EMERGENT SCENARIO W/TRANSFUSION AND DIFFICULT AIRWAY

Create a Preoperative Assessment in Talis using the following information. You can create a patient from scratch using MRN 9999999. DO NOT CREATE A NEW PATIENT WITH ANY OTHER MRN IN OUR PRODUCTION SYSTEM AS THIS NUMBER MAY BELONG TO AN ACTUAL PATIENT.

Procedure: Explanatory laparotomy, abdominal washout for post-partum hemorrhage Emergency: Yes Patient Class: Inpatient Anesthetic Technique: General Anesthesia PostOp Diagnosis: Post-Partum Hemorrhage ASA Class: 5

Surgeon: Toni Golen, MD

Patient and Case Information

Allergies: Penicillin [anaphylaxis] Airway: Patient’s Medications: Pre-Natal Vitamins Mallampati [Class III] Zofran (4mg as needed) Mouth Opening [Adequate (>3 cm)] Thyromental Distance [>6 cm] Medical History Hyomental Distance [>3 cm] Mandibular Prognatism [Limited] History of Present Illness: 35 year old female G2P2 s/p c-section with hypotension with concern for Dental: Good intra-abdominal bleeding. Taken emergently to Head/Neck Range of Motion: Limited OR for exploratory laparotomy. Cardiovascular: None Pre-Procedure Vitals: Pulmonary: Asthma: well controlled Height: 60 in HR: 110 BP: 78/42 Neuromuscular: Migraines Weight: 157 lb spO2:97 Endocrine: None NPO Status: Solids > 6, Clears > 2 Anesthesia Alert: Language Other than English Blood Type: A neg, Electronic Crossmatch Eligible (Russian) Source of Information: Patient Anesthesia History: Previous w/o complications PostOp Location: ICU

Next, create an Intraoperative record in Talis using the Preop for the patient you created above. Use the clinical events listed below: Clinical Documentation

Start Case – Enter Anesthesia Start Time (A Time)

Page 1 Created by S. Nabel - BIDMC Updated 5/21/2020

Line IV: Right, 18 Gauge, In Situ, Wrist

Checklist:  Anesthesia machine and monitors checked prior to anesthesia  Monitors applied and functional prior in pre-anesthesia assessment  Patient re-evaluated and found appropriate for planned anesthetic prior to induction  Patient medical history and physical re-evaluated, including medications, allergies and anesthetic risks and plan

Add signature to case

Enter Patient In Room Time (B Time) 350 mL RBCs

Enter Anesthesia Induction Time 100 mg Propofol IV-Bolus 100 mg Succinylcholine IV-Bolus 50 mg Rocuronium IV-Bolus

Enter Intubation Time

Enter Airway/Intubation Notes:  1st attempt: 2b w/CMac3, attempted to pass bougie, unsuccessful.  2nd attempt: 2b w/CMac, unsuccessful.  3rd attempt: FOB w/5.5 mm, ovossapian – very challenging.  Difficult Airway: YES  ETT# 7.0  Tube taped at 22 cm

Enter Monitors and Warming Devices:  ECG: 5 lead  Pulse Ox  Capnography  BP Cuff: Right Arm  IV Fluid Warmer – Ranger

ECG Rhythm: Sinus 200 mcg Phenylephrine IV-Bolus

Enter Patient Position: Supine

350 mL RBCs administered w/ comment “Given for acute blood loss”. RCB Unit#: W205623905 2mg Midazolam IV-Bolus

Page 2 Created by S. Nabel - BIDMC Updated 5/21/2020

100 mcg Phenylephrine IV-Bolus 8 mcg Epinephrine IV-Bolus Enter Time Out

Enter Procedure Start Time 4 mcg Epinephrine IV-Bolus

Massive transfusion protocol activated 300 mcg Phenylephrine IV-Bolus 1000 mg Tranexamic Acid IV-Bolus 4 mcg Epinephrine IV-Bolus 100 mcg Phenylephrine IV-Bolus Line IV: Left, 16 Gauge, External Jugular

