Author: Robert

Anesthesia Record

Please X all meds when given

Date

E Sheet Printed? Yes No

Client / Animal	Surgeon	Anesthesia Technicians	Procedures
Body Kg. / Weight Lbs.	MM Color/CRT/Pulse	Physical / Status E G F P C
Species	Age/Sex	Mental / Status	Lab Tests – List pertinent abnormalities below
Premed Drugs, Dose, Route, Time		Premed Effect - Ramsay Sedation Score / 1 - 2 - 3 - 4 - 5 - 6 / Did patient vomit? YES NO
Induction Agent	Amount Drawn Up	Route	Unused Amount
Drug, Dose, Route, Time	Drug, Dose, Route, Time	Drug, Dose, Route, Time	Drug, Dose, Route, Time
Inhalant use - Isoflurane / Sevoflurane / None	Inhalant System / Adult Circle / Ped Circle / Bain W/Block	Reservoir Bag Size	ET Tube Size
IV Catheter Size ________________ / Total # Used ____________	IV Fluid Type	Total Fluids Given	Comments/Alerts

Temp 0F/C
Fluid total

Notes

Time

:			:			:			:			:			:			:			:			:			:			:			:			:

CODES
A-A Anesth
S-S Surgery
T Tournequet
E Extubate
Pulse
V SAP
— MAP
Λ DAP
O2 Sat
CO2
X PPV
D Doppler NIBP
O Oscil. NIBP
I Direct IBP

240
220
200
180
170
160
150
140
130
120
110
100
90
80
70
60
50
40
30
20
10
0
Gas %

Recovery Notes T,P,R MM,CRT Post OP Meds/Dose/Route/Time
Pain/Sedation Scores Completed By _________________________

See Other Side For Pain and Sedation Scales

NATIONAL INSTITUTES OF HEALTH
WARREN GRANT MAGNUSON CLINICAL CENTER
PAIN INTENSITY INSTRUMENTS
Jul-03
Modified FLACC Scale
DATE/TIME
Face
0 - No particular expression
1 - Occasional grimace, withdrawn, disinterested
2 - Frequent grimace, clenched jaw
Legs
0 – Normal position or relaxed
1 – Uneasy, restless, tense
2 – Kicking, or legs drawn up
Activity
0 – Lying quietly, normal position, moves easily
1 – Squirming, shifting back and forth, tense
2 – Arched, rigid or jerking
Cry
0 – No cry, whine(awake or asleep)
1 – Moans or whimpers; occasional yipe
2 - Crying steadily, screams, frequent yipes
Consolability/Stress
0 – Content, relaxed
1 – Reassured by occasional touching, hugging or being talked to, distractible
2 – Difficult to console or comfort
TOTAL SCORE
RAMSAY SEDATION SCALE
1 – Patient anxious, agitated, restless
2 – Patient cooperative, oriented, tranquil
3 - Patient responds to commands only
4 – Brisk response to light gabellar tap or auditory stimulus
5 – Sluggish response to light gabellar tap or auditory stimulus
6 - No response to the stimulus mentioned in items 4 and 5