Anaesthesia record

Pre-GA medication Dose Route Time

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Induction agent(s) Dose Route Time

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F�IV catheter Position: Size:

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Procedure(s): Anticipated problems:

History:

Clinical findings/results/medications:

ASA classification

I No organic disease

II Mild systemic disease

III Severe systemic disease (not incapacitating)

IV Severe disease (constant threat to life)

V Moribund (life expectancy < 24 h) Add ‘E’ for emergencies

ASA Grade:

Temperament:

HR: RR:

Pulse quality:

MM: CRT:

Thoracic auscultation:

Temperature: °C

Name:

Owner:

Breed:

Age: Sex:

Weight:

Anaesthetist:

Clinician:

Tim

e

220 210 200 190 180 170 160 150 140 130 120 110 100

90 80 70 60 50 40 30 20 10

Sym

bo

ls

● HR

o RR ø IPPV

˅ SAP – MAP ˄ DAP

Doppler

Anaesthetic Safety

Checklist completed

(see overleaf)

F

ET tube / LMA / Mask Cuffed / Uncuffed Size: F�Eye(s) lubricated Breathing system:

T+0 T+15 T+30 T+45 Time

Heart rate

Resp. rate

MM & CRT

Temp.

Pain score

Recovery instructions:

IV catheter care: F Remove once recovered F Maintain & flush

Date:

Fluids/Drugs/Monitoring

Iso / Sevo %

O2 / N2O / Air L/min SpO2 %

Jaw tone -/+/++ Palpebral -/+ Eye position ↓ / →

Notes Patient position

Patient warming

Throat pack

Placed F

Removed F

Swabs

In: Out:

Sharps

Out: In:

Recovery

SAFETY CONCERNS COMMUNICATED

Airway, Breathing, Circulation (fluid balance), Body Temperature, Pain

ASSESSMENT & INTERVENTION PLAN confirmed

ANALGESIC PLAN confirmed

Person assigned to MONITOR patient

Pre-Procedure — Time Out

Patient NAME & PROCEDURE confirmed

DEPTH of anaesthesia appropriate

SAFETY CONCERNS COMMUNICATED

Pre-Induction

Patient NAME, owner CONSENT & PROCEDURE confirmed

IV CANNULA placed & patent

AIRWAY EQUIPMENT available & functioning

Endotracheal tube CUFFS checked

ANAESTHETIC MACHINE checked today

Adequate OXYGEN for proposed procedure

BREATHING SYSTEM connected, leak free & APL VALVE OPEN

Person assigned to MONITOR patient

RISKS identified & COMMUNICATED

EMERGENCY INTERVENTIONS available

Anaesthetic Safety Checklist

This checklist was written by the AVA with design and distribution support from