RSUP Dr.

Hasan Sadikin
Fakultas Kedokteran UNPAD
Bandung

ANESTHESIA CARD
Preoperative D/ : .....................................................
.....................................................................................
Surgical Procedure : ...................................................
.....................................................................................
Postoperative D/ : ....................................................
.....................................................................................
Surgeon
: ...........................................................
Ass Surgeon : ...........................................................

Name
Age
No RM
Date

: ...................................................................
: ......................................................... M / F
: ....................................................................
: ...................................................................

Room : .............................................Urgent / Elektive

Department : ...............................................................
Informed consent : ......................................................
.....................................................................................
Anesthesiologist
: .................................................
Ns Anesthesiologist : ..................................................

MEDICAL STATUS
BW : ............... kg
BH : ...................... cm
Blood type : .................
Consciousness : ..........................................................
GCS : E M V :
Airway : Intubated / Not Intubated
Blood Pressure : ................... mmHg
Pulse : ................. x/mnt, reg/ireg/adequate/inadequate
Support : 1) .............................. g/kgBB/mnt
2) .............................. g/kgBB/mnt
Respiratory : spontan/assisted/controlled, RR : ..........x/mnt, BC/SM/SMNR, O2 ............L/mnt, SpO2 : ......%
Laboratory : .........................................................................................................................................................
.....................
..............................................................................................................................................................................
..............................................................................................................................................................................
ECG
: ..........................................................................................................................................
Rontgent
: ...........................................................................................................................................
LFT
: ..........................................................................................................................................
Others Examination : .......................................................................................................................................
.............................................................................................................................................
Co-Existing Diseasea
Nervous System
: .....................................................................................................................................
Respiratory System
: .....................................................................................................................................
Cardiovascular System : .....................................................................................................................................
Gastrointestinal System : ....................................................................................................................................
Urinary tract System : .....................................................................................................................................
Musculoskeletal System : ....................................................................................................................................
Metabolic System
: .....................................................................................................................................
Coexist condition
: .....................................................................................................................................
Medical taken within the last week (drug &
dose) : ...................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
...........
Physical Status ASA : I / II / III/ IV / V / E
Premedication : Oral / IM / IV / Rectal
Time Of Delivery
: ..................
Drug : ................. dose : ...................
Result : Satissfied/ circulatory depressed / resp depress / psych depress / tachicardy /
Anesthetic Technique : General / regional / combined / ................................

ANESTESI UMUM
Induction
: perfect / agitated / vomit / cough / spasms / ..........................................................
Technique
: semi open / semi closed / closed / .....
Respiratory Controlled : spontan / assisted / controlled
Mech Ventilator setting: Tidal volume : mL
RR : x/mnt
I : E ratio :
PEEP : ............
PIP : ...........
FiO2 : ........... %
Special Technique
: hypotermia / hipotension / bypass / ...........................................................................
MONITORING
Medikasi
1.
3.
5.
7.
9.
11.
13.
Pemberian Cairan
1.
4.
7.
10.
13.

2.
4.
6.
8.
10.
12.
14.
2.
5.
8.
11.
14.

3.
6.
9.
12.
15.

REGIONAL BLOCKADE
Technique : caudal / Saddles block / intravenous regional / epidural / peripheral nerve blockade / spinal /
topikal /..........
Site of puncture : ..................................... Level of sens block : .......................................................
Drug : .............................................. Consentration : ...................... % dose : .......................... mL
Another drug : ............................................ dose : ................................................
Vasokonstriktor : adrenalin / noradrenalin / none
Consentration : ..........................................................
Time of
: Puncture : ........................
Analgesia : ...................... lamanya : ...................... jam .................... menit
Surgery : ...................... lamanya : ..................... jam .................... menit
Adjuvant to Anesthesia: ..............................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
Patient Condition during Operation
Patient position : supine / prone / lithotomi / semi sitting / Fowler / lateral decubitus (R / L)/ trendelenburg /
knee chest / jack knife / .............................................
Airway : face mask / LMA / single lumen ETT / single lumen spiral ETT / double lumen ETT (R / L)
Size : ............... ETT : Depth from gum : ............................
Time of Anesthesia : 1 jam / 1 2 hr / 2 4 hr / 4 6 hr / > 6 hr
Fluid
Total Fluid input

: 1. Kristaloid
: ....... mL
2. Koloid
: .... mL
3. Blood
: ........................................ mL
4. Blood component : ....................................... mL
Total Fluid Output :
1. Blood
: ........................................ mL
2. Urine
: ........................................ mL
Baby Condition : Live / Death
Sex : M / F
Apgar score : 1 minute : ..........

5 minute : ..........

10 minute : ...........

Post Operative Condition

Recovery Room / ICU / NICU / PICU/ NCCU / Resusitation Room
Conciousness : ..........................................................
GCS : E M V :
Blood Pressure : ................... mmHg
HR : ................. x/mnt, reg/ireg/adekuat/inadekuat
Support : 1) .............................. g/kgBB/mnt
2) .............................. g/kgBB/mnt
Respiration : spontan, RR : ..........x/mnt, BC / SM / SMNR, O2 ............L/mnt, SpO2 : ......%
controlled : Ventilator mode: ..........................
: Tidal volume : mL
RR : x/mnt
I : E ratio : .
PEEP : ............
PIP : ............
PS : ...........................
FiO2 : .............
Trigger : ................
SpO2 : ................... %
Special Precaution : ............................................................................................................................................
..............................................................................................................................................................................
Treatment : ...........................................................................................................................................................
..............................................................................................................................................................................

MONITORING
S

43

42

60

41
40

48

39
38

36

37
36

24

35
34
33

12

220

220

200

200

180

180

160

160

140

140

120

120

100

100

80

80

60

60

40

40

20

20

Modified Aldrete's Scoring System

Signs
Activity

Criteria

Move all extremities voluntarily or on command

Move two extremities
Unable to move extremities
Respiratory
Can breath deeply or coughs freely
Dyspneic, shallow, or limited breathing
Apneic
BP 20 % of preanesthetic level
Circulatory
BP 20 50 % of preanesthetic level
BP 50 % of preanesthetic level
Consciousness Fully awake
Arousable on calling
Not responding
O2 Saturation > 92 % on room air
Suplemental O2 req to maintain SpO2 > 90 %
SpO2 < 92 % with O2 Suplementation
Score 8 required for discharge

Score

30 60 90

120

Discharge
Time

2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
Total Score :

Instruction :
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Doctors
Nurse
OK
RR

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