SIR CHARLES GAIRDNER HOSPITAL - Charlie's ED

APS Pocket Guide January 2021 Page 1 of 44

SIR CHARLES GAIRDNER HOSPITAL

ACUTE PAIN POCKET GUIDE Last Updated: January 2021

Dr Brien Hennessy and Jill Kemp

Also available in PDF format – contact Sharon or Hilda.

Table of Contents

OVERVIEW: SCGH ACUTE PAIN SERVICE ................................................................................. 3 APS Staff ...................................................................................................................................................................................... 3 APS patients .............................................................................................................................................................................. 3 APS resources ........................................................................................................................................................................... 4 Registrar and Fellow attachments ................................................................................................................................... 4

ANZCA Pain Medicine Clinical Fundamental .................................................................................................................. 5 SCGH APS objectives for After Hours work ...................................................................................................................... 5 Examples of other areas that may be covered during the pain attachment ................................................... 6

APS ward rounds and in-hours medical cover ........................................................................................................... 7 In-hours medical cover ............................................................................................................................................................. 7 APS patient list .............................................................................................................................................................................. 7

Saturday Pain Round ............................................................................................................................................................. 8 On-call registrar APS cover ................................................................................................................................................. 8

After-hours assistance ............................................................................................................................................................... 8

ACUTE PAIN MANAGEMENT PLANNING ................................................................................ 9 Routine postoperative orders............................................................................................................................................ 9 Taking ownership of analgesia prescribing for peri-operative patients…………………………………..……..11 Opioid tolerant patients ................................................................................................................................................... .12 Liver Transplant patients ................................................................................................................................................ .12

STARTING APS TREATMENTS ............................................................................................... 13 Starting treatment: in theatre and PACU ................................................................................................................... 13 Starting treatment: in the ward ..................................................................................................................................... 13

CEASING APS TREATMENTS ................................................................................................. 14 Ceasing epidurals and regionals .................................................................................................................................... 14 Cessation as a ‘trial’ ............................................................................................................................................................. 14 Ceasing PCA and NCA ......................................................................................................................................................... 15

APS PROTOCOLS ................................................................................................................. 16 Patient-Controlled Intravenous Analgesia (PCA) ................................................................................................... 16 Nurse-Controlled Analgesia (NCA) ............................................................................................................................... 17 Neuraxial and regional analgesia .................................................................................................................................. 18

Epidural analgesia ................................................................................................................................................................... 18 Plexus and peripheral regional analgesia .................................................................................................................... 19 Pump Initiated Bolus recommendation for Regional Catheters……………………………………………..………20 Intrathecal morphine ............................................................................................................................................................. 20 Intrathecal local anaesthetic infusions .......................................................................................................................... 21

ANTICOAGULATION and REGIONAL CATHETERS .................................................................. 22


ACUTE PAIN TROUBLESHOOTING: PCA and NCA .................................................................. 23 Inadequate analgesia despite PCA ................................................................................................................................ 23

Intercostal nerve blocks......................................................................................................................................................... 23 Nausea and vomiting with PCA/NCA........................................................................................................................... 24 Sedation with PCA/NCA .................................................................................................................................................... 24 Respiratory depression with PCA/NCA ...................................................................................................................... 25 Pruritus .................................................................................................................................................................................... 25

ACUTE PAIN TROUBLESHOOTING: REGIONALS ..................................................................... 26 Epidural-associated hypotension ................................................................................................................................. 26 Inadequate analgesia with epidural ............................................................................................................................. 27

No block/patchy block ........................................................................................................................................................... 28 Unilateral block ......................................................................................................................................................................... 29 Block too high/too low .......................................................................................................................................................... 30

Epidural haematoma/abscess ........................................................................................................................................ 31 Pain despite plexus or peripheral block ..................................................................................................................... 33

POSTOPERATIVE NAUSEA and VOMITING (PONV) PROTOCOL ............................................. 34 Midazolam infusion ................................................................................................................................................................. 35

OTHER PAIN MANAGEMENT ............................................................................................... 35 Ketamine infusion................................................................................................................................................................ 35 Acute neuropathic pain ..................................................................................................................................................... 36 Opioid conversion ................................................................................................................................................................ 37 Communication with General Practitioner ............................................................................................................... 38 Communication with WA Health Department ......................................................................................................... 38

PAIN ASSESSMENT .............................................................................................................. 38 Usual SCGH APS routine review .................................................................................................................................... 38

Notes review................................................................................................................................................................................ 38 At the bedside ............................................................................................................................................................................. 39 Management plan for next 24 hours ............................................................................................................................... 39

Taking a pain history .......................................................................................................................................................... 40 Chronic Pain and/or Addiction ...................................................................................................................................... 40 Dressing Changes ………………………………………………………………………………………..…………………….……….41 Chest injuries/rib fractures in the elderly……………………………………………… ..……. …………………….….42

OTHER SCGH MULTIDISCIPLINARY PAIN MANAGEMENT TEAMS .......................................... 42 Palliative Care Team ........................................................................................................................................................... 42 Chronic Pain Team .............................................................................................................................................................. 42

Weekly meeting with Chronic Pain Team ..................................................................................................................... 43 Alcohol and Drug Service…………………………………………………………………………………………………………....43 Consultation Liaison Psychiatry…………………………………………………………………………………………………..43


OVERVIEW: SCGH ACUTE PAIN TEAM

The SCGH Acute Pain Service (APS) promotes safe and effective management of acute pain by: Use of advanced pain management therapies with regular clinical review; Development of evidenced-based guidelines; quality improvement and research Implementation of risk management strategies; Liaison with other SCGH pain teams and related teams (Chronic Pain and Palliative

Care, Drug and Alcohol, Consultation Liaison Psychiatry); including referral to an outpatient transitional pain clinic, as well as preoperative optimisation and phone advice;

Hospital-wide education of trainees, ward medical and nursing staff;

The APS provides a 24-hour service: Mon to Fri 0800-1700hrs Pager 4120 Sat 0800-1300hrs Pager 4120 All other times Pager 4823 (Anaes Reg on-call)

APS Staff

Clinical Nurse Consultant Jill Kemp Clinical Nurses: (job share) Maggie Ferrero Deb Ralph Candice Elliott Nursing Relief Staff: Cody Wilson, Kate Narbey Medical: Brien Hennessy, (Director, APS) Bojan Bozic Brad Lawther Lucy Dempster Lindy Roberts Max Majedi Matt Brbich Dan Ellyard Medical Relief Staff: Angela Palumbo Steve Lamb Silke Brinkman Bridget Hogan Dale Currigan Conor Day Kate Wessels Cat Goddard Kat Travis

APS Patients

2 main groups: 1. Postoperative patients with advanced pain therapies (e.g. PCA, neuraxial and

plexus catheters); added to the Acute Pain list by PACU nursing staff. 2. ‘Consults’ from surgical and medical teams directly to the APS (in-hours) or to the

anaesthesia registrar on-call (after-hours). An e-referral should be completed by the referring team RMO/registrar (not required for requests from ICU).

If you see a new patient after-hours, please add their name to the red APS clipboard folder in PACU to ensure APS follow-up.


APS Resources

APS Protocols On the department website.

o Go to MS Teams SCGH Acute Pain Service Team Powerapp SCGH APS Handbook.

In red folders in PACU, the library, ICU, the APS nurses office; Contain information on:

o Regional analgesia including safe LA doses, anticoagulant management, epidural-related hypotension, epidural disconnection, neurological symptoms;

o Intravenous analgesia; o PONV; o Other therapies – ketamine, calcitonin, entonox, naloxone, gabanoids,

methadone, IV lignocaine, buprenorphine; o Other protocols – chronic pain patients, limb amputation, acute neuropathic

pain, opioid conversion, analgesia in pregnancy and lactation, paediatric patients at SCGH, opioid tapering before joint replacement.

For any enquiries or suggestions about this Pocket Guide or APS protocols please contact Dr Brien Hennessy. Acute Pain Guidelines Acute Pain Management: Scientific Evidence, 4th edition, available at

www.anzca.edu.au/resources/college-publications/ APS staff have knowledge of other useful references.

