Patient Anesthesia Monitoring Form- Canine/Feline

Pet Name: _____________________

Weight (kg): ________ ASA Status: ________

Date of Birth:___________ Species:

Dog

Cat

Temperature: _____

Date: ____________

Procedure(s): ___________________________________

Heart Rate/Pulse: _____ Pulse Quality: _____ Respiratory Rate: _____

Premedication

Route of Admin
0 kg 1 mg/ml =
0.05 mg/kg x ______
0
0.2 to 0.4 mg/kg x ______ kg 10 mg/ml =
0 kg 100 mg/ml =
1 to 4 mg/kg x ______

Acepromazine (1 mg/ml)
Butorphanol (10 mg/ml)

0 ml (maximum single dose 1.5 mg)

________
0
to
0 ml
________

SC or IM
IM

0 kg =
0.035 to 0.065 ml/kg x ______

0 kg ______
0 mg/ml =
0.1 to 0.2 mg/kg x ______
0
0 mg/ml =
______ mg/kg x ______ kg ______
________________________________ (_____mg/ml)

0 to 0 ml
________
0 ml
________

IM

Dexmedetomidine/Ketamine/Torbugesic (DKT) (fractious cats)

Midazolam (_____ mg/ml)

Associate

SC or IM

0 to 0 ml
________
0 to 0 ml
________

Telazol (100 mg/ml) (fractious dogs)

Time Given

IM

Evaluation After Premedications & Prior to Induction

Temperature: ________

Heart Rate/Pulse: ________

Pulse Quality: ________

Respiratory Rate: ________

Sedation Level: none / mild / adequate / excessive

Induction

Amount Given
0 kg 10 mg/ml= ________
0 to 0 ml
1 to 6 mg/kg x ________
0
0
0 to 0 ml
________ mg/kg x ________ kg ________ mg/ml = ________

Propofol (10 mg/ml) IV

________________________________ (________mg/ml)

Fluid Therapy

1st hour under anesthesia

0
0
10 ml/kg/hr x ________kg=
________ml/hr
0
0
5 ml/kg/hr x ________kg= ________ml/hr
0
0
to
0
5 to 10 ml/kg/hr x ________kg= ________ml/hr

Lactated Ringers Solution (LRS) (canine dose)

Lactated Ringers Solution (LRS) (feline dose)
________________________________________

Intubation
Time Intubated:____________
Local & Regional Blocks
Bupivacaine 0.5% (5 mg/ml)
Lidocaine 2% (20 mg/ml)

Time Surgery Started:____________

0
0 to 0 g/min
1 to 5 g/kg/min x ________kg
= ________
0
0
0
________mg/kg x ________kg ________mg/ml = ________ml

IV

Amount Given Route of Admin

Time Given

Associate

IV

IV

NSAID / Opioid / Antibiotic Medication

Associate

IM or IV

0
0 to 0
0.25 to 0.5 mg/kg x ________kg
20 mg/ml = ________ml
0
0 to 0
2.5 to 5 ml/kg x ________kg = ________ml
0
0 to 0
0.1 to 0.2 mg/kg x ________kg 5 mg/ml = ________ml

Ephedrine (5 mg/ml) (every 15-20 minutes; 2 dose limit)

Time Given

IM

IV

Hetastarch 6% Solution (bolus)

______________________ml

(decrease 50- 75% in pregnant patients)

0
0 to 0
0.1 to 0.2 mg/kg x ________kg
1mg/ml = ________ml
0
0 to 0
2 to 4 mg/kg x ________kg 20mg/ml = ________ml

Lidocaine (20 mg/ml) (feline bolus)

______________________ml

(maximum feline dose 1 mg/kg; decrease 50- 75% in pregnant patients)

Route of Admin

Lidocaine (20 mg/ml) (canine bolus)

______________________ml

Catheter Gauge:____________ Endotracheal Tube Size: ___________ Associate: ____________

0 kg = ________ml
0 to 0
0.012 to 0.021 ml/kg x ______
0
0
0.01 mg/kg x ________kg
0.2 mg/ml = ________ml
0
0
0
to
0
0.02 to 0.04 mg/kg x ________kg ______ mg/ml = ________ml

Epinephrine (1 mg/ml) (CPR dose)

______________________________ (_____mg/ml)

Total Volume Administered

0
0
5 ml/kg/hr x ________kg=
________ml/hr
0
0
2.5 ml/kg/hr x ________kg= ________ml/hr
0
0
to
0
2.5 to 5 ml/kg/hr x ________kg= ________ml/hr

Atipamazole (5 mg/ml) (Dexmedetomidine reversal; feline dose)

Dobutamine

___________ ml

after 1st hour under anesthesia

Emergency Medications

Atropine (_____ mg/ml)

___________ ml

(give to effect)

Block Type

0
0 to 0 ml
1 to 2 mg/kg x ________kg
5 mg/ml = ________
0
0 to 0 ml
1 to 2 mg/kg x ________kg 20 mg/ml = ________

Glycopyrrolate (0.2mg/ml)

(give to effect)

Associate

IV
IV
IV
SC or IM or IV

Time Given

Drug, Strength, Dose, Duration

NSAID: _____________________________________________

PO SC IM IV

NSAID TGH:_________________________________________________________________

Opioid: _____________________________________________

PO SC IM IV

Opioid TGH:_________________________________________________________________

PO SC IM IV

Antibiotic TGH:_______________________________________________________________

Antibiotic: __________________________________________

Recovery
5/25/2011

Time Surgery Ended: ___________

Time Extubated: ___________

Time Sternal: ____________

Pain Assessment (0-4):___________

Temperature: __________________

Heart Rate/Pulse: __________

Pulse Quality: ______

Respiratory Rate: _______________

Pets Name: ___________________________

Induction ____:____ 5 min _____:_____ 10 min _____:_____ 15 min ____:_____ 20 min _____:_____ 25 min _____:_____ 30 min ____:_____ 35 min _____:_____ 40 min _____:_____ 45 min ____:____

Sevo %
O2 Flow (L/min)
Fluid Rate (mL/hr)
Heart/Pulse Rate
SpO2
RR
CRT/MM

Pulse Quality
ECG Rhythm
ETCO2
BP (Sys/Dia/MAP)

Temperature
Anesthetic Depth
(Appropriate/Light/Deep)

50 min ____:_____ 55 min ____:______ 60 min ____:_____ 65 min _____:_____ 70 min ____:______ 75 min ____:_____ 80 min ____:______ 85 min _____:_____ 90 min ____:_____ 95 min ____:____

Sevo %
O2 Flow (L/min)
Fluid Rate (mL/hr)
Heart/Pulse Rate
SpO2
RR
CRT/MM

Pulse Quality
ECG Rhythm
ETCO2
BP (Sys/Dia/MAP)
Temperature
Anesthetic Depth
(Appropriate/Light/Deep)

5/25/2011