0.2 Perioperative Role & Scope of Practice of the Certified Anesthesia Technologist

Professional Scope & Regulatory Framework

ASATT Scope of Practice (September 2023 Revision)

The ASATT Scope of Practice defines the clinical functions ASATT validates for certified anesthesia technology personnel through standardized education and the national certification examination. It states that anesthesia technologists and technicians work under the direction of an anesthesia provider as members of the anesthesia care team recognized in American Society of Anesthesiologists (ASA) practice guidelines. ASATT does not outline a scope for non-certified technicians; the document applies only to holders of an active, unencumbered Cer.A.T. or Cer.A.T.T.

A scope of practice is the legally authorized boundary for the assessment, intervention, and level of care a practitioner may provide. The Scope document notes that scope is found in federal laws, Medicare regulations, accreditation standards, clinical settings, job descriptions, hospital policies, and legal opinions. An employer may narrow a technologist's functions through a job description or policy, but it may not allow an employee to work outside the legal scope. Practicing outside scope creates legal liability for the practitioner, the supervisor, and the organization.

Boundaries in Day-to-Day Practice

• Medications: Technologists must know drug classes, side effects, interactions, and ACLS/PALS medication sequences, and they keep medications in date and dispose of remnants properly. Administering medications remains a function defined by state law and institutional policy for licensed providers.
• Vascular access: ASATT validates peripheral intravenous catheter insertion for Certified Anesthesia Technologists. Arterial and central venous cannulation are performed by the anesthesia provider; the technologist prepares, primes, levels, zeros, and troubleshoots the monitoring system and understands its indications.
• Local competencies: Facilities document which validated functions each technologist performs, and those local limits can be narrower than the ASATT scope.

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Differentiating Technologists (Cer.A.T.T.) from Technicians (Cer.A.T.)

The Scope of Practice lists most competencies for both credentials: airway management and ventilation support, fluid and blood component management, pharmacology, pathophysiology and anesthesia management, biotechnology and monitoring equipment, and critical event management. The distinctions it draws are specific:

Where Certified Technologists Work

The Scope lists operating rooms, obstetric suites, interventional and diagnostic radiology, the PACU, ICU, catheterization laboratory, emergency room, endoscopy areas, dental suites, ambulatory surgery suites, animal and research laboratories, and MRI.

Regulatory Compliance Duties Named in the Scope

• Follow The Joint Commission (TJC) accreditation policies, sentinel event and national patient safety goal requirements, and environment-of-care rules
• Keep sterile supplies within expiration dates and rotate inventory by accepted standards
• Follow Material Safety Data Sheet (now Safety Data Sheet) guidance on hazardous materials and OSHA guidelines for anesthesia and patient safety
• Keep maintenance records for essential anesthetic equipment and run quality control after repair or service
• Know College of American Pathologists (CAP) and CMS Clinical Laboratory Improvement Amendments (CLIA) rules for ancillary laboratories, and follow AABB recommendations for banked and salvaged blood
• Help prepare the department's capital budget and train or orient staff as needed

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Core Clinical Functions Across the Phases of Anesthesia

1. Pre-Induction: Workstation & Environment Verification

Before every patient, the Cer.A.T.T. performs a systematic equipment evaluation that follows the 2008 ASA Recommendations for Pre-Anesthesia Checkout Procedures:

• High-Pressure System Inspection: Verifies backup cylinders are seated with correct Pin Index Safety System (PISS) configurations and that the auxiliary oxygen cylinder is at least about half full (roughly 1,000 psig; a full cylinder reads about 1,900–2,200 psig).
• Intermediate-Pressure System: Connects pipeline gas hoses utilizing Diameter Index Safety System (DISS) connections and confirms pipeline pressures maintain 50 to 55 psig.
• Low-Pressure System & Vaporizers: Verifies vaporizers are properly mounted on the interlock manifold, tightly locked, adequately filled with appropriate anesthetic agents, with filler ports sealed; performs negative-pressure leak testing on machines with check valves.
• Breathing Circuit & Absorbent: Checks circle system integrity by closing the APL valve, occluding the Y-piece, pressurizing the circuit to 30 cmH2O, and confirming the pressure holds for at least 10 seconds; examines carbon dioxide absorbent granules for exhaustion (ethyl violet color changes) or desiccation.
• Scavenging & Suction: Connects active/passive scavenging systems, ensuring scavenging interface relief valves are patent and vacuum flow is set in the indicated range; verifies suction is strong enough to clear the airway.

