Continuous Peripheral Nerve blocks using local anaesthetic Type: Clinical Guideline Register No: 12035 Status: Public Developed in response to: Clinical requirements CNST requirements Contributes to CQC Regulation 12 Consulted With Post/Committee/Group Date Pain Consultants Dr Tom Durcan, Dr Mark Alexander- 26/2/16 Williams Anaesthetists Dr Pete Berry 26/2/16 Pain Service Manager Lynne Mustard 26/2/16 Pain Pharmacist Dawn Tarala 26/2/16 Resus Officer Lee Seager 26/2/16 Professionally Approved By Dr Mark Alexander-Williams 26/2/16 Version Number 2.1 Issuing Directorate Anaesthetics Ratified by: DRAG Chairmans Action Ratified on: 21 st March 2016 Executive Management Board Sign Off April 2016 Date Implementation Date 30 th September 2016 Next Review Date February 2019 Author/Contact for Information Jayne Somerset Clinical Nurse Specialist, Pain Management Policy to be followed by (target staff) Medical and nursing staff involved in the administration of local anaesthetic for wound infiltration to facilitate post-op pain relief Distribution Method Hard copies distributed to all wards and depts. Available electronically on the Intranet.and Website Related Trust Policies (to be read in conjunction with) Policy for the Use of Medicines Consent Policy Diagnostic & Therapeutic Equipment Training Policy Observation Policy Document Review History Version No Authored/Reviewed by Active Date 1.0 Jayne Somerset Clinical Nurse Specialist 16 th October 2012 2.0 Jayne Somerset Clinical Nurse Specialist 30 March 2016 2.1 Jayne Somerset 30 th September 2016 1
INDEX 1. Purpose 2. Background 3. Indications for Continuous Peripheral Nerve Blocks. 4 Diagnosing and treating Local Anaesthetic Toxicity 5 Scope 6 Staffing and Training 7 Pre Procedure 8 During the procedure 9 Post procedure 10 Implementation and Communication 11 Infection Control 12 Risk Management 13 Audit and monitoring 14 References Appendix 1: For the AAGBI Safety Guideline for the Management of Severe Local Anaesthetic Toxicity (2010) follow link below. http://www.aagbi.org/sites/default/files/la_toxicity_2010_0.pdf http://www.aagbi.org/sites/default/files/la_toxicity_notes_2010_0.pdf If unable to use link, follow Table 1 and 2 Table 1: AAGBI Safety Guideline for the Management of Severe Local Anaesthetic Toxicity (2010 Table 2: Suggested regime for Lipid emulsion from the AAGBI (2010) Appendix 2 Local Anaesthetic Infusions guidance for ward use Appendix 3: CNST competency for Elastomeric ON-Q pump Appendix 4: CNST competency for Pain Buster 2
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1. Purpose 1.1 The guideline is designed to provide instruction and guidance in the safe administration of local anaesthetic used for Peripheral Nerve blocks. In the event of Local anaesthetic toxicity, the guideline also sets out a management plan to treat this. 2. Background 2.1 Peripheral Nerve blocks are useful for the management of postoperative and trauma pain. They are used to interrupt pain transmission in the peripheral nervous system. This is achieved by blocking the somatic and sympathetic nerve fibres (those involved in pain transmission), at various sites, after they leave the spinal canal by the administration of local anaesthetic. Local anaesthetic is administered perineurally (around the nerve) either continuously or as a single one-off injection. Their aim is to target a specific area where pain is expected to occur. Appropriate blocks exist for almost all areas of the body. 2.3 One-off injections of local anaesthetic are often used peri-operatively and provide enhanced pain relief for up to 24 hours, depending on the local anaesthetic used, and the area where they are injected. However, a catheter for continuous infusion of local anaesthetic can be inserted perineurally to extend the analgesia beyond the duration of single shot blocks. These may be left in situ for up to 5 days post-op. In the context of a multimodal approach to pain control, they have proved to be both safe and effective, with the added benefit of reducing the patient s opioid requirement and their related complications. Studies have shown a 40-70% reduction in opioid use when used alongside PCA (Patient controlled analgesia), compared with PCA alone. 