**ACORP Appendix 5 **

**[Surgery]{.smallcaps}**

**[Version 3]{.smallcaps}**

1\. **Major survival surgery.** The *Guide* defines a major survival
surgery as a surgery in which a major body cavity is penetrated and
exposed or surgery in which substantial impairment of physical or
physiological functions is produced. Examples of such surgeries provided
in the *Guide* include laparotomy, thoracotomy, craniotomy, joint
replacement, and limb amputation.

a\. Will more than one major survival surgery be performed on any animal
as part of the proposed experimental plan?

No. Proceed to item 2.

Yes. Complete item 1.b. and 1.c. below.

b\. Provide a [complete scientific justification]{.underline} for
performing more than one major survival[ surgery on individual
animals]{#Text1}:

c\. [Give the interval(s)]{.underline} between the multiple surgeries,
[and the rationale]{.underline} for choosing the interval(s) here, then
proceed to item 2:

2\. **Description of Procedure(s).** Describe the surgical procedure(s)
in enough detail so that the IACUC reviewers can determine what
procedure(s) are actually being performed. If several different
surgeries are being performed, be sure to describe each one. When
finished, proceed to item 3:

3\. Provide the names of the personnel who will perform the surgery;
then proceed to item 4. Note that the surgical experience of each person
involved in surgery should be listed in item E of the ACORP:

4\. Provide the names of the personnel who will perform the anesthetic
induction and monitor the animal during surgery here, then proceed to
item 5:

5\. Provide the building and room number(s) where the surgical
procedure(s) will be performed. A dedicated surgical facility must be
used for major survival surgeries on non-rodent species (the definition
of a major survival surgery is provided in item 1 above). If allowed by
local policy, non-survival surgery on non-rodent species and survival
surgery on rodent species may be performed in a procedure room or
laboratory. Then proceed to item 6:

6\. **Pre-operative procedures.** Pre-operative procedures should
include all preparations of the animal(s) for surgery. Check and
describe which of the following procedures will be performed. Then
proceed to item 7.

Fasting (rarely used in rodents or rabbits). [[ Indicate]{#Check3}[ the
length of the fasting period]{#Check3}]{.underline}[:]{#Check3}

Withhold water. [[Indicate the length of time that water will be
withheld]{#Check3}]{.underline}[:]{#Check3}

Catheter placement. [[Indicate the site(s)]{#Check3}]{.underline}[ in
which venous catheter(s) will be]{#Check3}[ placed for vascular access
during surgery: ]{#Check3}

Other. [[Describe]{#Check3}]{.underline}[ other pre-operative
procedures:]{#Check3}

7\. **Pre-operative medications. ** Complete the following table.
Include any antibiotics, sedatives, or tranquilizers, and the anesthetic
agent(s) that will be used to induce anesthesia prior to surgical site
preparation; then proceed to item 8.

+-------+----------------------------+----------+------------------+-------------+
| Agent | Dose (mg/kg) & volume (ml) | ## Route | Frequency        | Duration    |
|       |                            |          |                  |             |
|       |                            |          | (e.g. times/day) | (e.g. days) |
+-------+----------------------------+----------+------------------+-------------+
|       |                            |          |                  |             |
+-------+----------------------------+----------+------------------+-------------+
|       |                            |          |                  |             |
+-------+----------------------------+----------+------------------+-------------+
|       |                            |          |                  |             |
+-------+----------------------------+----------+------------------+-------------+
|       |                            |          |                  |             |
+-------+----------------------------+----------+------------------+-------------+
|       |                            |          |                  |             |
+-------+----------------------------+----------+------------------+-------------+
|       |                            |          |                  |             |
+-------+----------------------------+----------+------------------+-------------+

8\. **Preparation of the surgical site.** [Detail]{.underline} how the
surgical site(s) will be prepared prior to surgery. Include details of
hair-clipping, skin disinfection, and the use of surgical drapes. Then
proceed to item 9:

9\. **Intraoperative medications.** Complete the following table
including any anesthetic agents, paralyzing agents, fluids, or other
pharmaceuticals that will be administered to the animal during surgery.
Also include experimental pharmaceuticals. Then proceed to item 10.

