Documentation + Preop Textbook Info

Documentation Tips/guidelines

  • The chart serves as a legal "time-lapse" of the patient’s physiology. It describes the patient experience.

    • Hemodynamics: Heart rate and Blood Pressure must be recorded at a minimum frequency of every 5 minutes.

      • Note: While modern monitoring systems can track data more frequently, the paper record mandates this 5-minute interval to demonstrate ongoing vigilance.

    • Continuous Monitoring: EKG and Pulse Oximetry must be monitored continuously from the moment the patient is "on monitors" until they are handed off in the Post Anesthesia Care Unit (PACU).

    • 15-Minute Block Documentation: Document the following parameters every 15 minutes:

      • Heart Rhythm (e.g., Normal Sinus Rhythm - NSR)

      • SpO2 (oxygen saturation)

      • EtCO2 (end-tidal CO2)

      • Temperature

    • Critical Exception: If a significant change occurs (e.g., sudden desaturation or arrhythmia), it must be documented at the exact time it occurs in the notation section.

Airway & Ventilation Management

  • Documentation must reflect the patient’s respiratory status and the safety of the airway.

    • Ventilator Settings: Document the following settings, typically every 15 minutes:

      • Mode (e.g., Pressure-Controlled Ventilation - PCV / Volume-Controlled Ventilation - VCV)

      • Rate of ventilation

      • Tidal Volume (TV)

      • Peak Pressure

      • PEEP (Positive End-Expiratory Pressure)

    • The "Post-Intubation" Check: Explicitly state the patient's condition after securing the airway.

      • Standard Phrase: "Dentition intact and in pre-operative condition."

      • Notation Requirements:

        • "Atraumatic ETT (Endotracheal Tube) placement"

        • "Bilateral breath sounds confirmed"

    • Extubation Criteria: Document the "emergence story."

      • Example of Documentation: "Patient VSS (vital signs stable), spontaneous respirations with tidal volume > 400mL, follows commands/opens eyes. Suctioned and extubated."

      • Note: Omit "follows commands" for deep extubations.

Neuromuscular Blockade (NMB) & Reversal

  • This area is considered high-risk for litigation and postoperative respiratory complications.

    • Train-of-Four (TOF) documentation: Document the presence of twitches both prior to administering reversal and again after reversal to demonstrate the return of neuromuscular function.

    • The Legal Trap: If no reversal is provided and sustained TOF/tetany is not documented, there is no evidence to support that the patient was safe for extubation.

Patient Positioning & Protection

  • Pressure injuries or nerve palsies can lead to litigation, particularly as the patient is unconscious and under medical care.

    • The Safety Check: Explicitly document that "pressure points were checked and padded."

    • Standard Positioning Practices: Neck/Head must be maintained in a neutral spine position. Bilateral arms must be positioned at less than 90 degrees, palms up (supinated), and can be either secured or tucked with "thumbs up."

Symbolic Key & Charting Tips

  • Consistency in symbols is critical to prevent misinterpretation by other healthcare providers or legal counsel.

    • Parameter Symbols:

      • Heart Rate: "." (Dot that is filled in)

        • Connect dots to demonstrate trends over time.

      • Blood Pressure: "∨ / ∧"

        • Use an upside-down "T" to represent Arterial Line pressures.

      • Spontaneous Respiration: "○"

        • Represented as a plain circle that is empty.

      • Assisted Respiration: "∅"

        • Circle with a slash (indicates masking/pressure support).

      • Mechanical Ventilation: "⊗"

        • Circle with an "X."

    • Pro Tip: The "Fluid Line" Rule: When documenting IV fluids, use a straight horizontal line across the timeline hours.

      • Avoid drawing "up and down" steps unless there was an intentional change in rate.

      • Important: Vertical lines can lead to misinterpretation as "bolusing and stopping," potentially resulting in claims of fluid overload or mismanagement.

The Chart as a Narrative

  • The principle of documenting accurately:

    • If it isn't documented, it didn't happen.

    • If it is documented incorrectly, you are defending a lie.

  • Your documentation of "Normal" every 5 minutes proof of your presence and attention.

    • Exceptions: Use the "Notation" section for any incidents that break the 5 or 15-minute documentation rhythm.

Textbook Chapter Extra Info

  • Routine, indiscriminate "panel" testing is obsolete and not cost-effective; rather, preoperative diagnostic testing should be dictated strictly by the patient's history, physical examination, and the specific surgical risk.