2.4 Nerve fibres differ in their sensitivity to local anaesthetics. Small nerve fibres (those involved in pain transmission) are more sensitive than large nerve fibres (those involved in touch, proprioception and movement) while myelinated fibres are blocked before non-myelinated fibres of the same diameter. Thus the loss of nerve function proceeds as loss of pain, temperature, touch, proprioception, and then skeletal muscle tone. This explains why the patient can still feel touch but not experience pain. Some blocks will provide pain relief but will not immobilise the limb. This is dependent on the local anaesthetic used and its concentration. For example, higher concentrations may effect skeletal muscle tone and temporarily cause paralysis. For some surgery this is advantageous to immobilise the limb but, for other surgery, early mobilization is essential. The anaesthetist will tailor the local anaesthetic and concentration to patient requirement. 2.5 Local anaesthetics work through two different mechanisms. By directly blocking the transmission of pain from nociceptive afferents, by binding to fast sodium channels within the axon membrane, the action potential is prevented. By inhibiting the local inflammatory response to injury, which normally sensitises nociceptive receptors and contributes to pain and hyperalgesia. 4
2.6 Local anaesthetics generally have a lipid-soluble hydrophobic aromatic group and a charged, hydrophilic amide group. The bond between these two groups determines the class of the drug, and may be amide or ester. Examples of amides include lignocaine, bupivacaine, ropivicaine. These are used within the Trust. Amides are metabolised hepatically. When compared to other types of local anaesthetic, their half-life is longer. Therefore, they can accumulate if given in repeated doses or by infusion, especially where the patient is unable to metabolise and excrete these drugs effectively. This is one example of how LA toxicity can occur. 2.7 The severity of local anaesthetic toxicity is related to the maximum concentration achieved in the blood and may vary from simple reports of agitation, drowsiness, and metallic taste, to seizures, coma, and cardiac arrest with increasing plasma levels. This forms the basis for patient observation whilst the infusion is in progress. 2.8 The regime to be used for the patient is considered carefully by the anaesthetist, who is responsible for prescribing the LA based on the patient s clinical status (such as age, body weight, disease state of patient, concomitant medications etc.) To avoid complications, the lowest flow rate, volume and drug concentration required to produce the desired result is used. 3.0 Indications for Continuous Peripheral Nerve Blocks. Surgical procedure / trauma Shoulder trauma / surgery Unilateral surgical / trauma pain from chest and upper abdomen: cholecystectomy, thoracotomy, renal and breast surgery, ribs fractures Upper arm surgery Lower arm surgery Unilateral: Thoracotomy and major breast surgery (T4-5), rib fractures, Nephrectomy (T7) Hip and femur surgery and fractures Femur fractures, knee surgery Total knee replacement, major knee surgery Tibia and fibula surgery and fractures Ankle surgery Suggested Block Interscalene Intrapleural Supraclavicular, Infraclavicular, axillary approaches to brachial plexus nerve block. Axillary approaches to brachial plexus nerve block. Ulnar, radial, and median nerves can be blocked where brachial plexus block does not cover area required. Thoracic paravertebral Posterior Lumbar plexus block blocking the femoral, obturator nerves, and lateral cutaneous nerve of the thigh. Femoral nerve Femoral and sciatic (parasacral or gluteal or subgluteal approach) Sciatic (anterior or gluteal or subgluteal or lateral popliteal approach) Femoral or saphenous + sciatic 5
4. Diagnosing and treating Local Anaesthetic Systemic Toxicity (LAST) 4.1 A variety of factors influence the likelihood and severity of LAST occurring. These include; Individual patient risk factors Concurrent medications Location and technique of block used Local anaesthetic used Total anaesthetic dose (product concentration x volume) Timeliness of detection Adequacy of treatment 4.2 LAST can occur where intravascular injection takes place. The effect of this will be seen immediately. when there is an accumulation of the drug. This can be from overdose, or where metabolism of the drug is slowed (the pharmacokinetics of a drug may be altered by existing co-morbidities such as cardiac or hepatic failure, alterations in plasma protein binding, or interactions with other drugs. This can occur at any time. 4.3 Classic symptoms of LAST include the patients subjective symptoms due to CNS (Central Nervous System) excitability. LA toxicity signs and symptoms form the basis for patient observation. See Section 8. Early / mild toxicity symptoms Confusion Vagueness / restlessness Metallic taste Twitching Auditory changes Tingling or numbness in and / or around the mouth Dizziness or feeling light-headed The patient may not divulge these symptoms so always ask if they experience any of the above and ask the patient to let a member of medical staff know immediately if they occur. Severe Toxicity symptoms From central nervous system (CNS) excitability the patient may experience seizures progressing to CNS depression (coma, respiratory arrest) In classic descriptions of LAST cardiac toxicity does not precede CNS toxicity. However where LAST is due to accidental intravascular injection, these CNS symptoms maybe bypassed; seizure activity may progress quickly to cardiac excitation (hypertension, tachycardia, ventricular arrthymias) In higher blood concentrations, cardiac excitability may be followed by cardiac depression (bradycardia, asystole, decreased contractility, and hypotension). 6
4.4 There may be large variability in LAST clinical presentation. Seizures are the most common presenting symptom. From research, less than 20% of patients present with signs of early / mild toxicity listed above. It is hard to ascertain if this was due to lack of clinical observation. 4.5 The management of LAST can be referred to in the Appendix section. These are the guidelines set out by the Association of Anaesthetists of Great Britain and Ireland (AAGBI) in 2010. They are the most up to date guidelines for the treatment of LAST. Management consists of Recognition, Immediate management, Treatment, and Follow-up. 4.6 For the infusion of Intravenous Lipid emulsion, which is used in LAST, there is not a set regime for the MEHT Trust. The table and link found in the Appendix section shows details of suggested infusions by the AAGBI. This is not a standard of medical care. The ultimate judgement with regard to a particular clinical procedure or treatment plan must be made by the clinician in the light of the clinical data presented and the diagnostic and treatment options available. 4.7 Early detection remains the most effective way of reducing the frequency and severity of LAST. This is why patient observation is paramount. Refer to Section 8 5. Scope 5.1 Anaesthetic staff, trained nurses, medical staff, therapy staff, and auxiliary staff involved in the care of patients receiving an administration of local anaesthetic to obtain a peripheral nerve block. 5.2 Exclusion/Inclusion criteria are set out in section 7.1. 6. Staffing and Training 6.1 Medical and nursing staff administering local anaesthetics must be trained in its use. This includes the exclusion criteria, adverse effects; namely Local Anaesthetic toxicity, and the actions to be taken if these occur. Any shortfall in knowledge and competence should be recognised by staff and they should contact the IPMS should they need further training. 6.2 Local anaesthetic infusions are administered via a delivery device. Staff involved in this should be competent to use the delivery device. This will include the Elastomeric pump, which maybe used for the procedure. These may include the On-Q, and Pain Buster pump. Competency in using these delivery devices is essential prior to using them. Refer to the Diagnostic & Therapeutic Equipment Training Policy. Both CNST competencies are attached to this guideline. 6.3 The IPMS (Integrated Pain Management Service) is available for advice and consultation via the pager system, and through the PAS referral system. 6.4 Training and education is provided by the IPMS, both formally and informally for all clinical staff. 7
6.5 Medical staff will be informed of revised guidelines via senior medical staff within the IPMS at audit meetings and twice yearly teaching sessions for all FY1 and FY2 doctors. 7 Pre Procedure 7.1 Patient is selected considering the exclusion / inclusion criteria. Exclusion criteria Allergy to LA Patient refusal Unqualified ward staff Infection Coagulopathy Suspected Compartment Syndrome 7.2 Procedure explained and consent given by the patient which must be documented. Refer to Consent Policy. 7.3 The catheter is sited aseptically. 7.4 Appropriate delivery device chosen and in working order. Appropriate safety checks carried out on device. See separate Competency Statement according to device chosen. 7.5 Ensure wound catheter clearly marked, along with administration line used that is connected to delivery device. This is to reduce the risk of intravenous administration. 7.6 Check insertion site of catheter. Is dressing intact, no sign of leakage or swelling? 7.7 Patient has working Intravenous (IV) access. 7.8 Check ward staff are competent to care for a patient with a local anaesthetic infusion and corresponding delivery device. 7.9 Ensure infusion regime prescribed clearly. 8. Post Procedure 8.1 Ensure nursing staff on the ward are able to care for a patient with a LA (local anaesthetic) infusion and are able to use the delivery device chosen. 8.2 Ensure IV access present and patent. 8.3 Check prescription of LA against what patient receiving. Check pump program is correct. 8.4 LA toxicity signs and symptoms form the basis for patient observation. See Section 3. 8
8.5 Patient observations for continuous infusions include Below 5mls/hr 5mls/hr and above i. Catheter site inspection i. Ensure IV access present and patent ii. General post-op observations; BP, ii. Catheter site inspection pulse, RR, Temp + PAR Score iii. Pump in working order iii. General post-op observations; BP, pulse, RR, Temp & PAR Score iv. These are to be carried out 2-4 iv. Pump in working order hourly depending on clinical need. v. These are to be carried out 1-4 hourly depending on clinical need 8.6 For continuous LA infusion with BOLUS option: Ensure IV access present and patent. General observations as above and additional as stated below. Only Nurses trained to use Elastomeric ON-Q device can care for patient. ONLY the Nurse looking after the patient may deliver the bolus dose. Bolus doses of LA are high in volume. LA toxicity is more likely to occur when bolus doses are given. Observations post bolus, include BP, Pulse, RR, and signs / symptoms of LA toxicity. These observations are to be taken immediately post bolus delivery, and then 15 minutes post bolus and 30 minutes post bolus. If unintentional IV administration occurs LA toxicity will occur immediately. LA toxicity due to overdose can be generally picked up within 30 minutes post bolus. 8.7 The Pain-Buster pump is inserted under direct vision by the surgeon into the wound. These pumps run at 2ml/hr from a reservoir of 48mls (therefore will run automatically for 48hrs unless removed or are displaced). Some patients are discharged with the Pain Buster still in situ and running. Advice is given to the patient regarding the Pain Buster by the ward staff prior to discharge, until they return the following day for removal. 8.8 If local anaesthetic toxicity is suspected STOP infusion / bolus immediately. Call the on-call anaesthetist. Ensure resuscitation equipment is close to patient. If the patient becomes unresponsive, call the resuscitation team immediately. Follow treatment steps according to Appendix Tables 1 and 2. 8.9 Removal of the LA catheter is carried out aseptically. Inspection of the catheter carried out to ensure tip is intact. If the patient has a temperature 38.5 C, send tip to microbiology for culture and sensitivity. 9. Implementation and communication 9.1 Approved guidelines are accessible from the staff intranet. 9.2 In addition, the clinical guideline will be disseminated to the ward through Pain Link nurses within their ward setting. 9.3 The new guideline will be introduced to anaesthetic staff through anaesthetic meetings. 9
9.4 Medical staff will be informed of revised guidelines via senior medical staff within the IPMS at audit meetings and twice yearly teaching sessions for all FY1 and FY2 doctors. 9.5 Pharmacy involved and made aware of the new guideline. 10. Infection Control 10.1 The catheter used for the LA infusion is sited aseptically. 10.2 Trust protocol for prevention of cross infection is to be adhered to prior to, during and after siting of the LA catheter. 10.3 Disposable equipment is to be disposed of appropriately according to waste segregation policy: i.e clinical waste. 11. Breach of Guideline 11.1 A risk event form should be completed and submitted to the Risk Management Department for non-compliance with this guideline. 11.2 Incidence of clinical risk or patient complaints resulting from non-compliance with this guideline are to be recorded via the central risk events database and PALS (Patient Advisory Liaison Service) if involved. 12. Audit and monitoring 12.1 Link nurses on the wards are to monitor LA infusion use and report any adverse events or training needs to the IPMS. Clinical meetings for Link nurses are held three times a year. Potential audit discussion and problems can be evaluated in this meeting. 12.2 The IPMS manager and lead consultant will liaise at corporate level to put strategies in place to address issues. 13. References 1. Cochrane Database Syst Review. 2009 Jul 8;(3):CD006954. Local anaesthetic wound infiltration and abdominal nerves block during caesarean section for postoperative pain relief. Bamigboye AA, Hofmeyr GJ. Source Department of Obstetrics and Gynaecology, Mediclinic Private Hospital, Department of Obstetrics and Gynaecology, University of Witwatersrand, PO Box 15184, Nelspruit, Mpumalanga, South Africa, 1200. 2. http://www.frca.co.uk/article.aspx?articleid=100446 3. www.nysora.com 4. Neal, Joseph M., Bernards, C.M., Butterworth, J.F., Di Gregorio, G., Drasner, K., Hejtmanek, M.R., Mulroy, M.F., Rosenquist, R.W., Weinberg, G. (2010) Asra Practice Advisory on Local Anaesthetic Systemic Toxicity Regional Anaesthesia & Pain Medicine: March/April 2010 - Volume 35 - Issue 2 - pp 152-161 10
