clinical practice guideline · assessment of current scientific and clinical research information....

Clinical Practice Guideline

Peripheral Nerve Blocks in Upper and

Lower Extremity

Authors

Peggy Barksdale MSN, RN, OCNS-C, CNS-BC

Melissa Yager MS, RN, CNS, ONC

Reviewers

Kathy Bomar, BSN, RN, ONC, CNRN

Charla Johnson, MSN, RN, ONC

Deanna Leach, MS, ARNP, ONC

NAON Clinical Practice Guideline: Peripheral Nerve Blocks in Upper and Lower Extremity of 19 [Type text] [Type text]

Copyright 2014

National Association of Orthopaedic Nurses

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means,

electronic or mechanical, including photocopy, recording, or any information storage and retrieval system without

the written permission of the National Association of Orthopaedic Nurses.

Published for NAON by:

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[email protected]

Disclaimer

This clinical practice guideline (CPG) was developed under the direction of the National Association of Orthopaedic

Nurses Evidence-based Practice and Research Committee and is provided as an educational tool based on an

assessment of current scientific and clinical research information. The tool is not intended to replace a clinician’s

independent judgment and critical thinking but to enhance the clinician’s ability to manage care of the orthopaedic

patient with a peripheral nerve block in the upper or lower extremity. Individual facility specific policy and

procedure should be followed relating to care of the orthopaedic patient with a peripheral nerve block.

Levels of Evidence

The evidence within this clinical practice guideline is rated to differentiate evidence of varying strengths and

quality. “The underlying assumption is that recommendations from strong evidence of high quality would be more

likely to represent best practices than evidence of lower strength and less quality” (Newhouse, 2007, p. 90). Refer

to the Appendix for an explanation of the levels of evidence contained within this guideline.

mailto:[email protected]


Table of Contents

Introduction ................................................................................................................................................ 4

Purpose ....................................................................................................................................................... 5

Rationale for Guideline ................................................................................................................................ 5

Goal of Clinical Practice Guideline ................................................................................................................ 5

Assessment of Scientific Evidence ................................................................................................................. 5

Nursing Diagnosis ........................................................................................................................................ 6

Description .................................................................................................................................................. 6

Definition of the Problem ............................................................................................................................. 7

Pathophysiology .......................................................................................................................................... 7

Utilization of Clinical Quality Indicators ....................................................................................................... 7

Nursing Interventions and Expected Outcomes............................................................................................. 7

Patient Care Management ........................................................................................................................... 9

Interventions ............................................................................................................................................ 9

Diagnostic Tests ..................................................................................................................................... 11

Risk Factors and Association Complications ............................................................................................ 11

Education – Patient & Family:................................................................................................................. 12

Discharge Destination ................................................................................................................................ 12

Trends and Controversies ........................................................................................................................... 13

Web Sites .................................................................................................................................................. 14

Professionals: ......................................................................................................................................... 14

Patient and Family: ................................................................................................................................ 14

References ................................................................................................................................................. 15

Appendix: System for Rating the Strength of Evidence ............................................................................... 19


Introduction There are an estimated 644,243 total knee replacements (Agency for Healthcare Research and Quality, 2011c) and

305,755 total hip replacements (Agency for Healthcare Research and Quality, 2011b) done in United States

annually. Statistics of anesthesia injected peripheral nerve block (PNB) (Agency for Healthcare Research and

Quality, 2011a)listed 131,645done annually.

Orthopaedic surgery has lent itself to regional anesthesia due to the ability to isolate anesthesia to the extremity

being operated on. The name regional anesthesia came about as the method of blocking a nerve plexus under

direct vision during general anesthesia as to reduce anesthesia requirements and provide pain relief post-

operatively (Hadzic, 2007) (Level V).

Regional anesthesia for total joint replacement, upper and lower extremity fractures and anterior cruciate ligament

reconstruction, has shown to be beneficial with few major complications in the literature (Brull, Prasad, & Chan,

2009) (Level III), (Williams, et. al., 2006) (Level II), (Chan, Fransen, Parker, Assam & Chua, 2012) (Level I), (Parker,

Griffiths,&Appadu, 2009) (Level III), (Stone, Wang,& Price, 2008) (Level III). Peripheral nerve block is a favorable

regional anesthetic/analgesic option for extremity surgery and provides perioperative benefits. There are

numerous types of peripheral nerve blocks such as femoral, sciatic, popliteal fossa, lumbar plexus, tibial, peroneal,

saphenous, obturator, psoas, adductor canal, interscalene, supraclavicular, infraclavicular,and axillary. Peripheral

nerve block can be a single injection which has a limited duration of local anesthetic action, or be a continuous

peripheral nerve block (CPNB) which offers prolonged analgesia, or a combination of both (Hadzic, 2007) (Level V).

There is increasing popularity of CPNB with less side effects than an indwelling epidualcatheter and it extends relief

in the post-operative recovery period (Wiegel, Gottschaldt, Hennebach, Hirschberg, &Reske, 2007) (Level IV).

Table 1. Types of Peripheral Nerve Blocks

Name of Block Location of Surgery Examples Location of

Nerve Block

Interscalene block Mid humerus to

shoulder

Rotator cuff repair

Shoulder arthroscopy

Clavicle surgery

Neck

Supraclavicular block

or infraclavicularblock

Elbow and below

(elbow, forearm or

hand)

Wrist fracture

Wrist arthroscopy

Hand surgery

Above or below

collarbone

Axillary block Elbow and below

(elbow, forearm or

hand)

Wrist fracture

Wrist arthroscopy

Hand surgery

Axilla

Brachial Plexus nerve

block

Shoulder or humerus Total joint replacement

Fractures

Neck

Femoral nerve block Knee Partial joint replacement

Total joint replacement

ACL repair

Upper thigh

Sciatic nerve block Knee Partial joint replacement

Total joint replacement

Buttock


Popliteal nerve block Foot or ankle Achilles tendon repair

Foot procedures

Side of thigh or

behind knee

Lumbar plexus block Hip Hip arthroscopy

Total hip replacement

Back

Lateral cutaneous

Psoas

Subcostal

Hip Hip fracture Back

Adapted from “Peripheral nerve blocks” by FOAA Anesthesia Services, n.d.;“Nerve blocks (subcostal, lateral

cutaneous, femoral, triple, psoas) for hip fractures (review),” by M. Parker, R. Griffiths, and B. Appadu, 2009,The

Cochrane Collaboration 2, pp.2-3. Copyright 2009 by the Cochrane Library; and“Femoral nerve blocks for acute

postoperative pain after knee replacement surgery (protocol)” by E. Chan, M. Fransen, D. Parker, P. Assam, and N.

Chua, 2012,The Cochrane Collaboration7, p.2.Copyright 2012 by the Cochrane Library.

Purpose The purpose of the clinical practice guideline for PNB in the upper and lower extremity is multifactorial (1) to

maintain safety and decrease risk of injury to the patient; (2) to educate nurses on the assessment, ongoing

monitoring for pain and symptoms of anesthetic toxicity, and potential complications. This clinical practice

guideline also provides an explanation of the pathophysiologic mechanisms involved and the steps to be

implemented to ensure patient safety, quality of care and positive outcomes.

Rationale for Guideline Due to the increasing use of PNBsit is necessary to be aware of complications, particularly falls occurring in this

susceptible population (Marcus, 2009) (Level V). Orthopaedic nurses care for patients that have nerve blocks in

both in-patient and out-patient settings (Pulido, Colwell, Henpecked,& Morris, 2002) (Level II). Anesthesia

continues to introduce various types of PNBs. Nursing has been seeking direction to provide safe/quality care of

patients with nerve blocks by using evidence-based practices.

Goal of Clinical Practice Guideline The goal of the CPG is identification of evidence-based measures that will provide orthopaedic nurses with the

knowledge base needed to effectively deliver high quality care among patients undergoing surgery of the upper

and lower extremities utilizing nerve blocks for anesthesia/anesthetic pain management.

Assessment of Scientific Evidence Studies have shown PNBs and CPNBs have a reported low incidence of complications and promote better

postoperative analgesia, increased patient satisfaction, and have positive influence on surgical outcome and

patient rehabilitation when compared with intravenous opioids. Anesthetic literature identifies that the

complications may be the result of under-reporting. Major complications are rare. However, minor adverse effects

associated with CPNB may be more common. One caution is that the motor blockade of the knee may be


prolonged thus preventing early mobilization, affecting quadriceps weakness, and placing patients at risk of falling.

Another less reported caution is associated with supraclavicular nerve blocks and the risk for phrenic nerve palsy

(Cornish, et al., 2007) (Level IV). The literature presents studies that challenge variable limitation such as the

control group inclusion, sample size, type of surgery, technique or pain relief of CPNB (Brull, Prasad, & Chan, 2009)

(Level III), (Wiegel, Gottschaldt, Hennebach, Hirschberg, &Reske, 2007) (Level IV).

