ANAESTHESIA RECORD GOK/KSA

NAME DATE WARD

IP No. AGE GENDER Male Female THEATRE
WT (kg) HT (cm) ANAESTHETISTS
PRE- OP DIAGNOSIS SURGEONS
INTRA-OP DIAGNOSIS SCRUB NURSES
PROPOSED PROCEDURE PROCEDURE DONE
PRE-OPERATIVE ASSESSMENT | OTT
SMOKING ALCOHOL OTHER DRUG USE

CARDIOVASCULAR SYSTEM COMMENTS (Positive findings/ recommendations)

Normal Abnormal Yes No H.R. B.P Pallor
Hypertension/Hypotension
Easy fatiguability
Murmur
Chest pain/ angina / CAD
Congestive Heart Failure
Arrythmia
Peripheral Vascular Disease
Congenital/Valvular Heart Disease
Other

RESPIRATORY SYSTEM
Normal Abnormal R.R. SpO2 Cyanosis
Asthma

ANAESTHESIA RECORD
T. B.
C.O.P.D.
Other

ENDOCRINE SYSTEM
Normal Abnormal
Diabetes
Thyroid Disease
Recent steroid use
Other

NEUROLOGICAL SYSTEM
Normal Abnormal

Seizures G.C.S.
Elevated ICP E
Neuromuscular disease M
C.V.A./ Cerebrovascular disease V
Other Tot:
RENAL
Normal Abnormal
ARF
CRF
HAEMODIALYSIS
Other

GASTROENTEROLOGICAL
Normal Abnormal
Hepatitis/ Cirrhosis/ Jaundice
Increased risk of reflux
P.U.D
Other

OTHER SIGNIFICANT ANAESTHETIC AND MEDICAL HISTORY/ PHYSICAL EXAMINATION

HISTORY OF PRESENTING ILLNESS

 AIRWAY Yes No COMMENTS (Positive findings/ recommendations)
Loose teeth
Dentures
Anatomical abnormalities
Mallampati classification __________________
Other

CURRENT MEDICATION
1 4 STEROID USE
2 5 YES NO
3 6

ALLERGIES:

SIGNIFICANT LAB RESULTS

Haematology Hb_____ Hct_____ PIts____ Positive findings/ recommendations
WBC_____ PT_____ INR_____APTT_____
Normal Abnormal N/A
Renal function tests
Liver function tests
Glucose
Sickling Test
Other______________________________
OTHER SIGNIFICANT PRE-OP TESTS
CXR Normal Abnormal
N/A

E.C.G. Normal Abnormal

N/A

Echo Normal Abnormal

N/A
Cardial Cath Normal Abnormal
N/A

Other Normal Abnormal

N/A

ASA: 1 2 3 4 5 E
PRE-OPERATIVE ORDERS / INSTRUCTIONS

Name__________________ Signed____________________Date________________Time____________
DRUGS UNITS
X-Anaesthesia
S-Surgery

O-Respiration

-Temperature

C-C.V.P

T-Tourniquest

O2 L/min REGIONAL

Air N2O L/min

% Caudal
Vapour
INFUSIONS RATE

Spinal

Epidural

Bler’s

FLUIDS 1 block
2
3 Combined

BLOOD/BLOOD PRODUCTS Spinal/epidural

WB/ FB

PACKED CELLS Other

FFP

PLTS / CRYO

AIRWAY TIME 15 30 45 0 15 30 45 0 15 30 45 0 15 30 45 0 15 30 45 0 15 30 45 0 15 SITE

OROPHARYNGEAL HR
190
NASOPHARYNGEAL R/L
180
TECHNIQUE
LMA SIZE______
170
UNDER MASK
160

OTHER
150
INTUBATION
140
DIRECT VISION
130
BLIND
120
FIBREOPTIC LOCAL
TEMP
110 ANAESTHETIC
ASLEEP AWAKE
42 100
IN SITU Drug:
41 90
TOPICAL SPRAY___________
40 80 Concentration:
BLADE Size_______________
39 70
CURVED STRAIGHT
38 60
DIFFICULTY_______________
37 50
Volume:
ENDOTRACHEAL TUBE
36 40
ORAL Additive
35 30
NASAL R/L
34 20
ENDOBRONCHIAL R/L
SIZE_________________ SpO2 Spo2

LENGTH______________ ETCO2 ETCO2

E.C.G. E.C.G.
CUFF
CVP CVP
PACK YES LAP LAP
NO
OTHER_____ OTHER
TIME IN______
POSITION POSITION TOTALS
TIME OUT
YES URINE URINE
NG TUBE
NO FBI E.B.L.
MONITORS
ECG_____________ PRECORDIAL STETH TEMP 1 TEMP 2 URINARY CATHETER PULSE OX _______ ETCO 2 CVP NIBP_____________ NERVE STIMULATOR ANAES GAS ANALYSER OTHER
LOCATION

INDUCTION TIME INDUCTION METHOD: VENTILATION: VENT. SETTINGS INTRAVENOUS ACCESS CENTRAL VENOUS ACCESS ARTERIAL LINES OTHER ACCESS
1 RAPID SEQUENCE METHOD: IPPV SPONT T.V. _______________
1_____G SITE_____________ 1 SIZE__________ 2 SIZE_________ 1 SIZE________ 2 SIZE________ 1 SIZE________
2 INHALATIONAL MANUAL OTHER RATE_______________ 2______G
SITE_____________ LENGTH__________ LENGTH_________
3 INTRAVENOUS CIRCUIT: CLOSED OPEN I:E _________________ SITE________ SITE________ SITE________
4 PEEP_______________ 3______G SITE_____________ SITE__________ SITE_________
PRE-OXYGENATION TYPE:______________
OTHER TYPE________ TYPE_______ TYPE_______
OTHER___________ VENTILATOR TYPE:____________ 4______G SITE_____________ TYPE_________ TYPE________
INCISION TIME
 RECOVERY
+
Blood TIME
Pressure
200

150

100

50

Oxygen L/min
SpO2
ETCO2
E.C.G

Drowsy
CRS Arousable
Fully conscious

RR

40

30

20

10

TEMP
42
41
40
39
38
37
36
35
34

Fluids

Urine

Drains

Anaesthetist called to see patient prior to return to ward Yes No

Time patient fit to return to ward ______________ Recovery room nurse signature ____________
 ANAESTHETIC COMPLICATIONS/ COMMENTS

REVERSAL POST-OPERATIVE FLUIDS

REVERSED BREATHING SPONT
YES NO

EXTUBATED YES NO VENTILATED

REVERSAL: AIRWAY ORAL ETT

NASAL ETT
TRACHEOSTOMY
TRANSFER: RECOVERY ICU HDU

POST-OPERATIVE NOTES

1ST POST-OPERATIVE DAY REVIEW

Name __________________________ Signed ___________________ Date _______________