| Sıra | DOSYA ADI | Format | Bağlantı |
|---|---|---|---|
| 01. | Anesthesia Medication Medications Anesthesia | ppt | Sunumu İndir |
Transkript
Anesthesia Record Jutarat Luanpholcharoenchai Department of Anesthesiology Srinakharinwirot University
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Anesthesia record forms 1. Preanesthetic preparation and evaluation 2. Informed consent & Consent form 3. Anesthesia record 4. Post anesthesia record (PACU record) 5. Post anesthesia visit
1.Preanesthetic preparation and evaluation
HN ……..…..…./….…… AN ……..…..…./….…… Date …..../…..../….… Consent for surgical procedure N YName …..…………...…...……..……………………. Student Name ………………...……...………………………Yr.….Group.……Ward ………… Age ………. yr Sex M F Staff Anesthesiologist …………..………… Report approved N YMedical HistoryPresent Illness:……………………………………..……………………………………………………………………………………………..... ……………………………………………………………………………………………………………………………………………………………..Medical Problem(s):……………………………………………………………………………………………………………………………….………………………………………………………………………………………………………………………………………………………………..Concurrent Medications:………………………………….…………………………………………………………………………………..…… ……………………………………………………………………………………………………………………………………………………………..Allergic history: มมมมมมมมมม มมมมม มมมมมมมม มมมมม มมม Previous anesthesia: มมม ม; มมม GA RA NBมมมมมมม มมม ม: มมม…………….....………………………………มมมมมมมมมมมมมมมมม ………….……..…..…………………………………Family history: มมมมมมมมมมมมมมมมมม DM / HT / IHD มมม Past history: มมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมม ม: มมม ….…….…………………......………………………… มมม ม: มมม ….…….…………………......…………………………มมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมม มมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมม มมมม มมมมม ม: มมม ….…….…………………......………………………… มมมมม ……………. มมมมมมมมมมมมมมมมม ………………………………..Social habit: มมมมม มมมม มม; มมม …...………………………Socioeconomic status: มมมม ……..……… มมมมมมมม ……….……มมมมม มมมม มม: มมม…..…….………………………………………Payment: มมมมมมมม มมมมมมมมม มมมมมมม 30 มมมมมมมมมมมมม มมมม มม: มมม…...…….…………………………………มมมมมมมมม มมม.มมมมม มมมมมมมม ……...…………….Preanesthetic Evaluation and Preparation FormDepartment of Anesthesiology, Faculty of Medicine, SWU+ discontinue drugs eg aspirin clopidogrel herbals etc.Smoking pack/yearGA intubation LV ???, PONV???RA SB –PDPH???Hx malignant hyperthermia
Systemic Reviewม. มมมมมมมมม มมมมมมม มมมมมมมมม มมมมมมมมม 1 มมมมมมมมมมมมมมมมมมมมมมม มมมมม มมม. มมมมมมมมมมมมมมมมมมมมมมมม มมม มมมมมมมมมมม (contact lens) มมมมม มมม. มมมมมมม มมมมม มมมมม มมมมมมมมมมมมมมมมมมมมมมมมมมม มมมมม มมม. มมมมมมม มมมมมมมมมมม มมมมม มมมมมมมมม มมมมมมมมมมมมมม มมมมม มมม. มมมมมมมมมมมมมม มมมมมมมมมมมมมมม มมมมมมมมมม/มม มมมม มมมมมมมมมมมมมม มมมมม มมม. มมมมมมมม มมมมมมมมมม มมม มมมมมมมมมมมมมมมมมมมมมมม มมมมมมมมมมม มมมมม มมม. มมมมมมมมมมมมมมมมมมมม มมมมมมม มมมมมมมม มมมมมมมมม มมมมมม มมมมมมมมมมม มมมมม มมม. มมมมมมมมมมมมมมมม มมมมม มม มมมมมมมมมมมมมมมม มมมมมมมมมมมมม มมมมม มมม. มมมมมมมมมม มมมมม มมมมม มมม. มมมมมมมมมมมมมมมมมมมมมมม มมมมมมม มมมมมมมมมมมมมมมมมม มม มมมมม มมม. มมมมมมมมมมมม มมมมมมมมมม มมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมม มมมมม มม(มมมมมมมม)ม. มมมมมมมมมมมมมมมมมมมมมมมมมม …………………………ม. มมมมมมมมมมมมมมมมมมม มมมมม มมIn ambulatory case เเเเเเเเเเเเเเเเเเเเเเเเเเเเเ !!!!!
