APPENDIX: Surgery/Procedures
Texas A&M University Kingsville
IACUC
FORM INSTRUCTIONS:
Important: Please type all answers.
 Fill in the protocol information table
 Answer all of the questions.
 An [x] is equivalent to a “yes.”
PROTOCOL INFORMATION
PI Name:
Date:
Protocol Title:
TAMUK IACUC
ORSP #:
1. Preoperative Care. Answer a-d for each surgery or procedure.
a. [
] Food will be withheld. State the length of time:
b. [
] Water will be withheld. State the length of time:
c. [
] Prophylactic antibiotics will be given. Give the name, dose, route, and frequency of
administration:
d. [
] Analgesics will be given. Give the name, dose, route, and frequency of administration:
2. Anesthesia
a. Give the name, dose, route and frequency of administration of the anesthesia to be used.
b. [
] Muscle relaxants or paralytic drugs will be used. If checked, answer the following (i-iv):
i. Give the name, dose, route, and frequency of administration and a scientific justification for each
agent.
ii. Describe how pain and distress will be assessed during paralysis.
iii. Give the name, dose, and route of any anesthesia or analgesia to be given during paralysis.
iv. If analgesics and/or anesthetics will not be used during paralysis, provide a scientific
justification.
3. Animal, Instrument and Surgeon Preparation. Complete all of the checklists below.
Animal Preparation. Please check all that apply:
Operative site will be shaved.
Operative site will be disinfected with betadine or
chlorohexidine and alcohol.
Operative site will be disinfected by other method.
Operative site will be draped with sterile material.
Please list:
Instrument Preparation. Please check all that apply:
Instruments will be sterilized using a steam autoclave.
Instruments will be sterilized using ethylene oxide gas.
Instruments will be sterilized using chemical means.
Please list solution and
contact time:
Instruments will be sterilized using a bead sterilizer
between animals.
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IACUC Appendix
Surgeon Preparation. Please check all that apply:
Surgeon will wear sterile gloves.
Surgeon will wear exam gloves.
Surgeon will wear sterile gown.
Surgeon will wear surgical mask.
Surgeon will wear hair bonnet.
4. Surgery/Procedure
a. Indicate where the surgery, or procedure will take place, (including building, floor and room number).
b. Give a detailed description of the surgery/procedure and indicate the number of times each
surgery/procedure will be performed.
c. [ ] This procedure is a major surgery (one that penetrates and exposes a body cavity or produces
substantial impairment of physical or physiological function).
Provide scientific justification if more than one major surgery is proposed.
d. Give a detailed description of the criteria that will be used to assess adequacy of anesthesia and
animal intraoperative well-being.
5. Post-surgical/Post-procedural care. Procedures known to cause pain in humans should be
considered painful to animals. If animals will be subject to procedures that have potential for pain,
describe the post operative care and analgesics.
a. Identify the person from your lab who will be responsible for post-procedural care and pain relief.
b. Describe how pain and distress will be monitored and the criteria that will be used to identify pain and
distress.
c. List the methods of analgesia that will be used to prevent or relieve post-procedural pain and distress.
i. Give the name, dose, route, and frequency of administration of pain-relieving drugs.
ii. Describe non pharmacological methods such as cage padding, bandaging, application of cold
packs, etc.
d. Describe post-procedural care, which may include administration of parenteral fluids for maintenance
of water and electrolyte balance, monitoring for post surgical infections, monitoring of the surgical
incision and removal of sutures or wound clips.
e. Describe the steps you will take if pain cannot be adequately managed.
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