Acute Pain Leeds General Infirmary

							       Pain Management Services




                  SpR’s Induction
                                   package




Leeds pain Management Service version 2 (Adult LGI) January 2008. Review January 2009
             Adult Acute Pain Leeds General Infirmary
  (Chronic pain and paediatrics are covered by separate anaesthetic teams and have separate
                   guidelines that can be found on the anaesthetic website)

Who’s who?

The Adult Acute Pain service is a Nurse Specialist and Consultant
Anaesthetist led service.

Pain Management Nurse Specialists (Acute and Chronic pain)
We have a team of Nurse Specialists with a responsibility for inpatient Pain
management who work 8am to 6pm Monday to Friday.

Bleep 07659 523319

The pain management office extension 23341 and fax extension 28168

The Acting Team Leaders (Pain Nurse Specialists) for acute / chronic pain are
Nikki Keep (07659 531637) and Joanne Barratt (07659 507985)

Acute Pain Consultant Anaesthetists (contact via switch)
There are Consultant Anaesthetists who have fixed sessions for Acute Pain
(as shown below). When they are not available or out of hours the acute
anaesthetist/anaesthetic SpR will be asked to manage any acute pain
problems.

Monday pm                   acute anaesthetist
Tuesday pm                  appointment pending
Wednesday pm                Dr. Pete Kimpson
Thursday pm                 acute anaesthetist
Friday pm                   acute anaesthetist

The Consultants have daily input into pain management via ward rounds and
liaise with the pain management nurse specialists. SpR’s are welcome to
attend ward rounds and teaching sessions, please arrange this by contacting
the pain office. The majority of patients we manage are post-operative. Other
patients include acute non post-op cases e.g. fractured hip/ ribs, acute
pancreatitis, acute on chronic patients e.g. sickle cell etc.

With the nurse specialists we
    are involved in teaching nurses and trainees,
    carry out surveys and audit using the epidural database and
    are involved in research projects
    Lead on policy and practice development

If you are interested in audit or research within our department please contact
any member of the team.




Leeds pain Management Service version 2 (Adult LGI) January 2008. Review January 2009
Chronic Pain Anaesthetists
Dr Louise Lynch (contact via switch) and Dr Dudley Bush are available to see
patients with chronic pain problems. Patients should first be seen by the pain
nurse specialists, who will assess these patients and request advice or input
from these consultants if appropriate. Referral criteria and guidelines for the
management of chronic pain can be found on the Leeds Health Pathways or
pain web site.

Out of hours cover

Clarendon Wing

The Anaesthetic SpR for Labour ward covers wards in the Clarendon Wing
49v, 60, 61, 62, 62a(SHDU), 54a (Plastics HDU).

The nurse specialists will update you on any problem patients at the end of
their shift for any patients who may require further review/interventions out of
hours.

All patients with epidurals should be reviewed at least once a day on the
weekend and bank holidays.

Jubilee Wing

The General ICU SpR covers Ward 8 (GHDU), Ward 15 and other areas
intermittently receiving epidurals. The Nurse Specialists will update you on
any problem patients at the end of their shift. All patients with epidurals should
be reviewed at least once a day on the weekend and bank holidays.

We expect you to be aware of the areas you cover out of hours and
encourage patient review when you have time. The ward nurses are regularly
updated and assessed by our team in their competencies with epidurals and
therefore will try to manage simple problems without contacting you
unnecessarily.

If you are called to see a patient and you are busy you must refer the ward
staff on to another anaesthetist- Acutes SpR or senior SpR. It is unusual for
everyone to be tied up. You must follow the call up when you are available.
It is not acceptable to just say no!

Which wards take Epidurals/Paravertebrals?

Wards are only deemed competent to manage epidurals/paravertebrals after
a comprehensive program of nurse training and assessment. There must be
competent nursing staff on the ward at all times when managing these
patients. Therefore we have a limit on the number of wards that are deemed
competent – the so called ‘accredited wards’. Each accredited ward has a
‘Link nurse’ who liaises with the Nurse Specialists to update and maintain
ward nurse competency.




