Safe spinal documentation

Documentation of risks

• Risks discussed:
  • Hypotension
  • Urinary retention
  • Pain on injection
  • Headache
  • Nerve damage
  • Bleeding/ haematoma
  • Failure

Documentation of procedure

• Operator and supervisor
• Position
• Antiseptic solution used
• Asepsis – gloves, gown, mask, hat, drape
• Level/ space
• Local anaesthetic used
• Spinal needle used- gauge and tip design
• How many attempts
• Visualisation of CSF
• What was injected
• Any pain or paraesthesia, and if it resolved
• Testing of the block – e.g. sensation, motor block, sympathetic

Example

• Performed by ____, supervised by ____
• Sitting
• 0.5% chlorhexidine spray – allowed to dry
• Hat, mask, sterile gown and gloves, sterile drape.
• L3/4 by landmark
• 1% lidocaine to skin
• 25G pencil point spinal needle
• 2nd pass
• Clear CSF seen – free flowing
• 2.5ml 0.5% heavy L-bupivicaine + 150 mcg morphine injected
• Brief paraesthesia on 1st attempt- resolved on withdrawing needle
• Dense motor block developing prior to GA