PS03 2014: Regional analgesia and anaesthesia

 

List:

·         Things to be prevented

·         General requirements

·         Specific requirements

·         Post-procedural care

·         Infusion management

·         Catheter removal

·         Labour epidural

 

This statement applies for any of:

·         Neuraxial block

·         Large dose

·         Catheter left in situ

 

Things to be prevented:

Never events

·      Wrong site blocked

·      Wrong substance injected (especially antiseptic)

Other 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)

 

General requirements:

Proceduralist

·      Trained, skilled, experienced (or supervised)

·      Knows stuff (anatomy, sonoanatomy, phys, pharm, equipment)

·      Knows procedure (indications, contraindications, complications)

Patient consent

·      Process

·      Expectations

·      Risks

·      Benefits

·      Alternatives

·      Informed financial consent

·      (note textbook consent sometimes impossible in obstetrics)

Assistant

·      Nurse/midwife trained and available (see PS08)

Location

·      Engineering and electrical safety

·      Equipment

·      Monitoring (see PS55)

Documentation

·      Consent

·      Preparation

·      Method

·      Drug and dose

·      Complications

Instructions

·      e.g. for management of catheter

 

Specific requirement:

Basic

·      IV access

·      Oxygen if sedated

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

Coagulation status

·      History and examination

·      Medication review

·      Blood tests if necessary

·      Note antiplatelet and NOAC effects are not easily testable or reversible!

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)

 

Post-procedure care:

Protocols for

·      General management

·      Adverse effects: recognition and management (e.g. opioid toxicity)

·      Complications: recognition and management (e.g. PDPH)

Observations

·      Block-dependent. May include:

o   Vital signs

o   Urine output

o   Pain score

o   Sedation score

o   Sensory/motor block

o   Catheter site

Pain service review

·      At least daily

·      On-call service

Personnel

·      Proceduralist or delegate (doctor, pain nurse, midwife)

Location

·      Block-dependent

Duration

·      Block-dependent

Other analgesia

·      Charted for during and after regional analgesia

 

Infusion management:

Tubing

·      Unmistakeable labelling

·      Colour-coding

Infusion pump

·      Unmistakeable labelling

·      Preferably specific pump type

Programming

·      Limits on bolus size and infusion rate

·      Block-dependent

Titration

·      Based on observations

 

Catheter removal:

Performance

·      Trained nurse or doctor

Medications

·      Timed with anti-haemostatics

Documentation

·      Date/time

·      Site appearance

·      Catheter integrity

 

Labour epidural:

Oversight

·      must be managed by doctor in addition to midwife

Consent

·      Procedure

·      Expectations

·      Benefits

·      Risks

·      Alternatives

Assistant

·      midwife present throughout procedure

Monitoring

·      until all effects have subsided

 

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