Principal Investigator:
Protocol title:
Species:
Amendment title:
ADMINISTRATIVE USE ONLY
DATE RECEIVED:
DATE REVISED:
TRACKING NO:
APPROVAL NO.:
APPENDIX I
SURGERY
PLEASE COMPLETE THE HEADER FOR IDENTIFICATION PURPOSES Header completed
Species:
Please note: Only one species (animal) may be listed on appendices
Complete this appendix for proposed survival and non-survival surgical procedures, including
terminal perfusion and tissue-harvest procedures completed under anesthesia.
1.
2.
Terminal (nonsurvival) surgery.
Include exsanguinations and perfusions as a non-survival procedure if this procedure is exclusively a terminal
bleed. These two procedures must only be completed under a surgical plane of anesthesia.
Survival Surgery(ies).
Minor survival surgery. All surgeries that do not involve penetration or exposure of a major body cavity
(abdomen, thorax, cranium) or cause substantial impairment of physical or physiological functions (i.e.
orthopaedic or neurosurgery).
Single major survival surgery. Surgery in which a major body cavity is penetrated and exposed or
surgery in which substantial impairment of physical or physiological functions is produced (i.e. laparotomy,
thoracotomy, craniotomy, joint replacement, limb amputation).
MULTIPLE major survival surgeries. The animal undergoes more than one major surgery and recovers
from anesthesia between procedures.
Provide a scientific justification for performing more than one major survival surgery on individual animals:
3. Surgical Procedures (Include Terminal and Survival Surgeries)
Name of procedure(s)
-1UMDNJ-NEWARK IACUC PROTOCOL Appendix I - Surgery
FORM REVISED 11/22/2005 Last printed 8/1/2016 4:21 PM Last saved by terryce
Principal Investigator:
Protocol title:
Species:
Amendment title:
4. Description of Procedures.
Describe each surgical procedure in sufficient detail from the skin incision to closure of the incision site
including, surgical manipulations and materials and suture materials and wound closure techniques.
5 . Operating room location.
Indicate the building and room number where the surgeries will be performed:
6.
Pre-operative procedures.
Pre-operative procedures should include all preparations of the animal(s) for surgery. Check and describe
which of the following procedures will be performed.
Pre-surgical determination of CBC, Superchem, clotting parameters
Overnight fasting (rarely used in rodents or rabbits).
Catheter placement
Other. Describe other pre-operative procedures:
No preoperative tests or procedures will be performed.
7. Pre-operative medications.
No preoperative medications will be administered.
The following preoperative medications will be administered. Please complete table below.
Include any antibiotics, tranquilizers, preemptive analgesics and induction agents to be administered.
Agent
Dose (mg/kg)
Volume
Route of administration
Dose (mg/kg)
Volume
Route of administration
8. Anesthesia
Agent
9. Will paralytic agents be used?
No
Please continue to #10.
Yes.
Respond to 9.a and 9.b.
-2UMDNJ-NEWARK IACUC PROTOCOL Appendix I - Surgery
FORM REVISED 11/22/2005 Last printed 8/1/2016 4:21 PM Last saved by terryce
Frequency
Principal Investigator:
Protocol title:
Species:
Amendment title:
9.a.
9.b.
10.
Please justify the use of any medications which are paralyzing agents.
Paralytic agent(s).
Agent
Dose (mg/kg)
Volume
Route of administration
Frequency
Post-operative Analgesia
10.a. Post-operative pain relief for all vertebrate animals undergoing survival surgery is required unless
scientifically justified. Complete the analgesic data table as follows:
Agent
10. b.
Dose (mg/kg)
Volume
Route
Frequency
Duration?
Justification for not using post-operative analgesia (when applicable):
10. c. Describe procedures for postoperative care.
11. Post-operative complications
Describe any possible or expected post-operative complications and what will be done if these
complications arise. Indicate how frequently the postoperative animal will be monitored.
12. Post-operative survival
How long will the animal(s) survive after surgery?
Group
Survival Time: Hours, days, weeks, months
1.
2.
3.
4.
13. Personnel information.
Please list who will be responsible as follows: If more than one individual
will have responsibility, please add rows as needed.
Procedure
Preoperative care
Anesthesia
Surgery
Postoperative care
Large animal
Name
Lab phone
Pager
-3UMDNJ-NEWARK IACUC PROTOCOL Appendix I - Surgery
FORM REVISED 11/22/2005 Last printed 8/1/2016 4:21 PM Last saved by terryce
Cell
Principal Investigator:
Protocol title:
Species:
Amendment title:
Medical records*
*
List the names of research staff who will be responsible for ensuring that large animal health records are
complete and accurate and include post-operative observations and procedures.
DATE
SIGNATURE OF PRINCIPAL INVESTIGATOR
DATE
SIGNATURE OF CO-PRINCIPAL INVESTIGATOR
DATE
SIGNATURE OF DEPARTMENT CHAIRPERSON
-4UMDNJ-NEWARK IACUC PROTOCOL Appendix I - Surgery
FORM REVISED 11/22/2005 Last printed 8/1/2016 4:21 PM Last saved by terryce