1. Peripheral Nerve Infusion Chart – adult Education Slide Presentation A presentation prepared by the Pain Interest Group Nursing Issues in association with the Agency of Clinical Innovation Pain Management Network Please direct comments to: April 11, 2016 Emily Edmonds Coordinator State Pain Forms Pain Interest Group Nursing Issues CNC Acute Pain Service Blacktown Hospital Phone: 9881 7649 Email: emily.edmonds@health.nsw.gov.au emily.edmonds@health.nsw.gov.au Jenni Johnson Manager Pain Management Network Agency for Clinical Innovation (ACI) Phone: 9464 4636 Email: jenni.johnsons@aci.health.nsw.gov.au jenni.johnsons@aci.health.nsw.gov.au OR

2. Peripheral Nerve Infusion Chart - adult The Peripheral Nerve Infusion prescription and observation chart for adult patients has been developed by a team of experts in the field of acute pain including clinical nurse consultants, anaesthetists and pharmacy representatives. The Peripheral Nerve Infusion chart – adult, is not suitable for paediatric patients. Standardisation of this chart promotes best practice in prescribing, pain assessment and management of adverse effects in those patients receiving local anaesthetic via an infusion modality. 2

3. Aim of this presentation: This presentation aims to explain  how to use the chart for prescribing local anaesthetic for a peripheral nerve infusion  how to record the administration of local anaesthetic drugs used for a peripheral nerve infusion  how to complete the clinical observations  guidelines on the management of patients receiving a peripheral nerve infusion including the management of adverse effects 3

4. Peripheral Nerve Infusion Chart - adult 4 Page 2 Page 1 Page 2 Prescription, programs, Cessation of regional infusion Page 1 Management guidelines Local anaesthetic toxicity Page 3 Catheter insertion details Local anaesthetic administration, removal of catheter(s) Page 3

5. Peripheral Nerve Infusion Chart - adult 5 Observation pages: for up to 4 days

6. 6 For detailed information regarding the management of Continuous Peripheral Nerve Infusions, refer to local hospital policy or procedure Yellow and Red Zone Response guidance for local anaesthetic toxicity

7. Prescription page: 7 Page 2 Program prescription options: Continuous infusion Rescue bolus dose PCRA (Patient Controlled Regional Analgesia) PIB (Programmed Intermittent Bolus) Patient label and allergy adverse reactions Private patients: pain specialist referral, name and signature of the doctor making the referral Type of block and local anaesthetic prescription Cease regional infusion instructions

8. Peripheral nerve infusion prescription: 8 SMITH 3/3/15 PSmith Prescriber to complete patient allergy and ADR section in full Handwrite patient details OR affix patient label (First prescriber to check patient label is correct) PRIVATE PATIENTS: A pain specialist referral from the referring doctor (name), signature and date

9. Local anaesthetic prescription: 9 Peripheral nerve infusion prescription to include: Type of block, local anaesthetic and total volume Space provided for pharmacist reconciliation Prescriber’s signature, printed name and contact Left fascia iliaca NIL Ropivacaine 0.2 % NIL 15/4/16 TSmith SMITH 7511 100 mL Below is an EXAMPLE prescription Refer to hospital policy for local guidelines on prescribing local anaesthetic for peripheral nerve infusions

10. Program options: 10 2  Below is an EXAMPLE of a CONTINUOUS INFUSION program and a RESCUE BOLUS DOSE for administration by a registered nurse Refer to hospital Peripheral Nerve Infusion policy for local guidelines on peripheral nerve infusion program prescribing 5 mL 5  10  2 - TSmith SMITH 15/04/16 TSmith SMITH 7511 5

11. Program options: 11 Below is an EXAMPLE for a PCRA (Patient Controlled Regional Analgesia program) Refer to hospital policy for local guidelines on Peripheral Nerve Infusion program prescribing 5 8 5 mL 5mL 30 mins TSmith SMITH 

12. Catheter insertion details: 12 10:3015/4/16 THall SRose Page 3 Catheter insertion information If a catheter was placed during surgery, insertion details may be recorded on the operation or anaesthetic record Local anaesthetic infusion commenced

13. Removal of regional catheter(s): 13 5/10/15 10:00 SRose SRose ROSE

14. 14 The Peripheral Nerve Infusion chart provides observations for a maximum of 4 days. If the infusion continues beyond 4 days, a new chart must be started and a new prescription written. Observation pages:

15. 15 Observations: Pain score Infusion delivery: Infusion rate, PCRA dose or PIB dose Rescue bolus dose administered Infused total cumulative Two initials for administration of rescue bolus dose Pump program settings checked Catheter site check Lower limb assessment Sensory dermatome assessment (if applicable)

16. Documenting observations: Pain Assessment: ‘R’ for rest ‘M’ for movement 16 RR RR R MMR M M 1100 1200 1300 1500 1400 15/4/16

17. 17 Observations: Lower limb assessment Sensory dermatome assessment: only if applicable 5 5 5 7 7 7 7 7 7 5 ES SH ES LR LR LR LR LR TS ES TS Pump program settings check Catheter site(s) check Infusion delivery

18. 18 Management Guidelines:

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20. The standardisation of this chart promotes best practice in prescribing, pain assessment and management of adverse effects in those patients receiving a peripheral nerve infusion Comments or questions can be directed to your implementation officer or the project leaders Emily Edmonds or Jenni Johnson (for contact details see introduction slide) The feedback register can be located on the ACI website: http://www.aci.health.nsw.gov.au/networks/pain-management/acute-pain-forms 20