CLINICAL GUIDELINE FOR AN EPIDURAL INFUSION IN CHILD HEALTH 1. Aim/Purpose of this Guideline

Transcription

1 CLINICAL GUIDELINE FOR AN EPIDURAL INFUSION IN CHILD HEALTH 1. Aim/Purpose of this Guideline 1.1. The purpose of this guideline is to provide guidance on caring for children who are receiving epidural pain relief. 2. The Guidance 2.1. McKinley Body Guard Pump 545 and yellow Microset Bodyguard giving set must be used for epidural infusions. The pump is kept in a locked box which attaches to a drip pole. The key must be held by the nurse in charge. Prior to the patient leaving recovery the asset number of the epidural should be recorded on the recovery sheet and paediatric pain service yellow database form. A Registered Sick Children Nurse or Registered Nurse (child) must always be available or allocated to a child receiving an epidural infusion who has been appropriately trained to look after epidural infusions. The child must have a patent cannula for the duration of the infusion and should remain insitu for 8 hours after epidural has been discontinued. This allows intravenous access in case of medical complications. The epidural infusion must be prescribed on EPMA with full instructions. Naloxone should also be prescribed in case of respiratory distress. The infusion rate must not be adjusted beyond the patients prescribed limits. Bags and rate of infusions must be changed by two registered nurses, one of which must be Registered Sick Children Nurse, Registered Nurse (child) or a doctor. The nurse must be competent in the administration of intravenous drugs and undergone relevant training and assessment in the management of epidural infusions. An aseptic non touch technique must be use. Delays in renewing bags should be avoided to achieve constant analgesia. If the epidural contains an opioid (e.g. Fentanyl), no other opioids should be given whilst the epidural infusion is running unless prescribed by the anaesthetist or Pain Team. However, epidural infusions without an opioid added may be supplemented by intravenous or oral opioids to improve analgesia. Yellow epidural administration lines should be changed weekly. An aseptic non touch technique must be used as per aseptic non touch technique policy. Page 1 of 11

2 Epidural infusion pumps should be placed at trunk height to prevent syphoning of contents due to effect of gravity Clinical Observations Observations should be recorded every 15 minutes in the recovery ward and then every 30 minutes until 2 hours post-op in the surgical ward. Then; Parameter Frequency Comments Sedation score Respiratory rate, heart rate and oxygen saturation Hourly until infusion is discontinued Hourly until infusion is discontinued See paediatric pain assessment chart Blood pressure Hourly for the first 12 hours, then this may be reduced to four hourly Pain score Hourly See paediatric pain assessment chart Nausea/vomiting/Pruritus assessment Hourly for the first 12 hours then 4 hourly until the infusion See paediatric pain assessment Motor block is discontinued 4 Hourly this must be increased to hourly if there are any concerns See paediatric pain chart for assessment (modified Bromage score) If the infusion rate is increased then observations should be recorded every 30 minutes for a further hour to ensure the patient is in a stable condition. If a bolus dose has been given the administrator should not leave the ward for 20 minutes so that they may respond promptly to respiratory depression or hypotension. Daily inspection of epidural site for redness, tenderness, leaking and dressing integrity (see section 2.4 for leaking epidurals). Contact Paediatric Pain Team or on call anaesthetist to assess the patient fully. Sensory block should be assessed if there are any concerns regarding whether the epidural is covering the patients pain. Contact Paediatric Pain Team or on call anaesthetist to assess the patient fully. Pressure areas must be assessed daily as children with epidural infusions are at an increased risk due to decreased sensation and motor blockade. Page 2 of 11