2. Induction & Rapid Sequence Induction (RSI)

During the vulnerable period of anesthetic induction, the technologist functions at the head of the operating table alongside the anesthesia provider:

• Pre-Oxygenation & Seal: Assists with establishing an airtight mask seal delivering 100% oxygen to achieve denitrogenation, commonly targeting an end-tidal oxygen concentration (EtO2) of about 90%.
• Rapid Sequence Induction (RSI): When indicated for patients at high risk of pulmonary aspiration (e.g., full stomach, bowel obstruction, acute trauma, severe gastroesophageal reflux, pregnancy), the technologist assists with:
  • Precise application of cricoid pressure (Sellick's maneuver) upon loss of consciousness when requested by the provider, applying approximately 10 Newtons of force initially and increasing to 30 Newtons to occlude the esophageal lumen against the C6 vertebral body without distorting the laryngeal cartilages.
  • Immediate handoff of the direct or video laryngoscope blade upon muscle relaxant onset.
  • Smooth withdrawal of the intubating stylet as the endotracheal tube passes the vocal cords.
  • Cuff inflation using an aneroid endotracheal tube manometer, titrating cuff pressure strictly to 20 to 30 cmH2O. This range is critical: pressures below 20 cmH2O permit micro-aspiration of secretions around the cuff, while pressures exceeding 30 cmH2O exceed capillary perfusion pressure of the tracheal mucosa (~30 mmHg or ~40 cmH2O), causing mucosal ischemia, ulceration, and tracheal stenosis.
  • Immediate verification of ventilation via continuous end-tidal carbon dioxide (EtCO2) waveform capnography and bilateral chest auscultation.

3. Invasive Hemodynamic Line Support

The Cer.A.T.T. is responsible for setting up, priming, calibrating, and troubleshooting invasive monitoring systems:

• System Preparation: Primes rigid, non-compliant pressure tubing with 500 mL of 0.9% normal saline (plain or heparinized per institutional policy). Pressurizes the pneumatic flush bag to 300 mmHg, which drives the continuous micro-flush device to deliver 3 mL/hr of flush solution to maintain catheter patency and prevent thrombus formation.
• Zero-Referencing & Leveling:
  • Levels the air-fluid interface stopcock of the transducer precisely to the phlebostatic axis, defined anatomically as the intersection of the fourth intercostal space and the mid-axillary line (representing the level of the right atrium).
  • Closes the stopcock to the patient, opens it to atmospheric pressure, and initiates zero calibration on the physiologic monitor.
  • Hydrostatic Physics: The physical position of the transducer dictates measurement accuracy. For every 1 inch (2.54 cm) the transducer is placed above the phlebostatic axis, the hydrostatic fluid column decreases the measured blood pressure by approximately 1.86 mmHg (or ~0.74 mmHg per cm). Conversely, placing the transducer below the phlebostatic axis creates an artificial hydrostatic pressure increase.
• Dynamic Response (Square-Wave) Testing:
  • Performed by activating the fast-flush pigtail valve to expose the transducer to 300 mmHg of pressure, observing the resulting waveform and post-flush oscillations.
  • Adequately Damped System: Displays a steep vertical square wave followed by 1 to 2 rapid oscillations before returning to baseline arterial pulsation.
  • Underdamped System: Displays multiple ringing oscillations (>3 oscillations) with an exaggerated, artifactually high systolic spike and an artificially low diastolic pressure. Caused by excessive tubing length (>150–200 cm), multiple stopcocks, or patient hyperdynamic states.
  • Overdamped System: Displays a sluggish, blunted waveform with no post-flush oscillations, artifactually low systolic pressure, and artifactually high diastolic pressure. Caused by entrapped air bubbles in the transducer chamber or tubing, blood clots at the catheter tip, compliant (soft) extension tubing, or loose connections.

