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Patient Name: MRN: DOB: Age: Sex: M F Weight: kg Height: cm BMI: |
Date of Surgery:
OR Room: Surgeon: Anesthesiologist: CRNA/Resident: |
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Procedure:
CPT Code: Diagnosis: |
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| ASA Class: I II III IV V VI E | Anesthesia Type: General (GETA/LMA) Regional (Spinal/Epi) MAC/Sedation Combined Block | |
| Patient In Room | Anesthesia Start | Induction | Intubation | Surgical Start (Incision) | Surgical End | Extubation | Anesthesia End | Patient Out | Total Times |
|---|---|---|---|---|---|---|---|---|---|
| : | : | : | : | : | : | : | : | : |
Anesth: ___ hr ___ min Surg: ___ hr ___ min |
| Symbols: | V = Systolic | ^ = Diastolic | X = MAP | • = Heart Rate | ○ = Resp Rate | T = Temp |
| Time | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| SpO2 (%) | ||||||||||||
| ETCO2 | ||||||||||||
| FiO2 (%) | ||||||||||||
| RR / Mode | ||||||||||||
| TV / PIP | ||||||||||||
| PEEP | ||||||||||||
| Temp (°C) | ||||||||||||
| BIS / TOF |
| Induction Agent | Dose | Time | Route | Muscle Relaxant | Dose | Time | Initials |
|---|---|---|---|---|---|---|---|
| Propofol | IV | Succinylcholine | |||||
| Fentanyl | IV | Rocuronium | |||||
| Midazolam | IV | Cisatracurium | |||||
| Lidocaine | IV | Vecuronium |
| Agent | Start | Stop | % Range |
|---|---|---|---|
| Sevoflurane | |||
| Desflurane | |||
| Isoflurane |
| Drug | Conc | Rate | Total |
|---|---|---|---|
| Propofol | |||
| Remifentanil | |||
| Dexmed. |
| Time | Drug | Dose | Route | Time | Drug | Dose | Route |
|---|---|---|---|---|---|---|---|
| Abx: ___________ | IV | Ephedrine | IV | ||||
| Ondansetron | IV | Phenylephrine | IV | ||||
| Dexamethasone | IV | Glycopyrrolate | IV | ||||
| Paracetamol | IV | Neostigmine | IV | ||||
| Ketorolac | IV | Sugammadex | IV | ||||
| Fentanyl | IV | Labetalol | IV | ||||
| Morphine | IV | Hydralazine | IV |
| Fluids | Vol (mL) |
|---|---|
| Crystalloid | |
| Colloid | |
| Blood Prod. | |
| TOTAL IN |
| Output | Vol (mL) |
|---|---|
| Urine | |
| EBL | |
| Other | |
| TOTAL OUT |
| Time | pH | Hb | Glu | Lac |
|---|---|---|---|---|
| Time | Event Description | Vital Signs | Intervention / Response | Provider |
|---|---|---|---|---|
Include: Technique details, complications, hemodynamic course, respiratory management, special considerations...
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Reversal Given (Drug/Dose): ________________ TOF Ratio > 0.9 Spontaneous Resp Adequate Following Commands / Protective Reflexes Outcome: Extubated in OR Transported Intubated Condition: Smooth Coughing Laryngospasm |
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Destination: PACU ICU
Ward Transport Vitals: BP: ___/___ HR: ___ SpO2: ___% O2: ___L Patient Condition: Stable Unstable Handover To: _____________________________ Pain Control: IV PCA Epidural |
I attest that I personally performed/medically directed the anesthesia services documented in this record.
