1

2

4

8

Age (yrs)

<60

61-70

>71

 

Cardiac signs

No failure

Diuretic, digoxin, antianginal or antiHT

Peripheral oedema; warfarin

Raised JVP

Chest X-ray

 

 

Borderline cardiomegaly

Cardiomegaly

Respiratory history

No dyspnoea

Dyspnoea on exertion

Limiting dyspnoea (one flight)

Dyspnoea at rest (rate>30/min)

Chest X-ray

 

Mild COAD

Moderate COAD

Fibrosis or Consolidation

Blood pressure (systolic) mm Hg

110-130

131-170

100-109

>171

90-99

-

<89

Pulse (beats/min)

50-80

81-100

40-49

101-120

>121

<39

GCS

15

12-14

9-11

<8

Haemoglobin (g/dl)

13-16

11.5-12.9

16.1-17

10-11.4

17.1-18

<9.9

>18.1

White cell count (x 1012/l)

4-10

10.1-20

3.1-4

>20.1

<3.0

 

Urea (mmol/l)

<7.5

7.6-10

10.1-15

>15.1

Sodium (mmol/l)

>136

131-135

126-130

<125

Potassium (mmol/l)

3.5-5.0

3.2-3.4

5.1-5.3

2.9-3.1

5.4-5.9

<2.8

>6.0

ECG

Normal

 

AF (60-90)

Any other abnormal rhythm or >5 ectopics/min. Q waves or ST/T wave changes.

PHYSIOLOGICAL SCORE (CIRCLE APPROPRIATE VALUE)

 

 

Physiological score (TOTAL):    [         ]

 

OPERATIVE SEVERITY SCORE (CIRCLE APPROPRIATE VALUE)

[Definitions of surgical procedures with regard to severity are guidelines: not all procedures are listed and the closest should be selected].

 

 

 

 

 

 

1

2

4

8

Operative severity*

Minor

Moderate

Major

Major+

Multiple procedures

1

 

2

>2

Total blood loss (ml)

<100

101-500

501-999

>1000

Peritoneal soiling

None

Minor (serous fluid)

Local pus

Free bowel content, pus or blood

Presence of malignancy

None

Primary only

Nodal metastases

Distant metastases

Mode of surgery

Elective

 

Emergency resuscitation of >2 hours possible **. Operation <24 hrs after admission.

Emergency (immediate surgery; <2 hrs needed).

*Surgery of moderate severity includes appendicectomy, cholecystectomy, mastectomy, TURP; Major surgery includes laparotomy, bowel resection, cholecystectomy with choledochotomy, peripheral vascular procedure or major amputation; Major+ includes any aortic procedure, abdominoperineal resection, pancreatic or liver resection, oesophagogastrectomy;

**Indicates that resuscitation is possible even if this period is not actually utilised.

 

Operative Severity Score (TOTAL):     [            ]

 

 

 

 

 

 

 
 

COMPLICATIONS RECORD SHEET (on discharge)

Give dates for all complications; for infection give bacteria cultured if known. Definitions of complications is given in the next sheet.

 

Haemorrhage

       Wound

        Deep

        Other

 

Yes/No

Yes/No

Yes/No

Infection

        Chest

        Wound

        Urinary tract   

        Deep

        Septicaemia

        Pyrexia of unknown origin

        Other

 

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Wound Dehiscence

        Superficial

        Deep

 

Yes/No

Yes/No

Anastomotic leak

Yes/No

Thrombosis

        Deep vein thrombosis

        Pulmonary embolism

        Other

             Cerebrovascular accident

             Myocardial infarct

 

Yes/No

Yes/No

 

Yes/No

Yes/No

Cardiac failure

Yes/No

Impaired renal function (urea rise >5 mmol/l from preop levels

Yes/No

Hypotension (<90 mm Hg for 2 hours)

Yes/No

Respiratory failure

Yes/No

 

Any other complications:

 

In the event of death give date of death:

 

Post-mortem findings:

 

 

 

 

 

 

 

  

 

DEFINITION OF COMPLICATIONS

 

Wound haemorrhage: Local haematoma requiring evacuation.

Deep haemorrhage: Postoperative bleeding requiring re-exploration.

Chest Infection: Production of purulent sputum with +ve bacteriological cultures, with or without chest radiographic changes or pyrexia, or consolidation seen on chest radiograph.

Wound infection: Wound cellulitis or discharge of purulent exudates.

Urinary infection: The presence of >105 bacteria/ml with the presence of white cells in the urine, in previously clear urine.

Deep infection: The presence of an intra-abdominal collection confirmed clinically or radiologically.

Septicaemia: Positive blood culture.

Pyrexia of unknown origin: Any temperature above 370C for more than 24 hrs occurring after the original pyrexia following surgery (if present) had settled, for which no obvious cause could be found.

Wound dehiscence: Superficial or deep wound breakdown.

Deep venous thrombosis and pulmonary embolus: When suspected; confirmed radiologically by venography or ventilation/perfusion scanning, or diagnosed at post-mortem.

Cardiac failure: Symptoms or signs of left ventricular or congestive cardiac failure which required an alteration from preoperative therapeutic measures.

Impaired renal function: Arbitrarily defined as an increase in blood urea of >5 mmol/l from preoperative levels.

Hypotension: A fall in systolic blood pressure below 90 mm Hg for more than 2 hours as determined by sphygmomanometry or arterial pressure transducer measurement.

Respiratory failure: Respiratory difficulty requiring emergency ventilation.

Anastomotic leak: Discharge of bowel content via the drain, wound or abnormal orifice.