Transcript Slide 1

Anesthesia Training:
Documenting Fluids IN and OUT
Objectives
By the end of this module the participant will be able to:
Add a new fluid from each fluid family to the Fluids Flowsheet
Add an Additive to an IV
Perform a bag level
Document urine output (cumulative)
Pause an infusion
View Fluid totals and detail in the Fluid Balance Graph
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Fluid Families
“Colour Coded”
Fluids IN:
Blood products
Drug Infusions
• eg.Dopamine, Epinephrine
IV Fluids: Anesthesia IV Fluids
Fluids OUT:
Urine
Blood out
Other Fluids
• Eg. Chest tube drainage
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Fluids in Anesthesia Manager:
Behavior of Different Fluid Types
Fluids IN:
Continuous: Gravity infusions (eg. NS, LR, RBC’s)
• fluid balance determined by bag level
• To get any balance result you have to perform an action within the “fluid
dialogue box” (validate, cancel, bag level…)
Bolus: Amount directly added to the fluid balance
Based on rate: Infusions at a specific rate (ml/hr).
• These update the fluid balance in real time (eg. Epidural infusion)
Drips: Dose and rate (depends on dilution)
• Specific rate, updated in real time to the fluid balance (eg. Propofol or narcotic
infusion)
Fluids OUT:
Cumulative: Partial/Total
• indicated by a circled value in the flowsheet. This functionality is used for
closed system fluid monitoring (e.g. urine bag)
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Fluid Flowsheet Symbols
• Colors correspond to fluid families
•
•
•
•
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Forward arrows indicate an active infusion
Up arrows indicate an infusion on pause
Forward arrow with horizontal line above=bag level documented
Large arrow indicate validation
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Fluid Flowsheet Symbols (cont.)
• Single numbers indicate
•boluses or fluid out totals-eg. Dumped urine of 250 ml.
•Infusion rates in ml/hr-eg. Propofol infusion @ 6 ml/hr
•Initial volume of ”continuous fluids”-eg. 1000 ml NS
• Circled numbers indicate cummulative fluid out totals
• Red X indicates a discontinued order
• Blue ”carrots” indicate start and stop times of orders
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Med Infusions and Fluids (All)
This is our default
flowsheet for the addition
of all medication infusions
and fluids
Accessed by clicking
“Medications & Fluids (All)”
in Navigation Bar
Default “Fluids IN” include:
• 0.9% NS (1000 mL)
• Ringers Lactate (1000 mL)
• 2/3-1/3 (1000 mL)
Default “Fluids OUT”
include:
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• Blood (Cumulative)
• Urine (Cumulative)
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1.Click in the
Fluids
appropriate time cell
corresponding to
0.9% NS-Dcoument
window opens
In-Initiating a Default Fluid
Eg: 1000 ml of NS at 19:55
2. New Bag of
1000 mL. is the
default.
Highlight other
quantity or type
in actual volume
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3. Injection site
defaults to
generic IV
4. Hit the check
mark to confirm
entry onto the
record
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Fluids In-Initiating a Default Fluid
Eg: 1000 ml of NS at 19:55
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Fluids In-Initiating a Default Fluid
Options
What other options exist in
the Document Window?
Base Solution Volume:
• 50, 100, 250, 500, 1K, 2K or
• Custom volume
Fixed Infusion Rate
• Eg. Volumetric Pump
Addition of Additives
Site of Administration
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Fluids In-Initiating a Default Fluid
Eg: 375 ml. LR with 20 mm KCl/L @ 125 ml/hr in the L ACF
1.Click in the appropriate time
cell corresponding to Ringers
Lactate-Document window will
open
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Fluids In-Initiating a Default Fluid
Eg: 375 ml. LR with 20 mm KCl/L @ 125 ml/hr in the L ACF
2. Change default
volume of 1000 ml. to
375 mL.