Registrar and Fellow attachments

These comprise: o 2-week attachments of an ANZCA Introductory or Basic Trainee or trainee

in intensive care or emergency medicine, often prior to going on the night roster.

o Fellow attachments, usually a morning per week for 3 months. The 2-week attachment is exclusively to the APS for:

o Morning APS round with consultant and nurses until approx. 1230. o Attendance and presentation of patient referrals at weekly handover

meeting between APS and pain clinic (Thursday 1230-1300). o Afternoon review of remaining patients (apart from Friday which is covered

by a senior registrar). o In the afternoon, the APS 2-week registrar carries the APS pager: the CNC

(pager 3726) and CN (pager 3870) and a consultant are available for assistance as required.

After the first day, APS registrars are expected to present patients on the round and at the meeting with the Chronic Pain Team by giving a short summation of the current problem, past and current pain management, and present situation/plan.

Registrars are also responsible for e-referrals to the Chronic Pain Team.

http://www.anzca.edu.au/resources/college-publications/


Please discuss all consultations and any complex issues or areas of concern with the APS consultant of the session.

ANZCA Pain Medicine Clinical Fundamental

The APS is keen to support ANZCA anaesthesia trainees in completing the

requirements of the Pain Medicine Clinical Fundamental. Please raise with the APS Consultants or CNCs any ANZCA learning outcomes that you wish to cover during your time with the APS.

Dr Max Majedi is the Pain Medicine Clinical Fundamental Tutor. Dr Lindy Roberts is available to do workplace-based assessments (WBA) on a Thursday (usually in the 2nd week). Please approach any of the APS consultants (at the beginning of the session) if you wish to complete a WBA during your time with the APS. For those who are not ANZCA trainees, please let us know what it is you would like

to achieve during your time with us.

SCGH APS objectives for after-hours work

The following list includes the things that you will need to do when you are on the after-hours anaesthesia roster. Most registrars will achieve these during their 2-week APS attachment.

Know what resources are available to assist with management of acute pain problems both in and out-of-hours, APS guidelines; 1. Other staff. 2. Recognise patients with complex pain problems and the difficulties these may

pose for assessment and management. 3. Demonstrate appropriate guidance-seeking from more experienced staff. 4. Demonstrate appropriate assessment of patients with acute pain and acute on

chronic pain. 5. Document assessment and management plans in patient records with sufficient

detail and clarity for subsequent review. 6. Order (includes knowing indications and contraindications):

a. Regional analgesia b. Epidural analgesia c. Patient-controlled intravenous analgesia (PCA) d. Nurse-controlled analgesia (NCA) e. Ketamine infusion f. Anti-emetics g. Paracetamol h. NSAIDs i. Stepdown analgesia.

7. Program PCA, ketamine and Sapphire pumps (regional/epidural). 8. Know how to commence a PCA after-hours.


9. Demonstrate assessment of an epidural block using ice. 10. Administer an epidural bolus dose. 11. Troubleshoot inadequate pain relief with an epidural using the algorithms in this

pocket guide. 12. Manage:

a. Postoperative nausea and vomiting b. Inadequate analgesia with PCA c. Inadequate analgesia with NCA.

13. Know how to assess and manage: a. Inadequate pain relief with regional infusions. b. Epidural-related hypotension c. Motor block with epidural analgesia d. Epidural/regional catheter disconnection.

14. Know the criteria for removal of an epidural/regional catheter.

Examples of other areas that may be covered during the pain attachment

Postoperative care of regional blocks - brachial plexus, intercostal, paravertebral,

intrathecal, lumbar plexus, femoral nerve, sciatic nerve – including assessment and management of new neurological symptoms/signs.

Local anaesthetic safe doses and toxicity

Acute neuropathic pain

Identification of patients at risk for persistent post-surgical pain including follow up.

Applied analgesic pharmacology

Pain physiology

Assessment and management of pain associated with: Recent limb amputation Major cancer surgery Opioid tolerance Pre-existing chronic pain Addiction Naltrexone implant or tablets Methadone Maintenance Therapy

Buprenorphine (Suboxone or Subutex) Cognitive impairment Renal impairment/failure Hepatic impairment/failure Prolonged fasting Multi-trauma including rib fracture and other chest trauma, head injury, spinal

trauma


APS Ward Rounds and In-hours Medical Cover

In-hours medical cover

Day Registrar start time

Morning consultant 0830-1230

Afternoon consultant (via switch)

MON 0800 Matt Brbich/Bojan Bozic (alternative weeks)

Matt Brbich/Bojan Bozic (alternative weeks)

TUE 0800 Max Majedi Max Majedi

WED 0800 Brien Hennessy/Lucy Dempster

Brien Hennessy/Lucy Dempster

THU 0800 Lindy Roberts Lindy Roberts

FRI 0830 Brad Lawther/Dan Ellyard (alternative weeks)

Brad Lawther/Dan Ellyard (alternative weeks)

If Consultants are on leave, they are usually covered by another consultant or a Fellow. Check the mudmap or contact the Duty Anaesthetist (ext. 71242) if you require advice about who is covering. The APS Round each weekday is started by the CNC and the registrar at 0800 (0830

on Fridays, following department continuing education meeting). The Consultant and Fellow join the round at 0830. The CN conducts a second round of less complex patients, often those that are ready to be discharged from the service, but who need a final visit.

The 2-week registrar has an afternoon off (usually Friday); cover is provided by another registrar (see mudmap).

Please contact Dr Brien Hennessy (Director APS) prior to commencing your attachment with the APS for an overview of the service. If he is on leave refer to the APS CNC (pager 3726).

APS Patient List

Compiled by the APS nurses using the Theatre Management System, the APS

clipboard list in PACU and the APS consult list. The nurses categorise the patients into 3 groups:

1. ‘CHECK NOTES’ – unlikely to need APS review, chart checked usually by the CN.

2. ‘REVIEW’ – ‘routine’ patients, seen by either the main round or the CN. 3. ‘COMPLEX’ – seen as a priority on the morning consultant round (e.g. pre-

existing chronic pain, opioid tolerant). The 2-week registrar holds the APS page in the afternoon and returns it to the

nurses’ office at 1700.


Saturday Pain Round

Staffed by:

o One of the APS Nurses (CN or reliever) and o An APS Consultant (occasionally a Fellow)

Check the department rosters. Medical staff must complete a P8 Medical Call Back form to be paid. Usually starts at 0800 in the anaesthesia department - please contact the APS

nurse (pager 4120) on Friday to confirm. Continues until all patients have been reviewed. A call back form must be

submitted for this time. Contact the on-call anaesthesia registrar (pager 4823) at the end of the round to

handover any patients who need to be reviewed on Sunday (or public holiday).

On-call Registrar APS cover

Ward staff will page the on-call registrar with pain problems. Please respond promptly and professionally and if possible, review the patient in-

person. There is no substitute for an adequate assessment. Please document your assessment and management in the patient notes.

If you can’t attend due to theatre commitments, it is acceptable to give an interim phone order (if appropriate) or ask the after-hours RMO to assess the patient and then discuss management with you. When this happens, it is expected that you will review the patient later.

Always consider that surgical complications, can be the cause of increasing pain (if you’re not sure, ask the surgical registrar to review the patient).

Inform the ward nurse looking after the patient about any changes. If you change any infusions (e.g. PCA), amend the chart order. Ensure you document your assessment and management in the inpatient notes. Handover problems to the next registrar or to the APS.

After-hours assistance

Consult resources (Pocket Guide, APS Guidelines Folder in

Recovery/Library/Website/MS Teams more experienced registrars, consultants). Discuss the need for patient review and any management problems with the

anaesthetist on-call. The Chronic Pain Consultant on-call may be contacted for very complex issues.


If you see a new patient after-hours, please add the name to the red APS folder in PACU to ensure in-hours APS follow-up.

Please inform the APS nurse or 2-week registrar next morning if you have encountered complex or challenging problems overnight.

ACUTE PAIN MANAGEMENT PLANNING

Ensure that during the pre-anaesthetic assessment you: Identify patients in whom pain management may be difficult (pre-existing chronic

pain, opioid tolerance, previous/current substance abuse, reactions to analgesics, surgery with a high risk of chronic pain e.g. limb amputation, pregnancy or lactation);

Discuss and document analgesic options; Note that the orthopaedic department and APS have a protocol “Opioid tapering prior

to joint replacement surgery” for referring patients on high dose opioids back to their GP for opioid reduction prior to elective joint surgery. This is usually done from the orthopaedic clinic but occasionally patients are identified in the PAC. Seek APS advice if unsure. (Note: It would also be appropriate to consider opioid tapering or rotation prior to other surgeries, especially if the patient is on high dose opioids >60mg oral morphine equivalents per day).

Routine Post-operative orders

Please: DO NOT prescribe oral opioids 1 hourly PRN

Write ‘Not with PCA/NCA/epidural’ next to order or ‘Give with PCA/NCA/epidural (as applicable) next to order. Print your surname legibly (required for drug register)

Drug Dose Paracetamol 1 g QID po/IV 48 hrs, then PRN.

Please dose adjust in patients under 50kg or with liver dysfunction. If uncertain, check with hepatology team (e.g. in liver transplant)

Anti-inflammatory (one only)

Celecoxib 200 mg PO BD with food 3-5 days, then PRN. OR Naproxen SR 500 mg PO BD with food for 3-5 days, then PRN.

Tramadol 50-100 mg 4 hrly PRN PO/slow IV. Maximum dose 600mgs (SR/IR in 24 hours) Consider dose reduction if patient on SNRI/SSRI.

Buprenorphine SL (preferable if ‘at risk’ group for addiction)

The APS considers buprenorphine as the primary stepdown analgesia in all patients <70. Immediate release buprenorphine (SL) for prn analgesia Younger (up to 65 yrs) 200-400 mcg 2 hrly PRN Elderly (65 – 70 yrs) 200 3 hrly PRN (watch for sedation)


Buprenorphine is NOT indicated for patients who are elderly (over 70 years) or frail as it seems to cause sedation that is long-lasting and difficult to reverse with naloxone. Avoid prescribing sublingual buprenorphine for patients after excision of floor of mouth tumours. Many of these patients will have unreliable absorption because of the location of the surgical wounds and also because of markedly reduced saliva production either secondary to the pathology/surgery or following radiotherapy to the area.

Buprenorphine patches

On occasion, the APS prescribes buprenorphine patches on a time-limited basis (usually 1 week). The criteria for this includes: major surgery; likely ongoing opioid requirements and pain for at least one week; and no other background slow release opioid is being administered. Slow release buprenorphine (transdermal patch) typically for 7 days

Patients aged < 70 yrs: 5 mcg/hr > 70 yrs: Not recommended

When charting, include cessation date (write ‘cease on [DATE]’ on the medication order). Don’t prescribe patches where opioid requirements are likely to decline rapidly postoperatively.

Hydromorphone IR Younger: 1-2mg 2 hourly PRN Elderly (above 65 yrs) 0.5 – 1mg 2 hourly PRN Opioid tolerant 2-4 mg 2 hourly PRN

Oxycodone IR (avoid if ‘at risk’ group for addiction)

Younger: 5-10mg 2 hrly PRN (rarely used). Elderly: (greater than 65yrs): 2.5 – 5mg 2-3 hrly PRN. Very elderly (greater than 80 yrs) or frail: 1-2.5mg 3 hrly PRN.

Tapentadol (only SR formulation available)

Starting dose 50mgs BD (where applicable). Opioid tolerant patients may require higher doses at commencement of therapy. Please note SCGH does not currently stock IR Tapentadol.

Methadone Consultant supervised prescription only. Please ensure there is a medication plan for patients who are being discharged on Methadone, started on this admission. Many will require chronic pain clinic follow up.

Anti-emetics Ondansetron 1mg IV / 4 mg wafer PO 6hrly PRN. Cyclizine 25-50 mgs IV 8 hourly PRN (dilute in 10mls sterile water and administer SLOWLY over at least 10 minutes).

Aperients If opioids likely to be required for more than 48 hrs. Not if recent bowel surgery.


Note: When choosing/prescribing PRN and slow release opioid analgesia for patients with Asian heritage, consider that their genetic makeup may make them more sensitive to opioids than other population groups.

Taking Ownership of Analgesia Prescribing for Peri-Operative Patients

In an effort to combat the social problems associated with prescription opioid and

other pain medication (e.g. pregabalin) abuse, it is the prescriber’s responsibility to carefully consider duration and quantity of any opioids and gabanoids initiated to opioid-naïve patients peri-operatively.

For APS referred patients, APS staff will make discharge plans, including cessation dates and discharge quantities on the inpatient medication chart and also on the APS Discharge Analgesia Plan.

For patients not referred to the APS (especially minor elective or emergency procedures), please use the inpatient medication chart to guide prescription. If you don’t consider a medication is needed for discharge circle the (no) in the fine-print on the side of the medication box and clearly label the order NOT FOR DISCHARGE.

In view of the joint ANZCA and FPM Position Statement on the use of SR (slow-release) opioid preparations in the treatment of acute pain, the prescription of SR opioids to opioid naïve patients should be under the direction of a Consultant, and must have a specified and limited duration.

If you are discharging patients with opioids/gabanoids educate them on the likely duration of pain and prescribe a small quantity of analgesia for discharge. State the number of days and exact quantity of tablets (not everyone needs a whole box).

If anaesthetists do not do this, the prescription of high-risk medications is otherwise left to the most junior member of the surgical team and is invariably excessive and inappropriate in terms of choice and quantity of analgesia given.

It is not appropriate to discharge patients with opioids ‘just in case’. If they haven’t used prn opioids in the 24 hours prior to discharge, then they likely don’t need any opioids for discharge.


Opioid Tolerant Patients

Some useful strategies: 1. Consider seeking advice from an APS Consultant; 2. Continue usual opioid (write ‘Give with PCA/epidural/NCA’) next to the order as

the default action by nursing staff is to withhold long-acting opioids) 3. If the patient is unable to take their usual opioid (e.g. NBM), replace this via another

route. 4. Epidurals/regionals are useful but may not prevent opioid withdrawal and may not

cover the site of ‘usual’ pain, so give usual opioid as well; 5. Involve the drug and alcohol service if on once daily methadone maintenance or

high-dose buprenorphine (Suboxone, Subutex); also for those on naltrexone; 6. Consider IV methadone (0.1 mg/kg up to 10 mg) before or after induction (giving in

the induction room can give you a measure of tolerance), especially for complex surgery (e.g. spinal surgery, sarcoma surgery);

7. Ketamine infusion (intraoperatively and postoperatively); 8. Other intraoperative adjuvants include IV lignocaine, dexmedetomidine and

magnesium; 9. Consider other non-opioids such as premedication with a gabanoid. If charting a

postoperative gabanoid, please ensure that you write a cease date or make a plan for follow-up with the APS.

10. Consult APS Guidelines for: “Management of Patients with Chronic Pain”, “Acute Pain and Addiction”.

Liver Transplant Patients

Hepatology requests that analgesic plants for OLT patients are as simple as possible. Please prescribe:

1. Fentanyl PCA 2. Buprenorphine patch 5mcg/hr 3. Sublingual buprenorphine 200-400mcg, 2/24 PRN (not with PCA).

Avoid ketamine, tapentadol, tramadol, methadone or lignocaine.


STARTING APS TREATMENTS

Starting treatment: in Theatre and PACU

Send a written order to PACU at the start of the case and the PACU nurses will make

up and program the pump while the patient is in theatre as well as add the patient to the computerised “APS List” which is downloaded daily before the round.

Considerations prior to commencing a PCA include: o Physical or mental barriers, such as paralysis, incoordination or cognitive

impairment. o Concurrent sedative use o Patient history of opioid use and concurrent opioid therapy. o Morbid obesity, obstructive sleep apnoea (or any sleep disorder) or any

condition that may increase the risk of respiratory depression. o Renal or hepatic impairment. o Previous sensitivity to a specific opioid.

If your patient goes straight to ICU, please ensure the patient can be found by the APS Team by adding a sticker to the PACU APS Clipboard.

Starting treatment: on the Ward

Ward nurses will fill/re-fill syringes and some wards, who have received training, will program PCA and Ketamine infusions. If you need a pump programming refresher, please contact the APS nurses (pager 4120). Please do not commence intravenous opioid or ketamine infusions for patients on ward outside G Block. In-hours (0800-1600 Monday to Friday, 0800-1300 Saturday):

Organised by the APS nurses.

After-hours: The on-call anaesthetic reg. may need to program or re-program pumps on the wards. The following may be of help: night CNS, PACU staff, and a more senior registrar.

If you start a new treatment on the wards after-hours, please add the name to the red APS folder in PACU to ensure APS follow-up.

Standardised APS orders are a risk management strategy. If you plan to vary from standard orders, please document the reason in the patient’s notes and notify the APS

CNC or APS Consultant of the session.


