Kelley Windsor PCNSBC Lane Faughnan RN Objectives Describe the experience of managing continuous peripheral nerve block catheters CPNBs at our pediatric hem onc institution Describe the nursing implications in managing pediatric patients with CPNBs as inpatients and outpatients ID: 317842
Download Presentation The PPT/PDF document "Continuous Nerve Block Infusions: Use ..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Continuous Nerve Block Infusions: Use in Children and Adolescents in Both Inpatient or Outpatient Settings
Kelley Windsor, PCNS-BC
Lane Faughnan, RNSlide2
Objectives
Describe the experience of managing continuous peripheral nerve block catheters (CPNBs) at our pediatric hem/
onc
institution
Describe the nursing implications in managing pediatric patients with CPNBs as inpatients and outpatients
Identify strategies to prevent and manage complications of CPNB
Review case studies
Time for questions and discussionSlide3
Our experience, 2005-2011Slide4
Background information
St. Jude Children’s Research Hospital treats children and young adults with life-threatening diseases of childhood, mostly cancer
60 inpatient bed facility, large outpatient service
Started using CPNB catheters in 2005
Prior to 2005, epidurals were our standard regional pain management
Started with one anesthesiologist, then expanded to all anesthesiologists placing nerve block cathetersSlide5
Our experience 2005-2011: Incidence and indications
248 Catheters
155 patients
About 50:50
male:female
Surgical
Indications (91%)
Limb-sparing surgery
AmputationProsthesis revisionTumor resection Closed manipulationOther orthopedic surgeries
Non-surgical
indications (9%)
Pathological fractures
Tumor-related pain
End of life regional painSlide6
Our experience 2005-2011: Patient diagnoses
%
of 248 catheters
placed;
patients may have had simultaneous or recurrent cathetersSlide7
Incidence and duration of CPNB by Indication: Surgical vs Non-surgical
Block indication
Surgical
Non-surgical
Patients
141
14
Catheters (%)
226 (91.1)
22 (8.9%)
Catheter-days
1337
439
Infections
(% catheters)4 (1.8)2 (9.1)Duration mean (days)5.920Duration median (days)513.5Duration range (days)1-295-81Slide8
50.8%
Number and duration of
CPNBs by year
*One block of 81 days was reported in 2008 (end of life pain management) and affects the average duration data for 2008. Excluding this block, the average is 7.8 days duration.
Average duration
Median duration
C
atheters over 7 days
Number of CathetersSlide9
Our experience 2005-2011: Block sitesSlide10
Our experience 2005-2011: Location of care
CPNB totals for 2005 - 2011:
248 catheters
1776 catheter days
68.6% of these days were
inpatient
days
31.4
% of these days were outpatient days
123 catheters had outpatient days (average time
outpt
: 4.6 days)
5 patients (5 catheters) were placed as outpatients with
no inpatient staySlide11
Neuroanatomy
:
l
ower extremity
Editors:
Chelly
, Jacques
E. Title
: Peripheral Nerve Blocks: A Color Atlas, 3rd
Edition Copyright
©2009 Lippincott Williams & WilkinsSlide12
Brachial Plexus after forequarter amputationSlide13
Our experience 2005-2011: block infusions
Medications:
bupivacaine
or
ropivacaine
; tried
clonidine
, but no anecdotal support for useInfusion rates: vary, based on size of patient and location of blockSlide14
Our experience 2005-2011: nerve block infusions
Analgesic efficacy:
efficacy of NBI therapy in children and adults has been well documented in the literature
Dressing changes
: started with
tegaderm
, then silver impregnated dressings, back to
tegaderm
, back to silver impregnated dressingsRemoval of catheter: done inpatient or in pain clinic ; duration of catheter depends on type of surgery or indicationsSlide15
Fall 2009
Winter
2009
Spring
2010
Summer 2010
Fall
2010
Winter 2010
Spring 2011
Summer 2011
Fall 2011
Winter 2011
Spring 2012
Silver dressingIncluded in CPNB kitNo silver dressing included Silver dressing
Included in CPNB kit
No silver dressing included
Silver dressing
recommended but packaged separately
Silver Dressing Use with CPNB at St. Jude: Infections
3 cases each w and w/o the silver dressing
July Sept 2010
May (2) July Sept 2011
May 2011: change in dressing change practice/providerSlide16
Nursing implications: inpatient and outpatient managementSlide17
Known Complications
Infection
Exit site
Tunnel track
Device malfunctions
Broken catheter
Dislodged / accidental removal
Pump disconnection
Pump malfunctionInfusion leakAnalgesia complications
Incomplete block or inadequate pain control
Numbness
Potential interference with patient care
Not compatible with
