Patient information | Level of agreement |
Patient name | Strong |
Patient date of birth | Strong |
Patient gender | Strong |
Patient medical record number/hospital number | Strong |
Patient weight | Strong |
Patient height | Strong |
Patient American Society of Anesthesiologists (ASA) physical status classification | Strong |
Patient allergies | Strong |
Procedure preparation | |
Block performed by _________ (name) | Strong |
Grade of block performer (e.g. consultant, fellow, resident, registrar) | Weak |
Name of supervisor (if applicable) | Strong |
Documentation of patient consent gained (as per local standards e.g. written, verbal) | Strong |
Documentation of individual risks of procedure discussed (as per local standards) | Strong |
Pre-anesthetic / block evaluation | Strong |
Coagulation considered | Weak |
Pre-procedure diagnosis (post-operative pain management / surgical diagnosis) | Strong |
Timeout / World Health Organisation (WHO) checklist | Weak |
Stop moment performed | Strong |
Intravenous access | Strong |
Regional anesthesia procedure name | Strong |
Patient position during regional anesthesia procedure | Strong |
Monitors applied | Strong |
Baseline vital signs | Strong |
Pre-medication (type and quantity of sedation) | Strong |
Level of sedation (no sedation / light sedation / deep sedation / general anesthesia) | Strong |
Procedure performance | |
Time and date of regional anesthesia procedure | Strong |
Aseptic agent used | Strong |
Aseptic technique used as per local policy | Strong |
Skin infiltration with local anesthetic | Strong |
Needle design: tip, manufacturer, length, gauge | Strong |
Local anesthetic used for regional anesthesia technique (concentration and volume) | Strong |
Epinephrine dose if used (concentration) | Strong |
Adjunct used (e.g. bicarbonate, clonidine etc.) | Strong |
Specific for peripheral nerve block performance | |
Side of block | Strong |
Technique of needle localization (ultrasound / nerve stimulator / landmark) | Strong |
No Evoked Motor Response (EMR) <_____mA (when applicable i.e. when nerve stimulator used) | Strong |
Minimum current and current duration (if nerve stimulator used) | Strong |
Absence of blood on aspiration | Strong |
Catheter depth at the skin | Strong |
Absence of pain / paresthesia during injection | Strong |
Complications | Strong |
Specific for neuraxial procedure performance | |
Technique (approach used eg, median/paramedian) | Strong |
Vertebral level of needle insertion | Strong |
Technique used: loss of resistance to saline/air for epidural insertion | Strong |
No of attempts | Strong |
Epidural needle depth at loss of resistance | Strong |
Catheter depth at the skin | Strong |
Note on aspiration and action taken | Strong |
Epidural test dose (if applicable) | Strong |
Absence of pain/paresthesia during injection | Strong |
Dermatomal level of spinal of epidural block achieved (if assessed) | Strong |
Complications | Strong |
Postprocedure | |
Patient vital signs after the procedure | Strong |
Postprocedure instructions (as per local standards) | Strong |