intrathecal opioids post anaesthetic care sch · k:\chw p&p\epolicy\2017 epolicy\oct...

$: INTRATHECAL OPIOIDS POST ANAESTHETIC CARE SCH · K:\CHW P&P\ePolicy\2017 ePolicy\Oct 17\Intrathecal Opioids -Post Anaesthetic Care - SCH v2.docx This Policy/Procedure may be varied,$
Policy No: 2017-215 v1 Policy: Intrathecal Opioids: Post-Anaesthetic Care - SCH

This document reflects what is currently regarded as safe practice. However, as in any clinical situation, there may be factors which cannot be covered by a single set of guidelines. This document does not replace the need for the application of clinical judgement to each individual presentation.

Approved by: SCHN Policy Procedure and Guideline Committee Date Effective: 1 November, 2017 Review Period: 3 years Team Leader: Registered Nurse Area/Dept: Pain and Palliative Care

Date of Publishing: 5 October 2018 2:55 PM Date of Printing: Page 1 of 13 K:\CHW P&P\ePolicy\2017 ePolicy\Oct 17\Intrathecal Opioids - Post Anaesthetic Care - SCH v2.docx This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory.

INTRATHECAL OPIOIDS: POST-ANAESTHETIC CARE - SCH

POLICY©

DOCUMENT SUMMARY/KEY POINTS

o Intrathecal Opioid administration must be documented on the Anaesthesia and Recovery Room Record and National Inpatient Medication Chart (NIMC)

o An alert sticker must be applied to the patient’s Anaesthesia and Recovery Room Record and National Inpatient Medication Chart (NIMC). If more than one chart is in use a sticker must be applied to each chart.

o Patients receiving Intrathecal Opioid must be monitored with continuous Pulse Oximetry with hourly observations recorded for 24 hours after administration

o Naloxone must be prescribed and available in the clinical area

o The patient receiving Intrathecal Opioid must remain an inpatient for at least 24 hours post-dose.

o Clinicians must observe for rare but potentially catastrophic complications of Intrathecal Opioids including neurological damage due to spinal cord compression from haematoma (early) or abscess (late)

o Caution should be taken with additional opioids or sedatives due to the risk of respiratory depression. Additional opioids or sedatives must be prescribed by the Pain Management Service or Anaesthetic Registrar after consultation with the Anaesthetic Consultant

o Key words: Single-shot; Intrathecal; Epidural; Caudal; Opioid; Analgesia


This document reflects what is currently regarded as safe practice. However, as in any clinical situation, there may be factors which cannot be covered by a single set of guidelines. This document does not replace the need for the application of clinical judgement to each individual presentation.

Approved by: SCHN Policy Procedure and Guideline Committee Date Effective: 1 November, 2017 Review Period: 3 years Team Leader: Registered Nurse Area/Dept: Pain and Palliative Care


CHANGE SUMMARY Not applicable. This is a new SCH document

READ ACKNOWLEDGEMENT

• This document should be read by all clinical staff providing care for a patient receiving Intrathecal Opioid at Sydney Children’s Hospital (SCH)

• Required training/education: SCH nursing staff caring for a child receiving Intrathecal Opioid must have also read:

o Practice Guideline: Opioid Management – SCH http://webapps.schn.health.nsw.gov.au/epolicy/policy/3101

http://webapps.schn.health.nsw.gov.au/epolicy/policy/3101



TABLE OF CONTENTS 1 Purpose and Scope .................................................................................................. 4 2 Definitions ................................................................................................................. 4 3 Administration .......................................................................................................... 5 3.1 Documentation and Handover .................................................................................... 5

Figure 2: Alert Sticker locations and prescribing examples ............................................... 6 4. Monitoring ................................................................................................................ 9 5. Management of Complications ..............................................................................10 5.1 Complications of Intrathecal Administration ...............................................................10 5.2 Opioid-related side effects .........................................................................................10

Figure 3 – Management of opioid-related side effects ......................................................11 6. References/Bibliography .........................................................................................12 APPENDIX ...........................................................................................................................13 Bromage Scale As Appears On Multi-Modal Analgesia Record ............................................13



1 Purpose and Scope

• The purpose of this document is to provide guidelines for patient safety and quality clinical care for the child receiving Intrathecal Opioid for post-operative analgesia.

• The aim is to minimise the incidence and severity of adverse events related to the administration of Intrathecal Opioid and provide a guideline of how to manage any adverse events that may occur

• This document describes the procedure for care of a patient who has received Intrathecal opioids intra-operatively, specifically Morphine which has up to 24 hours action post-injection. Fentanyl may be given intrathecally intra-operatively but has a much shorter duration of action so the following may not apply.

• SCH nursing staff caring for a child receiving Intrathecal Opioid must have also read:

o Practice Guideline: Opioid Management – SCH http://webapps.schn.health.nsw.gov.au/epolicy/policy/3101

2 Definitions

Term Definitions

Intrathecal (Spinal) analgesia

Administration of a small, single bolus of local anaesthetic +/- an opioid drug into the intrathecal space and into the cerebrospinal fluid (CSF) with the intention of providing a diffuse sensory blockade to pain without hindering motor function.

Single-shot Epidural / Caudal analgesia

Single shot neuraxial analgesic techniques also include administration of local anaesthetic +/- opioid or adjuvant drugs into the epidural or caudal epidural space.

Delayed Respiratory Depression

Respiratory depression occurring 6-24 hours after administration. A rare but clinically significant complication following intrathecal opioid administration, this is especially so when hydrophilic drugs (e.g. morphine or HYDROmorphone) are used.

Motor Weakness

Loss of muscle strength. Bromage Score is the tool to test motor weakness. A Bromage Score of <3 persisting beyond 6 hours after administration requires immediate clinical review.

Rostral spread of opioid

Distribution of an opioid within the cerebrospinal fluid during epidural/intrathecal administration; spread is determined by fat and water solubility properties of the opioid; spread is to the superior part of the spinal cord and anterior or ventral part of the brain.




3 Administration

• Intrathecal Opioid must be administered by a paediatric anaesthetic consultant or an anaesthetic trainee under direct supervision of a paediatric anaesthetic consultant.

• Intrathecal Opioids are administered for a variety of surgical indications and are done so at the discretion of the Anaesthetic Consultant.

• Only preservative free products are to be used. • Intrathecal Opioid must be documented on the Anaesthetic Chart • Naloxone must be prescribed on the National Inpatient Medication Chart (NIMC) and

be available in the clinical area

3.1 Documentation and Handover • Intrathecal Opioid administration must be documented on the Anaesthesia and

Recovery Record and paediatric NIMC, including time of administration • Anaesthetists must:

o Notify the Post-Anaesthetic Care Unit (PACU) nurse that the patient has received Intrathecal Opioid

o Within working hours - inform the Acute Pain Service CNC (Pager #44612) about the patient to ensure follow-up.

o Out of working hours - inform the on-call Anaethetics Registrar

o Apply an alert sticker to the front and back of the patients NIMC (i.e. the once only medication section and the PRN section). If more than one chart is in use a sticker must be applied to each NIMC. If Patient-Controlled Analgesia (PCA) is prescribed, a sticker must be applied to the prescription chart. See Figure 1 for sticker locations.

o Prescribe on the NIMC:

Naloxone for reversal – for dosing, refer to Figure 2 – Management of opioid-related side effects

Additional analgesia, with consideration of patients’ individual risk factors (medications, comorbidities etc)

Antiemetics

NOTE:

Caution should be taken with additional opioids or sedatives due to the risk of respiratory depression. Additional opioids or sedatives must only be prescribed by the Pain Management Service or Anaesthetic Registrar after consultation with the Anaesthetic Consultant. The use of continuous intravenous opioid infusions or controlled-release oral opioids is not recommended for the first 24 hours after administration

Within the Paediatric Intensive Care Unit, additional opioids and sedatives may be prescribed by the Intensivists

o It is the responsibility of the Anaesthetist and Anaesthetic Nurse to ensure the alert sticker has been applied to all medication charts and Multimodal Analgesia Infusion Record (as per Figure 2)



• Patients receiving Intrathecal Opioid may be transferred to the allocated ward once PACU discharge criteria are met

o Refer to Clinical Guideline: Post Operative Care in Post-Anaesthetic Care Unit (PACU) – SCH http://webapps.schn.health.nsw.gov.au/epolicy/policy/3464

• The PACU nurse must: o Notify the receiving ward nurse that the patient has received Intrathecal

Opioid. Subsequent shift handovers must include this information o Ensure the patient has been added to the Acute Pain Service Ward Rounds

List • The ward nurse must ensure the patient is not discharged within 24 hours of receiving

Intrathecal Opioid

Figure 2: Alert Sticker locations and prescribing examples

Anaesthesia and Recovery Room Record




NIMC Once Only Section

NIMC PRN Section



Patient-Controlled Analgesia Prescription



Multi-Modal Analgesia Infusion Record

4. Monitoring

• Patients receiving Intrathecal Opioid must be monitored on continuous pulse oximetry with hourly observations of respiratory rate, SpO2, pulse and sedation score recorded on the Standard Paediatric Observation Chart (SPOC) for 24 hours after administration

• Sedation score must be recorded hourly on the SPOC, using University of Michigan Sedation Score (UMSS). If sedation score >1 activate escalation as outlined in Section 5.2, Figure 2 – Management of opioid-related side effects

• Temperature must be recorded on the SPOC 4-hourly as routine. If temperature exceeds 38.5°C, activate escalation as outlined in Section 5.1 Complications of Intrathecal Administration and continue to monitor hourly until temperature returns to normal parameters



• Motor block scores (Modified Bromage Scale) must be recorded on the Multimodal Analgesia Infusion Record form. Motor block score should be recorded once in PACU and then hourly until 6 hours post-injection and motor score returns to expected level of function. Thereafter scores may be recorded 4-hourly. If motor block persists beyond 6 hours after injection, follow escalation as outlined in Section 5.1 Complications of Intrathecal Administration

o Bromage Scale guidance appears on reverse of Multi-modal Analgesia Infusion Record: See APPENDIX

• Pain scores should be recorded hourly for 24 hours after administration. If analgesia is inadequate, follow action as outlined in Figure 2 – Management of opioid-related side effects

• Patients must be monitored for altered bowel and bladder control/sensation, back pain, numbness or tingling) or weakness in lower limbs. See Section 5.1 Complications of Intrathecal Administration

•

5. Management of Complications

5.1 Complications of Intrathecal Administration ALERT Rare but potentially catastrophic complications of Intrathecal Opioids include neurological damage due to spinal cord compression from haematoma (early) or abscess (late). Clinicians must observe for:

• Motor block persisting beyond 6 hours of administration o Motor Block Score (Modified Bromage Scale)

If score <3 : Call for BTF Clinical Review If score ≥3: Monitor routinely as per Section 4

• Change in sensation (numbness or tingling) or weakness in lower limbs • Fever (temperature above 38.5°C) • Back pain • Altered bowel and bladder control/sensation

Action – Activate Rapid Response as per SPOC. The treating team should then urgently contact the Anaesthetist or Acute Pain Service

5.2 Opioid-related side effects • The information in Figure 2 is in addition to and complements SPOC criteria, with

specific reference to patients receiving Intrathecal Opioid • The escalation criteria as laid out on SPOC has priority in all situations • If the patient is receiving Opioid PCA, see also:

o Practice Guideline: Opioid Management – SCH




Figure 3 – Management of opioid-related side effects

ADVERSE EFFECT ACTION

Over-sedation

Increasing loss of consciousness develops gradually with opioid overdose and may provide earlier warning of impending overdose than the respiratory rate.

Sedation Score should aim for score to be equal to or less than 1 on the UMSS as per Paediatric Multimodal Pain Observation Chart (MPC)

If sedation score is in the BLUE zone of the MPC

Continue to monitor patient regularly If sedation scores in YELLOW or RED zone of the MPC

Follow local procedures as per SPOC AND:

Utilise basic airway management and support techniques

Consider naloxone for over sedation when respiratory compromise is present – see dosing below

Respiratory Depression

A fall in respiratory rate is a late sign of respiratory depression. Strict hourly monitoring of patient as per protocol is essential to detect this sign of respiratory depression.

If respiratory rate is in the YELLOW zone on SPOC

Activate Rapid Response as per SPOC Utilise basic airway management and

support techniques If respiratory rate is in RED zone on SPOC

Give oxygen by mask and supported ventilation if required

Activate Rapid Response as per SPOC Consider IV naloxone 5 micrograms/

kg/dose (up to 100microg/dose) to a maximum of 4 doses (as prescribed on the NIMC)

Nausea

Nausea and or vomiting can be a side effect of opioids; this is a sensitivity and is NOT an allergy. This should resolve 24 hours after Intrathecal Opioid dose

Administer antiemetics as prescribed on the NIMC If symptoms persist

In hours: contact Acute Pain Service Out of hours: call for a clinical

review/Anaesthetic Registrar on-call

Pruritus6, 7

A common side effect of intrathecal opioid administration, the mechanism for which is unclear. Pruritus it is NOT an allergy. This should resolve 24 hours after Intrathecal Opioid dose

Administer Naloxone 0.5mcg/kg/dose, IV 15-minutely PRN x 3 Antihistamines may be considered. Only non-sedating antihistamines (e.g. loratadine) should be used. Avoid sedating agents such as promethazine

Inadequate analgesia

If Pain score is in the YELLOW zone on the MPC (follow criteria on SPOC) Ensure regular and breakthrough analgesia is given as prescribed For escalation: In-hours: contact Acute Pain Service Out-of-hours: call for clinical review by the admitting team

• Admitting team should liaise with the Anaesthetic Registrar on-call



6. References/Bibliography

1. Children’s Health Queensland Hospital and Health Service (2016) Procedure: Intrathecal Opioids 2. Mariano, E.R (2017) Management of acute perioperative pain. UpToDate. Waltham, MA: UpToDate Inc.

https://www.uptodate.com.acs.hcn.com.au/contents/management-of-acute-perioperative-pain?source=search_result&search=Intrathecal%20opioids&selectedTitle=1~150#H795594971 (Accessed on 30/8/2017)

3. Prince of Wales Hospital and Community Health Services (2016) Clinical Business Rule: Intrathecal morphine, management of patients receiving a SINGLE dose for post-operative analgesia

4. Tsui,BC & Berde,CB. (2005). Caudal analgesia and anesthesia techniques in children. Current opinion in anaesthesiology, 18(3), 283-8

5. Walker,SM & Yaksh,TL. (2012). Intrathecal analgesia in neonates and infants: a review of clinical and preclinical strategies for the development of safety and efficacy data. Anesthesia and analgesia, 115(3), 638-62

6. Grant, G. J. (2017) Adverse effects of neuraxial analgesia and anesthesia for obstetrics UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com.acs.hcn.com.au/contents/adverse-effects-of-neuraxial-analgesia-and-anesthesia-for-obstetrics?source=see_link&sectionName=PRURITUS&anchor=H10#H10 (Accessed on 30/8/2017)

7. Portenoy, R. K., Mehta, Z. and E. Ahmed (2017) Prevention and management of side effects in patients receiving opioids for chronic pain. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com.acs.hcn.com.au/contents/prevention-and-management-of-side-effects-in-patients-receiving-opioids-for-chronic-pain?source=machineLearning&search=opioid%20pruritus&selectedTitle=2~150&sectionRank=2&anchor=H17#H17 (Accessed on 31/8/2017)

Copyright notice and disclaimer:

The use of this document outside Sydney Children's Hospitals Network (SCHN), or its reproduction in whole or in part, is subject to acknowledgement that it is the property of SCHN. SCHN has done everything practicable to make this document accurate, up-to-date and in accordance with accepted legislation and standards at the date of publication. SCHN is not responsible for consequences arising from the use of this document outside SCHN. A current version of this document is only available electronically from the Hospitals. If this document is printed, it is only valid to the date of printing.

https://www.uptodate.com.acs.hcn.com.au/contents/management-of-acute-perioperative-pain?source=search_result&search=Intrathecal%20opioids&selectedTitle=1%7E150%23H795594971%20

https://www.uptodate.com.acs.hcn.com.au/contents/management-of-acute-perioperative-pain?source=search_result&search=Intrathecal%20opioids&selectedTitle=1%7E150%23H795594971%20

https://www.uptodate.com.acs.hcn.com.au/contents/adverse-effects-of-neuraxial-analgesia-and-anesthesia-for-obstetrics?source=see_link&sectionName=PRURITUS&anchor=H10#H10



https://www.uptodate.com.acs.hcn.com.au/contents/prevention-and-management-of-side-effects-in-patients-receiving-opioids-for-chronic-pain/contributors



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APPENDIX

Bromage Scale As Appears On Multi-Modal Analgesia Record

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