• Regional analgesia by continuous infusion of local anaesthetic and/or intermittent patient or clinician-controlled bolus of local anaesthetic provides high quality pain relief and reduces the need for opioids.

• Use of NRFit dedicated equipment with unique connectors for delivery of regional analgesia is mandatory.

• Patients with regional analgesia need to be cared for in an appropriate environment and cared for by staff competent to do so.

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition.

Print copies must be destroyed after use.

Abbreviations

1. Effective analgesia is crucial to patient outcome after major surgery to ensure comfort, mobilisation, and decreased risk of potential post-operative complications such as DVT and chest infection.

2. As surgical techniques change and length of inpatient stay decreases, it is important to offer a safe, flexible method of analgesia which may be delivered in both a hospital and community environment if necessary for adult patients.

3. Blockade of pain impulses by local anaesthetic has been shown to give effective pain relief, and to decrease other methods of analgesia required – e.g., opioids with consequent decrease of side effects.

4. This document outlines the potential and actual use of Local Anaesthetic (boluses and infusions) within FHFT for adult patients, and the precautions and care required.

1. To ensure that there is a common understanding of use of local anaesthetic to ensure safe delivery of care by all health professionals involved in the care of patients, including the post-operative period.

2. To ensure that the necessary knowledge and competencies are practised throughout the Trust for delivery and care of the patient, knowledge of the drugs, potential side effects and use of any equipment delivering infusions.

3. To ensure that appropriate training in line with Trust policies should be undertaken by those using the equipment, delivering bolus injections, and caring for patients with these advanced analgesic techniques.

A peripheral nerve is one which lies outside of the central neural canal (i.e., excludes epidural and spinal blockade).

A continuous peripheral nerve blockade is achieved by placing a fine catheter close to a nerve or nerve receptors and infusing a solution of local anaesthetic solution either at an hourly rate and/or as prescribed bolus doses.

The presence of the catheter allows the block to continue for several days (i.e., post-surgery), thereby improving patient analgesia, and lessening the need for more invasive blocks or strong opioids.

Infusion rates will depend on the area being blocked and the expected rate of absorption from that area (depending on vascularity). More than one nerve may supply an area and therefore this technique usually requires adjuvant analgesia to avoid discomfort such as a weak opioid together with nonsteroidal anti-inflammatory drugs (NSAIDs) (unless contraindicated).

Where there is a situation which does require strong opioids, the total dose and risk of opioid and subsequent side effects in those with regional analgesia should be less.

Medical Staff

Local anaesthetic blocks are usually delivered by medical staff competent in the technique of nerve blockade either as a single injection or catheter placement for continuous infusion. It would be expected that they have the appropriate knowledge of full aseptic technique, intravenous cannulation, and resuscitation skills as per FHFT guidelines, as well as knowledge of the relevant anatomy, pharmacology of the drugs being used together with treatment of side effects.

The location of the catheter should be clearly documented in the patient’s notes (including being placed correctly on the LDA) and the catheter should be labelled by its inserter with its location.

Prescribers

Knowledge of safe total dose per 24 hours period is essential together with the necessary observations required and treatment of side effects/complications. Prescribing teams should review all prescriptions daily together with the pain scores and analgesic needs of the patient. They should be able to prescribe clearly in line with guidelines stating:

• the total dosage in mg/24 hours.

• the volume.

• the concentration to be delivered.

• the administration times e.g., hourly or as a timed bolus dose.

• dosage range and the duration for infusions.

Wherever possible, pre-printed drug chart/stickers or electronic prescribing should be used to ensure consistency in prescription practices.

Nursing Staff

Should be responsible for the assessment of patient’s pain and timely delivery of analgesia as per prescriptions – this may include changing an infusion. With appropriate training and competency assessment, nurses may administer bolus injections via a catheter.

Nursing staff are responsible for the regular on-going assessment of:

• Pain scores on rest and movement,

• Motor power and Sensory block (if appropriate)

• Signs of local anaesthetic toxicity

• Monitoring of vital signs i.e., pulse, respiratory rates, oxygen saturation and blood pressure at regular intervals.