3 2.3. Discontinuing Epidural Infusions When alternative oral analgesia is prescribed and proven to be effective the epidural infusion may be discontinued. DO NOT reduce the rate of the infusion before discontinuing as the epidural may become ineffective before opioids can be administered orally or intravenously. The catheter can safely be removed 12 hours following a dose of low molecular weight heparin (Enoxaparin/dalteparin). The next dose should not be administered for a further 2 hours after the removal of the catheter. The epidural catheter should only be removed by a nurse assessed to be competent. Any opioid left in the bag must be discarded using a denaturing kit. This should be witnessed by two nurses and documented in the ward's wastage book. On discontinuation, the pump should be cleaned according to the decontamination policy and returned to theatres or medical equipment library for storage. If the equipment is faulty it must be returned to Medical Physics after being cleaned according to the decontamination policy Problems Sedation/Respiratory Depression Opioids can cause sedation and respiratory depression. Assessing level of sedation is the key to early identification and treatment of opioid-induced respiratory depression. Pruritus This is occasionally a side effect of opioids and usually settles within 2-3 days of commencing opioids. Can be treated with an antihistamine, e.g. Chlorphenamine (may cause sedation) or low dose Naloxone. Removing the opioid from the epidural could be considered. Hypotension If systolic pressure is more than 20% below pre-op reading then give oxygen and fluid bolus if prescribed, call paediatric registrar to come and review the patient. DO NOT ELEVATE THE FOOT OF THE BED. Inadequate Analgesia If the patient complains of pain or appears to be in pain: o Assess severity and location of pain o Increase the rate of the infusion, as prescribed o Check catheter at insertion site and all connections for disconnection and leakage. o Assess sensory block on both sides. Contact Paediatric Pain Team or on call anaesthetist to review analgesia. Page 3 of 11

4 Back Pain Most common at insertion site. Mild back pain is common and usually transient. Severe, persistent and increasing back pain could be a sign of abscess/haematoma and must be investigated thoroughly. Contact Paediatric Pain Team or on call anaesthetist to assess the child. Leaking epidural If the patient is comfortable (suggesting the epidural is providing adequate analgesia), the dressing should be covered with a sterile pad and observe. Any heavy blood loss should be discussed with the Paediatric Pain Team or on call anaesthetist. If the patient is in pain the epidural should be removed and alternative analgesia commenced. Contact Paediatric Pain Team or on call anaesthetist to review. Disconnection The commonest site for disconnection is at the filter. If the epidural becomes disconnected contact the Paediatric Pain Team or anaesthetist. o DO NOT re-connect. o Wrap the two ends in a sterile towel or gauze. o Stop the epidural infusion. Headache Maybe due to a dural tap (incidence 1-2%). May not present until the patient mobilises. Administer analgesia, encourage bed rest and fluids. If headache continues a blood patch maybe required. Inform Paediatric Pain Team or on call anaesthetist to assess the child. Urinary retention A urinary catheter should be in situ due to the increased risk of urinary retention. The catheter should not be removed until the epidural infusion has been discontinued. Sensory block Sensory nerve fibres respond to pain, temperature, touch and pressure. As pain and temperature nerve fibres are similarly affected by local anaesthetic drugs, changes in temperature perception indicate where the epidural is working. Assessing sensory block is important to ensure the epidural is covering the patients pain to ensure the block is not too extensive, which may increase the risk of complications. Sensory block should only be assessed by a competent nurse, anaesthetist or doctor. Any concerns should be discussed with the Paediatric Pain Team or on call anaesthetist. Motor Block Increasing leg weakness usually means the infusion rate is too high. However it may be an indication that the patient is developing an epidural haematoma. If not diagnosed and treated properly, can lead to paraplegia. Any concerns should be discussed with the Paediatric Pain Team or on call anaesthetist. Use the flow chart to help differentiate (see next page). Page 4 of 11

5 MANAGEMENT OF LEG WEAKNESS WITH EPIDURAL INFUSIONS Contact the Paediatric Pain Team or on call anaesthetist to inform them of the situation Increasing leg weakness? Leg strength score 3 or 4 SCORE 4 Unable to move legs SCORE 3 Unable to lift heels, moves toes. Switch epidural infusion off And Reassess leg strength every 30 minutes SCORE 2 Able to flex hips, knees and free movement of feet. Recommence epidural infusion Yes Leg strength improving? SCORE 1 Free movement of hips, knees and feet Motor Function assessment (Modified Bromage scale) No More than 4 hours since stopping epidural infusion? Yes Suspect an epidural haematoma. Contact Paediatric Pain Team or on call anaesthetist. An epidural haematoma has to be evacuated within 8 hours of the onset of symptoms for your patient to have the best chance of recovery of neurological function. DO NOT DELAY. Page 5 of 11

6 Local Anaesthetic Toxicity (see Paediatric Pain intranet page for full guideline ) This is rare and is characterised by: Mild - Restlessness/confusion Light-headedness Numbness of tongue and lips (lip smacking) Tinnitus Double vision, blurred vision Moderate Heaviness of limbs Muscular twitching Convulsions Severe Cardiac arrhythmias Hypotension Respiratory arrest Cardiac arrest If the patient is experiencing any of these symptoms the epidural should be stopped immediately. Contact Paediatric Registrar or anaesthetist (bleep 3513) urgently to come and review the child. Intralipid may be used to treat toxicity. Intralipid rescue boxes are kept in theatres (general and trauma) and Eden ward. Any problems should be recorded in the appropriate patient records. Page 6 of 11

7 3. Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Adherence to the guideline Acute Paediatric Pain Service The child will be reviewed daily (Monday-Friday) and adherence to the guideline will be recorded on the Paediatric Acute Pain form (CHA1850) and in the medical notes and on maxims. Datix reports will be investigated. The pain forms will be audited on a yearly basis in combination with the Paediatric Pain audit The audit is reported back to the Matron for Child Health and to Paediatric audit and guidelines group. Acute Paediatric Pain Service Required changes to practice will be identified and actioned within 1 month. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 7 of 11

8 Appendix 1. Governance Information Document Title Clinical guideline for an epidural infusion in Child Health Date Issued/Approved: 30 th December 2015 Date Valid From: 30 th December 2015 Date Valid To: 30 th December 2018 Directorate / Department responsible (author/owner): Acute Paediatric Pain Service Contact details: Brief summary of contents To provide guidance on caring for children who are receiving epidural pain relief. Suggested Keywords: Target Audience Executive Director responsible for Policy: RCHT PCH CFT KCCG Medical Director Date revised: 30 th December 2015 This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Clinical guideline for an epidural infusion in Child Health Paediatric Practice Development forum Paediatric Audit and Guidelines group Divisional Manager confirming approval processes Name and Post Title of additional signatories Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Sheena Wallace Not Required {Original Copy Signed} Name: {Original Copy Signed} Internet & Intranet Intranet Only Page 8 of 11

9 Document Library Folder/Sub Folder Links to key external standards Related Documents: Training Need Identified? Paediatrics Association of Paediatric Anaesthetists of Great Britain and Ireland (2012) Good Practice in Postoperative and Procedural Pain Management, 2nd edition. Blackwell Publishing Ltd Royal Marsden Hospital. (2015) Manual of Clinical Nursing Procedures, ninth edition. On line at Twycross, A., Dowden, S.J. and Stinson, J. (2014) Managing Pain in Children: a clinical guide. West Sussex: Whiley- Blackwell. Paediatric Analgesia Guidelines Yes Registered nurse competent in administering intravenous medications. Staff Need to complete competency pack for PCA/Morphine infusions. Attendance to Child Health Pain Management study morning. 3 yearly update for medical devices. Version Control Table Date Version No Nov 10 V1.0 Initial Issue Summary of Changes Sept 12 V2.0 Format changed and content updated. Nov 15 V3.0 Content updated Changes Made by (Name and Job Title) Sarah Fox Paediatric Pain Specialist Nurse Sarah Fox Paediatric Pain Specialist Nurse Sarah Fox Paediatric Pain Specialist Nurse All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 9 of 11

10 Appendix 2. Initial Equality Impact Assessment Form Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description):clinical guideline for an epidural infusion in Child Health Directorate and service area: Acute Paediatric Pain Service/Child Health Name of individual completing assessment: Sarah Fox 1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at? Is this a new or existing Policy? Existing Telephone: Bleep 2283 The purpose of this guideline is to provide guidance on caring for children who are receiving epidural pain relief 2. Policy Objectives* Children with an epidural infusion are cared for safely 3. Policy intended Outcomes* Children with an epidural infusion are cared for safely Side effects are identified and dealt with safely Requirements for training identified 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? Regular audit of notes Regular review of children with epidurals by pain team Monitor Datix/medication error reports Patients Nursing staff No b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure. 7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence Age Sex (male, female, transgender / gender reassignment) Page 10 of 11

11 Race / Ethnic communities /groups Disability - Learning disability, physical disability, sensory impairment and mental health problems Religion / other beliefs Marriage and civil partnership Pregnancy and maternity Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please explain why. Signature of policy developer / lead manager / director Date of completion and submission Names and signatures of members carrying out the Screening Assessment Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust s web site. Signed _Sarah Fox Date November 2015 Page 11 of 11