how do i chart … epidural catheter insertion and anesthetic drugs low thoracic epidural pt sitting...

How do I chart …

EpiduralEpiduralCatheterCatheterInsertionInsertion

andand

AnestheticAnestheticDrugsDrugs

Low Thoracic EpiduralPt sitting – skin prep + LA – site T9-10#17 Touhy – LORTA – easy – space @ 7cmCatheter passed easily – no CSF / no paresth.Catheter 12cm @ skin - EpiGardTest dose: Lido 1.5% /w epi 1:200K 3ml - OK

EPID: Bupiv 0.25% + epi BOLUS (ml)

+ Fentanyl 5mcg/ml INFUSE (ml/h)66

5

Charting Regional - Epidural EventsCharting Regional - Epidural Events

• You want to “bookmark” the time you start the EpiduralYou want to “bookmark” the time you start the Epidural

• Look for the Macro Bar in the upper right part of the screenLook for the Macro Bar in the upper right part of the screen

RegionalRegionalAnesthesiaAnesthesia

StartStart

MonitoredMonitoredAnesthesia CareAnesthesia Care

StartStartGeneralGeneral

AnesthesiaAnesthesiaStartStart

• Clicking on one of these 3 Buttons will place a bookmark onClicking on one of these 3 Buttons will place a bookmark on the Timeline the Timeline

• For a Combined Regional – General Anesthetic:For a Combined Regional – General Anesthetic: – click Regional when starting Block – click Regional when starting Block – then click General when Inducing the GA – then click General when Inducing the GA

If you are familiar with adding an Event, skip to Slide 8 Click HereClick Here


• A “Tool Tip” appears when the cursor arrow hovers over a buttonA “Tool Tip” appears when the cursor arrow hovers over a button

• In this case, the name of the Macro button is “Regional Start”In this case, the name of the Macro button is “Regional Start”

• This button has been configured to add :This button has been configured to add : - event #1: the time that you began the Regional Anesthetic - event #1: the time that you began the Regional Anesthetic - a reminder: you need to select an “Anesthesia Type” - a reminder: you need to select an “Anesthesia Type”

- event #2: Oxygen by nasal cannula or facemask- event #2: Oxygen by nasal cannula or facemask

• when the button is left-clickedwhen the button is left-clicked a pop-up window appears a pop-up window appears

• you have two choices:you have two choices: - accept the time shown - accept the time shown (OK button or hit [Enter] key) (OK button or hit [Enter] key) - change the time - change the time (if you were delayed or (if you were delayed or forgot to click Regional Start) forgot to click Regional Start)

After clicking the Regional Start button:After clicking the Regional Start button:

• The button has a “depressed” look to showThe button has a “depressed” look to show that it has been clicked (no need to repeat!) that it has been clicked (no need to repeat!)

• There is now the symbol “R” on the TimeLineThere is now the symbol “R” on the TimeLine (in the 15:25 time box but reads 15:26) (in the 15:25 time box but reads 15:26)

• Hovering over the “R” symbol tells you whatHovering over the “R” symbol tells you what Events have been logged Events have been logged (Note: other Events show on the TimeLine (Note: other Events show on the TimeLine as blue squares) as blue squares)

Now you can direct your full attention toNow you can direct your full attention toperforming the Epidural.performing the Epidural.

Once the Case is well underway, you can Once the Case is well underway, you can complete the documentation. complete the documentation.



When the Case is underway and you have time to document, the TimeLine has moved along and the Regional Start bookmark has disappeared

Scroll BackScroll Back1 TimeBox1 TimeBoxat a timeat a time

Click HereClick Herefor larger for larger

time scrollstime scrolls

YellowYellowTimeBoxTimeBox

is current timeis current time

Once you see the “R” symbol, identify it as the Regional bookmarkby hovering over it with the mouse pointer

Note: The TimeBox is 15:25 but the Bookmark is for 15:26

Grey Squareshows position on

TimeLine


To document the insertion of the Epidural,You need to “Add Events”

There are a few ways to do this.

