The Anaesthetic Department and the Acute. Pain Management Service is committed to. ensuring the safety of all internal patients.

Transcription

1 Guideline Title: Clinical guideline for Continuous Local Anaesthetic Infusion for post operative pain relief for Peripheral Nerve, Muscle Sheath and wound Infusion Document Number: WN_GL2015_XXX Summary: The Anaesthetic Department and the Acute Pain Management Service is committed to ensuring the safety of all internal patients. The OLHS ensure that the delivery of Regional Anaesthesia pain management techniques will be delivered in a safe effective manner by accredited Anaesthetic Department Acute Pain Service and nursing staff. The standardisation delivery of Regional Analgesia for acute pain management is in line with best evidence based practice. Key Words: Anaesthetics, Local Anaesthetics, Health Care, Nursing Guidelines, Drugs, Acute Pain Service, Infusions, Nerve Blocks, Catheters. Directorate: Functional Sub Group: Clinical Corporate New Replaces: Endorsement Date: Publication Date:

2 Next Review Due: (5 years following publication) Applies To: Clinical Network: National Standards that this Guideline Applies To: Approved By: Chief Executive Version Control and change history: Version Date from Date to Amendment 1.0 Original Version CONTENTS PAGE 1. Purpose 2. Key Principles 3. Use of the Guideline 4. Document Retention 5. References and Links 6. Attachments

3 1: Purpose This guideline provides governance and guidance to all Registered Nurses and Enrolled Nurses with Medication Endorsement within the Orange LH Services for a standard approach to the management of patients who have been prescribed Regional Analgesia via continuous infusion, peripheral nerve catheter/s, muscle sheath or wound infusions for trauma or post operative surgery for acute pain management. This document outlines the potential and actual use of Local Anaesthetic analgesia used by the Anaesthetic, ICU, Emergency Departments and Acute Pain Service outlining the precautions and care required. Regional Analgesia using catheter/s or nerve blocks are usually delivered by an Anesthetist Anaesthetic Registrar, ICU, Emergency Department and Pain Team who are deemed competent in the clinical technique of regional nerve blockade either as a single injection or catheter/s placement for continuous infusion or single top up injection. Regional analgesia catheter/s and nerve blocks are a technique which can reduce harmful effects of pain, aid recovery and healing, shorten length of stay, improve quality of pain management treatment and minimise suffering to the client, prevent escalation of opioids in acute and chronic pain management patients. Definition: Must Should Clinician Infusion Rate Local Anaesthetic Nerve Block Top Up Dose Regional Anaesthesia Indicates a mandatory practice required by law or considered by the NSW Health to be necessary in the interest of patient safety Indicates a practice strongly recommended by the Local Health District (LHD). A decision not to conform to a recommended practice must be able to be substantiated and the rationale is to be clearly documented in the patient s clinical notes. A health practitioner or health service provider (whether or not the person is Registered with the Australian Register of Health Professionals), e.g. nurses, midwives, medical practitioners, allied health practitioners, social workers, psychologists, aborig health worker etc. Infusion rates will depend on the area being blocked and the expected rate of absorption from that area (depending on vascularity). Works by pharmacologically blocking the nerve supply to a certain part of the body. This is achieved by reversibly interrupting the conduction of the impulses along the fibres. A nerve block is a single injection of numbing medication (local anaesthetic) near specific nerves to decrease the sensory of pain in a certain part of the body during and after surgery. The reinforcement of anaesthesia by a never catheter "top-up additional dose local anaesthetic needed to restore pain relief. Is loss of sensation in a region of the body produced by application of an anaesthetic agent to all the nerves supplying that region, hence providing pain relief?

4 continuous peripheral nerve A continuous peripheral nerve blockade is achieved by placing a fine catheter close to a nerve or nerve receptors and infusing a solution of local anaesthetic either at an hourly rate or as prescribed bolus doses. The presence of the catheter allows the block to continue for a number of days post-surgery, thereby improving patient analgesia, and lessening the need for more invasive blocks or strong opiates. 2: Key Principles Effective analgesia is crucial to patient outcome after major surgery to ensure comfort, mobilisation and decreased risk of potential post-operative complications such as DVT and chest infection. Ensure that there is a common understanding when using a local anaesthetic, to ensure safe delivery of clinical practice and patient care by all health professionals involved. Ensure that the necessary knowledge and competencies are practised throughout the provision and delivery of patient care, knowledge of the drug/s, potential side effects and use of specific pump/delivery device. All clinicians MUST have education and be deemed competent in the clinical practice and management of Regional Analgesia to safely operate and adhere to requirements of the Australia & New Zealand College of Anesthetists and best clinical practice. Education of the patient prior to procedure or injection MAY be attended by the Anesthetist Anaesthetic Registrar, ICU Team, Emergency medical officer or Pain Team appropriately outlining the practice and management of Regional Analgesia prior to surgery or as a rescue block. 3: Use of the Guideline Procedure: Regional Analgesia using catheter/s or nerve blocks are usually delivered by an Anesthetist Anaesthetic Registrar, ICU team, Emergency medical officer or Acute Pain Team who is deemed competent in the clinical technique of regional nerve blockade either as a single injection or catheter placement for continuous infusion or single top up injection. The nerve infusion catheter will be inserted in the operating theatre or procedure room in theatres or ICU/HDU under a sterile field. Accredited Staff permitted to perform procedures 1. VMO Anesthetist 2. Anaesthetic Registrar 3. Acute Pain Service 4. ICU Consultant / ICU Registrar 5. Emergency Consultant / Emergency Medical Officer

5 Regional Analgesia Infusion using a single lumen catheter Paravertebral Femoral Sciatic Wound Infusion Nerve Catheter for top-up injection only Femoral Sciatic Rectus Sheath Transverses Abdominal Plan (TAP) Subcostal Serratus Pectoralis Single nerve injection as a rescue block Femoral Saphenous Fascia Iliaca Sciatic Transverses Abdominal Plan (TAP) Rectus Sheath Serratus I Subcostal Indications for Regional Anaesthesia Analgesia Patients experiencing pain after surgery / trauma part of a multimodal approach to analgesia to decrease opiate requirements, and avoid side effects to reduce presentations to ICU / HDU and reduce length of stay to health service encourage chest physio and mobilisation and meet goals Contraindications Patient refusal to treatment Previous adverse effects with local anaesthetics Superficial infection at site of potential insertion Inadequate knowledge and clinical skills to perform clinical practice Bleeding disorders When prescribing the local anaesthetic drug for infusion and or bolus dose the following information should be provided:

6 Peripheral nerve infusion or Bolus: Prescription

7 Prescribing Date and time with name of prescribing doctor Type of nerve infusion or block name of local anaesthetic to be infused concentration and total volume to be infused in % and mg/ml hourly rate or frequency of bolus dose if required maximum dose not to be exceeded over a 24 hour period mg / ml total volume site of catheter placement Drug concentration and parameters used within Orange LHS are intended to reduce administration and programming errors. Premixed polybags of Local Anaesthetic solutions are available from pharmacy. The following standard concentrations are used within Orange LHS % Ropivacaine (Naropin) only in 200ml volume % Bupivacaine (Marcaine) in 200ml volume The clinician preparing the Regional Infusion must: Correctly identify and verify the prescription has been completed as per NSW Health Peripheral Nerve Infusion or Bolus chart SMR used within the Western NSWLHD. Correctly identify and prepare the regional infusion pump and equipment within the work environment, wash hands and demonstrate non-touch technique when preparing commencing and connecting the infusion to the patient.

8 Ensure that the principles regarding administration and handling of local solutions are followed; ensuring all lines is labelled and the 5 rights of drug administration are adhered to. Programming of a Nerve Infusion The infusion pump must be programed according to the prescription provided by the medical officer on the Peripheral Nerve Infusion or Bolus chart infusion chart. The nerve infusion prescription must be programmed by two registered nurses or a registered nurse and enrolled nurse with medication endorsement, who have been deemed competent in the practice and management of a regional infusion. In the event that the nerve infusion prescription or program requires changing two registered nurses or registered nurse and enrolled nurse with medication endorsement, may make changes to the infusion pump. The nerve infusion chart must show a record of the new prescription, signed, dated and documented by the treating medical officer in the progress notes and by the nursing staff caring for the patient. Administration of Nerve Infusion No other IV / IM, oral or transdermal opioid drugs or sedatives are to be administered whilst the patient is receiving nerve infusion analgesia, unless reviewed or authorised by the treating medical officer or the Acute Pain Team. In the interests of patient safety, and to prevent large volume administration local anaesthetic drugs being delivered to the patient inadvertently, all nerve infusions must be administered via a dedicated pump used within the local facility. Patients receiving local anaesthetic infusion must have a patent IV cannula insitu for the duration of the infusion and 24hrs post removal. The cannula must be changed every 72hrs, dated and signed in accordance with the WNSWLHD Infection Control Policy. A dedicated infusion pump which is clearly labelled to be used for the delivery of the local anaesthetic. A dedicated infusion giving set which is portless and labelled for regional infusion to be used. Infusion pump settings to be checked at the commencement of each shift on patient transfer to another ward and when the bag is changed.

9 Insertion of catheter details: Catheter site check every 8 hours for - Integrity of dressing - Signs of leakage (if possible) - Signs of inflammation (if possible) Nerve catheter/s sites are to be dressed with a large occlusive waterproof transparent dressing and the catheter and filter secured with snap lock to prevent dislodgment. The "clear window" will allow for routine inspection of the nerve catheter insertion site. This dressing is applied by the proceduralist s at the time of the insertion. A bacterial filter: must be attached to the end of the nerve catheter/s for the entire length of the infusion or top-up. The filter is to be left intact unless it becomes inadvertently disconnected or contaminated. Disconnection: If the nerve catheter/s becomes disconnected from either the filter or the line, DO NOT reconnect. Place a sterile cap on the end cover with sterile gauze and secure. Contact the anaesthetic department and or acute pain team. If after hours, contact the on call medical officer for immediate review of the catheter which may then be removed or reconnected once assessed.

10 If the dressing is loose but still intact, the registered nurse is to reinforce it by placing another large sterile transparent film dressing over the site and reinforcing the edges of the dressing, making sure to cover any loose edges. Duration of infusion and or Top-up: Current practice is to continue nerve infusions or top-up for the minimum duration of 48 hours with review by the treating team. The risks/benefits of continuing regional analgesia should be considered daily by the treating team and documented in the patient s progress notes. Adequate resuscitation equipment must be available on the ward or working area and a working IV cannula insitu prior to injection. Patient MUST have full monitoring for the duration of the procedure and one hour post. Documentation and observations are recorded in the progress notes and Adult observations chart SAGO. Patients with nerve blocks to lower limbs may mobilise with support following assessment of limb strength. Ensure that limbs with motor block are supported at all times and pressure area care is carried out.

11 Observations for Continuous Infusion are to be recorded hourly for 6 hours, then second hourly or more frequently if patient s clinical condition warrants when a local infusion is in progress. When a single Nerve Block or Top-Up bolus has been given observations are reordered 15minly for 1hour and nursing staff informed prior commencement.

12 Pain Scores are to be determined from a pain assessment with the patient at rest and with relevant movement (such as deep breathing and coughing) utilising either the numerical pain scale 0 to 10 or verbal pain scale; no pain, mild pain, moderate pain, severe pain and worst possible pain. Pain score at rest to be recorded with the letter R Pain score with movement to be recorded with the letter M Removal of Catheter/s: Local anaesthetic infusion catheters can be removed by registered nurses who have been assessed as competent in aseptic technique If the catheter feels as if there is some resistance do not force removal, contact the acute pain team or the anaesthetist on call for advice. Check the catheter after removal to ensure the entire length has been removed and catheter intact. Procedure for Removal of Catheter Wash hands as per correct hand hygiene Gather equipment and a small dressing and gloves

13 Explain the procedure to the patient Position the patient comfortably where access to the catheter is easiest Remove the catheter slowly Observe the site for leakage, fluid or signs of infection. Check catheter to ensure tip is complete if not contact Acute Pain Team for advice. Clean with NaCl 0.9% and apply adhesive dressing over site Document in progress notes and on the Nerve Infusion chart Local Anaesthetic Toxicity Local anaesthetics, if prescribed correctly, will rarely cause toxic effects however if there is direct infusion into a vein or the solution is absorbed rapidly or a patient is unduly sensitive then the signs and symptoms of toxicity may occur. All staff working with local anaesthetic infusions should be aware of the signs and treatments of LA toxicity. If not acted upon in the early stages then respiratory and cardiac arrest can occur which is very difficult to reverse because the acidotic arrest state causes more of the drug to enter the cells and worsen the situation. Whilst treating the signs and symptoms symptomatically there are also directions for Intralipid Infusion treatment if the patient condition deteriorates. The infusion rate should be regularly checked and compared with the prescription to ensure correct rate is running and the site of infusion checked for leakage. Local anaesthetic toxicity can occur, especially if there is rapid absorption into the blood stream, or if inadvertently administered intravenously. This is very rare but it is important that the signs are recognised. If symptoms are: Mild Restlessness/confusion Light-headedness Numbness of tongue and lips (lip smacking) Tinnitus Double vision, blurred vision Moderate Heaviness of limbs Muscular twitching Convulsions

14 Severe Cardia arrhythmias Hypotension Respiratory arrest Cardia arrest Management of Local Anaesthetic Toxicity: Stop local anaesthetic infusion and follow Between the Flags protocol Continue all monitoring of the patient and observations Maintain oxygenation and a patent airway Consult with medical team, pain team or on call anaesthetist Continue to observe closely with the need to escalate response The standardisation of this Guideline promotes best practice in prescribing, pain assessment and management of adverse effects in those patients receiving a peripheral nerve infusion or local anaesthetic solution. 4: Document Retention Document Type Retention Schedule Retention Period e.g. Clinical Audit GDA Destroy after 6 years 5: References and Links 1. Australia & New Zealand College of Anaesthetists and Faculty of Acute Pain Management Scientific Evidence Fourth Edition 2015 available at publications/acutepain.pdf which has been endorsed by the National Health and Medical Research Council (NHMRC).

15 2. Australian and New Zealand College of Anaesthetist Guidelines for the Management of Major Regional Analgesia htm 3. AAGBI Safety Guideline produced by a Working Party that comprised: Grant Cave, Will Harrop- Griffiths (Chair), Martyn Harvey, Tim Meek, John Picard, Tim Short and Guy Weinberg. This Safety Guideline is endorsed by the Australian and New Zealand College of Anaesthetists (ANZC 4. Greater Western AHS 2007, Administration of Medications by Endorsed Enrolled Nurses 5. Greater Western AHS 2009 Medication Handling in Public Hospitals Patient Care Areas _Patient_Care_Area.pdf 6. NSW Health, 2007 Infection Control Policy, PD2007_ NSW Health Hand Hygiene Policy PD2010_ Clinical Excellence Commission Between the Flags program, 9. Pain Interest Group Nursing Issues, Agency for Clinical Innovation (ACI): Standardisation of NSW State Pain Forms: NSW Health Peripheral Nerve Infusion (Adult) SMR Appendix 1. PERIPHERAL NERVE INFUSION (ADULT)

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17 Appendix 2.

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