Continuous Nerve Block Infusions: Use in Children and Adolescents in Both Inpatient or Outpatient Settings

Kelley Windsor, PCNS-BCLane 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%)

– Limb-sparing surgery– Amputation– Prosthesis revision– Tumor resection – Closed manipulation– Other orthopedic

surgeries

• Non-surgical indications (9%)– Pathological fractures– Tumor-related pain – End of life regional pain

Our experience 2005-2011: Patient diagnoses

Osteosarcoma 65.6%11.7%

7.7%6.1%3.2% 4.9% 0.8% Osteosarcoma

Ewing Sarcoma

Other sarcoma

Acute Lymphoblastic Leukemia

Hematology other

Solid Tumor other

Infection (rule out ma-lignancy)

% 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 Surgical Non-surgicalPatients 141 14

Catheters (%) 226 (91.1) 22 (8.9%)

Catheter-days 1337 439

Infections (% catheters) 4 (1.8) 2 (9.1)

Duration mean (days) 5.9 20

Duration median (days) 5 13.5

Duration range (days) 1-29 5-81

2005 2006 2007 2008 2009 2010 2011

Catheters 3 11 12 33 69 59 61

Catheters >7days

0 1 0 9 21 30 25

Median du-ration

2 3 2.5 4 5 8 6

Average Duration

2 3.5 2.666666666666

67

10 6.797101449275

36

8.101694915254

25

6.901639344262

3

5

15

25

35

45

55

65

75

3

11 12

33

69

59 61

Nu

mb

er*

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

Catheters over 7 days

Number of Catheters

Our experience 2005-2011: Block sites

11959

3533

11femoral (48.0%)sciatic (23.8%)lumbar (14.1%)brachial (13.3%)perineal/tibialpopliteal

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 stay

2005

2006

2007

2008

2009

2010

2011

0

50

100

150

200

250

300

350

400

450

500

Inpatient and outpatient catheter days by year

Outpatient days

Inpatient days

Days

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

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 kit

No silver dressing included

Silver dressingIncluded 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/provider

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 stay2. Block duration >48h3. Male4. Lack of antibiotic prophylaxis5. Axillary or femoral location6. 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

Available in Spanish

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 non-

surgical 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

2005 2006 2007 2008 2009 2010 20110

10

20

30

40

50

60

70

80

0

0 0

0

0

2 4 # Total Infections

non-surgical blocks

surgical blocks

Number of blocks and number of infections, by year

Summary of 6 infectionsPrimary

diagnosisAge

(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 removalANC range

during block

Osteo-sarcoma

(OS)18.3 Primary limb-

sparing surgery

Sciatic 10Day 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 Cefuroxime + 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

insertionInduration 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) 39.3100 – 38,500

Sciatic 14 site painful (started 5/18), report of fever 37.9

OS 17 Primary limb-sparing surgery

Femoral 2/11Cef/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 6900-9500

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

Case Device type

ANC (x103/L)

Platelet count

(x106/L)Other contraindications

1 E 5300 283 T12 fracture, spinal metastases, fever2 NB 8300 362

3.1 NB 6300 39Spinal metastases3.2 E nd 94

3.3 E 4600 264 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 4888 E 5800 20 Fever9 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

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.