Assisting with Insertion. Care of Intraspinal Catheters

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Erin Sanders
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1 Guidelines included: Assisting with an Insertion Care of Various types of Intraspinal s Care of the Intraspinal Infusion Monitoring Removal of the Short Term Non Assisting with Insertion INR should be obtained and assessed prior to insertion Ensure that informed consent has been obtained by the MD Establish IV access and ensure Narcan and Ephedrine are available on the unit Obtained the necessary equipment from PACU Assist with patient positioning sidelying or over an overbed table Care of Intraspinal s Short-term Non- Intraspinal Intraspinal Dressing Changes Q weekly and if dressing becomes wet or loose.if a gauze dressing is under the transparent dressing it must be changed q 72 hours. Occlusive transparent dressing at site on lower back Cloth/Mefix tape to be used up distal length of catheter along back The catheter adapter end is looped over the shoulder Strict aseptic technique similar to central line procedure. Glove and mask are used. Q weekly and if dressing becomes wet or loose. If a gauze dressing is under the transparent dressing it must be changed q 72 hours Occlusive transparent dressing at site on patient side or abdomen Strict aseptic technique similar to central line procedure. Glove and mask are used. Filter/ Tubing Changes Q weekly under strict aseptic techniqueoptimally is best to coordinate tubing change with the cassette/bag change. Limit opening the system as much as possible Q weekly under strict aseptic technique. optimally is best to coordinate tubing change with the cassette/bag change. Limit opening the system as much as possible Cleansing Cleanse with providone-iodine in circular fashion. Cover a diameter of 2-3 inches and allow 2-3 minutes for area to dry completely. Cleanse with providone iodine in circular fashion. Cover a diameter of 2-3 inches and allow 2-3 minutes for area to dry completely. Other This catheter may or may not be sutured; extreme caution must be taken not to dislodge catheter. Peeling the dressing toward the insertion site is recommended. Steri- strips or sutures may be used to stabilize the catheter under the transparent dressing. Steri strips must be replaced with each dressing change. Dislodgment and infection are less common with this type of catheters. Intraspinal Guidelines p. 1 03/31/03

2 Care of the Continuous Infusion Prior to initiating intraspinal analgesia all medications and dosing must be assessed and evaluated for appropriateness. Continuous intraspinal infusions are to be administered via the specified intraspinal infusion device: Oncology- CADD pump, Palliative, Western Microject Epidural Pump or Microjet PCA for Intrathecal Ensure medication infusing as per physician's order - medication, dosage and rate of infusion and document on the Epidural Flow sheet Verify the system, check all connections and ensure they are secure and dry. If a disconnection is discovered wrap the free end with a sterile gauze and notify Anesthesiologist. The Reg.N. may infuse subsequent infusion bags/cassettes and change infusion rates according to physician's order and after checked by a second Reg.N./ person (in the home). No cleansing agents such as alcohol swabs to be used on connecting port/adapter of the intraspinal catheter. Alcohol is neurotoxic. The tubing should be changed in conjunction with the medication bag to avoid opening the system unnecessarily If an injection cap is used at the end of the catheter it must be changed at the time of the tubing change. Maintain a patent IV site while maintenance dosing is being established. As a guideline hourly volume for epidural route is mls/ hr and for intrathecal route is.3 to.7 mls/hr. Patient may receive other systemic narcotics while receiving intraspinal. Procedure for Set Up : Confirm bag label with MD orders and confirm with second RN/ person Prime specified pump tubing with solution from bag/cassette under strict aseptic technique. Attach filter. Turn off the infusion pump and clamp tubing (not catheter) and remove from pump. Insert new primed system into the pump. Disconnect old tubing at the catheter adapter and pump tubing connection and attach new primed system. Ensure all connections are tight and secured with tape. Tape all ports with tape. Label the new tubing and pump as INTRASPINAL DO NOT INJECT Re-initiate the pump at the prescribed rate. Intraspinal Guidelines p. 2 03/31/03

3 Intraspinal Infusions with Narcotics Writing orders for patient monitoring requirements during infusion is the MD s responsibility. The following are minimal guidelines and should be adjusted as the patient conditions warrants. Monitoring Activity Pain Scale Respiratory Rate Sedation Score (LOC) Urinary Retention Pruritis (head, face, neck) Nausea & Vomiting Parameters 1 st 24 hours Met Campus If > 3 requires intervention If <8 or <than specified notify MD Notify physician if sedation score > 2 If unable to void notify MD Notify MD if present. Intraspinal Infusions with Narcotics & Anesthetics Western Campus/ or with each or with each or with each or with each or with each or with each Monitoring Parameters 1 st Western Campus/ 24 hours Met Campus Activity or with each Pain Scale If > 3 requires intervention Respiratory If <8 or <than specified or with each Rate notify MD Blood Pressure If SBP less than 80 mm Hg and prior to or with each or as indicated by MD ambulation Notify MD Sedation Notify physician if sedation or with each score > 2 Block Level Notify M.D. if motor block or with each or sensation is higher than specified Skin Breakdown Notify MD prn Intraspinal Guidelines p. 3 03/31/03

4 Insertion Site of Intraspinal Observe for: 1 st 24 hours Met Campus Leakage Infection (redness, swelling, drainage) Bleeding Induration, Pain Western Campus/ or with each Exit Site of Transparent dressing Tubing Migration Leakage Infection (redness, swelling, drainage) Bleeding Induration, Pain Intactness All connections are secured and labeled and taped Exterior portion markings to be noted or measured on nontunneled catheters or with each or with each or with each Q 8h or with each General Monitoring All patients having a continuous intraspinal catheter will be monitored as outlined on the Epidural/Intrathecal Management -24 hours flowsheet and as indicated on the physician s orders. Areas for assessment include: level of sedation (LOS), Pain Scale (0-5), strength, sensation, side effects, and infusion related observations. The nature and frequency of patient monitoring will be individualized for each patient based on their present condition. Evaluate Assess findings relative to the patients palliative status and the intraspinal therapy. Monitor and document analgesia order and amount received q shift and with each assessment. The nurse is advised to notify the physician if assessment findings reveals any of the following. The nurse may stop the infusion if the patient s condition warrants: Decreased BP as indicated on MD orders Sedation level (LOS) > 2 Decreased Respiratory Rate as indicated on MD orders Decreased motor function Severe back pain Intraspinal Guidelines p. 4 03/31/03

5 Dizziness, seizure, confusion, complaints of metallic taste, tinnitus, visual disturbances (this may be due to the intraspinal catheter migrating into a blood vessel with inadvertent IV administration of a local anesthetic agent) Drugs not infusing (blockage), disconnection from pump tubing, migration of catheter, leaking catheter Drainage, redness, induration and pain at the site, Anaphylactic reaction Procedure Removal ( Short term ) Check re: anticoagulation of patient (i.e., platelet count, INR) if appropriate. If increased the MD should remove catheter. Position patient so that back is arched (side lying with knees up or leaning over the overbed table) Remove tape and dressing. Remove sutures if indicated Pull catheter out slowly and maintaining tension. Stop if resistance is encountered. May attempt to have patient increase arch of back. Check that catheter is intact. Note coloured tip should be present. Observe the area for bleeding, redness, edema or drainage. Cleanse insertion site with saline and cover area with bandage. Anesthetists should be notified and removal stopped if: does not withdraw easily or if colour tip not present. Patient complains of pain or electric shock in back of leg or down the leg; Excessive bleeding at skin site. Document removal, catheter intact with presence of coloured tip, site appearance and patient tolerance Intraspinal Guidelines p. 5 03/31/03

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