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Care of Patient Receiving a Continuous Peripheral Nerve Block (Perineural) Infusion (1.41)

Care of Patient Receiving a Continuous Peripheral Nerve Block (Perineural) Infusion (1.41) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Cardiovascular and Infusion

1.41

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
June 19, 2015

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 1.41

Original
Revision

Page
1
of 7

Title: Care of Patient Receiving a
Continuous Peripheral Nerve Block
(Perineural) Infusion

I. PURPOSE

To allow for safe administration of continuous peripheral nerve block (perineural)
infusions.

The management and care for an epidural catheter is covered by UWHC Hospital
Administrative Policy 8.92, Epidural and Intrathecal (Neuraxial) Analgesia.

II. POLICY

A. The overnight care unit at The American Center (TAC) will accept patients with
peripheral nerve catheters, and patients will be managed by the anesthesiologist as
no Acute Pain Service (APS) will be available. RNs and anesthesiologists will
follow Policy 1.41 as written.
B. Peripheral nerve block catheters will be placed by qualified anesthesia clinicians
(staff anesthesiologists, fellows, or residents) in the following areas: regional
block rooms, pre-operative areas, Post Anesthesia Care Units (PACU), Operating
Room (OR), Intensive Care Units (ICU), Surgical Trauma Unit (F4/4),
Cardiothoracic and Thoracic Surgery Unit (B4/5) and Emergency Department
(ED). The Acute Pain Service (APS) (Anesthesiologist at TAC) will evaluate
patients on an individual basis to determine the application of peripheral nerve
block catheters.
C. Only APS and anesthesiology staff may initiate, modify, or discontinue peripheral
nerve block infusion therapy. The primary service providers should request
changes in perineural therapy by communicating directly (verbally) with the APS
(Anesthesiologist at TAC) or via a written clinical progress note entry detailing
the request in the electronic medical record. The request should not be written as a
medical record order. Any emergent orders made by the primary service to
modify the perineural infusion must be communicated to the APS
(Anesthesiologist at TAC) immediately. Physicians/providers may not initiate,
modify or discontinue perineural therapy independent of APS.
D. APS (Anesthesiologist at TAC) is available 24 hours a day for consultation
regarding problems with the perineural catheter and/or infusion. The APS can also
be contacted for any desired therapy changes or questions at Pager 7246 or
"PAIN". If no response, call paging for the anesthesiology on-call resident (or
faculty), or call the UWHC Inpatient Operating Room at 263-8595.
E. Continuous peripheral nerve block infusions may be performed for both inpatients
and outpatients.
F. The following units provide care for patients with peripheral nerve catheters: Care

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Initiation Unit (F6/4), Orthopedics (B6/4), General Trauma/Trauma and Surgical
IMC (F4/4), Heart and Vascular Care (D4/5), Cardiothoracic and Thoracic
Surgery Unit (B4/5), Family Medicine and Forensics (D4/6), Transplant (B4/6),
Gynecology, Urology, Plastics and ENT (F6/6), General Surgery/Bariatrics
(F4/6), all PACUs, ICUs all units in American Family Children’s Hospital
(AFCH) and the overnight care unit at TAC. These are units that also care for
patients with epidurals.

III. PROCEDURE

A. Initiation of Peripheral Nerve Block Therapy
1. APS (Anesthesiologist at TAC) completes a standardized Regional
Analgesia Therapy Physician Order Form (order set) so that all APS care
providers have the necessary information to assure safe and efficient order
entry and verification.
2. Orders will include the analgesic medications to be infused; infusion rate;
parameters for monitoring the patient’s respiratory rate, blood pressure, heart
rate, sedation level and changes in strength or sensation of extremities;
treatment of side effects; and parameters when to notify APS
(Anesthesiologist at TAC).
3. A clear, bio-occlusive dressing will be applied to the site of the peripheral
nerve block catheter.
B. Preparation and Dispensing of Peripheral Nerve Block Infusions
1. The pharmacy sterile products production area personnel will place unique
yellow-colored warning labels and tactile feedback on all dispensed
products.
C. Administration of Peripheral Nerve Block Therapy
1. The initial (and subsequent) line connection of the perineural catheter to
designated analgesic pump administration tubing will be made by a member
of the APS (anesthesiologist, anesthesiology resident or anesthesiology APS
CNS), or by inpatient PACU nurses.
2. All peripheral nerve block infusions are administered through a designated
analgesia pump to differentiate the infusion from an IV infusion. The
designated analgesic pump uses specific pump set tubing. This tubing is
especially designed for use with the pump, and has no side ports, which
prevents accidental administration of medications.
3. All peripheral nerve block infusions should be clearly labeled to avoid
confusion with intravenous lines.
4. Review and verify orders for analgesic infusion prescription: medication,
concentration, rate, continuous, patient initiated boluses, and RN bolus
options. RNs may administer a bolus dose for perineural infusions as ordered
by APS (Anesthesiologist at TAC) via the pump bolus option.
5. Peripheral nerve block infusions are high alert medications. Review UWHC
Hospital Administrative Policy 8.33, High Alert Medication Administration.
6. Document the date and time in the medication administration record when
initiating new infusion bag.
D. Maintenance of Peripheral Nerve Block Infusions
1. An independent double-check of peripheral nerve block infusions is
performed anytime an infusion bag is changed or the pump is reprogrammed

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per UWHC Hospital Administrative Policy #8.33, High Alert Medication
Administration.
2. Document date and time in the medication administration record when nurse
boluses are given.
3. According to UWHC Nursing Patient Care Policy #14.33, Nurse-to-Nurse
Change-of-Shift Hand-Off, nurses will conduct a face-to-face hand-off at
change of shift. This will include verbal report and safety check, at the
bedside, including line reconciliation of the perineural infusion setup,
appropriate perineural solution and perineural infusion device. Line
reconciliation is intended to minimize the possibility of catheter and tubing
misconnections, and includes: 1) Re-checking all tubing and catheter
connections; 2) Tracing all patient tubes and catheters to their sources for
correct route; 3) Labeling all tubes and catheters at the point(s) of
connection.
4. Check the pump, catheter and site for proper infusion of the medication(s) a
minimum of every 8 hours. Visually inspect the volume of solution in the
bag to correlate it to the volume the pump reports as remaining to verify the
pump is accurately infusing. Be sure to check that the tubing is not kinked
between the bag and the pump or where it exits the pump. Observe for
leakage of fluid from the site or from the catheter itself, or an occluded
catheter or tubing. Notify the APS (Pager 7246) (Anesthesiologist at TAC)
if these problems occur.
a. If the catheter becomes disconnected from the infusion tubing,
place a sterile syringe on end of catheter and immediately notify
APS (Anesthesiologist at TAC). Strict sterile technique will be
used at all times when the closed system is interrupted.
b. If the perineural catheter becomes severed, place a clamp on the
catheter tubing connected to the patient and place a sterile
tegaderm over the exposed catheter end. Immediately contact APS
(Anesthesiologist at TAC).
5. Tubing for perineural infusions is not routinely changed in the hospital due
to the short duration of therapy and risk of opening a sterile, closed system.
Additionally, in the home setting, tubing is not changed in disposable
infusion systems.
6. Following initiation of the infusion, the nurse will:
a. Monitor and document the respiratory rate, blood pressure, heart
rate, sedation level and changes in strength or sensation of
extremities as ordered.
b. Monitor for sensory and motor deficit every 4 hours while awake
or as ordered.
a. Assess neurovascular integrity of the affected extremity or
region and compare to unaffected extremity.
b. Note temperature, color, capillary refill, mobility and
sensation. (NOTE: Numbness and some weakness are
expected.)
c. Assess circulation and pressure points on the affected limb.
c. Assess pain rating, presence of side effects and amount of pain
relief every 4 hours while awake or more frequently as appropriate,

Page 4 of 7

using the patient's designated pain rating scale (see UWHC
Hospital Administrative Policy #8.76, Pain Management).
d. Assess site for edema, discoloration, bleeding or hematoma
formation.
e. Monitor for potential complications:
a. Signs and symptoms of local anesthetic toxicity (e.g.,
numbness and tingling in fingers and toes, perioral
numbness and paresthesias, metallic taste in the mouth,
ringing in the ears, lightheadedness and dizziness, nausea,
vomiting, decreased hearing, tremor, blood pressure
changes, increased or decreased heart rate).
b. Respiratory insufficiency secondary to paralysis of
hemidiaphragm (interscalene infusions).
f. Make sure catheter is clearly labeled to avoid confusion with
intravenous lines.
g. Notify the APS (Pager 7246 or P-A-I-N) (Anesthesiologist at
TAC) for any questions or problematic assessments.
h. Document the integrity of the dressing, the site and affected
extremity, and the infusion system with head-to-toe systems
assessments according to UWHC Nursing Patient Care Policy
13.14, Documentation in the Inpatient’s Clinical Record.
7. During the continuous infusion, the APS (Anesthesiologist at TAC) will:
a. Verify continued catheter placement as needed.
b. Order the change of perineural infusion solutions as needed.
c. Remove the catheter. A member of the APS team
(Anesthesiologist at TAC) will provide removal instructions for
patients going home with the catheter.
d. Be responsible for approving all anticoagulant orders when
indicated.
8. Additional analgesics may be ordered by the Acute Pain Service (APS)
(Anesthesiologist at TAC) and may include oral opioids, IV PCA,
intermittent IV injections and other IV and oral analgesics and adjuncts.
a. Syringe bolusing of perineural catheters can only be performed by
a member of the APS (Anesthesiologist at TAC). An order must be
written immediately following the administration of boluses into
the perineural catheter and must clearly indicate "Already given;
Do not administer". APS personnel will administer peripheral
nerve block medications as outlined in the UWHC Department of
Anesthesiology Medication Policy.
b. Change the dressing, if necessary.
9. Notify the APS (Anesthesiologist at TAC) or designated responsible
provider (Anesthesiology staff) for inadequate analgesia.
E. "Hold" on Peripheral Nerve Block (Perineural) Therapy
1. There may be times when the APS (Anesthesiologist at TAC) will write an
order to "hold" the peripheral nerve block infusion with the intention to
either restart the infusion at a later time once side effects have resolved or to
evaluate if a patient can tolerate alternative modes of analgesia before
discontinuing a perineural catheter. Occasionally coagulation abnormalities

Page 5 of 7

or anticoagulant medication administration prevent perineural catheter
removal.
2. If a "hold" has been ordered the following actions are to be taken by the
nurse caring for the patient:
a. Turn the infusion pump "OFF"
b. Do not disconnect tubing
F. Discontinuation of the Peripheral Nerve Block (Perineural) Therapy and Catheter
1. Only the APS (Anesthesiologist at TAC) will discontinue (disconnect and
remove) the peripheral nerve block therapy and catheter.
a. The determination to discontinue a nerve catheter will be made in
consultation with the primary attending service.
b. The patient's coagulation status must be reviewed prior to
perineural catheter removal.
c. After the APS (Anesthesiologist at TAC) has disconnected the
catheter, then the pump, tubing and remaining solution should be
removed from the patient's room to avoid inadvertent
misconnection.
2. The APS (Anesthesiologist at TAC) will:
a. Document complete catheter removal (i.e., perineural catheter
removed, tip intact).
b. Specify which medications are to be continued and which are to be
discontinued, making sure alternative analgesics are ordered and
available to the patient.
3. After removal of the perineural catheter, the RN will:
a. Discard any wasted drug per Hospital Administrative Policy #5.27,
Waste Management.
b. Inspect the catheter site after removal. Notify the APS
(Anesthesiologist at TAC) of any evidence of infection or
bleeding.
c. Provide education. If the patient is to be discharged soon after the
catheter is discontinued, instruct the patient to have a family
member or other support person assess the catheter site as noted
above. Instruct the patient and family to notify the provider if
problems or questions arise concerning the site.
d. Advise primary teams regarding resuming anticoagulant therapy.
G. Outpatient Peripheral Nerve Block Infusions
1. Patients may be discharged with a continuous peripheral nerve block
infusion.
2. The anesthesiologist or a member of the APS (Anesthesiologist at TAC) will
provide teaching to patients and family prior to discharge.
3. The anesthesiologist or a member of the APS (Anesthesiologist at TAC) will
program the home pump prior to the patient’s discharge.
4. A member of the APS (Anesthesiologist at TAC) will call and follow- up
with patient at home.
H. Patient Teaching
1. Patient and family teaching should be coordinated by the Registered Nurse
throughout the patient's hospital admission.
a. Instruct the patient and their significant other regarding the
following:

