The Management Of Regional Analgesia Using A Nerve Catheter. Lead Nurse Acute Pain Specialist Nurse CLINICAL GUIDELINE

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1 Lancashire Teaching Hospitals NHS Foundation Trust The Management Of Regional Analgesia Using A Nerve Catheter KEY WORDS REF NO: Acute Pain, Regional Analgesia, Nerve Catheter. Local Anaesthetic Infusion AUTHOR AUTHOR S LINE MANAGER RATIFIED BY Name: Karen Williams Name: Gill Nixon Name: P MacDowall DIRECT 08/15 v Title: Acute Pain Specialist Nurse Title: Lead Nurse Acute Pain Specialist Nurse Title: Chair Evidence Based Guidelines Group INITIATING DIRECTORATE Anaesthetics TARGET AUDIENCE Adult patients undergoing upper or lower limb surgery using peripheral regional analgesia CLINICAL GUIDELINE DATE RATIFIED REVIEW DATE August 2018 The governing principles outlined within this document are fully supported in every respect by the Clinical Governance Sub-Committee. All members of staff are required to adhere to the principles involved as outlined within this document, together with any related procedures, which are enabled by this guideline. This guideline was produced in consultation with: Dr Shiva Tripathi Clinical Lead for Acute Sr. Ann Titterington Ward Manager Leyland Ward Pain Management CDH Dr G. Jones Consultant Anaesthetist Dr Z Townley Consultant Anaesthetist Bev Duncan Clinical Educator Katherine Longden Senior Pharmacist. Orthopaedics GROUP OR COMMITTEE APPROVED BY: (This will involve local or specialist group review / scrutiny using a body of expertise and knowledge who have confirmed that the document is fit for purpose. Where no such relevant body exists for the approval of a document approval may be obtained from those individuals or groups involved in the consultation process). DEFINITION OF CLINICAL GUIDELINES Clinical Guidelines are evidence based systematic statements to assist practitioners and patients in making decisions about appropriate health care for specific clinical circumstances. Page 1 of 8

2 1. Full Guideline Title Regional Analgesia 2. Adaptation Adapted from previous LTHTR approved guidelines for Regional Analgesia using a Nerve Catheter. Approved Guideline Aim Regional analgesia using nerve catheters will be delivered in a safe and effective manner on ward areas. 4. Disease/condition/target population For the management of acute postoperative/ trauma pain in adult patients undergoing upper or lower limb surgery using peripheral regional analgesia 5. Body of Guideline The Anaesthetist should discuss the use of a nerve catheter with the surgeon prior to surgery. Preoperatively the patient must receive information and an explanation of the technique The Anaesthetist must liaise pre-operatively with the nurse-in-charge of the relevant ward to ensure that adequate trained staff (day & nights) will be available to care for the patient on return to the ward. Nerve catheters must be sited in a clean environment e.g. theatres, anaesthetic room or recovery unit. All nerve catheters will be inserted using strict aseptic technique in line with the hospital aseptic non touch technique ANTT procedure (LTHTR, 201) including hand washing, the use of sterile gloves, sterile gown, hat, mask, appropriate skin preparation and sterile drapes around the injection site. Intravenous access must be maintained for the duration of the nerve catheter infusion. The infusion or top-up regime must be prescribed stating: drug name, volume and concentration, parameters of infusion rate, frequency and volume of any top-up regime and end point of nerve catheter placed. The Acute Pain Service must be informed by the initiating anaesthetist of all patients receiving regional analgesia using a nerve catheter Nerve catheter infusions must be administered via a B} BRAUN Easypump C-bloc Elastomeric disposable pump, either at a fixed rate of infusion of 5ml/hr or 8ml/hr or a variable rate pump may be used 2-14ml/hr. Recommended dose of Ropivicaine for an adult via a nerve catheter is 5-14ml/hr of 2mg/ml infusion. Two registered nurses should check the nerve catheter prescription chart when patient is transferred from one clinical area to another. Only Anaesthetists who are competent in the management of local anaesthetic toxicity should administer Intermittent top-ups. Following administration of intermittent top-up of local anaesthetic, the person administering the topup must be available for the next hour or ensure that they nominate a named deputy anaesthetist who is available. This also applies at the Chorley site. The skin exit should be should be covered with an occlusive transparent sterile dressing to facilitate 4hourly inspections for signs of infection or dislodgement. Problems with nerve catheters should be referred to the Acute Pain Service or out of hours the 2nd on-call Anaesthetist. This also applies at the Chorley site this is the anaesthetist on-call for CrCu who can be contacted via switchboard. However, the overall responsibility for the nerve catheter lies with the anaesthetist who initiated the technique, who should be informed of any significant or persistent problems. Patients should not be discharged home whilst nerve catheters remain insitu. Page 2 of 8