  ------- ---------------------------- ------- -----------
  Agent   Dose (mg/kg) & volume (ml)   Route   Frequency
                                               
                                               
                                               
                                               
                                               
                                               
  ------- ---------------------------- ------- -----------

10\. **Paralyzing agents.** Are any of the above medications considered
paralyzing agents?

No. Proceed to item 11.

Yes. **[Very Important!! ]{#Check24}**[Federal regulations prohibit the
use of paralytics (neuromuscular blocking agents) for surgery
]{#Check24}[[unless other appropriate anesthetic agents are used to
induce a ]{#Check24}[surgical plane of
anesthesia]{#Check24}]{.underline}[. Paralytics do not provide any pain
relief; therefore, animals are unable to respond physically to pain
because motor reflexes are paralyzed.
]{#Check24}[[Justify]{#Check24}]{.underline}[ the use of these agents
and indicate how the animals will be monitored to e]{#Check24}[nsure
that the depth of anesthesia is sufficient to prevent pain. Then proceed
to item 11:]{#Check24}

11\. **Physical support.** Decribe any physical methods used to support
patients during surgery (e.g. heating pads, blankets, etc.); then
proceed to item 12:

12\. **Intra-operative monitoring.** Describe methods used to monitor
the state of anesthesia and general well-being of the animal during
surgery. Then proceed to item 13:

13\. Will the animals regain consciousness following surgery?

No. You have completed this appendix. ***[No further information is
required in this appendix. Return to item T on the ACORP itself.
]{#Check8}***

Yes. Proceed to item 14.

14\. **Survival surgery considerations and post-operative care.**
Complete items 14.a-f. below. Then proceed to item 15.

a\. How long will the animal(s) survive after surgery? (If multiple
surgeries are planned, answer for the last surgery before euthanasia):

b\. Is the room where the procedures will be performed (listed in item 5
above) suitable for sterile/aseptic surgery?

c\. Indicate which of the following procedures will be used to maintain
a sterile field during surgery:

Sterile instruments.

Surgeon cap.

Sterile gloves.

Surgeon scrub.

Sterile drapes.

Sterile gown.

Face mask.

Other. [[ Describe]{#Check10}]{.underline}[:]{#Check10}

d\. List any methods used to support the patients in the immediate
post-operative period (e.g., heating pads, blankets, fluids, etc.):

e\. Unless scientifically or otherwise justified to the IACUC's
satisfaction, you are obligated to routinely provide post-operative pain
relief for all vertebrate animals undergoing survival surgery. Do you
plan to use analgesics to provide postoperative pain relief to the
animals following surgery?

No. [[Prov]{#Check18}[ide a justification for not using postoperative
analgesics ]{#Check18}]{.underline}[here:]{#Check18}

Yes. Complete the following table listing post-operative analgesics
agent(s) that will be used after surgery to control pain:

+-------+----------------------------+-------+------------------+-------------+
| Agent | Dose (mg/kg) & Volume (ml) | Route | Frequency        | Duration    |
|       |                            |       |                  |             |
|       |                            |       | (e.g. times/day) | (e.g. days) |
+-------+----------------------------+-------+------------------+-------------+
|       |                            |       |                  |             |
+-------+----------------------------+-------+------------------+-------------+
|       |                            |       |                  |             |
+-------+----------------------------+-------+------------------+-------------+
|       |                            |       |                  |             |
+-------+----------------------------+-------+------------------+-------------+
|       |                            |       |                  |             |
+-------+----------------------------+-------+------------------+-------------+
|       |                            |       |                  |             |
+-------+----------------------------+-------+------------------+-------------+
|       |                            |       |                  |             |
+-------+----------------------------+-------+------------------+-------------+

f\. Complete the following table for other medications (such as fluids,
antibiotics, anti-coagulants, and other pharmacological agents) that
will be administered post-operatively.

