Acute pain service protocol 2012.

DEPARTMENT OF ANESTHESIA AL RAZI HOSPITAL, KUWAIT

2012

Acute Pain Service:

Operations Manual Dr A.Hussain Al Mejade, FRCA

Dr Farah Jafri, MD

A L R A Z I H O S P I T A L , K U W A I T

ii

Acute Pain Service: Operations Manual 2012

Title: Acute Pain Service:

Operations Manual

Applicable at Department of Anesthesia Al Razi Hospital, Kuwait

Authors: Dr A.Hussain Al Mejade, FRCA Dr Farah Jafri, MD

Edition: First

Year 2012

Printed in Kuwait

*ACUTE PAIN SERVICE: OPERATIONS MANUAL BY DR FARAH JAFRI*

iii


FOREWORD

It’s a pleasure to write a forward for this Acute Pain Service Operations

Manual.

As a pain consultant, alleviation of post-operative pain has always been a

cardinal pillar of my professional ideology. Most patients are very

apprehensive about post operative pain and as anesthetists we are in a

position to offer our patients with multiple options to make their journey to

recovery as comfortable as possible.

To ensure that a high standard of care is delivered by the Acute Pain Service

in Al-Razi Hospital in Kuwait, we have systematically developed this

Operations Manual. The work consists of benchmark quality guidelines for

rational analgesia practice.

Dr Farah Jafri has been working as the coordinator of the pain service since

2010. She was entrusted with the responsibility of compiling the acute pain

service protocols and updating the pain service follow up sheets. I have

been regularly consulted during the writing of these protocols.

The pain service manual was written to help the anesthetists and pain team

at Al Razi hospital provide their patients with the best possible mode of pain

relief. The protocols are based on internationally certified and accredited

practices. There are chapters on the recovery room pain management,

epidural analgesia, patient controlled intravenous opioid analgesia, regional

anesthesia, pediatric analgesia and a chapter on multimodal analgesia. The

aim was to provide the readers with guidelines to implement safe pain

control techniques and deal with the common and uncommon complication

as they arise.

I am sure this book will serve its purpose to help our colleagues apply safe

and effective pain control for our patients.

Dr A. Hussain al Mejade.

Chairman and Pain consultant,

Al Razi Hospital, Kuwait

2012

iv


PREFACE

This pain service manual was written to assist the anesthetists and nursing

staff in implementing and monitoring the various pain control modalities

available at Al Razi hospital.

Acute pain control is an important part of a good post operative recovery

and rehabilitation plan, and it is of utmost importance in orthopedic

surgery.

The manual contains advice and tips on managing patients from immediate

post operative period in the recovery to care and monitoring in the wards.

There are chapters dealing with initiation and monitoring of epidurals,

patient controlled opioid analgesia, and regional nerve blocks. The doses

and dilutions are explained in detail and there are flowcharts for trouble

shooting complications and their management. There is a chapter on

multimodal analgesia, explaining the various pain scales and offering

guidance on how to choose the technique of pain relief based on the

patient’s current level of pain.

Pediatric pain relief is a separate chapter with advice on doses and

monitoring.

This manual was based on extensive research of the standard pain control

guidelines available in texts and online. Certain protocols are based on the

local experience of patient response to narcotics. Highest care was taken to

research the doses and the reader is advised to exercise their discretion is

choosing the best possible technique and doses for their patients.

During compiling this manual there were discussions and feedback was taken

from the Department of anesthesia at Al Razi Hospital to finalize a booklet

to cater to the needs of the anesthetists, technicians and nurses who are

involved in acute pain.

This work would not have been possible without the guidance and

supervision of Dr A. Hussain Al Mejade, Chairman and Pain consultant at Al

Razi orthopedic hospital.

The project of writing the hospitals pain protocols has been his initiative

and he has been involved in every step of the formulation and writing of

these protocols.

I am grateful for the constructive advice from the consultants and he

colleagues at Al Razi during compilation of this work.

v


I am appreciative of the hard work and practical advice of the pain nurse Ms

Amina, pain technician Mr. Satish and anesthesia technician Mr Karunakaran

during the research and finalizing of the protocols. They were our link with

the patients and the nursing staff.

The formatting, editing and proof reading, a daunting task, would not have

been possible without the help of Ms Fauzia Jafri and Dr Abid Ali Rizvi.

I hope this booklet will aid in providing the best possible care for our

patients.

We have been careful in avoiding errors during the writing of this manual.

As science is an ever changing field, we would like to remind our readers

that all suggestions and criticisms for the improvement of this manual are

confidently welcome.

Dr Farah Jafri, MD

Registrar, Department of Anesthesia,

Al Razi Hospital

Kuwait

22/Feb/2012

vi


TABLE OF CONTENTS

Chapter No Content Title Page

1 Pain Control in Recovery Room 07

2 Multimodal Approach to Pain Relief 13

3 Patient Controlled IV Analgesia 24

4 Epidural Analgesia 33

5 Regional Nerve Block 45

6 Pediatrics Acute Pain 56

7 Appendix: Service forms 66

PAIN CONTROL IN RECOVERY ROOM


1. PAIN CONTROL IN RECOVERY ROOM

Purpose

To provide the pain team and nursing staff a guideline for

implementing Recovery room pain management protocols

To provide steps for managing the complications that can occur

during implementation of the above protocols.

To provide effective and safe pain relief because inadequate pain

relief after surgery increases morbidity and delays patient

discharge from recovery room.

To discharge the patient from the recovery pain free and

comfortable.

Definitions and Abbreviations

PCA [PATIENT CONTROLLED ANALGESIA]: refers to a process where

patients can determine when and how much medication they

receive, regardless of analgesic technique. However, the term is

more commonly used to describe a method of pain relief which

uses disposable or electronic infusion devices and allows patients to

self-administer analgesic drugs

i.m intramuscular i.v intravenous

s.c sub cutaneous prn as per need

inj injection conc. concentration



Recovery Room Pain Management:

Practice

At the recovery room of the Al Razi Hospital, the nursing staff have been

trained and instructed to administer intravenous opioids for

postoperative pain relief.

They are competent in monitoring, assessing and assisting in the

management of the adverse effects and complications in post-anesthetic

patients.

Any patient who complains of distressing pain following surgery may be

prescribed the analgesia protocol outlined below.

This includes patients who are prescribed intravenous patient-

controlled analgesia (IV PCA) as they are recovering from the

anaesthetic.

Remember that these patients will only obtain pain relief from the PCA if

they are able to understand and activate the control button.

Your patient should be comfortable, when they are discharged from the

recovery room.



Opioid Protocol

Morphine (1 mg/ml), intravenous route:

Dilution 20 mg morphine to 20 ml with normal saline.

Adults:

Dose: 1-2 ml (1-2 mg) every 5 minutes as required.

For adult > 60 yr who is

50 kg, 1 ml boluses may be more appropriate.

Total dose limit: to be stated by anesthetist. If pain is not relieved within dose limit, the nursing staff will inform the anesthetist to reassess the patient.

Pediatrics: 20 g/kg every 5min IV Total dose limit: up to 5 doses.

Pethidine, intravenous route:

Dilution: 100 mg inj. Pethidine in 10 ml saline to make 10 mg /ml.

Adults: Dose: 10-20 mg (1-2 ml) every 5 minutes till pain control.

Total dose limit: to be stated by anesthetist. If pain not relieved with dose limit, the nursing staff will inform the anesthetist to reassess the patient.

Pediatrics: 0.25- 0.5 mg/kg

Tramadol, intravenous route:

Adults: 50- 100 mg iv, till pain control.

Alternatively, on preference of the anesthetist posted in recovery, Tramadol can be used.



For patients with an Epidural or Nerve Block Catheters

After assuring stable vitals, give bolus of injection Xylocaine 1% 5- 10 ml

via epidural/ nerve block catheter and wait for response.

If the pain is not relieved, then remove the catheter, and consider an

alternate mode of pain relief.

If pain is relieved, then increase the infusion rate and monitor vitals

every 5 min to watch for hypotension or bradycardia or local anaesthetic

toxicity.

Management of Complications due to Analgesics or Pain

Control Devices

Respiratory depression?

o All patients with significant sedation (difficult to rouse) are

at risk of developing respiratory depression.

o Resuscitate immediately if patient is physiologically

unstable. Secure patient’s airway, breathing and

oxygenation with manual ventilation and oxygen

supplement.

o Stop pain service device immediately.

o Consider Naloxone if patient is at risk of developing

significant sedation and deterioration.

Dose: 0.1-0.2 mg iv/im/sc and repeat at 3 minute

intervals until patient recovers or when a maximum

of 10 mg has been given.



Itching?

o Injection Chlorpheniramine (Allerfin) 2-5 mg iv or im.

Nausea/Vomiting?

o Ondansetron (Zofran) 4 mg IV q12hrs / PRN

o Metoclopramide (Primpran) 10 mg IV q6hrs / PRN

o Promethazine (Phenergan) 6.25 mg IV q6hrs / PRN

Dilute in 10 ml normal saline.

Assure IV patency before administration.

Inject slowly

Hypotension?

o Give fluid ± vasopressors. (Increments of injection

ephedrine 1.5mg)

Stop the infusion for 2 hours and then reassess.

Recommence infusion at a lower rate.

If pain relief is inadequate, continue the infusion after

fluid ± ephedrine, and consider co-analgesic.

o Consider converting to non-regional modes of analgesia if

hypotension remains a problem whenever adequate

blockade is established.

Unilateral Blockade?

o Withdraw epidural catheter by 1 cm and top-up with

another bolus, 5-10 ml of epidural LA.



References

Aubrun F. (2005). Management of postoperative analgesia in elderly patients. Regional Anesthesia and Pain Medicine 30(4): 363–79.

Wu CL. (2005). Acute postoperative pain. In Miller RD (ed.), Anesthesia, 6th ed. Philadelphia: Churchill Livingstone, Ch. 72

American Society of PeriAnesthesia Nurses (ASPAN). (2003). Pain and comfort guideline. Retrieved 10 September 2011 from http://www.aspan.org/painandcomfort.htm.

San Diego Patient Safety Taskforce. Tool Kit Patient Controlled Analgesia (PCA) Guidelines of Care for the Opioid Naïve Patient. Available at: http://www.hasdic.org/documents/Tool-Kit-PCA.pdf. Accessed December 5, 2010.

MULTIMODAL APPROACH TO PAIN RELIEF


2. MULTIMODAL APPROACH TO PAIN RELIEF

A multimodal approach to Acute Pain Management entails combining

several pain relieving techniques with different mechanisms of action.

The net result is usually better than if a single technique is relied upon.

Analgesics act at many different sites. To rely on a single drug to satisfy

the analgesic requirements for a patient is optimistic, often necessitating

a high dose, which increases the side effects.

To avoid this problem it is better to employ combination therapy with

drugs of differing modes and sites of action. This will allow a reduced

dose of each drug and thereby lessening the risk of side effects whilst

giving better analgesia.

There is a large variation between individual patient’s analgesic

requirements. Pain intensity depends on the type of surgery but it is

difficult to correlate pain intensity and surgery type due to wide inter-

patient variation. It is therefore not surprising that a standardized

postoperative analgesic regime applied to all patients would be

ineffective.

The importance of patient selection for differing analgesic approaches

cannot be over emphasized and this fact has possible major implications

for the cost-effectiveness of treatment and post-operative morbidity.



Pharmacotherapy Options

1. NSAIDS AND PARACETAMOL

Paracetamol is an effective analgesic for acute pain and that NSAIDs

improve analgesia when given in addition to paracetamol or opioids.

NSAIDs act synergistically with opioids which may result in significantly

reduced opioid requirements and possible reduction of the incidence of

opioid-induced side-effects.

Concomitant usage of regular NSAIDs with PCA/epidural/IM/IV

techniques can contribute to more effective analgesia.

There are many different NSAIDS which have differing efficacy and

incidence of side effects, but because they all inhibit prostaglandins,

they tend to have the same major potential problems/side

effects/relative contra-indications.

2. COX 2 INHIBITORS (COXIBS)

They are effective in the treatment of acute postoperative pain. When

given in addition to PCA opioids, coxibs reduce opioid consumption.

3. OPIOIDS

Opioids remain the mainstay of systemic analgesia for the treatment of

moderate to severe acute pain.

All full opioid agonists given in appropriate doses produce the same

analgesic effect and therapeutic index, although accurate determination

of equianalgesic doses is difficult due to interindividual variabilities in

kinetics and dynamics.



4. MORPHINE

Morphine remains the most widely used opioid for the management of

pain and the standard against which other opioids are compared.

5. TRAMADOL

Tramadol is commonly referred to as an atypical centrally acting

analgesic because of its combined effects as an opioid agonist and a

serotonin and noradrenaline reuptake inhibitor.

Although an effective analgesic, it may not provide adequate pain relief

if used as the sole agent for the management of moderate to severe

acute pain in the currently recommended doses.

Tramadol is an effective treatment of neuropathic pain.

Inhibition of 5HT3 receptors by ondansetron also decreased the

analgesic effect of 15ocalize.

Tramadol’s adverse effect profile is different from other opioids. The risk

of respiratory depression is significantly lower at equianalgesic doses

and it does not depress the hypoxic ventilatory response.

6. FENTANYL

Fentanyl is commonly used in the treatment of acute pain, especially

when its lack of active metabolites and fast onset of action may be of

clinical benefit.

Adverse Effects of Opioids

Common adverse effects of opioids are sedation, pruritus, nausea,

vomiting, slowing of GI function and urinary retention.



Meta-analyses have shown that the risk of side effects from opioids

administered by PCA is similar to the risks from traditional methods of

systemic opioid administration, with the exception of pruritus, which is

increased in patients using PCA.

Clinical Implications of Opioid Tolerance and Opioid-Induced

Hyperalgesia

Administration of opioids can lead to:

Opioid Tolerance: a desensitization of anti-nociceptive pathways to

opioids.

Opioid Induced Hyperalgesia [OIH]: a sensitization of pro-

nociceptive pathways leading to pain hypersensitivity.

Both these phenomena can significantly reduce the analgesic effect of

opioids.

The challenge faced by the clinician is that if inadequate pain relief is

due to OIH, a reduction in opioid dose may help; if it is due to opioid

tolerance, increased doses may provide better pain relief.

There are some features of OIH that may help to distinguish it from pre-

existing pain. With OIH, pain intensity may be increased above the level

of the pre-existing pain; the distribution tends to be beyond that of the

pre-existing pain as well as more diffuse.

When a patient who has been taking opioids for a while (either legally

prescribed or illicitly obtained) has new and ongoing tissue injury with

resultant acute pain, a reasonable initial response to inadequate opioid

analgesia, after an evaluation of the patient and in the absence of

evidence to the contrary, is a trial of higher opioid doses . If the pain



improves this would suggest that the inadequate analgesia resulted from

tolerance; if pain worsens, or fails to respond to dose escalation, it could

be a result of OIH.

Three main groups of opioid-tolerant patients/patients with OIH are

encountered in surgical and other acute pain settings:

1. Patients with chronic cancer or non-cancer pain being treated

with opioids, some of whom may exhibit features of opioid

addiction.

2. Patients with a substance abuse disorder either using illicit opioids

or on an opioid maintenance treatment program; and

3. Patients who have developed acute opioid tolerance or OIH due to

perioperative opioid administration, particularly opioids of high

potency.

Recognition of the presence of opioid tolerance or OIH may not be

possible if the patient’s history is not available or accurate. If a patient is

requiring much larger than expected opioid doses and other factors that

might be leading to the high requirements have been excluded, opioid

tolerance or OIH should be considered.

The use of local anaesthetics administered for the purpose of operative

surgery or during the course of general anaesthesia can also enhance

patient analgesia in the early postoperative period.

A variety of local anaesthetic techniques may be utilized for this

purpose, for example, local infiltration into the wound or a specific

blockade.



Management of these patients should focus on:

a) Effective analgesia

b) Prevention of withdrawal.

c) Attenuate tolerance or OIH:

Use of NMDA or opioid-receptor antagonists

Opioid rotation

Other adjuvant drugs

Combination Approach to Prescribing Analgesia

The Analgesic Ladder described by the World Health Organization is a

three-step approach to pain relief, the idea being to move to the next

step if the previous step is ineffective:

1. Simple non-opioid analgesics (Paracetamol +/- NSAID)

2. Weak opioids (Codeine, Dihydrocodeine, Tramadol) + Paracetamol +/- NSAID)

3. Strong opioids (Morphine etc. + Paracetamol +/- NSAID)

Post-operative pain starts at peak intensity and improves over time, so

analgesia may be started at a higher level and stepped down as pain

improves. Analgesic choice should be determined by the ‘step’ most

appropriate to the patient’s level of pain.

Tramadol is serotoninergic and is best not prescribed alongside

serotonin (5HT3) antagonist anti-emetics such as ondansetron, as the

efficacy of both drugs will be reduced.



Acute Pain Stepladder

This is a step wise approach to managing pain in the acute setting.

SEVERE PAIN? Score 3

o Epidural analgesia or Morphine PCA, or IM narcotic protocol

o Plus Diclofenac 100-150mg* in 24 hr, OR other NSAID

o Plus Paracetamol 1g qid regularly

MODERATE PAIN? Score 2

o Tramadol 400mg in 24hrs

o Plus Diclofenac 75-150mg/ 24 hr, OR other NSAIDs

o Plus Paracetamol 1g x qid regularly

MILD PAIN ? Score 1

o Paracetamol maximum 4g / 24 hr

o Diclofenac 100-150mg / OR other NSAID

*NSAIDs should not be prescribed for > 3 days in the first

instance.

Careful Use of NSAID in:

The elderly

Patients with aspirin sensitive asthma, diabetes, vascular disease

Patients after renal or major vascular surgery

Those receiving lithium, cyclosporine, dioxin, aminoglycosides,

antihypertensives (esp. ACE inhibitors), diuretics and

anticoagulants.



Pain/Sedation and Nausea Measurement Tools:

A variety of pain assessment tools exist, each one has its merits for use

for specific patient groups.

At Al Razi hospital, the patient population is diverse and can include

adults any age, with acute, chronic or malignant pain and cognitive or

physical impairments of varying origin. The doctors and nurses therefore

need to be educated about pain measurement tools to ensure their

appropriate use.

As a general rule, use what makes sense to the patient and be

consistent, use the same scale with the same person.

1. Pain Score (Verbal Description Scale)

Score Namely Description

0 None No pain at rest

No pain on movement.

1 Mild No pain at rest

Mild pain on movement.

2 Moderate Intermittent pain at rest

Moderate pain on movement.

3

Severe Continuous pain at rest

Severe pain on movement.

Examples of Movement: Patient attempts to touch the opposite side of

the bed or deep breathe.



This tool has been shown to be valid and reliable in the assessment of

acute pain. The advantages are that it can be verbally administered and

is easy for both patients and staff to use. It allows patients to describe

their pain in words rather than numbers. This tool has been

recommended for use with older people (Herr et al, 2004) and may be

used with some success in patients with cognitive impairment (Closs et

al, 2004).