3 Nursing Observations The nurse must observe for new signs and symptoms indicative of local anaesthetic toxicity i.e. tingling around the mouth, metallic taste in the patient s mouth, ringing in the ears, feeling drunk, dizziness, blurred vision or muscle twitching. Loss of consciousness, with or without tonic-clonic convulsions. Cardiovascular collapse: sinus bradycardia, conduction blocks, asystole and ventricular tachyarrhythmia may all occur. For intermittent top-up Only Anaesthetists who are competent in the management of local anaesthetic toxicity should administer Intermittent top-ups. Ensure patent IV access is patent prior to each top-up Following each intermittent top-up monitor and record respiratory rate, oxygen saturation, blood pressure, pulse, pain score, sedation score and EWS every 5 minutes for 0 minutes then every 15 minutes for one hour, followed by 4 hourly for duration of analgesic technique. The anaesthetist administering the top-up must be immediately available during this time. For An Infusion Ensure patent IV access is patent during time of infusion Monitor and record respiratory rate, oxygen saturation, blood pressure, pulse, pain score, sedation score, any signs of local anaesthetic toxicity and EWS: In Recovery: every 15 minutes On Ward: on return to ward half hourly for four hours, hourly for two hours, then four hours until nerve catheter infusion is discontinued. Care of Nerve Catheter The skin exit site should be checked 4 hourly for signs of inflammation or dislodgement. Only occlusive transparent sterile dressings should be used. Dressings should be left intact wherever possible. The catheter must be clearly labelled with local anaesthetic stickers. Removal of Nerve Catheter Any trained nurse on the ward can remove nerve catheters after discussion with the pain team or initiating anaesthetist. Anticoagulation The indwelling nerve catheter must be sited at least 12 hours after a prophylactic dose of low molecular weight heparin (LMWH) In patients who are on LMWH (low molecular weight heparin) catheter removal should be performed at least 12 hours after the last prophylactic dose of LMWH or 24 hours after therapeutic doses. The LMWH can be administered 4 hours after the catheter is removed. For patients receiving Rivaroxaban (eg after Total hip and knee replacements) and other factor Xa inhibitors ( see appendix1) Page of 8

4 Trouble Shooting 1. Inadequate analgesia: If pain score is 2 or more. Check prescription chart, increase infusion rate by 2ml/hr, if using a variable rate pump. Review pain score after 0 minutes. Repeat if necessary until maximum prescribed rate is reached. Check catheter for dislodgement. Contact acute pain nurse or 2nd on-call anaesthetist for advice. If fixed rate pump contact acute pain nurse or 2nd on-call anaesthetist. 2. Any sign or symptom of local anaesthetic toxicity: STOP ADMINISTRATION OF LOCAL ANAESTHETIC IMMEDIATELY. A-E assessment, In the event of change in patients condition and respond appropriately. In the event of cardio respiratory arrest commence Adult Basic Life Support. Summon help via Tel No Evidence of bleeding/haematoma formation Apply pressure to the site Contact acute pain nurse or 2nd on-call anaesthetist for advice 6. Clinical Algorithms None 7. Implementation strategy Ward managers, practice educators. Pain updates and teaching sessions. 8. Patient Resources Trust approved Patient information leaflets, DVDs etc. 9. References Association of Anaesthetists of Great Britain & Ireland (2010) AAGBI Safety Guideline: Management of Severe Local Anaesthetic Toxicity. London, AAGBI. Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (2010) Acute Pain Management: Scientific Evidence. rd edition. Melbourne, ANZCA & FPM. Electronic Medicines Compendium (emc) (201) SPC: Naropin 2 mg/ml solution for infusion. [Online] Available at: [Last accessed 15 June 2015]. Grant, S.A. et al (2001) Continuous peripheral nerve block for ambulatory surgery. Regional Anesthesia and Pain Medicine, 26 (), pp Illfeld, B.M. (2011) Continuous peripheral nerve blocks: a review of published evidence. Anesthesia and Analgesia, 11 (4), pp Klein, S.M. et al (2000) Interscalene brachial plexus block with a continuous catheter insertion system and a disposable infusion pump. Anesthesia and Analgesia, 91 (6), pp Page 4 of 8

5 Bombeli, T. and Spahn, D. (2004) Updates in perioperative coagulation: physiology and management of thromboembolism and haemorrhage. British Journal of Anaesthesia, 9 (2), pp Companion Documents / Appendices LTHTR (2015) Competency: Cannulation of a peripheral vein. LTHTR (2011) Peripheral Cannulation - ANTT Pictorial Guideline. 8. LTHTR (2011) Aseptic Non Touch Technique (ANTT) guideline LTHTR (201) The medicines management (general) policy LTHTR (201) Procedure for the timely recognition and response for patients at risk of deterioration... Page 5 of 8

