Download Use Case: Fit Healthy Patient for knee arthroscopy

Use Case: Fit Healthy Patient for knee arthroscopy
Goal in context: a 23 year old man with a knee injury is scheduled for a right knee
arthroscopy
He will receive a general anesthetic. An anesthetic record will be created as an accurate
and complete document of the anesthetic process by an Anesthetic Information
Management (AIM) system.
Success
Failure
Actors: patient Chris Gator, Anesthesiologist Dr. Gas, Surgeon Dr. Knife, Anesthesia
Assistant (CRNA), Circulating Nurse Jenny Runner, AIM system
Preconditions:
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Chris Gator is seen by Dr. Gas and has undergone a pre-anesthesia evaluation to
assess:
• Medical history
• Anesthetic history
• Medication history
Dr. Gas also does an appropriate physical examination and reviews diagnostic data
(if any).
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He determines the patient is ASA 1 and formulates an anesthetic plan and
discusses the risks and benefits of the plan with the patient. Dr. Gas plans to give
the patient a general anesthetic.
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Anesthetic equipment checks are done
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Medications are prepared
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Patient identity confirmed and documentation checks done. This includes a check
that the correct patient information is in the AIM system.
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Patient present in anesthetizing location
Use Case:
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Dr. Gas and/or Jenny Runner notes the time of patient entry into the operating
room on the AIM system. Jenny Runner confirms the patient identity and type of
surgery.
Dr. Gas decides to monitor blood pressure (BP), heart rate (HR), pulse oximetry
(SPO2), and inspired and expired gases. She places electrocardiograph (ECG)
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pads on the check to monitor leads II and V5, a BP cuff on the Right (R) upper
arm and a pulse oximeter probe on the left index finger. She checks that all
hemodynamic measurements are appropriate and hits a button to start the
recording of these monitored values on the AIM system. The monitored vital
signs described above are taken every minute. These vital signs are electronically
recorded on the anesthetic record.
In addition all of the described procedures are also documented on the anesthetic
record. Regulatory documentation is done as per each countries protocol.
Dr. Gas starts 18 g intravenous (iv) line in dorsum of left hand with 1 liter
Lactated Ringers (LR) solution so that medications can be given intravenously.*
One gram of ancef is administered through the iv line.* (This may vary as some
cases may not require antibiotics and practices may vary between countries.)
Patient is preoxygenated with oxygen with FiO2 = 1.0 at 8 liters per minute (L/M)
via a face mask held in place with a mask strap.*
Dr. Gas premedicates Chris with 2 mg midazolam injected into the iv line to
alleviate anxiety.*
Dr. Gas induces anesthesia with 200 mg propofol iv and 150 microgram (mcg)
fentanyl iv.
The patient loses closes eyes and becomes unconsciousness (this may not be
recorded on the anesthetic record).
Dr. Gas confirms the loss of consciousness with loss of eyelid reflex.
Dr. Gas holds the mask and hand ventilates the patient with 100% Oxygen.
After confirming adequate ventilation, she places a laryngeal mask airway
(LMA).* (intubation could be the alternative procedure)
Dr. Gas then confirms that the LMA is appropriately placed by hand ventilation
and checking the leak pressure (pressure at which a leak around the LMA is
detected).
Dr. Gas turns on 3% Sevoflurane and decreases the oxygen flow to 1 L/M and
initiates nitrous oxide at 2 L/M to provide maintenance anesthesia. The AIM
system is automatically collecting this information and recording it on the
anesthetic record. It is getting this data stream by device interfaces to the
anesthetic gas monitoring system.
Chris Gator begins to breathe spontaneously and Dr. Gas titrates fentanyl at 50
mcg per every 5 minutes until Chris has a spontaneous respiratory rate of 14
breaths per minute. [The surgical field is prepped with aqueous iodine solution
and draped in a sterile fashion by Dr. Knife.* (circulating nurse may also do this)
– this is not recorded on the anesthetic record]
Dr. Gas enters details of the fluids and pharmacologic agents administered to this
point and manually adjusts the times to reflect the time of administration.
The patient’s eyelids are taped close to prevent corneal abrasions and drying. A
nasopharyngeal temperature probe is placed and the temperature is recorded every
15 minutes during the case.
End expired CO2 and respiratory rate is recorded
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1
Jenny, Dr. Knife and Dr. Gas confirm the patient’s identity, surgical site, and
antibiotic administration (Time Out Procedure/Preoperative marking verification
checklist).1
Dr. Knife makes the incision in the right knee and surgery commences. Start of
surgery is documented.
Dr. Gas records size of LMA on the anesthetic record, time of induction, and
anesthetic agents on the anesthetic record.
Dr. Gas adjusts the level of sevoflurane and administers fentanyl to maintain the
patient’s BP and HR in a normal range throughout the surgical procedure.
Surgery is completed and the end of surgery time is documented.
The anesthetic gases are stopped and the patient is placed on 100% oxygen.
The total blood loss, urine output, fluid administration for the case is recorded on
the anesthetic record by the AIM system.
When Chris opens his eyes, the LMA is removed.
Chris is transferred from the operating room bed to a transport bed (trolley).
Dr. Gas puts a face mask delivering 100% oxygen on Chris.
The anesthesiologist and surgeon* (could be a nurse) transport Chris to the
recovery room [Post Anesthesia Care Unit (PACU) in the USA].
Chris is placed on monitors in the PACU and the anesthesiologist records the
initial vital signs on the anesthetic record.
Report is given to the PACU nurse and the care of the patient is transferred from
the anesthesiologist to the PACU nurse.
Required by National Patient Safety Agency in UK, Veterans Administration in the VA, Joint
Commission in the USA and International Joint Commission.