350 mL RBCs administered w/ comment “Given for acute blood loss”. RCB Unit#: W2055473345 4 mcg Epinephrine IV-Bolus 40 mg Rocuronium IV-Bolus 200 mcg Phenylephrine IV-Bolus 1unit/hr Oxytocin IV-infusion 60units/3000mL 4 mcg Epinephrine IV-Bolus 200 mcg Phenylephrine IV-Bolus 4 mcg Epinephrine IV-Bolus ECG Rhythm: Sinus 2mg Midazolam IV-Bolus 2 gm Cefazolin IV-Slow 1 mg Epinephrine IV-Bolus 16 mcg Epinephrine IV-Bolus Code Called ECG Rhythm: Ventricular Fibrillation Enter Comment “Drop in EtCO2 noted, Code Blue called, chest compressions initiated but no defibrillation required. EtCO2 returned to normal and ROSC noted on pulse check. New labs requested stat.” ECG Rhythm: Sinus Tachycardia 1000mg Calcium Chloride IV-Bolus 100 mcg/kg/min Propofol IV-Infusion 500mg/50mL 1000 mL Plasmalyte-A 350 mL RBCs administered w/ comment “Given for acute blood loss”. RCB Unit#: W205784523 350 mL RBCs administered w/ comment “Given for acute blood loss”. RCB Unit#: W205774562 205 mL Platelets administered w/ comment “Given for microvascular bleeding”. Platelets Unit#: W203572035 ECG Rhythm: Sinus Tachycardia 8 mcg Epinephrine IV-Bolus

Page 3 Created by S. Nabel - BIDMC Updated 5/21/2020

Enter Brachial Arterial Line  Placed using U/S Guidance  Prep: Chlorhexidine 2%/Isopropanol 70%  Catheter: 20 G  Left Side  Guide wire required  No complications

ECG Rhythm: Sinus 1000 ml LR 304 mL FFP administered w/comment “Given for elevated INR”. FFP Unit# W2035762928 1 mcg/kg/min Phenylephrine IV-Infusion 60mg/250mL

Enter TEE Performed w/comment “Left ventrical appropriately full and contracting well. Vena Cava of appropriate size. Overall unremarkable TEE.”

Enter CVP Line – Internal Jugular  Placed using U/S Guidance  Placed Sterilely  Prep: Chlorhexidine 2%/Isopropanol 70%  Catheter: MAC Trauma Inducer  Right Side  Vein Cannulated  Using Seldinger Technique w/J Wire  No complications

307 mL FFP administered w/comment “Given for elevated INR”. FFP Unit# W2035762928 60 mg Rocuronium IV-Bolus E.B.L. 3500 mL

Enter Procedure Finish Time

Transport to ICU for further stabilization intubated on phenylephrine infusion, propofol infusion, sedated on bag mask ventilation and full monitors.

Arrive in ICU and appropriate report given to care team Enter Anesthesia Stop (D Time)

Verify and resolve all case errors and finalize record

Page 4 Created by S. Nabel - BIDMC Updated 5/21/2020

Complete Post Op Note  Location: ICU  Vitals signs appropriate: Being managed by ICU Team  Respiratory function appropriate: Patient intubated  Cardiovascular function and hydration status appropriate: Being managed by ICU Team  Pain control satisfactory: Unable to assess  Nausea and vomiting control satisfactory: Unable to assess  Patient alertness: patient sedated  Neuraxial block: No  Complications: No complications

Page 5 Created by S. Nabel - BIDMC Updated 5/21/2020

GI SCENARIO W/MAC Conversion to GET

Create a Preoperative Assessment in Talis using the following information. You can create a patient from scratch using a MRN 9999999. DO NOT CREATE A NEW PATIENT WITH ANY OTHER MRN IN OUR PRODUCTION SYSTEM AS THIS NUMBER MAY BELONG TO AN ACTUAL PATIENT.

