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Date of Admission to hospital: Date of Admission to ICU/HDU: Name & nature of the operation ( Emergency/ Elective) Background comorbidities:
Exercise tolerance (If limited, also symptom which limits the exercise tolerance) Relevant preoperative investigations: ( TTE/Stress test/ Pulmonary function test/ Baseline Renal function tests if impaired)
ALLERGIES
Peroperative Course:
General Anaesthesia/ Spinal Anaesthesia/ Regional Anaesthesia Induction: Cormack and Lehanes Grade Any other difficulty in intubation or ventilation including bag and mask ventilation? ETT size: Approximate blood loss: IV fluids administered: Colloids Crystalloids: NS(0.9%)/ CSL Blood Products received ( include those currently running): PRBCs FFPs Cryoprecipitates Platelets Lines in situ: Arterial Line Peripheral line ( Gauge and site) CVC Inotropes: Ongoing sedation with: Analgesia Plan: Surgical complications if any:
Post Op: Antibiotic plan Nutrition plan DVT prophylaxis plan Any specific surgical plan including return to theatre in next 48 hours