A cumulative anaesthesia record system
Descrição do Produto
Anaesthesiu, 1982, Volume 37, pages 1121-1 125
A cumulative anaesthesia record system H a r r y Middleton, FFARCS, C o n s u l t a n t Anaesthetist, S u s a n Hales, NDD, ATC, Medical Artist, Medical Illustration Unit, R o y a l E a s t Sussex Hospital, Hastings
Summary The use of a cumulative anaesrhesia record draws attention to possible hazards, avoidr dangers of repeat administrations, recalls patients’ preferences and successful techniques und shows the complete course of un anaesthetic in the event of medicolegal problems.
Key words Records: anaesthesia
The need for a cumulative anaesthesia record system which fully presents a patient’s anaesthetic, surgical and medical history together with the problems presenting at the time of preparation for another anaesthetic has become increasingly important. Whether to administer a drug more than once in a given period, or in the face of a known reaction on a previous occasion, is a matter for clinical judgment. A sound decision may be reached once a good knowledge of the events of the past has been learnt. The cumulative system first described by Middleton’ was primarily intended to achieve optimum premedication and anaesthesia in patients presenting for repeated anaesthetics in plastic surgery and burns.2 Many of the problems, now familiar, were not then known and many of the anaesthetic drugs then used have passed from the scene. The use of a separatc punch card3 to assemble statistical data and to make a graphic record of the progress of the anaesthetic has given way. in the system now described, to an integral graphic record and statistics are gathered separately as required. The accumulation of information relevant to the anaesthetic places the anaesthetist in a much better position from a medicolegal viewpoint if he can now choose to avoid pitfalls previously discovered and now perhaps forgotten in the current hisotry. Sensitivities, previous corticostcroid treatment, technical difficultics, crowned teeth, hepatitis antigen, recent halothane administration and sickle cell trait all come to mind.
Design The base card (Fig. 1) contains permanent information-names, date of birth, record number and space for a red triangle4 to draw particular attention to known hazards of a permanent nature, such as allergies, crowned teeth and so on. About half of the base card is covered when the gummed edge anaesthetic sheets or slips are attached so the otherwise blank part is filled by potentially useful information such as instructions for the use of the system, ASA risk, Apgar scores, blood chemistry values and physiological data. A new anaesthetic slip is affixed to the same b a x card each time any anaesthetic is given. Each slip is folded once to present three surfaces, one whole side and two half-sides. Side A . This is a half-sheet intended for completion in the anaesthetic outpatient clinic5 or at the preoperative visit. Allocation of an ASA risk concentrates the mind on a more careful appraisal of the patient. Side B. This whole sheet forms the graphic section which can be used to plot every aspect of the progress of the anaesthetic. Space is provided for details of the personnel involved, dates and places, physiological events, the doses of drugs, the concentration of inhaled gases and vapours and the volume and duration of fluids or blood administered. The effect of premedication is quantified as a percentage. If it is thought that a larger dose should be given on a future
CUMU L A T l V E ANAESTHETIC RECORD CARD
ATTACH CAUTION
H N A hl
\LJ
1 O H t N A‘
t5
llN17 N 1 1 b H E A
REQUIRED U A l t Ut r I H l H
ONE C A R D O N L Y F O H t N T l R t PATIENT CAREER
3
3
2 A F F I X FIRST ANAESTHETIC SLIP H E H E DO NOT OVEFiLAP B .CK S H E t l
I
NISTRUCTIONS HL IIll
USE 24 HOUR CLOCK
B a i l F O t l L A b FL111US t l C
HOfU.!(8NTAL
IX Yii N
N I 1 HOtJ!,
STATE W H I C H
OXlOE
V C H T I C I L HARSFOR VAPOUH
,/rn#/I
i. STATE VAPOUR
ASSESSMENT OF PHYSICAL S T A T U S H X RISK I I
N Z R M A L H E A L T H Y PATIENT M I L 9 SYSTEMIC DISEASE i F V t R E SYSTEMIC DISEASE I H A ~L I M I rs ACTIVITY BUT I S NOT INCAPACITATING l < c P A C l T A T l N G SYSTEMIC DISEASE T H A T I S A CONSTANT THREAT TO LIFE A MORIBUND PATIENT N O T I X P E C T E D T O S U R V I V E 24 HRS
RISK I l l
I N b t H l F I L U R E S Ih TIME OF NOTESTO I N D I C A T E U H U G S NAh1E3 I U I N G U C T I O N M A I N T E N A Y C E A N U R E V E R S A L
SEC:I:,hs
RiSK IV
> parlihi
I & C A R E 01
I
INUtJCTIOh
0
SVR’.1l.AL
Y
S*b’IJLIL
.
