Date OR # Page of
Procedure(s) Surgeon(s)
START
STOP
Anesthesia Procedure
Room Time IN: OUT:
PRE-PROCEDURE
ANESTHETIC TECHNIQUE
AIRWAY MANAGEMENT
Magill forceps Oral ETT RAE L.T.A. Nasal ETT LMA # Stylet LMA Fastrach # DL LMA ProSeal # Tube size: FOI Awake Blade: Laser ETT LIS Attempts x EMG ETT Bougie Grade: I II III IV blind Armored ETT TTJV Atraumatic intubation/LMA DLT Secured at _________ cm Bronchial blocker system ET C02 present Breath sounds = bilateral Rigid FO laryngoscope Cuffed - min occ pressure Uncuffed ETT - leaks at Nerve blocks / Topical / ____________ cm H20 Nebulizer - See Remarks Oral airway Nasal airway Bite block Cannot Easy Head-tilt Max jaw-thrust Mask vent: Ventilate Circuit: Circle system NRB Bain Mask case Via tracheotomy / stoma Simple 02 mask Nasal cannula
Pre-02 GA Induction: Pt Identified: ID Band Questioned Guardian Steth: Esophageal Precordial Suprasternal Intravenous RSI Chart reviewed Permit signed Non-Invasive B/P V lead ECG Cricoid pressure Inhalation IM PR GA Maintenance: NPO since ____________ Full stomach Continuous ECG ST / Dysrhy. analysis Inhalation Inhalation / IV Patient reassessed prior to anesthesia & Pulse oximeter Nerve stimulator: GA / Regional combination TIVA End tidal C02 surgery; surgical site verified - Ready to proceed Ulnar Tibial Sedation & Analgesia / Monitored Anesthesia Care Peri-operative pain management discussed Regional: Oxygen monitor Facial Epidural Thoracic Lumbar Caudal with patient / guardian, plan of care completed ET agent analyzer Fluid / Blood warmer SAB Ankle Femoral Axillary Interscalene Pre-Anesthetic state: Temp:______________ Cell Saver BIS CSE Bier Continuous Spinal Cervical Plexus Awake Anxious Uncooperative Body warmer TEE ICP Other: Regional Technique: Calm Lethargic Unresponsive Airway humidifier: CPB EEG Position ___________________ Evoked potential: See remarks Prep PATIENT SAFETY Anesthesia machine # ____________ checked NG / OG tube Local Site Introducer Critical clinical alarms checked & activated Foley: OR Ward Doppler: Needle Secured with safety belt Axillary roll Arterial line LA Arm(s) secured on armboards: L R C-line/CVP Narcotic Arm(s) tucked: L R Arms < 90 PA line Additive Pressure points checked, padded, monitored IV(s) Test dose Rx Eye Care: Taped closed Ointment Attempts x Level By surgeon Saline Goggles Catheter: Test dose response: Prone - no pressure on orbits/nose/ears/genitals L.O.R. _______ cm Skin _______ cm Secured Remarks: POST ANESTHESIA CARE NOTES Location Time Awake Somnolent POST ANAESTHESIA INSTRUCTIONS: 02 Sat B/P Unarousable % Stable 1. Nil orally till Pulse Resp Temp Unstable Supplimental 2. T,P,R,BP 1/2 hourly. Pain care plan discussed with RN Oxygen Regional - dermatome level: OPA / NPA 3.Watch for effects of anaesthesia Continuous epidural analgesia LMA Recovery recorded on anes. form Intubated 4. IV fluids: Direct admit to hospital ward, Aldrete score _________ No intra-operative anesthesia adverse events noted 5. Analgesia For >24 hour admits:
Heme LOR CSF
Pares
+ + + -
A S
No adverse anesthesia related complications noted, satisfactory progress and recovery See progress notes for anesthesia related concerns
Iso Air
Sev
TOTALS
FLUIDS Urine EBL Gastric ECG % Oxygen Inspired (Fi02) 02 Saturation (Sa02) End Tidal C02 Temp: C F
OUTPUT
MONITORS