Procedure: EGD/Colonoscopy Emergency: No Patient Class: Inpatient Anesthetic Technique: MAC PostOp Diagnosis: Dysplastic Barrett’s; History of Polyps ASA Class: 2

Surgeon: Douglas Pleskow, MD

Patient and Case Information

Medical History Airway: Mallampati [Class IV] Allergies: NKDA Mouth Opening [Adequate (>3 cm)] Patient’s Medications: Omeprazole, Lipitor Thyromental Distance [>6 cm] Hyomental Distance [>3 cm] History of Present Illness: 72 year old male with Mandibular Prognatism [Adequate] history of short seg Barretts and colon polyps. Cardiovascular: Dyslipidemia Dental: Good Pulmonary: OSA: uses CPAP Head/Neck Range of Motion: Free Range of Motion GI: Reflux, colon polyps Pre-Procedure Vitals: Alert: Hx of waking up with MAC anesthesia for Height: 65 in prior EGD. Weight: 210 lb Anesthesia History: Previous w/complication of BP-Right: 124/93 waking under MAC for EGD. Source of Information: Patient NPO Status: Solids > 6, Clears > 2 Post Op Plan: GI Recovery

Next, create an Intraoperative record in Talis using the preop for the patient you created above. Use the clinical events listed below: Clinical Documentation

Enter Anesthesia Start Time (A Time) Enter Line IV: Right, 20 Gauge, Hand 50 mcg Fentanyl IV-Bolus

Page 6 Created by S. Nabel - BIDMC Updated 5/21/2020

Enter Patient In Room Time (B Time)

Checklist:  Anesthesia machine and monitors checked prior to anesthesia  Monitors applied and functional prior in pre-anesthesia assessment  Patient re-evaluated and found appropriate for planned anesthetic prior to induction  Patient medical history and physical re-evaluated, including medications, allergies and anesthetic risks and plan

Add signature to case Anesthetic spray to oropharynx

Enter Monitors and Warming Devices:  ECG: 5 lead  Pulse Ox  Capnography  BP Cuff: Left Arm  Blanket  Eye Care: Closed

0.2 mg Glycopyrrolate IV-Bolus ECG Rhythm: Sinus

Enter Anesthesia Induction Time O2-Aux 8/L min 150 mcg/kg/min Propofol IV-Infusion 500 mg/50 mL 20 mg Propofol IV-Bolus 100 mg Lidocaine IV-Bolus 130 mcg/kg/min Propofol IV-Infusion 500 mg/50 mL 20 mg Ketamine IV-Bolus

Enter Time Out Enter Procedure Start Time

10mg Ketamine IV-Bolus 2mg Midazolam IV-Bolus ECG Rhythm: Sinus ECG Rhythm: Sinus End Propofol Infusion 500 mg/50 mL 110 mcg/kg/min Propofol IV-Infusion

Page 7 Created by S. Nabel - BIDMC Updated 5/21/2020

Enter Comment: “During attempted endoscopy, patient was intubated by endoscopist in the trachea which led to severe coughing, breath-holding and possible laryngospasm leading to acute desaturation. Code blue called.”

20 mg Succinylcholine IV-Bolus

Intraop GI conversion from MAC to GET; Reason: Difficult Oxygenation Enter Comment: “CPR started; epinephrine given x2 during CPR. Once intubated, saturations improved.” 1 mg Epinephrine IV-Bolus 1 mg Epinephrine IV-Bolus

Enter Intubation Time Enter Airway/Intubation Notes:  Difficult mask ventilation  1st attempt: McGrath, unsuccessful; large epiglottis.  2nd attempt: Glidescope, successful

ECG Rhythm: Sinus 500 mL LR ECG Rhythm: Sinus 1000 mcg Epinephrine IV-Bolus

Enter Procedure Finish Time

Enter Extubation Time Extubation Comments:  Pharynx suctioned and clear  Extubated awake  Patient is maintaining patent airway

Transport to PACU Arrive in PACU: report given, patient stable, awake, alert and responsive.

Enter Anesthesia Stop (D Time)

Verify and resolve all case errors and finalize record

Complete Post Op Note  Vitals signs appropriate: Yes  Respiratory function appropriate: Yes  Cardiovascular function and hydration status appropriate: Yes  Pain control satisfactory: Yes  Nausea and vomiting control satisfactory: Yes  Patient alertness: patient awake and alert and participates in evaluation

Page 8 Created by S. Nabel - BIDMC Updated 5/21/2020

 Neuraxial block: No  Complications: No complications

Page 9 Created by S. Nabel - BIDMC Updated 5/21/2020

ORTHO SCENARIO W/COVID PRECAUTIONS AND REGIONAL BLOCK

Create a Preoperative Assessment in Talis using the following information. You can create a patient from scratch using a MRN 9999999. DO NOT CREATE A NEW PATIENT WITH ANY OTHER MRN IN OUR PRODUCTION SYSTEM AS THIS NUMBER MAY BELONG TO AN ACTUAL PATIENT.

