1. Continuous Nerve Block Infusions: Use in Children and Adolescents in Both Inpatient or Outpatient Settings Kelley Windsor, PCNS-BC Lane Faughnan, RN

2. 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

3. OUR EXPERIENCE, 2005-2011

4. 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

5. 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

6. Our experience 2005-2011: Patient diagnoses % of 248 catheters placed; patients may have had simultaneous or recurrent catheters

7. Incidence and duration of CPNB by Indication: Surgical vs Non-surgical Block indicationSurgicalNon-surgical Patients14114 Catheters (%)226 (91.1)22 (8.9%) Catheter-days1337439 Infections (% catheters)4 (1.8)2 (9.1) Duration mean (days)5.920 Duration median (days)513.5 Duration range (days)1-295-81

8. 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

9. Our experience 2005-2011: Block sites

10. 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

11. Neuroanatomy: lower extremity Editors: Chelly, Jacques E. Title: Peripheral Nerve Blocks: A Color Atlas, 3rd Edition Copyright ©2009 Lippincott Williams & Wilkins

12. Brachial Plexus after forequarter amputation

13. 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

14. 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

15. Fall 2009 Winter 2009 Spring 2010 Summer 2010 Fall 2010 Winter 2010 Spring 2011 Summer 2011 Fall 2011 Winter 2011 Spring 2012 Silver dressing Included in CPNB kit No silver dressing included Silver dressing Included 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

16. NURSING IMPLICATIONS: INPATIENT AND OUTPATIENT MANAGEMENT

17. 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

18. 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.

19. 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)

20. 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

23. STRATEGIES TO PREVENT AND MANAGE COMPLICATIONS OF CPNB: PATIENT CARE

24. 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

25. 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

26. 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

27. 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

28. STRATEGIES TO PREVENT AND MANAGE COMPLICATIONS OF CPNB: QUALITY IMPROVEMENT

29. 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

30. Improvement Goals: Nursing Education Pain Pointers Epidural/Nerve Block Calculator Improve use of current pt/family education materials

31. Improvement Goals: Nursing Education Epidural/Nerve Block Calculator (online)

32. 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

33. 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

34. Number of blocks and number of infections, by year

35. Summary of 6 infections Primary diagnosis Age (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 removal ANC range during block Osteo- sarcoma (OS) 18.3 Primary limb- sparing surgery Sciatic10 Day 0: Before and after catheter insertion Days 1 – 8: daily (ceftriaxone, cefuroxime, gentamicin, vancomycin) 4100-14,600 Femoral3/10Erythema around catheter site (Day 10)Unknown OS18 Primary limb- sparing surgery Femoral8 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 Sciatic8 OS18 Pathological fracture Femoral0/13 Day 0: after catheter insertion Induration and coagulase-negative staphylococci on catheter tip (Day 13) 37.5°C8700-37,200 OS10 Pathological fracture Femoral10 Day 0: Clinda on day 0, Days 1-14: daily (vanc, clinda, mero, etc) redness, fever, pain at site (started 5/13) 39.3 100 – 38,500 Sciatic14 site painful (started 5/18), report of fever 37.9 OS17 Primary limb- sparing surgery Femoral2/11 Cef/Vanc day 0 and 1 only Unknown4400-8600 Sciatic2/11 OS21 Limb sparing revision Femoral6 Cef/Vanc day 0 only cellulitis of entry site site at routine visit; d/c cath; culture of tip which grew coag neg staph 37.96900-9500

36. 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)

37. Risk/Benefit of Regional Analgesia for End of Life Pain Management Case Device type ANC (x10 3 /L) Platelet count (x10 6 /L) Other contraindications 1E5300283T12 fracture, spinal metastases, fever 2NB8300362 3.1NB630039 Spinal metastases 3.2End94 3.3E460026 4E210084 5E4100123 6NB130089Large wound in targeted area 7.1E6300477 7.2E22300488 8E580020Fever 9E5400241 10.1E450076 (trx) 10.2E4800106 (trx) E=epidural; NB=nerve block; ANC=absolute neutrophil count; nd=not done; trx=value after transfusion(s) Anghelescu et al, 2010

38. CASE STUDIES

39. DISCUSSION / QUESTIONS

40. 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.