Elective/Routine Case Evaluation Checklist (Part A)
ACA ____________________ Date _______________ Preceptor___________________
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Room Set-Up using the acronym MSMAIDS
Anesthesia Machine Check as per protocol
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Suction
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Monitors
o
o
Required (BP, ECG, SpO2, gas analyzer)
Other (temperature, peripheral nerve stimulator)
o
o
o
o
o
Laryngoscope, alternate blade
Oral, nasal airway
Appropriate ETT, cut, checked, +/- stylet, syringe, tape
Alternative airway device(s)
Back up plan
Airway
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Intravenous tubing set-up with appropriate solution, bag de-aired, +/- stopcocks, extensions
o
Supplies for insertion considering access points, catheter gauge
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Drugs
o
o
o
o
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Emergency (atropine, ephedrine, phenylephrine)
Induction
Adjuncts (sedation, antiemetics, antifibrinolytics, anticoagulants, antibiotics, LA’s etc.)
Maintenance infusions
Other Supplies
o
Eye protection
o
Head rests, gel pads, positioning devices
o
Fluid warmer
o
Body warmer
o
Infusion pumps (single channel, triple channel, syringe, PCA/PCEA)
o
Transducers, Invasive monitoring supplies (arterial, CVP)
o
Nerve block stimulator and supplies
o
Supplies for epidural/spinal insertion
o
Alternate breathing circuit
o
Difficult Airway Cart
o
CPDA-1 blood collection bags, blood collection mixer, ANH
o
Cell saver
o
Point-of-Care Glucometer, Hemachron, ABG
o
BIS/ICP monitor
o
Rapid infuser devices (Level 1, pneumatic device, pressure bag)
o
Pulmonary Artery Catheters/Cardiac Output set up/TEE
o
MH cart
Procedural assistance
o
Epidural/Spinal Assist
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Gather required supplies (needles, syringes, drugs etc.)
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Open tray using sterile technique, pass supplies aseptically
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Assist Anesthesiologist with drug preparation
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Help to position patient
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Other as required
o
Plexus Blocks
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Gather required supplies (nerve stimulator, needles, drugs etc.)
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Set-up nerve stimulator
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Help position patient
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Dial nerve stimulator up and down as instructed
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Inject local when instructed, aspirating every 5 ml’s
Checklist for Evaluation of ACA during Elective/Routine Case
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o
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Arterial/Central Line Insertion
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Gathers appropriate equipment
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Selects appropriate site
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Follows facility insertion protocol, performs or assists as appropriate
Awake topicalization/intubation
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Retrieves airway cart, prepares bronchoscope
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Assists with gargle, atomizer, nebulizer, pledgets
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Prepares and assists with SLN blocks, transtracheal injection
Preoperative Assessment (per Appendix A below)
Pre-Induction
o
Attends to warmth & comfort
o
Positions patient
o
Cycles monitors, interprets and records vital signs
o
Runs ECG strip as required
o
Pre-oxygenates
Induction
o
Calculates dose and administers induction agents
Maintenance of a Patent Airway
o
Supplements oxygenation (mask, NP, blow by)
o
Manages of an obstructed airway (jaw thrust, chin lift, CPAP)
o
Inserts of airway devices (oral, nasal)
o
Suctions as required
o
Provides mask ventilation (self inflating/flow inflating systems)
Laryngoscopy and Oral Intubation
o
Handles laryngoscope and endotracheal tube competently
o
Obtains best laryngoscopic view possible
o
Confirms tube placement