Airway Assessment & Predictors of Difficulty

  • Thyromental Distance: A distance of < 3 ordinary fingerbreadths (or < 6-7 cm in adults) from the prominence of the thyroid cartilage to the bony point of the lower mandibular border correlates with poor alignment of the pharyngeal and laryngeal axes.

  • Interincisor Gap: Normal mouth opening should be at least 4 cm; a gap of < 2 fingerbreadths (< 3 cm) is associated with difficult endotracheal intubation.

  • Atlantooccipital Joint Extension: Crucial for achieving the "sniffing" position to align the oral, pharyngeal, and laryngeal axes. Conditions like rheumatoid arthritis or Down syndrome warrant evaluation for cervical spine instability.

  • Obstructive Sleep Apnea (OSA): Highly predictive of difficult airway and postoperative respiratory depression.

    • Clinical Pearl: Use the STOP-Bang questionnaire to screen for OSA; a score of 3-4 indicates intermediate risk, and > 5 indicates high risk.

Fasting (NPO) Guidelines & Aspiration Prophylaxis

  • 2 hours: Clear liquids (water, black coffee, clear tea, pulp-free juice).

  • 4 hours: Breast milk.

  • 6 hours: Infant formula, nonhuman milk, and a light meal (e.g., toast and clear liquids).

  • 8 hours: Meals containing fried or fatty foods, or meat.

  • Latex allergies occur with cross sensitivity to tropical fruits (e.g., kiwi, papaya, chestnuts, avocados)

Cardiovascular Risk Stratification

  • Metabolic Equivalents of Tasks (METs): “Measures” a patient’s Functional capacity, which is a significant predictor of cardiac risk (aka, estimates cardiac reserve). 1 MET = oxygen consumption at rest (aka, 3.5 O2/kg/min for a 40 y.o. 70 kg male)

    • Good Capacity (> 4 METs): Ability to walk up a hill, climb two flights of stairs without stopping, or walk 4 blocks. These patients generally do not require further cardiac testing before surgery.

    • Poor Capacity (< 4 METs): Unable to do the above; equates to higher perioperative risk.

    • More specifically:

      • 1 METS: Can complete ADLs, but gets SOB when walking up flight of stairs

      • 4 METS: Can walk briskly or climb a flight of stairs without getting SOB, but cannot do streneuos activity

      • 10 METS: streneuous activity/job

  • Revised Cardiac Risk Index (RCRI): Evaluates risk based on 6 independent predictors: (1) high-risk surgery, (2) ischemic heart disease, (3) congestive heart failure, (4) cerebrovascular disease, (5) insulin-dependent diabetes, and (6) serum creatinine > 2 mg/dL.

    • Do not do elective procedure within 60 days of an MI, as the risk for re-occurent MI is highest within 30 days of the last one

    • If a patient has dizziness on exercise with a pacemaker, do not give sux because this means the pacemaker can be affected by changes in musculature tone

    • overall risk for MI d/t anesthesia is 0.3%

    • Unstable angina is characterized by substernal chest pain that began less than 2 months ago, has progressively increased in severity, duration, or frequency, is less responsive to pharmacologic therapy, occurs at rest, lasts longer than half an hour, or exhibits transient T-wave or ST segment changes.

  • Coronary Stents (CRITICAL TIMELINES): Elective noncardiac surgery must be delayed after percutaneous coronary interventions to balance the risk of stent thrombosis vs. surgical bleeding.

    • Balloon Angioplasty: Delay 14 days.

    • Bare-Metal Stent (BMS): Delay 30 days.

    • Drug-Eluting Stent (DES): Optimally delay 365 days (12 months); though it may be considered after 3-6 months if the risk of surgical delay outweighs the risk of thrombosis.

  • Coronary angiography is the best dx method to assess ventricular and valvular function

  • DM and HTN patients have highest risk of silent MIs

Perioperative Medication Management

  • Beta-Blockers: Continue perioperatively for patients already receiving them (for angina or HTN). Do not routinely initiate beta-blockers on the day of surgery, as the POISE trial showed this increases the risk of hypotension, bradycardia, stroke, and overall mortality.

  • ACE Inhibitors / ARBs: Controversial. Withholding them on the morning of surgery reduces the risk of refractory intraoperative hypotension, though mortality is unaffected.

  • Herbal Supplements: These frequently cause bleeding, cardiovascular instability, or prolonged sedation.

    • Clinical Pearl: Stop the "G" herbs (Garlic, Ginkgo, Ginseng, Ginger) 1 to 2 weeks before surgery due to bleeding risks.

      • Ginseng also reduces blood sugar levels in fasting patients

      • Stop Ephedra 24 hours prior due to depletion of catecholamines and risk of profound hemodynamic instability.

