Tumescent Anesthesia & Liposuction OR Record
Allergies:
ASA Status
Pre-Op HGB(g/dl)
Circulating RN
I or II
Anesthesia Start:
Surgery Start:
Time in OR:
Surgeon:
IV Access Started By:
1
2
1000ml.
1000ml.
1000mEq 1000mEq
Bag #
NaCl (0.9%)
Sodium Bicarbonate 10mEq/1000ml.
Epinephrine (mg.)
Dexamethasone (mg.)
Lidocaine (mg.)
mls. of bag infiltrated
Initial mls. in bag
Lidocaine mg. infiltrated
IntraOp Meds
Dosage
Route
ECG
Prep By
Pre-Op/Post-Op Dx:
Localized Adiposity
Anesthesia End:
Surgery End:
4
1000ml.
1000mEq
Pre-Op Meds: Valium Vicodin Clonidine Benadryl Prevacid
5
6
7
TOTALS
1000ml.
1000ml.
1000ml.
1000mEq 1000mEq 1000mEq
Time
Systolic BP 
MONITORING FLOWSHEET
MONITORS
3
1000ml.
1000mEq
Infiltrator
Given By
Diastolic BP 
Reason Given
Pulse 
Effect
Normal Sinus Rhythm = NS
NIBP SpO2
Time Pre-Op
200
190
180
:00
:30
:00
:30
:00
:30
:00
:30
:00
:30
:00
:30
:00
:30
:00
170
160
150
140
130
120
110
100
90
80
70
60
50
40
30
20
10
0
ECG Rhythm
SpO2
AREAS
TREATED
Infiltration
Begin
Suction
End
Total Volume Aspirate
Total Supernatant Fat
Infranatant Blood tinged Anesthetic
Pre-Op Temp:
Post-Op Temp:
Pre-Op Weight:
Abdomen, Lower
Abdomen, Upper
Ant-Lat Flnks(LH)
Post-Lat Flanks
Other:
Circulating Nurse: ________________________
ml.
ml.
ml.
Begin
End
AREAS
TREATED
Total ml. Anesthetic Solution
Total Volume IV Fluids infused
Urine Voided
Bra Fat
Male Chest
Chin & Neck
Jawline/Jowls
Thighs, Outer (Saddle bags)
Thighs, Inner
Thighs, Ant.
Thighs, Post
Infiltration
Begin
ml.
ml.
ml.
Suction
End
Total Lidocaine Dose
Patient’s Weight
Lidocaine Dose
Knees, Inner
Arms
Back
Inf-Gluteal(Banana)
Begin
End
mg.
kg.
mg./kg.
lb.
Patient Name:
DOB:
Sex:
Date:
Scrub Nurse: ________________________
Physician’s Signature: ________________________