Articles: Medical Records
Decoding Anesthesia Records
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 Anesthesia
records are among the most complex forms found in medical
records. The key to understanding them is to recognize that
forms are generated at two phases of the surgical experience:
preoperatively during the anesthesia evaluation and intraoperatively
during the administration of anesthesia. The preanesthesia
assessment collects data about the patient’s medical
and surgical history, anesthesia history, vital signs, height,
weight, allergies, and details of any family member’s
reactions to anesthesia.
The
analysis of all of the data leads the anesthesiologist to
assign a classification that defines the patient’s
medical condition and the urgency of surgery. Classifications
range
from I-VI. The healthiest person is assigned a classification
of I. A brain dead person waiting an organ procurement procedure
receives a classification of VI. The addition of E to the
classification indicates the surgery is being performed
on an emergency basis.
It is
of prime importance for the anesthesiologist to detect airway
problems in advance of intubation. Difficult airways can
occur because of facial deformities, a small mouth or
thick neck, trauma to the face or teeth, airway tumors,
cervical spine injuries, or burns or radiation to the head
or neck. The anesthesiologist evaluates the airway opening
by determining how much of the back of the throat is obscured
by the tongue. The airway is
graded on a I-IV scale. A grade I airway provides the best
view of the back of the throat. A grade IV offers the least
view and is the one most often associated with intubation
challenges. [1] The anesthesiologist concludes the preoperative
note by recording the type of anesthesia that will be provided:
GA (general anesthesia), MAC (monitored anesthesia care),
IV sedation, spinal, epidural, regional, IV bier, or others.
Intraoperative
anesthesia records invariably consist of a grid with the
time across the top in 5-minute increments, and a column
down the left side to record information about medications
or anesthetic gases and patient data. The grid starts with
the time the anesthesia begins. A symbol is typically used
to indicate when the incision was made. Doses of medication
are recorded at the beginning of surgery, and as each subsequent
dose is given. Vital signs are recorded using a series of
Vs. The upper V is the systolic (top number in the blood
pressure). The upside down V below it is the diastolic blood
pressure value. It is common to record the pulse as a period.
The trend in blood pressure is most important thing to review.
Look for sudden dips or elevations in blood pressure. Such
events will invariably be accompanied by notes of the anesthesiologist.
Various
monitors used during anesthesia include cardiac, pulse oximetry
(checks the oxygen level in the blood, and should be 95-100%),
and end tidal carbon dioxide (ETCO2). This is the partial
pressure or maximal concentration of carbon dioxide (CO2)
at the end of an exhaled breath, which is expressed as a
percentage of CO2 or mmHg (millimeters of mercury). The
normal values are 5% to 6% CO2, which is equivalent to 35-45
mmHg. Blood pressure and temperature monitors are also used.
The
anesthesiologist records the amount of fluid given during
surgery. This is sometimes documented as “crystalloids”
and “colloids”. Intravenous fluids are crystalloids.
An easy way to remember this is to recall that crystals
are often clear. Colloids consist of albumin (protein),
blood, HES (hydroxyethyl starch), and dextran. Colloids
are not clear. Blood and blood products are often abbreviated.
Packed cells (PC) or fresh frozen plasma (FFP) may be given.
Whole blood may be transfused if a patient is acutely bleeding
and a volume needs to be replaced. Cell savers take blood
out of the incision, filter it, and return it to the patient.
The
estimated blood loss (EBL) is one of the most important
pieces of information on the anesthesia record. Dry sponges
are weighed prior to the beginning of surgery. The EBL is
determined by emptying the suction canisters, recording
amounts of irrigating fluid used, and weighing the blood
soaked sponges. As a general rule, adults have 5000-6000
cc of circulating blood. A loss of 1000 cc or more during
surgery without blood administration will be reflected in
a drop in hemoglobin and hematocrit, and can be clinically
significant.
Why
is it so hard to read anesthesia records?
Anesthesia records contain large amounts of data
recorded in a cramped space. The space for writing information
is often smaller than is practical. There is usually insufficient
room to record events when things go wrong. It is rare for
a form to allow much space for additional notes. The anesthesia
record is notable for using graphic recording techniques,
abbreviations and symbols, some of which may not be standardized.
Although the format of the anesthesia record page is designed
to handle many parameters and pieces of information, it
is impossible to record every single aspect of the anesthetic
course. While vital signs are typically recorded every five
minutes, they may be monitored more frequently. Blood pressure
determinations recorded every five minutes may reflect an
“average pressure” from measures obtained at
two or three minute intervals, or even more frequently when
a patient is unstable. The chart reflects the trend. [2]
Sudden changes in the patient’s condition direct attention
away from recording data and toward administration of medications
or fluids; the completeness of the anesthesia record is
affected.
Automated
anesthesia records (AAR) are available in some settings,
but are not widely used. Information from electronic monitors
is automatically transmitted to a computer. A keyboard is
used to input additional information. The AAR has some drawbacks.
Interference with electronic signals (artifacts) may require
editing by the anesthesiologist. The most striking example
of this problem occurs during the surgeon’s use of
electrocautery to cut tissues and stop bleeding. The EKG
signal is lost during this time, resulting in erroneous
heart rate recording, possible erroneous recording of heart
arrhythmia, and triggering of alarms.
The
provider must then manually indicate the presence of electronically
generated artifacts. Other artifacts may be present on the
record without being recognized and identified by the anesthesiologist.
These drawbacks may be outweighed by the advantages of more
accurate recording and significant time savings. It has
been estimated that between 15 and 20 percent of a provider’s
time is spent documenting and recording events and data,
and it has been argued that relieving the provider of a
task will allow for more supervisory and cognitive activity,
thus preventing a crisis situation. [3] The move towards
computerizing medical records may result in a more widespread
use of AAR. However, whether handwritten or computer generated,
it is likely that anesthesia records will remain challenging
to interpret.
References
[1] Kuc, J. “Perioperative Records”, in Iyer,
P., Levin, B., and Shea, M.A., Medical
Legal Aspects of Medical Records, Lawyers and Judges
Publishing Company, 2006.
[2] Rodden, D. and Dlugose, D. “Nurse Anesthesia Malpractice
Issues”, in Iyer, P. and Levin, B. Nursing
Malpractice, Third Edition, Lawyers and Judges
Publishing Company, 2007.
[3] Id.
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