+-------+----------------------------+-------+------------------+-------------+
| Agent | Dose (mg/kg) & Volume (ml) | Route | Frequency        | Duration    |
|       |                            |       |                  |             |
|       |                            |       | (e.g. times/day) | (e.g. days) |
+-------+----------------------------+-------+------------------+-------------+
|       |                            |       |                  |             |
+-------+----------------------------+-------+------------------+-------------+
|       |                            |       |                  |             |
+-------+----------------------------+-------+------------------+-------------+
|       |                            |       |                  |             |
+-------+----------------------------+-------+------------------+-------------+
|       |                            |       |                  |             |
+-------+----------------------------+-------+------------------+-------------+
|       |                            |       |                  |             |
+-------+----------------------------+-------+------------------+-------------+
|       |                            |       |                  |             |
+-------+----------------------------+-------+------------------+-------------+

15.** Frequency and Responsibility for post-operative care.** Complete
items 15.a. -15.c. below, then proceed to item 16. [The names and
after-hours telephone (or other contact) numbers of the personnel listed
below must be provided to the VMU staff in case of an
emergency]{.underline}.

a.  Give the frequency of postoperative monitoring and how long the
    monitoring will continue:

b.  Who will be responsible for post-operative care until the animal can
    ambulate without danger to itself?[ ]{#Text77}

```{=html}
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```
a.  Who will be responsible for post-operative care thereafter
    (including after-hours, weekends, and holidays)?[ ]{#Text78}

16\. **Post-operative complications.** Complete items 16.a. - d. below;
then proceed to item 17.

a.  Describe any possible or expected post-operative complications and
    what will be do[ne if these complications arise: ]{#Text79}

b.  Provide criteria by which a decision to euthanatize a surgical
    patien[t post-operatively will be made: ]{#Text80}

c.  In case there is an emergency medical situation and you or your
    staff cannot be reached, identify drugs or classes of drugs that
    should not be use[d as part of the treatment plan: ]{#Text81}

d.  In the event that emergency euthanasia must be performed or an
    animal is unexpectedly found dead, how should the carcass be
    handled?[ ]{#Text82}

17\. **Responsibility for maintaining animal post-surgical medical
records. **Who will be responsible for maintaining accurate, daily,
post-surgical written medical records?

My research staff or I will be responsible. Proceed to item 18 below.

The veterinary staff will be responsible. Proceed to item 18 below.

Local policy does not mandate that postoperative medical records be
maintained for the species covered by this ACORP. ***[You have completed
this Appendix. ]{#Check20}**[[Do not answer item 18 or sign under item
18.]{#Check20}]{.underline}**[ Instead, go to item T on the
ACORP]{#Check20}*[. ]{#Check20}**

Other. [[Please explain]{#Check20}]{.underline}[, then proceed to item
18 below:]{#Check20}

18\. **Certifications. **Complete the following; then return to item T
on the ACORP and continue.

By my signature, I certify that

+----------------------------------------------+--------------+------+
| -   Each patient under observation or        | Signature(s) | Date |
|     treatment will be identified such that   |              |      |
|     care for individual animals can be       |              |      |
|     documented.                              |              |      |
|                                              |              |      |
| -   Daily postoperative medical records of   |              |      |
|     the patient will be maintained,          |              |      |
|     including an evaluation of overall       |              |      |
|     health, a description of any             |              |      |
|     complications noted, treatment provided, |              |      |
|     and the removal of sutures, staples,     |              |      |
|     wound clips, or other such devices.      |              |      |
|                                              |              |      |
| -   Records will document administration of  |              |      |
|     all medications and treatments given to  |              |      |
|     animals, including those given to reduce |              |      |
|     pain or stress.                          |              |      |
|                                              |              |      |
| -   As a minimum, daily records will cover   |              |      |
|     the postoperative period as defined by   |              |      |
|     local policy.                            |              |      |
|                                              |              |      |
| -   Each entry in the records will include a |              |      |
|     signature or the initials of the person  |              |      |
|     making the observation or treatment.     |              |      |
|                                              |              |      |
| -   All records will be readily available to |              |      |
|     the veterinary staff or the IACUC for    |              |      |
|     review.                                  |              |      |
|                                              |              |      |
| -   The names and contact numbers of persons |              |      |
|     to notify or consult in case of          |              |      |
|     emergencies will be provided to the      |              |      |
|     facility manager and veterinarian.       |              |      |
|                                              |              |      |
| Name of Principal Investigator(s)            |              |      |
+----------------------------------------------+--------------+------+
|                                              |              |      |
+----------------------------------------------+--------------+------+
|                                              |              |      |
+----------------------------------------------+--------------+------+
|                                              |              |      |
+----------------------------------------------+--------------+------+
|                                              |              |      |
+----------------------------------------------+--------------+------+
|                                              |              |      |
+----------------------------------------------+--------------+------+
|                                              |              |      |
+----------------------------------------------+--------------+------+