Amendment Appendix 4 (rev 9-08)
TO BE COMPLETED FOR ALL SURGERY PROJECTS
Check all that apply to your amendment ( IACUC Guideline 13 )
Species Type of Surgical Procedure
Terminal (non-survival) surgery
Survival surgery (once per animal)
Multiple survival surgery
Non-survival second surgery
Check (x) and provide appropriate location of surgery:
SOM-ULAR Surgery- Richards 7 th
floor Surgery Suite
SOM-ULAR Surgery- Stemmler 5 th floor Surgery Suite
SOM-ULAR BRB 3 Surgery Suites
SOM-ULAR Glenolden Surgery Suites
SVM-VHUP 4115 Surgery
SVM-Student 296E
Animal Facility Rodent Procedure Room Bldg/Rm Number:
Investigator’s Lab. Bldg/Rm Number:
If other, specify
1.
List the names, roles, training and years of experience of those who will perform the surgery.
Name Role in the Procedure Years Experience with
Procedure
Note: The Principal Investigator is responsible for the training of all personnel participating in the study. If individual training is necessary for a particular procedure, please contact ULAR staff for training.
2.
PRE-OPERATIVE FASTING
Will food be withheld?
If yes, for how long?
Yes
Will water be withheld?
If yes, for how long?
Yes
No
No

Amendment Appendix 4 (rev 9-08)
3.
PRE-ANESTHETIC/ANALGESIC, ANESTHETIC AGENTS & INTRA-
OPERATIVE ANALGESIC
Species Preanesthetic agent mg/kg
Pre- analgesic agent mg/kg
Anesthetic:
Induction
Dose (mg/kg or % gas)
Anesthetic:
Maintenance
Dose (mg/kg or % gas)
Intra-
Operative
Analgesic mg/kg
Route a.
Describe how you will determine depth of anesthesia and how it will be increased if necessary. b.
Describe the surgical procedure. Include descriptions regarding preparation for the surgical procedure (e.g. techniques used for skin prep, instrument prep, surgeon prep, etc), anesthesia, peri-operative analgesia, actual procedure, and the method of closure. c.
Do you anticipate the possibility of sudden death during the post-operative period?
NO YES.
If yes, please describe, including why this is the case, the expected mortality rates and any actions taken to limit mortality
4.
POSTOPERATIVE CARE : a.
Provide a description of the post-surgical care, include that provided immediately postoperatively and long-term. Include objective criteria that are suggestive of post-operative pain, the frequency and time course of observations, and the person(s) who are responsible for post-operative care.
Are analgesics administered? Yes No (If no, justify why not; If yes, complete chart)
Post Operative Analgesics and Sedatives and Antibiotics
Species Agent Dose mg/kg & Route Frequency of Adm.

Amendment Appendix 4 (rev 9-08)
5.
Will multiple survival surgery be required? Yes No
If yes, ” give a detailed justification for the necessity of the multiple survival surgeries. If they differ from the original surgery, please describe them in detail. What is the time interval between the surgeries?