POSTANESTHETIC NOTE

(BALANCED GENERAL ANESTHESIA)

Male/female patient of ? Years of age, with a diagnosis of? To whom was it performed? Under AGB
after medical evaluation and signing of informed consent, granting a RAQ? And an ASA?
Patient is admitted to the room, type 1/2 monitoring is performed, initial vital signs: BP, HR, SatO2,
RR, denitrogenization with O2 at 6 lt/min via face mask is started. , the following medications are
administered: (HERE MAY VARY) midazolam ?mg, fentanyl ? Mcg, propofol? Mg, vecuronium? Mg,
there is a latency of 3 minutes, we proceed to perform direct, atraumatic laryngoscopy, with a
Macintosh/Miller/McCoy blade no. ?, Orointubation was performed on the first attempt with a
Murphy/Cambridge type orotracheal cannula no. ¿? With/without balloon, observing Cormack?,
placing himself? Cc of pneumotamponade; Adequate placement is confirmed by clinic, auscultation
of lung fields, capnography line and air column, it is connected to the ventilatory circuit in volume
control/pressure control mode, with the parameters: tydall volume? Ml, FR ¿?, I:E ratio 1:2, PEEP
¿?.

Maintenance: Continuous monitoring, connected to ventilatory circuit, crystalloid/colloid

solutions/blood derivatives as required; sevoflorane/desflorane/isoflorane a? Vol%, with CAM ¿?-
¿?, capnography ¿?- ¿? mmHg, total dose fentanyl? Mcg, fentanyl rate? Mcg/kg/hr. WHEN THERE
ARE INFUSIONS THEY ARE PLACED HERE LIKE THIS: Fentanyl infusion at ¿?- ¿? Mcg/kg/min, with
total dose? Mcg.

Transanesthetic: Hemodynamically stable, average vital signs: BP ¿?, HR ¿?, SatO2 ¿?%, RR ¿?, IF
ATROPINE, EPHEDRINE WAS USED HERE ARE THE VITAL SIGNS FOR WHICH THEY WERE PLACED
AND THE DOSE, IF AT SOME TIME AMINES ARE REQUIRED, THE DOSE IS PLACED HERE, IN
ADDITION, THE MAXIMUM AND MINIMUM VITALS WOULD BE PLACED IN PLACE OF AVERAGE
VITALS. IF GASOMETRIES ARE TAKEN THEY ARE NOTED HERE, AND THE NUMBERS OF THE BLOOD
DERIVATIVES GO HERE TOO.BIS, TOF4, TEMPERATURE GO HERE ALSO

Adjuvants: ALL EXTRA DRUGS, OXYTOCIN, CARBETOCIN, ATROPINE, EPHEDHRINE

Water balance: Income: ? Ml, expenses?, total? (+ or -), bleeding ml, uresis ml

The surgical procedure is completed, gentle aspiration of secretions is performed, emersion by

metabolic lysis/pharmacological emersion with neostigmine mg, pneumotamponade is removed
and extubated without complications, the patient is transferred to the PACU/general
surgery/orthopedics floor with vital signs: TA? , HR ¿?, SatO2 ¿?%, FR ¿?, with Aldrete ¿?, Ramsay
¿?, EVA ¿?/10.

If the patient is orointubated:

Surgical procedure ends, aspiration of secretions is performed, patient passes orointubated with
cannula? To the floor of ¿?/a ICU with final vital signs: BP ¿?, HR ¿?, SatO2 ¿?%, RR ¿?.
 POSTANESTHETIC NOTE
(TOTAL INTRAVENOUS ANESTHESIA)
Male/female patient of ? Years of age, with a diagnosis of? To whom was it performed? Under TIVA
after medical evaluation and signing of informed consent, granting a RAQ? And an ASA?
Patient is admitted to the room, type 1/2 monitoring is performed, initial vital signs: BP, HR, SatO2,
RR, denitrogenization with O2 at 6 lt/min via face mask is started. , the following medications are
administered: (HERE MAY VARY) midazolam ?mg, fentanyl ? Mcg, propofol? Mg, vecuronium? Mg,
there is a latency of 3 minutes, we proceed to perform direct, atraumatic laryngoscopy, with a
Macintosh/Miller/McCoy blade no. ?, Orointubation was performed on the first attempt with a
Murphy/Cambridge type orotracheal cannula no. ¿? With/without balloon, observing Cormack?,
placing himself? Cc of pneumotamponade; Adequate placement is confirmed by clinic, auscultation
of lung fields, capnography line and air column, it is connected to the ventilatory circuit in volume
control/pressure control mode, with the parameters: tydall volume? Ml, FR ¿?, I:E ratio 1:2, PEEP
¿?.

Maintenance: Continuous monitoring, connected to ventilatory circuit, crystalloid/colloid

solutions/blood derivatives as required; ALL INFUSIONS ARE PLACED, EXAMPLE Fentanyl infusion at
¿?- ¿? Mcg/kg/min from 9:30 hrs-10:40 hrs, with total dose? Mcg, plasma concentration
between ?- ?, capnography ?- ? mmHg,

Transanesthetic: Hemodynamically stable, average vital signs: BP ¿?, HR ¿?, SatO2 ¿?%, RR ¿?, IF
ATROPINE, EPHEDRINE WAS USED HERE ARE THE VITAL SIGNS FOR WHICH THEY WERE PLACED
AND THE DOSE, IF AT SOME TIME AMINES ARE REQUIRED, THE DOSE IS PLACED HERE, IN
ADDITION, THE MAXIMUM AND MINIMUM VITALS WOULD BE PLACED IN PLACE OF AVERAGE
VITALS. IF GASOMETRIES ARE TAKEN, THEY ARE NOTED HERE, AND THE NUMBERS OF THE BLOOD
DERIVATIVES GO HERE TOO.

Adjuvants: ALL EXTRA DRUGS, OXYTOCIN, CARBETOCIN, ATROPINE, EPHEDHRINE

Water balance: Income: ? Ml, expenses?, total? (+ or -), bleeding ml, uresis ml

The surgical procedure is completed, gentle aspiration of secretions is performed, emersion by

metabolic lysis/pharmacological emersion with neostigmine mg, pneumotamponade is removed
and extubated without complications, the patient is transferred to the PACU/general
surgery/orthopedics floor with vital signs: TA? HR ¿?, SatO2 ¿?%, FR ¿?, with Aldrete ¿?, Ramsay ¿?,
EVA ¿?/10.

If the patient is orointubated:

Surgical procedure ends, aspiration of secretions is performed, patient passes orointubated with
cannula? To the floor of ¿?/a ICU with final vital signs: BP ¿?, HR ¿?, SatO2 ¿?%, RR ¿?.
 POSTANESTHETIC NOTE
(ENDOVEN GENERAL ANESTHESIA)

Male/female patient of ? Years of age, with a diagnosis of? To whom was it performed? Under AGB
after medical evaluation and signing of informed consent, granting a RAQ? And an ASA?

Patient is admitted to the room ¿?, type 1/2 monitoring is performed, initial vital signs: BP ¿?, HR
¿?, SatO2 ¿?%, RR ¿?, mask with reservoir/nasal tips is placed at ¿? Lt/min, the following
medications are administered: (HERE MAY VARY) midazolam ?mg, fentanyl ?, propofol ? In
fractional doses with a total dose? mg

Maintenance: Continuous monitoring, connected to ventilatory circuit, crystalloid/colloid

solutions/blood derivatives as required; total dose fentanyl? Mcg, fentanyl rate? Mcg/kg/hr.

Transanesthetic: Hemodynamically stable, average vital signs: BP ¿?, HR ¿?, SatO2 ¿?%, RR ¿?, IF
ATROPINE, EPHEDRINE WAS USED HERE ARE THE VITAL SIGNS FOR WHICH THEY WERE PLACED
AND THE DOSE, IF AT SOME TIME AMINES ARE REQUIRED, THE DOSE IS PLACED HERE, IN
ADDITION, THE MAXIMUM AND MINIMUM VITALS WOULD BE PLACED IN PLACE OF AVERAGE
VITALS. IF GASOMETRIES ARE TAKEN, THEY ARE NOTED HERE, AND THE NUMBERS OF THE BLOOD
DERIVATIVES GO HERE TOO.

Adjuvants: ALL EXTRA DRUGS, OXYTOCIN, CARBETOCIN, ATROPINE, EPHEDHRINE

Water balance: Income: ? Ml, expenses?, total? (+ or -), bleeding ml, uresis ml

The surgical-anesthetic procedure is completed without complications, the patient is transferred to

the PACU/general surgery floor/orthopedics/gynecology with vital signs: BP ¿?, HR ¿?, SatO2 ¿?%,
RR ¿?, with Aldrete ¿?, Ramsay ¿? , EVA ¿?/10.
 POSTANESTHETIC NOTE
(MIXED LOCK)

Male/female patient of ? Years of age, with a diagnosis of? To whom was it performed? Under AGB
after medical evaluation and signing of informed consent, granting a RAQ? And an ASA?
Patient enters room ¿?, type 1/2 monitoring is performed, initial vital signs: BP ¿?, HR ¿?, SatO2 ¿?
%, RR ¿?, patient is placed in left/right lateral decubitus position, asepsis is performed
thoracolumbar region, L2-L3 space is located (or those that have been located), skin and
subcutaneous tissue are infiltrated with simple 2% 60 mg lidocaine, Touhy no needle is introduced.
17/18 to epidural space, Pitkin test was performed, being positive, whitacre needle no. 25/27
transTouhy to subarachnoid space, cerebrospinal fluid output with normal macroscopic
characteristics, administered? Mg of hyperbaric/isobaric bupivacaine, whitacre needle is removed,
epidural catheter is placed through a Touhy needle, catheter is fixed, diffusion of anesthesia until ?,
adequate analgesia and anesthesia.

Transanesthetic: Hemodynamically stable, average vital signs: BP ¿?, HR ¿?, SatO2 ¿?%, RR ¿?, IF
ATROPINE, EPHEDRINE WAS USED HERE ARE THE VITAL SIGNS FOR WHICH THEY WERE PLACED
AND THE DOSE, IF AT SOME TIME AMINES ARE REQUIRED, THE DOSE IS PLACED HERE, IN
ADDITION, THE MAXIMUM AND MINIMUM VITALS WOULD BE PLACED IN PLACE OF AVERAGE
VITALS. IF GASOMETRIES ARE TAKEN, THEY ARE NOTED HERE, AND THE NUMBERS OF THE BLOOD
DERIVATIVES GO HERE TOO.

Adjuvants: ALL EXTRA DRUGS, OXYTOCIN, CARBETOCIN, ATROPINE, EPHEDHRINE

Water balance: Income: ? Ml, expenses?, total? (+ or -), bleeding ml, uresis ml

The surgical-anesthetic procedure is completed without complications, the patient is transferred to

the PACU/general surgery floor/orthopedics/gynecology with vital signs: BP ¿?, HR ¿?, SatO2 ¿?%,
RR ¿?, with Aldrete ¿?, Ramsay ¿? , EVA ¿?/10.
 POSTANESTHETIC NOTE
(PERIDURAL BLOCK)

Male/female patient of ? Years of age, with a diagnosis of? To whom was it performed? Under AGB
after medical evaluation and signing of informed consent, granting a RAQ? And an ASA?
Patient enters room ¿?, type 1/2 monitoring is performed, initial vital signs: BP ¿?, HR ¿?, SatO2 ¿?
%, RR ¿?, patient is placed in left/right lateral decubitus position, asepsis is performed
thoracolumbar region, L2-L3 space is located (or those that have been located), skin and
subcutaneous tissue are infiltrated with simple 2% 60 mg lidocaine, Touhy no needle is introduced.
17/18 to epidural space, Pitkin test is performed and administered? Mg of lidocaine with
epinephrine, as no hemodynamic changes were found, a dose of ? Mg of lidocaine with
epinephrine, an epidural catheter is placed through a Touhy needle, the catheter is fixed, a latency
of 15 minutes is given, diffusion of anesthesia until adequate analgesia and anesthesia.

Transanesthetic: Hemodynamically stable, average vital signs: BP ¿?, HR ¿?, SatO2 ¿?%, RR ¿?, IF
ATROPINE, EPHEDRINE WAS USED HERE ARE THE VITAL SIGNS FOR WHICH THEY WERE PLACED
AND THE DOSE, IF AT SOME TIME AMINES ARE REQUIRED, THE DOSE IS PLACED HERE, IN
ADDITION, THE MAXIMUM AND MINIMUM VITALS WOULD BE PLACED IN PLACE OF AVERAGE
VITALS. IF GASOMETRIES ARE TAKEN, THEY ARE NOTED HERE, AND THE NUMBERS OF THE BLOOD
DERIVATIVES GO HERE TOO.

Adjuvants: ALL EXTRA DRUGS, OXYTOCIN, CARBETOCIN, ATROPINE, EPHEDHRINE

Water balance: Income: ? Ml, expenses?, total? (+ or -), bleeding ml, uresis ml

The surgical-anesthetic procedure is completed without complications, the patient is transferred to

the PACU/general surgery floor/orthopedics/gynecology with vital signs: BP ¿?, HR ¿?, SatO2 ¿?%,
RR ¿?, with Aldrete ¿?, Ramsay ¿? , EVA ¿?/10.
 POSTANESTHETIC NOTE
(SUBARACHNOID BLOCK)

Male/female patient of ? Years of age, with a diagnosis of? To whom was it performed? Under AGB
after medical evaluation and signing of informed consent, granting a RAQ? And an ASA?
Patient enters room ¿?, type 1/2 monitoring is performed, initial vital signs: BP ¿?, HR ¿?, SatO2 ¿?
%, RR ¿?, patient is placed in left/right lateral decubitus position, asepsis is performed
thoracolumbar region, L2-L3 space is located (or those that have been located), the skin and
subcutaneous tissue are infiltrated with simple 2% 60 mg lidocaine, whitacre needle no. 25/27 to
subarachnoid space, cerebrospinal fluid outflow with normal macroscopic characteristics,
administered? Mg of hyperbaric/isobaric bupivacaine, whitacre needle is removed, diffusion of
anesthesia until adequate analgesia and anesthesia.

Transanesthetic: Hemodynamically stable, average vital signs: BP ¿?, HR ¿?, SatO2 ¿?%, RR ¿?, IF
ATROPINE, EPHEDRINE WAS USED HERE ARE THE VITAL SIGNS FOR WHICH THEY WERE PLACED
AND THE DOSE, IF AT SOME TIME AMINES ARE REQUIRED, THE DOSE IS PLACED HERE, IN
ADDITION, THE MAXIMUM AND MINIMUM VITALS WOULD BE PLACED IN PLACE OF AVERAGE
VITALS. IF GASOMETRIES ARE TAKEN, THEY ARE NOTED HERE, AND THE NUMBERS OF THE BLOOD
DERIVATIVES GO HERE TOO.

Adjuvants: ALL EXTRA DRUGS, OXYTOCIN, CARBETOCIN, ATROPINE, EPHEDHRINE

Water balance: Income: ? Ml, expenses?, total? (+ or -), bleeding ml, uresis ml

The surgical-anesthetic procedure is completed without complications, the patient is transferred to

the PACU/general surgery floor/orthopedics/gynecology with vital signs: BP ¿?, HR ¿?, SatO2 ¿?%,
RR ¿?, with Aldrete ¿?, Ramsay ¿? , EVA ¿?/10.