CEASING APS TREATMENTS

Ceasing epidurals and regionals

Usual duration of epidurals/regionals

Specialty Surgery type Ceased on

Orthopaedics Primary THR, DHS, hemiarthroplasty Day 1 0600

Minor joint (e.g. RCR) Day 1 0600

Major joint (e.g. revision THR) Day 2 0600

TKR 2–3 days Day 3 0600

Vascular Solely for sympatholysis After 24 hours

AAA Day 3 0600

BKA/AKA epidural Day 3 0600

BKA/AKA sciatic catheter Day 5 0600

Thoracics Open thoracotomy Day 2 0600 or (continue until ICC removal).

Urology Brachytherapy After last treatment

Open cases Day 3 0600

General surgery

Open colectomy, liver resection, major upper abdo. Either epidural or abdominal wall catheters

Day 3 0600

‘Fast-track’ colonic (esp. transverse incision) Day 2 0600

Day of surgery is day 0.

Chart the cease date on the Regional Chart when ordering the infusion. Omitting cease dates or designating longer than normal duration without explanation may delay postoperative rehabilitation regimens.

Cessation as a ‘trial’

SCGH treats the cessation of all epidurals and regionals (apart from those used for brachytherapy and sympatholysis) as a ‘trial’. Ward staff: Cease the regional infusion at 0600 hours. Give stepdown analgesia at the time of cessation. If the patient remains NBM when the epidural/regional is ceased (e.g. upper GI

surgery), the APS may prescribe PCA for stepdown analgesia (this should be connected before the epidural/regional is ceased).


Leave the regional infusion and catheter intact. After 3 hours, assess pain on movement. If pain is adequately controlled with

stepdown analgesia and patient anti-coagulant status is as per APS policy, the epidural/regional catheter is removed.

If pain control is insufficient, nursing staff will contact the APS. A decision is then made to either restart the epidural/regional infusion or commence alternative analgesia (e.g. PCA, SR opioids).

When ordering epidurals/regionals, please make sure that you have charted a cease date and ordered stepdown analgesia (e.g. buprenorphine) so that the cessation trial can occur.

Ceasing PCA and NCA

These are ceased by (accredited) ward nursing staff when the patient meets the following criteria:

C = current or planned movement causes minimal pain; E = evidence of gut function; / able to take SL Buprenorphine A = analgesic use low; S = stepdown analgesia charted; E = exceptions for nurse cessation are those with past/current history of chronic. pain or addiction, or where in-hospital pain management has been complex.


APS PROTOCOLS

Patient-Controlled Intravenous Analgesia (PCA)

Standard PCA orders (for safety) as per the following table

Drug Concentration Bolus dose Lockout interval Fentanyl 1000 mcg in 50mls NS 20 mcg/ml 20 mcg 6 mins

Hydromorphone 10 mg in 50ml NS 400 mcg/ml 200 mcg 6 mins

Written on the blue and white Intravenous Analgesia Chart. Sign and print your surname clearly (needed by ward nursing staff for the drug

register). Complete medication chart with Routine Postoperative Orders (page 9). No background infusion is charted. Other Analgesia with PCA The anaesthetist prescribing the PCA should document (on the yellow medication chart against the order for each agent) which of the other ordered analgesics should be withheld or given whilst the PCA is running, as follows:

o “Not with PCA” (usual for opioid-naïve). o “Give with PCA” (usual for opioid-tolerant).

A multimodal approach should be taken by ordering regular paracetamol and NSAID or COX-2 inhibitor if no patient contraindication. Both reduce opioid requirements and paracetamol also decreases opioid-related side effects. NSAID or COX-2 agents are usually charted for five days only (unless the patient usually takes them). Other opioids (by any other route) should not be given except as ordered by an experienced anaesthetist/pain specialist.

For opioid-tolerant patients, usual opioid (or substitute) should be given.

For opioid-naïve patients, care should be taken in administering other opioids and other short-acting opioids are not administered concurrently. ‘Atypical’ slow

release opioids (eg: buprenorphine patch, tapentadol SR, tramadol SR) may be co-administered but only as ordered by the Consultant Anaesthetist, Acute Pain Service or orthogeriatric service.

Gabanoids may be co-administered in some circumstances as they are opioid sparing and effective for neuropathic pain. Usual starting dose of pregabalin is 25 mg BD. Caution in the elderly. Tramadol (caution in the elderly) and Tapentadol SR (caution in the elderly if also has a PCA) may be given at the same time as PCA.


Nurse-Controlled Analgesia (NCA)

Opioid infusion – for patients who can’t use a PCA (e.g. cognitive impairment,

delirium, dementia, physically unable to activate the PCA button). Order an infusion rate range and PRN boluses on the IV Analgesia Chart. Nurses

can titrate the rate and give boluses as needed. Consider whether the patient requires a continuous NCA infusion, often nurse-

controlled bolus only is sufficient and safer. In this instance, write a 0 for rate range. Sign and print your surname clearly (needed by ward nursing staff for the drug

register). Complete medication chart with Routine Postoperative Orders (page 9). Standard NCA orders: NCA is ordered on the blue Intravenous Analgesia Chart

Order should include infusion fluid and additive and a bolus order as per standardised protocol in table below.

Drug Dose Solution To Total Rate range bolus dose

Fentanyl 1000 mcg NS 50 ml 0 to 40 mcg/hr (0 to 2mls/hr)

20 mcg (1mls)

Hydromorphone 10 mg NS 50 ml 0-800 mcg/hr (0 to 2mls/hr

200 mcg (1mls)

Other Analgesia with NCA The anaesthetist prescribing the NCA should document (on the yellow medication chart against the order for each agent) which of the other ordered analgesics should be withheld or given whilst the NCA is running, as follows:

o “Not with NCA” (usual in opioid-naïve and the elderly). o “Give with NCA” (usual in opioid tolerant, but should be reviewed with

consultant).

A multimodal approach should be taken by ordering regular paracetamol and NSAID or COX-2 inhibitor if no patient contraindication. Both reduce opioid requirements and paracetamol also decreases opioid-related side effects. NSAID or COX-2 agents are usually charted for five days only (unless the patient usually takes them). Other opioids (by any other route) should not be given except as ordered by an experienced anaesthetist/pain specialist.

For opioid-tolerant patients, usual opioid (or substitute) should be given.

For opioid-naïve patients, other opioids and sedative medications should NOT be prescribed unless ordered by the Consultant Anaesthetist, Acute Pain Service or orthogeriatric service. Note, short acting opioids are never administered concurrently.

Gabanoids and Tramadol should NOT be prescribed if the patient requires an NCA for non-physical reasons.


Neuraxial and Regional Analgesia All neuraxial and regional local anaesthetic infusions, whether delivered by Sapphire

pumps or disposable devices (e.g. ‘Painbuster’), are charted on the yellow and white Regional Infusion Chart. (The exception for this is IV lignocaine, which is prescribed on the blue and white Intravenous Analgesia Chart, see protocol).

All regional anaesthetic infusions must be connected by an Anaesthetic Consultant, Fellow, Registrar, APS nursing staff or by the medical practitioner who inserted the catheter. This is a safety measure to prevent the infusion being connected to an intravenous or other line.

Include information about site and depth of insertion. Complete cessation date and time (see page 9). All surgical areas stock standard solutions (ropivacaine 0.2% plain and with fentanyl

4 mcg/ml). Other solutions need to be ordered from Pharmacy – send order (fax 71346) to sterile

services before 1600.

When ordering epidurals/regionals, be mindful of maximum recommended local anaesthetic doses, especially in patients <50 kg and the elderly. See APS Protocol on LA toxicity for guidance.

Epidural Analgesia

Complete medication chart with Routine Postoperative Orders (page 9) and write ‘not

with epidural’ against opioids (unless opioid tolerant in which case write ‘may be given with epidural’). Please note oral/sublingual/IV opioids may be given if the epidural infusion solution is local anaesthetic only – in this case, write ‘may be given with epidural’ against the opioid order.

Ward nursing staff can assess blocks, give boluses (except if there is a patient-administered bolus) and titrate the infusion rate.

If using Patient-Controlled Epidural Analgesia, don’t chart a nurse-administered bolus.

PCEA is not appropriate if the patient is haemodynamically unstable. Standard epidural orders:

Nurse-controlled epidural analgesia

Patient-controlled epidural analgesia (PCEA)

Solution 200 ml ropivacaine 0.2% + fentanyl 4mcg/ml or 200ml ropivacaine 0.2%.

200 ml ropivacaine 0.2% + fentanyl 4mcg/ml or 200ml ropivacaine 0.2%.

Rate range 4-15 ml/hr* 4-15 ml/hr*

Starting rate At discretion of anaesthetist At discretion of anaesthetist

Bolus dose 4 ml of infusate (staff-initiated)

4 ml of infusate (patient-initiated), lockout 30 mins Limit in 1 hour 400 mcg/kg

* limit total dose Ropivacaine to 400 mcg/kg/hr (for a 50 kg patient this is 20mg/hour or 10 mls/hour total including boluses).


Plexus and Peripheral Regional Analgesia

Complete medication chart with Routine Postoperative Orders (page 9). If block does not completely cover pain, nursing staff can supplement with charted

opioids. Chart a flat infusion rate with no boluses - ward nursing staff DON’T give boluses or

titrate the infusion rate.

Please refer to the Anaesthetic Guidelines file for troubleshooting Plexus and Peripheral Regional Analgesia blocks. Anaesthetic Guidelines Files located in PACU, ICU, HDU, Anaesthetic Library and the APS office.

Standard regional orders: Infusion only Patient-controlled regional

analgesia (PCRA)

Solution 200 ml ropivacaine 0.2% 200 ml ropivacaine 0.2%

Rate range Flat rate usually 5mls/hr * Note Paravertebrals/Lumbar Plexus may require up to 10mls/hr

Flat rate, usually 5 ml/hr

Starting rate Flat rate Flat rate

Bolus dose Nil 4 ml of infusate (patient-initiated), lockout 30 mins Limit in 1 hour 400 mcg/kg


Pump Initiated Bolus recommendation for Regional Catheters

These are guidelines only and do not override decisions based on the clinical judgement and experience of the prescriber. If delivering large bilateral boluses, ask the PACU Nurse to stagger the bolus start times. This reduces rapid rise in serum levels of local anaesthetic. The prescriber must consider the patient’s weight and maximum hourly dose including any continuous background infusion. For ropivacaine, the total dose should be ≤ 28mg/hr (0.4mg/kg/hr); reduce dose in the elderly or sick or when giving the dose via sites with greater absorption (e.g. paravertebral).

Intrathecal Morphine

If Intrathecal Morphine is administered in theatre please place a yellow

intrathecal morphine sticker (with date and time of administration) on the Anaesthetic chart, intravenous opioid analgesia chart (if applicable) and the medication chart.

Whilst intrathecal morphine provides very effective analgesia (e.g. for open prostatectomy), morphine is relatively water-soluble and thus migrates in a cephalad direction in the CNS. This can result in delayed respiratory depression (up to 24

Prescribe either a pump initiated bolus OR a patient initiated bolus All quantities are in 0.2% Ropivacaine

Evidence shows that a fixed continuous infusion is as good as PIB

Location of regional

Suitable for Pump Initiated Bolus?

Maximum bolus

Maximum Frequency Background infusion

Interscalene Y 5ml 1 hourly 2 ml/hr Y

Supraclavicular Y 5ml 1 hourly 2ml/hr Y

Infraclavicular Y 5ml 1 hourly 2ml/hr Y

Erector Spinae Y 20ml 4-6 hourly 2ml/hr N

Paravertebral Y (test for spread to epidural space) 10-15ml 2-3 hourly 2ml/hr

N

Rectus sheath Y (advised) 20ml 4-6 hourly 2ml/hr N

TAP Y (advised) 20ml 4-6 hourly 2ml/hr N

Lumbar Plexus Y 20ml 4-6 hourly 2ml/hr N

Femoral Nerve Y 5ml 1 hourly 2ml/hr Y

Adductor Canal Y 20ml 4-6 hourly 2ml/hr Y

Sciatic N Y


hours). These patients are monitored with hourly sedation scores for the 24 hours after intrathecal morphine is administered.

Intrathecal Local Anaesthetic Infusions

Run occasionally by the APS on the wards, for example where an attempted epidural

insertion has resulted in a dural puncture or for complex surgery where an epidural may not provide adequate analgesia (e.g. where sacral segments are involved). Should only be commenced with input from an anaesthetist or APS consultant.

Nursing Staff are not as familiar with these as they are with epidural Infusions. Only anaesthesia staff may administer boluses, remembering that this is the

equivalent of a continuous spinal and thus much lower doses are required than those used for epidural analgesia. Typical rates are 2- 4 ml/hour of 0.1% Ropivacaine.

For guidance, ask one of the APS consultants or anaesthetists or consult the guidelines folder.

In order to avoid an intrathecal infusion being mistaken for an epidural infusion, please clearly mark the yellow and white Regional Order with ‘Intrathecal’ and ‘Boluses should not be given by nursing staff’. The Regional pump should be clearly marked with “Intrathecal infusion – no boluses or rate changes”.


ANTICOAGULATION AND REGIONAL CATHETERS

To minimize the risk of haematoma, anticoagulation status must be clarified prior to

the neuraxial or plexus/peripheral regional catheters removal or manipulation (e.g. catheter withdrawal to manage unilateral block).

If coagulopathy is suspected (e.g. for patients with liver disease or following major liver resection), order and review coagulation studies prior to ordering catheter removal/manipulation. A patient with abnormal coagulation may require factor administration prior to catheter removal.

The risk of infection increases the longer a catheter is left in situ. The literature generally describes higher rates for epidural abscess than for epidural haematoma

Anticoagulant Catheter removal or manipulation Subcutaneous heparin (unfractionated) (usually given 0800 and 2000)

A minimum of 6 hrs after the last dose Wait at least 2 hrs before giving next dose

Low molecular weight heparin (Clexane) (usually given 2000)

A minimum of 12 hrs after the last dose Wait at least 2 hrs before giving next dose

Low molecular weight heparin (Clexane) – therapeutic dose (1.5mg/kg).

A minimum of 24 hrs after the last dose. Wait at least 2 hrs before giving next dose.

Warfarin Ensure INR < 1.5 If > 1.4 might need FFP cover (check with consultant of the session and treating team)

Heparin infusion Cease infusion for 2 hrs, check APPT and ensure normal. Liaise with treating team regarding timing. 2 hrs after catheter removal, bolus heparin and recommence infusion.

Apixaban After removal wait 6 hours before next dose.

Rivaroxaban Wait 18 hours after previous dose before catheter removal or manipulation. After removal wait 6 hours before next dose

The above recommended times are based upon patients with normal renal and liver function, who have no other reasons for coagulopathy. Please discuss more complex cases or any cases where you are unsure with the APS consultant.


ACUTE PAIN TROUBLESHOOTING: PCA AND NCA

Inadequate analgesia despite PCA

1. Check the pump to see how many times the patient is using the button each hour

(compare number of pushes with number of successful doses) a. If low use, check why

i. Nausea when presses button? Change opioid in the PCA ii. Doesn’t understand how to use PCA

1. If cognitively intact, encourage patient to use PCA 2. If cognition impaired, change to NCA

b. If high use i. If fentanyl use greater than 200 mcg/hour or hydromorphone use is

greater than 2mg an hour consider: 1. Changing the opioid (see Pocket Guide). 2. Adding ketamine (0.05mg/kg/hour, i.e. 4 mg/hour in an 80kg

patient) 3. Adding other adjuvant analgesics

2. Use a multimodal approach if the PCA is not adequately controlling the pain a. Make sure the patient is on non-opioid adjuvants (check contraindications)

i. Paracetamol (IV works quickly) ii. NSAID (consider IV parecoxib 40mg for rescue) iii. Tramadol or Tapentadol supplementation iv. Gabanoids if there is a neuropathic component. v. Clonidine S/C or oral.

b. Make sure the patient is getting the most out of the PCA (see step 1 above) c. Add ketamine infusion. d. Change the opioid to a different one (Opioid Rotation).

When you start a PCA in a patient with severe pain you may need to load them with opioid IV (especially if you are using fentanyl). Nurses on the wards can’t give IV opioids. Ask for some fentanyl and draw 100 mcg into 10mls, give 2 mls (20mcgs) every 5 minutes until the patient is comfortable and then start the PCA. Monitor oximetry, sedation and RR during loading and for 20 minutes after last dose.

Intercostal Nerve Blocks

Intercostal nerve blocks may be used to augment PCA or NCA analgesia. For

example, they may be given in theatre or by the APS (mainly on postoperative day 1) where PCA is not covering pain well enough to allow coughing and/or ambulation. The blocks generally last 4-6 hours and can be repeated if necessary. Dose: Ropivacaine 0.375% 10ml-20ml per side. A single level injection

technique is sufficient to cover 3-6 dermatomes. Potential complications include:


Pneumothorax (very uncommon with 23g needle). LA toxicity (aspirate every 3 mls during injection).

TAP Blocks are another option in this situation, but should not be performed on wards as this is a major regional block and requires transfer to PACU. If you need help with either of these procedures, contact the APS consultant of the session.

Nausea and vomiting with PCA/NCA

See PONV Protocol Consider changing to another opioid (e.g. fentanyl to hydromorphone) Look for the aetiology and ensure that simple causes are treated (e.g. by insertion of

NGT or putting it on free drainage)

Sedation with PCA/NCA

Is almost always a prelude to respiratory depression (opioid induced ventilatory

impairment). Make sure the patient is receiving supplemental oxygen and that respiratory rate,

sedation score and oximetry are being measured at least hourly. Check usage of PCA for last few hours. Exclude other causes (e.g. intracranial pathology, especially if neurosurgical patient

or trauma history). Ensure patient isn’t getting sedatives as well as opioids (unless they are

benzodiazepine tolerant). Consider reducing the opioid bolus dose (PCA) or infusion rate (NCA). Cease any long-acting opioids. Consider monitoring in a high dependency area.


Respiratory depression with PCA/NCA

Many people have a respiratory rate of 6-8 when asleep If the RR is less than this

o On the phone: ask about respiratory rate, instruct the nurse to administer supplemental oxygen and indicate you will come and see the patient immediately

o Look for other signs of opioid toxicity (pupil size, sedation score, ability to rouse)

o Cease NCA or remove PCA handset from patient If you need to give naloxone

o Dilute 400 mcg (1 ampoule) in 10mls o Give 1 ml at a time and wait 1 minute for effect of each bolus before giving

another. Remember naloxone may not last as long as the opioid, so consider a naloxone

infusion (see Naloxone Protocol in APS Guideline Folder) and monitoring in a high dependency area (e.g. General HDU).

Pruritus

Commonly treated with antihistamines which tend to sedate the patient but not treat

the itch very well. Treated with ondansetron or SC naloxone (100 mcg 2 hourly PRN) Try changing the opioid

o For a PCA, rotate from one opioid to another o For epidural-associated pruritus, remove fentanyl from the epidural solution

and run plain local anaesthetic


ACUTE PAIN TROUBLESHOOTING: REGIONALS

Epidural/Spinal-associated hypotension

Nursing staff will follow the guidelines on the Regional Analgesia Chart (intravenous

fluid bolusing and APS notification). On the phone:

o BP low but patient asymptomatic Ask the nurse about the extent (to ice) of the epidural block. If block not excessive, leave epidural rate the same and ask nurse to give fluid bolus stat and go to review the patient.

o BP low and patient symptomatic Ask nurse about the extent (to ice) of the block, ask nurse to turn off if excessive. Check that IV fluids are running (as per Regional Analgesia chart) and that patient has legs raised and oxygen on Go immediately and review the patient.

On the ward:

o Look for other causes of hypotension (e.g. haemorrhage, sepsis, myocardial event).

o Consider surgical or medical review if indicated. o Ensure patient is euvolaemic with fluid loading. o Check catheter tip is in the epidural space (i.e. not intrathecal). o Add oral midodrine 10mg 4 hourly for duration of epidural (can be

continued for 24 hours if associated with a single shot spinal). Document withhold if SBP >130mm/Hg.

o Don’t leave the epidural turned off for more than 45 minutes or the block will vanish and severe pain will result and then the patient will need a further bolus which might lead to more hypotension.

Low-dose metaraminol infusion may be used for epidural-related hypotension.

o Patients must be cared for in the High Dependency Unit (HDU)/G45. o Do not prescribe PCEA (use continuous infusions with nurse initiated

boluses only)


Inadequate Analgesia with Epidural

Nursing staff should do the following before calling the APS:

o Block assessment (with ice) and check BP o Give a bolus of the infusate (if charted) and increase infusion rate by 2

ml/hr o Repeat the assessment and bolus (as required) up to two boluses for one

episode of uncontrolled pain.

If you are called to see a patient in pain despite an epidural, check: o For other causes of increasing pain (e.g. bleeding, sepsis, compartment

syndrome, pulmonary embolus, cardiac event). o Level of catheter insertion (see yellow and white Regional Analgesia chart):

ensure that epidural has been optimally sited to cover the surgical area (e.g. a very low thoracic or lumbar epidural may not cover an upper abdominal or thoracic wound as xiphisternum is approximately T7, spine of scapula approximately T4).

o Whether the epidural has ever been effective: check in-patient notes for pain levels in PACU and earlier on the ward, number of rate changes or boluses given. If the epidural has never been effective, it is less likely that you will be able to fix it. It may need to be supplemented (e.g. with PCA) or abandoned.

o Site of pain: some sites of pain (e.g. usual back pain, shoulder tip pain from diaphragmatic irritation) may not be able to be covered by the epidural.

o Extent of sensory block: test upper and lower level with ice; look for a difference in sensation compared with the skin of the upper arm or face (rather than asking about degree of coldness).

o The back: look at the epidural site to ensure that the catheter has not been dislodged and that the infusate is not leaking.

Then use the troubleshooting flowcharts on the following pages.

o If you can’t completely resolve the pain with two (or fewer) boluses, then start a PCA/NCA (take the fentanyl out of the epidural solution so that it is just plain local anaesthetic).


No block/patchy block

Check if catheter is out of the epidural space

If NO If YES, abandon epidural@

Epidural LA bolus e.g. 4-6 mls 1.0% lignocaine with 1:200 000 adrenaline**

Effective?

NO PARTIALLY COMPLETELY

Abandon epidural ++ Increase infusion rate by 2 mls/hr

OR

Supplement with PCA$$

Further LA bolus**

AND

Consider epidural clonidine 50mcg **

@ Slight leakage may occur with a partially effective block (this may not require

epidural cessation but rather the addition of a PCA or NCA). ** Check BP prior to bolus administration. Ensure safe total LA doses administered. $$ If supplementing epidural with a PCA, remove fentanyl from the epidural solution

and order LA only. ++ If epidural abandoned in the night, leave the epidural catheter in situ until APS

review the next day.

Check if catheter is leaking


Unilateral block

Check length of catheter in the epidural space

Less than or equal to 3 cm More than 3 cm

Check anticoagulation^^

Withdraw catheter to 3 cm (aseptic technique)

Epidural LA bolus e.g. 4-6 mls 1.0% lignocaine with adrenaline**

Effective?


Abandon epidural ++ Further LA bolus** No further action

## If block is unilateral on same side as unilateral surgery, no further action is required.

^^ See protocol ‘Anticoagulation and regional analgesia’. ** Check BP prior to bolus administration. Ensure safe total LA doses administered. ++ If epidural abandoned in the night, leave the epidural catheter in situ until APS

review next day.


Block too high/too low

Check length of catheter in the epidural space

Less than or equal to 3 cm More than 3 cm

Check anticoagulation^^

Withdraw catheter to 3 cm (aseptic technique)

Epidural LA bolus e.g. 4-6 mls 1.0% lignocaine with adrenaline**

Effective?


Supplement with PCA$$ Increase infusion by 2ml/hr

Consider epidural clonidine 50mcg **

^^ See protocol ‘Anticoagulation and regional analgesia’. ** Check BP prior to bolus administration – if low, see APS protocol ‘Hypotension

and epidurals’. Ensure safe total LA doses administered. $$ If supplementing epidural with a PCA, remove fentanyl from the epidural solution

and run LA only. NB. Caution should be exercised if the block is high - boluses should not be

given if the block is higher than T4 (although consideration may be given to withdrawing the catheter using the above flowchart).


Epidural haematoma/abscess

Early diagnosis and treatment can prevent permanent sequelae.

Diagnosis may be difficult and/or delayed in the presence of a working epidural, especially in the lumbar region, as motor and sensory deficits commonly occur as a result of intrathecal or epidural local anaesthetic.

If a patient has unexpected or lower limb weakness with an epidural, turn off the epidural infusion and review in 2 hours. If no improvement, discuss with the APS consultant of the session (in-hours) or the anaesthetist on-call (after-hours) and refer patient for urgent MRI.


From day 2 onwards, the epidural site is routinely inspected for evidence of local infection. If pain or erythema is present at the epidural site, carry out assessment (below) and discuss with the APS consultant of the session. The patient will be followed up daily on the APS round. If the patient is for discharge, they must be advised to seek urgent medical advice if pain, redness or swelling is a problem at the site or limb weakness, bladder or bowel dysfunction occurs. The Acute Pain Service will distribute an information leaflet to all patients post epidural and prior to discharge. Assessment:

Extent, location and severity of pain at site

Extent of erythema

Neurological symptoms and signs

Recent or current pyrexia

Any predisposing factors (e.g. cancer, sepsis, debilitation, or immunosuppression). Document all findings in the patient record. If there is any evidence of generalised sepsis, which may lead to haematogenous seeding of the epidural catheter, contact the APS consultant regarding possible early removal.


Pain despite Plexus or Peripheral block

Many blocks are used at SCGH (e.g. sciatic, adductor canal, femoral, fascia iliaca,

lumbar plexus, brachial plexus, paravertebral, intercostal). All are run with local anaesthetic only. These blocks may not completely cover the site of pain and patients are usually

charted for supplemental opioids. Manage as per “Troubleshooting regional (plexus and nerve) blocks (in APS

Guidelines file/Anaesthesia Department Intranet). If the patient has pain despite a regional block the easiest solution is to add suitable

oral analgesia or a PCA (if they do not have an oral route). Consider the administration of anti-neuropathic agents (e.g. gabanoids or ketamine

or Tapentadol). Additional assessment is required if patients who have had a single shot nerve block

or a nerve catheter infusion exhibit unexpected or new neurological compromise. (See APS Guidelines file for protocol).


POSTOPERATIVE NAUSEA and VOMITING (PONV) PROTOCOL

If patient is nauseated on return to ward after surgery:

In the post operative setting where the patient already has nausea or vomiting, agents such as metoclopramide and prochlorperazine have little or no effect. Ondansetron and other drugs of the same class (such as tropisetron, or granisetron) will improve existing nausea and vomiting in less than half of cases.

If administering cyclizine, dilute in 10mls of water for injection and give over > 5 minutes.

Manage ongoing causes of nausea: Opioid administration (consider opioid

rotation and maximise non-opioids) Bowel obstruction

Dehydration

Has Ondansetron been given in the last 6 hours?

NO YES

Administer: Ondansetron 4mg PO or IV

Either, wait until 6 hours has elapsed and repeat

Repeat as required 6 hourly

Cease after 48 hours

Or, a Midazolam infusion may be useful Contact the Acute Pain Service Pager: 4120 (in-hours) Pager: 4823 (after-hours)


Midazolam Infusion

See APS Protocol: ‘Midazolam Infusion for persistent PONV’ Low dose midazolam infusion is an effective and safe treatment for persistent post-operative nausea and vomiting. It is indicated when management of ongoing causes of nausea (e.g. dehydration), opioid review (maximisation of non-opioid analgesia and/or rotation to a different opioid) and administration of first line anti-emetics have failed.

Give a bolus of 0.5 to 1 mg of IV midazolam to assess efficacy. Review patient after 30 minutes. If nausea/vomiting has improved, commence midazolam by infusion. Order infusion on the IV Analgesia Chart in the “Other infusions” area at the

bottom of the front page:

10 mg midazolam in 100ml of Normal Saline Infusion rate 0.5 mg/hour Starting rate as per effective bolus dose.

Infusion generally runs until the PCA is removed.

OTHER PAIN MANAGEMENT

Ketamine infusion

See APS Protocol: ‘Guideline on ketamine for acute pain management’ This is a useful adjuvant for patients with: Opioid tolerance (reduces tolerance) Pain that is poorly responsive to opioids (e.g. phantom limb pain) Neuropathic pain (acts more quickly than many other anti-neuropathic agents). Ketamine is ordered on the IV Analgesia Chart in the “Other infusions” section. To prevent diversion, it is administered in a locked pump. The starting rate is 0.05 - 0.1 mg/kg/hr. Please note that nursing staff do not titrate these infusions, so you will need to order a fixed infusion rate. For example, for a 80kg patient:

Ketamine 200mg to 50ml with N/Saline Rate = 4mg per hour = 1ml/hour

Potential side effects should be explained to patients: dysphoria, “funny dreams” and (infrequently) hallucinations. Avoiding ketamine bolus in awake patients usually


minimises side effects. If side effects are experienced, consider reducing the infusion rate or commencing low dose oral/SL benzodiazepine.

Acute Neuropathic Pain

The following drugs are commonly used by the APS for acute neuropathic pain:

1. Ketamine: works quickly. 2. Amitriptyline start at 25 mg (young) or 10 mg (age > 70 years). Alternatively use

nortriptyline: 10mg good for insomnia. 3. Tapentadol SR common starting doses are 50-100mg BD in the young, 50 mg BD

in the elderly. 4. Gabanoids (gabapentin and pregabalin): adjust dose in patients with renal

impairment - see APS protocol. 5. Other antidepressants (e.g. duloxetine). 6. Intravenous lignocaine. 7. Calcitonin (phantom limb pain and Complex Regional Pain Syndrome) 8. Tramadol. 9. Methadone.

See: APS Protocols ‘Acute Neuropathic Pain Treatment Protocol’ ‘Guideline for the administration of calcitonin’ ‘Use of gabanoids in acute settings’ ‘Methadone protocol’ Intravenous lignocaine protocol’


Opioid Conversion

See APS Protocol: ‘Opioid conversion guidelines’ NB: opioid conversion is complex and advice should be sought from the APS Consultant of the session. SCGH APS Opioid Conversion Worksheet

Step Drug Route Dose Frequency : Current 24hr use 24hr total

: Halve dose As above As above 24hr total

: Convert to Morphine equivalent

Morphine As above 24hr total

: Convert to desired route Morphine 24hr total

: Limit to maximum 180 mg/d PO Morphine (60 mg/d IV/IM/SC)

Morphine As above 24hr total

: Convert to desired drug As above 24hr total

: Background dose = 2/3 of “step 6”

As above As above 24hr total

: Order background frequency

As above As above

: Calc breakthrough = 1/6 of daily background (step 7)

As above As above Per dose

Final Order Background: opioid route dose frequency Breakthrough: opioid route dose frequency

Opioid Oral IV/IM/SC

Morphine 30 mg 10 mg

Oxycodone 20 mg 10 mg

Fentanyl - 100-150 mcg

Hydromorphone 4-6 mg 2 mg

Codeine 120 mg 120 mg

Buprenorphine 0.8 mg SL 0.3 mg

Tapentadol 75mgs Note lowest dose is 50mgs

Tramadol 120 mg 120 mg * Fentanyl patch 12mcg/hr = buprenorphine patch 20 mcg/hr = oral morphine 40 mg/day ** Hydromorphone conversion from oral to parenteral usually 2:1 *** Buprenorphine is 25 to 50 times more potent than morphine


COMMUNICATION WITH GENERAL PRACTITIONERS

Where patients have complex analgesic regimes, substance abuse and/or chronic pain the APS liaises directly with the patient’s GP to advise them of the pain management plan for discharge. A phone call is placed and followed up with faxed information via a pro forma letter. These letters are available in the APS office.

COMMUNICATION WITH THE WA HEALTH DEPARTMENT

If the APS have opioid rotated or substantially changed a patient’s pain management regime, or there is a concern that opioids may be abused or diverted, the pro forma letter is also faxed to the Health Department (fax: 9222 2463). This specifies that the patient has been reviewed by an acute pain consultant and is authorised to receive analgesic medications as specified.

PAIN ASSESSMENT

Usual SCGH APS review

Notes review

Anaesthesia chart

o Preoperative: co-morbidities (cardiac, respiratory), pre-existing chronic pain, substance abuse, psychiatric history, opioid tolerance, allergies and drug reactions.

o Intraoperative: opioid amount, use of regional blocks (single shot, catheter), complications.

o PACU: opioid loading, initial analgesia (PCA, NCA, epidural, regional infusion), other analgesia, complications.

Operation notes o Type of surgery – what surgical complications might occur with the

particular procedure (e.g. compartment syndrome, intra-abdominal sepsis/bleeding)?

o Surgical findings, incision type, surgical complications, any plans for further surgery.