MRI
Location of catheters related to activities of daily living / physical therapySlide18
Risk Factors for Infection
Results from
adult studies:
ICU stay
Block duration >48h
Male
Lack of antibiotic prophylaxis
Axillary or femoral location
Frequent dressing changes
Source:
Capdevila
, X.,
Bringuier
, S., &
Borgeat, A. (2009). Infectious risk of continuous peripheral nerve blocks. Anesthesiology, 110(1), 182-188.Slide19
Standard of Care: Inpatient
Assessment and Documentation:
Every fours hours (pain score, block exit site, dressing clean and dry, connections secure, motor strength)
Change infusion bag and tubing q96h
Patient Safety:
Two independent double checks for initiation of infusion, bag changes, and dosage changes
Quality improvement process for every day that infusion is running
Patient and Family Education:
Identify appropriate patients for keeping NBI for outpatientHow long will they need the nerve block?Is there a caregiver to manage pump?Preparing written handouts (Do You Know)Slide20
Standard of Care: Outpatients
Assessment and Documentation:
NBI site and dressing assessed with each outpatient clinic visit
Change dressing every 7 days or if soiled or wet
Pump checks done with visits to Pain Clinic
Patient Safety:
Two independent double checks for initiation of infusion, bag changes, and dosage changes
Quality improvement process for every day that infusion is running
All bag changes are done by RNs at the hospitalTeaching done prior to patient leaving the hospital (going into hospital housing) Oncall MD as support for any problems with block
Patient and Family Education
Do You Know…Nerve Block Infusions
Do You Know…CADD Solis Pump
Pain DiarySlide21Slide22
Available in SpanishSlide23
strategies
to prevent and manage complications of
CPNB:
Patient careSlide24
Preventing Complications
Insertion Techniques
Sterile technique
Tunneling catheters
Dressing
Type of dressing (silver impregnated
vs
not)
Frequency of dressing change (every 7 days, or when dirty or loose)Site AssessmentSlide25
Managing Complications: Disconnected catheter
Assess patient: means a trip to medicine room
A
ssess catheter – broken or disconnected?
If broken:
We would typically discontinue the catheter
Anesthesiologist may repair it if indicated (end of life) or schedule patient for new catheter
If disconnected:
Parents are taught to protect integrity of catheter tip with red capContaminated bags are discontinued and new bag hooked upSlide26
Managing Complications: Leaking catheter
Assess patient; assess catheter – leaking from pump, tubing, or exit site?
Kinked or occluded? Trouble shoot to find problem.
Leaking at exit site? Reduce infusion rate.
Leaking from tubing or pump? Replace bag and/or pumpSlide27
Managing Complications: Incomplete pain control
Assessment: phone call or clinic visit
Pain assessment and review PRN pain medication usage and effectiveness
With or without cold test
Intervention
May bolus NBI with local anesthetic to test effectiveness
If bolus works, may increase rate or concentration of anesthetic
If not, may discontinue blockSlide28
strategies
to prevent and manage complications of
CPNB:
Quality ImprovementSlide29
Improvement Goals: QI
Reduce infection at site
Ensure antibiotic coverage, especially in the non-surgical patients
Improvement of nursing documentation
To meet standard of care inpatient and outpatientSlide30
Improvement Goals: Nursing Education
Pain Pointers
Epidural/Nerve Block Calculator
Improve use of current pt/family education materialsSlide31
Improvement Goals: Nursing Education
Epidural/Nerve Block Calculator (online)Slide32
Improvement Goals: New Devices and Techniques
Devices:
CADD Solis: new pump with drug library
Techniques:
Continue sterile technique, including gown
USG and nerve stimulator
Tunnel all catheters
Dressing:
Use silver impregnated dressingRemove catheter within one week, unless end of lifeSlide33
Improvement Goals: Responding to QI
Each adverse event should be carefully reviewed as early as possible to identify contributing factors
“Minor” or “expected” events should also be gathered and reviewed for increasing trends that signal a lapse in policy or a new problem
Changes in staffing
New device or supplierSlide34
Number of blocks and
number of infections, by yearSlide35
Summary of 6 infections
Primary diagnosis
Age (years)
Pain source
Block
site
ICU days/ catheter duration (days)
Antibiotic coverage (not counting
Septra
)
Signs of infection (day of diagnosis)
Temperature at time of CPNB removal
ANC range during block
Osteo
-sarcoma (OS)18.3Primary limb-sparing surgery
Sciatic
10
