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Post‐procedural considerations

Immediate and ongoing care

When caring for a patient receiving regional analgesia, it is important to monitor them for the following at regular intervals (Macintyre and Schug [99]):
  • pain score, functional activity score, sedation score and respiratory rate
  • blood pressure and heart rate
  • motor block: motor function should be assessed and any decreasing motor function should also be noted
  • sensory block: any increasing sensory deficit should be noted as it may reflect the development of complications; however, routine monitoring of sensory block is not required and may not be helpful with a CPNB.

Education of the patient and relevant others

Patients in the ambulatory setting with a CPNB must accept a degree of responsibility for self‐management of the catheter and infusion pump at home as they will not have clinician support 24 hours a day. Patient education needs to start in the pre‐operative setting and extend to and be reinforced in the post‐operative setting.
Instructions must be both verbal and written, and they should include key contact numbers of healthcare professionals who are available around the clock in case problems occur. Patient and family general education should include information on:
  • medical equipment, i.e. patient guidelines on how to manage the infusion system at home
  • observing for drug‐related side‐effects
  • observing for procedure‐related side‐effects
  • what to do if they have pain
  • whom to contact if they have any problems, including details of the pain service and out‐of‐hours contact details
  • when to call for further advice and help and how to clamp the tubing
  • how to use supplemental oral analgesia if they have pain
  • whether the catheter will be removed at home by the patient, at home by the nurse or on return to the hospital.
Additionally, all patients discharged with a CPNB should receive the following general instructions:
  • Do not drive or operate machinery, equipment (including for sports or hunting) or tools for the duration of the block.
  • Protect the operative limb (due to motor loss and loss of feeling) for the duration of the block.
  • Keep the catheter site clean and dry.
  • Observe for warning signs such as infection, haematoma, compartment syndrome and local anaesthetic toxicity.
Table 10.5 outlines the principles of care for a patient receiving a CPNB infusion.
Table 10.5  Care of a patient receiving a continuous peripheral nerve block infusion (CPNB)
Observations and careComments
Observe for the warning signs of:
  • infection
  • haematoma (nerve compression)
  • nerve trauma
  • compartment syndrome
These include:
  • increase in pain or continuous pain
  • fever, chills or sweats
  • bowel or bladder changes
  • difficulty breathing
  • redness, warmth, discharge or excessive bleeding from the catheter site
  • pain, swelling or a large bruise around the catheter site
Observe for signs and symptoms of local anaesthetic systemic toxicityThese include:
  • dizziness or light‐headedness
  • blurred vision
  • ringing or buzzing in the ears
  • metallic taste in the mouth
  • numbness and/or tingling of the fingers or toes, or around the mouth
  • drowsiness
  • confusion
Dressing maintenanceDo not remove the dressing as this may move or remove the catheter. The catheter dressing may be reinforced with a clear occlusive dressing as needed, taking care not to move or remove the catheter.
Monitoring and care of the infusion pump systemThis includes:
  • The infusion pump should be labelled as per the prescription.
  • The infusion pump should be running at the prescribed rate.
  • Check for kinks in the tubing. If the tubing is kinked, massage that area of the tubing to facilitate flow.
  • Troubleshoot any pump alarms.
Other monitoring and careThis includes:
  • assessment of the catheter site
  • assessment of the integrity of the dressing
  • assessment of the sensory, motor and vascular condition of the limb (capillary refill, colour and motor function of the affected extremity will help to differentiate intended block from potential nerve compromise or ischaemic pain)
  • limb positioning (maintain a neutral position)
  • assessment of the skin with attention to the ‘hot spots’: the heel should be free from continuous contact with the pillow or bed
  • patients may have difficulty with weight bearing if the lower limb has been blocked; care should be taken to prevent falls and provide assistance when mobilizing
Patient/family educationThis includes:
  • Ensure the patient or their carer is competent to continue care of the CPNB at home.
  • Provide both written and verbal information; check the patient's understanding of the information provided.
  • Document the information provided.
Peripheral nerve catheter removal (see Procedure guideline 10.2: Peripheral nerve catheter removal and follow local guidelines)
Indications for catheter removal:
  • end of infusion
  • infection
  • failure to control pain
  • catheter leaking
Source: Adapted from Schug et al. [166].
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