1.1   Major regional analgesia (eg epidural, intrathecal, or nerve plexus) must only be initiated by anaesthetists with appropriate training and experience in the technique, or by trainees under appropriate supervision. All persons who undertake such procedures must understand the relevant anatomy, physiology, pharmacology and potential complications of the particular procedure and the contraindications to its use. They must be able to recognise and promptly treat any complications.

1.2   Selection of the appropriate technique (nerve plexus, epidural, intrathecal etc) and site (e.g. lumbar vs thoracic epidural, interscalene vs axillary brachial plexus block) should be based on individual patient history and analgesic requirements.

1.3   Complications of major regional analgesic techniques can occur due to the physiological changes that may result from nerve blockade, adverse effects from the drugs administered (local anaesthetic, opioid and adjuvant medications), or problems associated with insertion of the needle and/or catheter.

1.4   The anaesthetist or trainee instituting a major regional analgesic technique must have an assistant with the appropriate training.

1.5   Informed consent must be obtained from the patient prior to the institution of any regional analgesia and prior to any sedation.

1.6   All techniques should be performed using appropriate infection control measures. Gowns, masks and gloves should be worn during insertion of epidural or spinal needles/catheters.

1.7   Intravenous access must be secured prior to commencement of any major regional analgesic technique and maintained for the duration of that analgesia.

1.8   Patients must be monitored in accordance with Professional Documents PS18 Recommendations on Monitoring During Anaesthesia and PS41 Guidelines on Acute Pain Management, as appropriate.

1.9   The responsible anaesthetist must be in attendance throughout the institution of the technique, until a satisfactory blockade has been obtained, the patient is stable and the potential for immediate complications has passed. If the technique has been instituted for anaesthesia as well as subsequent analgesia, an anaesthetist must be present for the duration of that anaesthetic.

1.10   Major regional analgesia remains the responsibility of the anaesthetist initiating the technique. The anaesthetist may delegate subsequent management of the patient to another medical practitioner or registered nurse or to a pain service, provided that these personnel have received appropriate training and provided the anaesthetist is satisfied with the competence of the person(s) to whom management has been delegated. This competence includes, but is not limited to, an understanding of the technique, the drugs and equipment used, monitoring requirements and the recognition and management of any side effects.

1.11   A record of the technique, including method, drugs (and dose) used, and any complications or problems encountered, must be made in the patient’s medical record by the responsible anaesthetist. All analgesic drugs must be prescribed by an anaesthetist.

1.12   A record of the instructions given for the subsequent management of the patient (including drug orders and monitoring requirements) must also be made by an anaesthetist and form part of the patient’s medical record.

1.13   Nursing staff may play a key role in the management of the patient after the major regional analgesia has been established and the patient is stable (see 1.10 above). Appropriate ongoing education and accreditation of relevant nursing staff are essential.

1.14   Appropriate written protocols and procedures must be in place for the continued management of each technique. Formal institutional protocols and guidelines for each technique are recommended.

2.1   The availability of suitable levels of nursing care and the presence of appropriately trained nursing staff.

2.2   The clear labelling of any catheter in order to minimise the risk of accidental administration of other substances not intended for analgesia.

2.3   When infusion pumps are utilised, they should be dedicated to use for continuous regional (epidural and major plexus or nerve) analgesia infusions only and clearly marked as such. The maximum rate of infusion that can be delivered by the pump should be limited to that suitable for such applications in order to minimise the risk of inadvertent high infusion rates and consequent delivery of excessive amounts of analgesic drug.

2.4   Written protocols and guidelines must be in place for the continued management of the technique. Tailoring of analgesic regimens to the individual patients requires that regular assessments of adequacy of analgesia and any adverse effects of analgesic drugs or techniques are performed and documented.

2.4.1   The following parameters should be monitored and recorded on a regular basis: pain score, blood pressure, heart rate, temperature, respiratory rate, sedation score, oxygen saturation, sensory and motor function.

2.4.2   Proper assessment and control of pain requires patient involvement and the use of self-reported measures, and frequent assessment and reassessment of pain intensity and the effect of any intervention. Pain should be assessed both at rest and during activity. Unexpected levels of pain, or pain that suddenly increases, may signal the development of a new medical or psychiatric diagnosis. In the case of epidural or intrathecal analgesia, back pain or nerve root pain may signify the presence of an epidural abscess or haematoma.

2.4.3   Protocols for the recognition and treatment of side effects (pharmacological or physiological) that may result from the use of analgesic drugs (local anaesthetic, opioids, adjuvant medications) should be available.

2.4.4   Protocols for the recognition and management of possible complications resulting from the use of indwelling catheters should be available. In the case of epidural or intrathecal analgesia, these complications may include epidural abscess, epidural haematoma and spinal cord or nerve root compression. In such cases, urgent assessment is essential. Should imaging be required, an MRI is preferable to a CT scan.

2.5   Patients must be reviewed at least daily by an anaesthetist and an anaesthetist must be available for consultation or management of complications at all times. The catheter insertion site should be inspected for signs of inflammation/infection and a review of neurologic function should be performed.

2.6   The catheter may be removed by a registered nurse, who has received the appropriate education, on the orders of an anaesthetist. Details of the removal of the catheter, the date, time, and state of the catheter and insertion site must be documented in the patient’s record. Follow-up assessment is desirable. An appropriate protocol must be available that relates timing of the removal of a catheter (as well as catheter insertion) to the timing of administration of any anticoagulant medication.

2.7   Surgical and/or other medical staff caring for the patient must be aware of the analgesic technique used, its potential complications and any specific implications for the surgery performed or other management issues for the patient. The need for appropriate consultation with specialised pain management staff should be communicated to other medical staff.

3.1   Epidural analgesia has the potential to change many of the normal physiological processes of labour and delivery. From the time that epidural analgesia is instituted, it is essential that the mother is under the care of a medical practitioner with obstetric training who can assess the mother as necessary, and rapidly effect delivery of the baby by whatever technique is appropriate.

3.2   The practitioner establishing regional analgesia must establish that the mother has consented to the procedure after having been informed about advantages, disadvantages and alternatives. This should normally be part of ante-natal education.

3.3   From commencement to completion of epidural analgesia in labour, there must be appropriately skilled staff and equipment available to monitor and care for both mother and fetus, and to manage any complications arising from the epidural analgesia or labour.