Anaesthesia Notes for a PICU Patient on Tracheotomy

1. Pre-Anaesthesia Evaluation Note

Patient Identification

• Full name, date of birth, MR number, bed/unit
• Date and time of evaluation
• Anaesthesiologist's name and grade

Indication for Tracheotomy

• Prolonged mechanical ventilation (most common in PICU)
• Pulmonary toilet / inability to clear secretions
• Depressed level of consciousness / failure to protect airway
• Upper airway obstruction
• Weaning failure from translaryngeal ETT
• Expected prolonged ventilation in neuromuscular disease

Current Airway Status

• Current ETT: size, position, depth, days in situ
• Ventilator settings at time of evaluation (mode, FiO₂, PEEP, PIP, TV)
• Degree of respiratory dependency (fully ventilator-dependent vs. partial)
• Recent ABG / SpO₂ trend

Medical & Anesthetic History

• Underlying diagnosis
• Relevant comorbidities (cardiac lesions, pulmonary hypertension, coagulopathy, immunosuppression)
• Previous anaesthetics and any adverse events (malignant hyperthermia, difficult airway, drug reactions)
• Current medications and infusions (vasopressors, inotropes, sedation/analgesia, anticoagulants)
• Allergies (drug, latex, etc.)
• Last oral intake (NGT/NJT feeds — timing of pause)

Physical Examination

• Airway assessment: neck anatomy, neck extension, trachea central/deviated, previous neck surgery or radiation, obesity, short neck, anatomical abnormalities
• Cardiovascular: HR, BP, rhythm, presence of CVL
• Respiratory: current ventilation status, bilateral air entry, secretions
• Weight (for drug dosing)
• IV access: patency, sites

Investigations

• CBC, coagulation (PT/INR, aPTT — especially if anticoagulated)
• ABG (most recent)
• Chest X-ray (ETT position, lung fields)
• Blood group & screen if indicated
• Electrolytes, glucose

ASA Physical Status

• Document ASA class (most PICU tracheotomy patients are ASA III–IV)

Anaesthesia Plan

• Technique: General anaesthesia (GA) — topical LA ± GA, or sedation/regional in specific cases
• Agents planned: induction agent (e.g., ketamine, propofol, midazolam), opioid (fentanyl, morphine), neuromuscular blocking agent (rocuronium, atracurium, suxamethonium), maintenance agent
• Airway plan: whether to maintain existing ETT until surgical access, timing of ETT withdrawal and tracheotomy tube insertion, anticipated difficulty
• Contingency plan if tube dislodges or cannot be exchanged
• Monitoring plan: routine + arterial line, capnography, SpO₂
• NPO/feed pause plan

Consent

• Informed consent: risks discussed (bleeding, infection, tube displacement, hypoxia, cardiac events, death), alternatives explained
• If child — consent from parent/guardian; assent if age-appropriate
• In emergency — document deemed urgent and consent waived/obtained from surrogate

2. Intraoperative Anaesthesia Record

Header

• Date, start time, end time
• Operative procedure: "Surgical Tracheotomy" or "Percutaneous Dilatational Tracheotomy (PDT)"
• Surgeon, anaesthesiologist, assistant, scrub/circulating nurse
• Patient ID (name, DOB, MR#)
• Location: PICU bedside or OR (note if bedside procedure)

Equipment Check

• Confirm pre-procedure check of anaesthesia machine/ventilator
• Suction available, emergency drugs drawn
• Difficult airway trolley available
• Alternative tracheotomy tubes available (one size larger, one smaller)

Monitoring (document on time-grid at ≤5-minute intervals)

• SpO₂
• ECG / HR
• NIBP or arterial line BP (systolic/diastolic/MAP)
• EtCO₂ (capnography — critical for this procedure)
• Temperature
• Airway pressures (PIP, PEEP)
• Ventilator settings at each time point

Induction

• Time of induction
• Pre-oxygenation / FiO₂ adjustment before procedure
• Drugs: name, dose (mg/kg), route, time
  • Example: Ketamine 1.5 mg/kg IV at 10:02, Fentanyl 2 mcg/kg IV at 10:02, Rocuronium 0.6 mg/kg IV at 10:04
• Response to induction (haemodynamic changes, SpO₂)
• ETT position confirmed with capnography before procedure start

Airway Management During Procedure

• Pre-procedure ETT depth
• Time ETT was withdrawn to proximal trachea (to allow surgical access to tracheal rings 2–4)
• Time of tracheotomy tube insertion
• Confirmation of tracheotomy tube placement: bilateral chest movement, EtCO₂ waveform, SpO₂
• Tracheotomy tube: type, size, cuffed/uncuffed, cuff inflation pressure

Anaesthesia Maintenance

• Continuous infusions: drug name, concentration, rate, total dose given
• Bolus doses as given
• Ventilator settings during procedure (if changed)

Haemodynamics & Events

• Graphical record of BP, HR, SpO₂, EtCO₂ at ≤5-min intervals
• Note any significant events: desaturation, hypotension, arrhythmia, bleeding, tube displacement
• Document management of any event

Fluids & Blood Products

• IV fluids: type, volume, rate
• Blood products if given (PRBCs, FFP, platelets) — volume, time
• Estimated blood loss (EBL)
• Urine output during procedure

Positioning

• Supine with neck extension (roll under shoulders)
• Document that pressure areas were padded

Procedure Notes (brief)

• Technique used: open surgical vs. percutaneous dilational
• Any anaesthetic complications or unusual events

3. Postoperative / Post-Procedure Note (PICU Handoff Note)

Condition at End of Procedure

• Haemodynamic stability (HR, BP at end of procedure)
• SpO₂ and EtCO₂ at completion
• Tracheotomy tube confirmed in situ, cuff inflated, ties secured
• Ventilator reconnected; settings documented