      • Discontinue St. John's Wort 5 days to 2 weeks prior as it induces cytochrome P-450 enzymes and prolongs anesthetic effects.

Pulmonary Assessment & Smoking Cessation

  • Smoking Cessation Timelines:

    • 12 to 48 hours: Decreases carboxyhemoglobin (CO) and nicotine levels, shifting the oxyhemoglobin dissociation curve back to normal and improving tissue oxygen delivery.

      • **however, even 6-9 hours will substantially reduce CO levels, but not COMPLETELY to normal (needs minimum 24 hours for that, but not longer)

    • 4 to 8 weeks: Required to see a significant reduction in postoperative pulmonary complications (improves ciliary function and clears secretions). Similar outcomes as to someone who is a nonsmoker.

      • Stopping for shorter than this amount of time actually worsens the anesthetic prognosis because now the respiratory tissues are having increased sputum production

    • **smoking causes increased closing volumes and mucociliary dysfunction (NOT ciliary hyperplasia or alpha 1 antitrypsin deficiency), also elevated CO levels

  • Pediatric URI: A child with a mild, uncomplicated upper respiratory infection (clear rhinorrhea, afebrile) can safely undergo minor procedures. However, if the child has severe lower respiratory tract involvement (fever >38°C, purulent secretions, wheezing), elective surgery must be postponed for 4 to 6 weeks to allow airway hyperreactivity to resolve (6 weeks if viral).

  • COPD: Bronchitis (increased sputum production) and Emphysema (decreased elastic recoil)

    • Bronchitis on x-ray is only visible if there is a concurrent secondary respiratory illness

      • There will elevated hematocrit and frequent cough, increased airway resistance

    • Emphysema on x-ray will show hyperinflation

      • There will be normal hematocrit with minimal coughing and normal to increased airway resistance

    • Delay surgery for a COPD patient if they have: increased Paco2 > 50, severe symptoms of pulmonary congestion (NOT normal s/s of chronic COPD). COPD will be most likely to show up on chest x-ray as compared to bronchitis, upper respiratory infection, or asthma

  • upper abdominal or thoracic surgeries are associated with the highest risk of postop respiratory complications

  • Increased BUN and decreased serum albumin levels are associated with increased periop pulmonary morbidity

Endocrine & Systemic Considerations

  • Diabetes Mellitus: Aim for perioperative blood glucose levels < 180 mg/dL. Oral hypoglycemics are typically held the morning of surgery. Patients with type 1 diabetes must continue to receive their basal insulin (often at a reduced dose) to prevent diabetic ketoacidosis. Diabetics have a high rate of silent ischemia due to autonomic neuropathy.

    • insulin pumps only have to be d/c’ed for long surgeries or when MRI/x-ray/defibrillation will be used (e.g., cardioversion)

  • Corticosteroid Coverage: Patients treated with > 20 mg of prednisone daily for more than 3 weeks are at high risk for HPA axis suppression and will require perioperative stress-dose steroids (e.g., hydrocortisone) to prevent profound hypotension under anesthesia.

  • Renal Failure: Focus on volume status and serum potassium. Ideally, potassium should be measured within 6 to 8 hours of surgery, and elective surgery should be delayed if K+ > 5.5 mEq/L.

ASA Physical Status Classification

  • ASA I: Normal healthy patient (E.g., nonsmoker, no alcohol use)

  • ASA II: Mild systemic disease without substantive functional limitations (e.g., well-controlled HTN/DM, current smoker, pregnancy, BMI 30-40, mild lung disease, social drinker).

  • ASA III: Severe systemic disease with substantive functional limitations (e.g., poorly controlled HTN/DM, morbid obesity BMI >40, history of MI >3 months ago, COPD, ESRD with dialysis, CAD with stents, CVA, TIA, implanted pacemaker, active hepatitis, moderate reduction in EF).

  • ASA IV: Severe systemic disease that is a constant threat to life (e.g., MI <3 months ago, ongoing cardiac ischemia, severe valve dysfunction, CVA, TIA, CAD with stents, ERSD but not doing dialysis, severe reduction in EF, sepsis, DIC).

  • ASA V: Moribund patient not expected to survive without the operation (e.g., ruptured AAA, massive trauma, intracranial bleed with mass effect, ischemic bowel).

  • ASA VI: Declared brain-dead patient for organ harvesting.

  • "E" denotes an emergency procedure

  • Even just ONE outlier in the hx will automatically move the patient into a higher category ASA class