4. Pump Rateenter in at
125 ml/hr
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3. Scroll to the
additive-KCl-20
mmol
5. Use pull down
menu to select
“Antecubital Left”
6. Adjust
Starting Time if
required
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Fluids In-Initiating a Default Fluid
Eg: 375 ml. LR with 20 mm KCl/L @ 125 ml/hr in the L ACF
IV fluids with additives are indicated by a + sign after the order label
Putting your mouse pointer on the treatment name will show full fluid details
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Fluids In-Initiating a non Default Fluid
Standard Option
1. Mouse over “Electrolyte Replacement”
3. Pick a
fluid
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2. Right click over any
electrolyte fluid and
“Add Item”
OR
4. Adjust starting
time-default is
beginning of the
case
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Fluids In-Initiating a non Default Fluid
Standard Option
“Add and Document”
• Brings up “document
window” prior to order
appearing on the record
 Can
 Can
 Can
 Can
 Can
adjust time
adjust volume
enter additives
set pump rate
adjust site
“Add”
• Enters new order onto the
record
• User must now click on
desired time on the timeline
to open the “Document
Window” and enter
information
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5. Click on either5.“Add
Clickand
on either
Document”
“Add and
OR
Document”
“Add”
OR “Add”
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Fluids In-Initiating a non Default Fluid
Standard Option
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Fluids In-Initiating a non Default Fluid
Protocol Option
Protocols
• are groups of standard
orders that you can add to
the patient chart in part or
in whole
• Anesthesia Manager has
been configured with a
protocol labeled
*Anes_Fluids In”
 that allows for the selection
of the most commonly used
anesthetic fluids
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Presentation Title
Fluids In-Initiating a non Default Fluid
Protocol Option-*Anes_Fluids IN
*Anes_Fluids In
• Most commonly used fluids
used in an anesthetic
• (B) indicates Bolus
delivered fluid
• IV INF or IV Continuous
indicates gravity or rate
delivered fluid
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Fluids In-Initiating a non Default Fluid
Protocol Option-*Anes_Fluids IN
Eg. Add a unit of PRBC’s to be delivered over time
1. 1.Click
Click
on on
thethe
“protocol”
“protocol”
icon
icon
OR
OR
Pull Pull
down
down
the “Order
the “Order
Menu”
Menu”
2.Select the “*Anes_Fluids In”
protocol
3. Select “RBC ml Cont.
x 7 days
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4. Default starting time is the
beginning of the case (Anesthesia
Standard session)
5. Hit “Add” to
have order
appear on record
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Fluids In-Initiating a non Default Fluid
Protocol Option-*Anes_Fluids IN
Eg. Add a unit of PRBC’s to be delivered over time
1. Document the
volume to be
administered
•RBC ml IV now appears on
the record
•To add a unit of RBC, place
cursor over appropriate time
on timeline and click to
open “Document Window”
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2. Enter the Unit #
3. Adjust the site
if required
4. Tick the checkbox to
document on the record
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Fluids In-Initiating a non Default Fluid
Protocol Option-*Anes_Fluids IN
Eg. Add a unit of PRBC’s to be delivered over time
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Fluids IN-Pausing an Infusion
1. Click at relevant timeDocument Window opens
2. Change
“Action” to Pause
3. Enter in
“Bag Level”
if desired
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4. Hit Check
Mark
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Fluids IN-Pausing an Infusion
Upward arrow (BOLD) indicates infusion put on hold at a specific time
Continued upward arrows indicate infusion still on hold
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Fluids IN-Restarting an Infusion
1. Click at desired
time to resume
infusion
2. By default, action
returns to “Infusing”
3. Hit check
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Fluids IN-Restarting an Infusion
Forward arrow (BOLD) indicates that infusion has restarted
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Fluids IN-Discontinuing a Fluid
1. Click at desired
time-Document
Window opens
3. Click “Yes”
to prompt
2. Click on “X”
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Fluids IN-Discontinuing a Fluid
4. Enter bag
level and hit
“OK”
X indicates Fluid has been discontinued
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Fluids Out
Fluids Out (Default)
• Blood (cumulative)
• Urine (cumulative)
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Fluids Out-Initiating a Default Fluid
eg. Urine Output of 250 ml.
3. Adjust
time if
required
2. Enter volume of
“Fluid Out”
1. Click cursor on appropriate
“Fluid Out” at desired time
(Document window opens)
4. Hit OK to
appear on
record
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Fluids Out-Initiating a Default Fluid
eg. Urine Output of 300 ml.