Note: successful regional analgesia may mean that if the patient is also receiving opioid analgesia, they may suddenly experience more side effects such as sedation and respiratory depression. Close monitoring of patients with concurrent opioids is required, and opioids may need to be reduced.

Nursing staff should always follow the Trust’s deteriorating patient guidance and activate NEWs scoring as appropriate. Adverse reactions should be reported to the prescriber or doctor on the ward and further instruction on administration received.

Nurses should contact the Inpatient Pain Team for further advice if required. Out-of-hours the on-call anaesthetist can be contacted.

Who to call for help?

Inpatient/Acute Pain Service: available in normal working hours aim to:

• Review inpatients with advanced analgesic techniques: Regional Analgesia (RA) especially Continuous Epidural Analgesia (CEA), and non-standard Patient Controlled Analgesia (PCA)

• Respond to inpatients with complex pain issues such as chronic pain

During office hours Monday to Friday staff should first contact Inpatient Pain Team on:

• FPH - Bleep 5252 or extension 134571

• WPH - Bleep 4820 or extension 154435

• HWD – 07776633562 (or bleep 4820 if no response)

Outside these times for urgent advice the owning medical team can contact the on-call anaesthetist on:

• FPH - Bleep 5002

• HWD & WPH - 07768463877

When contacting the pain team or anaesthetist please ensure the patient’s own medical team have reviewed and optimised the analgesia and that you have the MRN number at hand.

Pharmacists

As part of the regular monitoring, pharmacists should ensure adherence to guidelines with regards to appropriateness, accuracy, safety, and clarity of prescribing.

1. Pain occurs because of stimulation of nerve receptors and the on-going transmission of this stimulation via nerve fibres to ultimately the spinal cord and brain where it is registered as an unpleasant physical and emotional experience and will cause both physiological and subjective responses in a person.

A selection of receptors in the skin and subcutaneous tissues can detect pain whilst the onward transmission occurs via the smaller nerve fibres. There are a variety of nerve fibres which vary in size and function to include movement, sensation of heat and cold, touch and position as well as the sympathetic or autonomic nervous system which controls parameters such as dilation and constriction of blood vessels. The smaller fibres do not have a protective sheath of myelin and therefore are more easily blocked than the larger ones.

The dose of local anaesthetic which is required to block a larger nerve fibre for motor power or sensation will inevitably block the smaller fibres as well. The onset and recovery of nerve block, for example, for movement is usually preceded by the smaller nerve fibres often demonstrated by a change in sensation and blood pressure before motor power returns.

2. Once stimulated the nerve undergoes a process known as depolarisation to transmit the impulse. This is caused by a variety of changes within the nerve involving sodium channels in the nerve membrane which open and allow sodium into the cell. Local anaesthetics block the sodium channels and hence on-going transmission of painful stimuli. Because the nerve fibres connect via synapses throughout the body to reach the spinal cord and brain local anaesthetics can be applied:

• Peripherally – to block skin/subcutaneous receptors

• To a particular nerve or nerve plexus

• To the epidural or spinal nerves

3. This document offers guidance to the use of peripheral and nerve plexus local anaesthetic blocks requiring either a bolus dose and/or infusion technique via a catheter excluding epidural or spinal use which is covered in other guidance. This guidance is aimed (but not exclusively) at:

Group 1: Fascial Plane

• Rectus Sheath, Transversus Abdominis Plane (TAP), Erector Spinae, Serratus Plane, Pectoral, Quadratus Lumborum, Fascia Iliacus, Subcostal TAP.

Group 2: Peri-neural (Nerve Block)

• Brachial Plexus (Interscalene, Infraclavicular, axillary), isolated nerves of forearm, Femoral, Sciatic.

Paravertebral

Indications for peripheral nerve blockade include:

• Patients expected to experience pain after traumatic event i.e., surgery

• As an alternative when epidural analgesia is contraindicated

• As part of a multimodal approach to analgesia to decrease opioid requirements, avoid urinary catheterisation and potentiate more rapid mobilisation.

