Anesthesia and Surgical Care

ASC
Procedural Sedation
 Procedural Sedation
• Those patients who undergo painful or difficult procedures where
cooperation and/or comfort will be difficult or impossible without
pharmacologic support.

• Where
• ICU.
• Emergency Department.
Healthcare practitioners responsible for providing
procedural sedation must:
• Be competent in:
• Techniques and various modes of sedation.
• Pharmacology of sedation drugs including side effects, their management and
the use of reversal agents.
• Monitoring requirements during Sedation and Post-Sedation.
• Response to complications mainly management of airway complication.

• Have the privilege granted to perform moderate and deep sedation

• Be qualified and competent to perform BLS and /ALS.

The individual responsible for providing Intra-
sedation monitoring must:
• Be competent in:
• Monitoring requirements
• Response to complications
• Use of reversal agents
• Recovery criteria.

• Has current BLS certification

Before Procedure
• Anesthesia / Conscious
Sedation Consent Form
• Procedural Sedation
Assessment Form
• Pre – Sedation Assessment
• Sedation Plan
During Procedure
• Procedural Sedation Assessment
Form
• Intra – Sedation Assessment
After Procedure
• Procedural Sedation Assessment
Form
• Recovery
‫• تتم كتابة التشخيص وليس ال ‪ Complaint‬أو إسم ال‬
‫‪Procedure‬‬

‫• إختيار نوع التخدير‬

‫• كتابة جميع بيانات المريض‬

‫• كتابة جميع بيانات الطبيب والشاهدين‬

‫اإلسم وال ‪ ، ID‬أو إستخدام ال ‪ ، Stamp‬إن وجد‬ ‫•‬
‫التوقيع ‪ ،‬وال يغنى عنه إستخدام ال ‪ ، Stamp‬إن وجد‬ ‫•‬

‫• تتم كتابة نفس التاريخ والوقت (‪ ) Military‬لكل من‬

‫المريض‪ ،‬الطبيب والشاهدين‬
• Pre – sedation assessment
• All items must be completed

• Sedation Plan

• All items must be completed

• Intra – sedation assessment
• All items must be completed

• Monitoring must be done every 5 minutes

till patient met recovery criteria

• Recovery ( Alderet Score)

• All items must be completed

• Score of 9 – 10 is sufficient to discharge
the patient from the recovery.

‫ إن وجد‬، Stamp ‫ أو إستخدام ال‬ID ‫• كتابة اإلسم وال‬

‫) لكل من‬Military( ‫• كتابة نفس التاريخ والوقت‬
‫الطبيب والتمريض‬
‫• أن يكون وقت التوقيع هو نفس وقت آخر‬
‫ تم للمريض‬Monitoring
Anesthesia Care
• Anesthesia shall only be provided in operating theater, radiology
department, dental clinic and cath. Lab.

• Only anesthesiologists shall manage anesthesia in all locations where

anesthesia is provided.
Before Procedure / Surgery During Procedure / Surgery
• Anesthesia / Conscious • Anesthesia / Sedation Assessment
Form
Sedation Consent Form
• Pre – Induction Assessment
• Intra – Operative Monitoring
• Pre – Anesthesia / Sedation
Assessment Form After Procedure / Surgery

• Pre – Anesthesia Assessment • Post-Anesthesia / Sedation Recovery

Form
• Anesthesia Care Plan
• Post – procedure monitoring
• Recovery
‫• تتم كتابة التشخيص وليس ال ‪ Complaint‬أو إسم ال‬
‫‪Procedure‬‬

‫• إختيار نوع التخدير‬

‫• كتابة جميع بيانات المريض‬

‫• كتابة جميع بيانات الطبيب والشاهدين‬

‫اإلسم وال ‪ ، ID‬أو إستخدام ال ‪ ، Stamp‬إن وجد‬ ‫•‬
‫التوقيع ‪ ،‬وال يغنى عنه إستخدام ال ‪ ، Stamp‬إن وجد‬ ‫•‬

‫• تتم كتابة نفس التاريخ والوقت (‪ ) Military‬لكل من‬

‫المريض‪ ،‬الطبيب والشاهدين‬
• All items must be completed
• Just Tick the Box
• If male patient
• Tick NA Box
• Don’t Tick No Box 
• If you tick Yes, Please Specify
• If you tick others, Please Specify

• If No current medications, Tick NA

Box
• Write physical examination
• Don’t forget WT and Height
• Write General Condition
• If you tick others, Please Specify

• Tick Box
• If you tick Yes, Please mention

• Anesthesia Care Plan

• All items must be completed

‫• بيانات الطبيب‬
‫ إن وجد‬، Stamp ‫ أو إستخدام ال‬، ID ‫• اإلسم وال‬
‫ إن وجد‬، Stamp ‫ وال يغنى عنه إستخدام ال‬، ‫• التوقيع‬
‫ نفس تاريخ ووقت ال‬،) Military( ‫• التاريخ والوقت‬
Anesthesia / Sedation consent
• During MR file audit, these parts
not completed.

