CICU Clerking Guidance
Please could we all document as a consistently reproducible minimum data set, in the Medical summary section:
- Operation e.g. (t)AVR, 3xCABG with LIMA to LAD and 2SVG to x and y, (m)MVR, MV Repair etc.
- Brief reason for why operation was needed
- Significant PMH (if not clearly documented in the PMH section)
- allergies
- Preop significant echo findings (e.g. LVEF 45-50%, Severe AS PG 99 MG 48, etc.)
- Preop significant angio findings (e.g. 95% stenosis LMS, occluded RCA)
- Preop pulmonary function tests (FEV1 and FVC with percentages)
- Preop Creatinine
- Preop Hb
- Preop anticoagulant use and when stopped
- Intubation grade
- CPB and X-clamp times
- Vasoactive medication required intraop coming off or post bypass, or mechanical support required pre/post CPB
- Products given intraop and near patient coagulation testing results
- Significant intraop surgical/anaesthetic events/findings (e.g. significant bleeding, additional bypass runs, TOE findings (paravalvular leak, poor LV/RV, residual pathology, etc. ))
- And obviously anything else felt to be significant.
Please see the CICU handbook (2nd ed. 2016, p10) for further guidance on admission clerking.
Here is an example:
(t)AVR and CABGx2 (LIMA to LAD, SVG to PDA)
Background: 68F, Transfer from X Hospital
NSTEMI
Incidental finding severe AS
Echo: EF 50-55%, LVH, no RWMA, AS with PG 110 MG 52
Angio: LMS stenosis 90%, Occluded RCA
PFTs: Fev1 1.6 (65%) FVC 2.8 (69%)
Cr: 145
Hb: 110
Clopidogrel stopped 5 days before operation
PMH:
Iron deficiency anaemia
Left mastectomy
CKD
Grade IIa view
CPB 146min XC 118min
Off CPB on 5NA 3DA
Products: 1xPLTS, 1xCRYO, 2xFFP. Further bleeding so 1500 octaplex given. TEG normal.
TOE: well seated valve. Preserved LV fx.
Southampton Cardiac Anaesthesia 