Leeds pain Management Service version 2 (Adult LGI) January 2008. Review January 2009
General Surgery

All the General Surgical wards 60, 61, 62, 62a (SHDU) are accredited for
managing epidurals/paravertebrals. The exception is ward 60a, the day ward.

Vascular Surgery

49V and 15 are accredited for epidurals/paravertebrals

Orthopaedics

None of the wards are accredited for epidurals
However the plastic HDU (54a) is accredited to receive epidural/paravertebral
patients.

If you feel this method of pain relief is necessary for your orthopaedic/spinal
patient, then discuss with your designated Consultant and book a bed on 54a.

Please note the Nurse Specialists do not, currently, provide any service to
Chapel Allerton Hospital.

Neurosurgery

Neurosurgical HDU 23a only is accredited for epidurals/Paravertebrals

ICU (ward 3,5,7,6)

All accredited for epidurals/paravertebrals

HDU (ward 8)

Accredited for epidurals/paravertebrals

Guidelines

The White folder ‘Pain Management Guidelines’ is available in every clinical
area providing guidelines/ protocols/ algorithms/ observation forms on all
aspects of Acute pain Management. These guidelines can also be found on
the pain website/ anaesthesia website and the Leeds Health Pathways.
Please make yourself familiar with these.

The Analgesic Ladder

The analgesic ladder used at the LGI will be familiar to many.

Paracetemol 1g po/pr/iv 6 hourly regularly.
This should be prescribed, unless contra-indicated, to all patients receiving
other methods of analgesia.


Leeds pain Management Service version 2 (Adult LGI) January 2008. Review January 2009
NSAIDs:
Diclofenac 50mg po / pr 8 hourly regularly.
Precautions include – sensitivities, renal dysfunction or oliguria, the elderly
and active peptic ulcer disease. (Paracoxib 40mg od) for those who you don’t
get around to giving a premed or NBM and can’t have PR.

Weak opioids
Dihydrocodeine: 30mg 6 hourly po.
This dose has the same analgesic properties as 60 mg 6 hourly and less of
the side effects. NB: Should not be used routinely with patients on other
systemic or epidural opioids unless discussed with the pain team/Consultant
Anaesthetist. Dihydrocodeine should be considered as the first line option in
most cases, where clinically indicated alternatives such as Tramodol or
codeine may be used but this should be the exception rather than the rule.

Spinal Anaesthesia

This method is often used alone or in combination with a general anaesthetic.
We do not currently advocate the addition of opioids to spinals due to
respiratory depression and sedation without appropriate monitoring or
observation (we are working towards this but nurse training and appropriate
observation forms need to be in place first!)
We use 27 or 25 gauge needles except in exceptional circumstances. We
recommend siting these with the patient awake and sitting. We advise strict
asepsis during insertion – including gown, gloves and mask.

Morphine Patient Controlled Analgesia (PCA)

The standard settings are as follows:
Morphine 50mg in 50 mls 0.9% saline.
1 ml or 1 mg bolus.
5 minute lockout.

For the elective patient, education and familiarisation should take place prior
to theatre. A Patient Information leaflet is available to support this process.

Settings are occasionally varied (non standard prescription- separate form) for
specific patients- these must be reported to or discussed with the Acute Pain
Team.

PCA should be prescribed on the blue prescription form – found in recovery.
The recovery nurses will make up, check and attach a PCA on your request.
There are 2 PCA prescription forms, a standard form and a non-standard
form. The Nurse Specialists are able to administer morphine boluses following
completion of a standing prescription on the prescription form.

We advise prescribing of oxygen 2-4l/min with a PCA along with prn
antiemetics Cyclizine 50mg 8 hourly and second line ondansetron 4mg iv 8
hourly.


Leeds pain Management Service version 2 (Adult LGI) January 2008. Review January 2009
Standard analgesics (Paracetemol and NSAID unless contra-indicated)
should be prescribed concurrently.
Naloxone should also be prescribed – as per the PCA algorithm.

Members of the acute pain team review non-standard PCA patients daily and
withdrawal of the PCA is based on the discontinuation criteria and should be
instigated by the ward team.

Epidural Analgesia

If an epidural is considered beneficial for the patient and there are no
apparent contra-indications, this should be discussed with the patient pre-
operatively and informed consent obtained with documentation of this. A
Patient Information leaflet is available to support this process.

