Cardiovascular system

Nervous system

Respiratory system

Digestive system

Others

All of following items have to be met:

One has to be excluded if any of following items is met:

Gender

Age

岁

Weight

kg

Height

cm

ASA Grade

History of anesthesia

Education background

Combined diseases and drug use and organ complications

Systolic pressure (SP)

mmHg

Diastolic pressure

mmHg

Temperature

degree Celsius

Pulse

次/分

Breath

次/分

Doctor signature

Date

yyyy-mm-dd

Consciousness

Mental state

Speak capacity

Meningeal irritation sign

Pupil

Left eye

Diameter

mm

Shape

Direct light reflect

Indirect ligh reflect

Response for Adjustment

Righ eye pupil

Diameter

Shape

Direct reflect for light

Indirect reflect for light

Response for adjustment

Volume of input

ml

Volume of output

ml

Volume of urine

ml

AIS

TCDB

GCS

ISS

Hb

g/L

RBC

X10^9/L

%

WBC

X10*3/L

PLT

X10*9/L

Date of test

K

mmol/L

Na

mmol/L

Cl

mmol/L

Ca

mmol/L

Glu

mmol/L

Date of test

yyyy-mm-dd

Prothrombin time

秒

Thrombin time (TT)

秒

Activated partial thromboplastin time (APTT)

秒

Fibrinogen (FIB)

g/L

Date of examination

yyyy-mm-dd

ALT

IU/L

AST

IU/L

Serum bilirubin

μmol/L

Direct bilirubin

umol/L

Serum albumin

g/L

Serum globulin

g/L

Serum total protein

g/L

A/G

Date of test

yyyy-mm-dd

pH value

PaO2

mmHg (Kpa)

PaCO2

mmHg (Kpa)

Actual bicarbonate, AB

mmol/L(22～27 mmol∕L)

Standard bicarbonate, SB

mmol/L(22～27 mmol∕L)

BB

mmol/L(45～55mmol/L)

CO2CP

mmol/L(22～31 mmol/L)

BE

mmol/L(±2.3mmol/L)

Oxygenation index (PaO2/FiO2)

mmHg

Blood lactic acid concentration, LAC

mmol/L

Procalcitonin, PCT

ng/ml

Date of test

Creatinine

umol/L

Urea nitrogen

Date of examination

yyyy-mm-dd

ECG

Description for the abnormal findings

Date of examination

yyyy-mm-dd

Was there hemorrhage?

If yes, please select

Location of hemorrhage

Volume of hematoma

ml

Whether there is ischemic infarct

If yes, please select

Location of infarction

The infarction located at

Maximum diameter of infarction layer

cm x cm

Chest X-ray examination

Description of the abnormal findings

Date of examination

yyyy-mm-dd

Bleeding assessment

分

Acetate Ringer's solution

ml

Normal saline

ml

5% glucose solution

ml

5% glucose saline

ml

Other

ml

HAES-steril

ml

Succinylated Gelatin Injectim

ml

Other

ml

Red cell

U

Plasma

ml

PLT

U

Cold precipitation

U

Albumin

g

Used Cell Saver or not?

Autologous blood volume after return and washing

ml

Name of the operation

Time of the operation start

yyyy-mm-dd-hh-min.

Time of finishing the operation

yyyy-mm-dd-hh-min.

Urine vulume

ml

Time of starting the anaesthesia

yyyy-mm-dd-hh-min.

Wake time

yyyy-mm-dd-hh-min.

Extubation time

yyyy-mm-dd-hh-min.

Nasogastric tube

ventricle drainage tube

Position of Peritoneal drainage tube

Number of Peritoneal drainage tube

根

Mean Artery Pressure, MAP

mmHg

Heart Rate, HR

bit/min

Oxygen saturation, SpO2

%

EEG double spectrum index, BIS

EEG double spectrum index, BIS

Temperature, T

摄氏度

Phenylephrine

次数

Dose of Phenylephrine

mg

Number of using Atropine

次

Dose of Atropine

mg

Number of using Nitroglycerin / nicardipine

次

Dose of Nitroglycerin / nicardipine

mg

Number of using Esmolol

次

Dose of Esmolol

mg

Doctor signature

Date of signature

yyyy-mm-dd

Total minutes of anaesthesia

Minutes

Total minutes of operation

Date

年/月/日(yyyy-mm-dd)

Estimated blood loss at moment

ml

%

Dosage of adrenaline

μg/kg.min

The colloidal liquid has been input

ml

Inputted crystal liquid

ml

Autologous blood volume has been input

ml

Input of allogeneic red blood cells

U

Urine vulume from begining of the surgery

ml

Usage of cell saver

If yes, whether the blood is all returned after the washing

Time of RBC

min

time of PLT

min

Time of FFP

时、分（Hour/minutes)

Date of confirmation

年/月/日(yyyy-mm-dd)

Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Other (Description)

Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Ischemic stroke

Date of confirmation

年/月/日(yyyy-mm-dd)

Date of confirmation

年/月/日(yyyy-mm-dd)

Date of confirmation

年/月/日(yyyy-mm-dd)

Other (Description)

Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

年/月/日(yyyy-mm-dd)

Other (Description)

Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

年/月/日(yyyy-mm-dd)

Death

Date of death

年/月/日(yyyy-mm-dd)

Reason of death

Relationship between death and surgery

Correlation of death and blood transfusion

Date of confirmation

年/月/日(yyyy-mm-dd)

Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

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Date of confirmation

年/月/日(yyyy-mm-dd)

Date of confirmation

年/月/日(yyyy-mm-dd)