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Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) Trial Intervention Form (Amputation) PATIENT NUMBER / / / 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. --------------------------------------------------------------------------------------------------------------------------------1 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 / / / 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: --------------------------------------------------------------------------------------------------------------------------------2 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): --------------------------------------------------------------------------------------------------------------------------------3 Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) Trial Intervention Form (Amputation) PATIENT NUMBER SECTION 3: / / / 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 --------------------------------------------------------------------------------------------------------------------------------4 Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) Trial Intervention Form (Amputation) PATIENT NUMBER SECTION 3: / / / 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: --------------------------------------------------------------------------------------------------------------------------------5