Physical ExaminationBP / mmHg P /min RR /min T oC Body weight kg Height cm BMI =General appearance:Heart: Lungs:Abdomen:Nervous system:Musculoskeletal system:Airway:Oral cavity Mouth opening cm TM jointsTrachea midline shift; R L Thyromental distance cm Neck motionMallampati's classification NostrilsDental condition; Tooth mobility…….. …….. …….. …….. …….. …….. …….. ……..Extracted tooth or edentulous arch……………………… Removable dentureInvestigationsCBC: Hb gm% Hct % WBC /mm3 Platelet /mm3 Blood group: A B AB O Rh: neg. pos.FBS/BS mg%; BUN mg%; Creatinine mg%; E'lytes: Na+ mEq/L K+ mEq/L Cl- mEq/L HCO3- mEq/LLFT: Alb Glob A/G TP AST ALT ALP TB DB IDBCoagulogram: PT PTT INR Other blood test:CXR ECGOthers:Caries Crown Bridge evaluation for DIFFICULT INTUBATION !!!Limit mouth opening <4 cmThyromental distance <6.5 cmLimit neck extension Mal ampati class III, IVSUSPECTED DIFFICULTINTUBATION
Anesthesia PlanPreoperative Diagnosis:……………………………………………………………………………………………………………………….……Proposed Operation(s):………………………………………………………………………………………………………………………….…Anesthesia risk(s):……………………………………………………………………………………………………………………….….……….Risk of gastric reflux: N Y ………………………………… ASA physical status: 1 2 3 4 5 6 EPreanesthetic preparation:………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Premedication:…………………………………………………………………………………………………………………………………………Anesthetic choice: GA………………………. RA…………………………. Combined G-RA/LA………………….. MACAgent(s): Induction………………….. Intubation…..……………….. Narcotics…….……………… Inhalation …………………….Muscle relaxant…....………… Reversal ………………..……… LA………………………………………… Other……………………..Fluid replacement: Crystalloid Colloid Blood / Blood product replacement required N YPosition:………………………………………………………………… Monitoring: Routine Invasive ………………………..…Special technique(s):……………………………………………………………………………….. Extubation after surgery: N YPostanesthesia care planNeed ICU care postop: N Y PACU care: Routine Special………………………………………..………………………Medical problems suspected difficult ventilation / intubationReference “ ASA guideline 2014”NPO, ICU booking, DTX at ... blood& blood component preparationOne lung ventilationCardiopulmonary bypassDeliberated hypotensionPe ipheral nerve monitoringAntihypertensive, anxiolysis, bronchodilator,...
