Documenting post LMA removal

  1. We are having a discussion about how to properly document a patient who had their airway managed by the LMA vs. the ET tube. Half the group feels that regardless of the LMA or ET tube, the airway was intubated and as such the documentation should reflect that the patient was extubated. Others feel that since the LMA is not the typical intubation (not in the trachea) then the patient was never intubated. I can see both sides, however I am leaning more to the fact that this was an advanced airway management, patient is still at risk (although less) for a spasm or airway complications and as such should be documented as extubated if we receive the patient without an airway in place. Of course patient's who never received any type of airway management (spinals, MAC) should be documentated as never intubated.
    Any input on this topic??
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  2. 5 Comments

  3. by   CRNA, DNSc
    Why not simply document- LMA removed intact. Extubation is commonly used as a short cut of saying Endo Tracheal Tube removed.


    Quote from ckalston
    We are having a discussion about how to properly document a patient who had their airway managed by the LMA vs. the ET tube. Half the group feels that regardless of the LMA or ET tube, the airway was intubated and as such the documentation should reflect that the patient was extubated. Others feel that since the LMA is not the typical intubation (not in the trachea) then the patient was never intubated. I can see both sides, however I am leaning more to the fact that this was an advanced airway management, patient is still at risk (although less) for a spasm or airway complications and as such should be documented as extubated if we receive the patient without an airway in place. Of course patient's who never received any type of airway management (spinals, MAC) should be documentated as never intubated.
    Any input on this topic??
  4. by   ckalston
    I am working on getting something like that in our computer. We are paperless in terms of charting and most of our charting is canned text (of course we can type patient notes). Right now our choices for airway include: Extubated, Never intubated, extubated within 3 minutes of arrival to PACU. It would be a simple matter of adding the LMA removed intact to the choices, but unfortunately the person that did that for us has left the position. We (managers) start our training in 2 weeks to learn how to update the choices which will be a good thing.
    Thanks for your comments,
    Cliff

    Quote from CRNA, DNSc
    Why not simply document- LMA removed intact. Extubation is commonly used as a short cut of saying Endo Tracheal Tube removed.
  5. by   yoga crna
    I never thought much about and haven't documented extubation of the LMA. I think you can do either way on this, except if there is blood in the oropharynx or unusual secretions. That would be useful information in the subsequent care of the patient.

    What I do think is critical is that the CRNA or anesthesiologist should be the one documenting this. It is legal folly to have two versions of what goes on in the OR. Let the person doing a procedure document it. I NEVER chart sponge counts or nursing things that do not directly relate to my anesthesia. My circulating nurses simply chart "refer to anesthesia record" for my part of the procedure.

    Many of us forget the real purpose of the medical record which is for patient care and not legal reasons. I am of the school that you can over-document when you should be taking care of the patient.

    Yoga CRNA, JD
  6. by   mwbeah
    Quote from ckalston
    We are having a discussion about how to properly document a patient who had their airway managed by the LMA vs. the ET tube. Half the group feels that regardless of the LMA or ET tube, the airway was intubated and as such the documentation should reflect that the patient was extubated. Others feel that since the LMA is not the typical intubation (not in the trachea) then the patient was never intubated. I can see both sides, however I am leaning more to the fact that this was an advanced airway management, patient is still at risk (although less) for a spasm or airway complications and as such should be documented as extubated if we receive the patient without an airway in place. Of course patient's who never received any type of airway management (spinals, MAC) should be documentated as never intubated.
    Any input on this topic??
    It is advanced airway management but not and intubation. The name implies a mask anesthetic, i.e. "Laryngeal Mask Airway". The indications/ contradincations for use are the same as for a mask.


    Hope this helps,
    Mike
  7. by   carcha
    I must say whenever I am looking after a patient after hours I will write the time the patient has his airway support withdrawn. I feel its important in the event theres a post op problem to know at what time the patient was self ventilating.

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