Procedure: ORIF Left Hip Emergency: Yes Patient Class: Inpatient Anesthetic Technique: General Anesthesia; Spinal in OR PostOp Diagnosis: Left Hip Fracture ASA Class: 3

Surgeon: Edward Rodriguez, MD

Patient and Case Information

Allergies: NKDA Airway: Patient’s Medications: None Mallampati [Class II] Mouth Opening [Adequate (>3 cm)] Medical History Thyromental Distance [>6 cm] Hyomental Distance [>3 cm] History of Present Illness: 82 year old male with Mandibular Prognatism [Adequate] history of EtOH abuse, presents with left hip fracture after fall out of bed. Dental: Good Cardiovascular: LVH Head/Neck Range of Motion: Free Range of Motion COVID: Status unknown and cannot be confirmed preoperatively. Pre-Procedure Vitals: Height: 65 in HR: 87 Anesthesia Alert: Consent by other than patient Weight: 176 lb BP-Left: 112/83 Blood Type: A +, Electronic Crossmatch Eligible Anesthesia History: None NPO Status: Solids > 6, Clears > 2 Source of Information: Daughter Post Op Location: OR for PACU care due to COVID

Next, create an Intraoperative record in Talis using the Preop for the patient you created above. Use the clinical events listed below: Clinical Documentation

Start Case – Enter Anesthesia Start Time (A Time)

Line IV: Left, 20 Gauge, In Situ, Antecubital Fossa

Page 10 Created by S. Nabel - BIDMC Updated 5/21/2020

2 mg Midazolam IV-Bolus

Enter Patient In Room Time (B Time) Enter Patient Position:  Supine  Pressure points padded  Head on pillow  Eyes, ears and nose free from pressure  Both arms padded and tucked securely away from torso

Checklist:  Patient transported by OR team from room directly to OR due to COVID status  Anesthesia machine and monitors checked prior to anesthesia  Monitors applied and functional prior in pre-anesthesia assessment  Patient re-evaluated and found appropriate for planned anesthetic prior to induction  Patient medical history and physical re-evaluated, including medications, allergies and anesthetic risks and plan

Enter Antibiotic Comment: Prophylactic antibiotic was administered preoperatively

Add signature to case Enter Monitors and Warming Devices:  ECG: 5 lead  Pulse Ox  BP Cuff: Right Arm  Capnography  IV Fluid Warmer – Ranger  Temp: esophageal

Enter Anesthesia Induction Time

Enter Regional Block – Spinal  Position: Sitting  Sterile prep & drape  Interspace: L 4-5  Needle: 22 G Quincke  Paresthesia down left heel on first attempt with good CSF flow, resolved on removal of needle.

25 mcg Fentanyl IV-Bolus 40 mg Lidocaine IV-Bolus 80 mg Propofol IV-Bolus 40 mg Rocuronium IV-Bolus

Page 11 Created by S. Nabel - BIDMC Updated 5/21/2020

Enter Intubation Time

Enter Airway/Intubation Notes:  McGrath Video Laryngoscope  Laryngoscopy grade 1, vocal cords seen  Rapid Sequence Induction  Oral intubation: 1 attempt  Easy mask ventilation  ETT# 7.5  Stylette used  Tube taped at 21 cm

ECG Rhythm: Sinus 0.4 mg Hydromorphone IV-Bolus 500 ml LR 1 gm Vancomycin IV-Slow

Enter Time Out Enter Procedure Start Time

350 mL PRBCs given w/comment ‘given Hct 19’ Unit # W204789872 0.2 mg Hydromorphone IV-Bolus ECG Rhythm: Sinus 50 mcg Phenylephrine IV-Bolus ECG Rhythm: Sinus 50 mcg Phenylephrine IV-Bolus E.B.L. 750mg 1000 mg Tranexamic Acid IV-Bolus ECG Rhythm: Sinus

Enter Line IV: Right, 18 Gauge, Wrist

50 mcg/kg/min Phenylephrine IV-Infusion 60 mg/250mL

Enter Procedure Finish End Phenylephrine Infusion 500 ml LR

Enter Start of Emergence 200 mg Suggamadex IV-Bolus

Page 12 Created by S. Nabel - BIDMC Updated 5/21/2020

Enter Extubation Time Extubation Comments:  Pharynx suctioned and clear  Extubated awake  Patient is maintaining patent airway

Transport to OR for PACU care due to COVID status Arrive in OR and document report given and patient stable, awake, alert and responsive.

