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Continuous peripheral nerve block, also known as perineural local anesthetic or PLA, delivers anesthetic medication via a catheter placed underneath the skin adjacent to localized nerves to reduce or eliminate pain. Peripheral nerve block is considered safe and effective regional anesthesia for:
* post-op pain (shoulder, elbow, forearm, wrist, hand, finger, knee, leg, ankle, and foot)
* severe back pain
* neck pain
* intractable wound pain
* posttraumatic neuropathy
* phantom limb pain
* pain associated with severe peripheral vascular disease.
Peripheral nerve block can deliver medication for 3 to 6 days. The healthcare team will customize the length of time and volume of medication based on the patient's diagnosis and individualized pain care needs. However, all pain from the surgical procedure may not be relieved with the use of peripheral nerve block alone. Your patient will most likely need additional oral analgesics, oral anti-inflammatories, or adjunct pain medications to provide complete alleviation of pain.
Advantages of peripheral nerve block include significantly reduced pain after surgery; decreased need for pain medication; less adverse reactions to oral or I.V. pain medication, such as nausea, vomiting, constipation, itching, respiratory depression, and sedation; better rest after surgery; and easier participation in physical therapy.
Recent research has shown that peripheral nerve block was superior to patient-controlled analgesia (PCA) and associated with fewer adverse reactions, such as sedation, nausea, vomiting, constipation, and sensorimotor deficits. The research results also noted that peripheral nerve block utilized in post-op abdominal patients revealed a 94% patient satisfaction rate compared with the 88% patient satisfaction rate of those who had PCA. This 2013 study also revealed that the major complications commonly associated with PCA (sedation and respiratory depression) weren't noted in peripheral nerve block patients.
The peripheral nerve block device usually consists of a locked clear housing box that contains the infusion pump balloon or cartridge, medicine fill ports located at the top of the balloon or cartridge, flow clamps, an air-eliminating filter, a flow rate controller, sterile I.V. tubing with a closed end cap, and a flow rate adjustment key.
The pharmacist, anesthesiologist, or certified registered nurse anesthetist (CRNA) mixes the medication to fill the deflated balloon or balloons. The type of local anesthetic medication selected can greatly impact the length and quality of pain control. There are four medications frequently utilized for peripheral nerve block: lignocaine (2 hours duration of action), prilocaine (4 hours duration of action), bupivacaine (6 hours duration of action), and levobupivacaine (6 hours duration of action). The balloon is filled with the medication by attaching a sterile syringe to the fill port located at the top of the balloon. As the balloon inflates, pressure begins to build, priming the attached tubing with the medication.
The syringe is removed and a sterile closed end cap is attached to the fill port, ensuring the tubing is clamped after priming to prevent unintentional loss or leakage of the medication. The primed tubing is then attached to a sterile catheter that's placed under the patient's skin adjacent to a specific nerve. The sterile catheter is covered with a transparent, occlusive, sterile dressing to reduce the likelihood of infection and prevent the catheter from migrating out of place. As the medication filters down the tubing into the catheter insertion site, the area will grow numb, easing the patient's pain.
The CRNA or anesthesiologist typically utilizes an ultrasound to guide him or her in the correct placement of the catheter. A sterile sleeve should be placed over the ultrasound after the insertion site has been prepped. The American Society of Regional Anesthesia and Pain Medicine recommends antiseptic hand washing, sterile gloves, surgical masks and hats, and the use of alcohol-based chlorhexidine antiseptic solutions during the insertion of a peripheral nerve block catheter to reduce the possibility of infection.
Verify that the balloon is accurately and correctly labeled with the medication's name, dosage, volume, and infusion rate with a second nurse per your healthcare facility's policy. Ensure that the catheter and tubing are securely attached, then select the appropriate rate on the flow rate controller (usually between 1 and 20 mL/hour). Two nurses are often required to check anesthetic medications before replacing any balloon within the peripheral nerve block infusion pump. Many facilities only allow CRNAs or anesthesiologists to replace the medication balloons because of the risk of accidentally infusing a large amount of medication into peripheral tissue.
Monitor the catheter insertion site for signs of localized allergic reaction, such as erythema, edema, or the presence of drainage (see Catheter site care). If any of these signs are present, consult with the healthcare team immediately to consider discontinuing the peripheral nerve block, changing the medication, or adding anti-inflammatory medications or antibiotics to reduce the likelihood of complications. Conduct frequent pain assessments to ensure that the peripheral nerve block is effective. Administer oral or I.V. analgesics as ordered to supplement the peripheral nerve block and obtain a tolerable pain level.
