PS03 2014: Regional anaesthesia

 

List:

·        Goals

·        Discussion

·        Preparation

·        Procedure

·        Aftercare

 

Goals:

No never events

·     Wrong site blocked

·     Wrong substance injected (especially antiseptic)

No complications

·     LAST: seizure/LOC or cardiac arrest

·     High neuraxial block: resp depression, LOC

·     Anaphylaxis

·     Nerve damage

·     Bleeding/haematoma

·     Infection/abscess

·     Hypotension

·     Respiratory depression

·     Failed block

·     (Dural puncture headache)

 

Discussion:

Content

·     Indications

·     Contraindications (especially anticoagulants)

·     Process

·     Expectations

·     Risks

·     Benefits

·     Alternatives

·     Informed financial consent

·     N.B. textbook consent sometimes impossible in obstetrics

Documentation

·     Consent

·     Preparation

·     Procedure

 

Preparation:

Location

·     Engineering and electrical safety

·     Equipment

·     Monitoring (see PS55)

Equipment

·     Ultrasound/nerve stimulator desirable

·     Intralipid desirable

Monitoring

·     Must: conscious state, RR, BP

·     Available: ECG, SpO2 (I would have thought both are compulsory…)

·     Duration: at least 30 mins or until vital signs stable

Personnel

·     Proceduralist: trained, knowledgeable, capable

·     Assistant: trained and available exclusively

Treatment

·     IV access

·     Oxygen if sedated

 

Procedure:

Infection control

·     Facemask/gown/gloves

·     Sterile field and prep

·     Ensure prep cannot be injected

Block time-out

·     Using surgical consent + patient ID band

·     With assistant (nurse or doctor)

·     Said out loud

·     Confirm patient / surgery / site / side

·     Mark the area

·     Re-confirm site and side just before needling

·     Repeat if a) new block in new position b) long break

When to leave

·     Block working

·     Potential for immediate complications has passed

·     Patient stable

·     (If regional anaesthesia: cannot leave unless handed over)

 

Aftercare:

Protocols

·     General management (e.g. frequency of observations)

·     Adverse effects (e.g. opioid toxicity)

·     Complications (e.g. PDPH)

Equipment

·     Tubing: colour and label

·     Pump: specific type, label

·     Programming: with safety limits

Observations

·     Vital signs

·     Urine output

·     Pain score

·     Sedation score

·     Sensory/motor block

·     Catheter site

Analgesia

·     Regional and systemic charted

·     Transition analgesia

Review

·     Acute pain service daily – proceduralist or delegate

·     On-call service

Catheter removal

·     Trained nurse or doctor

·     Timed with anti-haemostatics

·     Documentation: date/time, site appearance, catheter integrity

 

 

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