We read with great interest the excellent recommendations by Klein et al. [1], which provide us with an updated guideline of the minimum standards of care of the Association of Anaesthetists. We are in full agreement with the Working Party’s recommendations that uniform guidance is a powerful tool in ensuring there is a baseline level of monitoring at each anaesthetising location. The guideline sets down the minimum monitoring that is mandatory before anaesthesia or sedation can proceed and offers guidance to hospitals on minimum equipment purchases.

We believe that there are two issues which require clarification. First, what is ‘monitoring’, as opposed to ‘a monitor’? Second, what is ‘better’ or ‘best’ practice with regard to monitoring during a particular procedure?

We would have welcomed a section on ‘optimal’ monitoring for specific types of surgery. Anaesthetists aim to provide the best treatment for their patients and must have access to the most appropriate tools for optimum performance, and not just the ‘minimum’. Hospitals, departments and individual anaesthetists acquiring new monitoring equipment and devices operate within a band of options ranging from ‘minimum’, below which they should not be allowed to proceed with an anaesthetic, to ‘optimal’ monitoring. The recommendations should reflect this attitude to monitoring and be updated regularly. As ‘optimal’ requirements have not been listed, hospital administrators and managers may decide that ‘minimum’ is good enough; hence the minimum becomes the default position for equipment acquisition. In most hospitals, surgeons get the best and newest devices whereas anaesthetists make do with a minimum standard of care.

Most clinicians think of monitors as devices used continuously throughout, or for most of, a procedure to notify, through an alarm, deviations from normal, for example a neuromuscular function monitor, ECG, capnograph or pulse oximeter. Others think of modern monitors as arrays, with an average of some 12 channels, with a multitude of alarms, used for everyday monitoring during anaesthesia. Neither concept is strictly correct.

Almost any device can have multiple functions, of which monitoring is one. For example, a videolaryngoscope is an intubation device, an airway inspection device and is a monitor of correct placement of a tracheal tube or a supraglottic airway device [2]. The pandemic has taught us that routinely increasing additional distance between the intubating clinician and the patient’s airway is the new norm [3]. We seem to have missed the point that the videolaryngoscope is also a great monitor, albeit applied intermittently (as with neuromuscular function monitoring). Not recommending, in the current guideline, videolaryngoscope monitoring of an airway device placement is a missed opportunity. Like most other monitors, videolaryngoscopy provides real-time, visual and recordable information for insertion of a tracheal tube, supraglottic airway device, temperature probe or gastric tube, while a supervising anaesthetist can use the monitor's view to provide guidance and feedback.

When it comes to monitoring, not all devices are equal, with each monitor having its strengths and weaknesses. Simply stating that pulse oximetry is a basic, essential, non-negotiable device does not specify which oximeters are inadequate or sub-standard in particular scenarios.

We agree with the Working Party that the 2021 guidelines were necessary and long overdue due to the introduction and design improvements in new monitoring technology. The list of ‘monitors’ should be expanded to include devices such as the videolaryngoscope, a device which, if used as a monitor, can reduce adverse airway incidents, a primary consideration during any anaesthetic.

我们非常感兴趣地阅读了 Klein 等人的优秀建议。[ 1 ]，它为我们提供了麻醉师协会最低护理标准的最新指南。我们完全同意工作组的建议，即统一指导是确保每个麻醉位置都有基线监测水平的有力工具。该指南规定了在进行麻醉或镇静之前必须进行的最低限度监测，并就最低设备采购量向医院提供指导。

我们认为有两个问题需要澄清。首先，什么是“监控”，而不是“监视器”？其次，在特定程序期间进行监测的“更好”或“最佳”做法是什么？

我们会欢迎关于特定类型手术的“最佳”监测的部分。麻醉师的目标是为他们的患者提供最好的治疗，并且必须获得最合适的工具以获得最佳性能，而不仅仅是“最低限度”。医院、科室和个体麻醉师获得新的监测设备和设备，在一系列选项范围内运作，从“最低”（低于该最低），他们不应进行麻醉，到“最佳”监测。建议应反映这种对监测的态度并定期更新。由于未列出“最佳”要求，医院管理人员和管理人员可能会认为“最低”就足够了；因此最小值成为设备获取的默认位置。在大多数医院，

大多数临床医生将监护仪视为在整个或大部分过程中持续使用的设备，通过警报通知正常情况的偏差，例如神经肌肉功能监护仪、心电图、二氧化碳图或脉搏血氧仪。其他人将现代监护仪视为阵列，平均有大约 12 个通道，带有大量警报，用于麻醉期间的日常监测。这两个概念都不是严格正确的。

几乎任何设备都可以具有多种功能，监控就是其中之一。例如，视频喉镜是插管设备、气道检查设备，是正确放置气管导管或声门上气道设备的监视器 [ 2 ]。大流行告诉我们，定期增加插管临床医生和患者气道之间的额外距离是新的常态 [ 3]]。我们似乎忽略了这一点，即视频喉镜也是一种很好的监测器，尽管它是间歇性应用的（如神经肌肉功能监测）。在当前的指南中，不建议对气道装置放置进行视频喉镜监测是一个错失的机会。与大多数其他监护仪一样，视频喉镜检查为气管导管、声门上气道装置、温度探头或胃管的插入提供实时、可视和可记录的信息，而监督麻醉师可以使用监护仪的视图提供指导和反馈。

在监控方面，并非所有设备都是平等的，每个显示器都有其优点和缺点。简单地说脉搏血氧饱和度仪是一种基本的、必不可少的、不可转让的设备，并没有说明在特定情况下哪些血氧仪不合适或不合标准。

我们同意工作组的意见，即 2021 年指南是必要的，并且由于新监测技术的引入和设计改进而早该发布。“监视器”的列表应该扩大到包括视频喉镜等设备，如果用作监视器，可以减少不良气道事件，这是任何麻醉过程中的主要考虑因素。