Principal Investigator:
Protocol # (if available):
Date:
SECTION G: PROCEDURES UTILIZING ANESTHESIA
Repeat this section for each species and for each distinct procedure requiring anesthesia, including surgery
and/or other procedures where anesthesia may be used (oral gavage, blood collection, etc.). All planned
anesthetic events should be documented.
G1. Procedure/ Description
Species
Procedure
Chronological
narrative of
procedures*
Procedure
outcome
Survival.
Terminal. Animals do not recover from anesthesia. Omit sections G8-11.
Personnel
performing these
procedures**
*include frequency of procedure if repeated; justification for use of chemical restraint &/or paralytics, if applicable
**list procedure(s) on Personnel Qualifications Form of each person performing procedure
G2. Multiple Procedures Requiring Anesthesia
Will any of the animals have had survival surgery or other procedure requiring anesthesia prior to this
protocol? Mark an “X” in applicable box.
Yes. Describe below:
No.
Will any of the animals experience more than one surgical procedure requiring anesthesia as part of
this protocol? Mark an “X” in applicable box:
Yes. Include a new Section G for each distinct surgical procedure. Describe frequency of
repeated surgical procedures and provide scientific justification below:
No.
1
G3. Pre-Procedural Support
Will pre-procedural support be provided? Mark an “X” in applicable box(es):
No. The procedures do not require pre-procedural support.
Yes. Specify pre-procedural actions and indicate method(s) below:
Food withdrawal
Duration of food withdrawal:
Fluid withdrawal
Ophthalmic ointment to eyes
Clipping fur
Duration of fluid withdrawal:
Povidone iodine (or Chlorhexidine) + alcohol skin scrub, 3 alternating cycles
Drugs or fluids (other than anesthetics) Describe below:
Product
Dose
Route
Frequency
Duration of
Treatment
Other (describe below):
G4. Intra-Procedural Support
What forms of intra-procedural support will be provided? For “Method,” include type, route of
administration and frequency (or continuous if applicable).
Fluids
Method:
Supplemental Heat
Method:
Other
Method:
G5. Description of Anesthesia
How will anesthetics be used?
For chemical restraint (e.g., ketamine, metatomidine, isoflurane, diazepam used to
immobilize/minimize stress during blood draw, injection, other procedure.)
For pain relief (surgery or other potentially painful procedure)
List anesthetics, sedatives:
Drug
Dose
Route
Describe how adequate anesthesia will be ensured below:
2
Frequency
Duration of
Treatment
G6. Use of Paralytics
Will paralytics be utilized? Mark an “X” in applicable box.
Yes. The procedure requires paralytics. Use of paralytics must be justified in the narrative (G1).
No.
List anticholinergics, other paralytics:
Drug
Dose
Route
Frequency
Duration of
Treatment
Describe how adequate depth of anesthesia and pain relief will be ensured during use of paralytics:
G7 Monitoring During Anesthesia
Indicate the indices that will be used for monitoring animal health while the animal is anesthetized
during surgery. Mark an “X” in applicable box(es):
Respiratory Rate/Effort
Reflexes
Mucous Membrane
Heart Rate (indicate method below):
Body Temperature
ECG
Capillary Refill Time
Pulse Oxygen
Oxygen Saturation
Palpation
Other:
Auscultation
G8 Monitoring During Recovery (if survival)
Indicate the parameters that will be used for monitoring animal health during anesthetic recovery.
Mark an “X” in applicable box(es):
Respiratory
Mucous membrane
Capillary refill time
rate/effort
Activity
Reflexes
Body Temperature
Other:
G9 Monitoring for Post-Procedural Complications (e.g., monitoring for cyanosis after gavage, tissue
swelling or sloughing post-injection).
Will post-procedure monitoring be provided? Mark an “X” in applicable box.
No. The procedures do not require post-procedural monitoring.
Yes. The procedures require post-operative animal support (Describe monitoring below):
3
G10 Post-surgical care
Will post-surgical care be provided? Mark an “X” in applicable box.
No. The procedures do not require post-surgical support.
Yes. The procedures require post-surgical animal support (Describe below):
Is the procedure expected to cause pain or distress? Mark an “X” in applicable box(es).
No. Pain or distress is not expected.
Yes. Pain or distress during or after the procedure is possible.
Will analgesics be provided?
No. Analgesics will not be provided. Provide scientific justification for withholding below:
Yes. List analgesics provided after recovery. Include any reversal agents used.
Product
Dose
Route
Frequency
Duration of
Treatment
Timing of
Administration
Will products other than analgesics be provided (e.g., antibiotics provided at or after recovery)?
Yes.
No. Antibiotics are not necessary
Product
Dose
Route
Frequency
4
Duration of
Treatment
Timing of
Administration
G11 Monitoring during the study until termination (if survival)
Is the procedure expected to cause chronic pain or distress? Mark an “X” in applicable box.
No. Chronic pain or distress is not expected.
Yes. Chronic pain or distress is possible.
Identify the most likely cause of the pain or distress Mark an “X” in applicable box(es).
Infectious disease
Tumor burden
Phenotypic side effects
Antibody
Post-procedure/surgical
Other:
production
complications
Identify the following:
Monitoring Parameter
Frequency of Obs.
Action
Not eating or drinking
Fecal and urine output
Body weight
Behavioral change (guarding, hiding)
Licking, biting, scratching site
Hair coat (ruffled fur, lack of grooming)
Posture or ambulation (tucked, stiff)
Activity level (restlessness, pacing,
reluctance to move)
Sweating or salivation
Oculonasal discharge
Teeth grinding
Other:
Other:
G12 Tissue Collection
Will tissues be collected as part of this procedure?
No. Tissues will not be collected.
Yes. Tissues will be collected from alive, anesthetized animals (provide details below):
Tissue
Volume
Collection
Method
Frequency of
Collection
Disposal
Method
AND/OR
Yes. Tissues will be collected from euthanized animals. Provide details below:
Tissue
Collection
Method
Volume
5
Disposal
Method