The “formal” way is to use the menu“Insert/View” and select “Add Events”

OR - You could use the “F6” key

This is what happens:

A large pop-up box appears with the CurrentCurrent time entered asthe default time.

Since you wanted 15:26 or thereabouts, this will require the tediousjob of editing the time.

Charting Regional - Epidural EventsCharting Regional - Epidural EventsThe SIMPLEST method is to Left-Click on the TimeLine

But the question is: Where Exactly?

If you click in the 15:25 TimeBox, the Add Events box time will default to 15:25 but the Regional bookmark says 15:26.This can be easily altered by clicking on the Minutes and typing in the time you want.

OR – click on the 15:30 TimeBox!

You can use You can use these tiny these tiny

arrows, too. arrows, too.


This is the Left half of theAdd Events pop-up

The “Event Set” named“A062-Regional-Epidural”was left-clicked

The list of “Events” thenappeared in the rightpanel

The idea is to select allEvents that you want to use to document

Hold down the [Ctrl] keywhile you left-click on each desired event

Anesthesia Types are available, too


In this view, the sliderfor the right panel hasbeen used to view theEvents in the lowerpart of the panel

More selections using the [Ctrl]-click methodhave been made

Left-ClickLeft-Clickthis arrow to usethis arrow to use

the selectionsthe selections


The Selected Events are listed

Click in “Comments” boxes as needed to complete the notes

The last Comment to be entered here would show that theTest dose was 3mL

When done, When done, click on OKclick on OK


To review the selected Events, you open up the “Event Log”

You can click on theEvent Log buttonORthe Events menuitem in Insert/ViewORpress the F4 key

This is the Event Log that is shown:

Uh-oh!I forgot to

change the time!

RA “Start” after Epidural!

Charting Regional - Epidural EventsCharting Regional - Epidural EventsIf you want to change (edit) a Comment, double-click on the Event lineand the Edit Event box appears

Highlight the text to edit

Type in new text, then Type in new text, then hit [Tab] keyhit [Tab] key

to move focus to [OK]to move focus to [OK]

Use [Enter] key or ClickUse [Enter] key or Click


You can edit the time of multiple logged events as a group.You can edit the time of multiple logged events as a group.

Multi-select by Left-Click on the first and [SHIFT] Left Click on the Multi-select by Left-Click on the first and [SHIFT] Left Click on the last event to be edited.last event to be edited.

Now Click on the Edit Button…Now Click on the Edit Button…


The pop-up shown below allows us to add 2 minutes to all the The pop-up shown below allows us to add 2 minutes to all the selected Events at one time.selected Events at one time.

Here is the result:Here is the result:


If you need to change an Event (e.g. Approach was Midline),you will have to Delete the “Paramedian” event and Add a new one

This screen capture shows “Paramedian” is goneand “Midline” is added at the bottom

Charting Regional - Epidural EventsCharting Regional - Epidural EventsThe Program tracks every item that is entered, edited or deleted

““ParamedianParamedian” deleted” deleted

Time and Person Time and Person trackedtracked

The next step is to document the Epidural drugs given

Every Event modified to 15:27Every Event modified to 15:27

Charting Regional - Epidural DrugsCharting Regional - Epidural Drugs

When Anesthesia Manageris first opened, there is adefault list of drugs listedunder “Medications (All)”

The option “Show Headings”is very useful to organize how the drugs are displayedand how to add new drugsto a specific category.

Since no Local Anestheticsare listed, we will have toadd the ones we want.


The “generic” method to adddrugs is to right-click on oneof the drug family headings.

In this case, since there is no heading for Local Anesthetics,right-click on the MedicationsBar and select “Add Item”.

You would select the drug family for “Regional BlockAnesthetics” and then the individual drug wanted.

There is an easier way!

Click on the “deck of cards” icon calledProtocols. This will display a library ofgroups of drugs and fluids from whichto choose.


This is the Protocols window that pops up after clicking the button.

This protocol This protocol has been has been selectedselected

These drugs are These drugs are members of this members of this

protocolprotocol


The way drugs are listed outside of Protocols can be confusing.

A drug is listed as a Bolus, or an Infusion, or a part of a Combination.

Fortunately, we can list them all together in one Protocol!

This is an This is an INFUSION combo INFUSION combo

Bupiv + FentBupiv + FentN.B. mL/hN.B. mL/h

This is aThis is aBOLUS comboBOLUS comboBupiv + Fent Bupiv + Fent N.B. mL onlyN.B. mL only

Select the drugs you want by clicking on them, one at a time.

Charting Regional - Epidural DrugsCharting Regional - Epidural DrugsWhen you have selected the drugs you want, click on the Add buttonand when prompted, click OK

What you see next can be a bit confusing.

Charting Regional - Epidural DrugsCharting Regional - Epidural DrugsThe Protocol window remains, but the previous Bupiv protocolhas disappeared!

The program assumes you don’t want any further drugs fromthis Bupiv/Fent protocol but that you might want to look at otherprotocols.

Click on the Cancel button to finish. The next time you openthe Protocols window, the Bupiv/Fent protocol will be there.

Charting Regional - Epidural DrugsCharting Regional - Epidural DrugsWhen you return to the Medication listing there is now anew category called “Regional Block Anesthetics”

New DrugNew DrugFamilyFamily

Hover the pointer Hover the pointer to highlight a to highlight a

drug linedrug line

To enter a drug dose, click in the TimeBox in the desiredtime column.

In this case, we want to document that we gave a 3 mL test dose of Lido 1.5% /w epi 1:200K


This is the standard drug dose entry pop-up window.

It has been customized for this drug to speed entry.

The time is from The time is from the TimeBox you the TimeBox you

clickedclicked

Focus is here when the window opens Focus is here when the window opens

– no need to click – – no need to click – you can type directly the doseyou can type directly the dose

The default The default route is EPIDroute is EPID

Confirm and close –Confirm and close –either mouse clickeither mouse click

or hit [Enter] key (faster)or hit [Enter] key (faster)

Bolus drug – Bolus drug – so Infusion greyed outso Infusion greyed out

Charting Regional - Epidural DrugsCharting Regional - Epidural DrugsSometimes when you return to the Medication listing, only the drug with the new dose shows on the screen.

Click on the Refresh/Restorebutton to show the completedrug list.


Now we want to enter the initial bolus dose of the Bupiv-Fent mixture,Now we want to enter the initial bolus dose of the Bupiv-Fent mixture,in the next 5 minute TimeBox:in the next 5 minute TimeBox:

mL only = BolusmL only = Bolus

As a 2-drug combo,As a 2-drug combo,2 lines are2 lines arehighlightedhighlighted

Click within the highlighted 2 linesClick within the highlighted 2 linesto enter the drug doses.to enter the drug doses.


This is a Combination Medication drug entry window:

With 2 drugs, you need to click With 2 drugs, you need to click in a dose box to startin a dose box to start

You need to do You need to do the math yourself:the math yourself:

6 mL = 30 mcg of Fent6 mL = 30 mcg of Fent


We now want to enter the Infusion dose settings.

You can select Bupiv and Fentanyl separately to chart as Infusions but Anesthesia Manager will chart these infusionsin the Medication Infusions & Fluids section.

To keep everything together in the Medications section, it is necessary to configure the 2 drugs as a Infusion Combination:

mL/h = InfusionmL/h = Infusion

Charting Regional - Epidural DrugsCharting Regional - Epidural DrugsThis is the Infusion Combo dose entry window:

Simply enterSimply entera new Pump Ratea new Pump Rate

here to start /changehere to start /changeinfusion rateinfusion rate

You do not need to You do not need to enter any rates forenter any rates for

either Bupiv or Fent!either Bupiv or Fent!


