Transcript Charting Regional - Epidural Events A

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: