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ANESTHESIA RECORD

Date OR # Page of

Procedure(s) Surgeon(s)

START

STOP

Anesthesia Procedure
Room Time IN: OUT:

PRE-PROCEDURE

MONITORS AND EQUIPMENT

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

Des N20 Oxygen AGENTS

Iso Air

Sev

TIME: Hal (ET%) (L/min) (L/min) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )

TOTALS

FLUIDS Urine EBL Gastric ECG % Oxygen Inspired (Fi02) 02 Saturation (Sa02) End Tidal C02 Temp: C F

OUTPUT

(ml) (ml) (ml) SYMBOLS

MONITORS

B/P CUFF PRESSURE

ARTERIAL LINE

PERI-OP MEDS

TIME

X
200 180 160
150 150 180 180

MEAN ARTERIAL PRESSURE

PULSE

VENTILATION

140 120 100 80


Pre-procedure Vital Signs
100 120 120

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

(cm H20) (cm H20)

DOWN:

Symbols for Remarks Position

TOTAL TIME:

History from:

Patient Parent / Guardian Significant Other

Chart Poor Historian Language Barrier

PRE-ANESTHESIA EVALUATION
AGE SEX

See previous anesthesia record dated _________________ for information


HEIGHT WEIGHT

PROPOSED PROCEDURE

M
PREVIOUS ANESTHESIA / OPERATIONS NONE CURRENT MEDICATION(S) NONE

F
in / cm lb / kg
Hx Illicit drug use

Hx Herbal / OTC drug use

MP1 MP2 MP3 MP4


WNL

T-M distance = M-O distance = Neck FULL LIMITED NONE ROM

Morbid obesity Hx difficult airway Teeth poor repair Teeth Chipped / Loose:

AIRWAY

Edentulous Facial hair Short muscular neck

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:

Pre-procedure Pulmonary Physical Exam:

WNL

CARDIOVASCULAR

Hypertension Hyperlipoproteinemia CAD / Cardiomyopathy Angina Stable / Unstable Myocardial infarction CHF DOE PND Peripheral Vascular Dz Exercise Tolerance METs: > 4 <4

Pre-procedure Cardiac Physical Exam:


ETHANOL USE: No Yes Frequency ________________ Hx ETOH abuse Quit

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

FAMILIAL ANES PROBLEMS:

No

Yes

Description _________________________

WNL
TIUP Pre-eclampsia HELLP

PREGNANCY
SGA LGA PROM

AROM

Mg DRIP:

__________gm/hr SROM PITOCIN DRIP G: P: INDUCTION

WEEKS GEST: EDC: 1

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

HISTORY PRESENT ILLNESS / SURGICAL DIAGNOSIS


MEDICATION

USED

DESTROYED

RETURNED

PLANNED ANESTHESIA GA Local / MAC Epidural Caudal Cont Spinal CSE

Special Monitors / Airway / Concerns:


PROVIDER WITNESS

Deep Sedation SAB Regional: PRE-ANESTHESIA DIRECTIONS / MEDICATIONS

EVALUATOR / DATE:

NPO per ASA EVALUATOR / DATE: Guidelines

See previous anesthesia record dated _________________ for information

lb / kg

NONE

DIAGNOSTIC STUDIES

LABORATORY STUDIES

POST ANESTHESIA CARE NOTES Somnolent Unarousable

Supplimental OPA / NPA Intubated Direct admit to hospital ward, Aldrete score _________ No intra-operative anesthesia adverse events noted

See progress notes for anesthesia related concerns

CONTROLLED MEDICATIONS
RETURNED