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Editorials: Editorial

Worldwide Standards of Practice for Anesthesia

Enright, Angela MB, FRCPC

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doi: 10.1213/ANE.0000000000002928
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Many national societies of anesthesiology publish guidelines and standards of practice for their members.1–3 These are updated regularly and expanded as practice and technology develop and change. They are intended to guide members on a large variety of topics related to the practice of anesthesia. However, the main reason for their creation was to improve patient safety. No patient should suffer harm as a result of anesthesia care.

In this month’s issue of Anesthesia & Analgesia, we publish a landmark article by Gelb et al4 from the International Standards for a Safe Practice of Anaesthesia Workgroup. What is notable in this publication is the fact that the World Federation of Societies of Anaesthesiologists and the World Health Organization have worked together to develop and endorse these global standards. The World Federation of Societies of Anaesthesiologists (WFSA) has previously published standards,5 and these are now updated to include many new recommendations.

Readers may find the terminology somewhat unusual.4 Instead of mandatory or obligatory, the words HIGHLY RECOMMENDED are used to indicate the need for a particular monitor, for example, a pulse oximeter. This is to conform with the language used by the World Health Organization. RECOMMENDED means the monitor should be available for use where indicated. SUGGESTED means it would be advisable to have the monitor but it is not essential.

The authors have also attempted to link their recommendations to those of the Lancet Commission on Global Surgery and the Disease Control Priorities 3, in relationship to where surgery and anesthesia are performed6,7—district, regional, or tertiary care hospitals. Each group uses slightly different language, but the intent of the standards document is very clear. All locations where anesthesia is performed must adhere to the HIGHLY RECOMMENDED anesthesia standards. These are the minimum requirements. Finally, the attendance of a trained and vigilant anesthesia provider is the key to improving patient safety, everywhere.

There is much literature to demonstrate that many centers in low- and middle-income countries do not have the resources to match these guidelines.8,9 So what is to be done? As a result of the motion passed at the World Health Assembly in 2015,10 including surgery and anesthesia as an essential part of universal health care, countries are now preparing their National Surgical, Obstetric, and Anesthesia Plans.11 It is essential that they include provision for the human and material resources necessary for the delivery of safe anesthesia. These will not come cheaply, but the economic losses will be catastrophic if ignored.6

Anesthesia safety has improved significantly since the 1980s because of vigilance, monitoring, and the institution of standards and guidelines. This is particularly so in high-income regions of the world. Now, we must assist our colleagues in less fortunate areas to achieve the same success. Governments, through their Ministries of Health and Finance, must commit to providing the resources necessary to facilitate adherence to the International Standards for the Practice of Anesthesia described here.4 The commitment involves not just the purchase of necessary equipment and monitors but also the development of the technical support personnel to maintain and repair them. Additionally, it includes having a consistent medication supply chain. No patient should undergo anesthesia and surgery without having in place, at minimum, the HIGHLY RECOMMENDED standards. Anesthesia providers everywhere will appreciate governmental efforts to ensure that these standards are met, but, even more importantly, so will surgical patients and their families.


Name: Angela Enright, MB, FRCPC.

Contribution: This author wrote the manuscript.

Conflicts of Interest: A. Enright is the former President of World Federation of Societies of Anaesthesiologists.

This manuscript was handled by: Jean-Francois Pittet, MD.


1. Dobson G, Chong M, Chow L, et al. Guidelines to the practice of anesthesia-revised edition 2018. Can J Anesth. 2018;65:76–104.
2. American Society of Anesthesiologists. Available at: Accessed March 30, 2018.
3. Association of Anaesthetists of Great Britain & Ireland. Available at: Accessed March 30, 2018.
4. Gelb AW, Morriss WW, Johnson W, Merry AF. World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia. Anesth Analg. 2018;126:2047–2055.
5. Merry AF, Cooper JB, Soyannwo O, Wilson IH, Eichhorn JH. International Standards for a Safe Practice of Anesthesia 2010. Can J Anaesth. 2010;57:1027–1034.
6. Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386:569–624.
7. Debas HT, Donkor P, Gawande A, et alEssential Surgery. Disease Control Priorities2015. Washington, DC: World Bank Group 2Available at: Accessed March 30, 2018.
8. Hodges SC, Mijumbi C, Okello M, McCormick BA, Walker IA, Wilson IH. Anaesthesia services in developing countries: defining the problems. Anaesthesia. 2007;62:4–11.
9. Epiu I, Tindimwebwa JV, Mijumbi C, et al. Challenges of anesthesia in low- and middle-income countries: a cross-sectional survey of access to safe obstetric anesthesia in East Africa. Anesth Analg. 2017;124:290–299.
10. World Health Assembly Resolution 68.15. Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage. Geneva, May 2015. Available at: Accessed March 28, 2018.
11. Weiser TG, Bekele A, Roy N. Safe surgery globally by 2030: the view from surgery. Anesth Analg. 2018;126:1105–1108.
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