Our recommendations are:

Level of insertion related to surgical site-Insert the epidural at the midpoint of
the dermatomal level for that incision.
High thoracic for sternotomy
Mid thoracic for thoracotomy
Mid/Low thoracic for upper GI
Low Thoracic for lower GI

We recommend siting epidurals with the patient awake and sitting. We advise
strict asepsis during insertion – including gown, gloves and mask. Tuohey
needle size 16G.

Use loss of resistance to saline via the mid-line or paramedian approach
leaving 5 cm of catheter in the epidural space. If you are not confident with
your technique then ask for help from either the Acute Pain consultant for that
day or your designated Consultant.

A transparent dressing Tegaderm allows the insertion site to be inspected at a
later date, with mefix to secure around. The ODAs’ are familiar with this
method of fixation. We recently audited the use of a neoderm dressing (which
has a thicker white edge) and found superficial infection rates rose when this
dressing was used. We have since returned to using Tegaderm dressings. A
re-audit of dressings is scheduled for later in 2007.

Intra-operatively 2 techniques are recognised:
i)     Loading with 0.25% levobupivacaine +/- diamorphine then starting the
       infusion pump running.
ii)    Repeated boluses of 0.25% levobupivacaine +/- diamorphine as
       directed by patient signs.

Standard solutions for the post-operative period are:
i)    Plain bupivacaine: 0.1, 0.15% or 0.25%.
ii)   Bupivacaine 0.1% or 0.15% with fentanyl 2mcg/ml.


Leeds pain Management Service version 2 (Adult LGI) January 2008. Review January 2009
As a general guide we start 0.1% with fentanyl at 0-15ml/hr unless there are
reasons to avoid opioids.

Any deviation from the standard solutions will mean the prescribing
anaesthetist takes a 24 hour responsibility for the epidural(including changing
of infusion bags every 24 hours for the life of the prescription).

Again oxygen should be prescribed and given to the patient along with anti-
emetics as outlined earlier. Concurrent Paracetemol and NSAID should also
be prescribed unless there are contra-indications.

Epidurals should be prescribed on the yellow forms available in recovery with
parameters completed and the form signed.
By entering your patient on the computer database in recovery, the pain
management nurse specialists will institute follow up. The onus to enter your
patient on the database is on you; if you do then your patients will be followed
up. You will need to obtain log in details for this.

If you don’t enter your patient’s details on the database the pain team will not
see your patients.

All parameters should be filled in on the database prior to patient discharge
from PACU. Please ensure that the printed form is inserted in the patients’
notes.

We do not advocate the use of other drugs in epidurals e.g. ketamine or
midazolam, although guidelines do exist for the non standard epidural using
Clonidine.

A Clonidine epidural must only be instituted after discussion with a member of
the Pain team and the patients must be managed on the HDU or ICU
environment.

Epidural pumps are the Graseby CADD. Please make yourselves familiar with
them , extra training can be arranged at your request please contact the pain
team for more information. If you are unable to locate a pump and you think
your patients care will be compromised then contact a Consultant member of
the pain team and fill in a critical incident form.

The ward nursing staff are not able to give boluses down or flush epidurals.

Generally 10 mls from the pump (instructions to do this are in the back of the
pumps lockbox) should be used for bolusing to avoid the possibility of catheter
contamination. Please ensure that the ward staff aware that a bolus has been
give so that they can increase the level of monitoring. It is imperative that the
anaesthetist should not bolus and disappear!

The pain management nurse specialists are able to bolus epidurals provided
this is prescribed on the epidural prescription in the box provided.



Leeds pain Management Service version 2 (Adult LGI) January 2008. Review January 2009
Website

Please see the Anaesthetic website, Pain Management website or the Leeds
Health Pathways via the LTHT homepage for…

-Coagulation and epidurals guidelines
-All of the RCA recommended Audits on Acute Pain Management
-Pain Management Guidelines
-Non Standard PCA and Epidurals
-Patient information leaflets- Pain after surgery/PCA/Epidural/Entonox etc




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Leeds pain Management Service version 2 (Adult LGI) January 2008. Review January 2009