ARTERIAL LINE
PERI-OP MEDS
TIME
X
200 180 160
150 150 180 180
PULSE
VENTILATION
O / SV
SPONTANEOUS
/ AV
100 100 100
ASSISTED
80
80
/ CV
CONTROLLED TOURNIQUET
Pulse
Resp
60
50 50
40
LOCATION:
BP
Temp Sa02 Tidal Volume (ml) Respiratory Rate Peak Pressure PEEP CPAP
20
mmHg:
UP:
VENT
DOWN:
TOTAL TIME:
History from:
PRE-ANESTHESIA EVALUATION
AGE SEX
PROPOSED PROCEDURE
M
PREVIOUS ANESTHESIA / OPERATIONS NONE CURRENT MEDICATION(S) NONE
F
in / cm lb / kg
Hx Illicit drug use
Morbid obesity Hx difficult airway Teeth poor repair Teeth Chipped / Loose:
AIRWAY
ALLERGIES
NONE
SYSTEM
RESPIRATORY
Chronic tonsillitis Chronic OM Recent URI TB / +PPD Pneumonia Productive cough SOB / Dyspnea OSA Orthopnea Wheezing Abnormal ECG Dysrhythmia Hypovolemia Chronic fatigue Pacemaker / AICD Murmur Valvular Dz / MVP Hx Rheumatic fever Endocarditis Aneurysm N&V Diarrhea IBS / Chrohn's Dz Pancreatitis Gallbladder Dz Diverticulum Colon polyps Muscle weakness Neuromuscular Dz Paralysis Paresthesia(s) CVA / TIA Seizures / Epilepsy Psychiatric disorder Prostate BPH / CA UTI / Incontinence Diabetes mellitus: Type I / II / Gest. Pituitary disorder Asthma / RAD Bronchiolitis COPD Emphysema Bronchitis Respiratory failure Pleural effusion Pulmonary embolism Sinusitis / Rhinitis Environ. allergies
COMMENTS
TOBACCO USE: No Yes _______ Packs / Day for ______ Years Quit
DIAGNOSTIC STUDIES
ECG:
WNL
CARDIOVASCULAR
Hypertension Hyperlipoproteinemia CAD / Cardiomyopathy Angina Stable / Unstable Myocardial infarction CHF DOE PND Peripheral Vascular Dz Exercise Tolerance METs: > 4 <4
LABORATORY STUDIES
WNL
HEPATO / GASTROINTESTINAL
Obesity Cirrhosis / Liver Dz Hepatitis / Jaundice Bowel obstruction Ulcers Hiatal hernia GERD
T&S / T&C:
WNL
NEURO / MUSCULOSKELETAL
Arthritis / DJD / DDD OA / RA / Gout Back Problems (LBP) Scoliosis / Kyphosis Headaches / Migraine ICP / Head injury LOC / Unconscious
HCG: LMP:
Location
U/A:
WNL
RENAL / ENDOCRINE
Thyroid disease Bladder Dz / tumor Renal stones Renal insufficiency Renal Failure / Dialysis Adrenocortical insuff.
WNL
OTHER
Immunosuppressed Sickle Cell Dz / Trait Recent steroids Cushingoid Sepsis / Infection Transfusion Hx Weight loss / gain Hearing loss Peripheral edema Multiple gest VBAC IUGR
Anemia Bleeding disorder Cancer Chemotherapy Radiation Tx Nonambulatory Eye Dz / Glaucoma HIV / AIDS G6PD Deficiency
No
Yes
Description _________________________
WNL
TIUP Pre-eclampsia HELLP
PREGNANCY
SGA LGA PROM
AROM
Mg DRIP:
PHYSICAL STATUS
POST ANESTHESIA CARE NOTES Awake Time Somnolent 02 Sat B/P Unarousable % Stable Pulse Resp Temp Unstable Supplimental Pain care plan discussed with RN Oxygen Regional - dermatome level: OPA / NPA Continuous epidural analgesia LMA Recovery recorded on anes. form Intubated Direct admit to hospital ward, Aldrete score _________ No intra-operative anesthesia adverse events noted For >24 hour admits: No adverse anesthesia related complications noted, satisfactory progress and recovery See progress notes for anesthesia related concerns DATE PROVIDER
E
CONTROLLED MEDICATIONS
TIME
USED
DESTROYED
RETURNED
EVALUATOR / DATE:
lb / kg
NONE
DIAGNOSTIC STUDIES
LABORATORY STUDIES
Supplimental OPA / NPA Intubated Direct admit to hospital ward, Aldrete score _________ No intra-operative anesthesia adverse events noted
CONTROLLED MEDICATIONS
RETURNED