Acute pain service protocol 2012.

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This pain service manual was written to assist the anesthesiologists and nursing
staff in implementing and monitoring the various pain control modalities
available at Al Razi hospital in Kuwait. The manual contains advice and tips on managing patients from immediate post operative period in the recovery to care and monitoring in the wards. 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 t o
research the doses and the reader is advised to exercise their discretion is
choosing the best possible technique and doses for their patients.

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Acute pain service protocol 2012.

  1. 1. 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
  2. 2. 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*
  3. 3. iii Acute Pain Service: Operations Manual 2012 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
  4. 4. iv Acute Pain Service: Operations Manual 2012 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.
  5. 5. v Acute Pain Service: Operations Manual 2012 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
  6. 6. vi Acute Pain Service: Operations Manual 2012 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
  7. 7. PAIN CONTROL IN RECOVERY ROOM Page 7 Acute Pain Service: Operations Manual 2012 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
  8. 8. PAIN CONTROL IN RECOVERY ROOM Page 8 Acute Pain Service: Operations Manual 2012 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.
  9. 9. PAIN CONTROL IN RECOVERY ROOM Page 9 Acute Pain Service: Operations Manual 2012 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.
  10. 10. PAIN CONTROL IN RECOVERY ROOM Page 10 Acute Pain Service: Operations Manual 2012 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.
  11. 11. PAIN CONTROL IN RECOVERY ROOM Page 11 Acute Pain Service: Operations Manual 2012  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.
  12. 12. PAIN CONTROL IN RECOVERY ROOM Page 12 Acute Pain Service: Operations Manual 2012 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.
  13. 13. MULTIMODAL APPROACH TO PAIN RELIEF Page 13 Acute Pain Service: Operations Manual 2012 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.
  14. 14. MULTIMODAL APPROACH TO PAIN RELIEF Page 14 Acute Pain Service: Operations Manual 2012 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.
  15. 15. MULTIMODAL APPROACH TO PAIN RELIEF Page 15 Acute Pain Service: Operations Manual 2012 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.
  16. 16. MULTIMODAL APPROACH TO PAIN RELIEF Page 16 Acute Pain Service: Operations Manual 2012 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
  17. 17. MULTIMODAL APPROACH TO PAIN RELIEF Page 17 Acute Pain Service: Operations Manual 2012 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.
  18. 18. MULTIMODAL APPROACH TO PAIN RELIEF Page 18 Acute Pain Service: Operations Manual 2012 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.
  19. 19. MULTIMODAL APPROACH TO PAIN RELIEF Page 19 Acute Pain Service: Operations Manual 2012 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.
  20. 20. MULTIMODAL APPROACH TO PAIN RELIEF Page 20 Acute Pain Service: Operations Manual 2012 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.
  21. 21. MULTIMODAL APPROACH TO PAIN RELIEF Page 21 Acute Pain Service: Operations Manual 2012 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).
  22. 22. MULTIMODAL APPROACH TO PAIN RELIEF Page 22 Acute Pain Service: Operations Manual 2012 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.
  23. 23. MULTIMODAL APPROACH TO PAIN RELIEF Page 23 Acute Pain Service: Operations Manual 2012  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/h ttp://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
  24. 24. PATIENT CONTROLLED INTRAVENOUS ANALGESIA Page 24 Acute Pain Service: Operations Manual 2012 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 during implementation of the above protocols. 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.
  25. 25. PATIENT CONTROLLED INTRAVENOUS ANALGESIA Page 25 Acute Pain Service: Operations Manual 2012 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.
  26. 26. PATIENT CONTROLLED INTRAVENOUS ANALGESIA Page 26 Acute Pain Service: Operations Manual 2012 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
  27. 27. PATIENT CONTROLLED INTRAVENOUS ANALGESIA Page 27 Acute Pain Service: Operations Manual 2012 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.
  28. 28. PATIENT CONTROLLED INTRAVENOUS ANALGESIA Page 28 Acute Pain Service: Operations Manual 2012 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.
  29. 29. PATIENT CONTROLLED INTRAVENOUS ANALGESIA Page 29 Acute Pain Service: Operations Manual 2012 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
  30. 30. PATIENT CONTROLLED INTRAVENOUS ANALGESIA Page 30 Acute Pain Service: Operations Manual 2012 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.
  31. 31. PATIENT CONTROLLED INTRAVENOUS ANALGESIA Page 31 Acute Pain Service: Operations Manual 2012 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.
  32. 32. PATIENT CONTROLLED INTRAVENOUS ANALGESIA Page 32 Acute Pain Service: Operations Manual 2012  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
  33. 33. EPIDURAL ANALGESIA Page 33 Acute Pain Service: Operations Manual 2012 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 during implementation of the above protocols. 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.