Contraindications for peripheral nerve blockade include:

• Patient refusal

• Previous adverse effects with local anaesthetics

• Superficial infection at site of potential insertion

• Inadequate knowledge to perform block

• Inadequately experienced ward staff to care for patient post insertion

• Grossly abnormal bleeding disorders

1. Local Safety standards for Invasive Procedures (LocSSIPs) must be followed. All staff involved in establishment of regional analgesia should be aware of the monitoring guidelines and be confident that the ward has adequately trained staff prior to the commencement of the procedure.

2. Use of NRFit dedicated equipment with unique connectors for delivery of regional analgesia is mandatory.

3. Catheters should only be placed adjacent to nerves by experienced practitioners with knowledge of both the relevant anatomy and an acceptable method for nerve location e.g., electrical stimulation or ultrasound. The patient should have had prior discussion of the technique and the potential complications of nerve damage and local anaesthetics and be happy to undergo the procedure. Catheter insertion and consequent injection of local anaesthetic should be performed in a suitable environment where an aseptic technique can be performed and where there are adequate resuscitation facilities.

4. The choice of the catheter rests with the operator – nerve stimulator/catheter specific sets are available, but the use of epidural catheters may be acceptable. Here are some examples of what could be used:

• Epidural sets (Portex 16G Tuohy Epidural) are used for central neuraxial techniques (i.e., Epidural, Paravertebral) and fascial plane blocks (fascia iliaca blocks).

• Braun/Pajunk nerve catheter sets are used for plexus and paravertebral blocks.

• Pajunk wound catheters or their equivalent can be used for Rectus sheath, preperitoneal or wound infiltration.

5. ‘Stop before you block’ must be observed. Consent should be taken and documented. If block is occurring alone (i.e., not being done as part of surgical procedure where surgeon marks the site) site should be clearly marked by operator ahead of block.

6. Aseptic technique should include adherence to the WHO’s 5 moments for hand hygiene1, use of the correct personal protective clothing and an appropriate skin cleansing preparation and sterile drapes around the injection site. A trained assistant should be present to help with the trolley preparation, location of nerve and consequent catheter insertion. Whatever skin cleansing preparation is used, the preparation must be allowed to air dry prior to insertion of any needle or catheter (1-2 minutes).

7. Insertion of catheters may have less associated risks if performed in the awake patient although, many patients prefer to be asleep for the procedure, and they should be made aware of the potentially slightly increased risk of neural damage.

8. The catheter should be inserted to a reasonable depth percutaneously, if possible, prior to being secured to minimise movement and covered by a clear dressing to allow visibility and assessment of the insertion site.

9. Operators should be aware of local infection guidelines (including the use of antibiotics in special circumstances) and be aware of potential hazards in respect of insertion and removal in patients on anticoagulants or with impaired clotting.

10. Catheters should be labelled as to their location by the healthcare professional who inserted them and confirmed visually and verbally on handover to the PACU and/or ward staff. EPIC documentation and the LDA should also be checked to ensure they are documented appropriately.

The Trust’s medicines policies must be followed. Prior to surgery and the initiation of the infusion the operator will consider the suitability of the patient for specific infusions based on:

• Age and physiology

• Risk versus benefit

• Effectiveness of analgesia with respect to type of surgery / injury

• Specific contraindications

Preparation of Infusions

Infusions should be prepared in a sterile environment or supplied pre-filled where possible. The infusion device and catheter must be clearly labelled ‘Local Anaesthetic Infusion’ and the site to which it is attached labelled likewise.

The nerve catheters should be labelled with their location (e.g., sciatic) and type of therapy intended to be delivered (e.g., “infusion” or “bolus only”).

All patients must have IV access maintained for the duration of the infusion.

Regional analgesia infusions must be connected by an anaesthetist, pain nurse or nurse in charge of PACU and be checked by a second registered healthcare professional.

