Full range of adult blade sizes, preferably Macintosh pattern.
- Appropriate range of paediatric laryngoscope blades when providing paediatric anaesthesia.
Video-assisted laryngoscope (considered essential in all large level 1, level 2 and level 3 hospitals and high turnover obstetric units).
Magill adult and paediatric endotracheal tube-introducing forceps.
Nonmetallic or plastic-coated, malleable endotracheal tube-introducing stylettes.
Inflating device (syringe and a cuff pressure manometer) for endotracheal tube cuffs.
Two kidney dishes as receivers for clean and dirty oral and endotracheal instruments.
Designated difficult airway management trolleys with appropriate equipment should be in every theatre complex.
Anaesthesiologist’s chair on wheels with backrest.
A wall clock with a sweep second hand or digital equivalent should be present in each theatre.
Suction unit for exclusive use by the anaesthesiologist, generating a minimum negative pressure of 50 kPa at a minimum airflow of 25 l/minute into a reservoir bottle of at least one-litre capacity. Adequate length of suction tubing and an appropriate range of cannulas/catheters for oral and endotracheal suction.
Anaesthesia and surgical suction bottles should be graduated for volume.
A monitor - defibrillator with adult and infant electrodes per theatre suite must be available.
The ability to provide external cardiac pacing is desirable in all age groups, including neonates and paediatric patients.
Operating table with Trendelenburg-position controls at the head of the table.
- Two lateral padded straight arm supports.
- Appropriate padding and equipment for the positioning of patients to prevent injury.
Drug trolley for exclusive use by the anaesthesiologist.
Topical anaesthesia spray.
Two intravenous (IV) infusion poles.
An appropriate selection of IV fluids and IV cannulas must be available.
In-line warmer for blood and IV fluids.
Pressure infuser for both 500 ml (blood) and 1 000 ml IV bags.
Infusion devices: volumetric pumps and/or syringe drivers.
A pair of strong scissors.
A method of securing the anaesthesia breathing system to the operating table.
Warming blankets/convection warmers for use in the theatre.
Availability of warming blankets/convection warmers is an absolute requirement for neonates and infants.
Where infants and small children are to be anaesthetised, a full range of the necessary paediatric equipment (as outlined above) must be available.
Electrical generator backup for hospital and/or theatre complex.
Uninterruptible power supply (UPS) or battery backup for life-support equipment.
In the event of a power outage (failure of main Eskom power supply), the following guidelines should be followed:
- If the theatre complex only has one electrical backup system (generator/UPS), current elective cases should be completed as soon as possible, and all other cases postponed until the main power is restored. Urgent emergency cases may continue (See Appendix F [Safety incident reporting and learning]).
- If a theatre complex has a second backup power supply, e.g., a second generator or UPS unit, elective cases can continue if it is verified that the second backup supply has adequate capability for the duration of the power outage.
- Equipment battery backup is not deemed to be a second backup power supply as the duration of the battery supply is not dependable enough to continue with an elective list.
Recommended items
- A telephone in each theatre for communication.
- Individual illumination of the anaesthesiologist’s area, including an emergency backup, battery-powered illumination source.
- Blood salvage system.
- High-flow blood/fluid warmer.
- Syringe drivers programmed to administer target-controlled IV anaesthesia.
- Intermittent pneumatic calf compressors and related consumables.
- Low amperage peripheral nerve stimulator to assist with regional anaesthesia techniques per theatre suite.
- Equipment for patient-controlled analgesia (PCA).
- Transportable ventilator and monitor.
- Video-assisted or normal light source fibre-optic bronchoscope. A rigid bronchoscope (this need not be for exclusive use by the anaesthesiologist) with attachments for ventilating apnoeic patients (available in the theatre suite).
- All electrical equipment should be able to operate from batteries, particularly when a reliable emergency electrical supply is not available.
Monitors
Essential items
- A stethoscope.
- A multi-parameter vital signs monitor, incorporating and displaying:
- An electrocardiogram (ECG) channel with 3- and/or 5-lead ECG monitoring. The unit must incorporate a diathermy filter.
- Heart rate: Derived from ECG, pulse oximetry or non-invasive blood pressure (NIBP) readings.
- An automated electronic NIBP module displaying systolic, mean, and diastolic blood pressure (BP), with an appropriate range of cuffs.
- Pulse oximetry, displaying oxygen saturation and a plethysmograph.
- Anaesthetic agent analyser and capnography, displaying end-tidal anaesthetic agent concentrations and CO2 in mmHg, kPa or a percentage, and a capnograph.
- Patient temperature for oropharyngeal, oesophageal, rectal, bladder or tympanic use, reading 22–42 °C minimum range.
- Alarms: adjustable alarm limits for all parameters.
- Oxygen monitor (inspired and expired), with a low-limit alarm (may be incorporated in the multi-parameter vital signs monitor or the anaesthesia machine).
- Whenever an automatic ventilator is used, a breathing circuit pressure monitor with high- and low-limit alarms must be incorporated.
- A peripheral nerve stimulator to monitor neuromuscular function when muscle relaxants are used, with double burst stimulation, train-of-four and post-tetanic count facilities.