  34. 34. EPIDURAL ANALGESIA Page 34 Acute Pain Service: Operations Manual 2012 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.
  35. 35. EPIDURAL ANALGESIA Page 35 Acute Pain Service: Operations Manual 2012 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
  36. 36. EPIDURAL ANALGESIA Page 36 Acute Pain Service: Operations Manual 2012 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
  37. 37. EPIDURAL ANALGESIA Page 37 Acute Pain Service: Operations Manual 2012 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.
  38. 38. EPIDURAL ANALGESIA Page 38 Acute Pain Service: Operations Manual 2012 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
  39. 39. EPIDURAL ANALGESIA Page 39 Acute Pain Service: Operations Manual 2012 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.
  40. 40. EPIDURAL ANALGESIA Page 40 Acute Pain Service: Operations Manual 2012 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.
  41. 41. EPIDURAL ANALGESIA Page 41 Acute Pain Service: Operations Manual 2012 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 50g/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
  42. 42. EPIDURAL ANALGESIA Page 42 Acute Pain Service: Operations Manual 2012 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.
  43. 43. EPIDURAL ANALGESIA Page 43 Acute Pain Service: Operations Manual 2012 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).
  44. 44. EPIDURAL ANALGESIA Page 44 Acute Pain Service: Operations Manual 2012  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
  45. 45. REGIONAL NERVE BLOCK Page 45 Acute Pain Service: Operations Manual 2012 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 during implementation of the above protocols. 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: The PCA pump needs to be programmed with the 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
  46. 46. REGIONAL NERVE BLOCK Page 46 Acute Pain Service: Operations Manual 2012 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
  47. 47. REGIONAL NERVE BLOCK Page 47 Acute Pain Service: Operations Manual 2012 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.
  48. 48. REGIONAL NERVE BLOCK Page 48 Acute Pain Service: Operations Manual 2012 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
  49. 49. REGIONAL NERVE BLOCK Page 49 Acute Pain Service: Operations Manual 2012 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.
  50. 50. REGIONAL NERVE BLOCK Page 50 Acute Pain Service: Operations Manual 2012 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.
  51. 51. REGIONAL NERVE BLOCK Page 51 Acute Pain Service: Operations Manual 2012 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
  52. 52. REGIONAL NERVE BLOCK Page 52 Acute Pain Service: Operations Manual 2012 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.
  53. 53. REGIONAL NERVE BLOCK Page 53 Acute Pain Service: Operations Manual 2012 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
  54. 54. REGIONAL NERVE BLOCK Page 54 Acute Pain Service: Operations Manual 2012 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.
  55. 55. REGIONAL NERVE BLOCK Page 55 Acute Pain Service: Operations Manual 2012 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%20Ana esthetic%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.
  56. 56. PEDIATRIC ACUTE PAIN POLICY Page 56 Acute Pain Service: Operations Manual 2012 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: The PCA pump needs to be programmed with the 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.
  57. 57. PEDIATRIC ACUTE PAIN POLICY Page 57 Acute Pain Service: Operations Manual 2012 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.
  58. 58. PEDIATRIC ACUTE PAIN POLICY Page 58 Acute Pain Service: Operations Manual 2012 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.
  59. 59. PEDIATRIC ACUTE PAIN POLICY Page 59 Acute Pain Service: Operations Manual 2012 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
  60. 60. PEDIATRIC ACUTE PAIN POLICY Page 60 Acute Pain Service: Operations Manual 2012 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.
  61. 61. PEDIATRIC ACUTE PAIN POLICY Page 61 Acute Pain Service: Operations Manual 2012 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).
  62. 62. PEDIATRIC ACUTE PAIN POLICY Page 62 Acute Pain Service: Operations Manual 2012 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
  63. 63. PEDIATRIC ACUTE PAIN POLICY Page 63 Acute Pain Service: Operations Manual 2012 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.
  64. 64. PEDIATRIC ACUTE PAIN POLICY Page 64 Acute Pain Service: Operations Manual 2012 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
  65. 65. PEDIATRIC ACUTE PAIN POLICY Page 65 Acute Pain Service: Operations Manual 2012 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.
  66. 66. Appendix 1: EPIDURAL FORM Page 66 Acute Pain Service: Operations Manual 2012 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
  67. 67. Appendix 2: Patient Controlled Analgesia Form Page 67 Acute Pain Service: Operations Manual 2012 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
  68. 68. Appendix 3: Nerve Block Form Page 68 Acute Pain Service: Operations Manual 2012 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
  69. 69. Appendix 4: Back Side of Each Form Page 69 Acute Pain Service: Operations Manual 2012 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.
  70. 70. Notes Page 70 Acute Pain Service: Operations Manual 2012 Notes
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