1.1. Nursing guidelines for the use of local anaesthetic infusions/infiltrations via a nerve catheter for the management of pain.

Transcription

1 CLINICAL GUIDELINE FOR USE OF LOCAL ANAESTHETIC INFUSION/INFILTRATION VIA A NERVE CATHETER FOR THE MANAGEMENT OF PAIN. 1. Aim/Purpse f this Guideline 1.1. Nursing guidelines fr the use f lcal anaesthetic infusins/infiltratins via a nerve catheter fr the management f pain A nerve blck is a technique which can be used t prvide analgesia pstsurgery, trauma r nerve injury. It can be used as part f a multimdal apprach t analgesia t reduce piid requirements and side-effects The injectin f lcal anaesthetic t nerves in the affected area blcks the pain impulses travelling frm the receptrs t the brain After surgery lcal anaesthetic can be injected either near nerves, fr example a wund infiltratin, r a jint cavity. The anaesthetist r surgen can extend the effect by inserting a fine bre catheter int the apprpriate area and infusing lcal anaesthetic. This can be via an elastmeric device, infusin pump r prescribed blus injectin. 2. The Guidance 2.1. Prfessinal respnsibility A registered nurse wh has attained cmpetency in IV drug administratin; received training, assessment and been deemed cmpetent in managing the infusins r administering a prescribed blus shuld be respnsible fr the delivery f treatment. This includes training in the use f the McKinley 595 infusin pump and treatment f lcal anaesthetic txicity Supprtive mechanism Fr advice between the hurs f cntact the Pain Specialist Nurses via bleep. Out f hurs cntact the n-all anaesthetist Prescriptin All prescriptins are the respnsibility f anaesthetist/dctr. The prescriptin shuld be timed and dated. The duratin f treatment may be prescribed by the anaesthetist r its discntinuatin may be at the discretin f the clinical team Prescriptin fr the McKinley 595 infusin. There are tw standard prescriptins using pre-packed bupivacaine (levbupivacaine) bags. Prtcl A: Bupivacaine 0.125%, 0-10ml/hur Prtcl B: Bupivacaine 0.125%, 0-5ml/hur with ptinal patient cntrlled blus f 0-5ml. Page 1 f 10

2 The pumps als have a 3 rd prtcl: Prtcl C: 0-20ml/hur. This can be used with different lcal anaesthetic preparatins but nly at the discretin f the anaesthetist. The prescriptin shuld specify hw the drug shuld be diluted Prescriptin fr Elastmeric infusin. Bupivacaine (levbupivacaine) 0.5% 100mls. Rate f 2 5mls as prescribed dependent n the device being used Prescriptin fr Blus. Bupivacaine (levbupivacaine) 0.25% 10mls every six hurs. This dse may be altered accrding t patient weight Equipment and delivery - The patient must have a patent intravenus cannula in situ fr the duratin f the infusin/treatment Elastmeric Devices e.g. Pain Busters. The elastmeric device shuld be filled accrding t the manufacturer s guidelines using an aseptic nn-tuch technique. The elastmeric device must be nly be used fr lcal anaesthetic infusins. The line must be clearly labeled. Always check that the infusin is cnnected t the crrect infusin prt. Remember t recrd date and start time t assist with nging infusin mnitring. Elastmeric devices must nly be filled by healthcare prfessinals wh have received the apprpriate training. Never ver fill r refill the device Infusin pump: McKinley 595. The McKinley 595 infusin pump labeled nerve blck/wund infiltratin is nly t be used fr lcal anaesthetic infusins. Pump identity numbers must be recrded n setting up infusin. There is a dedicated grey clured giving set which is t be used with s it is easily identifiable as a lcal anaesthetic infusin. The line shuld be labeled apprpriately. The infusin bag and rate must nly be changed be an apprpriately trained registered nurse. The pump must be placed at trunk height t avid syphning. Delays in changing the infusin bag shuld be avided t achieve cnstant analgesia. An aseptic nn-tuch technique must be used. Giving sets must be changed every 72 hurs. NB. Additinal lcal anaesthetic bluses shuld nly be given by the anaesthetist r apprpriate clinician. Page 2 f 10

3 Nerve catheter blus injectin. Prepare drug fr administratin accrding t prescriptin using an aseptic nn-tuch technique. Check catheter insertin site fr signs f migratin, leakage and infectin. D nt inject if there are any cncerns and cntact the patient s medical team, Pain Specialist Nurse r anaesthetist. Ensure the catheter is apprpriately labeled and a filter is in situ Using an aseptic nn-tuch technique attach the syringe and aspirate fr bld using a lw frce fr 30 secnds. If bld is aspirated, d nt administer the blus. Infrm the medical team, anaesthetist r Pain Specialist Nurses. If n bld aspirated, inject 5mls ver 2-3 minutes. Wait 5 minutes Ask the patient t infrm yu f any duble visin, tinnitus, numb muth r metallic taste. Observe fr any twitching f the limbs r sudden cnfusin. If the patient exhibits n side effects, inject the remaining vlume ver 5 minutes. Remve the syringe ensuring there is a sterile cap r bung n the line Mnitring and management Clse mnitring is essential nt nly t detect ptential cmplicatins frm the surgery r trauma but als any adverse reactins frm the lcal anaesthetic agents Clse Patients shuld be nursed in an area where there is adequate mnitring and cmpetent staff Observatins shuld be recrded n the Natinal Early Warning Scre chart (NEWS) and the Analgesia Assessment chart using the specific scring system fr mtr pwer and lcal anaesthetic txicity Intravenus access must be maintained whilst the infusin/treatment is in prgress and cannula care carried ut as per RCHT prtcl The catheter insertin site shuld be bserved at each blus r at least twice daily if infusin running, fr signs f infectin r leakage. Any prblems shuld be reprted t the medical team, anaesthetist r pain specialist nurse Mbility patients with blcks t lwer limbs may mbilise with supprt fllwing assessment f limb strength. Mtr bck is cmmn. Ensure that limbs with mtr blck are supprted at all times and pressure area care is carried ut. Page 3 f 10

4 On cmmencement f treatment clinical bservatins: pulse, bld pressure, respiratins, sedatin and pain scres shuld be recrded: Every 15 mins fr 1 hur Every 30mins fr 2 hurs Hurly fr 4 hurs 4 hurly thereafter unless patient s cnditin indicates therwise. Pain scres shuld be recrded at rest and n mvement Lcal anaesthetic txicity and mtr pwer mnitring shuld be recrded n the Analgesia Assessment chart: Hurly fr 2 hurs 4 hurly thereafter r unless the patient s cnditin changes r a blus is administered Ptential cmplicatins Lcal anaesthetic txicity can ccur, especially if there is rapid absrptin int the bld stream, r if inadvertently administered intravenusly. This is very rare but it is imprtant that the signs are recgnised Signs f txicity: 1. Mild Restlessness/cnfusin Light-headedness Numbness f tngue and lips (lip smacking) Tinnitus Duble visin, blurred visin 2. Mderate Heaviness f limbs Muscular twitching Cnvulsins 3. Severe Cardia arrhythmias Hyptensin Respiratry arrest Cardia arrest Treatment f txicity If symptms are: 1. Mild: Stp lcal anaesthetic infusin and infrm medical team. Attach ECG and mnitrs Maintain xygenatin and BP Cnsult with medical team, Pain Team r n call anaesthetist Cntinue t bserve clsely. Page 4 f 10

