Download Intervention amputation

Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) Trial
Intervention Form (Amputation)
PATIENT NUMBER
/
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Intervention Form (Amputation)
(Please complete text in BLOCK CAPITALS, tick the appropriate box or enter numbers into
the boxes provided.)
Date of Amputation:
/
/
(dd/mm/yy)
Date of Previous Intervention:
/
/
(dd/mm/yy)
Recruiting Consultant: _____________________________________________________________
Patient’s Date of Birth:
Trial Leg:
/
LEFT
Time of Last Follow-up:
/
(dd/mm/yy)
RIGHT
Gender:
MALE
FEMALE
None
1/12
3/12
6/12
Date of Readmission:
SECTION 1:
/
/
(dd/mm/yy)
Amputation details
(to be completed by the Consultant Surgeon please)
Time of arrival in anaesthetic room:
:
(hh:mm)
Time of start of anaesthetic procedures:
:
(hh:mm)
Time of start of operation:
:
(hh:mm)
Type of anaesthetic:
GENERAL
REGIONAL
Leg amputated:
LEFT
Level of amputation:
DIGITS
FOREFOOT
TRANS-TIBIAL
TRANS-FEMORAL
RIGHT
Time of departure from theatre:
:
(hh:mm)
Time of departure from recovery room:
:
(hh:mm)
Amputation at the trans-tibial or trans-femoral level constitute a primary end-point of the trial and
further follow-up is no longer required.
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Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) Trial
Intervention Form (Amputation)
Patients undergoing amputation of the digits or forefoot remain as trial participants and continue
being followed-up.
PATIENT NUMBER
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/
/
Human Resources
(please enter numbers of each grade of staff present)
Surgeons:
Anaesthetist:
Consultant
Consultant
Registrar
Senior Registrar
Senior House Officer
Registrar
House Officer
Senior House Officer
Nursing Staff:
Grade A
Grade B
Grade C
Grade D
Grade E
Grade F
Grade G
Technicians:
ODA/ODP
Additional information:
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Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) Trial
Intervention Form (Amputation)
PATIENT NUMBER
SECTION 2:
/
/
/
Surgical Materials
(to be completed by theatre staff nurse; please enter the numbers of each item used during the
procedure)
Sutures:
Trays:
Prolene 3/0
Medium Basic Trays
Prolene 2/0
Amputation
Vicryl 1/0 ties
Diathermy Tongs
Vicryl 2/0 tie 9044
Diathermy Pad
Silk 2/0
Diathermy Lead
Other
Diathermy Tip
Swabs and Gowns:
Miscellaneous:
Gowns (disp) x 1
Redivac Drain
Gowns (disp) x 3
Discard-a-pad
Gowns (linen) x 1
Masks
Gowns (linen) x 3
Caps
Swabs x 5 (Taped)
Sterile Gloves
Swabs x 5 (10 x 10)
Dressing (please specify type): ______________________________
Additional Information / Equipment (excluding Scalpel Blades and other items of nominal cost):
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Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) Trial
Intervention Form (Amputation)
PATIENT NUMBER
SECTION 3:
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/
Medications in Theatre
(to be completed by the anaesthetist please)
Drug Name
Bupivacaine
Regional Block:
Dose / % per
No of amps
ampoule
used
0.25%/10ml
0.50%/10ml
0.75%/10ml
Other:
Drug Name
Propofol
Propofol pre-filled syringes
Thiopentone
Fentanyl
Alfentanyl
Morphine
Diamorphine
Vecuronium
Atracurium
Methoxamine
Ephedrine
Heparin
Ondasetron
Neostigmine
Glycopyrrolate
Atropine
Midazolam
Water
Saline
Other Drugs:
Temazepam (pre-med)
Cefuroxime
Other:
Anaesthetic Drugs:
Dose / % per ampoule
200 mg
500 mg
250 – 500 mg
100 g
1 mg
10 mg
10 mg
10 mg
50 mg
20 mg
30 mg
5000 units
4 mg
2.5 mg
600 g
0.6 mg
10 mg
10 ml
10 ml
No of amps used
10 mg
750 mg
Maintenance Anaesthetic:
Isoflurane
Sevoflurane
Propofol
Other:
O2
N2O
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Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) Trial
Intervention Form (Amputation)
PATIENT NUMBER
SECTION 3:
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/
Medications in Theatre (cont.)
Intravenous Fluids:
Type
Volume of
Units
Hartmanns Solution
Normal Saline
Gelofusine
Other:
500 ml
500 ml
500 ml
Number
Given
Type
PPS
Dextran 70
Blood
Volume of
Units
400 ml
500 ml
Equipment and Disposables Used by Anaesthetist:
Item
Number
Item
IV Giving Sets
IV Cannula: Venflon
Arterial Cannula:
Vygon Ledercath
Arrow
Vasocan
Quickcath
Arterial Pressure Kit
Tegaderm Dressing
Lectrocath
CVP Catheter Set
Regional Block Pack
Regional Block Needle
Stimuplex Needle
3-way Tap
Number
Given
Number
Endotracheal Tube
Guedel Airway
Post-op Oxygen Mask
Nasal Cannulae
Epidural Pack
Spinal Needle: 22G
Spinal Needle: 24G Sprottie
Laryngeal Mask Airway
“Bair Hugger” Warmine
Blanket
Syringes: 50 ml; 20 ml
Syringes: 10 ml; 5 ml; 2 ml
Needles
ECG Electrodes
Sterile Gloves
Other:
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