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How do I chart … Low Thoracic Epidural Pt sitting – skin prep + LA – site T9-10 #17 Touhy – LORTA – easy – space @ 7cm Catheter passed easily – no CSF / no paresth. Catheter 12cm @ skin - EpiGard Test dose: Lido 1.5% /w epi 1:200K 3ml - OK Epidural Catheter Insertion and EPID: Bupiv 0.25% + epi + Fentanyl 5mcg/ml BOLUS (ml) INFUSE (ml/h) 66 5 Anesthetic Drugs Charting Regional - Epidural Events If you are familiar with adding an Event, skip to Slide 8 Click Here • You want to “bookmark” the time you start the Epidural • Look for the Macro Bar in the upper right part of the screen Regional Anesthesia Start Monitored Anesthesia Care Start General Anesthesia Start • Clicking on one of these 3 Buttons will place a bookmark on the Timeline • For a Combined Regional – General Anesthetic: – click Regional when starting Block – then click General when Inducing the GA Charting Regional - Epidural Events • A “Tool Tip” appears when the cursor arrow hovers over a button • In this case, the name of the Macro button is “Regional Start” • This button has been configured to add : - event #1: the time that you began the Regional Anesthetic - a reminder: you need to select an “Anesthesia Type” - event #2: Oxygen by nasal cannula or facemask • when the button is left-clicked a pop-up window appears • you have two choices: - accept the time shown (OK button or hit [Enter] key) - change the time (if you were delayed or forgot to click Regional Start) Charting Regional - Epidural Events After clicking the Regional Start button: • The button has a “depressed” look to show that it has been clicked (no need to repeat!) • There is now the symbol “R” on the TimeLine (in the 15:25 time box but reads 15:26) • Hovering over the “R” symbol tells you what Events have been logged (Note: other Events show on the TimeLine as blue squares) Now you can direct your full attention to performing the Epidural. Once the Case is well underway, you can complete the documentation. Charting Regional - Epidural Events When the Case is underway and you have time to document, the TimeLine has moved along and the Regional Start bookmark has disappeared Grey Square shows position on TimeLine Scroll Back 1 TimeBox at a time Click Here for larger time scrolls Yellow TimeBox is current time Once you see the “R” symbol, identify it as the Regional bookmark by hovering over it with the mouse pointer Note: The TimeBox is 15:25 but the Bookmark is for 15:26 Charting Regional - Epidural Events 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 Current time entered as the default time. Since you wanted 15:26 or thereabouts, this will require the tedious job of editing the time. Charting Regional - Epidural Events The 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 these tiny arrows, too. Charting Regional - Epidural Events Anesthesia Types are available, too This is the Left half of the Add Events pop-up The “Event Set” named “A062-Regional-Epidural” was left-clicked The list of “Events” then appeared in the right panel The idea is to select all Events that you want to use to document Hold down the [Ctrl] key while you left-click on each desired event Charting Regional - Epidural Events In this view, the slider for the right panel has been used to view the Events in the lower part of the panel More selections using the [Ctrl]-click method have been made Left-Click this arrow to use the selections Charting Regional - Epidural Events 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 the Test dose was 3mL When done, click on OK Charting Regional - Epidural Events To review the selected Events, you open up the “Event Log” Uh-oh! I forgot to change the time! You can click on the Event Log button OR the Events menu item in Insert/View OR press the F4 key This is the Event Log that is shown: RA “Start” after Epidural! Charting Regional - Epidural Events If you want to change (edit) a Comment, double-click on the Event line and the Edit Event box appears Highlight the text to edit Type in new text, then hit [Tab] key to move focus to [OK] Use [Enter] key or Click Charting Regional - Epidural Events 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 last event to be edited. Now Click on the Edit Button… Charting Regional - Epidural Events The pop-up shown below allows us to add 2 minutes to all the selected Events at one time. Here is the result: Charting Regional - Epidural Events 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 gone and “Midline” is added at the bottom Charting Regional - Epidural Events The Program tracks every item that is entered, edited or deleted “Paramedian” deleted Every Event modified to 15:27 Time and Person tracked The next step is to document the Epidural drugs given Charting Regional - Epidural Drugs When Anesthesia Manager is first opened, there is a default list of drugs listed under “Medications (All)” The option “Show Headings” is very useful to organize how the drugs are displayed and how to add new drugs to a specific category. Since no Local Anesthetics are listed, we will have to add the ones we want. Charting Regional - Epidural Drugs The “generic” method to add drugs is to right-click on one of the drug family headings. In this case, since there