5 2. Mderate r Severe (2 r 3) Stp lcal anaesthetic infusin Attach ECG and mnitrs Phne fr help immediately fast bleep 4444 medical team / anaesthetist r cardiac arrest 2222 Maintain airway and give high flw xygen Hyptensin will be treated with IV fluids Cnvulsins will be treated with diazepam Cmmence CPR if in cardiac arrest Cllect Lipid Rescue Bx frm the nearest recvery area r Eden ward if patient is in lcal anaesthetic induced cardiac arrest. Treatment will require intravenus Intralipid 20% (frm the Lipid Rescue Bx). The initial dse is 1.5ml/kg ver 1 minute, fllwed by an intravenus infusin f 15ml/kg ver 1 hur. Fr a 70kg adult this means 100mls ver 1 minute fllwed by 1000mls ver 1 hur. Refer t The Assciatin f Anaesthetists f Great Britain and Ireland safety guideline Management f Severe Lcal Anaesthetic Txicity Difficulty injecting thrugh the catheter r leakage at the site ask the surgical team r anaesthetist Lcal infectin at the catheter site ask surgical team r Pain specialist nurse t review. It is likely that the catheter will have t be remved Remval f catheter The catheters must be remved n day 5 r sner if infectin r leakage ccurs. This can be reviewed at the time (if felt necessary) and the catheters left in fr a maximum f 7 days Using an aseptic nn-tuch technique remve the dressing. Apply gentle tractin t the catheter. This shuld be enugh t remve it. If there is any resistance infrm the surgical team. The catheter shuld nly be remved by a trained member f staff Ensure the blue tip is intact n the end f the catheter dcument in patient s nursing evaluatin Send the tip fr MC&S if infectin is suspected Cver with a nn-cclusive dressing Remve the dressing after 24 hurs. Page 5 f 10

6 1. Mnitring cmpliance and effectiveness Element t be mnitred Lead Tl Frequency Reprting arrangements Acting n recmmendatins and Lead(s) Change in practice and lessns t be shared Adherence t guideline Acute Pain Team The patient will be reviewed daily by the acute pain team r n call anaesthetist and adherence t the guideline will be recrded in the patient s medical ntes and MAXIMS database. DATIX reprts will be investigated Pain frms will be audited yearly The audit is reprted t the Acute pain lead cnsultant, the Pain Team gvernance lead and anaesthetic gvernance lead. Acute Pain Team Required changes will be identified and actined within 1 mnth. A lead member f the tem will be identified t take each change frward where apprpriate. Lessns will be shared with all relevant stakehlders. 2. Equality and Diversity 2.6. This dcument cmplies with the Ryal Crnwall Hspitals NHS Trust service Equality and Diversity statement which can be fund in the 'Equality, Diversity & Human Rights Plicy' r the Equality and Diversity website Equality Impact Assessment The Initial Equality Impact Assessment Screening Frm is at Appendix 2. Page 6 f 10

7 Appendix 1. Gvernance Infrmatin Dcument Title Date Issued/Apprved: 01/12/2015 Clinical Guideline fr use f Lcal Anaesthetic Infusin / Infiltratin via a Nerve Catheter fr the Management f Pain. Date Valid Frm: 01/12/2015 Date Valid T: 01/12/2018 Directrate / Department respnsible (authr/wner): Jayne Thmas Pain specialist nurse Cntact details: Brief summary f cntents Suggested Keywrds: Target Audience Executive Directr respnsible fr Plicy: Nursing guidelines fr the care f a patient with a nerve catheter and the administratin f lcal anaesthetic infusin/infiltratin/blus injectin Lcal anaesthetic, nerve catheter, lcal anaesthetic infusin, lcal anaesthetic blus Date revised: 1/12/15 This dcument replaces (exact title f previus versin): Apprval rute (names f cmmittees)/cnsultatin: Divisinal Manager cnfirming apprval prcesses Name and Pst Title f additinal signatries RCHT PCH CFT KCCG Medical Directr Cntinuus lcal anaesthetic infusin nursing guidelines Acute Pain lead cnsultant and Pain services Duncan Bliss Nt required Name and Signature f Divisinal/Directrate Gvernance Lead cnfirming apprval by specialty and divisinal management meetings Signature f Executive Directr giving apprval Publicatin Lcatin (refer t Plicy n Plicies Apprvals and Ratificatin): {Original Cpy Signed} Name: {Original Cpy Signed} Internet & Intranet Intranet Only Page 7 f 10