Avoiding Local Anaesthetic Toxicity

There are limitations on the drugs and concentrations which should be infused to ensure decreased risk of local anaesthetic toxicity. All drug infusions should take account of patient weight and the recommended safe dose in mg/kg as per BNF. When prescribing the local anaesthetic drug, the following information should be provided: (Pre-printed drug charts/stickers are available in some areas and templates will be available on electronic documenting systems.)

• Name of drug.

• Site of catheter where drug is to be infused.

• Concentration of solution being infused in % and mg/ml.

• Hourly rate or frequency of boluses required with lockout for PCRA.

• Maximum dose not to be exceeded over a 24-hour period – in mls and in milligrams.

Stock availability

Current drugs usually used, depending on stock availability, include:

• Bupivacaine pre-filled bags at a concentration of 0.125% (i.e., 1.25 mg per ml). The bag volume can vary from 240ml to 480ml.

• Levobupivacaine pre-filled bags at a concentration of 0.125% (i.e., 1.25 mg per ml). The bag volume can vary from 100ml to 200ml.

Sterile 10 ml ampoules of bupivacaine are available in concentrations of 0.25% and 0.5 %. (i.e., 2.5 and 5 mg/ml respectively) on all sites. The upper recommended dose of bupivacaine as an initial loading dose is 1.5 – 2 mg/kg (calculated on ideal body weight). The maximum 24-hour allowable dose of bupivacaine and/or levobupivacaine is 400mg/24 hours. This should be considered when calculating further bupivacaine/levobupivacaine administration as infusion or boluses.

Maximum doses of local anaesthetic should always be calculated on ideal body weight.

Patient Controlled Regional Analgesia (PCRA)

Regional analgesia can be administered in several ways: by intermittent boluses (by a clinician or by patient controlled regional analgesia (PCRA) using an appropriate pump), continuous infusion, or a combination thereof.

Elastomeric devices may be used to deliver the infusion, or a volumetric infusion pump specifically dedicated to that purpose. PCRA can be used to supplement a basal continuous rate with a bolus of local anaesthetic to allow a patient to manage incidental pain related to (postoperative) recovery activities and help meet individual analgesic requirements. PCRA can provide more timely pain relief, more control for the patient, and convenience for both the patient and nurse to reduce the time required to obtain and administer required supplemental boluses. If bolus is used, the lockout interval should be at least 4 hours to allow for peak effect of the supplemental local anaesthetic dose.

**IV Patient controlled opioid Analgesia (PCA) and PCRA SHOULD NEVER be prescribed in conjunction, only oral analgesia should be prescribed if pain still not adequately managed with PCRA.

If IV opioid PCA is required, then PCRA should be ceased or switched to continuous infusion +/- intermittent clinician bolus.

Similarly, intravenous lidocaine SHOULD NEVER be commenced on a patient either on an infusion of LA or on a PCRA. If IV lidocaine is considered, the regional analgesia infusion should be stopped for 4 hours prior to commencing IV lidocaine infusion** Please refer to trust PCA and IV lidocaine guidelines for inpatients.

Regimens for regional analgesia

PCRA 0.125% bupivacaine/levobupivacaine

There are 2 options for PCRA depending on which group the patient is in: 1. Fascial plane, or 2. Nerve block (peri-neural).

PCRA is NOT suitable for paravertebral nerve catheters, and they should utilise a continuous regime +/- clinician bolus.

Fascial Plane (Group 1)

Nerve Block (Group 2)

Note: for single nerve catheter 2ml/hr for multiple nerve catheters (via splitter) 4ml/hr.

If deviating from this, then please ensure robust documentation, stating rationale.

Continuous Regional Analgesia Infusion with 0.125% bupivacaine or levobupivacaine:

• Option 1: Continuous infusion of up to 10 ml/h with boluses.

• Suggested boluses:

  • (a) Clinician bolus of 20 ml bupivacaine/levobupivacaine 0.125% (via Cadd-Solis pump)- maximum frequency 6 hourly or

  • (b) manual bolus of 10ml bupivacaine 0.25% - maximum frequency 8 hourly.

