dressing changes in adults and children. Contributes to CQC Outcome number: 4

Transcription

1 Administering Intra-Nasal Diamorphine to Burns Patients Clinical Guideline Trust Register No: Status: Public Developed in response to: Improving efficacy of analgesia for burns dressing changes in adults and children. Contributes to CQC Outcome number: 4 Consulted With Individual/Body Date Pharmacy Pain Service Children s Burns Ward Jackie Wallis Lynne Mustard Sue Boasman May 2018 May 2018 May 2018 Professionally Approved By Dr Peter Berry May 2018 Version Number 3.0 Issuing Directorate Ratified by: Burns and Plastics DRAG Chairmans Action Ratified on: 18 th June 2018 Trust Executive Board Date: August 2018 Implementation Date 22 July 2018 Next Review Date June 2021 Author/Contact for Information Policy to be followed by Distribution Method Related Trust Policies (to be read in conjunction with) Dr Patricia Richardson- Consultant Anaesthetist All clinical staff working in the burns unit Intranet, Website and internal department distribution Clinicians and Nursing Staff. Infection Prevention Clinical Guidelines Administering Intra-nasal Diamorphine to Children 0-16 years Document Review History Version No Reviewed by Issue Date 1.0 Dr Patricia Richardson, Consultant Anaesthetist Aug Amendments to 7, 8.4 & Appendices Dr Patricia Richardson, Consultant Anaesthetist Mar 2010 on Dosages following audit 2.0 Dr Patricia Richardson, Consultant Anaesthetist Nov Amendments to Appendix 4 based on Dr Patricia Richardson, Consultant Anaesthetist May mg ampoules Mr Niall Martin, Consultant Burns Surgeon 2.2 amendment to appendix 4 back to Dr Patricia Richardson, Consultant Anaesthetist February mg ampules 3.0 Dr Patricia Richardson, Consultant Anaesthetist 22 nd July 2018

2 Index 1. Purpose 2. Equality and Diversity 3. Scope 4. Staff Training 5. Indications for Use 6. Contraindications and Cautions for Use 7. Dosage of Intranasal Diamorphine 8. Procedure and Communication 9. Absorption 10. Monitoring and Post-administration Care 11. Infection Control Procedures 12. Audit and monitoring 13. References Appendix 1 Appendix 2 Appendix 3 Appendix 4 Table of diluent required for weight of child Advice sheet for parents following administration of intra nasal diamorphine Advice sheet for adults following administration of intra nasal diamorphine Guideline summary 1. Purpose

3 1.1 Intra-nasal diamorphine is a fast-acting analgesic for the relief of moderate to severe pain. Giving drugs by the nasal route is well described and has several advantages (see refs at end). 1.2 The purpose of this document is to provide a robust guideline for Trust Clinicians to follow when prescribing and administering intra-nasal diamorphine to a burns patient (adult or child) undergoing a painful procedure anticipated to last <30 minutes. 1.3 A summary of this guideline is attached as Appendix A copy of this policy will be kept on the burns unit This document must be adhered to and the steps of administration followed by all staff. 2. Equality and Diversity 2.1 Mid Essex Hospital Services NHS Trust is committed to the provision of a service that is fair, accessible and meets the needs of all individuals. 3. Scope 3.1 Adults and children over 10kg and 12 months of age attending the Burns Unit (inpatient or outpatient), undergoing a potentially painful dressing change or procedure likely to take less than 30 minutes. 4. Staff Training 4.1 This drug can be administered by any registered nurse working in the Burns Unit once the drug has been accurately prescribed. 5. Indications for Use 5.1 Analgesia for procedural burn pain. 5.2 Intra-nasal diamorphine can also be of benefit in the rapid control of background burn pain, especially on presentation. 6. Contraindications and Cautions for Use 6.1 Contraindications Children <10kg and/or <12 months of age Known allergy to diamorphine A head injury / raised intra-cranial pressure Epistaxis Airway / respiratory problem Concomitant midazolam use Phaeochromocytoma Biliary colic

4 Acute alcoholism Diamorphine is also contra-indicated where there is a risk of paralytic ileus, or in acute diarrhoeal conditions associated with antibiotic-induced pseudomembranous colitis or diarrhoea caused by poisoning (until the toxic material has been eliminated). 6.2 Cautions Concomitant opiates Burns patients are often taking long-acting opiates to control background pain. Intra-nasal diamorphine use is appropriate where this opiate dose is stable, the patient is alert and shows no signs of opiate overdose. Intra-nasal diamorphine has been used successfully with an oral opiate coadministered. However, the dose and timing of this should be noted and considered to avoid over dosage History of drug addiction The euphoria or high experienced during diamorphine use makes is less suitable for patients with a history of drug addiction Interaction with other medicinal products Use with caution if patient is on other CNS excitation or CNS depressive agents Pregnancy and breast-feeding Safety has not been established in pregnancy Diamorphine should not be given to females who are breast feeding as there is limited information available Medical History Use with caution or in reduced doses in patients with toxic psychosis, CNS depression, myxoedema, prostatic hypertrophy or urethral stricture, severe inflammatory or obstructive bowel disorders, hypotension, shock, convulsive disorders or adrenal insufficiency. 7. Dosage of Intranasal Diamorphine 7.1 The table of diluent is detailed in Appendix Children: Dose:100 micrograms/kg to a maximum of 5mg. 7.3 Adult (age above 16 years of age): Dose according to Weight: > 65kg: 10mg

5 50 65 kg: 7.5mg < 50kg: 0.1mg/kg (as per child) 7.4 The adult dose is split between 2 syringes containing 5mg and 2.5mg/5mg 7.5 Each syringe contains 0.2ml of the DILUTED solution (all of which is administered to the patient) regardless of dose to be given (see Table 1). Dose is adjusted by changing the concentration, not the volume. 7.6 Top-ups if required may be given as 0.05mg/kg or half initial dose after 15 minutes. 7.7 The dosage used may be titrated up or down at subsequent procedures if necessary to achieve good analgesia. 8. Procedure and Communication 8.1 Explain procedure to the patient and/or parent/guardian/carer. Reassure the patient that this is a painless, quick method of effective pain relief. Explain that some may sneeze after administration and /or have a funny taste in their mouth. 8.2 Obtain verbal consent from patient and any parent, carer or guardian as appropriate. Intra-nasal diamorphine has a rapid onset of effect and so all equipment required for the procedure should be prepared and ready prior to administration of the drug. Administration Instructions 8.3 Ensure equipment for administration of oxygen by a face mask is available in the unlikely event of oxygen desaturation. 8.4 Check the patients weight (in kg) and ensure correct dose prescribed 8.5 Note time and dose of last opiate. If any concerns, discuss with the prescriber. 8.6 Ensure nostril is clear of mucus, using gentle suctioning or by blowing the nose if necessary. 8.7 Assess likely post-procedural analgesic requirements. Administer paracetamol +/- ibuprofen if appropriate so that these are effective when diamorphine wears off 8.8 Dosing for a Child (16 years of age or younger) or adult < 50kg follow the next 5 bullet points A child or adult < 50kg will receive 100 micrograms/kg of diamorphine.

6 8.8.2 Use Table 1 (Appendix 1) to determine the amount of diluent (0.9% Normal Saline) required. The smaller the patient the larger the amount of diluent Use a 1ml syringe to add the said volume of diluent to a 5mg Diamorphine ampoule (see Appendix 1 for volume required) Draw 0.2ml of solution into a syringe, attach syringe to a mucosal atomizer. ( If atomiser unavailable, administer without) Discard all but 0.2ml of the resultant solution (following controlled drugs procedure, recording discarded amount in CD book). 8.9 Dosing for an adult (over 16 years of age and > 50kg): Prescribe diamorphine 7.5mg for patients under 65kg or 10mg for patients over 65kg. (Patients less than 50kg use 0.1mg/kg as per dosing for a child). These doses are a guide and patients sensitivity and previous exposure to opiates must be taken into account Doses over 5mg should be administered via two syringes and both nostrils used. One syringe will contain 5mg in 0.2ml and the second 2.5mg (or 5mg) in 0.2ml. Drug administration 8.10 Draw air into the syringe and flick syringe to cause air to lie between liquid drug and syringe plunger. This will ensure that as drug squirts into the nose it is followed by air which will flush out the atomiser Ask the patient to lie back in a comfortable position with head tipped back. Younger children may be wrapped in a blanket and held in the parent/guardian/nurses arms 8.12 Repeat the process for the second syringe in adult patients. 9. Absorption 9.1 Absorption can be as fast as IV route and the same opiate side effects can occur. Peak plasma levels are reached at 5 minutes. Optimum effects last for 20 minutes but pain relief may be experienced for longer. 10. Monitoring and Post Administration Care 10.1 Opiate related side-effects (eg respiratory depression, nausea/vomiting and drowsiness) are possible although rare. A verbally responsive patient does not require formal monitoring during the course of the procedure If there are concerns about adequacy of ventilation, administer facial oxygen and medical help should be summoned immediately.

7 10.3 Practitioners administering these drugs must be proficient in the emergency response and resuscitation of patients demonstrating adverse effects Airways maintenance, oxygen delivery and the administration of naloxone must be considered Out-patients should be given a Patient Advice Sheet prior to discharge. These are available in two forms; Intranasal Diamorphine Advice Sheet for parents/guardians of children attending burns out-patients (Appendix 2) and Intranasal Diamorphine Advice Sheet for burns out-patients (Appendix 3). 11. Infection Control Procedures 11.1 Trust guidelines on Infection Control will be adhered to by all staff when preparing and administrating this drug Hands must be decontaminated according to the Trust s Handwashing Policy before and after the procedure If there is a potential for contact with bodily fluids, then gloves and aprons should be worn. 12. Audit and monitoring 12.1 Any concerns or critical incidents to be reported to the duty anaesthetic consultant and via the Datix system. 13. References Alexander-Williams JM, Rowbotham DJ. Novel routes of opioid administration. British Journal of Anaesthesia 1998; 81: 3 7 British National Formulary for children British Medical Association and the Royal Pharmaceutical Society of Great Britain. London: BMJ Books; Wallingford, Oxon: Pharmaceutical Press. Hallett A, O Higgins F, Francis V, Cook TM. Patient-controlled intranasal diamorphine for postoperative pain: an acceptability study. Anaesthesia 2000; 55: Kendall JM, Reeves BC Latter VS Multicentre randomised controlled trial of nasal diamorphine for analgesia in children and teenagers with clinical fractures BMJ 2001: Leeds Teaching Hospitals NHS Trust. Children s Pain Service April Intra-nasal diamorphine. Wilson JA, Kendall JM, Cornelius. Intranasal diamorphine for paediatric analgesia: assessment of safety and efficacy. Journal of Accident and Emergency Medicine 1997; 14: Skopp G, Gannmann B, Cone EJ, Aderjan R. Plasma concentrations of heroin and morphine-related metabolites after intranasal and intramuscular administration. J Anal Toxicol 1997 Mar-Apr; 21 (2):

8 Appendix 1 Table 1: Volume of diluent (Sodium Chloride 0.9% in mls) used to dilute the contents of a 5mg ampoule of Diamorphine according to weight in kg Please note: PROTOCOL FOR 5mg DIAMORPHINE AMPOULES Ensure you are using the correct ampoules Weight (kg) Approx age* (years) Volume of diluent (NaCl 0.9%) to be added to 5mg Diamorphine ampoule (mls) Resultant dose of Diamorphine in 0.2mls (micrograms) Adult <65kg 1st syringe 0.2 2nd syringe 0.4 Adult >65kg 1st syringe 0.2 2nd syringe 0.2 *only use age to estimate dose where obtaining a weight is not possible. 5mg + 2.5mg = 7.5mg total (0.2mls +0.2 mls) 5mg + 5mg = 10mg total (0.2mls +0.2 mls) Adults may weigh less that 50kg and children more. Use dose per weight if unsure.

