Automated electronic anaesthesia records

The 5th Edition of the AAGBI ‘Recommendations for standards of monitoring during anaesthesia and recovery’ 1 recommends that ‘… blood pressure … must be recorded at least every five minutes, and more frequently if the patient is clinically unstable. It is recognised that contemporaneous records may be difficult to keep in emergency circumstances, but modern patient monitoring devices allow accurate records to be completed or downloaded later from stored data. Automated electronic anaesthetic record systems that can also make hard copies for the medical notes are recommended.’ (my italics). This is commendable advice. Leaving aside the medicolegal difficulties in trying to defend one's anaesthetic management several years after the event based on an incomplete, incorrect or missing record of infrequent vital sign recordings, there is also a strong argument supporting the use of automated anaesthesia records for ‘Big Data’ research 2. Evidence from a number of recent observational studies consistently associates intra-operative hypotension with increased postoperative mortality and morbidity, particularly for elderly patients 3-5. However, it is uncertain whether this relates to the lowest blood pressure, the rate at which the blood pressure falls, the intermittency of hypotension, the duration of a single hypotensive episode, the total time spent hypotensive, other variables, or a combination of these 6. Many of the studies have used point prevalence (pre-induction and lowest mean/systolic blood pressures) when defining hypotension, but this misses the vast array of time vs. blood pressure data that it would be possible to analyse using automated recordings. Such research is urgently needed, when put into context. Lots of patients require hip fracture surgery (65,000 annually in the UK, 400,000 annually in the US) and intra-operative hypotension is common among these patients (56 - 89%, depending on the definition) 7. Collaborative collection of automated blood pressure data, therefore, would quickly be able to establish how hypotension effects common adverse ‘ischaemic’ outcomes (delirium, death, myocardial ischaemia, acute kidney injury) and also how anaesthetists might better manage intra-operative blood pressure. The imminent iHype (Intraoperative Hypotension in the Elderly, see www.i-hype.org) should give some insight into the value of such data collection. In their accompanying editorial, Lumb and McClure make the important point that the guidelines are ‘high level document… perhaps most useful … as a standard for clinicians to persuade those who hold the purse strings that investment in monitoring is required.’ 8. Although the current guidelines should stimulate hospital investment in this direction, given the range of important research questions that could be answered by collating large amounts of simple, accurate vital sign data, I would like to encourage the AAGBI to insist on, rather than just recommend, automation in future iterations of the guidelines.