Accuracy of Vasopressor Documentation in Anesthesia Records

Journal of Cardiothoracic and Vascular Anesthesia
David B Wax, Justin B Feit

Abstract

To determine the accuracy of documentation of vasoactive medication administration in anesthetic records. Cross-sectional observational study. Single academic center. Attending and resident anesthesiologists. None. An auditor inspected the anesthesia worktop between cases looking for partially used syringes of vasopressors, and the anesthesia record for the preceding case was reviewed for entries related to administration of these agents. In 100 anesthesia records for cases in which a phenylephrine and/or ephedrine bolus was apparently administered, 26% (95% CI: 18-35%) had full documentation and 36% (95% CI: 27-46%) had no documentation. In the 38% of cases that had partial documentation, a median of 50% (interquartile range 33%, 67%) of the total amounts given were documented. The authors found complete or partial omission of documentation of bolus doses of vasopressors in anesthesia records in the majority of cases in which such drugs were given. This finding has the potential to jeopardize the data integrity of local and pooled case registries and conclusions of retrospective studies that utilize these data.

References

Sep 1, 1992·Journal of Clinical Anesthesia·D N Thrush
Jul 29, 2008·Annals of Vascular Surgery·Frédéric JacquesJean-François Blair
Jun 16, 2010·Annals of Plastic Surgery·Chen ChenBernard T Lee
Aug 25, 2011·Canadian Journal of Anaesthesia = Journal Canadien D'anesthésie·Terrence L TrentmanSteven J Hattrup
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May 29, 2013·Microsurgery·Jimmy Yu Wai ChanLawrence Hin Lun Liu
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Jan 1, 2015·Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-Head and Neck Surgery·William R HandScott T Reeves

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Citations

Oct 19, 2016·Anesthesia and Analgesia·Luis I RodriquezRichard H Epstein
Jun 28, 2017·Plastic and Reconstructive Surgery·Ashley Szabo EltoraiDennis P Orgill

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