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)
Number and duration of
CPNBs by year
80
69
70
59
60
61
Number of
Catheters
40
33
50.8%
30
Catheters
over 7 days
20
11
10
0
Catheters
Catheters >7days
Median duration
Average Duration
12
Average duration
3
2005
3
0
2
2
Median duration
2006
11
1
3
3.50
2007
12
0
2.5
2.67
2008
33
9
4
10
*
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
1 1
33
35
119
59
femoral (48.0%)
sciatic (23.8%)
lumbar (14.1%)
brachial (13.3%)
perineal/tibial
popliteal
Our experience 2005-2011:
Location of care
CPNB totals for 2005 - 2011:
• 248 catheters
• 1776 catheter days
31.4% of these days were
outpatient days
123 catheters had outpatient days
(average time outpt: 4.6 days)
Days
68.6% of these days were inpatient
days
500
Inpatient and outpatient catheter
days by year
450
Outpatient days
400
Inpatient days
350
300
250
200
150
100
50
2011
2010
2009
2008
2007
2006
0
2005
5 patients (5 catheters) were
placed as outpatients with no
inpatient stay
Neuroanatomy: lower extremity
Editors: Chelly, Jacques E. Title: Peripheral Nerve Blocks: A Color Atlas, 3rd 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
Fall
2009
Winter
2009
Spring
2010
Silver dressing
Included in CPNB kit
Sept 2010
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 >48h
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 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 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
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
# Total Infections
0
0
2006
2007
0
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
17
OS
21
ICU days/
catheter
duration (days)
Sciatic
10
Femoral
Primary limb- Femoral
sparing surgery
OS
OS
Block
site
8
Sciatic
8
Femoral
0/13
Femoral
10
Sciatic
14
Primary limb- Femoral
sparing surgery Sciatic
Limb sparing
revision
3/10
Femoral
2/11
2/11
6
Antibiotic coverage
(not counting Septra)
Signs of infection (day of diagnosis)
Day 0: Before and after
catheter insertion
Days 1 – 8: daily
(ceftriaxone, cefuroxime, Erythema around catheter site (Day 10)
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;
day post
febrile
Day 0: after catheter
insertion
Day 0: Clinda on day 0,
Days 1-14: daily (vanc,
clinda, mero, etc)
Induration and coagulase-negative
staphylococci on catheter tip (Day 13)
redness, fever, pain at site (started
5/13)
site painful (started 5/18), report of
fever
Cef/Vanc day 0 and 1 only
Cef/Vanc day 0 only
cellulitis of entry site site at routine
visit; d/c cath; culture of tip which grew
coag neg staph
Temperature at
time of CPNB
removal
ANC range
during block
4100-14,600
Unknown
36.8
(8/1)
600-4500
37.5°C
8700-37,200
39.3
100 – 38,500
37.9
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
(x10 /L)
1
E
5300
283
T12 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)
Device
type
ANC
(x103/L)
Anghelescu et al, 2010
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.