It's imperative to inform the patient that he or she may experience loss of feeling at and around the surgical site. Great care must be taken to minimize the risk of injury during this time of sensory loss to the affected extremity or surgical site.
Although peripheral nerve block can be an effective pain management tool, there are potential risks, including:
* injury due to weakness/numbness
* nerve damage
* drug reaction
* ringing in the ears
* inability to take a deep breath.
According to recent research studies, the risk of permanent nerve injury is reported to be very rare, occurring in the range of 1 in 5,000 to 1 in 10,000 cases. Permanent nerve injury can occur if the anesthetic medication is injected directly into the nerve's intraneural space, the needle penetrates the nerve directly causing traumatic damage, a hematoma develops causing nerve compression and subsequent nerve damage, or the tourniquet that's often applied to the affected limb during catheter insertion results in tourniquet neuropathy. To reduce the likelihood of patient injury, perform frequent head-to-toe clinical assessments and catheter site assessments, monitor continuous ECG rhythms, frequently assess vital signs, and monitor serum coagulation levels before and after catheter placement.
Adverse reactions to local anesthetics utilized in peripheral nerve block aren't uncommon, mostly due to inflammation and localized skin irritation from the infusion of medication into the tissue. Closely monitor the catheter insertion site for signs of a potential localized reaction, such as erythema, swelling, or pain.
Although allergic reactions are uncommon, they can occur. Be alert for contact dermatitis, delayed swelling at the insertion site, and signs and symptoms of anaphylaxis (itching, hives, bronchospasm, and angioedema).
Inform the patient that it's typically necessary to administer sedating medications during peripheral nerve block insertion to minimize the risk of movement and unintentional damage to the nerve. Advise the patient to:
* Protect the affected limb after the procedure because decreased sensation can increase injury risk.
* Observe the catheter insertion site and the extremity for signs of a potential nonallergic or allergic reaction.
* Ensure that the sterile dressing remains intact.
* Avoid showering the affected site because water can loosen the sterile dressing and potentially contaminate the catheter insertion site.
* Ensure that the catheter and tubing are secured during all movement and transfers to prevent catheter dislodgement.
Continuous peripheral nerve block can optimize your patient's healthcare experience and be an effective tool to manage post-op pain. With careful clinical assessments, your patients can begin their healing process while experiencing minimal pain.
* Check the tubing for closed clamps or kinks.
* Make sure there's fluid in the pump.
* Keep the dressing over the catheter site clean and dry; it's normal to have a small amount of clear or pink-colored drainage under the dressing.
* Ensure that the patient doesn't shower or take a tub bath while the catheter is in place; your patient may sponge bathe.
* Monitor for significant changes in the patient's pain level or a change in numbness in the arm, hand, leg, or foot.
* Observe for potential drug reactions, such as rash or itching.
* Monitor for pump leakage, such as wet areas, medication leakage, a rapidly deflated medication balloon, fluid noted within the clear housing box, or fluid pooling underneath the sterile dressing/catheter insertion site.
* Be alert to the following risks:
-redness, tenderness, swelling, or pus-like drainage at the catheter insertion site
-bleeding from the insertion site
-discoloration of the hand, fingers, foot, or toes
-numbness and tingling around the face or mouth; metallic taste in the mouth
-feelings of electrical shock in the affected extremity (this may signal that the catheter has migrated onto the actual nerve)
-numbness or tingling lasting more than 24 hours after the catheter is removed.
When continuous peripheral nerve block is utilized on a lower extremity, the affected extremity should be supported with a brace, an immobilizer, or pillows and treated as nonweight-bearing until there's a return of sensation and motor function. Affected upper extremities should be supported by an orthopedic sling until sensation and motor function return.
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Kainzwaldner V, Rachinger-Adam B, Mioc-Curic T, et al. Quality of postoperative pain therapy: evaluation of an established anesthesiology acute pain service [in German]. Anaesthesist. 2013;62(6):453-459.
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New York School of Regional Anesthesia. Complications of peripheral nerve blocks. http://www.nysora.com/regional_anesthesia/other_topics/3132-compliations_of_regi.
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