8 Dcument Library Flder/Sub Flder Links t key external standards Related Dcuments: Training Need Identified? Clinical / Pain The Assciatin f Anaesthetists f Great Britain and Ireland safety guideline Management f Severe Lcal Anaesthetic Txicity. Rectus sheath guidelines Yes Administratin f IV drugs. McKinley pump 595 training. Staff need t attend a training sessin and carry ut witnessed and supervised practise t gain cmpetency Versin Cntrl Table Date Versin N 10 Jun 10 V1.0 Initial Issue Summary f Changes 1 Feb 11 V2.0 Additin f Mnitring Cmpliance table. 15 Jan 12 V2.1 5 Aug 13 V2.2 Gvernance infrmatin mved t an appendix. EIA updated. Gvernance infrmatin amended t align with frmat f Updated gvernance infrmatin table t include KCCG. 2/11/15 V3 Refrmatted t Trust template 2/11/15 V3.1 2/11/15 V3.2 Additin f infrmatin regarding blus administratin Additin f infrmatin regarding the treatment f lcal anaesthetic txicity and remval f catheter. Changes Made by (Name and Jb Title) Andrew Rgers Crprate Recrds Manager Andrew Rgers Crprate Recrds Manager Andrew Rgers Crprate Recrds Manager Andrew Rgers Crprate Recrds Manager Jayne Thmas Pain specialist nurse Jayne Thmas, Pain specialist nurse Jayne Thmas, Pain specialist nurse All r part f this dcument can be released under the Freedm f Infrmatin Act 2000 This dcument is t be retained fr 10 years frm the date f expiry. This dcument is nly valid n the day f printing Cntrlled Dcument This dcument has been created fllwing the Ryal Crnwall Hspitals NHS Trust Plicy n Dcument Prductin. It shuld nt be altered in any way withut the express permissin f the authr r their Line Manager. Page 8 f 10

9 Appendix 2 Initial Equality Impact Assessment Frm Name f Name f the strategy / plicy /prpsal / service functin t be assessed (hereafter referred t as plicy) (Prvide brief descriptin): Clinical guideline fr the use f lcal anaesthetic infusin/infiltratin via a nerve catheter fr the management f pain. Directrate and service area: Is this a new r existing Plicy? Anaesthetics/pain Existing Name f individual cmpleting Telephne: assessment: Jayne Thmas 1. Plicy Aim* Wh is the strategy / plicy / prpsal / service functin aimed at? Nursing guidelines fr the use f lcal anaesthetic infusin via a nerve catheter fr the management f pain. 2. Plicy Objectives* Safe management fr patients with nerve catheters. 3. Plicy intended Outcmes* 4. *Hw will yu measure the utcme? 5. Wh is intended t benefit frm the plicy? 6a) Is cnsultatin required with the wrkfrce, equality grups, lcal interest grups etc. arund this plicy? b) If yes, have these *grups been cnsulted? Patient will be managed safely and effectively Regular audit Review f patients by acute pain team Mnitring f DATIX reprts. Patients and staff n C). Please list any grups wh have been cnsulted abut this prcedure. 7. The Impact Please cmplete the fllwing table. Are there cncerns that the plicy culd have differential impact n: Equality Strands: Yes N Ratinale fr Assessment / Existing Evidence Age Sex (male, female, transgender / gender reassignment) Race / Ethnic cmmunities /grups Page 9 f 10

10 Disability - Learning disability, physical disability, sensry impairment and mental health prblems Religin / ther beliefs Marriage and civil partnership Pregnancy and maternity Sexual Orientatin, Bisexual, Gay, hetersexual, Lesbian Yu will need t cntinue t a full Equality Impact Assessment if the fllwing have been highlighted: Yu have ticked Yes in any clumn abve and N cnsultatin r evidence f there being cnsultatin- this excludes any plicies which have been identified as nt requiring cnsultatin. r Majr service redesign r develpment 8. Please indicate if a full equality analysis is recmmended. Yes N 9. If yu are nt recmmending a Full Impact assessment please explain why. Signature f plicy develper / lead manager / directr Date f cmpletin and submissin Names and signatures f members carrying ut the Screening Assessment Keep ne cpy and send a cpy t the Human Rights, Equality and Inclusin Lead, c/ Ryal Crnwall Hspitals NHS Trust, Human Resurces Department, Knwledge Spa, Trur, Crnwall, TR1 3HD A summary f the results will be published n the Trust s web site. Signed Date Page 10 f 10