ACUTE PAIN SERVICE REFERRAL FORM Acute Pain Service Liaison Nurse: Caz McLoughlin BRADMA Phone ext. 62802 or Mobile: 0408 168 995 Hours: 0800 - 1600 Mon - Fri DATE: WEIGHT: OPERATION: □ □2 □3 □4 □5 □E ASA: 1 □OSA □History Chronic Pain - Yes/No of PONV □Peptic □Obesity □Substance Ulcer Abuse CO-MORBITIES: □Renal □IHD □Anxiety Impairment / Cardiac Failure / Depression □Liver □Diabetes Impairment Mellitus □Other □PCA □Regional infusion □Epidural □Intrathecal INTERVENTION: □Ketamine □Opioid infusion infusion □Paravertebral □Other infusion REGIONAL Solution: CATHETER Skin to space (cm): INSERTION Catheter mark at skin(cm): DETAILS; Insertion level: Rate: □GA □Regional □ TIVA ANAESTHETIC □Spinal □LA □ TYPE; NIL □Epidural □IV Sedation REFERRAL □ □ □ Anaesthetist / surgeon PACU Ward ANAESTHETIST; CONTACT;
ACUTE PAIN SERVICE REFERRAL FORM Acute Pain Service Liaison Nurse: Caz McLoughlin BRADMA Phone ext. 62802 or Mobile: 0408 168 995 Hours: 0800 - 1600 Mon - Fri DATE: WEIGHT: OPERATION: ASA: □ 1 □2 □3 □4 □5 □E CO-MORBITIES: Chronic Pain - Yes/No □OSA □History of PONV □Peptic Ulcer □Obesity □Substance Abuse □Renal Impairment □IHD / Cardiac Failure □Anxiety / Depression □Liver Impairment □Diabetes Mellitus □Other INTERVENTION: □PCA □Regional infusion □Epidural □Intrathecal □Ketamine infusion □Opioid infusion □Paravertebral infusion □Other REGIONAL CATHETER INSERTION DETAILS; Solution: Skin to space (cm): Catheter mark at skin(cm): Insertion level: Rate: ANAESTHETIC TYPE; □GA □Regional □ TIVA □Spinal □LA □ NIL □Epidural □IV Sedation REFERRAL Anaesthetist / surgeon □ PACU □ Ward □ ANAESTHETIST; CONTACT;
Acute%20Pain%20Services%20Referral%20Form.docx