o
Connects to breathing circuit, adjusts ventilator parameters, aware of PAW
o
Secures tube
Rapid Sequence Induction with Cricoid Pressure
o
Preoxygenates
o
Administers induction drugs
o
Instructs assistant when to apply cricoid pressure
o
Intubates
o
Confirms tube placement, instruct assistant when to release cricoid pressure
o
Connects to breathing circuit
Drug preparation and administration
o
Drugs are prepared in a safe manner (3 check system and labeled, dated and signed)
o
Required drugs are prepared and ready on anesthesia machine throughout case
o
Utilizes both needles and needleless systems appropriately
Drug Infusions, Preparation and Administration
o
Gathers appropriate type of pump
o
Prepares medication
o
Sets up pump, starts infusion, adjusts as required
Management of Maintenance Phase of Anesthesia
o
Vigilance, watchfulness and adherence to the anesthetic goals as determined by the Anesthesiologist
o
Adjusts neuromuscular blockade, narcotics, volatile gases
o
Fluid maintenance and replacement, calculation of fluid deficit
o
Interprets of lab results
o
Adjusts ventilator parameters
o
Refills vaporizers/re-zeros lines
o
Ongoing drug preparation and administration
o
Monitors drug infusion therapy
o
Documents legibly, accurately and in a timely fashion
o
Communicates clearly, concisely
o
Maintains neat environment
o
Administers conscious sedation
Checklist for Evaluation of ACA during Elective/Routine Case
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o
o
o
o
Emergence and Extubation
o
Assesses patient readiness (spontaneously breathing, obeys commands etc)
o
Conducts leak test if applicable
o
Emergency intubation equipment available
o
Suctions
o
Deflates cuff, pulls tube at full lung volumes
o
Applies appropriate oxygen therapy and monitors
Transportation of Patient
o
Sets up transport monitor, oxygen source, ventilatory devices as appropriate
o
Readies patient for transport (simplify lines and tubes, ensure sufficient supplies for the duration of the
transport)
o
Prepares/retrieves the emergency airway kit as appropriate
o
Assists with patient transport from bed/stretcher to OR/procedure table
PACU/ICU
o
o
o
o
o
o
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Provides eye care, attends to position/pressure points
Inserts NG tube as required
Asks for assistance, calls Anesthesiologist back appropriately
Recognizes emergencies & risky situations, initiates intervention
Gives concise report
Conducts brief patient assessment at handover
Documents PACU vital signs, completes order sheet
Enacts emergency protocols
Assesses and troubleshoots equipment
Assesses PACU conditions (pain, nausea, reduced urine output, hypotension, delerium etc.) and
provides report to Anesthesiologist
Expert Assistance for Resuscitation/Complex Cases
o
o
o
o
o
o
o
o
o
o
o
ACLS
Massive hemorrhage
Anaphylaxis
Difficult airway
Burn debridement & grafting
ICU patients for surgical procedures
Turn prone/supine
Acute normovolemic hemodilution
Uncooperative patient
Mentally challenged patient
Other
Appendix A: Pre-operative Patient Assessment (of appropriate detail & duration to the situation at hand)
1.
2.
3.
4.
5.
6.
Reviews PAC sheet, truncates preoperative assessment appropriately
Identifies the patient (name bracelet)
Looks the patient: How do they look in general? Are they anxious, having pain or cold?
Ensures patient comfort & warmth
Confirms patients understanding of planned procedure
Gathers appropriate information in a succinct fashion: Previous surgical and anesthetic history, Family history of
anesthetic concerns, GERD/dyspepsia, Allergies, Medical history: Do you see a doctor for any reason on a regular
basis?, Smoking history, Alcohol/recreational drug use, Rx medications /OTC/herbal remedies, NPO status
7. Review of systems as needed (CNS, CVS, Resp, other)
8. Reviews labs (hematology, biochemistry, ECG, CXR)
9. Physical assessment
o Vital signs: Ht _____ Wt _____ B/P ________ HR/ Rhythm _________ RR ______
o Airway
o Inspection, Auscultation (Heart, Lungs, Carotids)
o Assessment of arterial & venous access, vertebral anatomy, neurological
10. Assign ASA score
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Patient Education per Anesthesiologist instructions
Checklist for Evaluation of ACA during Elective/Routine Case