6 Appendix 1. and anticoagulation guidance Purpose To ensure safe practice of administration and management of regional anaesthesia/analgesia by medical, nursing and midwifery staff on the ward in Lancashire teaching hospitals NHS Trust. Scope This guidance can be used by suitably trained medical/nursing/midwifery staff to aid in the care of any patient receiving regional anaesthesia/analgesia at Lancashire teaching hospitals NHS Trust. Guidance Introduction: Whether or not to avoid or modify regional anaesthesia in a patient with abnormalities of coagulation can be a challenging question for any healthcare practitioner. Due to recent increase in emphasis of prophylaxis and treatment of thromboembolism there has been an increase in the number of patients receiving anticoagulants and the number of different anticoagulants in use. Furthermore a number of pathological processes may lead to abnormalities of coagulation (eg sepsis, trauma, pre-eclampsia). Emphasis on a continuum of risk: It is important to emphasise that any abnormality of coagulation is a relative contra-indication to regional anaesthesia. Any decision must be taken with due consideration of the risks and benefits of the procedure and alternatives management methods to the individual patient on a case by case basis. Older guidelines are often binary in their approach, for example it is often said that a neuraxial technique should be avoided in someone with a platelet count of <75 X10 9 /L, however it is acceptable to perform them in someone with a platelet count >75 X10 9 /L. In practice the difference in risk between patients with a platelet count of 74 X10 9 /L and 76 X10 9 /L is likely to be minimal. Also it needs to be noted that not all regional anaesthetic techniques pose the same risks, with epidural catheters posing a much more serious risk compared with superficial blocks and local infiltration. Page 6 of 8

7 Medication Recommended time after the administration of the drug for performing regional blocks and INSERTION and REMOVAL of nerve and neuraxial catheters Recommended restrictions in administration of the anticoagulant whilst the catheter is in place Recommended minimal time between performance of regional block or removal of catheter and the administration of the next dose of anticoagulant. Heparins Heparin Alternatives Antiplatelet Drugs Unfractionated, SC prophylactic dose > 4 hours or normal APTT ratio Caution > 1 hour Unfractionated, IV > 4 hours or normal APTT ratio Caution > 4 hours Low molecular weight, Prophylactic dose > 12 hours Caution > 4 hours Low molecular weight, Treatment dose > 24 hours Avoid > 4 hours Danaparoid, Prophylactic dose Avoid (Consider Anti factor 10a levels) Avoid > 6 hours Danaparoid, Treatment dose Avoid (Consider Anti factor 10a levels) Avoid > 6 hours Fondaparinux, Prophylaxis dose > 6-42 hours (Consider Anti factor 10a levels) Avoid > 6-12 hours Fondaparinux, Treatment dose Avoid (Consider Anti factor 10a levels) Avoid > 12 hours NSAIDS No additional precautions No additional precautions No additional precautions Aspirin No additional precautions No additional precautions No additional precautions Clopidogrel 7 days Avoid > 6 hours Prasugrel 7 days Avoid > 6 hours Ticagrelor 5 days Avoid > 6 hours Tirofiban 8 days Avoid > 6 hours Eptifibatide 8 days Avoid > 6 hours Abciximab 48 days Avoid > 6 hours Dipyridamole No additional precautions No additional precautions > 6 hours Page 7 of 8

8 Oral anticoagulants Medication Rivaroxiban (CrCl>0mls/min) Dabigatran (Prophylactic or treatment dose) Recommended time after the administration of the drug for performing regional blocks and INSERTION and REMOVAL of nerve and neuraxial catheters Recommended restrictions in administration of the anticoagulant whilst the catheter is in place Recommendations on the insertion and management of regional anaesthesia techniques in patients receiving anticoagulant medication. Recommended minimal time between performance of regional block or removal of catheter and the administration of the next dose of anticoagulant. Warfarin INR 1.4 Avoid Immediately after Prophylactic dose > 18 hours Avoid > 6 hours Treatment dose > 48 hours Avoid > 6 hours (CrCl>80mls/min) > 48 hours Avoid > 6 hours (CrCl=50-80mls/min) > 72 hours Avoid > 6 hours (CrCl=0-50mls/min) > 96 hours Avoid > 6 hours Apixaban Prophylaxis > hours Avoid > 6 hours 10 days Avoid 10 days Thrombolytic drugs (Alteplase, streptokinase, anistreplase, reteplase Page 8 of 8