    Or manual bolus of 20ml bupivacaine 0.25% - maximum frequency 12 hourly.

• Option 2: Continuous infusion of up to 13 ml/h and NO clinician or manual top up boluses.

Dilution

Dilute solutions are found to be effective for analgesia and concentrations over 0.125% are not usually necessary. Very large volumes could cause swelling and catheter displacement and leakage in more superficially placed catheters. In all cases the dose range of infusion is prescribed, and, in any case, the maximum recommended dose should not be exceeded.

Bilateral Catheters

For specific operations or conditions, there may be bilateral catheters inserted e.g., rectus sheath blocks for a laparotomy; bilateral mastectomies or hernias, when care should be taken to ensure that the sum of each catheter infusate does not exceed the total hourly recommended amount. Bilateral catheters should be attached via a splitter to one infusion device. (See section 11.2)

Rate of Infusion

A range of rate of infusion should be prescribed together with the necessary supportive therapy such as oxygen according to the Trust guidelines and potential fluid bolus and/or ephedrine boluses should hypotension occur. Clinician administered IV, IM or oral opioids may be simultaneously administered without additional risks in line with Trust guidance. Care should be taken that there is no concurrent prescription and/or administration of local anaesthetic and opioid mixture in the infusions for example in an epidural or lidocaine infusion.

Staff Competency

Bolus of local anaesthetic either manually or via the infusion pump can only be administered by the anaesthetist or a healthcare professional with the appropriate competency, such as the inpatient pain nurse.

1. Local anaesthetic for regional analgesia can be delivered via a catheter using a variety of devices:

• Specific Infusion Pump with a variety of protocols (for indefinite time period)

• Single use elastomeric pre-filled infusion device

• Bolus dose administration by patient or medical/nursing staff.

2. All devices and catheters must be clearly labelled, and the devices are kept exclusively for local anaesthetic use. Examples of infusion devices:

• Smiths-Medical CADD Solis Infusion Pump

• AutoFuser pump – see Mastectomy_Enhanced_Recovery guidelines

This is a specific pump to deliver the agreed pre-set protocols of LA infusions over a variety of protocols which will include patient controlled regional analgesia programme for additional bolus doses if required. It is also possible to deliver a clinician bolus through the pump. The baseline infusion consists of 0.125% bupivacaine or levobupivacaine which is available in a pre-filled bag from pharmacy. The local anaesthetic infusion pumps should only be used for dilute infusions of local anaesthetics.

In the case of Bilateral Rectus sheath/wound/preperitoneal/sub-pectoral catheters, ‘Y’ splitters should be used as only a single pump is advisable. (See following pictures)

Filter and nerve catheter holders have NR Fit connections.	Y connector has NR Fit onnections

The local anaesthetic infusion pump has a facility for an additional bolus which is security coded enabling only anaesthetists, recovery nurses and pain nurses to access. All boluses should be given under close monitoring conditions.

	NR-Fit compatible giving sets and connecting devices, such as filters and splitters, must be used.

3. It would be expected that staff familiar in the use of the local anaesthetic infusion pumps for administering epidural infusion analgesia would be able to operate it for local anaesthetic infusion as the competency is identical. It is expected that all staff familiar with the care of local anaesthetic infusions via the epidural pump will be sufficiently trained to care for patients receiving regional analgesia infusions.

4. Local anaesthetic is bacteriostatic. The regional analgesia circuit should be manipulated as little as possible to reduce opportunity for infection. It is not necessary to change the filter or giving set during the duration of the infusion unless they become damaged or leak.

5. If the line requires changing, for reasons other than damage, then this decision should be made by either the Pain team or an anaesthetist, and rationale should be documented in the notes. The line must only be changed by those who hold an appropriate competency to make up the infusion pumps.