5. AAGBI Safety Guideline: Management of Severe Local Anaesthetic Toxicity. AAGBI: 2010 www.aagbi.org/publications/guidelines.htm 6 Lim Y.C., Choo,C.Y., Phua,S.K.D., Sim Y.Y., Ng J.J., Yoong C.S. (2011) Prospective Audit of complications related to Peripheral Nerve Blocks Regional Anaesthesia and Pain Medicine, September-October 2011, vol./is. 36/5 supplement 2 (E258), 1098-7339 7. Chelly,J.E., Ghisi,D., Fanelli,A. (2010) Continuous peripheral nerve blocks in acute pain management British Journal of Anaesthesia 105 (S1): i86-i96. 11
Appendix 1 Table 1 Step 1 RECOGNITION Step 2 IMMEDIATE MANAGEMENT Step 3 AAGBI Safety Guideline Management of Severe Local Anaesthetic Toxicity Sudden alteration in mental status, severe agitation or loss of consciousness, with or without convulsions Cardiovascular collapse: sinus bradycardia, conduction blocks, asystole and ventricular tachyarrhythmias may all occur Local anaesthetic (LA) toxicity may occur some time after an initial injection Stop injecting / infusing the local anaesthetic Call for help, if unresponsive start rescusitation procedures Maintain the airway and, if necessary, secure it with a tracheal tube Give 100% oxygen and ensure adequate lung ventilation (hyperventilation may help by increasing plasma ph in the presence of metabolic acidosis) Confirm or establish intravenous access Control seizures: give a benzodiazepine, thiopental or propofol in small incremental doses Assess cardiovascular status throughout Consider drawing blood for analysis, but do not delay definitive treatment to do this In circulatory arrest Without circulatory arrest TREATMENT Start cardiopulmonary resuscitation (CPR) using standard protocols Manage arrhythmias using the same protocols, recognising that arrhythmias may be very refractory to treatment Consider the use of cardiopulmonary bypass if available Give intravenous lipid emulsion (following the regimen below) Continue CPR throughout treatment with lipid emulsion Recovery from LAinduced cardiac arrest may take >1 h Propofol is not a suitable substitute for lipid emulsion Lidocaine should not be used as an anti-arrhythmic therapy Use conventional therapies to treat: hypotension bradycardia tachyarrhythmia Consider intravenous lipid emulsion(following the regimen below) Propofol is not a suitable substitute for lipid emulsion Lidocaine should not be used as an anti-arrhythmic therapy Step 4 FOLLOW-UP Arrange safe transfer to a clinical area with appropriate equipment and suitable staff until sustained recovery is achieved Exclude pancreatitis by regular clinical review, including daily amylase or lipase assays for two days Report cases as follows: in the United Kingdom to the National Patient Safety Agency (via www.npsa.nhs.uk) If Lipid has been given, please also report its use to the international registry at www.lipidregistry.org. Details may also be posted at www.lipidrescue.org 12
Table 2: Suggested regime for Lipid emulsion from the AAGBI (2010) Give an initial intravenous bolus injection of 20% lipid emulsion Immediately and Start an intravenous infusion of 20% lipid emulsion at 15 ml.kg 1.h 1 1.5 ml.kg 1 over 1 min Give a maximum of two repeat boluses (same dose) if: cardiovascular stability has not been restored or an adequate circulation deteriorates Leave 5 min between boluses A maximum of three boluses can be given (including the initial bolus) after 5 min and Continue infusion at same rate, but: Double the rate to 30 ml.kg 1.h 1 at any time after 5 min, if: cardiovascular stability has not been restored or an adequate circulation deteriorates Continue infusion until stable and adequate circulation restored or maximum dose of lipid emulsion given Do not exceed a maximum cumulative dose of 12 ml.kg 1 An approximate dose regimen for a 70-kg patient would be as follows: Give an initial intravenous bolus injection of 20% lipid emulsion 100 ml over 1 min Immediately and Start an intravenous infusion of 20% lipid emulsion at 1000 ml.h 1 Give a maximum of two repeat boluses of 100 ml after 5 min and Continue infusion at same rate but double rate to 2000 ml.h 1 if indicated at any time Do not exceed a maximum cumulative dose of 840 ml 13