9 Appendix 2 St Andrews Centre for Plastic Surgery and Burns INTRANASAL DIAMORPHINE ADVICE SHEET for parents/guardians of children attending burns out- Patients Your child has been given pain relieving medication, diamorphine, which can make them drowsy and sleepy. The effects should have worn off within an hour but there is a wide variation in the susceptibility of different people to these side effects and it is important that you consider how they affect your child and act accordingly. They may safely leave hospital when they have returned to their normal level of mobility, without dizziness and when you feel happy to take them home. Please ensure that an adult is with your child until you are confident that your child is not drowsy or sleepy to ensure that they do not harm themselves. Please feel free to ask for any further information you may require. If you have any concerns once you have left hospital, we may be contacted in the following ways. Childrens Burns Ward (E225) 24 hours

10 Appendix 3 INTRANASAL DIAMORPHINE ADVICE SHEET for Adult Burns Out-Patients You have been given pain relieving medication which can make you drowsy and sleepy. You may safely leave hospital after this time when you have returned to your normal level of mobility, without dizziness and when you feel well enough to do so. The drowsiness and sleepiness can affect your ability to drive, operate machinery, or make important decisions and you should avoid undertaking these tasks until you feel sure that these drug effects have worn off. It is a criminal offense to drive if your ability to do so is affected by prescribed sedative drugs such as those you have been given. The DVLA puts the responsibility for the decision to drive with you. Alcohol will enhance the effects of the drugs you have been given and is best avoided in the first few hours following diamorphine administration. There is a wide variation in the susceptibility of different people to these side effects and it is important that you consider how they affect you and act accordingly. Please feel free to ask for any further information you may require. If you have any concerns when you have left hospital, we may be contacted in the following ways. Burns Out-patients Monday- Friday 08:00-16:00 Saturday 09: Burns ward (E221) 24 hours

11 Appendix 4 Guideline Summary for Intra-nasal (IN) Diamorphine in Burns Indications: Analgesia for procedural pain Rapid control of background burn pain Contraindications for nurse administration: Child <10kg and/or < 12 months Opiate within last hour other than usual background analgesia Procedure: 1. Weigh patient in kg 2. Prescribe children (16 years or younger) IN diamorphine 0.1mg/kg +/- top up at 0.05mg 3. Prescribe adults (over 16 years of age) <65 kg: 7.5mg or >65kg: 10mg or by weight (as per child) if less than 50kg 4. Prepare for dressing procedure as analgesic effect evident within 5 mins 5. Use the table below to derive the volume of normal saline to be added to diamorphine powder 6. Once added, draw 0.2 mls of solution into 1 ml syringe with a small amount of air position to follow the liquid, and attach atomiser 7. Gentle tip patients head back, occlude one nostril and squirt drug into patients other nostril, aiming for tip of same side ear 8. Ensure dead space of atomiser flushed through with air either during same or separate injection 9. In adults, repeat process with second syringe Following IN administration Opiate toxicity (decreased conscious level, slow respiratory rate) is unlikely with this procedure. Facilities for oxygen administration and monitoring oxygen saturation must be available at all times. If the patient is within sight of nursing staff, verbally responsive and awake, monitoring equipment does not need to be applied. The duration of analgesic effect is variable but is likely to last minutes. Please record the efficacy of this technique to guide analgesic plan for subsequent procedures. Volume of diluent to be used to dissolve the contents of a 5mg ampoule of Diamorphine Volume of diluent (NaCl 0.9%) to be Weight (kg) added to 5mg Diamorphine ampoule (mls) Resultant dose of Diamorphine in 0.2mls (micrograms)

12 Adult <65kg 1st syringe 0.2 5mg + 2.5mg = 7.5mg total 2nd syringe 0.4 (0.2mls +0.2 mls) Adult >65kg 1st syringe 0.2 5mg + 5mg = 10mg total 2nd syringe 0.2 (0.2mls +0.2 mls)