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Child Health Guideline Identifier

Pain - regional infusions

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Introduction

Regional anaesthetic techniques are used as a means of providing postoperative analgesia.

Epidural analgesia is the most frequently used regional anaesthetic technique but peripheral nerve or plexus blocks are also used. These can be a single shot regional block or a continuous infusion technique.

Regional analgesia is accomplished by the use of local anaesthetics. These are agents that interfere with impulse transmision in specific nerve fibres innervating a body area.

The regional catheter is inserted by the anaesthetist after induction of anaesthesia or under direct observation by the surgeon. A bacterial filter is attached to the end of the catheter. Once analgesia is established by the anaesthetist an infusion of bupivacaine 0.125% or ropivacaine 0.2% is commenced. This weak local anaesthetic aims to provide analgesia without dense motor block.

Common types of regional infusions

  • Interpleural - catheter placed in the intrapleural space.
  • Extrapleural - Catheter is placed external to parietal pleura (usually across the necks of the ribs).
  • Paravertebral - catheter placed next to the vertebral column in the paravertebral space.
  • Brachial plexus - catheter placed into the perineural sheath around the brachial plexus.
  • Femoral nerve - catheter or block placed into perinueral sheath around the femoral nerve
  • Sciatic nerve - catheter or block placed along the sciatic nerve between the sciatic notch of the pelvis and the popliteal fossa (behind the knee).

Information for Patient & Caregivers

Where possible, the use of regional anaesthetic technique should be explained to the patient and parent(s)/carer pre-operatively. The anaesthetist will identify suitable children and explain the procedure to the child and family.

Medications used

The standard regional mix is supplied by pharmacy in premixed 100ml bags.

The standard concentration is Ropivicaine 0.2% or Bupivicaine 0.125%.

Regional Infusion Management

Prescription

The orders for the infusion are prescribed on a standard regional prescription form (CR3652). Changes to the regional prescription are only to be made by an anaesthetist.

Nurses are able to adjust the rate of infusion within the prescribed range following assessment of the patient's pain.

The usual infusion rate is:

  • < 3 months 0.1 - 0.2ml/kg/hr
  • > 3 months 0.1 - 0.3ml/kg/hr

These standard settings/drugs do not apply to all patients and have to be adapted to the individual situation by the anaesthetist or pain service.

In some circumstances a continuous infusion will not be prescribed. However the catheter may be left in-situ for further top-up administration if required. The catheter needs to be clearly labeled (regional) to prevent inadvertent administration of medication.

Equipment

  • CADD solis pump (sourced from equipment pool)
  • CADD solis lockbox key (kept with the controlled drug keys)
  • CADD® Yellow Striped Administration Set (21-7024-24)

Programming

A registered nurse, who has attended the pain study day and had their CADD pump competency signed off, can set up and programme the pump. This must be done with a second registered nurse both of whom must sign the regional infusion prescription (CR3652).

It is uncommon that a ward nurse will be required to set up a regional pump as the majority of regional infusions are set up by nursing staff in PACU.

On receiving the patient, ensure the pump is programmed as per the prescription (CR3652):

  • Paediatric regional
  • Continuous rate correct
  • Correct reservoir volume

The program should be rechecked when taking over a new patient or after a bag change. These program checks can be done by a single registered nurse. Any rate change, within the prescribed limits, should be checked by two registered nurses. A code (supplied to all registered nurses) will be required to make any changes to the program.

Changing medication bag and lines

Regional bags should be changed when empty or after 96 hours if it is a premixed infusion bag.

Line changes are not necessary as regionals are removed after 3 - 5 days. In unique situations where they may remain past this point please contact the pain service for advice on line change.

Documentation

Commencement and cessation of the regional should be documented on the back of the paediatric epidural/regional infusion (CR3652) form.

The following should also be documented on this form:

  • Rate changes
  • Bag changes (and bag volume discards)
  • Checks when taking over patient care
  • Top ups should be documented on the front of the form by the anaesthetist administering the top up.

Observations

Observations required can be found on the paediatric epidural/regional infusion form (CR3652). They are as follows:

Hourly 4 Hourly Observe and document every shift
HR, RR, SP02 
BP - 1st 4 hours
Level of consciousness
Pain Assessment
BP - unless paediatric early warning score (PEWS) > 3
Motor block (bromage score)
Pressure area cares (Glamorgan)
Nausea/Vomiting
Agitation/toxicity
Catheter and site
• Continuous oximetry for patients 'at risk' or requiring oxygen
• If asleep and PEWS are stable for over 6hrs: document level of consciousness and pain assessment 4 hourly.
• Continue observations for 4hrs after stopping epidural/regional infusion.

Top ups - monitor HR, RR, BP and Sp02 every 5 minutes for 15 minutes, then every 15 minutes for 1 hour.

Top ups

Only an Anaesthetist is able to administer top-ups via the regional catheters. Documentation of top-ups administered will be completed by an anaesthetist on the regional prescription form.

Pneumothorax Risk

There is potentially a risk of pneumothorax occurring on insertion of an interpleural catheter or in some approaches to a brachial plexus block.

Staff should have a low threshold for medical review of these patients. If signs of respiratory deterioration are noted, a chest x-ray should be done immediately to exclude a pneumothorax.

Local Anaesthetic Toxicity

The signs and symptoms include:

  • Tingling around the mouth and tongue
  • Light headedness and visual disturbances
  • Twitching of mouth and fingers
  • Convulsions
  • Unconsciousness
  • Respiratory and cardiovascular depression

In children who are unable to report these initial symptoms a first indication could be unusual twitching/ jerking of limbs. This can easily be confused for pain.

Motor Block

It is important to assess motor blocks as per the guidelines outlined on the regional/epidural prescription form as the motor nerves can be affected by the local anaesthetics used in the regional infusion.

For paravertebral, axillary and interscalene blocks this should be done by assessing upper limb motor function with bilateral hand and finger extension and flexion.

Securing Catheter

The regional catheter in most circumstances is secured in place with a transparent occlusive dressing. This is to be replaced by the anaesthetist/pain service if necessary.

Nursing staff may reinforce the dressing if required.

Weaning and transitioning the patient

  • Most children will have the regional infusion catheter in place for 2 -4 days.
  • The infusion should be stopped as directed by the Pain Service.
  • Generally the infusion rate does not need to be reduced prior to being discontinued.
  • Additional analgesia should be administered to minimise discomfort as the effects of the local anaesthetic wears off.
  • Intravenous access should be maintained for 4 hours following discontinuation of the infusion.

Removal of Catheter

The catheter should be removed approximately 4 hours after discontinuation of the regional infusion. This can be done by a registered nurse by initially washing their hands and then removing the dressing. Once the tape is removed the catheter should be removed slowly without force. If resistance is felt on removal - stop and call the pain service. DO NOT PULL.

Observe site for any leakage. Apply a band aid to the area.

Monitor the site for 24hrs post removal.

If the patient is for discharge the parents/caregivers should be educated on assessing the site at home for redness, discharge or increased pain at the site. If any of these arise the patient should be taken to their GP for review.

For patients receiving:

  • Low molecular weight heparin (Enoxaparin)
  • An intravenous heparin infusion
  • Warfarin

Refer to Pain Management Epidurals & Anticoagulation - RBP - Adult

References

  • Twycross, A., Dowden, S., & Stinson, J. (2014) Managing Pain in Children. A clinical Guide for Nurses and Healthcare Professionals (2nd ed.). United Kingdom: Wiley Blackwell.
  • McGrath, J, P., Stevens, J, B., Walker, M, S., & Zempsky, T, W. (2014) Oxford Textbook of Paediatric Pain. Oxford, United Kingdom: Oxford University Press
  • Shah, D, R., & Suresh, S. (2013) Applications of regional anaesthesia in paediatrics. British Journal of Anaesthesia, 111(S1) i114-i124.

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Document Control

  • Date last published: 18 January 2017
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Pain Service
  • Owner: Paediatric Pain Service
  • Editor: Greg Williams
  • Review frequency: 2 years

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