- A point-of-care (POC) device to estimate blood glucose.
- A POC device to measure haemoglobin and/or haematocrit.
- A thermometer that permanently displays the operating theatre temperature.
Recommended items
- Invasive pressure module for intra-arterial/IV pressure monitoring incorporated in the multi-parameter vital signs monitor or anaesthesia machine.
- Portable ultrasound device for guided nerve blocks and vascular access.
- Blood gas analyser.
- Transportable vital signs monitor.
- Scale for weighing swabs.
- Processed electroencephalogram (EEG) depth of anaesthesia monitor.
- Non-invasive cardiac output monitor.
- Coagulation monitoring device. (Essential in a theatre where heparin is used, e.g., cardiac surgery, vascular surgery).
- Transoesophageal echocardiography equipment.
- Near-infrared spectroscopy (NIRS) cerebral oximetry monitor. See Table below for essential equipment list (anaesthesia).
Essential equipment list (anaesthesia)
| Equipment Description | District Hospital | Regional Hospital | Tertiary/Central Hospital |
| Anaesthesia machine (basic) | X | X | X |
| Anaesthesia machine, with O2, air and N2O flow meters, with vaporisers, anaesthesia rising bellow ventilator, absorber and closed circuit, masks, suction unit, aneroid BP apparatus (with obese, adult and child cuffs) and oxygen monitor | |||
| Anaesthesia workstation | X | X | |
| Anaesthesia workstation: CPU controlled with electronic flow meters, electronic controlled vaporisers, integrated multi-mode ventilator (rising bellow or piston-driven), may include integrated patient monitor with ECT, ST-segment analysis, NIBP, invasive pressure, pulse oximetry, multi-gas analyser, spirometry, NMT, BIS or entropy | |||
| Anaesthesia trolley, mobile | X | X | X |
| Processed EEG depth of anaesthesia monitor (if not part of patient monitor) | X | X | |
| Blood/fluid warmer | X | X | X |
| Blood salvage system | X | X | |
| Cerebral oximeters (NIRS) | X | X | |
| Diagnostic set complete | X | X | X |
| Defibrillator, complete, mounted on a mobile trolley (adult and paediatric paddles) | X | X | X |
| Defibrillator with external pacing | X | X | |
| Difficult airway management equipment | X | X | X |
| Forced-air warmer | X | X | X |
| Fibre-optic laryngoscope | X | X | |
| Glucometer | X | X | X |
| Haemoglobinometer/centrifuge (Hct) | X | X | X |
| High-flow blood/fluid warmer | X | X | |
| Intermittent pneumatic calf compressors | X | X | |
| Jet ventilator | X | X | |
| Laryngoscope set, complete | X | X | X |
| Non-invasive cardiac output monitor | X | X | |
| PCA pump (reusable or disposable) | X | X | |
| Peripheral nerve stimulator | X | X | X |
| Platelet function monitor (access to) | X | ||
| POC diagnostics (blood gas, electrolytes, glucose and lactate) | X | X | |
| Portable ultrasound | X | X | |
| Pressure infusion devices (for blood, 500 ml and 1 000 ml fluid bags) | X | X | X |
| Pulse oximetry – advanced (Hb, non-invasive cardiac output, etc.) (access to) | X | ||
| Resuscitator, pulmonary, manual, adult, complete | X | X | X |
| Resuscitator, pulmonary, manual, child/infant, complete | X | X | X |
| Scale for weighing swabs (access to) | X | X | |
| Syringe drivers | X | X | X |
| Suction unit, mobile, 1x2-litre bottle / disposable bag, wall outlet | X | X | X |
| Suction unit, mobile, 1x2-litre bottle/disposable bag, electrical | X | X | X |
| TCI syringe drivers (for TCI anaesthesia) | X | X | |
| Trans-oesophageal echocardiography | X | ||
| Transport ventilator | X | X | |
| Transport vital signs monitor | X | X | |
| Thromboelastography (access to) | X | ||
| Video bronchoscope | X | X | |
| Videolaryngoscope (for district, if high volume obstetrics) | X | X | |
| Vital signs monitor: capnograph | X | X | X |
| Vital signs monitor with ECG, SpO2, NIBP, temperature, capnography, multi-gas analysis, invasive BP | X | X | |
| Vital signs monitor with ECG, SpO2, NIBP, temperature, capnography, multi-gas analysis | X | X | X |
| Vital signs monitor with SpO2 and NIBP | X | X | X |
| Volumetric infusion pump | X | X | X |
Abbreviations: BP – blood pressure, BIS – bispectral index, CPU – central processing unit, ECG – electrocardiogram, Hb – haemoglobin, Hct – haematocrit, NIBP – non-invasive blood pressure, NIRS – near-infrared spectroscopy, NMT – neuromuscular transmission, N2O – nitrous oxide, O2 – oxygen, PCA – patient-controlled analgesia, POC – point-of-care, SpO2 – blood oxygen saturation, TCI – target-controlled infusion.