is no heading for Local Anesthetics, right-click on the Medications Bar and select “Add Item”. You would select the drug family for “Regional Block Anesthetics” and then the individual drug wanted. There is an easier way! Click on the “deck of cards” icon called Protocols. This will display a library of groups of drugs and fluids from which to choose. Charting Regional - Epidural Drugs This is the Protocols window that pops up after clicking the button. This protocol has been selected These drugs are members of this protocol Charting Regional - Epidural Drugs 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 a BOLUS combo Bupiv + Fent N.B. mL only This is an INFUSION combo Bupiv + Fent N.B. mL/h Select the drugs you want by clicking on them, one at a time. Charting Regional - Epidural Drugs When you have selected the drugs you want, click on the Add button and when prompted, click OK What you see next can be a bit confusing. Charting Regional - Epidural Drugs The Protocol window remains, but the previous Bupiv protocol has disappeared! The program assumes you don’t want any further drugs from this Bupiv/Fent protocol but that you might want to look at other protocols. Click on the Cancel button to finish. The next time you open the Protocols window, the Bupiv/Fent protocol will be there. Charting Regional - Epidural Drugs When you return to the Medication listing there is now a new category called “Regional Block Anesthetics” New Drug Family Hover the pointer to highlight a drug line To enter a drug dose, click in the TimeBox in the desired time column. In this case, we want to document that we gave a 3 mL test dose of Lido 1.5% /w epi 1:200K Charting Regional - Epidural Drugs This is the standard drug dose entry pop-up window. It has been customized for this drug to speed entry. Focus is here when the window opens – no need to click – you can type directly the dose Bolus drug – so Infusion greyed out The time is from the TimeBox you clicked The default route is EPID Confirm and close – either mouse click or hit [Enter] key (faster) Charting Regional - Epidural Drugs Sometimes when you return to the Medication listing, only the drug with the new dose shows on the screen. Click on the Refresh/Restore button to show the complete drug list. Charting Regional - Epidural Drugs Now we want to enter the initial bolus dose of the Bupiv-Fent mixture, in the next 5 minute TimeBox: mL only = Bolus As a 2-drug combo, 2 lines are highlighted Click within the highlighted 2 lines to enter the drug doses. Charting Regional - Epidural Drugs This is a Combination Medication drug entry window: With 2 drugs, you need to click in a dose box to start You need to do the math yourself: 6 mL = 30 mcg of Fent Charting Regional - Epidural Drugs 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 infusions in 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 = Infusion Charting Regional - Epidural Drugs This is the Infusion Combo dose entry window: You do not need to enter any rates for either Bupiv or Fent! Simply enter a new Pump Rate here to start /change infusion rate Charting Regional - Epidural Drugs Setting the Pump rate auto-calculates the Fent rate The Solute amounts are pre-set for this combo Charting Regional - Epidural Drugs Here is the completed entry of the Epidural drugs: Large arrow shows start of Infusion Small arrow shows continuing Infusion With a rate change, there is a new large arrow Charting Regional - Epidural Drugs 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) Charting Regional - Epidural Drugs The screen capture below shows the “Custom” Bupiv-Fent combo which is yet to be defined. Note that the “Custom” Bupiv is in mg and mg/hr and not mL Before we define the “Custom” B-F combo, let’s remove the Bupiv 0.25% - Fent combo. Charting Regional - Epidural Drugs To Remove a drug you must first UNDO the doses entered and then CANCEL the order for the drug. Click in this box first Then Click Undo The dose is gone. Click any TimeBox for this combo. Charting Regional - Epidural Drugs This is the same dialog window for drug dose entry, EXCEPT this time we Click on the RED “X” to Discontinue / Cancel The process to Discontinue the B-F infusion is very similar. However, you will need to UNDO each pump rate change individually in order to clear the entire TimeLine for the infusion. To DISCONTINUE the drug order, the steps are the same as above. Charting Regional - Epidural Drugs 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. Similarly, Fentanyl @ 5 mcg/mL will be 25 mcg Charting Regional - Epidural Drugs Important Tip! You mix up your Comb before you set the Pump Rate! Don’t Touch these Boxes! Enter Pump Rate second. “Mix the Combo First” Enter the Solute amounts first. (Bupiv: 20 x 3.75) Charting Regional - Epidural Drugs Important Tip! You mix up your Comb before you set the Pump Rate! The rates in these Boxes were entered automatically when the Pump Rate was entered Pump Rate of 6 mL/hr entered Warning! Entering in any other sequence will FAIL miserably! Charting Regional - Epidural Drugs This is what it looks like on the Medication Flowsheet: If you want to see what the Pump Rate is without clicking on a drug TimeBox, you need to switch to the Med Infusions & Fluids Flowsheet: