Case Info Anesthesia type Date Provider ID MR # CRNA ID ASA Class Additional provider Co-morbidities: Arrhythmia ☐ Reactive Airway disease ☐ Diabetes ☐ Latex Allergy ☐ Trach/Laryn/Bronch ☐ ☐ Single Ventricle ☐ ☐ GERD Chromo Anomaly Malacia CHF ☐ Difficult Airway ☐ Hypertension ☐ H/O of ED ☐ Cyanotic CHD ☐ Cystic Fibrosis ☐ Hemaglobinopathy ☐ Obesity ☐ Acyanotic CHD VC Dysfunction Liver disease/failure Premi < 37 weeks ☐ ☐ ☐ ☐ Pulmonary HTN ☐ Pneumonia ☐ Renal Disease/failure ☐ ☐ Valve Disease ☐ BPD/CLD ☐ Hematologic ☐ Seizures ☐ Cardiomyopathy OSA Endocrine other Developmental Delay ☐ ☐ ☐ ☐ Metabolic Intracranial ☐ ☐ ☐ Spina Bifida ☐ Cerebral Palsy disorder Hemorrhage Failure to thrive ☐ H/O SIDS ☐ Hydrocephalus ☐ Other ☐ ☐ ☐ NO UNTOWARD EVENT Death (Excludes ASA 6 patients presenting for harvesting) Airway Trauma Anaphylaxis Failed Regional Burn ☐ ☐ ☐ ☐ Aspiration Arrhythmia req tmt High Spinal Case Cx Pre Induction ☐ ☐ ☐ ☐ Laryngospasm Cardiac Arrest Inad epidural/caudal Case Cx Post Induction ☐ ☐ ☐ ☐ Bronchospasm Shock CNS Injury Emergence delirium ☐ ☐ ☐ ☐ New Pulmonary Edema/CHF Post Dur Punc Inad Pain Control ☐ ☐ ☐ ☐ Croup/Stridor Headache Hypoxia w/esc Transfusion Reaction Periph Neuro Deficit Incorrect Op Site ☐ ☐ ☐ ☐ Reintubation Vascular Acc Compl Seizure Intraop Awareness ☐ ☐ ☐ ☐ Respiratory Myocardial Infarction Unplanned Dural Punc Medication Error ☐ ☐ ☐ ☐ Arrest Unable to ECMO Visual Loss Prolonged PACU stay ☐ ☐ ☐ ☐ Intubate Prolonged SaO2<90>60s-NonCyan Unpl Post Op Vent Unpl ICU Admit ☐ ☐ ☐ ☐ Intub/Vent Unrecog Diff Dental Trauma Pneumothorax ☐ ☐ Eye Injury ☐ ☐ Airway Equip Hypotherm in PACU Intractable N/V Prolonged NM Block ☐ ☐ ☐ ☐ Malfunction <36c Fall Incorrect Patient Malig Hyperthermia Return to OR ☐ ☐ ☐ ☐ Unpl Hosp Admit ☐
Case Info Anesthesia type Date Provider ID MR # CRNA ID ASA Class Additional provider Co-morbidities: Arrhythmia ☐ Reactive Airway disease ☐ Diabetes ☐ Latex Allergy ☐ Single Ventricle ☐ Trach/Laryn/Bronch Malacia ☐ GERD ☐ Chromo Anomaly ☐ CHF ☐ Difficult Airway ☐ Hypertension ☐ H/O of ED ☐ Cyanotic CHD ☐ Cystic Fibrosis ☐ Hemaglobinopathy ☐ Obesity ☐ Acyanotic CHD ☐ VC Dysfunction ☐ Liver disease/failure ☐ Premi < 37 weeks ☐ Pulmonary HTN ☐ Pneumonia ☐ Renal Disease/failure ☐ ☐ Valve Disease ☐ BPD/CLD ☐ Hematologic ☐ Seizures ☐ Cardiomyopathy ☐ OSA ☐ Endocrine other ☐ Developmental Delay ☐ Metabolic disorder ☐ Spina Bifida ☐ Cerebral Palsy ☐ Intracranial Hemorrhage ☐ Failure to thrive ☐ H/O SIDS ☐ Hydrocephalus ☐ Other ☐ NO UNTOWARD EVENT ☐ Death (Excludes ASA 6 patients presenting for harvesting) ☐ Airway Trauma ☐ Anaphylaxis ☐ Failed Regional ☐ Burn ☐ Aspiration ☐ Arrhythmia req tmt ☐ High Spinal ☐ Case Cx Pre Induction ☐ Laryngospasm ☐ Cardiac Arrest ☐ Inad epidural/caudal ☐ Case Cx Post Induction ☐ Bronchospasm ☐ Shock ☐ CNS Injury ☐ Emergence delirium ☐ New Croup/Stridor ☐ Pulmonary Edema/CHF ☐ Post Dur Punc Headache ☐ Inad Pain Control ☐ Hypoxia w/esc ☐ Transfusion Reaction ☐ Periph Neuro Deficit ☐ Incorrect Op Site ☐ Reintubation ☐ Vascular Acc Compl ☐ Seizure ☐ Intraop Awareness ☐ Respiratory Arrest ☐ Myocardial Infarction ☐ Unplanned Dural Punc ☐ Medication Error ☐ Unable to Intubate ☐ ECMO ☐ Visual Loss ☐ Prolonged PACU stay ☐ Prolonged Intub/Vent ☐ SaO2<90>60s-NonCyan ☐ Unpl Post Op Vent ☐ Unpl ICU Admit ☐ Unrecog Diff Airway ☐ Eye Injury ☐ Dental Trauma ☐ Pneumothorax ☐ Equip Malfunction ☐ Hypotherm in PACU <36c ☐ Intractable N/V ☐ Prolonged NM Block ☐ Fall ☐ Incorrect Patient ☐ Malig Hyperthermia ☐ Return to OR ☐ Unpl Hosp Admit ☐
Anesthesia_Pediatric_Outcome_Template.docx