2. Visual Analogue Scale (VAS).

NO PAIN------------------------------------------------------WORST

SCORE ZERO TEN

This type of scale is popular for its precision and so is widely used for

research and audit (Wood, 2004). The advantages are that it is relatively

easy to teach, understand, score and document. Plastic rulers have been

devised using the same principle. The patient is asked to mark on the

line, the position, which best represents, their current degree of

sensation. It is scored by the nurse measuring in millimeters from the

left side to the line marked by the patient (or as indicated on the reverse

of the ruler).

The VAS requires greater cognitive skills (Bird, 2003 and Wood, 2004)

and may not be appropriate in the post-operative setting, critically ill,

physically, visually or cognitively impaired (Rowbotham and Macintyre,

2003).



3. Assessment Tool for Use in Patients with Cognitive

Impairment or Inability to Report Pain.

SCORE DESCRIPTION

0 No pain Able to move without complaining.

1 Quite Resting quietly when undisturbed,

Flinches on movement.

2 Restless Resists repositioning/toileting but does comply.

3 Agitated Cries out even when undisturbed,

Refuses nursing intervention.

Patients who cannot report pain, and/or have difficulty doing so are at

high risk of under-treatment of pain (Herr, 2002).

References

Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine, 2010. Acute Pain: Scientific Evidence. 3rd ed. Australia: ANZCA. www.anzca.edu.au/publications/acutepain.pdf

BIRD, J., 2003. “Selection of pain measurement tools.” Nursing Standard. 18(13), pp. 33-39.

NHS Quality Improvement Scotland (NHS QIS), 2004. Best practice statements: postoperative pain management. Edinburgh: NHS QIS. www.nhshealthquality.org

Gould TH, Crosby DL, Harmer M, Lloyd SM, Lunn JN, Rees GAD et al. Policy for controlling pain after surgery: effect of sequential changes in management. British Medical Journal 1992; 305:1187-1193.

HERR, K et al., 2004. “Evidence based assessment of acutpain in older adults: current nursing practices and perceived barriers.” Clinical Journal of Pain. 20(5), pp. 331-340.

McCaffery, M., & Beebe, A. (1993). Pain: Clinical Manual for Nursing Practice. Baltimore: V.V.



Mosby, referenced from NIH Pain Consortium National Institutes of Health, http://painconsortium.nih.gov/pain_scales/http://painconsortium.nih.gov/pain_scales/http://painconsortium.nih.gov/pain_scales/http://painconsortium.nih.gov/pain_scales/ Date Last Modified: January 17, 2007. Accessed on 8 dec 2010.

Briggs M, Closs JS. A descriptive study of the use of visual analogue scales and verbal rating scales for the assessment of postoperative pain in orthopedic patients. J Pain Symptom Manage. 1999;18(6):438–446. Doi: 10.1016/S0885-3924(99)00092-5

Collins SL, Moore RA, McQuay HJ. The visual analogue pain intensity scale: what is moderate pain in 23ocalized23o? Pain. 1997;72(1-2):95–97. Doi: 10.1016/S0304-3959(97)00005-5.

Serlin RC, Mendoza TR, Nakamura Y, Edwards KR, Cleeland CS. When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function. Pain. 1995;61(2):277–284. Doi: 10.1016/0304-3959(94)00178-H

Correspondence of Verbal Descriptor and Numeric Rating Scales for Pain Intensity: An Item Response Theory Calibration J Gerontol A Biol Sci Med Sci (2010) 65A(7): 778-785 first published online January 27, 2010

http://painconsortium.nih.gov/pain_scales/




PATIENT CONTROLLED INTRAVENOUS ANALGESIA


3. PATIENT CONTROLLED INTRAVENOUS ANALGESIA

Purpose

To provide the pain team and nursing staff a guideline for

implementing Patient-controlled intravenous analgesia protocols.

To provide steps for managing the complications that can occur


Definitions

PATIENT CONTROLLED ANALGESIA [PCA]: refers to a process where

patients can determine when and how much medication they receive,

regardless of analgesic technique. However, the term is more commonly

used to describe a method of pain relief which uses disposable or

electronic infusion devices and allows patients to self-administer

analgesic drugs

BOLUS DOSE: This is the set dose of drug that the patient will receive

each time they activate the pump.

LOCKOUT DURATION: This is the time interval following a bolus dose

during which the pump will not respond to further presses of the button,

allowing time for the first dose to exert its full effect.

CONCENTRATION: The PCA pump needs to be programmed with the

concentration of drug being used. The standard drug concentration is

Morphine 1mg/ml.

BASAL RATE: The rate at which the drug is continuously infused in

addition to the bolus doses.



PCA BY PROXY: Any person instead of the patient presses the button so

that the patient receives a bolus dose, can lead to over sedation of the

patient.

OPIOID-TOLERANT PATIENTS: are those who have been taking, for a week

or longer at least 60 mg of morphine daily, or 30 mg of oral Oxycodone

daily, or 8 mg of oral Hydromorphone daily, or an equianalgesic dose of

another opioid.

OPIOID NAÏVE: patients are those who do not meet the definition of

opioid tolerant; who have not had doses of narcotics at least as much as

those listed above for a week or more.

Procedure: Patient Controlled Intravenous Analgesia

Patient controlled analgesia has the advantage of allowing individually

titrated opioid dosing, with temporal flexibility to accommodate

changing needs e.g. physiotherapy, mobilization, etc. In most patients, it

provides greater patient satisfaction than intermittent opioids.

Pre-operative Assessment

A. Patient`s capability to understand and use the PCA device should

be evaluated preoperatively or in the Anesthesia Clinic.

B. Evaluate the patient’s mental status, level of consciousness, and

developmental status.

C. Patient should understand the sequence: pain press the PCA

button pain relief.

D. A willingness to use PCA for pain management.

E. An understanding of the dosing interval.

F. Ability to self-administer a PCA dose by pushing the PCA button or

simulating action.



PCA Patient Education

A. Patient and family education is critical.

B. Education must include family members.

C. Clearly emphasize the hazards of anyone other than the patient

administering a PCA dose.

D. Stress that serious adverse events can result when family

members administer “PCA by proxy”.

E. Inform the patient about the safety features of the pump to

prevent overdose. Explain lockout interval, limit on dosage in a set

time interval and patient administered dosing.

Monitoring

Explain the elements, purpose, and frequency of ongoing monitoring, so

the patient understands and expects to be awakened, and to be

monitored frequently to assess level of sedation.

Opioid Tolerant or Opioid Naïve?

This history must immediately precede the intended course of PCA

therapy. If a wash-out period of a week or longer has occurred since the

above dosages were taken, reconsider whether the patient truly meets

this definition.

Pumps in the Service

1. Ivac Alaris

2. CADD Legacy

3. Disposable – Vygon Freedom 5



Drug Protocols

Drug Loading Dose

Concentration Bolus Basal Lockout Minutes

Morphine 1-5 mg 1 mg/ml 1-2 mg 0.5 mg/hour 15

Tramadol 50 mg 10 mg/ml 10 mg 0 – 10 mg/hr 10

Fentanyl 20 g 10 mcg/ml 10 g 0 or 0.2 ml/hr 10

Pethidine 25 mg 10 mg/ml 10 mg 0 or 0.2 ml/hr 20

Ketamine 2.5 mg 1 mg/ml 1-2 mg 0 or 0.2 ml/hr 15

Preparation

Drug Quantity that will be added to 0.9% Saline to make up a 50 mL solution.

Morphine 50 mg

Tramadol 500 mg

Fentanyl 500 gm

Pethidine 500 mg

Ketamine 50mg

Example: 5 ampules of Morphine 10 mg/ml will be 5ml, then add 45 ml of

0.9% Saline; total volume of the solution is 50 ml.

Dose Adjustment for Opioid Dependent Patients

Non-Naive Patients: Convert their current total oral/transdermal dose to

a total 24 hour IV dose of the planned PCA opioid; divide by 24 to give

the hourly Continuous Infusion rate in mg/hour. The PCA Demand dose

is initially calculated at 50% of the hourly rate.



Indications and Precautions for Using Fentanyl, Pethidine and

Ketamine PCA.

PCA using Injections Fentanyl, Pethidine and Ketamine are to be used

only after discussing with Pain Consultant.

1. Injection Fentanyl

Possible Indications

1. Patients with RENAL IMPAIRMENT (no active metabolites).

2. Patients > 70-75 YEARS (Morphine can cause high incidence of

confusion and hallucinations after 24-48 hours).

3. Patients with a HISTORY OF PREVIOUS ADVERSE REACTIONS TO

MORPHINE (including severe PONV, pruritus or drowsiness).

2. Injection Pethidine

It is recommended that Pethidine be used for short durations in carefully

monitored doses and only in patients who have demonstrated

intolerance to all other μ agonists.

Care with PCA Pethidine:

Pethidine is metabolized to Norpethidine.

High plasma levels of Norpethidine are associated with twitching

and (rarely) convulsions.

Suggested management of these complications is:

Twitching Reduce the infusion rate.

Convulsions Stop the infusion and treat accordingly.



3. Injection Ketamine

Ketamine is an anaesthetic with analgesic properties – a characteristic

that differentiates it from other anaesthetic induction agents.

The analgesic component works by binding to receptors in both

peripheral and central nervous systems, including opioid receptors, and

most notably as an agonist to the NMDA receptors (N-methyl D-

aspartate) in the dorsal horn of the spinal cord.

It has potential to reduce the “wind up” (hyperalgesia) of the pain

pathway in response to ongoing pain.

Possible Indications of Ketamine PCA

1. Patients with acute pain, in whom multimodal therapy with local

anaesthetics (including epidurals), opioid, Paracetamol, and

NSAID/COX-2 as appropriate are not providing adequate pain

relief, or are producing intolerable side-effects.

2. Patients with acute pain who are developing neuropathic pain.

Contraindications to Ketamine PCA

Hypertension Predisposed to hallucinations

Glaucoma Psychiatric illnesses

Raised ICP Sensitivity to Ketamine

Pregnancy/Lactation Ischemic Heart Disease



Precaution with Injection Tramadol PCA

1. Avoid in patients with history of epilepsy and head injury.

2. Reconsider use in patients on anti-depressants.

3. Possible risk of serotinergeric syndrome.

Co-Analgesia

i. Regular Paracetamol 1 gram every 4-6 hourly.

ii. A regular non-steroidal anti-inflammatory drug (Diclofenac 75mg

bid) can be prescribed if required (no contra-indications).

iii. Tramadol 50-100mgs prn, if required, to be administered with the

PCA, except with Tramal PCA.

iv. Tab Norgesic or Injection Norflex as adjuvant.

Trouble shooting PCA

Inadequate analgesia?

1. Stable patient? With intravenous PCA → boluses of

morphine 0.02mg / kg iv at 5 min intervals up to 0.1 mg/kg.

2. Consider a co-analgesic.

Respiratory depression?

1. All patients with significant sedation (difficult to rouse) are

at risk of developing respiratory depression.

2. Resuscitate immediately if patient is physiologically

unstable. Secure patient’s airway, breathing and

oxygenation with manual ventilation and oxygen

supplement.



3. Stop APS device immediately.

4. Consider Naloxone if patient is at risk of developing

significant sedation and deterioration.

Dose: 0.1-0.2 mg iv/im/sc and repeat at 3 minute intervals

until patient recovers or when a maximum of 10 mg has

been given.

Itching?

1. Injection Chlorpheniramine (Allerfin) 2-5 mg iv or im.

2. Tab Histan 4 mg: If tolerating oral intake.

Nausea/Vomiting?

1. Ondansetron (Zofran) : 4 mg IV q12hrs / PRN

2. Metoclopramide (Primpran) : 10 mg IV q6hrs / PRN

3. Promethazine (Phenergan): 6.25 mg IV slowly q6hrs /

PRN for nausea/vomiting (Safety precautions: Dilute in

10 ml normal saline. Assure IV patency before giving).

Constipated?

1. Add regular oral laxative Syrup Duphalac 10 ml tds, order

Dulcolex suppository.

2. Enema PR is an alternative, if constipation is distressing.

References

San Diego Patient Safety Taskforce. Tool Kit Patient Controlled Analgesia (PCA) Guidelines of Care for the Opioid Naïve Patient. Available at: http://www.hasdic.org/documents/Tool-Kit-PCA.pdf. Accessed December 5, 2010.



Great Ormond Street Hospital for Children NHS Trust [Internet]. London (GB): Pain Control Service; [reviewed 2010 May 25; cited 2010 Dec 5]. Patient controlled analgesia/nurse controlled analgesia (Tramadol, Pethidine and Ketamine PCA protocols). Available at: http://www.gosh.nhs.uk/clinical_information/clinical _guidelines/cpg_guideline_00143

Grass JA. Patient-controlled analgesia. Anesth Analg [Internet]. 2005 [cited 2010 Dec 5]; 101(Suppl):S44–S56. Available from: http://www.anesthesia-analgesia.org/content/101/5S_ Suppl/S44.full

Lehmann KA. Recent Developments in Patient-Controlled Analgesia. J Pain Symptom Manage [Internet]. 2005 May [cited 2010 Dec 5]; 29(5 Suppl):S72-89. Available from: http://www. Jpsmjournal.com/article/PIIS088539240500031X/fulltext

Medical College of Wisconsin. End-of-Life / Palliative Education Resource Center [Internet]. Milwaukee (WI): Fast Fact and Concept #092 [re-copy-edited 2009 Apr; cited 2010 Dec. 5]: Patient Controlled Analgesia in Palliative Care, 2nd Edition. Available at: www.eperc.mcw.edu

EPIDURAL ANALGESIA


4. EPIDURAL ANALGESIA

Continuous Infusion and Patient Controlled Epidural Analgesia

Purpose

Provide the pain team and nursing staff a guideline for

implementing the epidural analgesia protocols.

Provide steps for managing the complications that can occur


Definitions

CONTINUOUS EPIDURAL ANALGESIA: Continuous injection of local

anesthetic solution into the epidural space to relief pain.

PCEA [PATIENT CONTROLLED EPIDURAL ANALGESIA]: A pump

attached to a catheter in the epidural space and filled with

multiple doses of medications that are available whenever the

pump is activated by the patient.

DEMAND DOSE OR BOLUS: Fixed dose given by pump when patient

pushes the demand button.

LOCKOUT INTERVAL: Period during which pushing the demand

button does not result in administration of dose.

BASAL RATE: Rate at which drug is continuously infused by a

pump to relive pain; patient can give himself additional dose or

bolus if pain is unrelieved.

EPIDURAL ANALGESIA


Procedure

Protocol for Epidural & Patient Controlled Epidural Analgesia

The aim of epidural analgesia is to provide pain relief with minimal

sedation, allowing for increased mobility and cooperation with

physiotherapy after surgery.

To ensure adequate pain relief on the first postoperative night, it is

important that, no patient is discharged from recovery without a review

of the function of their epidural.

Patients with an epidural must be reviewed on the 1st postoperative

evening, usually by the ICU on-call. Due care taken for adequate

functioning of epidural and any need for supplemental analgesia or

sedation.

Initiation of Epidural Analgesia

Where epidural analgesia is used for postoperative pain relief, initiation

of the block will normally be the responsibility of the anesthetist involved

in the case.

Prerequisites before Sending Patients to the Ward with

Epidural Analgesia:

1. Patent IV access, IV Fluids.

2. Available O2 source.

3. Monitoring by staff that have knowledge of Basic Life Support.

4. Professional Accountability in the form of dedicated pain team or

on-call doctor for pain.

5. Staff trained to use equipment and drugs.

EPIDURAL ANALGESIA


Protocol Criteria

Preoperative Preparation and Patient Education

All patients selected for epidural analgesia should be notified by the

anesthetist pre-operatively, and given an explanation of the technique.

The patient planned for PCEA should know how to press the button;

with help of props, images and graphics or an actual pump.

Patient must be told to hear for the soft beep which indicates the

receipt of a dose.

The patient and relatives should be instructed that only the patient may

press the demand dose button and that the button is not to be pressed

if there is no pain.

Intraoperative Plan

For the epidural service to work well, the anesthetist in the Operation

Room has the responsibility for:

1. Insertion of the catheter including documentation of:

a. The depth at which the space was found.

b. The marking of the catheter on the skin.

Ideally there should be about 4 cm of catheter in the space.

2. Secure fixation of the catheter, so that the insertion site can

be easily inspected. It is suggested that, this can be achieved using

a clear dressing with the edges secured by Elastoplast. A square of

gauze may also be useful if there is any skin bleeding. Careful in-

theatre dressing is essential so that site inspection is easy. This

EPIDURAL ANALGESIA


also avoids the need to change the dressing in the ward, and thus

decreases the risk of infection and disconnections.

3. Initiation of epidural blockade. In many cases, the epidural is

used intra-operatively in combination with light general

anaesthesia, so that its effectiveness is demonstrated. If the

epidural has not been the principal means of intraoperative

analgesia, this may necessitate formal testing of the block, as the

apparent in-recovery comfort may be due to intravenous

analgesia and slow recovery from anaesthesia.

4. The anesthetist should ensure that the block is working well

before discharging from recovery.

5. Communicating with the ICU registrar for the evening rounds, if

there are any possible problems with the epidural. The epidural or

PCEA form should always be completed and kept in the follow-up

folder so that the patient can be reviewed.

6. To label the epidural catheter & fasten tightly the screw into

the bacterial filter.

7. To anchor the filter to the patient’s skin to avoid traction of the

pump tubing (for preventing accidental disconnection).

Bolus doses of drugs outside of the theatre, in the recovery unit and in

the ICU will only be administered by an anesthetist.

Insertion of epidural catheters should be avoided in patients who are

fully anti-coagulated. Epidural catheters must not be inserted or

removed within 4 – 6 hours of a subcutaneous dose of standard heparin

EPIDURAL ANALGESIA


or twelve hours of a subcutaneous dose of low molecular weight

heparin.

Postoperative Plan

All patients must have a patent intravenous cannula during and for up to

twelve hours after cessation of the epidural.

Concurrent use of parenteral / oral opioids (or any CNS depressants) is

not permitted unless prescribed by an anesthetist or a member of the

pain team.

The patient must be monitored by staff competent in the technique and

the monitoring requirements, and are able to recognize and respond to

adverse effects.

Continuous infusions will be given via an infusion pump. All connections

are to be via a Luer Lock and there should be no three-way taps or other

injection ports on the infusion line.

A bacterial filter must be included in the epidural infusion lines which

must be labelled as “epidural only”, to avoid accidental injection. Most

brands of filters are guaranteed to be effective for four days.

Disposal of Unused Drugs

Drugs remaining in the cartridge used for a local anaesthetic infusion via

a PCA OR infusion pump are disposed off and the amount documented

in the patient notes and in the pain service form.

Drugs remaining in a disposable infusion device are not removed from

the infusion device. The complete device and administration set are

disposed of in the sharps bin.

EPIDURAL ANALGESIA


Contraindications

1. Patient refusal.

2. Local sepsis, e.g. abdominal surgery (with Sepsis).

3. Coagulation disorders or treatment with anticoagulant drugs.

NB: Patients receiving anticoagulant therapy may receive epidural

analgesia, provided the guidelines with reference to insertion and

removal of the catheter are followed.

Regimes: For Postoperative Epidural Infusion

1. For ICU patients:

Injection Bupivacaine 0.1% and injection Sufentanil 0.16 g/ml.

Injection Bupivacaine 0.1% and injection Fentanyl 1-2 g/ml.

2. For all ward patients:

Injection Bupivacaine 0.125% without opioids.

Equipment Used for Epidural Drug Administration

1. Syringe Pump

With 50 ml syringe

For continuous epidural infusion.

2. Elastomeric Pump:

300 ml, 100 ml

For continuous epidural infusion.

3. CADD Legacy PCA Pump

EPIDURAL ANALGESIA


Drug Dilutions

1. For Use in Syringe Pumps

To make 50 ml of 0.125% Marcaine [plain]:

Mix:

12.5 ml of 0.5% Marcaine with 37.5 ml of Normal saline, OR

25 ml of 0.25% Marcaine with 25 ml of Normal saline.

2. For Elastomeric Pump [300 ml]

To make 300 ml of 0.1% Marcaine with (0.16 g/ml conc.) Sufentanil:

Mix: 60 ml of 0.5% Marcaine with 10 ml of Sufentanil from the vial and 230 ml of Normal saline.

To make 300 ml of 0.1 % Marcaine [plain]:

Mix: 60 ml of 0.5% Marcaine with 240 ml of Normal saline

3. For the Elastomeric Pump [100 ml]

To make 100 ml of 0.1% Marcaine with (0.15 g/ml conc.) Sufentanil

Mix: 20 ml of Marcaine 0.5% with 3 ml of Sufentanil from the vial and add 77 ml of Normal saline.

To make 100 ml of 0.1 % Marcaine

Mix: 20 ml of 0.5% Marcaine with 80 ml of Normal saline.

EPIDURAL ANALGESIA


Special Care for Patients on PCEA

Epidural infusion lines should be clearly identified.

Pump and cartridge must be labeled “for epidural connection

only”.

All patients must have a patent IV cannula during and for 12 hours

after cessation of epidural.

Ensure that the patient is not fluid-depleted before insertion of

epidurals, e.g. due to:

Bowel preparation

Fasting or starvation

Insensible water loss pre-operatively (up to 10ml/kg/hr)

Ensure hydration during the initial post-operative period with IV

fluids and later by good oral intake.

PCEA Initiation

i. Program the pump in Recovery Room.

ii. Set an initial base line infusion rate of 5ml/hr.

iii. Possibly increase up to 8-10 ml/hr, if analgesia proves inadequate

after the patient is settled and is using the PCEA satisfactorily.

iv. Bolus dose: 2-3 ml

v. Lockout: 30 minute

vi. Basal infusion rate: 6-8 ml/ hr

vii. Net infused volume (basal plus bolus) should not exceed 12 ml/hr.

viii. Normal Epidural Care: Regular Co-Analgesics and Side Effect

Assessments.

EPIDURAL ANALGESIA


Regimes for Patient Controlled Epidural Analgesia

ICU Patients:

0.1% Bupivacaine and (0.15 mcg/ml conc.) Sufentanil

0.1% Bupivacaine and (1-2 mcg/ml conc.) Fentanyl

Ward Patients: 0.125% Bupivacaine

Drug Dilutions for 100 ml Cartridge

Prepare two cartridges at the same time with identical solution.

Put patient label and send to ward.

They can be used alternatively; the anesthetist attending the

cartridge change can refill and keep the other for the next change.

Drug dilutions

To make 100 ml of: 0.1%Marcaine with (0.15 g/ml conc.) Sufentanil

Mix: 1 ampule/vial (20 ml) of 0.5 % Marcaine with 3 ml of Sufentanil

and 77 ml of Normal saline.

To make: 0.1% Marcaine with (2 g/ml conc.) Fentanyl

Mix: 1 ampule (20 ml) of 0.5% Marcaine with 4ml of (i.e. 2 ampules of

50g/ml conc.) Fentanyl and 76 ml Normal saline.

To make 100 ml of 0.125% Marcaine [Plain]

Mix: 25 ml of 0.5% Marcaine with 75 ml of Normal saline.

Monitoring in the Recovery

Temperature Respiration Movement

Pulse Sedation Sensation

Blood pressure Pain Score

EPIDURAL ANALGESIA


Monitoring in the Ward (Every 6 Hourly)

Temperature Sedation Level Movement

Pulse Pain Score on Movement Sensation

Blood Pressure Pain Score on Deep Breathing Urine Output

Respiration Nausea and Vomiting Bladder Distension

Troubleshooting Epidurals

1. Inadequate Analgesia

Stable patient with epidural or nerve block:

o Increase the basal infusion rate by 2ml/hr.

Severe pain:

o Give a 5 ml bolus of the same solution, OR

o Give bolus of 0.125-0.25% Bupivacaine OR 1% Xylocaine

via the epidural catheter.

o Monitor blood pressure every 10 min for 30 min.

Consider a co-analgesic.

2. Hypotension?

Give Fluids ± Vasopressors. (Increments of ephedrine 1.5mg iv).

Stop the infusion for 2 hours and then reassess again.

Recommence infusion at a lower rate.

Add co-analgesics if needed.

Consider converting to non-regional modes of analgesia if

hypotension remains a problem whenever adequate blockade is

established.

EPIDURAL ANALGESIA


3. Unilateral Blockade?

Withdraw epidural catheter by 1 cm and top-up with another

bolus, 5-10 ml of epidural LA.

4. Catheter Disconnection?

If the epidural catheter becomes disconnected from the patient side of

the bacterial filter, and it is a witnessed disconnection, then clean the

tubing aseptically, cut 10 cm off the catheter with a sterile blade and

aseptically connect to the adapter and filter.

If the disconnection from the patient side was not witnessed, then the

epidural must be removed as soon as possible, adhering to the

anticoagulant timing protocol.

If it becomes disconnected from the infusion side of the filter, it can be

reconnected. Do not clean the filter with anything, especially not

alcohol. Micro-organisms introduced up-stream of the filter will be

removed by it. (Alcohol is a neurotoxin and therefore should not be used

for cleaning.)

When should the Catheter be removed?

General time frame is:

Postoperative removal after three days

Earlier if analgesia is ineffective

Patient’s refusal to continue.

Catheters must not be removed:

Within 12 hr of a s.c. dose of low molecular weight Heparin (e.g. Clexane )

After 4-6 hr of standard Heparin (Minihep, Unihep, Calciparine).

EPIDURAL ANALGESIA


Do not give heparin until at least 4 hours after catheter removal.

Tips for Catheter Removal

Explain the procedure, position the patient with back flexed and

pull gently on the catheter.

After removal, inspect the catheter to check that the rounded tip is

present.

If a piece of catheter has broken off, inform the Consultant

Anesthetist. If the part is not visible, it is best left alone as surgical

exploration may cause more damage. Instigate clinical incident

reporting policy.

Spray puncture site with Opsite and apply a sterile dressing for 24

hours.

References

The Royal College of Anaesthetists. Good Practice in the Management of Continuous Epidural Analgesia in the Hospital Setting. [London]: Royal College of Anaesthetists, 2004 Nov. Available from: http://www.rcoa.ac.uk/docs/epid-analg.pdf. Accessed November 6, 2010.

De Andres J, Fischer HBJ, Ivani G et al. In consultation with European Society of Regional Anaesthesia and Pain Therapy (ESRA). Postoperative Pain Management – Good Clinical Practice General recommendations and principles for successful pain management. 2009. Available at: http://www.esraeurope.org/PostoperativePainManagement.pdf. Accessed November 6, 2010.

Herr K, Bjoro K, Steffensmeier J, Rakel B. Acute pain management in older adults. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center Research Translation and Dissemination Core; 2006 Jul. 113 p. Available at: National Guideline Clearinghouse http://www.guideline.gov/content.aspx?id=10198. Accessed November 6, 2010

REGIONAL NERVE BLOCK


5. REGIONAL NERVE BLOCK

Purpose

Provide the pain team and nursing staff a guideline for

implementing the Regional Nerve block analgesia protocols.

Provide steps for managing the complications that can occur


Definitions

CONTINUOUS NERVE BLOCK ANALGESIA: Continuous injection of local

anesthetic solution around the nerves to relief pain.

PCRA [PATIENT CONTROLLED REGIONAL ANALGESIA]: refers to a process

where patients can determine when and how much medication they

receive, regardless of analgesic technique. However, the term is more

commonly used to describe a method of pain relief which uses

disposable or electronic infusion devices and allows patients to self-

administer analgesic drugs

BOLUS DOSE: This is the set dose of drug that the patient will receive

each time they activate the pump.

LOCK-OUT DURATION: This is the time interval following a bolus dose

during which the pump will not respond to further presses of the button,

allowing time for the first dose to exert its full effect.


concentration of drug being used.

BASAL RATE: Rate at which drug is continuously infused by a pump to

relive pain; patient can give himself additional dose or bolus if pain is

unrelieved.

ESRA: EUROPEAN SOCIETY OF REGIONAL ANALGESIA

L. A: Local Anesthetic



Procedure

Peripheral nerve blocks are useful in providing surgical anesthesia and

postoperative analgesia.

Single injection techniques are limited in duration but can be extremely

useful in the immediate postoperative period.

Continuous catheter techniques can extend the duration of analgesia to

the desired length of time.

The peripheral nerve block techniques are indicated in patients expected

to have moderate to severe postoperative pain that is not easily

controlled with opioids or when opioid side effects are problematic.

