| Planned Procedure | |
| Medication and Allergies Reviewed | Yes/No |
| Vital Sign Reviewed? | Yes/No |
| BMI (Calculated) | |
| History & Physical Completed/Reviewed? | Yes/No |
| Lung Exam within normal limits | Yes/No |
| Heart Exam within normal limits | Yes/No |
| Prior Anesthesia Reaction? | Yes/No/Unknown |
| Mouth Opening Normal? | Yes/No/Other (see comment) |
| C-Spine Flex-Ext Normal? | Yes/No/Other (see comment) |
| Chin to Neck Distance greater or equal to 6 cm | Yes/No |
| Mallampati Class | Class I/Class II/Class III/ Class IV |
| ASA Staus | ASA 1/ASA 2/ASA 3/ASA 4/ASA 5 |
| Intended Level of Sedation | Level 1 - Minimal Sedation, Level 2 - Moderate Sedation, Level 3 - Deep Sedation |
| Medications to be titrated to effect | Diphenhydramine, Diazepam, Fentanyl, Midzolam, Other (Comment) |
| Patient has been assess prior to induction and was found to be a suitable candidate for planned procedure | Yes/No |
ICU Pre-Procedure Checklist
exp date isn't null, but text field is
Team Agrees:
☐Nursing, physician and respiratory therapist plan for time of ICU procedure to ensure appropriate equipment / resources are available
☐ Critical Information about procedure or patient is discussed i.e., Difficult airway, bleeding
☐ Correct patient, procedure, site, laterality
☐ Correct Position (if applicable)
☐ Confirm consent for procedure
QUALIFIED ICU ATTENDING
☐ ICU Attending must be notified of all ICU Procedural Sedation. Determine if Moderate or Deep Sedation required for procedure.
☐ Deep Sedation ordered? Must comply with UMich Deep Sedation policy which includes:
- Pre-Anesthesia/Procedure Evaluation
- Medication Administration & Monitoring
- Airway Management
- Post-Anesthesia/Procedure Evaluation within 48 hrs after procedure completion
☐ ICU Attending is not Proceduralist, and must remain present for entire procedure
Deep Sedation policy EXCLUDES patients who receive continuous or intermittent IV sedation per protocol to manage conditions requiring mechanical ventilation (e.g. traumatic injury, post-surgical intervention, acute respiratory failure, ARDS).
☐ Fellows and Residents are not permitted to administer Deep sedation
Respiratory Therapy for Moderate/Deep Sedation:
☐ Initiate pre-oxygenation with FIO2 1.0 for 15-30 min prior to the start of the procedure
☐ Trach, not on ventilator: Initiate full ventilator support (set rate/TV) if deep sedation and/or neuromuscular blockade is used.
☐ Ambu bag at bedside with mask
☐ Suction equipment at bedside
Nursing for Moderate/Deep Sedation:
☐ Initiate pre-oxygenation with FIO2 1.0 for 15-30 min prior to the start of the procedure
☐ Trach, not on ventilator: Document full ventilator support (set rate/TV) if moderate/deep sedation and/or neuromuscular blockade is used
☐ SPO2 monitor on and audible for the procedure
☐ Continuous visual monitoring/documentation q 5 min for HR, BP, RR, SPO2 and ECG during entire procedure, and post-procedure until patient’s vital signs within 10% of baseline
☐ Verification that safety equipment is at bedside i.e Ambu bag, extra trach if trach patient
☐ Crash cart available
☐ Document
