CLINICAL GUIDELINE FOR THE USE OF RECTUS SHEATH CATHETERS IN CHILDREN. 1. Aim/Purpose of this Guideline 1.1. Guidelines for the use of rectus sheath catheters for the management of pain following laparotomy in children. 1.2. Pain management can be difficult following laparotomy/abdominal surgery and the use of epidural analgesia is sometimes contraindicated. Local anaesthetic infiltrated into the rectus sheath via a narrow bore catheter can be used as an alternative for these patients. 2. The Guidance 2.1. The catheters are inserted during surgery; usually two catheters are used, one either side of the incision. A Lock-it dressing should be used to secure the catheter. Catheters should be labelled Rectus Sheath Catheters, along with date and time of insertion. 2.2. Professional responsibility. 2.2.1. Boluses should be delivered by doctors competent in the use of rectus sheath catheters and in the treatment of local anaesthetic toxicity. This will usually be a consultant anaesthetist or an anaesthetist in training. 2.2.2. Qualified nurses who have attained competency with the Trust IV drug administration and who have had additional training, assessment and have been deemed competent to bolus these catheters, may administer a bolus. 2.3. Support mechanism. 2.3.1. For advice between the hours of 0830 1630 contact Paediatric Pain Specialist Nurse via bleep 2283. 2.3.2. Out of these hours contact the 2nd on-call anaesthetist (obstetric). 2.4. Prescription/Dosages. 2.4.1. All prescriptions are the responsibility of an anaesthetist/doctor and should be prescribed on EPMA. 2.4.2. Doses: Children: 0.4mls/kg (up to 20mls) of 0.25% Levobupivicaine regularly every 6 hours, each side. Adults: 20ml of 0.25% Levobupivicaine regularly every 6 hours, each side. 2.4.3. Catheters can remain insitu for up to five days. If there is a need for the catheters to stay in longer then this must be discussed with the surgical team and paediatric pain team. The maximum time the catheters can remain insitu is 7 days. 2.5. Injecting a bolus via the rectus sheath catheter. 2.5.1. Ensure the patient has patent IV access at all times. 2.5.2. Check for any signs of migration, leakage and infection. Do not use Page 1 of 8
if there are any concerns. Contact the patient s surgical team, Paediatric pain team or anaesthetist. 2.5.3. Prepare the drugs for administration according to the prescription on EPMA. 2.5.4. Non-sterile gloves must be worn and an aseptic non touch technique should be used as per infection control guidelines 2.5.5. Ensure a filter is in place each side. 2.5.6. Attach the syringe and aspirate for blood using a low force for 30 seconds. If blood is present, do not administer the bolus. Contact the patient s surgical team, paediatric pain team or anaesthetist as the tip may have migrated and is no longer safe to give the bolus. 2.5.7. If no blood is aspirated, slowly administer the Levobupivicaine. After administering half the dose, stop and aspirate again to check for any signs of migration of the tip as before. Keep asking the child if they are experiencing any of the signs of toxicity (see below). 2.5.8. Repeat the above process on the other side 2.6. Potential complications. 2.6.1. Any difficulty injecting through the catheter or leakage at the site ask the surgical team or paediatric pain nurse to review. 2.6.2. Any signs of infection at the catheter site will need reviewing by either the surgical team or paediatric pain team. It is likely that the catheter will have to be removed. 2.6.3. Local anaesthetic toxicity can occur, especially if there is a rapid absorption into the bloodstream, or inadvertently administrated intravenously. THIS IS RARE BUT IT IS IMPORTANT THAT THE SIGNS ARE RECOGNISED Recognition Immediate management Treatment Restlessness Confusion Light headedness Numbness of tongue and lips Tinnitus Double or blurred vision Page 2 of 8 Mild Moderate Severe Heaviness of limbs Muscular twitching Convulsions Cardiac arrhythmias Hypotension Respiratory arrest Cardiac arrest Stop injecting local anaesthetic Inform medical team or call for help Attach ECG and monitoring Maintain airway and oxygenation Observe closely Consult with the pain team or on call anaesthetist or PERT 2222 Treat hypotension with IV fluids Treat convulsions with Diazepam CPR if in arrest. Lipid emulsion is used to treat toxicity, the LIPID RESCUE BOX is kept in both theatre recoveries and Eden ward. It will need to be collected and administered intravenously as soon as possible. Initial intravenous bolus of 20% lipid emulsion of 1.5ml/kg over 1 minute. And start an infusion of 20% lipid emulsion at 15ml/kg/hour.
For further information on the management of severe local anaesthetic toxicity please refer to the Association of Anaesthetists of Great Britain and Ireland safety guideline (2010). 2.6.4. If the rectus sheath catheters appear to be ineffective and are not controlling the child s pain, an alternative analgesic technique needs to commence as soon as possible i.e. PCA. 2.7. Removal of catheter. 2.7.1. The catheters must be removed on day 5 or sooner if infection or leakage occurs. 2.7.2. Catheters must only be removed by trained nursing staff. 2.7.3. The catheters must be removed using an aseptic non touch technique. Carefully remove the dressing and lock it and then with gentle traction remove the catheter. Repeat on the other side. Apply a nonocclusive dressing for at least 24 hours. 2.7.4. If there is any resistance, do not continue and inform the surgical team 2.7.5. Ensure the blue tip is intact at the end of the catheters and document in the notes. 2.7.6. If there are any signs of infection at the catheter site or the child is pyrexial, send the tip to microbiology for culture. 3. Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Adherence to the guideline Acute Paediatric Pain Service The child will be reviewed daily by the acute paediatric pain service or on call anaesthetist and adherence to the guideline will be recorded on the paediatric acute pain form (CHA2850) and in the medical notes. Datix will be monitored and reports will be investigated. Due to minimal number of paediatric patients receiving rectus sheath catheters being used, audits will be carried out on an ongoing basis. Datix s will be monitored at risk management meetings. Audits will be reported to the anaesthetic governance lead. Acting on recommendations and Lead(s) Change in practice and lessons to be shared Acute Paediatric Pain service Required changes to practice will be identified and actioned within 1 month. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website. Page 3 of 8
4.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 4 of 8
Appendix 1. Governance Information Document Title Date Issued/Approved: 05th May 2017 Clinical guideline for the use of rectus sheath catheters in children Date Valid From: 5th May 2017 Date Valid To: 5th May 2020 Directorate / Department responsible (author/owner): Acute Paediatric Pain Service Sarah Fox/Dr Julian Berry Contact details: 01872 252800 Brief summary of contents Guidelines for the use of rectus sheath catheters for the management of pain following laparotomy in children. Suggested Keywords: Target Audience Executive Director responsible for Policy: Rectus sheath catheters children analgesia RCHT PCH CFT KCCG Medical Director Date revised: 29/12/16 This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Clinical guideline for the use of rectus sheath catheters in children Divisional Manager confirming approval processes Head of relevant Division Name and Post Title of additional signatories Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): {Original Copy Signed} Name: {Original Copy Signed} Internet & Intranet Intranet Only Page 5 of 8
Document Library Folder/Sub Folder Links to key external standards Related Documents: Training Need Identified? Paediatrics Association of Anaesthetists of Great Britain (2010) Management of severe local anaesthetic toxicity. Yes Registered nurses need to be IV competent and also need to attend training session and carry out a witnessed supervised practice to gain competency. Version Control Table Date Version No Summary of Changes Changes Made by (Name and Job Title) January 2014 January 2017 V1.0 Initial Issue V2.0 Update of policy Acute Paediatric Pain Service Acute Paediatric Pain Service All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 6 of 8
Appendix 2. Initial Equality Impact Assessment Form Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description): Clinical guideline for the use of rectus sheath catheters in children Directorate and service area: Is this a new or existing Policy? Existing Paediatrics/Anaesthetics Name of individual completing Telephone: assessment: Sarah Fox 1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at? 01872 252800 Guidelines for the care of a child with rectus sheath catheters for pain relief. 2. Policy Objectives* To maintain safe standards of the delivery of this method of pain control. 3. Policy intended Children with rectus sheath catheters are cared for safely and Outcomes* appropriately. 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure. Side effects are identified and dealt with safely. Review of children by paediatric pain team Monitor of Datix reports. Children Nursing staff Medical staff No 7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence Age Sex (male, female, transgender / gender reassignment) Page 7 of 8
Race / Ethnic communities /groups Disability - Learning disability, physical disability, sensory impairment and mental health problems Religion / other beliefs Marriage and civil partnership Pregnancy and maternity Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please explain why. Signature of policy developer / lead manager / director Date of completion and submission Names and signatures of members carrying out the Screening Assessment 1. 2. Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust s web site. Signed _Sarah Fox Date _January 2017 Page 8 of 8