anesthesia training: documenting fluids in and out

Anesthesia Training: Documenting Fluids IN and OUT

Presentation TitleDate

Objectives

By the end of this module the participant will be able to:

Add a new fluid from each fluid family to the Fluids FlowsheetAdd an Additive to an IVPerform a bag levelDocument urine output (cumulative)Pause an infusionView Fluid totals and detail in the Fluid Balance Graph


Fluid Families“Colour Coded”

Fluids IN:Blood productsDrug Infusions• eg.Dopamine, Epinephrine

IV Fluids: Anesthesia IV Fluids• Eg. Ringers/NS/Colloids

Fluids OUT:UrineBlood outOther Fluids• Eg. Chest tube drainage


Fluids in Anesthesia Manager: Behavior of Different Fluid Types

Fluids IN:

Continuous: Gravity infusions (eg. NS, LR, RBC’s)• fluid administered NOT accounted in the Fluid Balance until a new bag

is started, the infusion is paused or a bag level is entered.

Bolus: Volume directly added to the fluid balance

Based on rate: Infusions at a specific rate (ml/hr). • These update the fluid balance in real time (eg. Running a fluid at a

specific “pump rate”

Drips: Dose and rate (depends on dilution) • Specific rate, updated in real time to the fluid balance (eg. Propofol or

narcotic infusion)

Fluids OUT:Cumulative: Partial/Total • indicated by a circled value in the flowsheet.


Fluid Flowsheet Symbols

• Colors correspond to fluid families• Forward arrows indicate an active infusion• Up arrows indicate an infusion on pause• Forward arrow with horizontal line above=bag level documented• Large arrow indicate validation


Fluid Flowsheet Symbols (cont.)

• Single numbers indicate •boluses or fluid out totals-eg. Dumped urine of 250 ml.•Infusion rates in ml/hr-eg. Propofol infusion @ 5-6 ml/hr•Initial volume of ”continuous fluids”-eg. 1000 ml NS

• Circled numbers indicate cummulative fluid out totals• Red X indicates a discontinued order• Blue ”carrots” indicate start and stop times of orders


Med Infusions and Fluids (All)

This is our default flowsheet for the addition of all medication infusions and fluids

Accessed by clicking “Medications & Fluids (All)” in Navigation Bar

Default “Fluids IN” include:• 0.9% NS (1000 mL)• 2/3-1/3 (1000 mL)• Ringers Lactate (1000

mL)

Default “Fluids OUT” include:• Blood (Cumulative)• Urine (Cumulative)


1.Click in the appropriate time cell corresponding to 0.9% NS-Dcoument window opens

2. New Bag of 1000 mL. is the default. Highlight other quantity or type in actual volume

3. Injection site defaults to generic IV

4. Hit the check mark to confirm entry onto the record

2. New Bag of 1000 mL. is the default. Highlight other quantity from drop down or type in actual volume

Fluids In-Initiating a Default Fluid Eg: 1000 ml of NS at 19:55


Fluids In-Initiating a Default Fluid Eg: 1000 ml of NS at 19:55


Fluids In-Initiating a Default Fluid“Labelling the Fluid”

Keeping Track of multiple fluids can be difficult• Solution is to label

the site


Fluids In-Initiating a Default Fluid“Labelling the Fluid”

Placing cursor over Fluid order will cause the Site to appear


Fluids In-Initiating a Default FluidOptions

What other options exist in the Document Window?

Base Solution Volume:• 50, 100, 250, 500, 1K, 2K

or• Custom volume

Fixed Infusion Rate• Eg. Volumetric Pump

Addition of Additives

Site of Administration


Fluids In-Initiating a Default FluidEg: 375 ml. LR with 20 mm KCl/L @ 125 ml/hr in the L ACF

1.Click in the appropriate time cell corresponding to Ringers Lactate-Document window will open


Fluids In-Initiating a Default FluidEg: 375 ml. LR with 20 mm KCl/L @ 125 ml/hr in the L ACF