Recovery room equipment
An area within the theatre suite, preferably with easy access from each theatre, must be provided for the recovery of patients from anaesthesia before discharge to the wards.
Equipment and drugs
Each bed space should be provided with:
- An oxygen flow meter with attachment for oxygen tubing for mask or nasal prongs.
- A hook, or pole, for suspension of IV fluids
- Suction equipment, including a receiver, tubing, a rigid handpiece and a range of suction catheters, including Yankauer.
- An automated NIBP monitor with appropriately sized cuffs.
- A stethoscope.
- A pulse oximeter.
- Means of measuring body temperature
Within the RR, there must be:
- A range of devices for the administration of oxygen to spontaneously breathing patients.
- A self-inflating manual resuscitator, e.g., Ambu® bag or similar, able to deliver 100% oxygen and allow manual ventilation. A minimum of two per recovery room complex is required.
- Equipment and drugs for airway management and endotracheal intubation.
- Emergency drugs.
- A range of IV equipment and fluids.
- Drugs and equipment for acute pain management.
- A range of syringes and needles.
- An ECG monitor.
- Patient-warming devices.
There should be immediate access to:
- A monitoring defibrillator, preferably with pacing capability.
- A blood warmer.
- A thermostatically controlled warming cupboard for IV solutions.
- A refrigerator for drugs and blood.
- A procedure light.
- A range of appropriate anaesthesia and emergency drugs.
- A surgical tray for procedures, including tracheostomy and chest drains.
- POC access to diagnostic services, e.g., blood glucose, blood gases and radiology.
- A peripheral nerve stimulator.
- Other equipment as appropriate to the patient’s condition, e.g., wire cutters.
- A ventilator
The recovery trolley or bed must:
- Have a firm base and mattress.
- Tilt from either end, both head up and head down, to at least 15 degrees.
- Be easy to manoeuvre.
- Have functional and accessible brakes.
- Have provision for the patient to be able to sit up.
- Have straps or side rails capable of being dropped below the base or easily removed.
- Include provision for a pole from which IV solutions may be suspended.
- Include provision for monitoring, mounting portable oxygen cylinders, underwater seal drains and suction apparatus for use during transport.
Routines for checking, cleaning, servicing and storage of equipment
Any institution at which anaesthesia is administered must provide efficient and reliable maintenance and repair services for all anaesthetic equipment. A suitable mechanism must exist whereby faulty essential equipment can be replaced immediately.
Regular sterilising, cleaning, and housekeeping routines for the care of anaesthesia equipment should be established in accordance with the SASA Guidelines for Infection Control in Anaesthesia in South Africa 2021 (Appendix G).
Service by an appropriately certified organisation or persons should be carried out on a regular and appropriate basis. Life support equipment should be serviced by a manufacturer approved license-holder company at intervals recommended by the manufacturer.
To promote maximum safety in relation to service procedures, the following points are important prerequisites:
- Individual anaesthetic machines should be clearly identified, either by the maker’s serial number, or preferably by a hospital marking. This identification must extend to all the readily removable components, such as canisters and vaporisers, so that the performance and checking of these can be followed without confusion.
- A record of service procedures performed on each machine, signed by the person responsible for the service, must be provided to the appropriate hospital personnel, e.g., department of anaesthesia, anaesthetic technical staff or theatre nursing staff, depending on local circumstances.
- In newly built operating theatres, where operating suites have undergone major structural alterations, before the commissioning of the area, all new and existing gas lines are pressure-tested, followed by gas flow and purity testing. This must be carried out by a third party licensed to install, and test medical gas lines.
- When any medical gas installation is tested, the persons that should be present are the mechanical engineer from public works/hospital group, the mechanical engineer from health infrastructure, the hospital/facility engineer; the medical engineer; the medical gas engineer and the third party doing the testing.
- The installation of new or altered gases requires certification once the installation is completed and deemed operational.
- Adequate time must be available for service personnel to perform regular and emergency servicing without compromising safety.
- Storage facilities should be available for nitrous oxide and oxygen within the operating theatre suite. This storage area should fulfil the criteria described in the appropriate South African Bureau of Standards (SABS) Code of Practice.
|
- Essential items are equivalent to a mandatory standard of care. - Recommended/desirable items should be available where resources allow and if appropriate for the surgical/ anaesthesia services delivered. - Regional (Level 2) hospital requirements will include most of the recommended equipment. - Tertiary (Level 3) and central/specialised hospital requirements must include all items listed as “Recommended”. - SASA recommends that all new facilities be provided with piped medical air and oxygen and nitrous oxide. - SASA recommends a medical air supply for all new operating theatres, including theatres for minor procedures/occasional use. - SASA recommends AA at all sites. - Video-assisted laryngoscope is considered essential in all large level 1, level 2 and level 3 hospitals and high turnover obstetric units. - The ability to provide external cardiac pacing is desirable in all age groups, including neonates and paediatric patients. - Warming blankets/convection warmers are an absolute requirement for neonates and infants. |
South African Society of Anaesthesiologists (SASA) Practice Guidelines_2022_Reviewed by: G Davies, A Reed and D Shmukler