Surgery and Anesthesia Form For Survival and Nonsurvival Surgeries Animal Welfare Act regulations require that

survival surgeries be performed using aseptic

techniques, and in non-rodent species the procedure must be done in a dedicated surgical facility. Investigators performing survival surgery must identify where this will take place. Individuals performing these procedures must be appropriately trained to perform them. Survival surgery can either be major or minor. Major survival surgery penetrates and exposes a body cavity or produces substantial impairment of physical or physiologic functions. Minor survival surgery does not expose a major body cavity and causes little or no physical impairment. Federal regulations permit only one major survival surgery, except when scientifically justified and approved by the IACUC.

This form is provided by the Institutional Animal Care and Use Committee (IACUC) for use by investigators who have survival surgery in their approved protocols. The form may be used

as is, or modified to be more useful to a particular research program. If you choose to modify the form, it is critical that the following elements be retained: Protocol number Pre-anesthetic medications section Anesthesia specifications Post-op medications section Analgesia section Anesthetic monitoring section Procedure description section Immediate post-operative (i.e., day of surgery) monitoring section The record is to be completed contemporaneously with the activities and be retained with the clinical or research records, as applicable. Do not leave items blank (e.g., for non-applicable items, put N/A or line them out).
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Surgical records are subject to on-the-spot review by the veterinarians from Laboratory Animal Services, the IACUC, USDA/Animal & Plant Health Inspection Service (for AWAcovered species), and site visitors from the Association for Assessment and Accreditation of Laboratory Care (AAALAC) International.

Surgery and Anesthesia Form For Survival and Nonsurvival Surgeries

SURGERY AND ANESTHETIC RECORD (Injectable or Inhalation Anesthesia) Animal ID: _______ Species: _________ Weight: ______(kg/lb) Sex: ______ Date: _________ Procedure: _________________Surgeon: ___________________ Anesthetist: ___________________ Investigator __________________ Protocol #: ______________ Start time: ____________ am/pm Asst or Tech: ___________________

End time: ____________ am/pm Fluids Type & Route: __________ Anesthetic gas type: ___________ Intubated? yes Ventilator? yes no no

Pre Anesthetics and Analgesics/Non-Inhalation Anesthetics Drug __ __ __ Dose* ______ ______ ______ Route ______ ______ ______ Time ______ ______ ______

Extubated time: _________am/pm Returned to cage: ______ _am/pm

Description of Operative Procedure

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Anesthesia Maintenance (record every 15 to 30 minutes)Fill in where applicable; modify as appropriate. Time Rate Temp. Respiration Gas% O2/L Color Fluids-ml Toe Pinch/Pedal withdrawal

This Section only applies to Survival Surgical Procedures

Post-Op Analgesics and Medications/Reversal Agents Drug ____________ ____________ Dose* ______ ______ Route ______ ______ Time ______ ______

Post-Op Recovery
Record information every 15-30 minutes until fully recovered (ANIMAL SHOULD BE STERNAL OR STANDING, HOLDING HEAD UP, AND RESPONSIVE TO STIMULATION) Time Respiration Color Sedation* Comments/Additional Observations Initials

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*Sedation Level: 1= Alert, Responsive, Moving around 2= Alert, Responsive, Not active

3= 4=

Eyes open, Responsive, Groggy Eyes closed, Nonresponsive, Heavily sedated

Day of Surgery Notes:

Use additional sheet(s) as necessary

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