The Solute amountsThe Solute amountsare pre-set forare pre-set for

this combothis combo

Setting the Pump Setting the Pump raterate

auto-calculatesauto-calculatesthe Fent ratethe Fent rate


Here is the completed entry of the Epidural drugs:

Large arrow Large arrow shows start of shows start of

InfusionInfusion

Small arrow shows Small arrow shows continuing continuing

InfusionInfusion

With a rate change, there With a rate change, there is a new large arrowis a new large arrow


Let’s suppose you want to use Bupiv 0.375% + Fent 5mcg/ml.This unusual choice is not listed in the Protocols.But you can build your own!

Select generic Bupivacaine (B) and Bupivacaine (INF)


The screen capture below shows the “Custom” Bupiv-Fent comboThe screen capture below shows the “Custom” Bupiv-Fent combowhich is yet to be defined.which is yet to be defined.

Note that the “Custom” Bupiv is in mg and mg/hr and not mLNote that the “Custom” Bupiv is in mg and mg/hr and not mL

Before we define the “Custom” B-F combo, let’s remove Before we define the “Custom” B-F combo, let’s remove the Bupiv 0.25% - Fent combo.the Bupiv 0.25% - Fent combo.


To Remove a drug you must first UNDO the doses entered and thenTo Remove a drug you must first UNDO the doses entered and thenCANCEL the order for the drug.CANCEL the order for the drug.

Click in this box firstClick in this box first

Then ClickThen ClickUndoUndo

The dose is gone.

Click any TimeBoxfor this combo.

Charting Regional - Epidural DrugsCharting Regional - Epidural DrugsThis is the same dialog window for drug dose entry, EXCEPTThis is the same dialog window for drug dose entry, EXCEPTthis time we Click on the RED “X” to Discontinue / Cancelthis time we Click on the RED “X” to Discontinue / Cancel

The process to Discontinue the B-F infusion is very similar.The process to Discontinue the B-F infusion is very similar.However, you will need to UNDO each pump rate change individuallyHowever, you will need to UNDO each pump rate change individuallyin order to clear the entire TimeLine for the infusion.in order to clear the entire TimeLine for the infusion.To DISCONTINUE the drug order, the steps are the same as above.To DISCONTINUE the drug order, the steps are the same as above.


For the Bolus dose of the Bupiv 0.375%, we need to enter the amount For the Bolus dose of the Bupiv 0.375%, we need to enter the amount of drug in the bolus – 5 mL => 3.75mg x 5 = 18.75mg.of drug in the bolus – 5 mL => 3.75mg x 5 = 18.75mg.

Similarly, Fentanyl @ 5 mcg/mL will be 25 mcgSimilarly, Fentanyl @ 5 mcg/mL will be 25 mcg


Important Tip! You mix up your Comb before you set the Pump Rate!Important Tip! You mix up your Comb before you set the Pump Rate!

“Mix the Combo First”Enter the Solute amounts first.

(Bupiv: 20 x 3.75)

Don’t Touchthese Boxes!

Enter Pump Rate second.

Charting Regional - Epidural DrugsCharting Regional - Epidural DrugsImportant Tip! You mix up your Comb before you set the Pump Rate!Important Tip! You mix up your Comb before you set the Pump Rate!

Pump Rate of 6 mL/hr entered

The rates in these Boxes were entered

automatically when the Pump Rate was entered

Warning! Entering in any other sequence will FAIL miserably!Warning! Entering in any other sequence will FAIL miserably!

Charting Regional - Epidural DrugsCharting Regional - Epidural DrugsThis is what it looks like on the Medication Flowsheet:This is what it looks like on the Medication Flowsheet:

If you want to see what the Pump Rate is without clicking on aIf you want to see what the Pump Rate is without clicking on adrug TimeBox, you need to switch to the Med Infusions & Fluidsdrug TimeBox, you need to switch to the Med Infusions & FluidsFlowsheet:Flowsheet:

how do i chart … epidural catheter insertion and anesthetic drugs low thoracic epidural pt sitting...

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