Indications for Peripheral Nerve Blocks

Upper Extremity Block Indication

Interscalene block Shoulder surgery, rotator cuff repair

Axillary/Infraclavicular Hand and wrist surgery

Lower Extremity Block Indication

Lumbar plexus Hip and knee surgery

Femoral nerve ACL repair/knee surgery

Sciatic nerve Foot and ankle surgery

Popliteal /ankle



Possible modes of local anesthetic infusion

Infusion mode is often a matter of clinician’s preference.

1. Intermittent bolus

2. Continuous infusion

3. Continuous infusion with Patient Controlled Boluses (PCA)

Continuous infusions and continuous infusion with PCA have been

shown to be superior to the intermittent bolus technique.

The successful use of peripheral catheters in the ambulatory setting

requires patient education that should start in the preoperative area and

extend into the postoperative period. Both patient and their caregiver

must be involved.

Available Infusion Pump

Disposable Elastomeric Pump

Pre operative assessment

Nerve blocks should be placed in patients after ensuring:

That the surgeon is familiar and supportive to these techniques.

Infusion pump is available.

Proper patient selection and education.



Local Anaesthetics and Dose Examples in Continuous

Peripheral Nerve Analgesia (ESRA Guidelines)

Site of catheter Local Anaesthetic 0.1-0.125%Bupivacaine

Dosage (0.1-0.2 ml/kg/hr of LA)

Interscalene 5-9 ml/h

Infraclavicular 5-9 ml/h

Axillary 5-10 ml/h

Femoral 7-10 ml/h

Popliteal 3-7 ml/h

Patient Controlled Regional Analgesia (PCRA) can be used to maintain

peripheral nerve block. A low basal infusion rate (e.g. 2 -3 ml/h)

associated with small PCA boluses (e.g. 2- 5 ml – lockout: 30-60 min) is

the preferred technique.

Observation of the Patient

All patients with local anaesthetic infusions or indwelling local

anaesthetic catheters must have a patent intravenous cannula in situ.

All general observations are recorded on the PAIN SERVICE OBSERVATION

CHART (i.e. pain score, level of consciousness, blood pressure, heart rate,

and respiratory rate).

Patients receiving a local anesthetic via continuous infusion or by

intermittent bolus injection must be observed for signs of local

anesthetic toxicity, and this must be documented on the Observation



Chart. These may manifest by the patient reporting feeling ‘funny’ or

lightheaded, feeling tingling or numbness around the mouth or tongue

or experiencing generalized tingling or twitching.

If any of these symptoms become apparent during a continuous infusion

or during/following an intermittent bolus injection, STOP the infusion or

the injection, administer oxygen and get immediate medical help. Be

prepared to initiate resuscitation and ensure that a 500ml bag of 20%

Intralipid is obtained in case needed as part of resuscitation. 20%

Intralipid is kept for this purpose in the ICUs.

Block Specific Instructions

For Fascia Iliaca and Lower Limb Blocks

Monitor toes and heels of affected leg for signs of pressure on skin

(redness, blanching).

Test and record motor power at each visit by asking the patient to

perform a straight leg raise. If the patient cannot perform a straight leg

raise, then stop the infusion.

Wait until motor power has returned and patient can perform a straight

leg raise, then restart the infusion.

Femoral or lumbar plexus blocks do not provide complete analgesia

therefore regular oral analgesics must be prescribed and administered in

conjunction with the local anaesthetic infusion.

Early mobilization is one of the main benefits of femoral and lumbar

plexus blocks and should be encouraged. Encourage the patient to sit

out of bed and to walk as soon as they are able, even if this is on the day

of operation.



Interscalene and Other Upper Limb Continuous Local

Anaesthetic Infusions

The shoulder, hand and fingers of the affected limb are monitored for

signs of pressure on the skin (e.g. redness, blanching).

The insertion site is observed to identify the development of a localized

hematoma.

Interscalene nerve block in particular may cause some complications.

The patient should have been warned of these effects, and be reassured

that these will disappear once the infusion is discontinued. Potential

complications include:

Phrenic nerve block affecting the diaphragm on the same side as the

block is common. Most patients do not notice a change, but they may

find it difficult to take a deep breath or cough properly.

Horner’s Syndrome – blockade of cervical sympathetic nerves can cause

a droopy eyelid and a constricted pupil on the same side as the block.

Hoarse voice due to recurrent laryngeal nerve block.

Removal of local Anaesthetic Block Catheters

During removal of the catheter, ensure that it is intact (confirmed by the

presence of a blue or black catheter tip), and document in the patient’s

notes. If the catheter is not intact, then it is kept for inspection, inform

the relevant I and this is documented in the patient’s notes.

The site is covered with a clear (occlusive) dressing to aid easy inspection

of the site.



Bleeding may occur at the site of the catheter insertion. If this occurs,

apply pressure to the site until the bleeding stops and document this in

the patient’s notes.

Disposal of Unused Drugs

Drugs remaining in the cartridge used for a local anaesthetic infusion via

a PCA OR infusion pump are disposed off and the amount documented

in the patient notes and in the pain service form.

Drugs remaining in a disposable infusion device are not removed from

the infusion device. The complete device and administration set are

disposed of in the sharps bin.

Key Elements of Patient Instructions Include

A. Protect the operative limb for the duration of the block.

B. Keep the catheter site clean and dry.

C. Do not run any machinery or vehicle for the duration of the block.

D. Approximate duration/resolution of the surgical block.

E. Use of supplemental oral analgesics/opioids.

F. Look for signs of catheter/local anesthetic infusion complications.

G. Observe catheter site for swelling, tenderness and drainage.

Complications of Continuous Catheter Techniques

LOCAL ANESTHETIC TOXICITY is a potential complication that can occur

when large volumes or high concentrations of local anesthetics are used.

INTRAVASCULAR PLACEMENT OF CATHETERS can be detected with

epinephrine containing local anesthetic test doses. Low concentrations



of a long acting local anesthetic are advisable. Patient and staff should

be provided with a list of signs of intravascular infusion of local

anesthetics: tinnitus, metallic taste in the mouth and anxiety. Stop

infusion, be prepared to manage and serious manifestation of L.A

toxicity, as per AAGBI (Association of I of Great Britain and Ireland). As

mentioned in the next page. These guidelines are available in the wards

and the intralipid is available in both ICU A and B.

CATHETER SITE INFECTION: Patients should be instructed to look for signs

of local infection at the catheter site, local tenderness, redness and

fever.

Although a rare occurrence, CATHETER MIGRATION must always be

considered. Catheter failure is the most common sign of migration.

Catheters may migrate into the intravascular compartment.

Intramuscular migration of the catheter will result in either a decrease or

complete cessation of analgesia. The infusion should be stopped since

there is a theoretical risk of myositis.

Careful dressing of the catheter site and use of surgical tape can reduce

CATHETER DISLODGMENT. Clear dressings are advantageous since they

permit visualization of the insertion site. Adhesive surgical strips may be

beneficial in regions that are difficult to secure. Catheters can also be

secured by suturing or tunneling. This may be helpful for longer-term

placement.



Management of Severe Local Anesthetic Toxicity

RECOGNITION [Signs of Severe Toxicity] Sudden alteration in mental status, severe agitation or loss of

consciousness, with or without tonic-clonic convulsions. CVS collapse: sinus bradycardia, conduction blocks, asystole and ventricular

tachyarrhythmias may all occur. Local anaesthetic (LA) toxicity may occur sometime after an initial injection.

IMMEDIATE MANAGEMENT Stop injecting the LA. Call for help. Maintain the airway and, if necessary, secure it with a tracheal tube. Give 100% O2 and ensure adequate lung ventilation (hyperventilation may

help by increasing plasma pH in the presence of metabolic acidosis). Confirm or establish IV access. Control seizures: give a benzodiazepine, thiopental or propofol in small

incremental doses. Assess CVS status throughout. Consider drawing blood for analysis, but do not delay definitive Rx for this.

TREATMENT IN CIRCULATORY ARREST: Start CPR using standard protocols. Manage arrhythmias using the same protocols, recognizing that arrhythmias may be

very refractory to treatment. Consider the use of cardiopulmonary bypass if available.

GIVE IV LIPID EMULSION: Continue CPR throughout Rx with lipid emulsion. Recovery from LA-induced 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.

WITHOUT CIRCULATORY ARREST

Use conventional therapies to treat: Hypotension, Bradycardia, Tachyarrhythmia CONSIDER IV LIPID EMULSION: Propofol is not a suitable substitute for lipid emulsion. Lidocaine should not be used as an anti-arrhythmic therapy.

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, & daily amylase/lipase assays for 2 days.

YOUR NEAREST BAG OF LIPID EMULSION IS KEPT AT ICU A



IV LIPID INFUSION DOSAGE

IMMEDIATELY AFTER 5 MINUTES

Give an initial IV bolus injection of 20% lipid emulsion 1.5 ml/kg over 1 min

AND

Start an IV infusion of 20% lipid emulsion at 15 ml/kg/hr

Give a maximum of 2 repeat boluses (same dose) if: cardiovascular stability has not been restored or an adequate circulation deteriorates.

Leave 5 min between boluses.

A maximum of 3 boluses can be given (including the initial bolus)

AND

Continue infusion at same rate, but:

Double the rate to 30 ml/kg/hr at any time after 5 min, if:

CVS stability has not been restored, Or, Adequate circulation shows

deterioration.

Continue infusion until stable and adequate circulation restored or maximum dose of lipid emulsion given.

DO NOT EXCEED A MAXIMUM CUMULATIVE DOSE OF 12 mg/Kg

Adapted from the AAGBI (The Association of Anaesthetists of Great Britain & Ireland) 2010 Safety Guidelines, published online at www.aagbi.org/sites/default/files/la_toxicity_2010_0.pdf

Note: The ultimate judgment with regard to a particular clinical procedure or treatment plan must be made by the clinician in the light of the clinical data presented, diagnostic/treatment options available.



