Anaesthesia Associate Patient Specific Directive

Allergies and Adverse Drug Reactions – List the or First Name: Surname: (Block Letters) substances & the nature of the reaction (write NKDA if none) It is mandatory to complete this section Hosp No. DOB: / Substance Reaction NHS No.

Consultant: Ward: Hosp: Sign (NAME) Date: (use addressograph if available)

Operation: ……………………………….……………. Date: ASA Scheduled Urgent Proposed: ……………………………………………. 1 2 3 4 5 E Performed: Elective Emergency ………………………………….…………. : Surgeon(s): Grade(s): Wt:

Consultant: BMI:

CVS: HR: BP: RS: Intubation Hazards: : Teeth: Mouth Opening: Smoker: Neck: Other: ECG: CXR: Past AnaestheticPROOF History: Past Medical / Clinical Details:

Starvation time: GOR Alcohol: Usual Medication: Additional Information / Other Investigations:

HB: PT: Na: Urea: Glucose: Sickle: Blood available: Platelets: APTT: K: Creat: Procedures discussed: Risks / Benefits discussed:

Regional: ......

Suppository: Fibreoptic:

Invasive  : NG tube: Dental damage

Approved by Medicines Safety Group (MSG) Reviewed and Re-registered Review Date Pharm Ref No. MID Ref No. LTH2023 November 2016 January 2020 January 2023 16/011 20191209_004 1 AIRWAY Induction Time: Mask Times Start of Surgery: Airway Finish: LMA Anaesthetic Equipment Checked: Throat pack Name of Anaesthetist: Easy Signature: Manageable Date: INTUBATION Nasal VASCULAR ACCESS ANAESTHETIC PROCEDURE Oral IV 1 Size IV 2 Other Blade Arterial RSI CVP Bougie Grade Cuff BREATHING SYSTEM Bain REGIONAL ANAESTHESIA Circle BLOCK: Tick  Technique T Piece Spinal Other (specify) Epidural RESPIRATION Caudal Spontaneous Brachial IPPV Other (specify) Ventilator PCV / PROOFVCV / VCAF f ANAES ANAES V MONITORING THEATRE MONITORING THEATRE T ROOM ROOM

Paw Sa02 Temp (state insertion) PEEP NIBP / IBP MISC ECG CVP Line

Eye Protection ET CO2 Nerve Stim

NG Tube Insp O2 Volatile Agent Blood Warmer Stethoscope Other (specify) Warming Blanket Alarms set Pressure Areas Padded HME Filter Position VTE

Comments: AA or medical supervisor to insert comments

2

: ...... ADDRESSOGRAPH  Anaesthesia Associate Signature All cannula flushed with sodium chloride 0.9% YES PROOF Postoperative Instructions O2: Fluids: Analgesia: Throat Pack removed: Other: 2 2 2 CO FiO T SpO Agent E T E 50 250 200 150 100 Temp ° C Temp

3 I acknowledge that I have prescribed the medicines identified for this patient in this care plan (by initialling the appropriate entries). I authorise the named Anaesthesia Associate on front page to administer these agreed medicines in line within the dose ranges set out below. I will be immediately available for the duration of the case.

Time: ...... Signed: ...... GMC number: ......

Please tick MEDICINE ROUTE CONCENTRATION DOSE RANGE medicines required MEDICAL GASES / INHALED AGENTS OXYGEN INH 30% to 100%

NITROUS OXIDE INH 0% to 70%

SEVOFLURANE INH 0% to 8%

ISOFLURANE INH 0% to 4 %

DESFLURANE INH 0% to 10% EMERGENCY MEDICINES ATROPINE IV 600 microgram / mL Dilute to 2 mL (sodium chloride 0.9%) 300 microgram bolus up to 1.2 mg

GLYCOPYRRONIUM IV 600 microgram / 3 mL 200 microgram bolus up to 600 micrograms

EPHEDRINE IV 30 mg / mL Dilute to 10 mL (sodium chloride 0.9%) 0 - 9 mg bolus up to 60 mg METARAMINOL IV 10mg / mL Dilute to 20 mL (sodium chloride 0.9%) 0.5 - 1 mg bolus up to 10 mg (unlicensed) ADRENALINE IV 1mg / mL (1 / 1000) 1 mg bolus (cardiac arrest) ANAESTHETIC MEDICINES PROPOFOL 1% IV 10 mg / 1 mL Up to 400 mg in dose range. 1 to 5 mg / kg

FENTANYL IV 100 micrograms / 2 mL Up to 200 micrograms

MORPHINE IV 10mg / mL Dilute to 10 mL (sodium chloride 0.9%) 1mg / mL up to 20 mg

ALFENTANIL IV 1 mg / 2 mL Up to 3 mg

MIDAZOLAM IV 5 mg / 5 mL Up to 5 mg

ATRACURIUM IV 50 mg / 5 mL Up to 100 mg

ROCURONIUM IV 50 mg / 5 mL Up to 100 mg SUXAMETHONIUMPROOFIV 100 mg / 2 mL Up to 200 mg (Single dose only) CYCLIZINE IV / IM 50 mg / mL Up to 50 mg

DEXAMETHASONE IV 3.3 mg / mL 50 - 200 micrograms / kg

ONDANSETRON IV 4 mg / 2 mL 50 - 200 micrograms / kg

PARACETAMOL IV 10 mg / mL 1 gram in patients over 50 kg NEOSTIGMINE / IV 2.5 mg / 0.5 mg / mL Dilute to 5 mL sodium chloride 0.9% 1 mL maximum for each 10 kg of patient GLYCOPYRROLATE

LOCAL ANAESTHETIC MEDICINES LIDOCAINE SC 200 mg maximum (3 mg / kg)

FLUID VOLUME SIGNATURE HARTMANNS SOLUTION Up to 4000 mL

SODIUM CHLORIDE 0.9% Up to 1000 mL

GLUCOSE 5% Up to 1000 mL RECORD ALL FLUIDS ADMINISTERED IN THEATRE BELOW Fluid Volume Fluid Volume mL mL 4