Nursing Diagnosis Risk for infection

Risk for injury

Risk for falls

Potential for peripheral neurovascular dysfunction

Risk for ineffective tissue perfusion: peripheral

Risk for impaired mobility (walking)

Risk for impaired transfer ability

Potential for knowledge deficit

Risk for anxiety

Risk for acute pain

Risk for ineffective breathing pattern

Description Peripheral nerve blocks are typically performed for surgeries of the upper and lower extremities but can also be

used for surgeries around the neck or groin.The operative part is exposed and prepped with antibacterial agent

(e.g., chlorhexidene).The patient may or may not be sedated when the procedure is performed. Peripheral nerve

block is accomplished by injecting a local anesthetic near the nerve/nerves that controls sensory and motor

function to a specific part of the body. Administration of this local anesthetic involves three elements: a syringe, a

needle, and a local anesthetic drug. The injection will temporarily numb the area. Ultrasound, which is preferred,

or a nerve stimulator is used for correct placement (Ehlers, Jensen, &Bendtsen, 2012) (Level II), (Swenson, et al.,

2006) (Level III). If a stimulator is used, a 2-inch, 21 gauge needle catheter is attached to the nerve stimulator to

locate the nerve. The catheter is tunneled with the use of a nerve stimulator in which the stimulation current must

be sufficient to elicit appropriate muscle twitch. The needle attached to the nerve stimulator is flushed with local

anesthetic solution. The needle continues to advance until twitching of the muscles is observed. The nerve

stimulator current is decreased. The effects of a peripheral nerve block are dependent on the medication used and

can last 8-24 hours (FOAA, 2014) (Level V). Peripheral nerve blocks can be either combined with general

anesthesia or epidural/spinal anesthesia or used as sole anesthetic (Sharma, Iorio, Specht, Davis-Lepie, & Healy,

2010) (Level III).

The anesthesiologist often uses a percutaneous catheter and a small lightweight portable infusion pump.

Adisposable mechanical or electronic pump that is able to maintain a constant flow rate or have a bolus option

places the local anesthetic into the wound regionally versus systemically (Richman, Lui, Courpas, et al.,2006) (Level

III).


Definition of the Problem In today’s anesthetic practice, regional anesthesia is performed with high success and few complications. Serious

adverse effects are rare.Adverse effects can be categorized as: local anesthetic toxicity, complications of needle

placement, or spillover of local anesthetic to the surrounding neural structures (Graber &Kraay, 2010) (Level

IV).Local anesthetic systemic toxicity (LAST) can occur because of unplanned intravascular injection or slow

absorption from the injection site. This can manifest as reactions ranging from auditory changes,

circumoralnumbness, and agitation to seizures and central nervous system (CNS) depression. Complication of

needle placement can include hematomas, dysesthesias, and other problems related to a specific nerve block.

Other adverse effects reported in the literature emphasize peripheral nerve injury, positive bacterial colonization,

hypotension, technical problems such as kinked, blocked, displaced or breakage of the catheter, unwanted alarms,

failure of pain relief, and incidences of persistent weakness in the femorisquadriceps.Decreased quadriceps

function may prevent early mobilization and place the patient at an increased risk of falling(Sharma, Iorio, Specht,

Davis-Lepie, & Healy, 2010) (Level III),(Watts & Sharma, 2007) (Level III), (Capdevila, Pirat, Bringuier, Gaertner,

Singelyn, et al., 2005) (Level IV), (Muraskin, Conrad, Zheng, Morey, &Enneking, 2007) (Level IV), (Wiegel,

Gottschaldt, Hennebach, Hirschberg, &Reske, 2007) (Level IV).

Pathophysiology A peripheral nerve is a complex structure consisting of fascicles held together by the epineurium, an enveloping

external connective sheath. Each fascicle contains many nerve fibers and capillary blood vessels embedded in a

loose connective tissue, the endoneurium. The perineurium is a multilayered epithelial sheath that surrounds

individual fascicles. Nerve fibers depend on a specific endoneurial environment for their function (New York School

of Regional Anesthesia, 2012) (Level V).

Local anesthetics are chemicals that inhibit neural excitation by preventing membrane depolarization. Anesthetics

interfere with the neuronal membrane's permeability to sodium. Disruption of sodium exchange results with the

inhibition the neuronal impulses between the affected extremity and the brain. This affects the sensory, motor &

sympathetic pathways, leaving the patient unable to feel or move the anesthetized extremity (Muraskin, Conrad,

Zheng, Morey, &Enneking, 2007) (Level IV).

Utilization of Clinical Quality Indicators Clinical quality indicators allow for the identification of areas that need improvement and serve as evidencebased

guides that assist with the measurement of the quality and safety of patient care (Smith, 2011) (Level II). Clinical

quality indicators specific to nerve block guidelines include improving patient safety and reducing risk of adverse

events and the prevention of complications (American Society of Anesthesiologists, 2012) (Level V).

