1. Anesthesia Training: Documenting Fluids IN and OUT

2. Presentation TitleDate 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

3. Presentation TitleDate Fluid Families “Colour Coded” Fluids IN: Blood products Drug Infusions eg.Dopamine, Epinephrine IV Fluids: Anesthesia IV Fluids Eg. Ringers/NS/Colloids Fluids OUT: Urine Blood out Other Fluids Eg. Chest tube drainage

4. Presentation TitleDate Fluids in Anesthesia Manager: Behavior of Different Fluid Types Fluids IN: Continuous: Gravity infusions (eg. NS, LR, RBC’s) fluid administered NOT accounted in the Fluid Balance until a new bag is started, the infusion is paused or a bag level is entered. Bolus: Volume 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. Running a fluid at a specific “pump rate” 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.

5. Presentation TitleDate Fluid Flowsheet Symbols Colors correspond to fluid families 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

6. Presentation TitleDate 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 @ 5-6 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

7. Presentation TitleDate 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) 2/3-1/3 (1000 mL) Ringers Lactate (1000 mL) Default “Fluids OUT” include: Blood (Cumulative) Urine (Cumulative)

8. Presentation TitleDate 1.Click in the appropriate time cell corresponding to 0.9% NS-Dcoument window opens 2. New Bag of 1000 mL. is the default. Highlight other quantity or type in actual volume 3. Injection site defaults to generic IV 4. Hit the check mark to confirm entry onto the record 2. New Bag of 1000 mL. is the default. Highlight other quantity from drop down or type in actual volume Fluids In-Initiating a Default Fluid Eg: 1000 ml of NS at 19:55

9. Presentation TitleDate Fluids In-Initiating a Default Fluid Eg: 1000 ml of NS at 19:55

10. Presentation TitleDate Fluids In-Initiating a Default Fluid “Labelling the Fluid” Keeping Track of multiple fluids can be difficult Solution is to label the site

11. Presentation TitleDate Fluids In-Initiating a Default Fluid “Labelling the Fluid” Placing cursor over Fluid order will cause the Site to appear

12. Presentation TitleDate 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

13. Presentation TitleDate 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

14. Presentation TitleDate 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. 3. Scroll to the additive-KCl-20 mmol 4. Pump Rate- enter in at 125 ml/hr 5. Use pull down menu to select “Antecubital Left” 6. Adjust Starting Time if required

15. Presentation TitleDate 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

16. Presentation TitleDate Fluids In-Initiating a Default Fluid Eg: 375 ml. LR with 20 mm KCl/L @ 125 ml/hr in the L ACF When a Fluid Volume other than the default of 1000 ml is chosen, starting a “new bag” will ALWAYS bring up the same Fluid Volume +/- additives. Eg: Patient arrived to OR with 375 ml of LR (+ 20 mmol KCL) remaining in bag (as per last slide) Bag is empty and you hang 1000 ml of LR. Notice how the “new bag” defaults to 375 (+20 mmlo KCL). You must change this to 1000 ml and uncheck the KCl or else your fluid balance will be INCORRECT

17. Presentation TitleDate Fluids In-Initiating a non Default Fluid Standard Option 1. Mouse over “Electrolyte Replacement” OR 2. Right click over any electrolyte fluid and “Add Item” 3. Pick a fluid 4. Adjust starting time-default is beginning of the case

18. Presentation TitleDate Fluids In-Initiating a non Default Fluid Standard Option “Add and Document” Brings up “document window” prior to order appearing on the record  Can adjust time (default time is beginning of “GA Anesthesia Standard” Session)  Can adjust volume/additives  Can set pump rate  Can adjust site “Add” Enters new order on the record (default time is beginning of “GA Anesthesia Standard” Session) User must now click on desired time on the timeline to open the “Document Window” and enter information 5. Click on either “Add and Document” OR “Add”

19. Presentation TitleDate Fluids In-Initiating a non Default Fluid Standard Option

20. Presentation TitleDate Fluids In-Initiating a non Default Fluid Protocol Option Protocols are groups of standard orders, one or more which can be added to the patient chart Anesthesia Manager has been configured with a protocol labeled * Anes_Fluids In”  that allows for the selection of the most commonly used anesthetic fluids

21. Presentation TitleDate 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  Values (Volume) will immediately be added to the Fluid Balance IV INF or IV Continuous indicates gravity or rate delivered fluid  Values (Volume) will only be added to the Fluid Balance when a “Bag Level” is performed or a Fluid is discontinued.

22. Presentation TitleDate 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.Click on the “protocol” icon OR Pull down the “Order Menu” 2.Select the “*Anes_Fluids In” protocol 3. Select “RBC ml Cont.” x 7 days 4. Default starting time is the beginning of the case (Anesthesia Standard session) 5. Hit “Add” to have order appear on record 1.Click on the “protocol” icon OR Pull down the “Order Menu”

23. Presentation TitleDate Fluids In-Initiating a non Default Fluid Protocol Option-*Anes_Fluids IN Eg. Add a unit of PRBC’s to be delivered over time 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” 1. Document the volume to be administered 2. Enter the Unit # 3. Adjust the site if required 4. Tick the checkbox to document on the record 200

24. Presentation TitleDate Fluids In-Initiating a non Default Fluid Protocol Option-*Anes_Fluids IN Eg. Add a unit of PRBC’s to be delivered over time

25. Presentation TitleDate Fluids IN-Pausing an Infusion 1. Click at relevant time- Document Window opens 2. Change “Action” to Pause 4. Hit Check Mark 3. Enter in “Bag Level” if desired

26. Presentation TitleDate 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

27. Presentation TitleDate Fluids IN-Restarting an Infusion 1. Click at desired time to resume infusion 2. By default, action returns to “Infusing” 3. Hit check

28. Presentation TitleDate Fluids IN-Restarting an Infusion Forward arrow (BOLD) indicates that infusion has restarted

29. Presentation TitleDate Fluids IN-Discontinuing a Fluid 1. Click at desired time-Document Window opens 2. Click on “X” 3. Click “Yes” to prompt 4. Insert “Bag Level” and hit “OK”

30. Presentation TitleDate Fluids IN-Discontinuing a Fluid X indicates Fluid has been discontinued

31. Presentation TitleDate Fluids Out Fluids Out (Default) Blood (cumulative) Urine (cumulative)

32. Presentation TitleDate Fluids Out-Initiating a Default Fluid eg. Urine Output of 250 ml. 2. Enter volume of “Fluid Out” 3. Adjust time if required 4. Hit OK to appear on record 1. Click cursor on appropriate “Fluid Out” at desired time (Document window opens)

33. Presentation TitleDate 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.

34. Presentation TitleDate 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 4. Hit OK to appear on record 1. Click cursor at new time point (Document window opens)

35. Presentation TitleDate 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.

36. Presentation TitleDate 1. Mouse over “Fluids Out” OR 3.Pick a fluid 4. Adjust starting time-default is beginning of the case 2. Right click over any electrolyte fluid and “Add Item” Fluids Out-Documenting a non Default Fluid Standard Option

37. Presentation TitleDate Fluids Out-Documenting a non Default Fluid Standard Option “Add and Document” Brings up “Document Window” prior to order appearing on the record  Can adjust time (default time is beginning of “GA Anesthesia Standard” Session  Can adjust amount “Add” 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 5. Click on either “Add and Document” OR “Add” 5. Enter in “amount” and hit “OK” 5. Enter in “amount” and hit check box

38. Presentation TitleDate Fluids In-Initiating a non Default Fluid Standard Option

39. Presentation TitleDate 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 4. Default starting time is the beginning of the session (Anesthesia Standard) 5. Hit “Add” to have order appear on record

40. Presentation TitleDate Fluids In-Initiating a non Default Fluid Protocol Option-*Anes_Fluids OUT

41. Presentation TitleDate 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.

42. Presentation TitleDate Fluid Balance 1.Click on the “Fluid Balance” icon OR Pull down the “Insert/View” menu OR Hit F9 on the keyboard 1.Click on the “Fluid Balance” icon OR Pull down the “Insert/View” menu OR Hit F9 on the keyboard

43. Presentation TitleDate Fluid Balance Gross Fluid Balance displayed in absolute amounts with accompanying pie graph 1. Hit “Fluid Balance Detail” icon The total for each fluid family is displayed The net Balance The “Total IN” and “OUT” are above and below the bar graph

44. Presentation TitleDate Fluid Balance “Pitfalls” In a gravity based infusion, the System has no idea as to how much fluid has been administered over a fixed period of time. Therefore, the fluid balance is recorded as 0 (ZERO)

45. Presentation TitleDate Fluid Balance “Pitfalls” A “Bag Level” must be performed on a gravity based infusion to tell the system the volume of fluid administered.

46. Presentation TitleDate 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.

47. Presentation TitleDate Questions And Answers