Elective/Routine Case Evaluation Checklist (Part A)

ACA ______Date ______Preceptor______

□Room Set-Up using the acronym MSMAIDS

Anesthesia Machine Check as per protocol

□Suction

□Monitors

  • Required (BP, ECG, SpO2, gas analyzer)
  • Other (temperature, peripheral nerve stimulator)

□Airway

  • Laryngoscope, alternate blade
  • Oral, nasal airway
  • Appropriate ETT, cut, checked, +/- stylet, syringe, tape
  • Alternative airway device(s)
  • Back up plan

□Intravenous tubing set-up with appropriate solution, bag de-aired, +/- stopcocks, extensions

  • Supplies for insertion considering access points, catheter gauge

□Drugs

  • Emergency (atropine, ephedrine, phenylephrine)
  • Induction
  • Adjuncts (sedation, antiemetics, antifibrinolytics, anticoagulants, antibiotics, LA’s etc.)
  • Maintenance infusions

□Other Supplies

  • Eye protection
  • Head rests, gel pads, positioning devices
  • Fluid warmer
  • Body warmer
  • Infusion pumps (single channel, triple channel, syringe, PCA/PCEA)
  • Transducers, Invasive monitoring supplies (arterial, CVP)
  • Nerve block stimulator and supplies
  • Supplies for epidural/spinal insertion
  • Alternate breathing circuit
  • Difficult Airway Cart
  • CPDA-1 blood collection bags, blood collection mixer, ANH
  • Cell saver
  • Point-of-Care Glucometer, Hemachron, ABG
  • BIS/ICP monitor
  • Rapid infuser devices (Level 1, pneumatic device, pressure bag)
  • Pulmonary Artery Catheters/Cardiac Output set up/TEE
  • MH cart

□Proceduralassistance

  • Epidural/Spinal Assist
  • Gather required supplies (needles, syringes, drugs etc.)
  • Open tray using sterile technique, pass supplies aseptically
  • Assist Anesthesiologist with drug preparation
  • Help to position patient
  • Other as required
  • Plexus Blocks
  • Gather required supplies (nerve stimulator, needles, drugs etc.)
  • Set-up nerve stimulator
  • Help position patient
  • Dial nerve stimulator up and down as instructed
  • Inject local when instructed, aspirating every 5 ml’s
  • Arterial/Central Line Insertion
  • Gathers appropriate equipment
  • Selects appropriate site
  • Follows facility insertion protocol, performs or assists as appropriate
  • Awake topicalization/intubation
  • Retrieves airway cart, prepares bronchoscope
  • Assists with gargle, atomizer, nebulizer, pledgets
  • Prepares and assists with SLN blocks, transtracheal injection

□ Preoperative Assessment (per Appendix A below)

□ Pre-Induction

  • Attends to warmth & comfort
  • Positions patient
  • Cycles monitors, interprets and records vital signs
  • Runs ECG strip as required
  • Pre-oxygenates

□Induction

  • Calculates dose and administers induction agents

□Maintenance of a Patent Airway

  • Supplements oxygenation (mask, NP, blow by)
  • Manages of an obstructed airway (jaw thrust, chin lift, CPAP)
  • Inserts of airway devices (oral, nasal)
  • Suctions as required
  • Provides mask ventilation (self inflating/flow inflating systems)

□Laryngoscopy and Oral Intubation

  • Handles laryngoscope and endotracheal tube competently
  • Obtains best laryngoscopic view possible
  • Confirms tube placement
  • Connects to breathing circuit, adjusts ventilator parameters, aware of PAW
  • Secures tube

□Rapid Sequence Induction with Cricoid Pressure

  • Preoxygenates
  • Administers induction drugs
  • Instructs assistant when to apply cricoid pressure
  • Intubates
  • Confirms tube placement, instruct assistant when to release cricoid pressure
  • Connects to breathing circuit

□Drug preparation and administration

  • Drugs are prepared in a safe manner (3 check system and labeled, dated and signed)
  • Required drugs are prepared and ready on anesthesia machine throughout case
  • Utilizes both needles and needleless systems appropriately

□Drug Infusions, Preparation and Administration

  • Gathers appropriate type of pump
  • Prepares medication
  • Sets up pump, starts infusion, adjusts as required

□Management of Maintenance Phase of Anesthesia

  • Vigilance, watchfulness and adherence to the anesthetic goals as determined by the Anesthesiologist
  • Adjusts neuromuscular blockade, narcotics, volatile gases
  • Fluid maintenance and replacement, calculation of fluid deficit
  • Interprets of lab results
  • Adjusts ventilator parameters
  • Refills vaporizers/re-zeros lines
  • Ongoing drug preparation and administration
  • Monitors drug infusion therapy
  • Documents legibly, accurately and in a timely fashion
  • Communicates clearly, concisely
  • Maintains neat environment
  • Administers conscious sedation
  • 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

□Emergence and Extubation

  • Assesses patient readiness (spontaneously breathing, obeys commands etc)
  • Conducts leak test if applicable
  • Emergency intubation equipment available
  • Suctions
  • Deflates cuff, pulls tube at full lung volumes
  • Applies appropriate oxygen therapy and monitors

□Transportation of Patient

  • Sets up transport monitor, oxygen source, ventilatory devices as appropriate
  • Readies patient for transport (simplify lines and tubes, ensure sufficient supplies for the duration of the transport)
  • Prepares/retrieves the emergency airway kit as appropriate
  • Assists with patient transport from bed/stretcher to OR/procedure table

□PACU/ICU

  • 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

  • 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. Reviews PAC sheet, truncates preoperative assessment appropriately
  2. Identifies the patient (name bracelet)
  3. Looks the patient: How do they look in general? Are they anxious, having pain or cold?
  4. Ensures patient comfort & warmth
  5. Confirms patients understanding of planned procedure
  6. 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
  • Vital signs: Ht _____ Wt _____ B/P ______HR/ Rhythm ______RR ______
  • Airway
  • Inspection, Auscultation (Heart, Lungs, Carotids)
  • Assessment of arterial & venous access, vertebral anatomy, neurological
  • Assign ASA score

□Patient Education per Anesthesiologist instructions

Checklist for Evaluation of ACA during Elective/Routine Case