Continuous Nerve Block Infusions Use in Children and
Continuous Nerve Block Infusions: Use in Children and Adolescents in Both Inpatient or Outpatient Settings Kelley Windsor, PCNS-BC 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 • Identify strategies to prevent and manage complications of CPNB • Review case studies • Time for questions and discussion
OUR EXPERIENCE, 2005 -2011
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 catheters
Our experience 2005 -2011: Incidence and indications • • 248 Catheters 155 patients About 50: 50 male: female Surgical Indications (91%) • Non-surgical indications (9%) – – – Limb-sparing surgery Amputation Prosthesis revision Tumor resection Closed manipulation Other orthopedic surgeries – Pathological fractures – Tumor-related pain – End of life regional pain
Our experience 2005 -2011: Patient diagnoses 3. 2% 6. 1% Osteosarcoma 0. 8% 4. 9% Ewing Sarcoma 7. 7% 11. 7% Other sarcoma Osteosarcoma 65. 6% Acute Lymphoblastic Leukemia Hematology other Solid Tumor other Infection (rule out malignancy) % of 248 catheters placed; patients may have had simultaneous or recurrent catheters
Incidence and duration of CPNB by Indication: Surgical vs Non-surgical Block indication Patients Surgical 141 Non-surgical 14 Catheters (%) 226 (91. 1) 22 (8. 9%) Catheter-days 1337 439 Infections (% catheters) 4 (1. 8) 2 (9. 1) 5. 9 20 5 13. 5 1 -29 5 -81 Duration mean (days) Duration median (days) Duration range (days)
80 Number and duration of CPNBs by year 69 70 59 60 61 Number of Catheters 40 33 50. 8% 30 Catheters over 7 days 20 10 0 Catheters >7 days Median duration Average Duration 11 12 Average duration 3 2005 3 0 2 2. 00 Median duration 2006 11 1 3 3. 50 2007 12 0 2. 5 2. 67 2008 33 9 4 10. 00 * Number 50 2009 69 21 5 6. 80 2010 59 30 8 8. 10 2011 61 25 6 6. 90 *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.
Our experience 2005 -2011: Block sites 11 35 33 119 59 femoral (48. 0%) sciatic (23. 8%) lumbar (14. 1%) brachial (13. 3%) perineal/tibial popliteal
Our experience 2005 -2011: Location of care 400 Inpatient days 350 300 250 200 150 100 50 2011 2010 2009 0 2008 5 patients (5 catheters) were placed as outpatients with no inpatient stay Outpatient days 2007 123 catheters had outpatient days (average time outpt: 4. 6 days) 450 2006 31. 4% of these days were outpatient days Days 68. 6% of these days were inpatient days 500 Inpatient and outpatient catheter days by year 2005 CPNB totals for 2005 - 2011: • 248 catheters • 1776 catheter days
Neuroanatomy: lower extremity Editors: Chelly, Jacques E. Title: Peripheral Nerve Blocks: A Color Atlas, 3 rd Edition Copyright © 2009 Lippincott Williams & Wilkins
Brachial Plexus after forequarter amputation
Our experience 2005 -2011: block infusions • Medications: bupivacaine or ropivacaine; tried clonidine, but no anecdotal support for use • Infusion rates: vary, based on size of patient and location of block
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 dressings • Removal of catheter: done inpatient or in pain clinic ; duration of catheter depends on type of surgery or indications
Silver Dressing Use with CPNB at St. Jude: Infections 3 cases each w and w/o the silver dressing July Sept 2010 Fall 2009 Winter 2009 Spring 2010 Silver dressing Included in CPNB kit Summer 2010 No silver dressing included Fall 2010 May (2) July Sept 2011 Winter 2010 Spring 2011 Silver dressing Included in CPNB kit Summer 2011 No silver dressing included May 2011: change in dressing change practice/provider Fall 2011 Winter 2011 Spring 2012 Silver dressing recommended but packaged separately
NURSING IMPLICATIONS: INPATIENT AND OUTPATIENT MANAGEMENT
Known Complications • Infection – Exit site – Tunnel track • Device malfunctions – Broken catheter – Dislodged / accidental removal – Pump disconnection – Pump malfunction – Infusion leak • Analgesia 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 therapy
Risk Factors for Infection • Results from adult studies: 1. ICU stay 2. Block duration >48 h 3. Male 4. Lack of antibiotic prophylaxis 5. Axillary or femoral location 6. Frequent dressing changes Source: Capdevila, X. , Bringuier, S. , & Borgeat, A. (2009). Infectious risk of continuous peripheral nerve blocks. Anesthesiology, 110(1), 182 -188.