2. Change default volume of 1000 ml. to 375 mL. 3. Scroll to

the additive-KCl-20 mmol

4. Pump Rate-enter in

at 125 ml/hr

5. Use pull down menu to select“Antecubital Left”

6. Adjust Starting Time if required


Fluids In-Initiating a Default Fluid Eg: 375 ml. LR with 20 mm KCl/L @ 125 ml/hr in the L ACF

IV fluids with additives are indicated by a + sign after the order labelPutting your mouse pointer on the treatment name will show full fluid details


Fluids In-Initiating a Default Fluid Eg: 375 ml. LR with 20 mm KCl/L @ 125 ml/hr in the L ACF

When a Fluid Volume other than the default of 1000 ml is chosen, starting a “new bag” will ALWAYS bring up the same Fluid Volume +/- additives.

• Eg: Patient arrived to OR with 375 ml of LR (+ 20 mmol KCL) remaining in bag (as per last slide)

• Bag is empty and you hang 1000 ml of LR. Notice how the “new bag” defaults to 375 (+20 mmlo KCL).

• You must change this to 1000 ml and uncheck the KCl or else your fluid balance will be INCORRECT


Fluids In-Initiating a non Default FluidStandard Option

1. Mouse over “Electrolyte

Replacement” OR

2. Right click over any electrolyte fluid and “Add Item”

3. Pick a fluid

4. Adjust starting time-

default is beginning of

the case



“Add and Document”• Brings up “document

window” prior to order appearing on the record Can adjust time (default time is

beginning of “GA Anesthesia Standard” Session)

Can adjust volume/additives Can set pump rate Can adjust site

“Add”• Enters new order on the

record (default time is beginning of “GA Anesthesia Standard” Session)

• User must now click on desired time on the timeline to open the “Document Window” and enter information

5. Click on either “Add and Document” OR “Add”



Fluids In-Initiating a non Default Fluid Standard Option


Fluids In-Initiating a non Default Fluid Protocol Option

Protocols• are groups of

standard orders, one or more which can be added to the patient chart

• Anesthesia Manager has been configured with a protocol labeled *Anes_Fluids In” that allows for the

selection of the most commonly used anesthetic fluids


Fluids In-Initiating a non Default Fluid “Protocol Option-*Anes_Fluids IN”

*Anes_Fluids In• Most commonly used fluids used in

an anesthetic

• (B) indicates Bolus delivered fluidValues (Volume) will immediately be added to the Fluid Balance

• IV INF or IV Continuous indicates gravity or rate delivered fluidValues (Volume) will only be added to the Fluid Balance when a “Bag Level” is performed or a Fluid is discontinued.


Fluids In-Initiating a non Default Fluid Protocol Option-*Anes_Fluids IN

Eg. Add a unit of PRBC’s to be delivered over time

1. Click on the “protocol” icon

ORPull down the “Order Menu”

2.Select the “*Anes_Fluids In” protocol

3. Select “RBC ml Cont.” x 7 days

4. Default starting time is the beginning of the case (Anesthesia Standard session)

5. Hit “Add” to have order appear on record

1. Click on the “protocol” icon

ORPull down the “Order Menu”




•RBC ml IV now appears onthe record

•To add a unit of RBC, place cursor over appropriate time on timeline and click to open “Document Window”

1. Document the volume to be administered

2. Enter the Unit #

3. Adjust the site if required

4. Tick the checkbox to document on the

record

200


Fluids IN-Pausing an Infusion

1. Click at relevant time-Document Window opens

2. Change “Action” to Pause

4. Hit Check Mark3. Enter in

“Bag Level” if desired


Fluids IN-Pausing an Infusion

Upward arrow (BOLD) indicates infusion put on hold at a specific timeContinued upward arrows indicate infusion still on hold


Fluids IN-Restarting an Infusion

1. Click at desired time to resume infusion

2. By default, action returns to “Infusing”

3. Hit check


Fluids IN-Restarting an Infusion

Forward arrow (BOLD) indicates that infusion has restarted


Fluids IN-Discontinuing a Fluid

1. Click at desired time-Document Window opens

2. Click on “X”

3. Click “Yes” to prompt

4. Insert “Bag Level” and hit “OK”


Fluids IN-Discontinuing a Fluid

X indicates Fluid has been discontinued


Fluids Out

Fluids Out (Default)• Blood (cumulative)• Urine (cumulative)


Fluids Out-Initiating a Default Fluideg. Urine Output of 250 ml.

