Spinal/Epidural Anesthesia Procedure Note

Date/Time: [Procedure start date/time] (Document actual start time of needle insertion; do not leave blank)

Location: [OR / L&D / Procedure suite / ICU / ED / Other - specify]

Procedure Type: [Spinal / Epidural / CSE / Other - specify]

Indication: [e.g., cesarean delivery anesthesia / labor analgesia / lower extremity surgery / postoperative analgesia / other - specify]

(For all safety-critical fields—sterile technique, anticoagulation, block assessment, complications—enter explicit "None" or "N/A" with brief rationale if not applicable. Do not leave blank.)

Pre-Procedure Assessment

• Contraindication screen: [Patient refusal: yes / no] | [Local infection at site: present / absent] | [Coagulopathy/thrombocytopenia: present / absent] (If present, include platelet count and relevant labs with date/time) | [Allergy to intended agents: present / absent] (If present, specify agent) | [Relevant anatomic concerns: present / absent] (If present, specify) | [Baseline neurologic deficits: present / absent] (If present, specify)
• Anticoagulation status: [Current anticoagulant/antithrombotic agents: none / list each with dose] | [Last dose date/time for each agent as verified] | [Labs informing decision with values and date/time] | [Plan relative to neuraxial timing and catheter management if applicable]
• Readiness: [IV access: confirmed / not available - explain] | [Resuscitation equipment immediately available: yes / no - explain]

Consent & Time-Out

Informed consent obtained from [patient / surrogate]. (If emergent circumstances limited consent, document constraints.) Time-out completed at [time] confirming correct patient, procedure, site/level, allergies reviewed, and anticoagulation status cleared.

Procedure Details

Positioning and approach: Patient positioned [sitting / lateral decubitus - left / lateral decubitus - right]. Approach [midline / paramedian]. Target interspace [e.g., L2-3 / L3-4 / L4-5 / other - specify], identified by [palpation / ultrasound]. (If ultrasound used, note findings and depth estimation.) Local infiltration: [agent, concentration, volume] via [needle size].

Sterile technique: (Do not infer sterility; explicitly document each element.)

• Hand hygiene performed: [yes / no - explain]
• PPE worn: [mask, cap, sterile gloves] (List all worn)
• Skin prep: [chlorhexidine in alcohol / povidone-iodine / other - specify]; allowed to dry fully: [yes / no - explain]
• Sterile drape applied and field maintained: [yes / no - explain]
• Break in sterility: [none / describe event and corrective action]

Needle technique: (Complete only the relevant components for procedure type; for CSE, document both.)

Spinal (if performed): Needle [type], [gauge]; introducer used: [yes / no]. CSF obtained: [yes - clear / yes - blood-tinged / no]. CSF flow: [free / slow]. Number of attempts: [number]. Interspaces attempted: [levels]. Paresthesia: [none / transient / persistent - describe action taken if present].

Epidural (if performed): Needle [type], [gauge]. Loss-of-resistance medium: [saline / air / saline and air]. Depth to LOR: [cm]. Number of attempts: [number]. Interspaces attempted: [levels]. Aspiration: [negative / blood / CSF] (If positive, describe action taken). Paresthesia: [none / transient / persistent - describe action taken if present].

CSE (if performed): Technique: [needle-through-needle / separate sites]. (Document epidural details, then spinal details as above.)

Medications administered: (List each medication. For epidural dosing, note incremental dosing and aspiration before each dose.)

• [Medication name] | [Concentration] | [Dose] | [Volume] | [Route: intrathecal / epidural] | [Time] (For epidural: Incremental dosing [yes / no]; aspiration prior [yes / no])
• (Add additional medication entries as needed)

Epidural Catheter Details

(Include only if catheter placed; otherwise omit section entirely.)

• Catheter: [type, size] | Depth at skin: [cm]
• Aspiration after placement: [negative / blood / CSF] (If positive, action taken: [describe])
• Securement: [sterile adhesive / occlusive dressing / suture / other - specify]
• Test dose: [agent, concentration, volume] | Time: [time] | Interpretation: [no intravascular or intrathecal signs / concerning findings - describe] | (If test dose omitted, document rationale)
• Initial infusion: [medication(s) and concentration(s)] | Rate: [mL/hr] | PCEA settings if applicable: [bolus mL / lockout min / max mL/hr]

Block Assessment

• Assessment method: [cold / pinprick / other] | Time from dosing: [minutes] | Assessment time: [time]
• Sensory level achieved: [highest dermatome] | Laterality: [bilateral / right-dominant / left-dominant]
• Motor assessment: [Bromage score / functional description] (Include if clinically relevant)
• Adequacy: [adequate / patchy / unilateral / inadequate] (If inadequate, describe pattern and corrective action)
• Overall result: [Successful spinal anesthetic / Epidural catheter functioning for labor analgesia / Unsuccessful - converted to (alternative) / other - specify]

Hemodynamics & Complications

• Hemodynamic events: [None / describe] | (If significant: Lowest BP [value] at [time], Lowest HR [value] at [time]) | Treatment: [fluids, vasopressor type and dose, other interventions] | Associated symptoms: [none / nausea / dyspnea / tinnitus / perioral numbness / other]
• Complications: [No complications] / (If present, for each: Event [wet tap / bloody tap / difficult placement / persistent paresthesia / suspected intravascular catheter / suspected intrathecal catheter / high spinal features / LAST concern / other] | Time: [time] | Management: [actions taken and patient response])

Post-Procedure Plan

• Monitoring: [Location] | Neuro checks: [frequency] (Specify especially if anticoagulated or difficult/bloody placement)
• Epidural catheter (if applicable): Expected duration [hours] | Troubleshooting threshold [criteria] | Removal plan [timing relative to anticoagulation; responsible team]

Procedure end time: [time] (Optional)