Clinical Guidelines (Nursing)

Wound Catheter Management

  • Introduction 

    Aim

    Indications and goals

    Definition of Terms

    Insertion

    Assessment of Equipment

    Management and Physical Assessment

    Companion Documents

    Links

    Evidence Table

    References


    Introduction 

    The use of continuous LA infusion may reduce pain and opioid requirement after surgery. It is used as part of a multimodal analgesia strategy. At the time of surgery a catheter is placed alongside a peripheral nerve or beneath the surgical incision to enable the delivery of LA directly where it is needed. Wound catheters are used currently and local anaesthetic delivered using a syringe pump colour coded yellow to identify LA. The syringe pumps are required to be programmed and the syringe refilled by nursing staff on the ward. The syringe pump is heavy and needs to be fixed to a pole which can inhibit mobility and physiotherapy.

    The ON-Q PainBuster® is an elastomeric pump that contains a reservoir of local anaesthetic (LA) that is infused at a constant and preset rate through a catheter that is fenestrated over 4 lengths depending on the catheter used. The soaker catheter can be placed perineurally (alongside a peripheral nerve) or under a surgical incision (wound). The PainBuster® is light and can be carried in a bag for improved patient mobility. The device cannot be refilled and the rate is fixed based on the ON-Q PainBuster® specifications. 

    Aim

    To provide nursing staff with a standardised guideline to enable safe and appropriate care of children with a PainBuster® for post-operative pain relief.

    Indications and goals

    • To  improve pain management and mobility for moderate to severe pain
    • To reduce opioid requirement and side effects

    The device is for continuous infusion of LA through a wound catheter in patients who are likely to have pain at the site of surgery eg: bone/cartilage donor sites, lower limb surgery and laparotomy. It is also used for continuous infusion of LA perineurally after upper limb or lower limb surgery where blocking a peripheral nerve’s conduction, is likely to reduce postoperative pain.

    Definition of Terms

    • Local anaesthetic: is a medication used to block pain in a specific surgical area by reversibly decreasing the rate of depolorisation and repolarization of excitable membranes (noiciceptors)
    • Elastomeric pump: is a small disposable pump that continuously delivers local anaesthetic which is connected to an ON-Q soaker catheter
    • The ON-Q soaker catheter: is a tube similar in size to an epidural catheter with fenestrations along a variable length (2.5cm, 6.5cm, 12.5cm and 25cm) and black markings indicating the distance from the most proximal fenestration. 
    • Wound: is any surgical incision requiring pain management using local anaesthetic

    Insertion

    • The soaker catheter is inserted, and the ON-Q PainBuster® device filled and attached in the operating theatre.
    • The soaker catheter must not be cut / shortened
    • Infusion soaks through the small fenestrations in the catheter as shown in Fig1

    Wound Cath Fig 1

    Fig1 Soaker Catheter (above)

    Assessment of Equipment

    • The tubing attached to the soaker catheter has a clamp. In order to work, the clamp must be unclamped.
    • At the time of filling, the elastomeric pump is round and firm. It should always be filled to its specified volume as delivery becomes inaccurate if it is under- or over-filled.
    • There are three layers:  the inner layer is where the anaesthetic agent is placed and does not contain natural rubber latex. The middle layer is made from natural rubber latex. The outer layer is PVC.
    • The elastomeric pump is pressurized to deliver LA at a specified rate that cannot be adjusted. 
    • The rate may be 2ml/h or 5 ml/h depending on the pump specification.
    • The time that the pump empties will depend on the volume of the elastomeric pump attached to the soaker catheter. For example, a 100ml ON-Q PainBuster® delivering at 2 ml/h will be empty 50 hours after the clamp is unclamped. A 270ml  ON-Q PainBuster® delivering at 5 ml/h will be empty 54 hours after the clamp is unclamped.   
    • During the infusion the elastomeric pump will lose shape, the outer layer will become wrinkled and the inner layer will take the appearance of a core as it deflates. It is not possible to determine if the pump is fully discharged (empty) by observing it.

    Wound Cath Fig2

    Fig 2. The ON-Q PainBuster® (above)


    Management and Physical Assessment

    • Acute management on return to the ward:
    • patients require routine post operative clinical observations as per the routine post anaesthetic observations guideline 
    • hourly pain assessment recorded on the flowsheet LDA assessment
    • check soaker catheter exit site at the skin and the operative wound dressing for excessive leak
    • ensure the fenestrations are within the wound (the distance from the most proximal soaker catheter fenestration can be determined by looking at the black markings on the soaker catheter). The first double black lines close together is at 10cm from the most proximal fenestration.
    • ensure the tubing is secured to the skin (Fig 3)
    • do not tape over the filter
    • check catheter is connected to the pump (Fig 2)
    • check catheter is unclamped
    • ensure the pump is not under the bedcovers (to avoid heating as the pump is calibrated to room temperature)
      Wound Cath Fig3

    Fig 3. Securing the tubing (above)

    Ongoing management

    • Infusion to continue until the date and time specified by the anaesthetist prescriber after which the soaker catheter can be removed and the whole system including the pump be disposed of appropriately
    • Assess for LA toxicity (link to Anaesthesia and pain Management regional/epidural)
    • Pain assessment – the ON-Q PainBuster® is used as part of a multimodal analgesia regimen and other additional analgesia will often still be necessary.
    • Managing complications/troubleshooting, catheter dislodged, pump not infusing, pain increasing despite analgesia medications and PainBuster® contact CPMS

    Removing the PainBuster® catheter

    • Explain the removal technique to patient if age/cognition appropriate and to the carer
    • Use Comfort Kids guidelines for procedures 
    • Use aseptic technique and universal precautions as per guideline
    • Lift the dressing securing the soaker catheter in place and loosen adhesive at the catheter site if present
    • Gently pull the soaker catheter out in one smooth movement, holding the catheter close to the exit site at the skin.
    • There may be some initial resistance if dermabond® has been used to prevent catheter migration. The catheter should be easily removed and is not painful
    • If any resistance stop and contact surgical team
    • Check the distal end marker to ensure the tip is intact
    • Cover site with a clear dressing

    Companion Documents

    Links

    Regional anaesthetic 

    Evidence Table

    The evidence table for this nursing guideline can be found here

    References

    Photos supplied with permission from the product specialist and trainer for ON-Q


    Please remember to read the disclaimer.


     

    The development of this nursing guideline was coordinated by Sueann Penrose, Clinical Nurse Consultant, Children's Pain management Service, and approved by the Nursing Clinical Effectiveness Committee. Updated February 2017.