References

VISCUSI, E, JAN, R, SCHECHTER, L, et al. Organization of an Acute Pain Management Service Incorporating Regional Anesthesia Techniques. New York: New York School of Regional Anesthesia; 2009 Mar 12. Available at: NYSORA http://www.nysora.com/ pain management/3055-organization_acute_pain_management.html. Accessed January 18, 2011.

Ashford & St Peter`s Hospitals. Guidelines for the Nursing Care of an Adult Patient Who has Received a Regional Nerve Block or Who is Receiving a Local Anaesthetic Agent Via an Indwelling Local Block Catheter (Either as a Continuous Infusion or Intermittent Bolus Injection). [London]: Ashford & St Peter`s Hospitals, 2009 July. Available from http://www.ashfordstpeters.nhs.uk/attachments/1203_Local%20Anaesthetic%20Guidelines.pdf. Accessed January 18, 2011.

Connolly, JD and Hutton, P. Fundamental Principles and Practice of Anaesthesia. Edited by Hutton P, Cooper G, James FM III, Butterworth J. London, Martin Dunitz Ltd. Publishers, 2002, Chapter 15, An Outline of Regional Anaesthesia; p. 205 – 234.

De Andres J, Fischer HBJ, Ivani G et al. In consultation with European Society of Regional Anaesthesia and Pain Therapy (ESRA). Postoperative Pain Management – Good Clinical Practice General recommendations and principles for successful pain management. 2009. Available at: http://www.esraeurope.org/PostoperativePain Management.pdf. Accessed January 18, 2011.

PEDIATRIC ACUTE PAIN POLICY


6. PEDIATRIC ACUTE PAIN POLICY

Purpose

Provide the pain team and nursing staff a guideline for implementing

the Pediatric analgesia protocols.

Provide steps for managing the complications that can occur during

implementation of the above protocols.

Provide effective and safe pain relief in the wards.

Provide the patient with pain relief that is satisfactory and facilitates

normal breathing, coughing and mobility as rapidly as possible.

Provide pain relief with minimal sedation, allowing for increased

mobility and cooperation with physiotherapy after surgery.

Definitions

CONTINUOUS NERVE BLOCK ANALGESIA: Continuous injection of local

anesthetic solution around the nerves to relief pain.

PCA [PATIENT CONTROLLED ANALGESIA]: A process where patients can

determine when and how much medication they receive, regardless of

analgesic technique. However, the term is more commonly used to describe a

method of pain relief which uses disposable or electronic infusion devices and

allows patients to self-administer analgesic drugs

BOLUS DOSE: Set dose of drug that the patient will receive each time they

activate the pump.

LOCKOUT DURATION: Time interval following a bolus dose during which the

pump will not respond to further presses of the button, allowing time for the

first dose to exert its full effect.


concentration of drug being used.

BASAL RATE: Rate at which drug is continuously infused by a pump to relive

pain; patient can give himself additional dose or bolus if pain is unrelieved.

L. A: Local Anesthetic. NSAID: Non Steroidal Anti- Inflammatory Drugs.



Procedure

Achievement of humane and safe analgesia in children relies on the following

key points:

Psychological

o Reassurance & explanation to both child and parents.

o Quiet, calm, child oriented environment.

Physical

o Alleviating pressure and movement from the pain site.

Monitoring

o Pain should be pro-actively managed by regular pain

assessment.

o Recheck after treatment to ensure effectiveness of strategy.

Pharmacological

o Regular simple and non-opioid analgesia.

o Supplementary analgesia as required.

o Titrating the pain relief modality.

The Analgesic Ladder

o A stepwise approach is useful, starting with simple analgesic

methods with few side effects and progressing to the sequential

addition of other analgesics having greater effect but additional

side effects.

Local Anaesthetic Techniques should be used whenever

possible as part of the post-operative analgesia.

Assessment of Acute Pain

We use three different assessment tools depending on the age and maturity

of the child. These tools have different ranges to be documented so it is

essential that the method used is documented on the recording chart.

One of the following methods should be used and the method used must be

documented on the chart used to record the child’s pain.

These “scores” are related to ranked categories and are used to facilitate

documentation in the limited space available on the chart.



1. FLACC Scale

Indicator

Individual Score (0, 1 or 2)

0 1 2

Face No particular expression

No smile

Occasional grimace/ frown.

Withdrawn

Disinterested

Frequent to constant quivering chin

Clenched jaw

Legs Normal position or relaxed

Uneasy, restless, tense Kicking, or

Legs drawn up

Activity Lying quietly,

Normal position,

Moving quietly

Squirming,

Shifting back and forth,

Tense

Arched,

Rigid or

Jerking

Cry No crying (awake or asleep)

Moaning or whimpering,

Occasionally complaining

Crying steadily,

Screaming or sobbing,

Frequently complaining

Consolability Content, relaxed Reassured by occasional touching, hugging or being talked to

Distractible

Difficult to console or comfort

Each of the five categories is scored from 0 to 2 to give a total score of 0 to 10

2. Faces Pain Scale – Revised

This is used for younger children. The faces used are not the traditional

“smiley” faces; as children have been found to confuse the emotion of

happiness and pain, which although related, are not the same and should be

managed differently.

It is important to follow these instructions. The score should be an even

number. To ensure reliability of this assessment tool the numbers should be

hidden from the child.



Faces Pain Scale – Revised (FPS-R) has been adapted from Pediatric Pain

Sourcebook <www.painsourcebook.ca> Version: 7 Aug 2007 CL von Baeyer.

In the following instructions, say “hurt” or “pain,” whichever seems right for a

particular child.

Say to the child in the following sequence:

These faces show how much something can hurt.

This face [point to left-most face] shows no pain.

The faces show more and more pain [point to each from left to right] up

to this one [point to right-most face] – it shows very much pain.

Point to the face that shows how much you hurt [right now].

Score the chosen face: 0, 2, 4, 6, 8, or 10, by counting left to right, so ‘0’ = ‘no

pain’ and ‘10’ = ‘very much pain.’ Do not use words like ‘happy’ and ‘sad’.

This scale is intended to measure how children feel inside, not how their face

looks.

3. Verbal Rating Scale

This is used for older children in exactly the same way as in adult patients

Pain on Movement None Mild Moderate Severe

Score 0 1 2 3



Methods of Analgesic Administration:

1. Enteral (Oral and Rectal) Analgesia

1. Diclofenac

2. Ibuprofen

3. Paracetamol

4. Tramadol

Uses

Enteral administration is the mainstay of analgesia and should be used

whenever not contraindicated.

Oral NSAIDs should be avoided in the absence of food or milk and a single

dose by another route is an acceptable alternative.

Frequency of monitoring of vital signs is dependent on the drug used.

2. Parenteral Analgesia

1. Morphine

2. Tramadol.

Uses

a) When oral or rectal administration of a drug is unsuitable, for example:

‘nil by mouth’ for surgical reasons.

b) Significant nausea or active vomiting.

c) If enteral preparation is not available.

d) Child compliance is doubtful.

Frequency of monitoring of vital signs is dependent on the drug used.

Strength of Drug Effect (Pharmacokinetics)

It is important to note that the route used, affects the time in the onset of

effect, the peak effect and the duration of action. For example, Morphine

given intravenously, will start to work within a minute, peak within 5 minutes

and wear off after an hour. If given intramuscularly or subcutaneously, the

effect may take 20 minutes to peak and will be at a lower level. However it

will last for several hours.



Patient Controlled Analgesia (PCA), IV Infusion of Morphine

Uses

PCA uses small doses of intravenous opiate (Morphine), given more frequently

to maintain an adequate level of analgesia. It is particularly useful for

moderate to severe pain to supplement existing enteral analgesia. IV infusion

may be used in conjunction with these methods or as a standalone method.

Monitoring

Vital signs and pain should be monitored every 15 minutes for the first hour

then hourly for 2 hours thereafter 4 hourly

Available Pump

IVAC ALARIS PCA Pump

Prescription: Use for PCA and IV infusion

Weight Drug Mixture Concentration

≥50 kg Morphine SO4 50 mg to 50 ml with 0.9% Saline 1 mg/ml

<50 kg Morphine SO4 1 mg/kg to 50 ml with 0.9% Saline 20 g/kg/ml

Loading dose Morphine Sulphate 0.1 mg/kg

Age Regime Bolus Lockout Background Infusion

≥ 16 y PCA 1 ml 15 min 0.5 ml/hr

8 y to <16 y PCA 0.5- 1 ml 15 min 0.2 ml/hr

An IV loading bolus may be required to achieve effective plasma levels quickly.

This may be given separately by a suitably trained member of staff. If not, it

will be necessary to press the demand button repeatedly at the lockout time

limit until adequate analgesia is achieved. The PCA button should be pressed

whenever necessary (there is pain).



Safety with this device is achieved by relying on the patient being unable to

press the button when they are asleep which will occur before they are in

danger of severe respiratory depression and by limiting the frequency that the

device will deliver a dose.

It is essential that the bolus button is not pressed by anyone other than the

patient or a suitably trained nurse. This must be emphasized to the parents

and visitors. Other children on the ward must not be allowed to press the

button.

Epidural Analgesia – Bupivacaine

Uses

Epidural infusions are used to manage pain following major surgery of the

torso or lower limbs.

Monitoring

It is essential that epidurals are only managed by specifically trained staff.

Vital signs and pain should be monitored every 15 minutes for the first hour

after the block, then hourly for 2 hours, and then 4 hourly. Following a bolus

of a change in the infusion rate, the child should be monitored closely for the

following 20 minutes with pulse and blood pressure measured every 5

minutes. Thereafter, hourly checks should be done. A block check should be

performed 4 hourly and 20 minutes after changes or boluses.

