ANESTHESIA RECORD
__ __ __ __ __ __
d d mm y y
Accession #: __________
Date:
Sex:_____________
Health Status:
1. (
2. (
3. (
4. (
5. (
) Normal
) Abnormal
) Abnormal (slight)
) Abnormal ( moderate)
) Abnormal (severe)
Fasting Duration:
1.
2.
3.
4.
5.
6.
7.
(
(
(
(
(
(
(
) < 2 hours
) 2-8 hours
) 8-16 hours
) 16-24 hours
) 24-48 hours
) >48 hours
) Undetermined
Pre Restraint
1.
2.
3.
4.
5.
6.
Activity:
( ) Very low/inactive
( ) Low
( ) Elevated
( ) Highly elevated
( ) Variable
( ) Undetermined
Demeanor:
1.
2.
3.
4.
5.
)
)
)
)
)
(
(
(
(
(
Comatose/moribund
Depressed
Alert/relaxed
Aggressive
Apprehensive/Panicked
Weight _________________ 1. ( ) kg
2. ( ) lb
Genus/Species_____________________________________
or
CommonName:___________________________________
Body Condition Score (1-9) ____
Fluid Restriction Duration:
Restraint Risk Class:
1.
2.
3.
4.
5.
6.
1.
2.
3.
4.
5.
6.
(
(
(
(
(
(
) <2 hours
) 2-8 hours
) 8-16 hours
) 16-24 hours
) 24-48 hours
) > 48 hours
Initial physical situation:
1. ( ) Free Ranging
2. ( ) Large enclosure
3. ( ) Small enclosure
4. ( ) Restraint equipment usage
5 ( ) Manual restraint used
6. ( ) Behavioral restraint event
(
(
(
(
)
)
)
)
Isolated animal
Single species group
Multiple species group
Colony
1. ( ) actual
2. ( ) estimate
Anesthesia Location________________
Complication:
1. ( ) None
2. ( ) Minor
3. ( ) Life Threatening
4. ( ) Fatal
5. ( ) Undetermined
Notes:_______________________________
) Lowest risk
) Low risk
) Moderate risk
) High risk
) Likely to die even without anesthesia
) Undetermined
Reason for Restraint:
1. ( ) Husbandry/animal management
a. ( )Animal Transfer
b. ( ) Identification
c. ( ) Measurement
d. ( ) Other
e. ( ) Sample Collection
2. ( )Medical
a. ( ) Diagnostic
b. ( ) Disease monitoring
c. ( ) Measurements
d. ( ) Other
e, ( ) Preventative health
f. ( ) Sample Collection
g. ( ) Treatment
3. ( ) Research
a. ( ) Measurements
b. ( ) Other
c. ( ) Sample collection
4. ( ) Safety
a. ( ) Animal
b. ( ) Human
c. ( ) Other
d. ( ) Recapture
Social:
1.
2.
3.
4.
(
(
(
(
(
(
Recovery:
1. ( ) Normal
2. ( ) Abnormal
3. ( ) Abnormal:prolonged recumbency
4. ( ) Abnormal: extended atypical mental status
5. ( ) Abnormal: violent
6. ( ) Died during recovery phase
ANESTHESIA RATINGS
Induction
Muscle relaxation
Overall
Excellent
1. ( )
1. ( )
1. ( )
Veterinarian: ( ) JMR
Recorded by: ( ) JLP
( ) TMW
( ) DLL
Good
2. ( )
2. ( )
2. ( )
( ) RLT
( ) JMR
( ) MT
( ) TMW
Fair
3. ( )
3. ( )
3. ( )
Poor
4. ( )
4. ( )
4. ( )
( ) Other_______________________
( ) RLT
( ) Other_________________________
Milestones:
Initial Effect Time_____:_____ Decreased responsiveness _____:_____Recum Time: ______:______Working anesthesia _______:______
Initial arousal ______:______ Control of head ______:______Ability to stand______:______ Return to normal ______:______
Time
Comments
Amount
Mg/%
Route
Time
Given
Success
Delivery
Effect
(Stage)
Time of
Effect
Bottle #
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Drug Given (and dose type)
PHYSIOLOGICAL DATA:
Body
Heart
Time
Temp
Rate
____:____
______F/C
BLOOD SAMPLE DATA:
Time Collected:__________:__________ Collected by:___________
Resp
Rate
O2
Sat
Blood Pressure
Sys /Dia / Mean
______
______
______
_____/_____/_____
______
_____/_____/_____
Hematology:
Chemistry:
Collection Site:
1. ( ) EDTA
1.
( ) Serum
( ) Cardiac
2. ( ) EDTA (liq)
2.
( ) Plasma
( ) Cephalic
3.
( ) Whole Blood
( ) Femoral vein
____:____
_______F/C
______
______
____:____
_______F/C
______
______
______
_____/_____/_____
____:____
_______F/C
______
______
______
_____/_____/_____
3. ( ) EDTA (dry)
____:____
_______F/C
______
______
______
_____/______/____
4. ( ) Heparin
( ) Jugular vein
____:____
_______F/C
______
______
______
_____/_____/_____
5. ( ) Heparin (liq)
( ) Metatarsal vein
____:____
_______F/C
______
______
______
_____/_____/_____
6. ( ) Heparin (dry)
( ) Saphenous vein
____:____
_______F/C
______
______
______
_____/_____/_____
7. ( ) Oxalate
( ) Tail vein
____:____
_______F/C
______
______
______
_____/_____/_____
______
______
_____/_____/_____
( ) Wing
_______F/C
______
8. ( ) Citrate
____:____
____:____
_______F/C
______
______
______
_____/_____/_____
9. ( ) Other
( ) Other
____:____
_______F/C
______
______
______
_____/_____/_____
____:____
_______F/C
______
______
______
_____/_____/_____
____:____
_______F/C
______
______
______
_____/_____/_____
Dose Type:
Se: sedative
I: immobili. dose
S: supl. dose
A or R: antagonist dose
O:other drugs/dose
M: maintenance
Delivery Method:
P:polesyringe
B:blowdart
D:metal dart
H:handsyringe
P. Plastic dart
F:facemask
T:endotracheal tube
ASC: air sac cannula
LMA: laryngeal mask
NC: nasal cannula
V:vascular catheter
C:Induction chamber
M:intramus
V:intravas
P:intraperito
S:subcutane
Success of Delivery:
C:complete
P:partial
N:none
%
Effect (depth of anesthesia):
0:no drug effect (awake animal)
1:light sedation
2:deep sedation
3:light anesthesia
4:surgical anesthesia
5:deep surgical anesthesia
6:medullary depression
7:death
C:\data\forms\anesthesia