Appendix 2: Local Anaesthetic Infusions guidance for ward use This includes all infusions delivered through Elastomeric On-Q device. Patient Observations Patient observations for continuous infusions only Below 5mls/hr 5mls/hr and above i. Catheter site inspection i. Ensure IV access present and patent ii. General post-op observations; BP, pulse, RR, Temp ii. Catheter site inspection iii. Pump in working order iii. General post-op observations; BP, pulse, RR, Temp iv. These are to be carried out 2-4 hourly depending on iv. Pump in working order clinical need. v. These are to be carried out 1-4 hourly depending on clinical need For continuous LA infusion with BOLUS option: i. Ensure IV access present and patent. ii. General observations as above and additional as stated below. iii. Only Nurses trained to use the Elastomeric On-Q device can care for patient. iv. ONLY the Nurse looking after the patient may deliver the bolus dose. ii. Bolus doses of LA are high in volume. LA toxicity is more likely to occur when bolus doses are given. iv. Observations post bolus, include BP, Pulse, RR, and signs / symptoms of LA toxicity. These observations are to be taken immediately post bolus delivery, and then 15 minutes post bolus and 30 minutes post bolus. If unintentional IV administration occurs LA toxicity will occur immediately. LA toxicity due to overdose can be generally picked up within 30 minutes post bolus. If local anaesthetic toxicity is suspected STOP the infusion immediately. Call the on-call anaesthetist. Ensure resuscitation equipment is close to patient. Intralipid (lipid emulsion) - the antidote for LA toxicity is kept in main theatre recovery. LA toxicity signs and symptoms include: Early mild toxicity Confusion Vagueness / restlessness Twitching Metallic taste Tingling or numbness in and / or around the mouth Auditory changes Dizziness or feeling light-headed Severe Toxicity Tonic-clonic convulsions Loss of consciousness Respiratory depression / arrest Tachycardia & Ventricular arrhythmias Bradycardia / hypotension Asystole (Cardiac Arrest) Cardiac symptoms usually develop after CNS symptoms if LA serum concentration rises slowly, but may develop first if LA toxicity is due to accidental iv injection. The patient may not divulge these symptoms so always ask if they experience any of the above and ask the patient to let a member of medical staff know immediately if they occur. Removal of catheter is instructed by the surgeon / anaesthetist. Remove using aseptic non touch technique. Grasp catheter and gently pull. If any resistance occurs, then STOP. Contact the surgeon / anaesthetist immediately. Integrated Pain Management Service JS/2015 14
Appendix 3: CNST competency for Elastomeric ON-Q pump MEDICAL DEVICE / EQUIPMENT COMPETENCY SELF ASSESSMENT STATEMENT Equipment category / name: On-Q Elastomeric Infusion Pump Competency Statement Number: CS-MISC-014-14 Areas where equipment used: Recovery & dedicated surgical wards Staff groups using this equipment: Training level: Risk Level Qualified recovery staff, Pain clinical nurse specialists, Anaesthetists and qualified nursing staff Complex Intermediate Basic External / DCCT DCCT / Super-user Self/ Peer High Medium Low The statements below are designed to assess your competence to use this device. You should self-assess your competency after you have received the relevant training. Responsibility for use of the equipment remains with you, so if you are in any doubt about your competence to use the device, you must seek additional training in liaison with your line manager / supervisor and then re-assess your competence against the statement. Sources of training support include the product operating manual and training from peers, super-users or Clinical Technicians as appropriate. Questions to ask yourself: Are you safe using this equipment? Do you know the following? Assessment Part 1 All staff 1 Outline exclusion criteria for local anaesthetic infusions Yes / No 2 Identify complications of a local anaesthetic infusion; specifically local anaesthetic toxicity Yes / No and action to be taken if adverse effects occur 3 Check integrity of the system Yes / No 4 Outlines the monitoring of a patient whilst local anaesthetic infusing Yes / No 5 Demonstrate how to check the pump is working Yes / No 6 Demonstrate how to turn pump off by using clamp Yes / No 7 Explain how the pump operates Yes / No 8 Understand that no alterations are to be made to the rate of infusion this is carried out by Yes / No Anaesthetist or CNS only. 9 Dispose safely of the sealed system Yes / No 10 Demonstrate removal of infusion catheter Yes / No 11 Demonstrate disposal / cleaning method / Storage of pump Yes / No 12 Demonstrates the completion of infusion in patients records Yes / No 13 Competency Performs nursing care of the person requiring REGIONAL BLOCKADE & record of supervised practise completed on / / Yes / No Part 2 Anaesthetists siting perineural catheter and commencing infusion 14 Identify exclusion