Carpenter syndrome Mucopolysaccharidosis type II (Hunter syndrome) Cat-eye syndrome Mucopolysaccharidosis type IS (Scheie syndrome) CHARGE Association Noonan syndrome Cornelia de syndrome Patau syndrome (Trisomy 13) Costello syndrome Pierre Robin syndrome Cri-du-chat syndrome Prune Belly syndrome Deletion 10p syndrome Rethore syndrome (Trisomy 9) Deletion 8p syndrome Fetal Rubella syndrome (Congenital rubella syndrome) DiGeorge syndrome (velocardiofacial syndrome) (conotruncal anomaly face syndrome) (22q11 deletion) syndrome Down syndrome (Trisomy 21) Short QT syndrome Edwards syndrome (Trisomy 18) Sickle cell disease Ehlers- Danlos Syndrome Sickle cell trait Ellis-van Creveld syndrome Situs inversus Fetal alcohol syndrome (FAS) Smith-Lemli-Opitz syndrome Fetal drug exposure Turner syndrome (45XO) Goldenhar syndrome VACTERL syndrome (VACTER/VATER/VATERR syndrome) Heterotaxy syndrome VACTERL-H syndrome (VATER association with hydrocephalus) (Briard-Evans syndrome) Heterotaxy syndrome, Asplenia syndrome Von Willebrand disease (vWD) Heterotaxy syndrome, Polysplenia syndrome Warkany syndrome (Trisomy 8) Holt-Oram syndrome Williams syndrome (Williams-Beuren syndrome) Jacobsen syndrome Wolff-Parkinson-White syndrome (WPW syndrome) Kabuki syndrome Wolf-Hirschhorn syndrome Kartagener syndrome (Siewert syndrome) (Primary ciliary dyskinesia) Other syndromic abnormality Klinefelter syndrome (XXY Syndrome) (If Other Syndromic abnormality, Specify ↓) LEOPARD syndrome Syndrome – Other – Specify SyndromeOthSp (620) Loeys-Dietz syndrome OPERATIVE Procedure Location: ProcLoc (1000) Cardiac OR ICU SICU General OR CVICU Radiology Suite Hybrid NICU Procedure Room
PercCentPress (4990) Right Internal Jugular PCPLocRJug (5000) Yes No Left Internal Jugular PCPLocLJug (5010) Yes No Right Subclavian PCPLocRSub (5020) Yes No Left Subclavian PCPLocLSub (5030) Yes No Right Femoral Vein PCPLocRFem (5040) Yes No Left Femoral Vein PCPLocLFem (5050) Yes No Other PCPLocOth (5060) Yes No CVP Placed by Anesthesia CVPPlaced (5070) Yes No Swan-Ganz Catheter SGCath (5080) Yes No Oximetric Central Line ScVO2 (5090) Yes No Ultrasound Guidance Used for Line Placement: UltraDopGuide (5100) None Arterial line Central venous line Both arterial & venous lines Neurologic Monitoring NeuroMonitor (5110) Yes No (If Yes →) Bispectral Index NeuroMonBIS (5130) Transcranial Doppler NeuroMonTCD (5140) NIRS (Cerebral) NeuroMonNIRS (5141) Other NeuroMonOth (5150) Yes No Yes No Yes No Yes No Lowest Recorded Intraoperative Temperature: LowIntraopTemp (5160) _________ ° C Lowest Intraoperative Temperature Site: IntraopTempSite (5170) Nasal Esophageal Bladder Rectal Axillary Skin Tympanic Other Transesophageal Echocardiography TEE (5180) Yes No ANESTHESIA Anesthetic Technique Date and Time of Induction: mm/ dd/ yyyy hh : mm _ _ / _ _ / _ _ _ _ _ _:_ _ InductionDT (5190) Induction Type: Inhalation IndTypeInh (5200) Yes No (If Yes →) Sevoflurane (5220) Yes No Isoflurane Yes No
IndAgentInhalIso (5230) Intravenous IndTypeIV (5240) Yes No (If Yes →) Sodium Thiopental IndAgentIVSodT (5260) Yes No Ketamine IndAgentIVKet (5270) Yes No Etomidate IndAgentIVEtom (5280) Yes No Propofol IndAgentIVProp (5290) Yes No Fentanyl IndAgentIVFent (5300) Yes No Midazolam IndAgentIVMid (5310) Yes No Dexmedetomidine IndAgentIVDex (5320) Yes No Sufentanil IndAgentIVSuf (5330) Yes No Remifentanil IndAgentIVRem (5340) Yes No Intramuscular (IM) IndTypeIM (5350) Yes No (If Yes →) Ketamine IndAgentIMKet (5370) Yes No Midazolam IndAgentIMMid (5380) Yes No Regional Anesthetic RegionalAnes (5400) Yes No (If Yes →) Regional Anesthetic Site: RegAnesSite (5410) Thoracic Epidural Catheter Lumbar Epidural Catheter Caudal Epidural Catheter Lumbar Epidural -Single shot Caudal Epidural – Single shot Lumbar Intrathecal -Single Shot Other (If Yes →) Regional Anesthetic Drug: Bupivicaine RegAnesDrugBup (5420) Yes No Bupivicaine/Fentanyl RegAnesDrugBupFen (5430) Yes No (Select all that Clonidine RegAnesDrugClon (5440) Yes No Fentanyl RegAnesDrugFen (5450) Yes No Hydromorphone RegAnesDrugHydro (5460) Yes No Lidocaine RegAnesDrugLido (5470) Yes No
Morphine RegAnesDrugMorph (5480) Yes No Ropivicaine RegAnesDrugRop (5490) Yes No Ropivicaine/Fentanyl RegAnesDrugRopFen (5500) Yes No Tetracaine RegAnesDrugTetra (5510) Yes No Other RegAnesDrugOth (5520) Yes No Intercostal Nerve Infiltration by Surgeon or Anesthesia: IntNerveInf (5530) Yes No Regional Field Block by Surgeon or Anesthesia: RegFieldBlock (5540) Yes No ANESTHESIA Airway Airway In-situ (ETT or Tracheostomy): Yes No Airway Type: No airway support Simple face mask Bag-mask Nasal cannulae Laryngeal Mask Airway (LMA) Endotracheal intubation Tracheostomy (If LMA →) Airway Size : 1.0 1.5 2.0 2.5 3.0 4.0 5.0 (If Endotracheal intubation →) Airway Size (mm): 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 Size not listed (DLETT, Tracheotomy) Cuffed Yes No (If Endotracheal intubation or Tracheostomy→) Airway Site: Oral Nasal Tracheostomy Endobronchial Isolation (DLETT, Bronchial Blocker) Yes No ICU Type Ventilator Used Intraop Yes No ANESTHESIA Transfusion Transfusion Yes No Transfusion (5630) (If Yes enter # of units or 0 if none ) Packed Red Blood Cells (PRBC)Units PRBCUnits (5660) ______ Platelet Pheresis Units PlateletsPheresis (5690) ______ Random Platelet Units PlateletsDonor (5700) ______ Fresh Frozen Plasma (FFP) – Units FFPUnits (5730) ______ Cryoprecipitate – CryoUnits (5760) ______ Whole Blood – Units WholeBldUnits (5790) ______