1. Pain scores should be recorded regularly alongside observations and if pain changes. The aim is for the pain scores should be 0 or 1 on movement and 0 at rest. All inpatients receiving regional analgesia should be monitored for sensation, motor power and signs of toxicity and the observations recorded with other vital signs on EPIC and NEWS scoring done.

2. Nursing staff must be aware of the potential side effects and complications of regional analgesia and their management. It is assumed that nurses with training for care of epidurals and knowledge of the side effects and potential signs of local anaesthetic toxicity will be able to care for patients with regional analgesia infusions.

3. Timely observations are necessary for the safe delivery of this method of analgesia. All observations will be recorded on the appropriate location on EPIC.

4. Observations should be performed on the patient regardless of whether an infusion is running, as the nerve catheter and skin should still be inspected for their integrity, any signs of infection or issues. Site checks should be documented against the nerve catheter LDA.

5. Observations should include:

• Full set of physiological observations including NEWS score.

• Pain assessment at rest and on movement.

• Sedation score.

• Nausea score.

• Pruritis score.

• Inspired volume using incentive spirometry for thoracic trauma patients such as those with fractured ribs.

• Monitoring for any signs of local anaesthetic toxicity.

• Catheter site check.

• Pump and Prescription check including:

  • Ensuring the pump is running appropriately and is programmed as per the prescription.

  • Route check to ensure the infusion is connected to the correct nerve catheter.

  • Documentation of the current programme, rate, total infused and any bolus that has been administered either by the patient or a clinician

This should all be documented in the appropriate location within EPIC.

6. Observations should be performed as per below based on the current analgesic regime.

Patient Controlled Regional Analgesia (PCRA)

Continuous Regional Analgesia

Nerve catheter only +/- clinician bolus

If respiratory rate falls below 8 per minute, administer oxygen, consider use of bag-valve-mask to support adequate ventilation, stop opioids, and administer naloxone 400micrograms stat (or in 100 microgram increments titrated to effect) and call CRASH call team (2222).

7. When commencing PCRA then this ideally should be done in the presence of an appropriate healthcare professional who can monitor the patient for the first 30 minutes after they push the PCRA button at 15-minute intervals. This could be in an area of higher levels of care such as PACU, ITU, SADU or if on the ward this may be in the presence of the anaesthetist or inpatient pain team.

8. If PCRA is started in PACU / ITU / SADU the patient must have pushed the button at least once and had observations for 30 minutes (at 15-minute intervals) after that to establish that they are stable post that bolus before they can then be transferred to the ward. This should be done regardless of whether they have pain to ensure they are safe with the therapy being delivered.

9. If the clinician initiating PCRA is content that the patient has previously had a bolus of local anaesthetic (for example on insertion of the nerve catheter(s)) and been monitored and stable, then they can document when they want the PCRA to be started and that they would like the usual observations followed and that they are content that the “first” push of the PCRA is then on the ward.

10. If patient is stable and infusion rate remains unchanged monitor 4 hourly after first 24 hours. If the patient is in pain, the rate of infusion changes, or the patient is in labile condition then continue with observations more frequently. After the first 24 hours if the patient is sleeping normally, they need not be roused for observations, but respiratory rate must be counted every 4 hours.

1. Sympathetic blockade by local anaesthetic can sometimes occur, particularly when a catheter is in close proximity to sympathetic nerves or is causing vasodilation. Other causes for decrease in blood pressure should be excluded before assuming they are due to the local infusion. Systolic blood pressure should be greater than 90mmHg systolic unless otherwise stated. Hypertensive patients may require a higher baseline to maintain organ function – particularly urine output. It would be expected that the anaesthetist involved in the catheter insertion would state acceptable parameters for systolic pressure (level and time period) after which intervention would be required in terms of fluid bolus as per chart.

2. If systolic blood pressure is less than 80mmHg stop local anaesthetic infusion and seek urgent help via NEWS call.

3. If systolic BP is less than 100mmHg:

• Give IV fluid bolus (if prescribed)

• Lay patient flat but do not ‘tip’ bed head down

• Call surgical SHO / HO

• Call Inpatient Pain Team or on-call anaesthetist

• Increase frequency of observations as per clinician guidance (e.g. every 15 minutes)

• Pain Team or anaesthetist may recommend reducing the rate of infusion or suspending it.

• Ephedrine boluses 3-6mg every 5 minutes can be given to increase BP if not responding to fluid bolus by appropriately trained personnel (As prescribed in the drug chart).

N.B. Patients who have been prescribed anti-hypertensive drugs should have their BP checked prior to the administration of the drug

Local anaesthetics if prescribed and administered correctly will rarely cause toxic effects. However, if there is direct infusion into a vein or the solution is absorbed rapidly, or a patient is unduly sensitive then the signs and symptoms of toxicity may occur. All staff working with local anaesthetic infusions should be aware of the signs and treatments of LA toxicity. If not acted upon in the early stages, then respiratory and cardiac arrest can occur (a CRASH call (2222) should be put out) which is very difficult to reverse because the ‘acidotic’ arrest state causes more of the drug to enter the cells and worsen the situation.

Signs of severe toxicity include sudden alteration in mental status; severe agitation or loss of consciousness, with or without tonic-clonic convulsions; cardiovascular collapse; sinus bradycardia, conduction blocks; asystole and ventricular tachyarrhythmias.

Local anaesthetic toxicity may occur sometime after initial injection. It should be treated promptly with Intralipid in accordance with the Trust’s Guidelines for the management of local anaesthetic toxicity located on the intranet and all emergency trollies.

Pain scores and sedation scores should be recorded and documented regularly with every observation when patient is awake – both at rest and on movement. If patient is asleep, then this may be recorded as “sleep” for this section, but respiratory rate should still be observed and documented. Recording “sleep” should not be done for more than 3 successive observations. If pain score is higher than mild pain = 1, ensure multimodal analgesia is given and if pain continues contact medical staff or inpatient pain team for further review and advice.

N.B. Strong opioids may be given alongside regional analgesia infusions.

• 0 = none

• 1 = mild (occasionally drowsy, easy to rouse)

• 2 = moderate (frequently drowsy, easy to rouse)

• 3 = severe (somnolent, difficult to rouse)

• S = normal night-time sleep (easy to rouse)

If Sedation score is 2 or more then medical help should be sought.

• 0 = no nausea

• 1 = nausea on movement

• 2 = nausea at rest

• 3 = active vomiting / retching

• 4 = persistent nausea

Patients should be regularly checked for feelings of nausea and vomiting, and all should have appropriate anti emetics prescribed and given.

1. Catheters are not sutured in place and therefore may easily fall out if not handled carefully. Dressing changes to the catheter exit site should only be carried out, when absolutely necessary, by a competent nurse trained in the technique or an anaesthetist. Ideally the dressing should be left undisturbed. The catheter is fixed with a ’fixing device’ removal of this fixing device would necessitate disconnection of the catheter and its threading through the ’fixing device’ – this should only be undertaken by competent staff as there is a high risk of catheter dislodgement. If the old dressing needs to be removed, any ‘fixing device, should be retained and covered with a clear adherent dressing. The dressing should be smooth and there should be no kinks in the catheter.

2. It is the nurses’ responsibility to check the catheter site regularly (minimum of 4 hourly) to check that the dressing is secure and remains covering the catheter. If the dressing is insecure or there is a leak of fluid, it should be secured with additional tape and pad. This should be documented in the site check on the LDA in EPIC.

3. Catheter Detachment in anticoagulated patient: If a local infusion catheter inadvertently falls out/is removed whilst a patient is anticoagulated there may be an increased risk of haematoma and a pressure dressing to the area should be applied.