Progress notes o Nursing and medical entries – pain, analgesia effectiveness, disease

effects, surgical plan, oral intake, other reviews (physio, psychiatry, drug and alcohol, social work esp. complex patients).

o APS entries (marked with green stamp). o Medication chart – breakthrough analgesia, background analgesia, side

effect treatment. o IV Analgesia or Regional Infusion Chart – pain scores (trends), side effects

(haemodynamics, sedation, nausea, motor block). o Other – bowels.


Old notes o Especially for patients with chronic pain, cancer pain, addiction, frequent

admissions.

At the bedside

Briefly introduce self and other team members, explain purpose of review. Degree of comfort and functional status (mobilisation etc.). What’s the patient worried about? Pain: site, intensity (rest and movement), functional assessment (ability to deep

breathe, cough, mobilise). Effectiveness of current treatments:

o Satisfaction with current analgesia. o If partially effective, it may be enough to optimise the dose of current

analgesia. o If ineffective, you may need to consider an alternative.

Side effects: nausea and vomiting, sedation, hypotension, pruritus. Check pain pumps (e.g. PCA use, epidural rate, number of staff-administered

boluses and efficacy). Pain Scores:

o Many patients can use the 0 (no pain) to 10 (worst pain imaginable) scale o If the patient doesn’t understand the scale or you don’t believe/understand

the number they give, try the following in decreasing order of complexity (for the patient)

None, mild, moderate, severe A little pain or a lot of pain Do you have pain? Yes/no Nursing staff report (e.g. on moving the patient) Use functional activity score as an adjuvant to pain scores

(particularly for patients with chronic and persistent pain).

Management plan for next 24 hours

Develop pain management plan. Discuss with patient. Talk with ward nursing staff about changes. Alert surgical or medical team to any concerns. Document assessment and plan in patient notes: date and time, surname(s) of those

involved in the review, current problem, plan. If complex, document a contingency plan (plan B) for your after-hours colleagues. Ensure that all orders are clear, complete and will cover next 24 hours. Make a note if the patient needs referral or has been referred to others services (e.g.

Pain Clinic, Drug and Alcohol, Palliative Care, Psychiatry Nurse Practitioner, Aboriginal Liaison Service).


Taking a Pain History

Reason for referral

Why is this patient being referred at this time? Team(s) involved in the patients care:

Team diagnosis; team(s) plans including discharge; team treatment preferences.

Involvement of allied health (e.g. social work, physiotherapy, OT). Involvement of Drug and Alcohol, Chronic Pain, Palliative Care Teams,

Psychiatry Nurse Practitioner, Aboriginal Liaison Officer. Demographic details History of the pain

Circumstances of onset, duration. Location, radiation, more than one site? Nature – nociceptive vs. neuropathic (e.g. burning, shooting). Temporal characteristics – continuous/intermittent. Intensity – now, at worst/at best, in previous 24 hours. Aggravating and relieving factors, associated features. Effect of treatments to date including side effects (PONV, pruritus,

constipation). Other relevant history

Current medications including analgesics (particularly look for opioid tolerance).

Allergies and drug reactions. Is there any previous pain history e.g. from previous admissions – how

did they go? Co-morbidities including:

Cardiorespiratory, e.g. OSA Renal and hepatic Chronic pain Substance abuse disorder Other psychological /psychiatric disorders Social issues

Cognitions (e.g. concern about addiction to opioids), beliefs (regarding pain, treatment etc), expectations, mood, coping strategies.

Results of examination and investigations. What is the pathological diagnosis?

Reference: FPM trainee support Kit, 2005.

Patients with Chronic Pain and/or Addiction

We all find acute pain management in these patients challenging.

Perform pain assessment. o Expect persistently high pain scores and use other measures (such as

ability to mobilise) to assess.


o Do not assume pain complaints stem from opioid tolerance, drug-seeking or behavioural issues – these patients may develop surgical complications also.

You are not expected to sort out all their problems after-hours.

Apart from the usual assessment, look closely at the in-hours APS plan to see if there are some clues about what you might do after-hours – in general terms, follow this plan.

If they are opioid-tolerant: o You are unlikely to cause problems (like respiratory depression) by

increasing the opioid dose (although need to ensure appropriate monitoring as often on multiple sedating agents).

o Make sure they are getting their usual opioid (this is their background requirement and should be given along with the PCA or regional).

Consider addition of ketamine (if they are not already on it) or increase the dose (by 50% e.g. from 0.05 mg/kg/hr to 0.1 mg/kg/hr).

Optimise non-opioid analgesic adjuvants.

If you are called to see a patient known to the Chronic Pain Team or the Palliative Care Team:

o Each of these teams has a consultant on-call o See the patient first and work out what the problem is and what the current

treatment is o Look at the old notes to see what has been done in the past o Call the consultant on for chronic pain or palliative care (via switchboard) –

have the notes handy in case he/she wants to ask you any additional questions.

o Consider involving Drug and Alcohol or Consultation Liaison Psychiatry services if appropriate.

Analgesia for Dressing Changes

1. Alprazolam 0.5mg orally. 2. Hydromorphone 4mg orally (dose adjust to 1-2mg in the elderly). 3. Nitrous oxide (ENTONOX).

1 and 2 to be administered at least 30 minutes prior to dressings and Entonox to be reserved for during the dressing change ONLY. CAUTION: with opioid naïve and patients with poor nutritional status as nitrous oxide may be contraindicated. (See APS ‘Entonox Protocol’ for contraindications and precautions).


Management of Chest Injuries/ including Rib Fractures in the Elderly, Frail or Patients with significant co-morbidities

It has been agreed between the Acute Pain Service, Trauma Service and Emergency Department that patients who meet the following criteria: >65 years old OR Significant comorbidities (especially chronic respiratory disease) OR No enteral route available AND >2 rib fractures or other severe chest injury

to be referred to APS as soon as possible.

Management should include: Consider regional technique such as paravertebral catheter/infusion.

Regular paracetamol.

Anti-inflammatory with caution (preferably a coxib), considering age/renal function.

Opioid: oral immediate release analgesia. If no oral route, prescribe PCA if patient able to use / otherwise NCA nurse bolus only (NO infusion).

Consider pregabalin/gabapentin if no other contraindications and the above is not sufficient.

Early physiotherapy input.

OTHER SCGH MULTIDISCIPLINARY MANAGEMENT TEAMS

Palliative Care Team

A Palliative Care Consultant is available via Switchboard 24 hours a day. If

your patient is under the Palliative Care Service, please discuss all analgesic management plans with the Palliative Care Consultant prior to implementing any changes.

For management of pain and other symptoms in patients with cancer and terminal

illness. In-hours, contact the registrar (pager 4001). Nurses pager 4874, 4480 or 3966. After-hours, consultant on-call via switchboard.

Anil Tandon, Consultant (also pager 3985). David Dunwoodie, Consultant (also pager 4578).


Chronic Pain Team

For management of pain of a long-standing nature or with acute exacerbation of such

pain (e.g. an acute exacerbation of chronic back pain).

In-hours, contact the Pain Fellow/Registrar for the wards (DECT 76524). After-hours, contact the Chronic Pain Consultant on-call via switchboard.

Weekly meeting with Chronic Pain Team

The APS/CPT meet once a week with Dr Max Majedi and Dr Lindy Roberts from

1230-1300 on Thursday in the Pain Management Department (Lower Ground G Block, green lifts) to discuss:

o Inpatients seen by the APS who require outpatient referral to the Pain Management Department transitional clinic for follow up post discharge, please refer to the APS ‘Protocol for referral by APS to the Pain Management Department’ for criteria used for such referrals.

Alcohol and Drug Service

All patients with substance abuse disorders should be followed-up by the Alcohol and

Drug Service.

These services are available Monday to Saturday, inclusive from 07:00-15:00. Contact the service (CNC Brenda Jones) on DECT 76323 or 76324.

Consultation Liaison Psychiatry

For management of patients with concomitant pre-existing or situational

psychiatric/psychological issues. For non-urgent review, contact the Psychiatry Liaison CNC (DECT 76520) or for

patients >65, contact Geriatric Psych CNC Les Nolan (DECT 72100). For urgent review requiring consultant psychiatrist input, this service is available

via switch.

NOTES


Documents

SIR CHARLES GAIRDNER HOSPITAL - Charlie's ED