Day 0:
Before
and after catheter insertion
Days
1 –
8
: daily
(ceftriaxone, cefuroxime, gentamicin,
vancomycin
)
4100-14,600
Femoral
3/10
Erythema around catheter site
(Day 10)
Unknown
OS
18
Primary limb-sparing surgery
Femoral
8
C
efuroxime +
Vanc
on procedure
day, and one day post
8/17
femoral
site
cellulitis;
required PO antibiotics; 8/19, cellulitis worse, required admission/IV antibiotics; febrile
36.8 (
8/1)
600-4500
Sciatic
8
OS
18
Pathological fracture
Femoral
0/13
Day 0:
after catheter insertion
Induration and coagulase-negative staphylococci on catheter tip (
Day 13)
37.5°C
8700-37,200
OS
10
Pathological fracture
Femoral
10
Day
0:
Clinda
on day 0, Days 1-14: daily (
vanc
,
clinda
,
mero
,
etc
)
redness, fever, pain at site
(started 5/13)
39.3
100
– 38,500
Sciatic
14
site painful (started 5/18),
report of fever
37.9
OS
17
Primary limb-sparing surgery
Femoral
2/11
Cef
/
Vanc
day 0 and 1 only
Unknown
4400-8600
Sciatic
2/11
OS
21
Limb sparing revision
Femoral
6
Cef
/
Vanc
day 0
only
cellulitis
of entry site
site
at
routine visit
;
d/c
cath
; culture of tip which grew
coag
neg
staph
37.9
6900-9500Slide36
Special circumstances
CPNB risk/benefit profile is unique for every patient
Pain control at end of life is priority over relative risks such as neutropenia, thrombocytopenia, local wound, or other contraindications
We have allowed CPNB to remain in site for prolonged periods under some end-of-life circumstances:
Catheter is controlling pain effectively (better than PCA or PO)
Catheter is functioning properly
Pt
/family willing, remain available for catheter maintenance (home health or outpatient visits)Slide37
Risk/Benefit of Regional Analgesia for End of Life Pain Management
Case
Device type
ANC
(x10
3
/L)
Platelet count (x10
6
/L)
Other contraindications
1
E
5300
283
T12 fracture, spinal metastases, fever
2
NB
8300
362
3.1
NB
6300
39
Spinal metastases
3.2
E
nd
94
3.3
E
4600
26
4
E
2100
84
5
E
4100
123
6
NB
1300
89
Large wound in targeted area
7.1
E
6300
477
7.2
E
22300
488
8
E
5800
20
Fever
9
E
5400
241
10.1
E
4500
76 (trx)
10.2
E
4800
106 (trx)
E=epidural;
NB=nerve block
; ANC=absolute neutrophil count;
nd
=not done;
trx
=value after transfusion(s)
Anghelescu et al, 2010Slide38
Case studiesSlide39
Discussion / QuestionsSlide40
Selected References
Anghelescu, D. L., Faughnan, L. G., Baker, J. N., Yang, J., & Kane, J. R. (2010).
Use of epidural and peripheral nerve blocks at the end of life in children and young adults with cancer: the collaboration between a pain service and a palliative care service.
Paediatr
Anaesth
, 20
(12), 1070-1077.Anghelescu, D. L., Harris, B. L., Faughnan, L. G., Oakes, L. L., Windsor, K. B., Wright, B. B., et al. (2012). Risk of catheter-associated infection in young hematology/oncology patients receiving long-term peripheral nerve blocks. Paediatr
Anaesth
.
Burgoyne, L., Pereiras, L.,
Bertani
, L., Kaddoum, R., Neel, M., Faughnan, L., et al. (2012). Long-term use of nerve block catheters in paediatric patients with cancer related pathologic fractures. Anaesth Intensive Care, 40(4), 710-713.Capdevila, X., Bringuier, S., & Borgeat, A. (2009). Infectious risk of continuous peripheral nerve blocks. Anesthesiology, 110(1), 182-188.Capdevila, X., Pirat, P., Bringuier, S., Gaertner, E., Singelyn, F., Bernard, N., et al. (2005). Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: a multicenter prospective analysis of the quality of postoperative analgesia and complications in 1,416 patients. Anesthesiology, 103(5), 1035-1045.Dadure, C., Bringuier, S., Raux, O., Rochette, A., Troncin, R., Canaud, N., et al. (2009). Continuous peripheral nerve blocks for postoperative analgesia in children: feasibility and side effects in a cohort study of 339 catheters. Can J Anaesth, 56(11), 843-850.Dadure, C., & Capdevila, X. (2012). Peripheral catheter techniques. Paediatr Anaesth, 22(1), 93-101.Dadure, C., Motais, F., Ricard, C., Raux, O., Troncin, R., & Capdevila, X. (2005). Continuous peripheral nerve blocks at home for treatment of recurrent complex regional pain syndrome I in children. Anesthesiology, 102(2), 387-391.Ganesh, A., Rose, J. B., Wells, L., Ganley, T., Gurnaney, H., Maxwell, L. G., et al. (2007). Continuous peripheral nerve blockade for inpatient and outpatient postoperative analgesia in children. Anesth Analg, 105(5), 1234-1242, table of contents.Ludot, H., Berger, J., Pichenot, V., Belouadah, M., Madi, K., & Malinovsky, J. M. (2008). Continuous peripheral nerve block for postoperative pain control at home: a prospective feasibility study in children. Reg Anesth Pain Med, 33(1), 52-56.