Puts[
I Cu)
ANAESTHETIST
<
COMPLtllOlv X LOMPLETION 0
PHOLtUUHt
~~
~
R’SK V
BLOOU P R E S S U H E D I A S T O L I C A o
RESPIRATIONQNOTE
I Y E X P I H E b GASES
X
8 ( t h i l U A i YFNOIISPHtSSIIHF
10
WITH OR WITHOUT A N OPERATION IN THE E V E k T O F A N EMERGENCY O P k R A T l O h PRECEDE R I \ K 8 Y E _
X
10
_
_
~
APGAR SCORES iEART
4ATE %ESPIRATORY FFORT
0 ABSENI ABSENT
IIUSCLE lONE
1 2 or 5 I
UNUtR
rniriii~r
-
STRONG
WEAK IRREGULAR
REGULAR
SOMF F it X, O h
ACTIVF MOVE U E N1
CHI
%€FLEX 4ESPONSE TO iTlMULATlON I F FEET
NONt
WtAK MOVEMECT
lOLOUR
ULUI OR
800” PlhK
PALE
1 O V E P 100
COUPLETLL’ E A T R E M I T I C S PlUK BLUE
1123
Forum PRE-ANAESTHETIC ASSESSMENT
I
by
-
O O C I O ~Name S
IN OUT PATIENT
Date
Proposed Operaiton
I
Anaesthetic problems in family history?
Peak
lirnl"
Flow . _
Conicorteroidr
_
OPINION
_
_
~
~
~
YESlNO
Jlf"ndlC*
___
YESiNO
~~
Pacemaker
YESiNO
C,OW"ed
YESINO
Dsnture
YESiNO
Teeth
I
$ ! 2 3
I
A . S . A . RISK
I
ANAESTHETIC RECORD
f i g . 2. Side A: prc-operative information sheet
occasion the increase will be suggested by the percentage by which the figure given falls short of loo",;. Conversely an effect rated at over loo"; suggests a decreased dose on a future occasion. I t is strongly recommended that no matter what time the procedure commences the chart be made out so that the hour falls on an hour line. This clarifies the timing of events for subsequent study. The symbols used are conventional and a few new ones are proposed for such parameters as capnography or central venous pressure. Side C. This half-sheet is intcnded for the use of the recovery ward staff or at postoperative visits and records such events as hypothermia, laryngeal spasm, nausea and vomiting. Possible variations
Patients summoned to attend for day-case surgery under general anaesthesia or major analgesia should receive with their calling notice a warning not to drive, not to operate machinery and to arrange to be escorted home. Lewis6 has drawn attention to the possible medicolegal consequences of failure to comply. An additional fold and tear-off slip to remind the patient o f thew warnings may be incorporated and a record that this has been given can be signed. When separate records art: required for statistical
purposes it is possible to superimpose a similarly printed iden1 or one-time carbon sheet over side B. This is detached as an original and the copy becomes the cumulative record. I f a computer is used to store data a print-out becomes the cumulative slipavailable wherever the patient's notes are read. Acknowledgments The authors are grateful to all the anaesthetists of the Ilastings Group of Hospitals who have tried out various drafts of the system and have given most useful comments and suggestions. Rrfer~vwes I . MlDoLtToN HG. A cumulative anaesthesia record system. Anaesrhesia 1958; 13: 337-40. 2. M I U U L ~ . I O HG. N Anaesthesia for burned children. Proceedings of The Ro.~alSocierv of Medicrne 1957; 50: 888-92. 3. NOSWORTHY MD. A method of keeping anaesthetic records and assessing results. Brirish Journal of Anue.srhrsia 1943; IS: 160 79. 4 The 'RED TRIANGLE' caution label produced by a medical committee of Southend District. Information ctrurtrsy of Dr R.S. Atkinson. 5 K E ~ PV R . The value of anaesthesia outpatient clinics. Lanwr 1962; 11: 44647. h. LEWISEB. Open forum. The Annual Conference of Linkmen of the Association of Anaesthetists of Great Britain and Ireland 1981. Anomfhesru 1982; 37: 242.
~
1124
Forum
R E.S H
SURNAME FORENAMES U N I T NUMBER
ST HELENS BUCHANAN BEXHILL
EVERSFIELD
ACCIDENT DEPT
OTHER
ANAESTHETIST
SURGEON
DATE
DATE OF BIRTH
i
PRE MEDICATION
TIME G I V E N
BY
EFFECT
HAS
[
INDUCTION
NOTES Mask
Tubesize
OroINaso Cuff Pack
MAINTENANCE
REVERSAL OPERATION PERFORMED
-2l33-0
Anaesthetisr's Signature
Time of
notes
I
I
I
I/
Fig. 3. Side B, peroperarive information recol-4
Forum POST
- ANAESTHETIC INSTRUCTIONS
OTHER RECOVERY COMMENTS
RECOVERY WARD REPORT Uneventful reccoYeTy
Na"S9a
Restless reCoverv
vomltlng
t"a"0llS
A~rwavobstruction
Pallor
h r e lhr-t sore e"er
Shivering Hvpothermm
"C
Headache
Pal"
GUM HERE
Fig. 4. Side C . postoperdtivr record.
1125
Lihat lebih banyak...
Comentários