PAEDIATRIC NERVE BLOCK / WOUND INFILTRATION Addendum to the MULTIDISCIPLINARY GUIDELINES FOR ACUTE PAIN MANAGEMENT IN CHILDREN AND YOUNG PEOPLE Policy Owner: Approved by: Ratified by: ABMU HB Pain Management Service & Paediatric Pain Management Forum [PPMF] Women & Child Health Directorate; Clinical Support Services Directorate - Anaesthetics & Critical Care ABMU HB Medicines Management Group; W&CH Clinical Governance/Quality & Safety Committee Issue Date: August 2012 Review Date: April 2015
1 PAEDIATRIC NERVE BLOCK / WOUND INFILTRATION Epidural infusions are not included in this procedure [for epidural analgesia refer to Section 9] 1.1 Introduction This procedure relates to the administration of a peripheral infusion of Local Anaesthetic [LA] infused either for nerve/plexus/compartment block or wound infiltration for peri-operative analgesia in children. Local anaesthetics exert their effect as analgesics by blocking sodium channels and hence impeding neuronal excitation and/or conduction. To optimise the analgesia from a LA infusion, the catheter for LA infusion must be placed as close to the nerve or nerve plexus to be blocked. This is generally achieved by the anaesthetist at the time of surgery. The nerve or nerve plexus is usually located either by use of ultrasound or else by electrical stimulation. The following are suitable for continuous block by LA infusion: Plexus e.g. Brachial plexus Compartment e.g. Fascia Iliaca Compartment [FIC] Planes e.g. Transversus Abdominis Plane [TAP] Individual peripheral nerve blocks e.g. Sciatic, femoral etc Other sites of infusion as indicated e.g. Paravertebral Direct infusion into a surgical wound 1.2 Indications Regional anaesthetic blocks/infusions are used to provide LA to a discrete area of the body for the management of moderate to severe pain in children; may also be used in a situation where a LA infusion may help with the pain management. Acute postoperative pain Acute pain following trauma or Acute exacerbation in a chronic pain condition 2
1.3 Contraindications 1.3.1 Absolute Parent/child refusal Local sepsis Allergy to local anaesthetics 1.3.2 Relative Coagulopathy 1.4 Prescription In addition to the child s own prescription chart, the dedicated PAEDIATRIC NERVE BLOCK / WOUND INFILTRATION prescription chart [see below] must be completed by the prescribing anaesthetist and be available for the nurse to check against the pump settings Regular paracetamol and, if appropriate, NSAIDs should also be prescribed [refer to Section 5.2] Other systemic opioids [IV or PO] could be administered as prescribed by the anaesthetist whilst the child is receiving LA infusion to improve analgesia The nurse looking after the child should ensure Naloxone and Ondansetron have also been prescribed to combat the potential side effects [respiratory depression and nausea & vomiting] associated with the use of strong opioids. Refer to Troubleshooting Section on the paediatric nerve block/ wound infiltration prescription chart [see below] Look for signs and symptoms of LA toxicity; for management refer to paediatric nerve block/wound infiltration prescription chart [see below] 3
LA continuous infusion prescription - McKinley Bodyguard 595 [grey pump] Protocol A [paeds] Protocol type Continuous only [200 ml] Bag volume [ml] 200 ml Units ml Drug/Concentration Levobupivacaine 0.125% [plain] Initial Rate [default] 5 ml/hr Range 0-15 ml/hr Bolus dose [to be given by anaesthetist] Every 20-minutes via pump [as required] Maximum dose Must NOT exceed 2.5mg/kg/6hr Key points when initiating LA continuous infusion: The LA infusion must be prescribed on the appropriate paediatric nerve block/wound infiltration prescription chart. This should then be attached to the child's drug chart Also prescribe the LA infusion on the 'PRN' side of the child s drug chart: i.e. Levobupivacaine 0.125% as per paediatric nerve block/wound infiltration chart 1.5 Equipment 1.5.1 Pump The dedicated paediatric McKinley Bodyguard 595 (grey pump) infusion devices must be used and set up using Paediatric Protocol A These dedicated infusion devices are stored in Main Theatre Recovery Room and are clearly marked Paediatric nerve block/wound infiltration designated for paediatric use only [MDA classification High Risk] 3 1.5.2 Infusion Set A dedicated administration set [clear grey tubing], incorporating an anti-siphon valve, must always be used with these infusion devices. 4
1.5.3 Regional anaesthetic catheter An epidural catheter, or similar device, will be inserted by the anaesthetist to deliver the LA infusion via the dedicated administration set and pump. An occlusive clear dressing must be placed over the catheter Any loose catheter tubing should be securely taped to the skin to prevent kinking and /or disconnection A filter [if used] should be securely taped to the child [in a place where it is comfortable] to avoid dislodgement of the catheter Routine dressing changes are not indicated and are only to be done by a member of the Acute Pain Team/anaesthetist as required Pumps must be attached to the drip-stand at the same level as the child to reduce the risk of siphoning. Anaesthetic and nursing staff must have received training and assessment in the use of these devices and achieved the relevant competencies. The Acute Pain Service/Consultant Anaesthetist will provide this training. 1.6 Designated Clinical Areas The child must be nursed in a Paediatric High Dependency setting or equivalent. The nursing staff in these clinical areas will be familiar with the equipment and the management of children on LA infusion. 1.7 Monitoring 1.7.1 Refer to the regional analgesia monitoring and assessment record: 15-minutes observation of vital signs for 1-hour after insertion of regional analgesia catheter or at the end of operation Observation of vital signs to be made HOURLY and regional analgesia observations 4-hourly once back to ward area Motor block assessment -using motor block scoring tool At night [i.e. 22.00-08.00h], after the first 24-hours post regional analgesia catheter insertion, the child s normal sleep pattern should not be disrupted for observations unless there is a cause for concern. However, routine oxygen saturation, respiratory rate, heart rate, and infusion recordings must continue 5
The Acute Pain Service will visit all children receiving LA infusion daily, more often if necessary. The Acute Pain Service will reduce or stop the LA infusion depending on the child s analgesic requirements, in consultation with the paediatric consultant anaesthetist 1.7.2 Pressure area care It is important that pressure area care is meticulous for all children receiving LA infusions: The decreased sensation produced by analgesia removes the usual warning signs that prompt children to move, whilst significant motor block may limit child movement: Both of these factors may contribute to the development of pressure areas Children with femoral nerve catheters must be turned 2-3 hourly, have extra pressure control devices in place and their skin regularly checked for signs of pressure Particular attention to pressure care should be given to the region or limb affected by the LA blockade 1.7.3 Nerve compression It is vital, during regular pressure area care, that special attention is made to avoid nerve compression Superficial nerves [e.g. common peroneal nerve] are vulnerable to damage from unrecognised pressure due to decreased sensation 1.7.4 Intravenous access All children with a LA infusion must have a patent intravenous [IV] access at all times After the LA infusion is discontinued, the IV cannula must remain in-situ until the catheter is removed 6
1.8 Leaking or disconnected regional anaesthetic catheter If the child is comfortable [suggesting the regional anaesthetic block is providing adequate analgesia] the dressing should be reinforced and the leakage observed If the child is uncomfortable and there is a leak, contact Acute Pain Team/oncall anaesthetist to consider re-siting or removing the catheter If there is an un-witnessed disconnection of the catheter from the filter, then discontinue LA infusion and remove catheter. Contact Acute Pain Team/on-call anaesthetist for alternative analgesia 1.9 Discontinuing LA infusion and removing the catheter LA infusions should only be discontinued following consultation with the consultant anaesthetist/acute Pain Team When it is decided the nerve block/wound infiltration is no longer required, the LA infusion is stopped and alternative analgesia administered If significant pain occurs after stopping the LA infusion, and despite alternative analgesia given, contact the Acute Pain Team/on-call anaesthetist Document LA catheter removal, noting the condition of the catheter tip and the child s skin at the entry site on the relevant section of the LA monitoring chart. If the catheter is broken or damaged document accordingly & inform the initiating anaesthetist/acute Pain Team immediately 7
Directorate of Women & Child Health Checklist for Clinical Guidelines being Submitted for Approval by Quality & Safety Group Title of Guideline: Name(s) of Author: Chair of Group or Committee supporting submission: Paediatric Nerve Block/Wound Infiltration Addendum to the Multidisciplinary Guidelines for Acute Pain Management in Children & Young People ABMU HB Pain Management Service & Paediatric Pain Management Forum [PPMF] Dr Piyush Singh, Consultant Paediatric Anaesthetist/ Pain Management Lead Issue / Version No: August 2012 / Version 1 Next Review / Guideline Expiry: April 2015 Details of persons included in consultation process: Brief outline giving reasons for document being submitted for ratification Name of Pharmacist (mandatory if drugs involved): Please list any policies/guidelines this document will supersede: W&CH Directorate; Clinical Support Services Directorate; ABMUHB Medicines Management Group This is a new procedure & relates to the administration of a peripheral infusion of Local Anaesthetic [LA] infused either for nerve/plexus/compartment block or wound infiltration for peri-operative analgesia in children. Bhavee Patel N/A newly developed guideline Keywords linked to document: Nerve Block; Wound Infiltration; Local Anaesthetic Date approved by Directorate Quality & Safety Group: File Name: Used to locate where file is stores on hard drive 21 st November 2012 ABM_W&CH_mgt\Clinical Governance\Policies & Procedures etc - Ratified\Paediatrics * To be completed by Author and submitted with document for ratification to Clinical Governance Facilitator 8