criteria for local anaesthetic administration Yes / No 15 Able to identify and locate equipment required Yes / No 16 Demonstrate how to unlock the pump with specific ON-Q key to make changes to the rate of Yes / No the infusion 17 Identify and site catheter in optimal area to maximise pain relief Yes / No 18 Able to secure catheter using appropriate dressing Yes / No 19 Prescribe regime to be used; Concentration of local anaesthetic: Continuous or variable Yes / No infusion 20 State the safety checks to be performed prior to using device Yes / No 21 Use the select-a-flow dial and ensure the safe removal and storage key Yes / No 22 Position the fixed flow rate to the patient s skin Yes / No 23 Protect the filter from exposure to water when necessary Yes / No 24 Able to initiate bolus / infusion Yes / No 25 Able to purge air from line Yes / No 15
You must be able to answer yes to all questions relevant to your role to consider yourself competent. If you are competent, you should date and sign your Diagnostic & Therapeutic Equipment Competency Record for this equipment. If you are not competent, please identify this on your record, signing and dating the record appropriately, and discuss with your manager how and when your training needs will be met. Your line manager should retain your Diagnostic & Therapeutic Equipment Competency Record. Self - assessment is undertaken on a one-off basis but will be reviewed annually at appraisal. 16
Appendix 4: CNST competency for Pain Buster MEDICAL DEVICE / EQUIPMENT COMPETENCY SELF ASSESSMENT STATEMENT Self assessment of competency should be measured against the statements below. These statements are designed to indicate competence to use this device. Responsibility for use of the equipment remains with Equipment name: Competency Statement Number: Staff groups who use this equipment: Training level: PainBuster Device. Used for continuous administration of Local Anaesthetic solution. Areas where equipment used: CS581 Recovery, and Theatre dedicated ward areas Qualified Recovery Staff, Pain Clinical Nurse Specialists, Qualified Nursing staff, and Anaesthetists High High Risk Device STOP - Do not use this item unless you are competent to do so the user, so if you are in any doubt regarding your competence to use the device, you should seek education to bring about improvement. Various methods including self-directed learning; coaching and formal training may be initiated. Consider local resources, product operating manual & discussion with colleagues / manager. Questions to ask yourself: Are you safe using this equipment? Do you know how to: Qualified Surgeon (1-7 only) Assessment 1 Identify exclusion criteria for local anaesthetic administration? Yes/No 2 Able to identify and locate equipment required; catheter, device, Yes/No solution? 3 Identify and site catheter in optimal area to maximize pain relief? Yes/No 4 Able to secure catheter using appropriate dressing to reduce risk of Yes/No dislodgement? 5 Prescribe regime to be used; Continuous infusion and concentration of Yes/No local anaesthetic? 6 State the safety checks to be performed prior to using the PainBuster Yes/No device? 7 Able to initiate infusion? Yes/No 17
Qualified competent Recovery and Ward Staff (8-16 only) 8 Outline inclusion exclusion criteria for Local Anaesthetic infusions? Yes/No 9 Identify complications of a Local Anaesthetic infusion; specifically Local Yes/No Anaesthetic Toxicity, and action to be taken if adverse effects occur? 10 Aware that different concentrations and volumes of local anaesthetic are used Yes/No for different blocks and why? 11 Outlines the monitoring of a patient whilst Local Anaesthetic infusion in Yes/No progress? 12 Demonstrates how to turn pump off by clamping infusion line? Yes/No 13 Demonstrates removal of wound catheter? Yes/No 14 Demonstrates disposal of pump and administration line? Yes/No 15 Demonstrates the completion of infusion in the patients records? Yes/No 16 Competency Performs nursing care of the person requiring REGIONAL BLOCKADE & Record of Supervised Practice completed on / / Yes/No You must be able to answer yes to all questions relevant to your role to consider yourself competent. If you are competent, you should date and sign your Diagnostic & Therapeutic Equipment Competency Record for this equipment. If you are not competent, please identify this on your record, signing and dating the record appropriately, and discuss with your manager how and when your training needs will be met. Your line manager should retain your Diagnostic & Therapeutic Equipment Competency Record. Self - assessment is undertaken on a one-off basis but will be reviewed annually at appraisal. 18