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Anesthesiologist Signature & Stamp |
CRNA / Resident Signature |
| Date: Time: | Date: Time: |
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Patient Name: MRN: Date: |
Anesthesiologist: Location: OR Block Room Pre-Op |
| Pre-Procedure Checklist | Patient Assessment |
|---|---|
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Patient identity verified (2 identifiers) Procedure/surgical site confirmed Informed consent obtained & documented Allergies reviewed (LA, antiseptic, adhesive) Coagulation status acceptable: INR: _____ PTT: _____ Plt: _____ × 10³/µL Anticoagulants: None Held ___days Neurological exam documented (baseline) IV access established Standard ASA monitors applied Oxygen/resuscitation equipment available Emergency drugs/lipid emulsion available Timeout performed |
Vital Signs: BP ___/___ HR ___ SpO2 ___% Weight: _____ kg (for LA dose calculation) Baseline Neurological Exam: Sensation intact bilaterally Motor function 5/5 all extremities No pre-existing deficits Deficits noted: _________________ Contraindications Screened: No infection at injection site No severe coagulopathy No patient refusal No allergy to local anesthetics No increased ICP (for neuraxial) |
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Type of Block: Spinal (Single-Shot) Epidural (Single-Shot) Epidural (Continuous Catheter) Combined Spinal-Epidural (CSE) Caudal |
Indication: Primary Anesthetic Post-operative Analgesia Labor Analgesia Chronic Pain Management Procedure: _____________________ |
Procedure Details: Time Started: __:__ Time Completed: __:__ Duration: _____ min Provider: _______________ |
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Patient Position: Sitting Lateral Decubitus (Left / Right) Prone (for caudal) Position Verified Stable: Yes |
Anatomical Level Identified: Tuffier's Line (L4-L5 interspace) Insertion Level: L___-L___ interspace Landmark Technique: Palpation Ultrasound Spine Anatomy: Normal Difficult (scoliosis, obesity, prior surgery) |
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Hand hygiene performed Sterile gloves worn Skin prep: Chlorhexidine-alcohol Povidone-iodine Allowed to dry completely (minimum 30 seconds) Sterile drape applied Sterile field maintained throughout procedure |
| Parameter | Details |
|---|---|
| Approach | Midline Paramedian Taylor (for caudal access) |
| Local Infiltration |
Drug: Concentration: _____% Volume: _____ mL Skin wheal raised Deeper tissues infiltrated |
| Introducer Needle | Gauge: _____ Used Not used |
| Spinal Needle |
Type: Whitacre Sprotte Quincke Other: _____ Gauge: 22G 24G 25G 27G 29G Length: _____ mm |
| Epidural Needle |
Type: Tuohy Crawford Hustead Gauge: 16G 17G 18G Length: _____ mm |
| Number of Attempts |
Total attempts: _____ 1 2 3 >3 Number of interspaces used: _____ Level(s): ______________ |
| Space Identification |
For Spinal: CSF flow clear CSF flow sluggish Bloody tap For Epidural: Loss of Resistance (LOR) to: Saline Air LOR at depth: _____ cm from skin Hanging Drop technique |
| Component | Drug Name | Concentration | Volume (mL) | Total Dose | Lot Number |
|---|---|---|---|---|---|
| Primary LA |
Bupivacaine Ropivacaine Lidocaine Other: _____ |
_____% | _____ mL | _____ mg | |
| Opioid |
Fentanyl Morphine Sufentanil Hydromorphone None |
_____ mL | _____ mcg/mg | ||
| Adjuvants |
Epinephrine 1:200,000 Clonidine Dexamethasone None |
_____ mL | _____ mcg/mg | ||
| Total Dose of Local Anesthetic: | _____ mL | _____ mg | Max Dose Check: ✓ | ||
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Epidural Catheter: Catheter placed Catheter type: Single-orifice Multi-orifice Catheter gauge: _____ G Depth inserted: _____ cm at skin Depth in epidural space: _____ cm Catheter aspirated - negative for blood/CSF Test dose given: Drug __________ Volume _____ mL |
Test Dose Response: Negative (no tachycardia, no motor block) Positive - repositioned Catheter Secured: Tunneled and taped securely Sterile dressing applied Filter attached Catheter marked clearly |
| Time Post-Injection | Sensory Level (Dermatome) | Motor Block (Bromage) | Vital Signs | Assessment |
|---|---|---|---|---|
| 5 min | R: T___ L: T___ | 0 1 2 3 | BP: ___/___ HR: ___ | Adequate Incomplete |
| 10 min | R: T___ L: T___ | 0 1 2 3 | BP: ___/___ HR: ___ | Adequate Incomplete |
| 15 min | R: T___ L: T___ | 0 1 2 3 | BP: ___/___ HR: ___ | Adequate Incomplete |
| 20 min | R: T___ L: T___ | 0 1 2 3 | BP: ___/___ HR: ___ | Adequate Incomplete |
| Final | Peak Level: T___ to S___ | Bromage: ___ | BP: ___/___ HR: ___ | Block: Successful Failed |