Nursing management of the line and filter should aim to prevent disconnection of the filter from the catheter and maintain the integrity of the system as well as promoting comfort at the filter site. Effective management of the catheter and line is essential in preventing any pulling of the actual catheter and its potential dislodgement or disconnection. It is also important in preventing any pressure damage to the skin integrity from the lines, filters, or catheters. If the catheter becomes disconnected or dislodged it should not usually be replaced and will usually require removal which can be undertaken by any competent health professional trained in aseptic technique. (See removal) If there is reluctance to remove the catheter and further advice is needed:

• Wrap the filter and catheter in sterile gauze

• Stop the infusion

• Contact the Inpatient Pain Team or, out of hours, the on-call anaesthetist on call.

• They can then review the patient and advise on what actions should be taken. This should then be documented on the care pathway and in the medical notes.

Factors to Consider Prior to Discontinuation

• Severity of pain expected after discontinuation of infusion.

• Patient’s ability to tolerate other routes of analgesia.

• It would be anticipated that this has been part of a multimodal analgesic approach therefore other analgesia has probably been administered, however if this is not the case, then analgesia must be prescribed before the infusion is stopped. Analgesia should be prescribed as regular as well as PRN as appropriate.

• Regular pain assessment should continue to ensure patient’s pain control is well managed.

• Patients or carers wishes should be taken into consideration. If a patient requests, they no longer wish to receive regional anaesthetic infusion analgesia then alternative options should be discussed ensuring the patient is fully informed prior to making a choice.

• A choice may be made to stop the infusion for a period before removing the nerve catheter to ensure pain is managed with alternative analgesia, e.g., 4 hours.

1. Fascial plane catheters (paravertebral, plexus, rectus sheath, preperitoneal/wound and sub-pectoral etc.) can be left in situ for up to 5 days, after which the risk of infection significantly increases. Every case should be considered on an individual basis and catheters can be left in situ for duration outside these guidelines, but the anticipated duration needs to be documented in the medical notes and this ideally should be discussed with an anaesthetist. If prolonged use is planned, then the catheters ideally should be tunnelled. Regional analgesia infusion catheters can be removed by registered nurses who have been trained and assessed as competent in aseptic technique.

2. Unless there is grossly abnormal clotting no special precautions are necessary. If in doubt seek advice from senior clinician. Catheters may be removed as long as the patient’s clotting profile is not grossly abnormal i.e., INR < 2 or platelet count ≥ 50,000units. If in doubt consult Anaesthetist or Inpatient Pain Team. It would be expected that if the bleeding history is negative that routine coagulation screening prior to removal would not be required. (FBC prior to surgery to confirm platelet count would be acceptable). The catheter should be removed taking into consideration the timing of cessation of heparin infusions (mainly vascular patients) and administration of prophylactic anticoagulation.

3. Catheter removal early in the day will ensure sufficient time to monitor patient during working hours for any signs of haematoma at the site of entry and exit.

4. Procedure for removal of catheter

• Clean hands in line with the ‘WHO’s 5 moments for hand hygiene’.

• Gather equipment – a small dressing pack, gloves, and small clear dressing to cover site.

• Explain the procedure to the patient.

• Position the patient comfortably where access to the catheter is easiest.

• Remove outer dressing and ‘fixing device’ device (if present).

• Observe the site for leakage, fluid, or signs of infection, take swab from site if any cause for concern.

• Remove the catheter slowly with gentle traction, if resistance is felt, stop and contact Inpatient Pain Team or on-call anaesthetist.

• Check catheter to ensure tip is complete – if not notify patient’s own medical team, the inpatient pain team or anaesthetist to review and advice of ongoing actions. Ensure this is documented on the care pathway and in the medical notes.

• Send catheter tip for culture if concerned about infection.

• Clean site with sodium chloride 0.9% and apply adhesive dressing over site.

• Ensure “tip(s) visualised” is documented on the care pathway.

1. The pain team should be informed of any serious complication or adverse event relating to local anaesthetic analgesia.

2. Patient Safety Incident forms should always be completed.

This guideline will be monitored through incident reporting and medical device training data and will also be discussed as required at Anaesthetic, Surgical and Inpatient Pain Team multidisciplinary team and departmental meetings.

This policy has been subject to an Equality Impact Assessment and is not anticipated to have an adverse impact on any group.