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 q 96 h • 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 outpatient • How long will they need the nerve block? • Is there a caregiver to manage pump? – Preparing written handouts (Do You Know)
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 hospital – Teaching 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 Diary
Avai lable in Sp anish
STRATEGIES TO PREVENT AND MANAGE COMPLICATIONS OF CPNB: PATIENT CARE
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 Assessment
Managing Complications: Disconnected catheter • Assess patient: means a trip to medicine room • Assess 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 cap – Contaminated bags are discontinued and new bag hooked up
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 pump
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 block
STRATEGIES TO PREVENT AND MANAGE COMPLICATIONS OF CPNB: QUALITY IMPROVEMENT
Improvement Goals: QI • Reduce infection at site – Ensure antibiotic coverage, especially in the nonsurgical patients • Improvement of nursing documentation – To meet standard of care inpatient and outpatient
Improvement Goals: Nursing Education • Pain Pointers • Epidural/Nerve Block Calculator • Improve use of current pt/family education materials
Improvement Goals: Nursing Education • Epidural/Nerve Block Calculator (online)
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 dressing – Remove catheter within one week, unless end of life
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 supplier
Number of blocks and number of infections, by year 80 0 70 2 60 4 non-surgical blocks 50 40 surgical blocks 0 30 20 10 0 # Total Infections 0 0 2006 2007 0 2005 2008 2009 2010 2011
Summary of 6 infections Primary diagnosis Age (years) Osteosarcoma (OS) 18. 3 OS 18 Pain source Primary limbsparing surgery 18 Pathological fracture OS 10 Pathological fracture OS 17 21 ICU days/ catheter duration (days) Sciatic 10 Femoral 3/10 Primary limb- Femoral sparing surgery OS OS Block site Sciatic 8 Femoral 0/13 Femoral 10 Sciatic 14 Primary limb- Femoral sparing surgery Sciatic Limb sparing revision 8 Femoral 2/11 6 Antibiotic coverage Signs of infection (day of diagnosis) (not counting Septra) Temperature at time of CPNB removal ANC range during block Day 0: Before and after catheter insertion Days 1 – 8: daily 4100 -14, 600 (ceftriaxone, cefuroxime, Erythema around catheter site (Day 10) Unknown gentamicin, vancomycin) 8/17 femoral site cellulitis; required PO Cefuroxime + Vanc on antibiotics; 8/19, cellulitis worse, procedure day, and one required admission/IV antibiotics; 36. 8 (8/1) 600 -4500 day post febrile Day 0: after catheter Induration and coagulase-negative 37. 5°C 8700 -37, 200 insertion staphylococci on catheter tip (Day 13) redness, fever, pain at site (started 39. 3 Day 0: Clinda on day 0, 5/13) 100 – 38, 500 Days 1 -14: daily (vanc, site painful (started 5/18), report of clinda, mero, etc) 37. 9 fever Cef/Vanc day 0 and 1 only Cef/Vanc day 0 only cellulitis of entry site at routine visit; d/c cath; culture of tip which grew coag neg staph Unknown 4400 -8600 37. 9 6900 -9500
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)
Risk/Benefit of Regional Analgesia for End of Life Pain Management Platelet Case count Other contraindications 6 (x 10 /L) 1 E 5300 283 T 12 fracture, spinal metastases, fever 2 NB 8300 362 3. 1 NB 6300 39 3. 2 E nd 94 Spinal metastases 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, 2010 Device type ANC (x 103/L)
CASE STUDIES
DISCUSSION / QUESTIONS
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.
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