Date: 2025-05-14

Type: Anesthesia Record

Source: epic_ihe_xdm

Procedure SummaryProcedure NameResponsible AnesthesiologistAnesthesia Start TimeAnesthesia Stop TimeXI LIVER RESECTION - LAPAROSCOPIC ROBOTIC ASSISTED, TAP Block (Abdomen)Zoller, Jonathan Kramer, MD05/14/25 122105/14/25 1439EventsDateTimeEventComment05/14/20251005In Preop1220In Room1221An Start1221An Start Data1227An InductionThe patient was reevaluated immediately before moderate or deep sedation use and before anesthesia induction.1230An Intubation1238Anesthesia Ready1248Arterial Line sampling artifact1308Proc Start1308Incision Start1403Local injected by surgeon1417Proc Fin1424An Extubation1427Out of Room1439Handoff to RNI completed my handoff to the receiving nurse during which we: 1. Patient identified 2. Responsible provider identified 3. Pertinent medical history reviewed 4. Procedure type and surgical course discussed 5. Intraoperative anesthetic management and any significant issues discussed 6. Expectations and concerns for postop period discussed 7. Questions solicited from receiving nurse 8. Patient disposition at the time of handoff: No value filed.1439An StopMedsNameTotallidocaine (cardiac) syringe 2 %100 mgpropofol200 mgfentaNYL100 mcgHYDROmorphone 2 mg/mL0.8 mgrocuronium150 mgphenylephrine 100 mcg/mL1.11 mgondansetron PF (ZOFRAN) 2 mg/mL injection4 mgglycopyrrolate0.4 mgcefOXitin (MEFOXITIN) 2,000 mg/20 mL in sterile water (premix) 2,000 mg2,000 mgmagnesium sulfate 2 g/50 mL2 gsugammadex200 mgLactated Ringer’s (LR) infusion700 mLAgentsNameO2% ExpiredN2O ExpiredO2N2OAirExpired SevofluraneInspired SevofluraneBloodNo blood administrations on file.Lines, Drains, and AirwaysTypeDetailsPlacementRemovalImplanted PortExisting LDA Placed by: Other hospital (Placed at Anderson); Type: Non-power (Per patient); Orientation: Left; Location: Chest05/01/25 0739 by Peripheral IVPlacement Date: 05/14/25; Placement Time: 1020; Catheter Size: 20 G; Orientation: Right; Location: Forearm; Removal Date: 05/15/25; Removal Time: 0911; Removal Reason: Discharge05/14/25 1020 by Estes, Sydney, RN05/15/25 0911 by Evjen, Sofia Amanda, RNUrethral CatheterPlacement Date: 05/14/25; Placement Time: 1235; Inserted by: G. St. Pierre, RN; Type: Double-lumen, Non-latex, Straight-tip, Temperature probe; Balloon Size: 10 mL; Urine Returned: Yes; Removal Date: 05/15/25; Removal Time: 0011; Removal Reason: Therapy complete05/14/25 1235 by St. Pierre, Grace Marguerite, RN05/15/25 0011 by Chesnut, Caden Riley, RNETTPlacement Date: 05/14/25; Placement Time: 1249 (created via procedure documentation); Mask Ventilation: 1; Technique: Direct laryngoscopy; Type: ETT - single; Single Lumen Tube Size: 8 mm; Cuffed: Yes; Laryngoscope: Macintosh; Blade Size: 4; Grade View: Grade I; Insertion Attempts: 1; Placement Verification: Auscultation, Capnometry; Removal Date: 05/14/25; Removal Time: 142405/14/25 1249 by Lewis, Bradley Mitchell, DO05/14/25 1424 by Lewis, Bradley Mitchell, DOArterial LinePlacement Date: 05/14/25; Placemnt Time: 1254 (created via procedure documentation); Size: 20 G; Orientation: Left; Location: Radial; Removal Date: 05/14/25; Removal Time: 1458; Removal Reason: Per order05/14/25 1254 by Lewis, Bradley Mitchell, DO05/14/25 1458 by Price, Austin Matthew, RNPeripheral IVPlacement Date: 05/14/25; Placement Time: 1254 (created via procedure documentation); Catheter Size: 18 G; Orientation: Left; Location: Wrist; Site Prep: Chlorhexidine; Insertion Attempts: 1; Removal Date: 05/15/25; Removal Time: 0911; Removal Reason: Discharge05/14/25 1254 by Lewis, Bradley Mitchell, DO05/15/25 0911 by Evjen, Sofia Amanda, RNWound05/14/25; 1406; Incision; Abdomen; 5 port sites; 11/26/25; Unknown05/14/25 1406 by St. Pierre, Grace Marguerite, RN11/26/25 0000 by Miller, Dawn K., RNdocumented in this encounter