Cumulative
• Simply means total
In this example, there was
no previous documentation
of urine output
Therefore, 0 + 250 = 250.
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Fluids Out-Initiating a Default Fluid
eg. Adding an additional Urine Output of 300 ml.
Previous “amount” of
250 ml is displayed in
the “Amount”
2. Add in new
“Partial”
amount-300 ml
1. Click cursor at new
time point (Document
window opens)
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4. Hit OK to
appear on
record
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Fluids Out-Initiating a Default Fluid
eg. Adding an additional Urine Output of 300 ml.
•Previous urine output of 200 ml. + current urine output of 300 ml. = 550 ml.
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2. Right click over any electrolyte
fluid and “Add Item”
Fluids Out-Documenting a non Default Fluid
Standard Option
1. Mouse over “Fluids
Out”
OR
4. Adjust starting
time-default is
beginning of the
case
3.Pick a
fluid
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Fluids Out-Documenting a non Default Fluid
Standard Option
“Add and Document”
• Brings up “Document
Window” prior to order
appearing on the record
 Can
 Can
 Can
 Can
 Can
“Add”
adjust time
adjust volume
enter additives
set pump rate
adjust site
• Enters new order onto the
record
• Default time is beginning of
the session
• User must now click on
desired time on the timeline
to open the “Document
Window” and enter
information
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5. Click on either “Add and
Document” OR “Add”
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Fluids In-Initiating a non Default Fluid
Standard Option
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Fluids In-Initiating a non Default Fluid
Protocol Option-*Anes_Fluids OUT
1. Click on the “protocol” icon
OR
Pull down the “Order Menu”
2.Select the “*Anes_Fluids Out”
protocol
3. Select “Neuro Drain#2
Cumulative x 7 days
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4. Default starting time is the
beginning of the session
(Anesthesia Standard)
5. Hit “Add” to
have order
appear on record
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Fluids In-Initiating a non Default Fluid
Protocol Option-*Anes_Fluids OUT
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Fluid Documentation: Audit Trail
Click on the Audit Trail button to see the History for that fluid order
• Who documented, changed the documentation, bag leveled, added additives.
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Fluid Balance
1. Click on the “Fluid Balance” icon
OR
Pull down the “Insert/View” menu
OR
Hit F9 on the keyboard
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Fluid Balance-Documenting “Fluids IN”
Gravity Fed Solutions
Vast majority of
“fluids IN”
Software can only
document the fact
that the solution is
running
• No idea how much
has been infused at
any given point.
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Fluid Balance-Documenting “Fluids IN”
eg. 500 ml NS Infused
2. Click on
“Bag Level”
1. Cursor at time point that
you want to document.
Document window opens
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3. Document “Bag Level”
and hit check mark
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Fluid Balance-Documenting “Fluids IN”
eg. 500 ml NS Infused
Validation cell appears
Fluid balance updated on the
fly
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Fluid Balance-Documenting “Fluids IN”
eg. hang new bag of fluid
Cursor at time point that
you want to document.
Document window opens
and shows fluid “infusing”
with previous level
documented at 500 ml.
1. Clikc on
“New Bag”. By
default, bag
level changes
to 0
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Fluid Balance-Documenting “Fluids IN”
eg. hang new bag of fluid
New fluid added
Fluid Balance updated
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Fluid Balance
1. Hit “Fluid Balance
Detail” icon
•Gross Fluid Balance displayed
in absolute amounts with
accompanying pie graph
The total for each fluid
family is displayed
The “Total IN” and
“OUT” are above and
below the bar graph
The net Balance
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Fluids in Anesthesia Manager: Exercise
Find the fluid flowsheet
Order a fluid from each family type, both Fluids IN and Fluids OUT.
• 0.9% NS
• Blood Product
• Chest Tube output
• Estimated Blood Loss
Enter information for each fluid order, paying close attention to each data
field in the validation windows.
Add the additive of 40 meq KCL to a D5W-1000 ml infusion started in the
left antecubital fossa
Look at the fluid balance window. Open the fluid balance detail for more
specific information about which fluids were given.
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Questions And
Answers
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