Memorial-610 Hospital for Animals

MEMORIAL-610 HOSPITAL FOR ANIMALS ANESTHESIA RECORD

Name (Client, Patient) / ID / Species / Breed / Sex / Birthdate / Date
<last-name>, <first-name>; “<animal>”
H:<area>-<phone> W:<business> / <number> / <species> / <breed> / <sex-name> / <birthday>
<age> / <date>
Weight
lbs / Temp
ºF / Pulse
BPM / Respir.
RPM / MM / CRT
sec / WBC
K/μl / PCV
% / CREAT
mg/dL / BUN
mg/dL / ALT
IU/L / ASA Status (Circle)
1 2 3 4 5 6
Procedure(s) / Pre-Emptive Pain Estimate / Surgeon / Anesthetist
1 2 3 4 5 6 7 8 9 10
Pre-Anesthetic Agents: / Support Measures: / Recovery:
Agent Amount (mls) / Route / Time / Premed Level / r Heating Pad r Pulse Ox / r Excellent
r Glycopyrrolate 0.2mg/ml ______/ r SQ rIM rIV / r Adverse / r Esoph. Steth. r ETCO2 / r Good
r Butorphanol 10mg/ml ______/ r SQ rIM rIV / r Very Sedate / r ECG r / r Fair
r Acepromazine 1mg/ml ______/ r SQ rIM rIV / r Sedate / r BP / r Poor
r Morphine 15mg/ml ______/ r SQ rIM rIV / r Little Effect / Tracheal Tube: / Rec. Vitals:
r / r SQ rIM rIV / r No Effect / Size: ______mm I.D. / Time:
Induction Agents: / r Cuff r No Cuff / Temp:
Agent Amount (mls) / Route / Time / Induction / Intubation Time:______/ Pulse:
r Propofol 10mg/ml ______/ rIV / r Excellent / r Difficulty ______/ Resp:
r Ketamine 100mg/ml ______/ r SQ rIM rIV / r Good / Extubation Time: ______/ Pain:
r Diazepam 5mg/ml ______/ r SQ rIM rIV / r Fair / System: r Semi-Closed Circle / r Recumbant
r Isoflurane / r Poor / r Bain System / r Sternal
r / CODE Status:
r Resuscitate
r DNR / Positioning:r Dorsal rVentral / Total Fluids
IV Cath Placement: r R r L
Type/Gauge: rForeleg rHindleg rJugular / r L. Lat. r R. Lat. / mLs
Time:
O2 Flow
r Isoflurane
r
200 / 200
190 / 190
x = Start Surgery / 180 / 180
Ä = End Surgery / 170 / 170
160 / 160
150 / 150
140 / 140
130 / 130
l = Heart Rate / 120 / 120
110 / 110
100 / 100
Ù = Systolic / 90 / 90
- = Mean Pressure / 80 / 80
Ú = Diastolic / 70 / 70
60 / 60
50 / 50
40 / 40
30 / 30
¢ = Respiration / 20 / 20
10 / 10
0 / 0
Fluids: LRS / Normosol-R / 0.9%NaCl
Temp:
SpO2:
PaCO2:
Notes: