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Sub-Field: 130.06

Package: Surgery

SURGERY(#130)-->130.06

Sub-Field: 130.06


Information

Parent File Name Number Package
SURGERY(#130) ANESTHESIA TECHNIQUE 130.06 Surgery

Details

Field # Name Loc Type Details
.01 ANESTHESIA TECHNIQUE 0;1 SET
  • 'G' FOR GENERAL;
  • 'M' FOR MONITORED ANESTHESIA CARE;
  • 'S' FOR SPINAL;
  • 'E' FOR EPIDURAL;
  • 'R' FOR REGIONAL;
  • 'O' FOR OTHER;
  • 'L' FOR LOCAL;
  • 'N' FOR NO ANESTHESIA;

  • LAST EDITED:  FEB 14, 2014
  • HELP-PROMPT:  Enter an anesthesia technique from the available list of techniques.
  • DESCRIPTION:  This is the anesthesia technique used during this case corresponding to the American Board of Anesthesiologists universal list of anesthesia techniques (except for REGIONAL, LOCAL and NO ANESTHESIA). If entered, this
    information will appear on various anesthesia reports. Select regional for peripheral nerve blocks or other techniques other than spinal or epidural.
  • SCREEN:  S DIC("S")="I Y'=""O"""
  • EXPLANATION:  Screen prevents selection of inactive entries.
  • DELETE TEST:  .01,0)= I $D(^SRF(DA(1),"CON")),$P(^("CON"),"^") D ^SROCOND I 0
.05 PRINCIPAL TECH 0;3 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • INPUT TRANSFORM:  D CHECK^SROPRIN
  • LAST EDITED:  MAR 16, 2004
  • DESCRIPTION:  This indicates whether this technique is the principal technique for this procedure. If this is the only technique used, 'YES' must be entered at this prompt. General anesthesia should take precedence over all other
    forms of anesthesia.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
2 PATIENT STATUS 0;4 SET
  • 'I' FOR INDUCED;
  • 'A' FOR AWAKE;
  • 'S' FOR SEDATED;

  • LAST EDITED:  JAN 26, 1987
  • DESCRIPTION:  This indicates the status of the patient while anesthetized.
3 APPROACH 0;5 SET
  • 'D' FOR DIRECT VISION LARYNGOSCOPY;
  • 'R' FOR RAPID SEQUENCE;
  • 'B' FOR BLIND;
  • 'BL' FOR BLIND LARYNGOSCOPY;
  • 'F' FOR FIBEROPTIC LARYNGOSCOPY;

  • LAST EDITED:  JAN 26, 1987
  • DESCRIPTION:  
    This is the code corresponding to the approach technique used for endotracheal intubation. This information is not required, but may be useful for documentation.
4 ROUTE 0;6 SET
  • 'O' FOR ORAL;
  • 'N' FOR NASAL;
  • 'T' FOR TRACHEOSTOMY;

  • LAST EDITED:  JAN 26, 1987
  • DESCRIPTION:  
    This is the code corresponding to the route of the endotracheal tube to the trachea. This information is not required, but may be useful for documentation.
5 LARYNGOSCOPE TYPE 0;7 SET
  • 'M' FOR MACINTOSH;
  • 'MI' FOR MILLER;
  • 'G' FOR GUEDEL;
  • 'W' FOR WIS-FOREGGER;
  • 'FS' FOR FIBEROPTIC STYLET;
  • 'FB' FOR FIBEROPTIC BRONCHOSCOPE;
  • 'FL' FOR FIBEROPTIC LARYNGOSCOPE;
  • 'O' FOR OTHER;

  • LAST EDITED:  AUG 12, 1987
  • DESCRIPTION:  
    This is the code corresponding to the type of scope or laryngoscope blade used to facilitate endotracheal intubation. Although not required, it may be useful for documentation.
6 LARYNGOSCOPE SIZE 0;8 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>100)!(X<1)!(X?.E1"."1N.N) X
  • LAST EDITED:  JAN 26, 1987
  • HELP-PROMPT:  ENTER A WHOLE NUMBER BETWEEN 1 AND 100.
  • DESCRIPTION:  This is the size of the laryngoscope used to facilitate endotracheal intubation. This information is not required, but may be useful for documentation.
7 STYLET USED (Y/N) 0;9 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JAN 26, 1987
  • DESCRIPTION:  This indicates whether a stylet was used to shape the endotracheal tube during intubation. This information is optional, but may be useful in documentation of this case.
8 LIDOCAINE TOPICAL 0;10 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JAN 26, 1987
  • DESCRIPTION:  
    This indicates whether topical lidocaine is utilized to facilitate endotracheal intubation. This information is not required, but may be useful for documentation.
9 LIDOCAINE IV 0;11 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JAN 26, 1987
  • DESCRIPTION:  
    This indicates whether intravenous lidocaine is administered prior to the endotracheal intubation. This information is not required, but may be useful for documentation.
10 TUBE TYPE 0;12 SET
  • 'P' FOR PVC LOW PRESSURE;
  • 'S' FOR SILASTIC LOW PRESSURE;
  • 'R' FOR REINFORCED;
  • 'B' FOR BIVONA CUFF;
  • '2R' FOR 2 LUMEN, RT. ENDOBRONCHIAL;
  • '2L' FOR 2 LUMEN, LT. ENDOBRONCHIAL;
  • 'T' FOR TRACHEOSTOMY CUFFED;
  • 'L' FOR LASER PROTECTED;
  • 'O' FOR OTHER;

  • LAST EDITED:  AUG 12, 1987
  • DESCRIPTION:  
    This is the code corresponding to the type of endotracheal tube used during the major portion of the procedure. This information is not required, but may be useful for documentation.
11 TUBE SIZE 0;13 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>100)!(X<1)!(X?.E1"."2N.N) X
  • LAST EDITED:  JAN 03, 1995
  • HELP-PROMPT:  Type a Number between 1 and 100, 1 Decimal Digit
  • DESCRIPTION:  This is the size of the endotracheal tube. This information is not required, but may be useful for documentation.
12 TRAUMA 0;14 SET
  • '1' FOR NONE;
  • '2' FOR LIP LACERATION OR HEMATOMA;
  • '3' FOR TOOTH CHIPPED, LOOSENED OR LOST;
  • '4' FOR TONGUE HEMATOMA OR LACERATION;
  • '5' FOR PHARYNGEAL LACERATION;
  • '6' FOR OTHER LARYNGEAL INJURY;
  • '7' FOR FAILURE TO INTUBATE AS INTENDED;

  • LAST EDITED:  NOV 30, 2010
  • DESCRIPTION:  Definition Revised (2004): The code corresponding to trauma resulting from the endotracheal intubation process. This should be documented on the anesthesia record. Choose from:
    1. None
    2. Lip laceration or hematoma
    3. Tooth chipped, loosened or lost
    4. Tongue hematoma or laceration
    5. Pharyngeal laceration
    6, Other laryngeal injury
    7. Failure to intubate as intended
    This information is entered by Anesthesia personnel and is not the responsibility of the Nurse Reviewer.
13 BITE BLOCK (Y/N) 0;15 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JAN 26, 1987
  • DESCRIPTION:  This indicates if a bite block is used to protect the endotracheal tube. This information is not required, but may be useful for documentation.
14 TUBE LUBRICATION 0;16 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • DESCRIPTION:  This indicates whether lubrication was used with the endotracheal tube. Although not required, this information may be useful for documentation.
15 TAPED AT LENGTH 0;17 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>100)!(X<1)!(X?.E1"."1N.N) X
  • LAST EDITED:  JAN 26, 1987
  • HELP-PROMPT:  ENTER A WHOLE NUMBER BETWEEN 1 AND 100
  • DESCRIPTION:  This is the length of the endotracheal tube at the external reference point. This information is not required, but may be useful for documentation of this case.
16 BREATH SOUNDS OK BILAT 0;18 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JAN 26, 1987
  • DESCRIPTION:  This indicates whether breath sounds are audible and equal bilaterally. This information is not required, but may be useful for documentation.
17 HEAT, MOISTURE EXCHANGER 0;19 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JAN 26, 1987
  • DESCRIPTION:  This indicates whether a passive heat and moisture exchanger is used in the breathing circuit. This information is not required, but may be useful for documentation and review.
18 BACT. FILTER IN CIRCUIT 0;20 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • DESCRIPTION:  This indicates whether a bacterial filter is used in the breathing circuit. This information is not required, but may be useful for documentation.
19 END VENT. T.V. 0;21 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>20000)!(X<1)!(X?.E1"."1N.N) X
  • LAST EDITED:  JAN 26, 1987
  • HELP-PROMPT:  Enter a whole number between 1 and 20000.
  • DESCRIPTION:  This is the anesthesia ventilator tidal volume setting at the end of the case.
20 END VENT. RATE 0;22 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>1000)!(X<1)!(X?.E1"."1N.N) X
  • LAST EDITED:  JAN 26, 1987
  • HELP-PROMPT:  Enter a whole number between 1 and 1000.
  • DESCRIPTION:  This is the anesthesia ventilator rate setting at the end of the operative procedure.
21 EXTUBATED IN 0;23 SET
  • 'O' FOR OR;
  • 'P' FOR PACU;
  • 'S' FOR SICU;

  • LAST EDITED:  JAN 26, 1987
  • DESCRIPTION:  This is the code corresponding to the location wherein the endotracheal tube is removed. This information is not required, but may be useful for documentation, review or concurrent monitoring.
22 REINTUBATED W/I 8 HRS. 0;24 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • LAST EDITED:  JAN 26, 1987
  • DESCRIPTION:  This indicates whether the patient required reintubation within 8 hours for ventilatory insufficiency or airway obstruction. Do not include intubation for a following surgical procedure.
23 PREOXYGENATION 0;25 SET
  • 'Y' FOR YES;
  • 'N' FOR NO;

  • DESCRIPTION:  This is used to document the process of preoxygenation prior to induction of anesthesia.
24 ANESTHESIA AGENTS 1;0 POINTER Multiple #130.47 130.47

  • DESCRIPTION:  This is information related to the anesthesia agents used for this technique.
25 CONTINUOUS 2;1 SET

  • LAST EDITED:  JAN 26, 1987
  • DESCRIPTION:  
    This indicates whether a catheter is placed for continuous or intermittent administration of a drug for spinal or epidural anesthesia.
26 BARICITY 2;2 SET

  • LAST EDITED:  JAN 26, 1987
  • DESCRIPTION:  This is the code corresponding to the baricity of the anesthesia drug fluid vehicle in relationship to the spinal fluid.
27 PUNCTURE SITE 2;3 SET

  • LAST EDITED:  JAN 26, 1987
  • DESCRIPTION:  This is the code corresponding to the spinal or epidural needle puncture site. This information is not required, but may be useful for documentation and review.
28 SPINAL APPROACH 2;4 SET

  • LAST EDITED:  JAN 26, 1987
  • DESCRIPTION:  This is the code corresponding to the approach of the placement of the spinal or epidural needle. This information is not required, but may be useful for documentation and review.
29 NEEDLE SIZE 2;5 SET

  • LAST EDITED:  JUN 18, 1987
  • DESCRIPTION:  This is the code corresponding to the needle size used for the spinal or epidural technique. This information is not required, but may be useful for documentation and review.
30 EPIDURAL METHOD 3;1 SET

  • LAST EDITED:  MAR 13, 1995
  • DESCRIPTION:  This is the code corresponding to the method used to determine the placement of the epidural needle. This information is not required, but may be useful for documentation and review.
31 MULTIPLE ATTEMPTS 3;2 SET

