Administration and Monitoring of Adult patients who are to receive Local Anaesthetic Boluses into a Wound Catheter Guidelines for Practice Trust Reference B21/2008 1. Introduction and Background 1.1 These guidelines give directives for the safe and effective monitoring of adult patients receiving a bolus of local anaesthetic into a wound catheter by a Ward Nurse 1.2 Local anaesthetics have the ability to provide excellent pain relief, however their effect is short lasting and best results are achieved via a continuous infusion (Horlocker 1998) 1.3 Local anaesthetic infusions are a good modality for managing certain types of postoperative, chronic or trauma induced pain. A catheter is inserted into the wound by the Surgeon before closing the wound 1.4 The use of a bolus for example after shoulder surgery to allow extra analgesia just before physiotherapy and to not impede their mobility around the ward while doing physiotherapy, which would be more difficult if there were tubes to watch out for and infusion devices to carry. 2. Scope 2.1 This guideline applies to all staff that administer and monitor patients who receive a Bolus of local Anaesthetic into a Wound. This covers the following staff groups: Registered Adult Nurse Registered Medical Staff Registered Midwife. 2.2 This guideline does not cover any Registered Practitioner to give a Bolus of local anaesthetic via the epidural route. 2.3 All staff must be competent in medicines administration and adhere to the Leicestershire Medicines Code for the administration of medicines. Nursing and Midwifery staff should also be competent in the administration of Intravenous Drugs (See section 4 for Education and Training requirements) 2.4 Patients with wound catheters will only be sent to clinical areas where the staff have been given the appropriate knowledge, training and competency to care for them. 3. Guideline Statements 3.1 Patient Selection The surgeon and anaesthetist will choose appropriate patients. 3.2 Exclusion Criteria / Contraindications a) Patients who are unable to give informed consent. b) Any patient that is known to be allergic to local anaesthetic. 3.3 Medication to be used It is Bupivacaine 0.25% (BNF 2006) up to 10 mls into the wound catheter. It is the prescriber s responsibility not to exceed this dose. Administration and Monitoring of Adult Patients receiving a Local Anaesthetic Bolus into a Wound Catheter Page 1 of 5
3.4 Procedure for the administration of a local anaesthetic bolus into a wound catheter is detailed in Appendix One 3.5 Patient Monitoring a) Correct and careful monitoring of these patients is necessary to ensure they have adequate pain relief, but do not experience any side effects or toxicity from the local anaesthetic. These might include tingling around the mouth, light headedness or palpitations (Murphy 2003) any signs of this an bolus administration should cease and urgent medical advise sought b) Observations of pain, respiratory rate, blood pressure, pulse, and pain score prior to the administration and every 15 minutes for 60 minutes c) Observations should then return to four hourly until the next requested dose when the process should be repeated. This is to ensure the catheter has not become displaced or show signs of infection and to monitor for side effects and signs of overdose. This should be repeated at the time of each bolus. d) These observations should be recorded with date and times on the routine observations chart and labelled as Wound Bolus e) The patient must have a patent intravenous cannula at all times 4. Education and Training 4.1 All staff who take on this role should be competent with the administration of IV medications and be able to use the same aseptic technique and safety checks to perform this procedure as with IV drug administration. a basic requirement for the administration of this technique 4.2 They should also have a good working knowledge of the use of local anaesthetics and complete a competency-based assessment which includes the ability to: a) Discuss the locations for wound catheters b) Identify the side effects of local anaesthetics c) Identify anaesthetic toxicity and know the emergency management d) Describe the patient observations e) Demonstrate the administration of the local anaesthetic bolus 4.3 The Ward Sister / Charge Nurse for clinical areas where patients will have a wound catheter for the administration of local anaesthetic will then identify a named cascade trainer who will be trained by one of the nurse specialists for acute pain. This trainer should be competent in the procedure. 4.4 The named cascade trainer will under guidance from an acute pain nurse have responsibility to ensure all registered nurses working within that ward or department are conversant with the correct procedure for administration and monitoring patients following a bolus of local anaesthetic via a wound catheter 4.5 Records of registered staff that have been shown the correct procedure and are competent will be kept by individual ward sisters, the nurse specialist for pain and recorded on EUHL.. Each member of staff will have their own record of training and competency certificate 4.6 In clinical areas where this is used all staff will be trained and assessed competent with the policy for administration and monitoring of local anaesthetic via a wound catheter as an extension to their IV training and competency assessment. Staff should only be trained in this technique once they have completed IV drug administration. Administration and Monitoring of Adult Patients receiving a Local Anaesthetic Bolus into a Wound Catheter Page 2 of 5
5. Monitoring and Audit Criteria Element to be monitored Drug Charts for relevant patients Lead Tool Frequency Reporting arrangements Acute Pain Nurse Specialist Audit is incorporated into the charts to check Procedure monitored on ward rounds. Incidents reported on datix. Reports shared at Acute Pain Operational Groups Inpatient Pain Operational Group (meet every 2-3 months) Lead(s) for acting on recommendations Lead Clinician for Acute Pain Team and the Acute Pain Team will raise concerns, issues and share best practice with the CBU Management teams for their action. Change in practice and lessons to be shared Update study sessions, dissemination of information through clinical area management Competency Assessments for all users Acute Pain Nurse Specialist /Relevant Managers Audit is incorporated into euhl to check for after the acute pain study day The registers from the Acute Pain Study Day to be monitored against euhl every six months to monitor Lead Acute Pain Nurse Specialist to liaise with relevant Managers if issues raised around Lead Acute Pain Nurse Specialists raise issues with Managers and share best practice with the CBU Management teams for their action. Update study sessions, dissemination of information through clinical area management 6. Legal Liability Guideline Statement Guidelines or Procedures issued and approved by the Trust are considered to represent best practice. Staff may only exceptionally depart from any relevant Trust guidelines or Procedures and always only providing that such departure is confined to the specific needs of individual circumstances. In healthcare delivery such departure shall only be undertaken where, in the judgement of the responsible healthcare professional it is fully appropriate and justifiable - such decision to be fully recorded in the patient s notes 7. Supporting Documents and Key References British National Formulary (BNF) 2006 London. Royal Marsden Manual of Clinical Nursing Procedures (Available via INsite) Horlocker T. (1998) Peripheral nerve block : regional anaesthesdia for the new millennium. Regional Anaesthesia and pain medicine.23 237-240 Murphy D. (2003) Nerve Blocks for Acute Pain : Principles. In clinical pain management Acute Pain. Rowbotham D. Macintyre P. (eds) Arnold London. Serpell M. (2003) Clinical pharmacology Local anaesthetics. In clinical pain management Acute Pain. Rowbotham D. Macintyre P. (eds) Arnold London. The Leicestershire Medicines Code 8. Key Words Local anaesthetic Bolus This line signifies the end of the document Administration and Monitoring of Adult Patients receiving a Local Anaesthetic Bolus into a Wound Catheter Page 3 of 5
DEVELOPMENT AND APPROVAL RECORD FOR THIS DOCUMENT Author / Lead Officer: Sue Daykin Job Title: Lead Acute Pain Nurse Specialist Approved by: Policy and Guideline Committee Date Originally Approved: 7 th July 2008 Latest Approval Date: 12 th February 2016 Next Review Date: February 2019 Version Number: V2 Details of Changes made during review: V1 reviewed January 2016 Changes include updating into Trust format, added in audit and monitoring criteria, removed Appendix two - certificate template Administration and Monitoring of Adult Patients receiving a Local Anaesthetic Bolus into a Wound Catheter Page 4 of 5
Appendix One Procedure for the administration of a Local Anaesthetic Bolus into a wound catheter Equipment Antiseptic cleaning agent 10ml Syringe and drawing up needle Medication as prescribed 0.9% Sodium chloride flush Sterile hub/bung Sterile Gloves Procedure This procedure requires two nurses to be working together to administer the treatment Action 1 Prior to administration, check that the first dose has been given and documented in theatre by An Anaesthetist 2 Record patients vital signs prior to administration 3 Wash hands with bactericidal soap and water. Apply bactericidal alcohol handrub and allow to dry. Apply sterile gloves. 4 Check the medication to be administered and diluents, according to the Leicestershire Medicines Code 5 Draw up the medication and label syringes 6 Check patient's name band against prescription. Clarify the correct route of administration 7 Clean the access portal of the bacterial filter. 8 Inject medication into the wound catheter as prescribed. Inject 5mls over a minute and wait for two minutes observing for any reaction. No resistance should be offered, if so stop and report. Then administer a further 5mls up to the prescribed dose of 10mls. 9 Document time of administration of medication and any complications / issues 10 Monitor vital signs, blood pressure and respirations at least every 15 minutes for 60 minutes, Rationale To ensure that local anaesthetic is being administered into the wound and not any other vessels and the patient has had no adverse event. To ensure baseline is recorded to monitor any To reduce risk of cross-infection To ensure the correct medication, amount and concentration is administered to the correct patient. To ensure correct medication administered To ensure correct patient receives correct drug. To prevent the introduction of contaminants and micro-organisms into the shoulder cavity. To ensure safe administration of the medication, resistance will indicate the catheter may have moved and therefore should not be used To ensure accurate recording of administration To monitor signs of hypotension and local anaesthetic toxicity Administration and Monitoring of Adult Patients receiving a Local Anaesthetic Bolus into a Wound Catheter Page 5 of 5