Ps03 2013 Guidelines For The Management of Major Regional Analgesia
Ps03 2013 Guidelines For The Management of Major Regional Analgesia
Ps03 2013 Guidelines For The Management of Major Regional Analgesia
2013
This document is intended to apply to central neuraxial blocks and all other
techniques where a catheter is inserted and left in situ, or where a significant dose of
local anaesthetic is administered, such that systemic toxicity may occur due to
absorption or inadvertent intravascular injection. It is not primarily intended to include
superficial peripheral nerve blocks such as facial or digital nerve blocks, or low
volume local anaesthetic procedures such as small areas of skin infiltration, although
many of the principles may still apply.
Major regional analgesia may be initiated for pain management alone, such as
providing analgesia in labour or in the perioperative setting for the provision of
perioperative analgesia. This may be combined with, but is distinct from, regional
anaesthesia which is initiated for surgical interventions and which requires
continuous presence of an anaesthetist (see PS53 Statement on the Handover
Responsibilities of the Anaesthetist). In some instances analgesia may follow on
from anaesthesia as a continuation of the technique.
2.1 Major regional analgesia requires the skill and expertise of a proceduralist
who is a medical practitioner, with training and experience in the technique,
or trainees under the supervision of such a practitioner. An understanding of
the relevant anatomy (including sonoanatomy where relevant), physiology,
pharmacology, equipment used and potential complications of the particular
procedure and the contraindications to its use is essential for safe conduct of
these procedures. Prompt treatment of side effects or complications may be
critical.
2.2 Complications of major regional analgesic techniques may occur due to the
physiological changes resulting from nerve blocks, adverse effects from the
2.3 Informed consent from the patient consistent with PS26 Guidelines on
Consent for Anaesthesia or Sedation should be obtained prior to the
institution of any regional analgesia. With respect to major regional
analgesia such discussion should include but not be limited to: nerve injury,
drug toxicity, haemodynamic changes, bleeding or bruising, infection, failed
or incomplete analgesia or post-dural puncture headache. It is recognised
that the timing of obtaining consent in some circumstances may not be ideal
(for example, pain relief in the post anaesthesia care unit (PACU) or in
labour ward (see item 4.2 below)), however, it can often be facilitated by
appropriate prior discussion with the patient. Documentation of such consent
is recommended.
2.6 Infection control measures to be followed, including the use of a sterile field,
facemask, gloves and gowns where appropriate, are stated in PS28
Guidelines in Infection Control in Anaesthesia. Skin preparation should be
conducted in such a manner that agents used for skin preparation are
unable to contaminate drugs or equipment used for neural blockade.
2.9 In addition to monitoring for any specific patient needs, monitoring during
establishment of major regional analgesia should include frequent and
2.10 After initiating the regional block it is the responsibility of the proceduralist to
remain immediately available until a satisfactory block has been achieved,
the patient is stable, and the potential for immediate complications has
passed. If the technique has been instituted for anaesthesia as well as
subsequent analgesia, the anaesthetist must be present for the duration of
that surgical procedure or until handover to another practitioner in
accordance with PS53 Statement on the Handover Responsibilities of the
Anaesthetist has occurred.
2.12 A record of the technique, including method, drugs and dose used,
complications or problems encountered should be documented in the
patient’s medical record by the proceduralist. In addition, instructions for the
subsequent management of the patient should be provided. These include
drug orders and monitoring requirements. Prescription of all analgesic drugs
is the responsibility of the proceduralist.
2.13 Written protocols and procedures should be in place for the continued
management of each technique, its side effects and common complications.
Formal institutional protocols and guidelines for each technique are
recommended.
In addition to the general principles listed above, the safe and effective management
of major regional analgesia, using repeated intermittent bolus doses or continuous
infusions of analgesic drugs via a catheter, requires the following:
3.2 When infusion pumps are utilised, they should be dedicated to use for
regional analgesia infusions only and clearly marked as such. In order to
minimise the risk of inadvertent delivery of excessive amounts of analgesic
drug the maximum rate of infusion, and the maximum size of bolus dose that
can be delivered by the pump should be limited according to the specific
dosage limits for each technique. An infusion pump designed for regional
analgesic infusions, in particular with a maximum infusion rate limit, should
be used wherever possible.
3.3 Tailoring of analgesic regimens to the individual patient requires that regular
assessments of adequacy and adverse effects of analgesic drugs or
techniques are performed and documented.
3.3.1 Monitoring and recording may include a selection from the following
parameters: blood pressure, heart rate, temperature, respiratory
rate, pain scores, sedation score, oxygen saturation, urinary output,
sensory levels and motor function.
3.5 A protocol for catheter removal that relates the timing of removal to the
timing of administration of anticoagulant medication, or in the presence of a
coagulopathy, should be available. A registered nurse, midwife, or other staff
member, with the necessary training, may remove the catheter on the orders
of the proceduralist. Details of the removal of the catheter, the date, time,
and state of the catheter and its tip, as well as the state of the insertion site,
should be documented in the patient’s record.
3.6 Surgical and/or other medical staff caring for the patient should be aware of
the analgesic technique used, its potential complications and any specific
implications for the surgery performed or other management issues for the
patient. The need for appropriate consultation with specialised pain
management staff should be communicated to other medical staff.
In addition to the principles listed above, safe regional analgesia in labour requires
adherence to the following principles:
4.1 Epidural and subarachnoid analgesia have the potential to change many of
the normal physiological processes of labour and delivery. From the time
that regional analgesia is instituted, it is essential that the woman is under
the care of a medical practitioner with obstetric training who can assess her
as necessary, and rapidly effect delivery of the baby by whatever technique
is indicated.
4.4 Skilled staff and monitoring equipment are required throughout regional
analgesia in labour, to ensure care for both woman and foetus, and for
management of any complications arising.
4.5 Following delivery of the baby, the woman should continue to be monitored
until all effects of the block have subsided.
5.3 Equipment and staffing of the area in which the patient is being managed
should satisfy the requirements of the relevant Australian and New Zealand
College of Anaesthetists professional documents, where appropriate.
PS02 Statement on Credentialling and Defining the Scope of Clinical Practice in Anaesthesia
PS09 Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional Medical,
Dental or Surgical Procedures
FURTHER READING
Macintyre PE, Schug SA, Scott DA, Visser EJ, Walker SM; Acute Pain Management:
Scientific Evidence Working Group of the Australian and New Zealand College of
Anaesthetists and Faculty of Pain Medicine. Acute Pain Management: Scientific Evidence.
3rd ed. Melbourne: ANZCA and FPM, 2010. From:
http://www.anzca.edu.au/resources/books-and-publications/acutepain.pdf. Accessed 1
November 2010.
ANZCA professional documents are reviewed from time to time, and it is the responsibility of
each practitioner to ensure that he or she has obtained the current version which is available
from the College website (www.anzca.edu.au). The professional documents have been
prepared having regard to the information available at the time of their preparation, and
practitioners should therefore take into account any information that may have been
published or has become available subsequently.
Whilst ANZCA endeavours to ensure that its professional documents are as current as
possible at the time of their preparation, it takes no responsibility for matters arising from
changed circumstances or information or material which may have become available
subsequently.
Promulgated: 1982
Reviewed: 1987, 1993, 1998, 2001, 2003, 2011, 2013
Date of current document: February 2013
© Copyright 2013 – Australian and New Zealand College of Anaesthetists. All rights
reserved.
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