Dynamic Response Characteristics Matrix

4. Autologous Blood Recovery (Intraoperative Cell Salvage)

During procedures with anticipated substantial blood loss (>1,000 mL, such as cardiac, major vascular, orthopedic spine, or trauma surgery), the Cer.A.T.T. manages autologous red blood cell recovery:

• Anticoagulation Setup: Assembles the double-lumen suction line connected to a collection reservoir. Primes the line with anticoagulant: either Acid Citrate Dextrose Solution A (ACD-A) or heparinized normal saline (typically 30,000 USP units unfractionated heparin per 1,000 mL 0.9% NaCl).
• Titration Ratio: Regulates anticoagulant infusion at a ratio of 1:5 to 1:7 (approximately 15 to 20 mL of anticoagulant per 100 mL of collected blood). Suction vacuum must be maintained between -100 and -150 mmHg; excessive vacuum (>150 mmHg) induces mechanical shear stress and red blood cell hemolysis.
• Centrifugal Separation & Washing: Within the rotating centrifuge bowl (Latham or continuous bowl), whole blood is separated by density into red blood cells, buffy coat (platelets/leukocytes), and supernatant plasma. The packed red cells are washed with 0.9% normal saline (minimum 500 to 1,000 mL wash volume) until the waste effluent is visually transparent. The final washed product typically has a hematocrit of about 50% to 65%, suspended in normal saline, with most of the anticoagulant, plasma, free hemoglobin, and activated clotting factors removed.
• Absolute Contraindications & Contaminants:
  • Topical Hemostatic Agents: Microfibrillar collagen (Avitene), oxidized regenerated cellulose (Surgicel), topical thrombin, and gelatin sponges (Gelfoam) must not be aspirated into the cell saver. Washing may not reliably remove these procoagulant materials, and reinfusion can activate clotting and contribute to disseminated intravascular coagulation (DIC). Suction is diverted to wall waste suction while hemostatics are in the field.
  • Irrigants & Cleansers: Sterile water (causes immediate osmotic hemolysis), hydrogen peroxide, chlorhexidine, and betadine.
  • Malignancy & Gross Infection: Aspiration through active tumor fields or gross gastrointestinal bowel contamination is contraindicated unless specialized leukocyte-depletion microaggregate filters are utilized under life-saving clinical exemptions.
• Fatal Air Embolism Prevention: Reinfusion bags must NEVER be placed inside a mechanical or pneumatic pressure infuser bag without first completely evacuating all air from the reinfusion bag. Autologous reinfusion bags contain air; applying external pressure drives air directly into the patient's venous circulation, causing massive, fatal venous air embolism.

5. Point-of-Care Testing (POCT) & Quality Assurance

The Cer.A.T.T. operates diagnostic analyzers within the surgical theater under Clinical Laboratory Improvement Amendments (CLIA) standards:

• Activated Clotting Time (ACT): Crucial during systemic heparinization for cardiopulmonary bypass or vascular cross-clamping. Baseline ACT is typically 80 to 120 seconds. Full systemic heparinization for cardiopulmonary bypass requires an ACT greater than 400 to 480 seconds prior to cannulation. After protamine reversal, ACT is rechecked to confirm it has returned toward baseline.
• Blood Gas & Electrolytes: Evaluates arterial blood gases (pH, PaCO2, PaO2, HCO3-, base excess), hemoglobin/hematocrit, lactate, and ionized calcium (vital for myocardial contractility during rapid blood transfusions).
• Quality Control: Runs required quality control (electronic checks and liquid controls at the frequency set by CLIA, the manufacturer, or an approved IQCP), documents calibration verifications, and ensures results interface seamlessly with the electronic health record (EHR).

6. Difficult Airway Cart Management

The technologist maintains immediate readiness of the ASA Difficult Airway Algorithm Cart:

• Video Laryngoscopy: Inspects and tests rigid hyperangulated blades (e.g., GlideScope) and standard geometry blades (e.g., McGrath, C-MAC), ensuring batteries are charged and recording monitors functional.
• Flexible Intubating Bronchoscopes: Verifies white balance, focus, optical lens integrity, light source intensity, and suction channel patency.
• Supraglottic Airway Conduits: Stocks second-generation supraglottic devices (e.g., LMA ProSeal, LMA Supreme, i-gel) and intubating conduits (LMA Fastrach).
• Emergency Surgical Airway: Verifies that scalpel-bougie-tube cricothyrotomy kits and percutaneous Seldinger kits are stocked and within expiration dates for the provider's use.

7. Professional Ethics & Intraoperative Communication

Technologists are vital advocates for perioperative patient safety, employing Crew Resource Management (CRM) principles:

• Closed-Loop Communication: Actively repeats back instructions, drug dosages, gas pipeline changes, and diagnostic values to eliminate ambiguity.
• Speaking Up for Safety: Utilizes the structured CUS communication framework when observing safety breaches (e.g., circuit disconnects, contamination, unverified medications): "I am Concerned, I am Uncomfortable, this is a Safety issue."