ANAESTHETIC PERI-OPERATIVE RECORD

ANAESTHETIC PERI-OPERATIVE RECORD 1. PRE-OPERATIVE ASSESSMENT Patient information: Name: John Smith Age: 68 Sex: Male Weight: 85 kg Height: 178 cm Date of assessment: 1 November 2024 Procedure: Right Total Hip Replacement Surgeon: Mr. David Jones Hospital: St. Thomas' Hospital Medical history: Previous medical history: Hypertension, controlled with medication. Mild osteoarthritis. Medications: Lisinopril 20mg daily, Paracetamol as needed. Previous surgical history: Appendectomy 20 years ago. Previous anaesthetic complications: Nil known. Allergies: Penicillin. Social history: Non-smoker, occasional alcohol consumption. Effort tolerance: Able to walk 200m on flat ground. Examination: Airway findings: Mallampati score II. Fasting status: Nil by mouth for 8 hours. Mouth opening: Adequate. Neck mobility: Full range of motion. Teeth/dentition: Good dentition, no loose teeth. Cardiovascular findings: BP 130/80 mmHg, regular heart rate. Respiratory findings: Clear chest auscultation. Special investigations: Laboratory tests: Full blood count, urea and electrolytes, coagulation screen within normal limits. Radiological tests: Chest X-ray clear. Summary: Fit for surgery. ASA classification: ASA II. Concerns: Potential for post-operative pain. Anaesthetic plan: General anaesthesia with regional block. 2. INTRA-OPERATIVE ANAESTHESIA General: Date of surgery: 1 November 2024 Surgeon: Mr. David Jones Hospital: St. Thomas' Hospital Anaesthetic start time: 09:00 Anaesthetic end time: 12:00 Total time – calculated from start and end times: 3 hours Intravenous lines, monitoring and other: Intravenous line: 18G in left arm. Other lines (central/arterial): Nil. Standard ASA monitors applied (ECG, SpO2, NIBP, Capnography): Yes. Other monitors: Bispectral index (BIS). Eyes taped shut: Yes. Pressure points padded: Yes. Warmer used: Yes. Calf compressors: Yes. Induction: Pre-oxygenation: 3 minutes. Drugs administered: Fentanyl 100mcg, Propofol 200mg, Rocuronium 50mg. Airway management (NPO2, Mask, LMA, ETT): Endotracheal tube. Positioning: Supine. Maintenance: Anaesthetic technique (Sedation/GA/RA): General Anaesthesia. Regional anaesthetic technique: Femoral nerve block. Ventilation: Controlled ventilation. Drugs administered: Isoflurane, Rocuronium. Fluids administered: Hartmann's solution 1000ml. Blood loss: 300ml. Urine output: 400ml. Emergence: Extubation: Awake and responsive. Intra-operative events: Complications/interventions: Nil. Notes: Patient stable throughout procedure. 3. POST-OPERATIVE CARE Immediate recovery: Vital signs: Stable, BP 120/70 mmHg, HR 70 bpm, SpO2 98% on room air. Pain score: 3/10. Nausea/vomiting: Nil. Further care: Transfer (back to ward/ICU): Back to ward. Ward prescription: Medication: Paracetamol 1g qds, Morphine 2.5mg PRN for pain. Discharge prescription: Medication: Paracetamol 1g qds for 7 days, review with GP in 2 weeks.