REGIONAL ANAESTHESIA DATA COLLECTION FORM MINISTRY OF HEALTH MALAYSIA

PATIENT DATABASE : Name Wad/Dicipline

Record No Tel Age RN

ASA : 1 / 2 / 3 / 4

NRIC Sex : M / F Diagnosis

Date of procedure

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

TYPE OF BLOCK: Lt / Rt Upper Limb : Interscalene Supraclavicular Infraclavicular

axillary

median ulnar radial other

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%

Total volume _______ ml Yes Yes Yes Continuous Infusion :

GA / Spinal Ropivacaine 0.2%

Ropivacaine 0.1%

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 :

Adequate / Partial / NA For APS to complete

Regular analgesic given Time to rescue : for analgesia (opoids) in the ward

oral / parenteral Not Required

<6H 6-12 H 12-18 H <6H 6-12 H 18-24 H >24H Time:

Not given

Time to motor power 3/5

(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

Refer to APS @ Anaesthetic Clinic if having complication/s :

Treatment rendered :

Yes

No

Supportive Excellent

Intervention_______________________________ Satisfied Poor

Level of satisfaction:

POST NERVE BLOCK OBSERVATION SHEET

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)