Documenting the assessment and the pain round
Pre-anaesthetic assessments, medication instruction letters to the surgeon and GP, and acute pain round notes.
A pre-anaesthetic assessment
Three weeks before a knee replacement.
Mr Morrison, 69, for right TKR on the 28th. Plan spinal with sedation.
OSA on CPAP, pressure 10, he'll bring his machine. BMI 33. Climbs two flights without stopping.
Paroxysmal AF on apixaban 5 BD, CHA2DS2-VASc 2. Last dose three days before surgery for the spinal, no bridging.
Metformin 1 g BD, HbA1c 6.8. Omit metformin on the morning of surgery.
Mallampati 2, good mouth opening, full dentition. Hb 141, eGFR 72.
Discussed spinal and sedation, nerve injury and post-dural puncture headache. He's happy to proceed.
Procedure
R TKR, 28th. Planned spinal anaesthetic with sedation.
Comorbidities
OSA on CPAP (10 cmH2O), to bring own machine. BMI 33. Paroxysmal AF, CHA2DS2-VASc 2. T2DM, HbA1c 6.8%.
Functional capacity
Two flights of stairs without stopping.
Airway
Mallampati 2. Good mouth opening. Full dentition.
Investigations
Hb 141. eGFR 72.
Medication instructions
- Apixaban: last dose 3 days before surgery, no bridging
- Metformin: omit on the morning of surgery
Consent
Spinal and sedation discussed, including nerve injury and post-dural puncture headache. Agrees to proceed.
Before and after the list
- Letter to the surgeon and GP
- The anaesthetic plan and the medication instructions with dates, so the apixaban stop is in writing at both practices.
- Acute pain round notes
- Day-one and day-two reviews of blocks, PCA and opioid use, with the step-down plan.
- Procedure note
- For a nerve block or epidural placed outside the anaesthetic record.
