RM.11.

4/Check list/2014
MINISTRY OF HEALTH RI
GENERAL DIRECTORATE OF HEALTH SERVICES Name :
Date of Birth: M/F
H. ADAM MALIK GENERAL HOSPITAL MR No :
JL Bunga Lau No 17 Medan Tuntungan Km 12 Kotak Pos 246
Attach Label

ANESTHESIA PREPARATION CHECK LIST

Ward : Date: Time: Western Indonesian Time
Type of Surgery:
Procedure :

Anesthesia Technique:

Electricity
 The anesthesia machine is connected to a power source, the (+) indicator light is on
 The monitoring screen is connected to the power source, indicator (+).
 The syringe pump is connected to a power source, indicator (+).
 The defibrillator is connected to a power source, indicator (+).
Medical Gas
 The oxygen hose is connected between the gas source and the anesthetic machine.
 O2 Flow meter in the anesthetic machine functions, the flow of gas out of the engine can
be felt.
 Compressed air is connected between the gas source and the anesthetic machine.
 Flow meter "Water" in the anesthetic machine functions, the flow of gas out of the engine
can be felt.
 N2O is connected between the gas source and the anesthetic machine.
 Flow meter N2O in the anesthesia machine functions, the flow of gas out of the engine
can be felt.
Anesthetic Machine
 Power ON
 Self calibration: DONE
 No breathing circuit leakage
 Volatile substances filled
 CO2 absorber is in good condition
Airway Management
 Face mask in the correct size.
 Oropharyngeal airway (Guedel) is in the correct size.
 Laryngoscope handle contains a battery.
 Laryngoscope blade is in the correct size
 Laryngoscope handle and blade work well.
 ETT or LMA is in the correct size, does not leak.
 Stylet (introducer)
 Syringe to inflate cuff.
 Magill Forceps
 Jackson-Ress Circuit
Monitoring
 ECG cable is connected to the monitor screen.
 ECG electrodes are in appropriate quantities and sizes.
 NIBP is connected to the monitor screen, the size of the cuff is appropriate
 SpO2 is connected to the monitor screen, well-functioned
 Capnography is connected to the monitor screen, well-functioned
 Temperature monitor is connected to the monitor screen.
Others
 Stethoscope is available.
 Suction is well-functioned
 Suction hose is connected, the suction catheter is in the correct size.
 Bandage for fixation.
 Blanket roll / Hemotherm / radiant heater is connected to a power source, well-functioned
 Blanket roll is lined with a pad
 Lidocaine spray/ jelly.
 Defibrillator jelly.
Drugs
 Epinephrine
 Atropine Sulfate
 Sedatives (Midazolam/ Propofol/ Etomidate/ Ketamine/ Thiopental)
 Opioid
 Muscle relaxant
 Antibiotics
 Ephedrine
 Dexamethasone
 Lidocaine 2%
 Sodium bicarbonate
 Tranexamic Acid
 Others: ………………………………………..
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………………………………………..
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Staff /Anesthesia team

 Anesthesiologist
 Anesthesiology resident
 Anesthesia nurse

Examiner
Anesthesia nurse: ................................................. Signature

Anesthesiologist: .................................................. Signature