Local anaesthetic infusion (Paediatric Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Audience

  • Highland HSCP
  • Secondary Care only:
    • Children’s ward, SHDU, ITU, Theatre and recovery areas
  • Paediatric only

Nerve and local anaesthetic infusions are used for post-operative analgesia for the following surgery:

  • Lower limb surgery
  • Upper limb surgery
  • Wound infiltration

ONLY 5mL/hr pumps should be used in paediatric patients.

  • Child MUST weigh more than 15kg
  • All LA infusions MUST be delivered via the local anaesthetic pump, which is a single use device.
  • The local anaesthetic pump MUST be filled in theatre under aseptic conditions i.e. gown, mask, and gloves.
  • The pump MUST NOT be re-filled under any circumstances.
  • The pump may be filled by anaesthetists, the acute pain nurse or by anaesthetic assistants who have received training in the filling of the local anaesthetic pump.
  • The system circuit MUST NOT be broken unless the local anaesthetic pump has been disconnected for emergency reasons.

The surgical team should be called for all routine surgical problems:

  • Nausea and vomiting
  • Hypotension
  • Sedation and respiratory problems
  • Urinary retention

For further advice, surgical medical staff may contact the Acute Pain Nurse (Bleep 1003). If not available, the On call / duty anaesthetist.

Acute Pain Nurse, on-call/duty anaesthetist or the responsible Consultant Anaesthetist MUST be contacted for inadequate analgesia or early signs of local anaesthetic toxicity including:

  • Flushed face
  • Numbness or tingling of lips or tongue
  • Tinnitius
  • Light headedness
  • Drowsiness
  • Twitching

Please clamp off the pump if such symptoms / signs arise.

Nursing management

  • All registered nurses caring for a child with a local anaesthetic infusion must have received training in the management of continuous local anaesthetic infusion and the local anaesthetic pump.
  • Routine post-op care should be given, unless instructed to do otherwise by the anaesthetist.
  • Pain, nausea, sedation, motor block (lower limb only) and signs of toxicity observations should be carried out:
    • Recovery: Every 15 minutes
    • On ward: Hourly for 4 hours
    • 2 hourly thereafter
  • The local anaesthetic pump and local anaesthetic catheter exit site must be checked 2 hourly for disconnections, leakage or signs of infection.
  • If you are concerned that the local anaesthetic pump may not be infusing, please contact the Acute Pain Nurse or the on-call/Duty anaesthetist.
  • The system circuit MUST NOT be broken at any time, unless the child is developing signs of local anaesthetic toxicity.
  • Ensure a patent IV cannula whilst the local anaesthetic infusion is in progress.
  • Administer prescribed regular and breakthrough oral analgesia.
  • Children with lower limb local anaesthetic nerve blocks MUST have support when mobilising.

Treatment of acute problems

1. Inadequate Analgesia

If the pain score is greater than 4 for more than one set of observations do the following:

  • Ensure that regular oral / rectal analgesia has been prescribed and administered.
  • Use breakthrough opioid / simple analgesic as able
  • Ensure that the pump is connected and the clamp is open.
  • Consider reasons for any increase in the pain e.g. surgical complications and ask for surgical review.
  • Contact the Acute Pain Nurse, the responsible anaesthetist or the On-Call / Duty anaesthetist for advice.

2. Hypotension

  • Hypotension is not usually due to the local anaesthetic block but may be caused by bleeding, sepsis, anaphylaxis, myocardial insufficiency or hypoxia. The cause should be identified and managed. If LA toxicity is questioned see management outlined below.

3. Mobility

  • Mobilise with support at all times. Children with lower limb local anaesthetic infusions may have leg weakness and be unable to weight bear.
  • Children with lower limb motor block MUST be assessed as “high risk” for pressure sores.

4. Signs of LA toxicity

Early signs and symptoms include :

  • Tinnitus
  • Flushed face
  • Lightheaded
  • Slurred speech
  • Muscle twitching

Late signs and symptoms include:

  • Profound hypotension
  • Bradycardia or ventricular arrhythmias
  • Seizures
  • Drowsiness
  • Coma
  • Respiratory / cardiac arrest

If any of the above signs and symptoms:

  • Clamp the local anaesthetic pump.
  • Contact Medical staff and the On-Call / Duty Anaesthetic urgently.
  • CALL 2222 AND INITIATE CPR PROCEDURES IF THE CHILD IS APNOEIC.
  • Obtain lipid rescue bag (ClinOleic 20%) stored in pharmacy cupboard, theatre corridor (bleep 1089 for access) and labour suite.

Removal of local anaesthetic catheter

  • Explain the procedure to the child and parent / carer.
  • An aseptic technique MUST be used throughout the procedure.
  • Wash hands thoroughly before starting the procedure.
  • Remove the dressing and wash hands again.
  • Clean the area around the catheter insertion site.
  • Using sterile gloves, place a sterile swab to the skin at the catheter insertion site.
  • With another swab, hold the catheter and gently pull to remove it.
  • Once the catheter has been removed, cover the site with an airstrip plaster and settle the child in a comfortable position.
  • Check catheter tip to confirm that it is intact.

Editorial Information

Last reviewed: 19/07/2024

Next review date: 30/09/2027

Author(s): Acute Pain Team.

Version: 2.1

Approved By: TAM Subgroup of ADTC

Reviewer name(s): C Wright, Acute Pain Nurse Specialist., L Reid, Nurse Specialist, Anaesthetics.

Document Id: TAM324