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Block Type(s) Performed: Interscalene (ISB) Supraclavicular Infraclavicular Axillary Femoral / Adductor Canal Sciatic (Subgluteal / Popliteal) Pecs Block (I / II) Serratus Anterior Plane Transversus Abdominis Plane (TAP) Quadratus Lumborum (QL) Paravertebral Erector Spinae Plane (ESP) Other: ____________________ |
Laterality: Left Right Bilateral Indication: Surgical Anesthesia Post-operative Analgesia Acute Pain Management Chronic Pain Management Surgical Procedure: _________________________________ |
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Equipment: Ultrasound machine: _____________________ Probe type: Linear (high-freq) Curvilinear (low-freq) Frequency: _____ MHz Sterile probe cover applied Sterile gel used |
Image Quality: Excellent visualization of target nerve(s) Adequate visualization Difficult visualization (obesity/edema/anatomy) Needle Approach: In-plane Out-of-plane |
| Block Name | Side | Needle Type/Size | LA Drug/Concentration | Volume (mL) | Nerve Stimulator | Time |
|---|---|---|---|---|---|---|
| L / R | Yes mA: ___ No | |||||
| L / R | Yes mA: ___ No | |||||
| L / R | Yes mA: ___ No | |||||
| Total Volume of Local Anesthetic: | _____ mL | Total Dose: _____ mg | ||||
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Aspiration prior to each injection (negative for blood) Incremental injection technique used (3-5 mL aliquots) Frequent verbal communication with patient maintained Monitoring for signs of intravascular injection (tachycardia, dizziness, tinnitus, metallic taste) Monitoring for signs of local anesthetic toxicity throughout procedure Patient able to report symptoms (pain, paresthesia) if awake 20% Lipid emulsion immediately available Real-time visualization of needle tip and LA spread under US |
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Catheter Details: Perineural catheter placed Block type: _________________________ Side: Left Right Catheter gauge: _____ G Catheter insertion depth: _____ cm at skin Catheter aspirated - negative for blood |
Bolus Dose via Catheter: Drug: __________ Concentration: _____% Volume: _____ mL Catheter Secured: Tunneled technique used Catheter taped securely Sterile dressing applied Filter attached Clearly labeled |
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Intra-Procedure Complications: None Bloody tap / traumatic puncture Paresthesia during needle insertion Persistent paresthesia after block Intravascular injection (recognized & managed) High/total spinal (neuraxial) Hypotension (SBP < 90 or >30% drop) Bradycardia (HR < 50 bpm) Respiratory distress Horner's syndrome (expected for ISB) Local anesthetic systemic toxicity (LAST) Pneumothorax (suspected) Other: _________________________ |
Management Actions Taken: Procedure stopped/repositioned IV fluid bolus: _____ mL Vasopressor given: Drug _____ Dose _____ Oxygen supplementation: _____ L/min Airway management required Lipid rescue initiated (for LAST) Patient reassured / anxiolytic given Imaging ordered (CXR for pneumothorax) Neurology consult requested Surgeon/attending notified Incident report filed Outcome: Resolved Ongoing monitoring |
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Block Success: Adequate sensory block achieved Adequate motor block (if intended) Patient comfortable / pain-free Partial block - supplementation planned Failed block - alternative plan initiated Time to Onset: _____ minutes Expected Duration: _____ hours |
Patient Instructions Given: Protect insensate limb / avoid injury Signs/symptoms of block resolution explained When to seek medical attention (persistent numbness, weakness) Fall precautions (especially lower extremity blocks) Catheter care instructions (if applicable) Contact number provided for concerns Written instructions given |
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Patient Discharged To: Operating Room (proceeding to surgery) Pre-operative holding area Ward / floor Day surgery (ambulatory) Vital Signs Stable: BP ___/___ HR ___ SpO2 ___% Follow-Up Plan: Routine post-op rounds by anesthesia Acute Pain Service (APS) follow-up for catheter management Phone follow-up in 24-48 hours Clinic follow-up if persistent symptoms No specific follow-up needed |
Procedure summary, challenges encountered, special considerations:
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Professional Attestation: I have personally performed/supervised this regional anesthesia procedure. The patient was informed of risks, benefits, and alternatives. Informed consent was obtained. The procedure was performed using sterile technique with appropriate monitoring and safety precautions.
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Anesthesiologist Signature |
Printed Name & Medical License # |
| Date: Time: |
Supervising Attending (if resident/fellow performed) |