F-18
Continuous Catheter Record
دليل السياسات والإجراءات في التخدير — Section M

Form F-18 Preview

Continuous Catheter Record + Infusion Order (2-Page Table Format)

CONTINUOUS CATHETER RECORD + INFUSION ORDER SHEET
Hospital: ________________________ | Dept of Anesthesia Form Code: F-18 | Version: ___ | Effective: ___ | PAGE 1 of 2
PATIENT IDENTIFIERS
Name: _______________________________ MRN: _______________ DOB/Age: _________ Wt (kg): _____
Allergies: _______________________________________     (Latex: ☐ Yes ☐ No | CHG: ☐ Yes ☐ No)
CATHETER DETAILS
Catheter type:
☐ Epidural
☐ Peripheral nerve catheter (PNC) 		Site/side: ________________________________________

Date/time: ________________________________________

Location: ☐ OR    ☐ Block    ☐ PACU    ☐ NORA
PRE-BLOCK SAFETY CHECKS & ASEPSIS
☐ Consent confirmed
☐ Stop-Before-You-Block done (peripheral):   ☐ Yes   ☐ N/A
☐ Baseline neuro exam documented:   ☐ Yes   ☐ No   ☐ N/A
☐ Anticoag reviewed & acceptable:   ☐ Yes   ☐ No   ☐ N/A
     Last dose/time: ________________________ 		Asepsis Precautions:
☐ CHG / Alcohol prep
☐ Sterile gloves
☐ Mask
☐ Sterile drape
☐ Sterile probe cover (if US used)
INSERTION DETAILS
Technique/approach: _________________________________

Needle set: ________________________________________

# attempts: _____     Catheter depth at skin: _____ cm 		Aspiration:
☐ Negative    ☐ Positive (action): ___________________

Test dose (epidural):
☐ Yes    ☐ No   |   details: _________________________
INITIAL BOLUS
Drug Conc Volume (mL) Time
LABELING & LINE SAFETY VERIFICATION
☐ Catheter securely fixed and labeled “EPIDURAL” or “PNC” + site + date/time

☐ Tubing appropriately labeled and line traced to correct route

☐ Epidural/PNC line physically segregated from IV lines (as per hospital policy)
CONTINUOUS CATHETER RECORD + INFUSION ORDER SHEET
Patient Name: _________________________ | MRN: _______________ Form Code: F-18 | PAGE 2 of 2
INFUSION ORDER
Solution (drug + conc): __________________________________________________________________________________
Basal Rate
(mL/hr)		 Bolus
(mL)		 Lockout
(min)		 Max / hr
(mL)		 Start Date/Time Double-Check
(If required)
☐ Done   ☐ N/A
MONITORING ORDERS BREAKTHROUGH PAIN PLAN
Vitals frequency:
________________________________________________

Motor block checks frequency:
________________________________________________

Fall precautions:
☐ Yes    ☐ No
If Pain Score > Target:

1. Give patient-controlled bolus (if enabled).
2. Rescue med: ______________________________
3. Check catheter site/connections.
4. Call APS/Regional team if pain unresolved.
ESCALATION TRIGGERS (Call APS / Regional Team Immediately)
☐ Increasing motor weakness

☐ New numbness beyond expected distribution

☐ Hypotension / bradycardia 		☐ Respiratory depression / excess sedation

☐ Signs of infection at catheter site

☐ Suspected LAST (Local Anesthetic Systemic Toxicity)
FOLLOW-UP PLAN
APS/Regional Review:    ☐ Daily    ☐ BID    ☐ Other: ______________

Expected removal date/time: ________________________________________

Special notes: ____________________________________________________________________________
__________________________________________________________________________________________
SIGNATURES
Ordering Clinician:

Name: ___________________________________________

Sign: __________________________ Date/Time: _______ 		Nurse Verification (Order Received & Pump Programmed):

Name: ___________________________________________

Sign: __________________________ Date/Time: _______
Standards alignment: CBAHI perioperative safety; regional catheter labeling + monitoring; anticoag safety per adopted guideline.