• JCI Requirement that must be done,

signed and timed

• These times must be consequence

• Tick Box for type of Anesthesia
• Complete all titles
• Pre – induction time is immediately
prior to induction of anesthesia,
between patient in OR and
Anesthesia start
• Timeout time and surgical incision time must be the same as in Timeout Form
• If no medications, IV fluids or
Blood/blood products
• Tick No box

• Tick box of monitors that attached to

patient
‫•‬ ‫‪During MR file audit, this part‬‬
‫‪not completed.‬‬

‫‪• Monitor patient every 5 minutes.‬‬

‫• بيانات الطبيب‬
‫• اإلسم وال ‪ ، ID‬أو إستخدام ال ‪ ، Stamp‬إن وجد‬
‫• التوقيع ‪ ،‬وال يغنى عنه إستخدام ال ‪ ، Stamp‬إن‬
‫وجد‬
‫• راجع الشريحه التاليه‬
 ‫وقت توقيع الطبيب هو نفس وقت ال‬
Leave OR and Last assessment done to patient
• During MR file audit, these parts not
completed.

• If you tick Yes, please mention

• If no medications, fluids or
blood/blood product, tick No
Recovery time started is the same as patient Leave OR, or delayed maximum 1 – 2 minutes
• Time of post – procedure status is
the same as Recovery Time Started
• 1st Follow Up Time is 5 minutes
after Time of post – procedure
status

• Then, follow up done by nurse

every 5 minutes.
Time of condition of patient upon transfer is 5 minutes after last Follow Up Time
Recovery time completed is the same as time of condition of patient upon transfer and
time of signature of doctor and nurse
‫•‬ ‫‪During MR file audit, these parts‬‬
‫‪not completed.‬‬

‫• بيانات الطبيب والتمريض‬

‫اإلسم وال ‪ ، ID‬أو إستخدام ال ‪ ، Stamp‬إن وجد‬ ‫•‬
‫التوقيع ‪ ،‬وال يغنى عنه إستخدام ال ‪ ، Stamp‬إن وجد‬ ‫•‬
‫الوقت والتاريخ‬ ‫•‬
‫الوقت (راجع الشريحه قبل السابقه)‬ ‫•‬
Surgical Care
Before Surgery:
• Patient initial assessment
• Physician’s initial patient assessment form.
• Neurology & Neurosurgery Physicians Initial Patient Assessment
• Gynecology / Obstetrics Physicians Initial Patient Assessment
• Orthopedic Physicians Initial Patient Assessment
• Urology Physicians Initial Patient Assessment
• Surgery Physicians Initial Patient Assessment
• Vascular Surgery Physicians Initial Patient Assessment

• Patient initial care plan

• Physician care plan form.

• Consent for surgery

• Surgical/invasive procedure consent form.
 ‫• تتم كتابة التشخيص وليس ال ‪Complaint‬‬
‫• تتم كتابة إسم ال ‪Procedure‬‬

‫• كتابة مضاعفات كمثال‬

‫• كتابة جميع بيانات المريض‬

‫• كتابة جميع بيانات الطبيب والشاهدين‬

‫اإلسم وال ‪ ، ID‬أو إستخدام ال ‪ ، Stamp‬إن وجد‬ ‫•‬
‫التوقيع ‪ ،‬وال يغنى عنه إستخدام ال ‪ ، Stamp‬إن وجد‬ ‫•‬

‫• تتم كتابة نفس التاريخ والوقت (‪ ) Military‬لكل من‬

‫المريض‪ ،‬الطبيب والشاهدين‬
After Surgery:

• Surgeon document patient post-surgical care plan in

physician care plan form.

• Nurse document patient post-surgical care plan in nursing

care plan form.
Implantable devices

• Implant / implantable device / prosthesis name and ID number (if applicable)

documented in:
• Pre-operative verification checklist.
• Operative report.
• OR/procedure area log book.

• Discharge summary form contain

• Implant name and ID number (if applicable)
• Any special instructions related to it.
• Pre – Operative / procedure
verification process checklist
contains implant name and ID
number (if applicable)
• Operative / procedure report
contains implant name and ID
number (if applicable)
OR Logbook contains implant name and ID number (if applicable)
• Discharge summary form contains
implant name and ID number (if
applicable)
• Discharge summary form contains
any special instructions related to it.