  • LAST EDITED:  JAN 26, 1987
  • DESCRIPTION:  This indicates whether more than one skin puncture was required to achieve proper placement of the needle.
32 TEST DOSE 4;0 POINTER Multiple #130.48 130.48

  • DESCRIPTION:  This is information related to the test dose of the anesthesia agent.
33 TEST DOSE VOL (ml) 3;3 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>10)!(X<1)!(X?.E1"."1N.N) X
  • LAST EDITED:  JAN 26, 1987
  • HELP-PROMPT:  Enter a whole number between 1 and 10.
  • DESCRIPTION:  
    This is the volume (mls.) of the test dose fluid vehicle.
34 DURAL PUNCTURE 3;4 SET

  • LAST EDITED:  JAN 26, 1987
  • DESCRIPTION:  This indicates whether dural puncture is recognized during the epidural needle or catheter placement. This information is not required.
35 CATHETER REMOVED BY 3;5 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • INPUT TRANSFORM:  S DIC("S")="S RESTRICT=""130.06,35"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  FEB 04, 1992
  • HELP-PROMPT:  Enter the name of the person who removed the catheter.
  • DESCRIPTION:  This is the name of the person removing the continuous catheter from the puncture site. This information is not required, but may be useful for documentation and review.
  • SCREEN:  S DIC("S")="S RESTRICT=""130.06,35"" D KEY^SROXPR I $D(SROK)"
  • EXPLANATION:  Entries in this field may be restricted based on locally selected keys.
36 ADMINISTRATION METHOD 3;6 SET

  • LAST EDITED:  JAN 26, 1987
  • DESCRIPTION:  
    This is the code corresponding to the method of administration of the anesthetic agent. This information is not required.
37 PURPOSE 3;7 SET

  • LAST EDITED:  JAN 26, 1987
  • DESCRIPTION:  This is the code corresponding to the reason for using a regional technique. This information is not required, but may be useful for documentation and review.
38 BLOCK SITE 5;0 POINTER Multiple #130.49 130.49

  • DESCRIPTION:  This is information about the block site.
39 EXTUBATED BY 6;1 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • INPUT TRANSFORM:  S DIC("S")="S RESTRICT=""130.06,39"" D KEY^SROXPR I $D(SROK)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
  • LAST EDITED:  FEB 05, 1992
  • HELP-PROMPT:  Enter the person responsible for extubation.
  • DESCRIPTION:  This is the name of the person responsible for removing the endotracheal tube. Although optional, this information may be useful for documentation.
  • SCREEN:  S DIC("S")="S RESTRICT=""130.06,39"" D KEY^SROXPR I $D(SROK)"
  • EXPLANATION:  Entries in this field may be restricted based on locally selected keys.
40 ANESTHESIA COMMENTS 7;0 WORD-PROCESSING #130.5

  • DESCRIPTION:  These are comments related to anesthesia care for this case.
41 MONITORED ANES CARE ?(Y/N) 8;1 SET

  • LAST EDITED:  JUN 18, 1987
  • DESCRIPTION:  This indicates whether the anesthesia personnel monitored this patient without anesthesia. This information is not required, but may be useful for documentation and review.
42 INTUBATED ? (Y/N) 8;2 SET

  • LAST EDITED:  JUN 18, 1987
  • DESCRIPTION:  This indicates whether an endotracheal tube is placed.
43 LEVEL 8;3 SET

  • LAST EDITED:  JUN 18, 1987
  • DESCRIPTION:  This is the code corresponding to the neurodermatome anesthesia sensory level.
44 DATE/TIME CATHETER REMOVED 8;4 DATE

  • INPUT TRANSFORM:  S Z=$E($P(^SRF(D0,0),"^",9),1,7),X=$S(X?1.4N.A!(X?1.2N1":"2N.A):Z_"@"_X,1:X),%DT="ETX" D ^%DT S X=Y K:Y<1 X K Z
  • LAST EDITED:  DEC 09, 1993
  • DESCRIPTION:  This is the date/time that the continuous regional block catheter was removed. Times entered without a date will be converted to the date of the operation at that time.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
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