2. Enter volume of “Fluid Out”

3. Adjust time if required

4. Hit OK to appear on record

1. Click cursor on appropriate “Fluid Out” at desired time (Document window opens)


Fluids Out-Initiating a Default Fluideg. Urine Output of 300 ml.

Cumulative• Simply means total

In this example, there was no previous documentation of urine output

Therefore, 0 + 250 = 250.


Fluids Out-Initiating a Default Fluideg. Adding an additional Urine Output of 300 ml.

Previous “amount” of 250 ml is displayed in the “Amount”

2. Add in new “Partial” amount-300 ml

4. Hit OK to appear on record

1. Click cursor at new time point (Document window opens)


Fluids Out-Initiating a Default Fluideg. Adding an additional Urine Output of 300 ml.

•Previous urine output of 200 ml. + current urine output of 300 ml. = 550 ml.


1. Mouse over “Fluids

Out” OR

3.Pick a fluid

4. Adjust starting time-

default is beginning of

the case

2. Right click over any electrolyte fluid and “Add Item”

Fluids Out-Documenting a non Default Fluid

Standard Option


Fluids Out-Documenting a non Default Fluid

Standard Option“Add and Document”• Brings up “Document

Window” prior to order appearing on the record Can adjust time (default time

is beginning of “GA Anesthesia Standard” Session

Can adjust amount

“Add”• Enters new order onto the

record• Default time is beginning of

the session• User must now click on

desired time on the timeline to open the “Document Window” and enter information


5. Enter in “amount” and hit “OK”

5. Enter in “amount” and hit check box


Fluids In-Initiating a non Default FluidProtocol Option-*Anes_Fluids OUT

1. Click on the “protocol” icon OR

Pull down the “Order Menu” 2.Select the “*Anes_Fluids Out” protocol

3. Select “Neuro Drain#2 Cumulative x 7 days

4. Default starting time is the beginning of the session (Anesthesia Standard)

5. Hit “Add” to have order appear on record


Fluids In-Initiating a non Default FluidProtocol Option-*Anes_Fluids OUT


Fluid Documentation: Audit Trail

Click on the Audit Trail button to see the History for that fluid order• Who documented, changed the documentation, bag leveled, added

additives.


Fluid Balance

1. Click on the “Fluid Balance” iconOR

Pull down the “Insert/View” menuOR

Hit F9 on the keyboard

1. Click on the “Fluid Balance” iconOR

Pull down the “Insert/View” menuOR

Hit F9 on the keyboard


Fluid Balance

•Gross Fluid Balance displayed in absolute amounts with accompanying pie graph

1. Hit “Fluid Balance Detail”

icon

The total for each fluid family is displayed

The net Balance

The “Total IN” and “OUT” are above and below the bar graph


Fluid Balance“Pitfalls”

In a gravity based infusion, the System has no idea as to how much fluid has been administered over a fixed period of time. Therefore, the fluid balance is recorded as 0 (ZERO)


Fluid Balance“Pitfalls”

A “Bag Level” must be performed on a gravity based infusion to tell the system the volume of fluid administered.


Fluids in Anesthesia Manager: ExerciseFind the fluid flowsheet

Order a fluid from each family type, both Fluids IN and Fluids OUT.• 0.9% NS• Blood Product• Chest Tube output• Estimated Blood Loss

Enter information for each fluid order, paying close attention to each data field in the validation windows.

Add the additive of 40 meq KCL to a D5W-1000 ml infusion started in the left antecubital fossa

Look at the fluid balance window. Open the fluid balance detail for more specific information about which fluids were given.


Questions And Answers

anesthesia training: documenting fluids in and out

Documents

new fluid

fluid order

fluid family

cummulative fluid

fluid balancebased

infusionview fluid totals

default flowsheet

epinephrineiv fluids