Set-up (Available Pumps)

Elastomeric Pumps of 300ml and 100 ml capacity

Prescription

Mixture Infusion

0.1% Bupivacaine (Plain) 0.2 to 0.4 ml/kg/hr

0.125% Bupivacaine (Plain) 0.2 to 0.4 ml/kg/hr



Caudal Analgesia & Peripheral Nerve Blockade

Uses

Caudal epidurals and peripheral nerve blockade techniques provide a local

anaesthetic block of pain transmission without the risk of systemic side effects

developing later. They should be considered for surgery and trauma to limbs

and surgery to the groin and genitalia. It is strongly recommended that some

form of local anaesthetic technique is used wherever possible as part of

analgesic management.

Management

They are instigated under the direction of anesthetists and should not be

considered risk free.

The following points are important:

Parents and child should be counseled beforehand (loss of sensation

can otherwise be distressing).

All must be aware that loss of sensation also removes protective

reflexes such as “hot”.

Supplementary analgesia often required with block (complete blockade

may not be necessary or possible and is not a failure of the technique).

Other analgesia must be implemented before the block wears off.

Except for epidural analgesia (or caudal opioids), all other pain control

methods described in this document can be used in the same doses.

Monitoring

Any limb given PNB should be checked whenever routine observations

are performed:

A. To evaluate whether the procedure is still effective.

B. Check that the limb is protected, & not in abnormal position.



Pediatric Drug Doses

Drug Route Dose Maximum Frequency (R: REGULAR)

Analgesic

Paracetamol Oral 20 mg/kg 90mg/kg/24h 4g/24 h

QID; R

Paracetamol Rectal Loading: 40 mg/kg; Maintenance 20 mg/kg

4g/24 h QID; R

Paracetamol IV 15 mg/kg; over 15 min 10-50 kg: 1g ≥50 kg: As adult

QID; R

Ibuprofen Oral 5 mg/kg 400 mg dose TID; R

Diclofenac

Oral & Rectal

Age> 6 mo: 1 mg/kg 150 mg/24 h TID; R

Morphine SO4 SC 0.15 mg/kg 3 hourly; prn

Morphine SO4 IV PCA

See page 6-56

Tramadol

Oral & IV

Age> 12 yr: 50 – 100mg 400 mg/24h 4-6 hourly; prn

Antiemetics

Ondansetron IV 0.1 mg/kg 4 mg BID

Metaclopramide IV 0.15 mg/kg QID

Others

Dexamethasone IV 0.15mg/kg 4mg TID

Naloxone IV 4 – 10 g/kg prn

Developed from an unformatted generic template document developed by: The West Midlands Anaesthetic Working Group of Partners in Pediatrics. Chaired by: Dr Alistair Cranston, Birmingham Children’s Hospital Dr Dori-Anne McCullough, Stafford District General Hospital Project Leader: Dr Tim Smith, Alexandra Hospital, Redditch. Date of implementation/approval 1 December 2007 Date of review 31 November 2010 Till Date- Under review



References

Midlands Anaesthetic Working Group of Partners in Paediatrics,

Chaired by Dr Alistair Cranston, Birmingham Children’s Hospital and Dr

Dori-Anne McCullough, Stafford District General Hospital. Project

Leader Dr Tim Smith, Alexandra Hospital, Redditch.

Hicks CL, von Baeyer CL, Spafford P, van Korlaar I, Goodenough B. The

Faces Pain Scale – Revised: Toward a common metric in pediatric pain

measurement. Pain 2001;93:173-183.

Bieri D, Reeve R, Champion GD, Addicoat L, Ziegler J. The Faces

Pain Scale for the self-assessment of the severity of pain

experienced by children: Development, initial validation and

preliminary investigation for ratio scale properties. Pain 1990;

41:139-150.

Appendix 1: EPIDURAL FORM


Appendix 1: EPIDURAL FORM

EPIDURAL FORM

NAME AGE SEX WARD ANESTHETIST FILE No DATE DIAGNOSIS MEDICAL PROBLEMS- (plz. tick): DM/HTN/IHD/CVA/COPD/ASTHMA/CRF/ SMOKER/ALCOHOLIC. Epidural infusion regimes, please tick one: Inj bupivacaine 0.125 % Inj bupivacaine 0.1% and injection fentanyl 1-2 mcg/ml - (only for ICU) Inj bupivacaine 0.1% and injection sufentanil 0.16 mcg/ml- (only for ICU) Mode, INFUSION ONLY- _ ml/hr

Day 1 am

pm

pm

2 am

pm

pm

3 am

pm

pm

4 am

pm

pm

Rate

Bolus

HR/NIBP

RR/ Spo2

Nausea/vomit

Sedation

Pain score Rest

Pain score Movt

Analgesics

Sign

NOTES

Appendix 2: Patient Controlled Analgesia Form


Appendix 2: Patient Controlled Analgesia Form

Patient Controlled Analgesia Form

NAME AGE SEX WARD

ANESTHETIST FILE No DATE

DIAGNOSIS MEDICAL PROBLEMS- (plz. tick): DM/HTN/IHD/CVA/COPD/ASTHMA/CRF/ SMOKER/ALCOHOLIC.

PCA Drug Options - Please tick one:

Injection MORphine Injection TRAmadol

PCA Dose 1 mg or _ mg 10 mg or _ mg

Lockout interval 15 min 10 min

Basal rate 0.5 mg/hr or _ mg/hr or no basal

No basal rate or _ mg/hr (1 – 20 mg/hr)

Bolus for Breakthrough Pain

0.02 mg/kg or _ mg every 5 min till 0.1 mg/kg

10 mg or _ mg every 5 min till 50 mg

DAY 1 am

pm

pm

2 am

pm

pm

3 am

pm

pm

4 am

pm

pm

Dose given

Attempts

RR/ SpO2

Sedation

Nausea/vomit

HR/ NIBP

Pain Score Rest

Pain Score Movt

Sign

NOTES

Appendix 3: Nerve Block Form


Appendix 3: Nerve Block Form

Form for Nerve Blocks with an Indwelling Catheter (Either as a Continuous Infusion or Intermittent Bolus Injection)

NAME: AGE: SEX: WARD FILE NO. DIAGNOSIS: ANESTHETIST: DATE MEDICAL PROBLEMS- (plz. tick): DM/HTN/IHD/CVA/COPD/ASTHMA/CRF/ SMOKER/ALCOHOLIC. Name of block:-

Drug concentration, please tick one: Injection bupivacaine 0.1 % Injection bupivacaine 0.125% Mode, please tick one: Bolus Only _ ml every _ hr OR Continuous Infusion by Elastomeric Pump (0.1ml/kg/hr) _ ml/hr

Day 1 am

pm

pm

2 am

pm

pm

3 am

pm

pm

4 am

pm

pm

Rate

Bolus

HR/NIBP

RR/ Spo2

Pain Score Rest

Pain Score Movt

Analgesics

LA Toxicity?

Catheter site clean?

Sign

NOTES

Appendix 4: Back Side of Each Form


Appendix 4: Back Side of Each Form

SEDATION AND MOTOR BLOCK SCORING

1. Mild: Occasionally drowsy; easily awakened. 2. Moderate: Frequently drowsy; drifts off to sleep during conversation. 3. Severe: Somnolent, difficult to rouse; minimal or no response to stimuli. S. Sleep: Normal sleep, easily awakened; RR>1O

MOTOR BLOCK BROMAGE SCALE Lower Limbs Upper Limbs

0 None, moves finger feet, knees, hips shoulder, arm, hand

1 Moves: feet and knees arm, hands, fingers

2 Almost Complete, moves: feet only fingers only

3 Complete, Does not move: feet or knees- hands or fingers

COMMON COMPLICATIONS BREAKTHROUGH PAIN IN EPIDURAL AND NERVE BLOCKS:

1. Check connections from epidural pump to catheter, Check pump – replace if empty

2. Give a 5-10 ml bolus of either the same solution or 0.125-0.25% bupivacaine 3. Monitor BP, watch for s/s of L.A toxicity.

RESPIRATORY DEPRESSION:

If RR < 10/min, very shallow and ineffective, or if patient is difficult to arouse:

Stop PCA, maintain IV, Apply O2, Naloxone (Narcan®) 0.1 mg STAT IV/SC every 2 min until RR > 10/min or when patient arouses easily.

NAUSEA / VOMITING: 1. Metoclopramide (primpran) - 10 mg IV q6hrs/ PRN 2. Promethazine (Phenergan) - 6.25 mg IV q6hrs /PRN for nausea/vomiting

(Precautions: Dilute in 10 ml NS; assure IV patency before giving; give slowly)

3. Ondansetron (Zofran) - 4 mg IV q12hrs /PRN nausea/vomiting. LOCAL ANESTHETIC TOXICITY:

Recognise by: Metallic taste in mouth, ringing in the ears, numbness of tongue / lips, dizzy and / or lightheaded sensation. If these occur: 1. Stop injection of local anesthetic 2. Call for anesthetist on call 3. Give 100% oxygen 4. Secure iv access 5. Arrange for Intralipid from ICU A or B

HYPOTENSION in A PATIENT with EPIDURAL: 1. Stop epidural, give iv fluid fast, 2. Inform anesthetist on call, 3. Prepare inj. ephedrine(one ampule in 10 ml saline)

EPIDURAL CATHETER DISCONNECTION:

Follow pain service policy

Inform the Anesthetist.

Notes


Notes

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2012

Acute pain service protocol 2012.

Health & Medicine

Transcript of Acute pain service protocol 2012.