Anaesthetic Recovery

• Sedation/analgesia restarted (agents, doses, infusion rates)
• Neuromuscular blockade: reversal given (neostigmine/sugammadex) or decision to maintain NMB — document rationale
• Level of consciousness / Richmond Agitation-Sedation Scale (RASS) score

Airway Assessment

• Tracheotomy tube position confirmed clinically and on CXR post-procedure
• Bilateral breath sounds
• EtCO₂ waveform present
• Suction of secretions performed

Post-Procedure Plan

• First tracheotomy tube change: planned for day 3–7
• Stay sutures in situ until first change
• Humidification started
• Cuff pressure monitoring (target <25 cmH₂O)
• Stoma care instructions

Complications

• Document any complications encountered intraoperatively and immediate postoperative period
• If none: "No intraoperative/immediate post-procedure anaesthetic complications"

Signature

• Anaesthesiologist name, designation, date, time, signature

Key Points Specific to PICU Tracheotomy Notes

Medicolegal Reminders

• Records must be contemporaneous, terse, accurate — avoid retrospective reconstruction
• All drug doses must include: name, dose, route, time
• Timing discrepancies between the anaesthesia record and nursing/surgical records are frequently targeted in malpractice — cross-check timestamps
• In critical incidents (e.g., cardiac arrest, severe desaturation), write a separate text incident note in addition to the graphical record
• Electronic records must be validated: artefactual automated data must be flagged and corrected

Sources: Morgan and Mikhail's Clinical Anesthesiology 7e (pp. 556–557); Barash, Cullen & Stoelting's Clinical Anesthesia 9e (pp. 196–197); Cummings Otolaryngology Head and Neck Surgery (Chapters 7 & 47); Miller's Anesthesia 10e (pp. 399–401)

Evening Round Note — PICU Patient with Tracheotomy

How to Write the Examination Section

Template (fill in your findings):

EXAMINATION:

General: Patient conscious / sedated / on ventilator, comfortable / in mild distress,
         afebrile / febrile, well-perfused / poorly perfused.

Airway: Tracheotomy tube in situ, size [4.0/5.0 etc.], cuffed/uncuffed,
        position secure, ties intact, stoma site clean / mild erythema /
        secretions present — colour [white/yellow/green], quantity [scant/moderate/copious].

Respiratory: SpO₂ ___ % on FiO₂ ___ via ventilator / T-piece / HME.
             Chest — bilateral air entry equal / reduced on [side],
             no added sounds / crepitations / wheeze heard.
             Ventilator: Mode [AC/SIMV/PSV/CPAP], Rate ___, TV ___ ml,
             PEEP ___ cmH₂O, PIP ___ cmH₂O, FiO₂ ___.

Cardiovascular: HR ___ bpm, BP ___/___ mmHg, CRT < 2 sec / > 2 sec,
                warm / cold peripheries, no oedema / pitting oedema present.

Abdomen: Soft, non-tender, bowel sounds present / absent.
         NGT in situ, feeds running / on hold. Urine output ___ ml/kg/hr.

Neurological: GCS ___ (E_V_M_) / RASS score ___.
              Pupils equal and reactive / unequal.
              Moving all 4 limbs / no spontaneous movement.

Lines & Access: PIV × ___ (sites), CVL in [right IJV/femoral/subclavian] — site clean.
                Arterial line in [right radial] — transducing well.

Skin/Wound: Tracheotomy stoma — clean / granulation tissue noted / excoriation.
            No pressure ulcers noted / stage ___ ulcer at ___.

How to Write SpO₂ Correctly

If on ventilator:

SpO₂ 98% on FiO₂ 0.40, PEEP 5 cmH₂O

If on T-piece / tracheotomy mask:

SpO₂ 96% on 40% Venturi mask via tracheotomy connector

If breathing spontaneously via tracheotomy (room air):

SpO₂ 97% on room air via tracheotomy

If SpO₂ is low — document the response:

SpO₂ dropped to 88%, improved to 96% after suctioning and FiO₂ increased to 0.60

Quick Example of a Full Evening Round Note

Date: 22/04/2026    Time: 18:30
Reviewed by: Dr. ___

Diagnosis: [e.g.] Post-viral ARDS, Day 8 of PICU admission, Day 3 post-tracheotomy

Vitals:
T: 37.4°C  |  HR: 98 bpm  |  BP: 94/58 mmHg  |  RR: 22/min (ventilated)
SpO₂: 97% on FiO₂ 0.45, PEEP 6 cmH₂O

Examination:
General: Sedated, on mechanical ventilation, haemodynamically stable.

Airway: Tracheotomy tube (size 4.5, cuffed) in situ. Stoma clean, no erythema.
        Secretions — white, moderate quantity, suctioned 2-hourly.
        Cuff pressure 20 cmH₂O.

Respiratory: SpO₂ 97% on FiO₂ 0.45. Bilateral air entry equal.
             No added sounds. Ventilator: SIMV, Rate 20, TV 180 ml,
             PEEP 6, PIP 22, FiO₂ 0.45.

CVS: HR 98, BP 94/58, CRT 2 sec, warm peripheries, no oedema.

Abdomen: Soft. NGT feeds at 30 ml/hr, tolerated. UO 2.1 ml/kg/hr.

Neurology: Sedated on midazolam + fentanyl infusion, RASS -2.
           Pupils 3mm, equal and reactive.

Lines: PIV ×1 (right hand), CVL right IJV — site clean.

Plan:
- Continue current ventilator settings, wean FiO₂ if SpO₂ >95%
- Regular tracheotomy suctioning, cuff pressure check BD
- Continue sedation protocol, daily sedation holds in morning
- Stoma care TDS
- Review morning ABG

Summary: Key Rules