2. Informed consent
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3. Anesthesia record
Name Weight kg.Age Sex Ward BMI Height cm.Anesthesia machine No. Pre-use check: Y N Consent: Y N PremedicationASA physical status: NPO hr.Proposed operationOperation performedAnesthesiologist Surgeon Scrub nurseNurse anesthetist Assistant Circulating nurseAgents Time Remarks:N2O / AirOxygenFi :UrineBloodFluidsFluid M5 6 ElossPreop. DiagnosisPostop. Diagnosis1 2 3 4FTotalIVAnesthetic agentsFi: isoflurane/sevoflurane/desfluraneInductions: thiopental, propofol, etomidate, ketamine, dormicumNarcotics: morphine, fentanyl,meperidineM.relaxant: atracurium, cis atracurium, vecuronium, succinylLocal anesthetic agents(continue): bupivacaine, xylocaine Vasopressor& inotrope: ephedrine,levophed, adrenalineOthers: CaCO3, transamineCrystalloids : ringer lactate,aceta ,0.9% NaClColloids : gelatin, strachs Others: mannitol
FiO2SpO2ETCO2EKGPawAnes. StartAnes. End Extubation in OR: Y NBreathing: o Spont. o A/CTransferred to:Total time o PACU o ICU o Ward Biopsy done Y N Eye coveredSpecimen Y NIV cath. # Site# Site# SiteCVP cath. # Site# SitePA cath. # SiteArt. cath # Site# SiteSpecial monitoring:Special techniques:Newborn data: TOB Sex M FAPGAR Score at minAssessed byRemark Choice of o GA o RA o MACPosition Anesthesia o CGRA o CGLARA/LA: Procedure Needle Gauge Complication(s):Drug(s) Anesthetic levelGA: o ETT o Under mask o LMA# o Tracheostomy# o Emergency airway o TIVAIntubation: o Routine o Rapid sequence o Awake Laryngoscope blade: o Curved # o Straight #o Direct o Blind o Fiberoptic o Laryngoscopic view: Grade ETT: o Std. o RAE o Flexible o Bronchocath o o Oral o NasalSize depth cm. No.attempts Airway: o Oral # o Nasal # Breathing system:Monitoring200 hr minSummary4Sys Dias Pulse Temperature Δ Anes. Start X Op.Start Anesth. End Intubation T Reverse R Blood Transfusion oCBasico Cuff o Non-cuff o Pack21 3220180Respiration160402034801401201003230Assisted A Controlled CRespiration: Spont. S603836FiO2 0.4SpO2 100ETCO2 35EKG SRPaw 15PEEP 4TV 550
4. Post anesthesia record( PACU record )
Operation performedDay case surgeryAnesthetic choice: r GA r RA r MAC r CGRA r CGLAAnesthesiologist SurgeonStatus on admission: Admission time TimeviaBreathing: r Spontaneous r Assist / Control L/minIntravenous fluids: AmountType mlType mlType mlType mlType mlBlood and blood components:Type mlType mlType mlDrain:Type mlType mlType mlUrine: color mlSurgical wound(s): (describe)Consciousness: r Alert r Arousable r Unconscious Airway: r Oral# r Nasal# r ETT# r SpO222020018016040201000C32O2Remark383634408060140120RRPost-Anesthesia RecordHRH Princess Maha Chakri Sirindhorn Medical Center
Oxygenation SpO2 > 92% on room airSpO2 > 90% on oxygenSpO2 < 90% on oxygenRespiration Breathes deeply and coughs freelyDyspneic, shallow or limited breathingApneaCirculation BP +/- 20% of normalBP +/- 20-50% of normalBP +/- more than 50% of normalConsciousness Fully awakeArousable on verbal commandUnresponsiveActivity Moves all extremitiesMoves two extremitiesNo movement Medication(s) dose route time Total scoreRemark: Complication(s) in PACU:Ο Hypotension Ο HypertensionΟ Arrhythmia(s) Ο HypoxiaΟ Airway obstruction Ο HypoventilationΟ Nausea/vomiting Ο ShiveringΟ Urinary retention Ο BleedingΟ Other8 Discharge summary: TimeSummary of fluid intake: IV/blood/blood components Summary of output: Duration of stay hr minType total ml Type total ml Ο Urine total ml Discharged/Approved byType total ml Type total ml Ο Drain total ml Transferred to Ο Ward Ο ICU Ο OR Type total ml Type total ml Ο total ml r Home discharge:56Modified Aldrete's Postanesthetic Recovery Score71234On arrival 15' 30'245' 60'15' 30' 15' 30'45' 60'21002102145' 60'10210
5. Postanesthesia visit
√ มมมม D1 มมม complications มมมมม -- มมมมมมมมม complicationcase GA มมมมมมมมมมมมมม PDPHCase RA, Nerve block มมมมมมมมม sedate มมมมมมมมมมมมมม awarenessมมมม pain score at rest /activity , pain management, มมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมมม
Anesthesia Medication Medications Anesthesia
Yıl : 2020
Anahtar Kelimeler
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