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i. Notify the nurse if integrity of dressing is not maintained.
ii. Report occurrence of burning at the insertion site,
increasing sensory or motor block, increasing pain, and
difficulty breathing.
iii. Importance of protecting the affected extremity from injury
while sensation is altered.
iv. Report symptoms of systemic local anesthetic toxicity
(described above).
2. Patient and family education tools may include:
a. Health Fact for You 4922, What You Should Know about Pain
Management
b. Health Fact for You 6870, Going Home with an Upper Extremity
Catheter
c. Health Fact for You 7163, Going Home with a Femoral Nerve
Catheter

IV. UWHC/UWSMPH CROSS REFERENCES

A. Department of Anesthesiology Medication Policy (UWSMPH Intranet Site)
B. Health Fact for You 4922, What You Should Know about Pain Management
C. Health Fact for You 6870, Going Home with an Upper Extremity Catheter
D. Health Fact for You 7163, Going Home with a Femoral Nerve Catheter
E. Hospital Administrative Policy 5.27, Waste Management
F. Hospital Administrative Policy 8.33, High Alert Medication Administration
G. Hospital Administrative Policy 8.76, Pain Management
H. Hospital Administrative Policy 8.92, Epidural and Intrathecal (Neuraxial)
Analgesia
I. Nursing Patient Care Policy 13.14, Documentation in the Inpatient’s Clinical
Record
J. Nursing Patient Care Policy 14.33, Nurse-to-Nurse Change-of-Shift Hand-Off
K. Pain Management Resources Website (U-Connect)

V. REFERENCES

A. Axley, M., & Horn, J. (2010). Indications and management of continuous infusion
of local anesthetics at home. Current Opinion in Anesthesiology, 23, 650-655.
B. Bingham AE et al. Continuous Peripheral Nerve Block Compared With Single-
Injection Peripheral Nerve Block – A Systematic Review and Meta-Analysis of
Randomized Controlled Trials. Regional Anesthesia and Pain Medicine 2012;
37(6): 583-594.
C. Capdevila, X., Pirat, P., Bringuier, S., & et al. (2005). Continuous peripheral
nerve blocks in hospital wards after orthopedic surgery: a randomized analysis of
the quality of postoperative analgesia and complications in 1,416 patients.
Anesthesiology, 103(5), 921-923.
D. Hadzic, A. (2011). Hadzic’s peripheral nerve blocks and anatomy for ultrasound-
guided regional anesthesia (New York School of Regional Anesthesia) (2nd Ed.).
New York, NY: McGraw-Hill.
E. Ilfeld, B. M. (2011). Continuous peripheral nerve blocks: a review of the
published evidence. Anesthesia & Analgesia, 113, 904-925.

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F. Richman JM et al. Does continuous peripheral nerve block provide superior pain
control to opioids? A meta-analysis. Anesthesia & Analgesia 2006;102(1):248-57.


VI. REVIEWED BY

Clinical Nurse Specialist, Anesthesia Acute Pain Service (UWSMPH)
Director, Professional Service (TAC)
Professor, Anesthesiology (UWSMPH)
Nursing Patient Care Policy and Procedure Committee, May 2015

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer