Local anaesthetic infusion (Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Audience

  • Argyll & Bute HSCP and Highland HSCP
  • Secondary Care
  • Routine post-op care should be given, unless instructed to do otherwise by the Anaesthetist.
  • On return from theatre, please check infusion rate against the prescription, ensure clamp is open and flow rate restrictor is secured to patients skin.
  • Pain, nausea, sedation, motor block and signs of toxicity observations must be carried out:
    • Recovery: every 15 minutes
    • On Ward: hourly for 4 hours
    • 4 hourly thereafter
  • Also check the pump and the local anaesthetic catheter for disconnections every 4 hours.
  • Ensure a patent IV cannula is in situ whilst the local anaesthetic is in progress, in case lipid rescue is required.
  • Administer the prescribed regular and breakthrough oral analgesia as normal.
  • Patients with a brachial plexus block should have their arm secured in a sling.
  • Patients with continuous intrascalene blocks should have 4 hourly respiratory rate and oxygen saturations. They may require continuous oxygen due to potential spread to phrenic nerve causing temporary hemidiaphram paralysis.

If there are any concerns regarding the wound infusion device please contact the Acute Pain Nurse or ITU Anaesthetist.

Local anaesthetic toxicity

Local anaesthetic toxicity is rare but life-threatening. Most deaths from local anaesthetic toxicity have been due to the inadvertent intravenous injection of a toxic dose of local anaesthetic.  Rapid recognition and appropriate treatment saves lives.

Early signs and symptoms  Late signs and symptoms
tinnitus  tonic-clonic convulsions 
flushed face  drowsiness 
circum-oral numbness  coma 
lightheadedness  respiratory arrest 
slurred speech  profound hypotension 
hypotension  bradycardia 
muscle twitching  ventricular arrhythmias 
  cadiac arrest - compounded by hypoxia 

Please monitor pain and nausea score and look for signs of toxicity as follows:

  • In Recovery: Every 15 mins
  • On Ward: Pain, nausea, sedation and signs of toxicity should be performed hourly for 4 hours,
  • then 4 hourly if the patient remains stable.

Pain, nausea and sedation to be recorded on NEWs chart.

Signs of toxicity and system check to be recorded on local anaesthetic chart.

  • Only the dedicated local anaesthetic pump may be used.
  • Routine post operative care should be given, unless instructed to do otherwise by the Anaesthetist.
  • Patients with a brachial plexus block should have their arm secured in a sling.
  • Ensure a patent IV cannula is in situ, whilst the local Anaesthetic Infusion is in progress.

If any of the signs and symptoms of local anaesthestic toxicity are present:

  • Clamp the wound infusion device line.
  • Contact the ITU Anaesthetist urgently
  • Administer Oxygen 10 L/minute via facemask if O2 Sats < 95%.
  • Call for help and initiate CPR procedures if the patient is apnoeic. Call 2222.
  • Obtain Lipid rescue bags: ClinOleic 20%, stored in surgical HDU, pharmacy cupboard, theatre corridor (bleep 1089 for access) and labour suite and commence as soon as possible.

Treatment of local anaesthetic toxicity is likely to have a good outcome if toxicity is recognised and basic resuscitation is started early. The basic tenets of treatment are:

  • prevent hypoxia which will cause brain damage and make fitting or arrhythmias more difficult to control
  • treat hypotension and arrhythmias early
  • ensure that fits are adequately treated
  • most reactions are short-lived if the above advice is followed.
  • Lipid rescue bags: ClinoOleic 20% stored in SDHU cupboard, pharmacy cupboard, theatre corridor (bleep 1089 for access) and labour suite

Editorial Information

Last reviewed: 31/10/2022

Next review date: 31/10/2025

Author(s): Acute Pain Team.

Version: 1

Approved By: TAMSG of the ADTC

Reviewer name(s): Louise Reid, Clinical Nurse Specialist, Claire Wright Acute Pain Nurse Specialist .

Document Id: TAM109

References

Self-management information