Deviation in the Standard of Anesthetic Care During Epidural Anesthesia

Evaluate breaches in the standard of care for a Deviation in the Standard of Anesthetic Care During Epidural Anesthesia

Answer the following questions to find out if the standard of care was followed for your case.

  • Did the patient request for epidural anesthesia?
    Yes
    No
    Answer unknown
    Why is this important?
    Epidural anesthesia is contraindicated if the patient declines.
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  • Was an informed consent obtained? Why is this important?
    Answer this question
    The laws of most states require that clinicians obtain an informed consent before providing treatment.
    (2011) 23 EOMSCA 3 475-484

  • Was a medical history obtained? Why is this important?
    Answer this question
    Past medical history (PMH) includes all past and current illness, hospitalizations, surgery, trauma, allergies, and medications. The date, location, and physician/surgeon for each hospitalization and/or surgery should also be included. Particularly important issues in the identification of manifestations of systemic disease include alcoholism, cancer, cardiovascular events, diabetes, and hepatic, renal, and psychiatric reasons for admission. Particularly important medications for oral manifestations include immunosuppressives, antibiotics, cardiac medications, and psychotropic.
    (2011) 55 EDECNA 1 15-28

  • Was a physical examination performed? Why is this important?
    Answer this question
    A complete and carefully focused physical examination serves as the core of the diagnostic process. The information obtained guides the further direction of the patient’s examination, enables the clinician to make educated evaluations, and be better equipped to advise the patient.
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  • With which of the following contraindications did the patient present? (Choose all that apply) Why is this important?
    Answer this question
    Contraindications for the administration of epidural anesthesia include: • Coagulopathy • Therapeutic anticoagulation • Immuno-suppressed patients • Increased intracranial pressure • Hypovolemia
    (2008) 10 EACUPN1 15-22

  • Was a pre-anesthesia evaluation performed? Why is this important?
    Answer this question
    The American Society of Anesthesiologist (ASA) standards and guidelines require that the patient have a pre-anesthetic evaluation. The timing of the pre-anesthetic evaluation is probably the most critical element for the efficient delivery of care. Pre-anesthesia evaluation is an exercise in patient communication and co-ordination of resources delivered in as cost effective mode as possible. When information including laboratory or diagnostic reports are necessary, physician's offices or hospital departments may be closed requiring either postponing the procedure, obtaining the information closer to the surgery and hoping that there are no major issues, or repeating a test which may have been done only a couple of weeks earlier.
    (2004) 22 EANESC 1 141-153

  • Did the anesthesiologist assign an American Society of Anesthesiology (ASA) score? Why is this important?
    Answer this question
    Once all the preoperative information is evaluated, the anesthesiologist assigns an American Society of Anesthesiology (ASA) score. Higher the ASA Score, there is increased likelihood of adverse events and adverse outcomes during anesthesia.
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  • With which of the following risk factors did the patient present? (Choose all that apply) Why is this important?
    Answer this question
    Risk factors are useful for identifying patients at an increased risk for a disease or for a particular outcome that results from a disease process.
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  • Was the patient kept well hydrated to avoid hypotension? Why is this important?
    Answer this question
    Hypotension caused by sympathetic blockade during epidural anesthesia may be prevented by fluid preload and patient positioning.
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  • Was the injection site examined for any lesions or abnormalities prior to the procedure? Why is this important?
    Answer this question
    A careful inspection of the patient’s back needs to be performed prior to beginning the epidural anesthesia. The back should be examined for any lesions or structural abnormalities.
    (2008) 22 EBPRCA 3 451-475

  • Was the patient on anti-coagulants? Why is this important?
    Answer this question
    Patients receiving anti-coagulant therapy who undergo epidural/spinal anesthesia or spinal puncture procedures are at risk for epidural or spinal hematoma, which may lead to long-term or permanent paralysis.
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  • When was the patient's last meal? Why is this important?
    Answer this question
    The guidelines recommend that the patient have had nothing by mouth for at least 8 hours before the procedure.
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  • Was a sterile approach used to perform the epidural anesthetic procedure? Why is this important?
    Answer this question
    Meticulous aseptic techniques which include handwashing, use of gloves, use of an antimicrobial soap, use of surgical masks and antiseptic solutions, reduce the risk of bacterial meningitis following neuroaxial blockade.
    (2008) 22 EBPRCA 3 451-475

  • Was a preservative-free epidural medication utilized? Why is this important?
    Answer this question
    All epidural medications must be preservative free.
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  • Which of the following precautions were not taken during the placement of epidural catheter? (Choose all that apply) Why is this important?
    Answer this question
    The patient must be placed in either the sitting or the lateral position, with the back and neck flexed and the spine straight and not rotated.
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  • Which of the following were not monitored throughout the procedure? (Choose all that apply) Why is this important?
    Answer this question
    The blood pressure (BP) should be monitored to observe for hypotension by measuring the BP every 2.5 minutes. Vital signs should be recorded on the anesthesia chart at least every 5 minutes.
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  • Was a continuous monitoring of the sensory and motor function performed? Why is this important?
    Answer this question
    A robust system of monitoring is mandatory for safe epidural analgesia practice which include regular observations and documentation of at least the epidural infusion, pain during movement, hemodynamic reactions, upper and lower sensory levels to cold or pinprick, catheter entry site for infection, and motor block (weak legs).
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  • Which of the following conditions did the patient develop? (Choose all that apply) Why is this important?
    Answer this question
    Epidural anesthesia is associated with substantial decreases in arterial blood pressure or because of pre-ganglionic sympathetic blockade. Once the sympathetic nervous system is blocked, vascular tone is diminished, and subsequent arterial vasodilation and venodilation results in decreased cardiac output and decreased arterial blood pressure.
    (2008) 22 EBPRCA 2 383-391

  • Which of the following symptoms did the patient develop after the procedure? (Choose all that apply) Why is this important?
    Answer this question
    Bacterial meningitis is a medical emergency. Meningitis presents most often with fever, severe headache, and an altered level of consciousness.
    (2000) 18 EANESC 2 461-485