Anesthesia Addendum (Intraoperative Event/Complication)

Anesthesia Intraoperative Event Addendum

Addendum Date/Time: [Date and time note written]

Author: [Name, credentials, and role]

Reference Case: [Procedure name]; [Surgeon/Proceduralist]; [Case date]; [Location]; [Case start time]

Anesthetic Type: [GA / neuraxial / regional / MAC]; [TIVA / inhalational]

Baseline Airway: [mask / SGA / ETT / tracheostomy] (Airway status at the time the event began.)

This addendum supplements the primary anesthesia record, which contains complete vital signs, flowsheet data, and medication administration times.

Event Summary

[1–3 sentence summary describing what occurred, severity, current patient status, and working impression labeled as suspected or confirmed]

Baseline Context

• [Pertinent comorbidities directly relevant to the event]
• [Pre-event vitals/status immediately preceding onset]
• [Anesthetic stage at onset: induction / maintenance / emergence]
• [Contributing setup factors or intraoperative context]

Timeline of Event

(Provide timestamped, chronological entries using 24-hour format. Use "approx" if exact times unavailable and state why.)

• [HH:MM]: [Onset/trigger recognized; who noticed; monitor values or observations that changed]
• [HH:MM]: [Escalation initiated: help called, equipment brought to bedside]
• [HH:MM]: [Key physiologic nadir/peak with values: SpO₂, MAP, ETCO₂, rhythm]
• [HH:MM]: [Intervention performed with dose/device and immediate response]
• [HH:MM]: [Resolution/stabilization status]

Interventions and Response

(Include only domains relevant to this event. Pull exact times, doses, and monitor values from the anesthesia record. Do not duplicate entire medication list.)

• Airway/Ventilation
  • [Devices and techniques attempted with attempt counts]
  • [Adjuncts used, positioning, and optimization maneuvers]
  • [Confirmation method] (Capnography required for ETT confirmation.)
  • [Complications encountered and management]
  • [Response including lowest SpO₂ and recovery timeline]
• Hemodynamics
  • [Fluids/blood products with type and volumes]
  • [Vasopressors/inotropes with dose, route, and time]
  • [Antiarrhythmics with dose, route, and time]
  • [CPR/defibrillation details if applicable]
  • [Diagnostics obtained (ABG, POCUS, ECG) and key results]
  • [Hemodynamic response and time course]
• Medications Temporally Related to Onset
  • [Agents/exposures given near onset with time/route/dose]
  • [Treatment medications with time/route/dose and observed response]

Immediate Outcome and Disposition

[Whether case proceeded, was paused, or aborted with rationale. Status at transfer: airway device and oxygen requirements, vasoactive support, neurologic status if relevant. Disposition (PACU / ICU / other) and ongoing monitoring needs.]

Communication and Handoff

(List names/roles and times. Do not reference internal incident reporting in this note.)

• [HH:MM]: [Surgeon/Proceduralist notified; summary of discussion]
• [HH:MM]: [PACU/ICU/ward team notified; preparations made]
• [HH:MM]: [Consultant(s) engaged and reason]
• [HH:MM or Postop]: [Patient/family disclosure: who present, explanation provided, questions/concerns, follow-up plan] (If disclosure deferred, document plan and responsible clinician.)

Follow-up Actions and Recommendations

• [Orders placed with rationale]
• [EHR alerts/flags to add with specifics]
• [Patient notification materials to be provided]
• [Referrals placed and expected timeframe]
• [Recommendations for future anesthetic care]
• [Outstanding items with responsible clinician and timeline]

Difficult Airway Details

(Include only if airway difficulty occurred.)

• [Relevant airway predictors]
• [Standardized descriptors: difficult mask ventilation; laryngoscopy view grade; difficult intubation with attempt count; failed intubation if applicable]
• [Attempt log: device, blade, adjuncts, view obtained, outcome for each attempt]
• [Oxygenation between attempts; lowest SpO₂ and duration]
• [Rescue pathway used and outcome]
• [Patient notification plan: difficult airway letter, EHR flag, communication to PCP/surgeon]

Aspiration/Regurgitation Details

(Include only if aspiration concern occurred.)

• [Witnessed vs suspected with supporting observations]
• [Material characteristics and estimated volume]
• [Immediate actions: suctioning, positioning, airway protection, bronchoscopy if performed]
• [Objective findings: oxygenation changes, airway pressures, auscultation]
• [Planned workup: CXR, ABG with timing]
• [Antibiotic decision with rationale]

Hemodynamic Instability/Arrest Details

(Include only for significant hemodynamic events or cardiac arrest.)

• [Triggering context: induction / positioning / surgical event / hemorrhage / other]
• [Rhythm diagnosis with supporting evidence and timing]
• [Interventions with doses and times]
• [Suspected vs confirmed etiologies, clearly labeled]
• [Outcome: ROSC time if applicable; stabilization status]

Awareness Concern Details

(Include only if intraoperative awareness is suspected.)

• [Basis for concern: patient report, clinical signs, anesthetic concentration, infusion status, equipment failure, paralysis with inadequate anesthetic]
• [Anesthetic technique at time of concern: volatile concentration trends, TIVA pump status, neuromuscular blockade status]
• [Immediate mitigation steps with doses and times]
• [Equipment/drug delivery verification and findings]
• [Postoperative plan: structured interview, patient's own words, counseling resources, follow-up contact]

Allergic Reaction/Hypersensitivity Details

(Include only if perioperative allergic reaction suspected.)

• [Temporal relationship to exposures with administration times]
• [Clinical phenotype: hypotension, bronchospasm, urticaria, angioedema, ventilation difficulty]
• [Treatment with doses and times: epinephrine, fluids, bronchodilators, antihistamines, steroids, vasopressin]
• [Tryptase sampling: acute sample timing and baseline sample plan]
• [Allergy list updates: suspected triggers with reaction description]
• [Allergy/immunology referral and follow-up plan]

Equipment Issue Details

(Include only if equipment malfunction affected or nearly affected patient care.)

• [Device identification: type, manufacturer, model, serial/asset number if available]
• [Failure mode and patient impact]
• [Troubleshooting steps and resolution]
• [Device removed from service; disposables preserved per institutional protocol]
• [Biomedical/clinical engineering notification status and time]