Nova Peri-Operative Anaesthetic Record Template

[Dr. Eleanor Vance] Consultant Anaesthetist MBBS, FRCA Practice Number: 1234567 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: City General 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: None known. • Allergies: No known drug allergies. • Social: Non-smoker, occasional alcohol consumption. • Effort tolerance: Able to walk 100 meters without significant shortness of breath. Examination: • Airway: - Fasting: 8 hours - Mallampati score: Class I - Mouth opening: 4 cm - Neck mobility: Full range of motion. - Teeth/ dentition: Dentures, upper and lower. - Other airway concerns: None anticipated. • Cardiovascular: Regular heart rate, no murmurs. • Respiratory: Clear lung sounds bilaterally. • Other: Nil. Special investigations: • Bedside: Nil. • Laboratory: Hb 14.2 g/dL, Creatinine 88 umol/L, Na 140 mmol/L, K 4.1 mmol/L. • Radiological: Chest X-ray clear. • Other: Nil. • Summary: Fit for surgery. Controlled hypertension. No significant anaesthetic risks identified. • ASA classification: ASA II • Concerns: Risk of post-operative pain. • Anaesthetic plan: General anaesthesia with peripheral nerve block for post-operative analgesia. 2. INTRA-OPERATIVE ANAESTHESIA General: • Date of surgery: 1 November 2024 • Surgeon: Mr. David Jones • Hospital: City General Hospital • Anaesthetic start time: 09:00 • Anaesthetic end time: 12:00 • Total time: 3 hours Intravenous lines, monitoring and other: • Intravenous line: 18G in left forearm. • Other lines (Central line/ Arterial line): Nil. • Standard ASA Monitors applied (ECG, SpO2, NIBP, Capnography): Yes • Other monitors: Temperature probe. • Eyes taped shut: Yes • Pressure points padded: Yes • Warmer: Forced air warmer used. • Calf compressors: Yes Induction: • Pre-oxygenation: 3 minutes with 100% oxygen. • Drugs administered: Fentanyl 100 mcg, Propofol 150mg, Rocuronium 50mg. • Airway management (NPO2, MASK, LMA, ETT): Endotracheal intubation, size 7.0 ETT. • Positioning: Supine. Maintenance: • Anaesthetic technique (Sedation/ GA/ RA): General Anaesthesia • Regional anaesthetic technique: Femoral nerve block performed. • Ventilation: Volume-controlled ventilation, Vt 500ml, RR 12/min, FiO2 0.4. • Drugs administered: Sevoflurane 1.5%, Rocuronium top-ups. • Fluids administered: Hartmann's solution 1500ml. • Blood loss: 300ml. • Urine output: 200ml. Emergence: • Extubation: Awake and breathing spontaneously. Intra-operative events: • Complications/ interventions: Nil. • Notes: Patient stable throughout the procedure. 3. POST-OPERATIVE CARE Immediate recovery: • Vital signs: BP 130/80 mmHg, HR 80 bpm, SpO2 98% on room air. • Pain score: 3/10. • Nausea/ Vomiting: Nil. • Other complications: Nil. Further care: • Transfer (Back to ward/ ICU): Back to ward. Ward prescription: • Medication: Paracetamol 1g qds, Morphine 2.5mg PRN for pain, Ondansetron 4mg PRN for nausea, Enoxaparin 40mg daily. Discharge prescription: • Medication: As per ward prescription, to continue for 24 hours post-operatively. Review pain control and discharge with appropriate analgesia.