Enter Anesthesia Stop (D Time)

Verify and resolve all case errors and finalize record

Complete Post Op Note  Vitals signs appropriate: Yes  Cardiovascular function and hydration status appropriate: Yes  Pain control satisfactory: Yes  Nausea and vomiting control satisfactory: Yes  Patient alertness: patient awake and alert and participates in evaluation  Neuraxial block: Yes; Bromage Score: 3  Complications: No complications

Page 13 Created by S. Nabel - BIDMC Updated 5/21/2020

ECT SCENARIO

Create a Preoperative Assessment in Talis using the following information. You can create a patient from scratch using a MRN 9999999. DO NOT CREATE A NEW PATIENT WITH ANY OTHER MRN IN OUR PRODUCTION SYSTEM AS THIS NUMBER MAY BELONG TO AN ACTUAL PATIENT.

Procedure: ECT Emergency: No Patient Class: Outpatient Anesthetic Technique: General Anesthesia PostOp Diagnosis: Depression ASA Class: 3

Surgeon: Kerry Bloomingdale MD

Patient and Case Information

Allergies: Latex Airway: Patient’s Medications: Lorazepam (Ativan) Mallampati [Class III] Sertraline (Zoloft) Mouth Opening [Adequate (>3 cm)] Trazadone Thyromental Distance [>6 cm] Abilify Hyomental Distance [>3 cm] Medical History Mandibular Prognatism [Adequate]

History of Present Illness: Depression Dental: Good Cardiovascular: Ischemic Heart Disease (Stent x2) Head/Neck Range of Motion: Free Range of Motion Pulmonary: Asthma Neuromuscular: Spinal Stenosis Pre-Procedure Vitals: Psychiatric/Social Hx: MDD w/psychotic features Height: 70 in Weight: 204 lb

Source of Information: Patient NPO Status: Solids > 6, Clears > 2 Anesthesia History: None Post Op Location: ECT Recovery

Next, create an Intraoperative record in Talis using the Preop for the patient you created above. Use the clinical events listed below: Clinical Documentation

Start Case – Enter Anesthesia Start Time (A Time)

Page 14 Created by S. Nabel - BIDMC Updated 5/21/2020

Enter Patient In Room Time (B Time) Checklist:  Anesthesia machine and monitors checked prior to anesthesia  Monitors applied and functional prior in pre-anesthesia assessment  Patient re-evaluated and found appropriate for planned anesthetic prior to induction  Patient medical history and physical re-evaluated, including medications, allergies and anesthetic risks and plan

Add signature to case

Enter Line IV: Right, 22 Gauge, In Situ, Hand

Enter Monitors and Warming Devices:  ECG: 5 lead  Pulse Ox  Capnography  BP Cuff to ankle

Enter Time Out

Enter Anesthesia Induction Time 70 mg Methohexital IV-Bolus 80 mg Succinylcholine IV-Bolus

Enter Patient Position: Supine Enter Airway:  LMA igel size #3  Airway adjunct: ECT bite block  Cricoid pressure

Enter Procedure Start Time Enter Antibiotic Comment: Prophylactic antibiotic is not necessary for this case or at the beginning of this case.

Enter Procedure Finish Time ECG Rhythm: Sinus Visual Seizure length 24s; 300 mL LR Enter Leave OR/Anesthesia Stop (C/D) Time

Verify and resolve all case errors and finalize record

Page 15 Created by S. Nabel - BIDMC Updated 5/21/2020

Complete Post Op Note  Vitals signs appropriate: Yes  Respiratory function appropriate: Yes  Cardiovascular function and hydration status appropriate: Yes  Pain control satisfactory: Yes  Nausea and vomiting control satisfactory: Yes  Patient alertness: patient awake and alert and participates in evaluation  Neuraxial block: No  Complications: No complications

Page 16 Created by S. Nabel - BIDMC Updated 5/21/2020