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Wt :
kg
Ht:
cm
Procedure Time DD MM YY
Trunk blocks Lt / Rt intercostal paravertebral lumbar plexus TAP ilio-inguinal spinal epidural other Landmark technique
am / pm
Performed by
axillary
Lower Limb : Lt / Rt femoral / saphenous sciatic : tibial / common peroneal a) popliteal b) subgluteal c) transgluteal d) distal lateral e) anterior fascia iliaca ankle other Nerve stimulator used : Yes / No Ropivacaine 0.5% l-bupivacaine0.25% Bupivacaine 0.25% Ropivacaine 0.375% l-bupivacaine 0.125%
Ultrasound guided : Yes / No Local Anaesthetic Ropivacaine 0.75% l-bupivacaine 0.5% Bupivacaine 0.5 % Others Lignocaine added Combined Anaesthetic Additives Catheter insitu : Yes / No Infusion rate : Marking at skin: No No No
Ropivacaine 0.2%
ml/hour
Bupivacaine 0.1%
l-bupivacaine 0.1%
Additives____________________
No
Complication/s / Problems during performance of block Yes Bleeding/vascular puncture Technical difficulty Poor needle visualization Anatomical variation Failed stimulation (if used) intraneural injection inadequate spread Supplement required : Sensory block : No
Horner's Syndrome phrenic nerve involvement epidural spread pneumothorax Failed block LA Toxicity :Prodromal symptoms / CVS / Other Yes
CNS
Adequate / Partial / NA
Motor block :
Regular analgesic given Time to rescue : for analgesia (opoids) in the ward
Not given
(against gravity)
18-24 H >24H
12-18 H
Complication/s ( Ward) No complication Persistent numbness Persistent weakness LA Toxicity :Prodromal symptoms / CVS / Infection Failed catheter others
Time:
Complication/s (after 1 month) Uncontactable No complication Persistent numbness Persistent weakness Infection others
CNS
Yes
No
Supportive Excellent
Level of satisfaction:
Date Time Seen by Technique Infusion Pain (rest) Pain (movement) Catether site Marking Sensation Catheter site Marking Sensation Motor power Clean, dressing intact, no leaking, swollen, inflame, bleeding. _____cm numbness, no sensation 3/5 (against gravity)