Nursing Interventions and Expected Outcomes Expected Outcomes:

1. Optimal pain management using a multimodal pain management approach and in collaboration with health

care providers (National Association of Orthopaedic Nurses, 2013) (Level VI)

2. Return of neuromuscular function and sensation


Assessment (including physical examination):

1. Review physician orders

2. Vital signs

3. Pain assessment, including the need for additional measures taken to control pain

4. Neurovascular assessment with attention to the sensory and motor responses below point of block

a. Color: pink, pale, cyanotic

b. Temperature: warm, cool, cold

c. Capillary refill: < 3 sec > 3 sec

Rapid, sluggish

d. Edema:None

+1 (barely detectable)

+2 (indent < 5 sec)

+3 (indent 5-10 sec)

+4 (takes 30 sec to rebound)

Shiny, Taut, Dependent, Weeps, General (anasarca)

e. Sensation:Present, Decreased, Absent with or without stimulation

i. Peroneal nerve- head of fibula to dorsum of foot

ii. Tibial nerve- ventral surface of foot

iii. Radial nerve- dorsal surface of hand, proximal part of first and second finger

iv. Median nerve- palmer aspect of web space between thumb and first finger

v. Ulnar nerve- fifth finger

f. Motion:Active (moves per self)

Passive (moves with assistance)

i. Dorsiflexion

ii. Plantar Flexion

iii. Toe extension

iv. Finger abduction. hyperextension, opposition

v. Wrist flexion

g. Pulses: Graded on a 0-4+ scale : 0 indicating no palpable pulse, 1+ indicating a faint but detectable

pulse, 2+ indicating a slightly more diminished pulse than normal, 3+ indicating a normal pulse, 4+

indicating a bounding pulse. (Hill&Smith, 1990)

i. Pedal: above dorsi-pedal artery of foot

ii. Post-tibial: inner larger bone between knee & ankle, posterior to medial malleolus

iii. Popliteal: behind the knee

iv. Groin/Femoral: depression between thigh & trunk

v. Radial: inner wrist

vi. Ulnar: opposite the thumb

vii. Brachial: antecubital space at elbow


h. Muscle strength (Seidel, 2011) (Level VI)

Muscle test is scored as follows:

i. No evidence of movement: Grade 0

ii. Trace of movement: Grade 1

iii. Full range of motion, but not against gravity (passive movement): Grade 2

iv. Full range of motion against gravity but not against resistance: Grade 3

v. Full range of motion against gravity and some resistance, but weak: Grade 4

vi. Full range of motion against gravity, full resistance: Grade 5

5. Catheter site inspection with visual inspection of catheter site to assess for redness, edema, induration, drainage, pain and intact dressing, and leakage around catheter

a. With a CPNB leakage is common: reinforce site, do not change or remove original dressing

6. Catheter inspection to ensure it is free of kinks and the clamp is in the open position

7. Skin inspection paying attention to areas of sensory deficit

8. Assess quadriceps weakness for femoral nerve block

9. Assess respiratory effort or loss of sensation at the level of the diaphragm for an interscalene or supraclavicular nerveblock

10. Examine the infusion pump (for CPNB) and medication label for patient identifiers, drug name, drug concentration, volume and rate. Label CPNB tubing with “nerve block” label and trace line from pump to patient to prevent inadvertent intravenous administration.

11. Assess and report signs of LAST to the physician or anesthesiologist including:auditory changes, circumoral numbness, metallic taste, agitation, seizures, CNS depression.

12. Document assessment findings routinely and with changes.

(Barker &Sikorski, 2007) (Level VI), (Parker, Griffiths &Applaud, 2009) (Level III), (Illfeld&Enneking, 2005) (Level II),

(Capdevila, et al., 2005) (Level III), Sargent,&Dunfee, 2005) (Level V), (Barnett & Strickland, 2007) (Level VI),

(Mahler, Salmond,&Pellino, 1998) (Level VI), (Altizer, 2007) (Level VI), (Neal, et. al., 2010) (Level V).

Patient Care Management

Interventions

Nursing interventions used in PNB focus on prevention of complications. Staff and patients should be educated to the insensate extremity. When a patient is unable to feel or move the extremity they are subject to harm.

1. Preoperative

a. Educate patient on the purpose and use of a peripheral nerve block to control pain

b. Educate the patient to be careful of insensate extremities

c. Educate the patient on the pain rating scale and the parameters for increasing/decreasing for CPNB’s per physician order

d. Educate patient that this is one modality of pain management and other medications will be available if block alone is ineffective for pain control

2. Intraoperative


a. Pad bony prominences

b. Assess skin

3. Postoperative

a. For all peripheral nerve blocks

i. Anesthesia or credentialed nursing staff may initiate, adjust and/or administer boluses

through the catheter. This may vary by specific state Nurse Practice Act

ii. Monitor the patient for analgesic efficacy and side effects

iii. Use analgesic(s) for breakthrough pain as ordered and anticipatory of block wearing off

iv. Inspect operative extremity

v. Avoid direct skin contact with ice or heat

vi. Pad and protect the extremity

vii. Evaluate activity levels and perform a functional assessment for safe patient

transfer/ambulation

viii. Initiate fall prevention strategies for safe ambulation, especially with lower extremity blocks

until sensory and motor function returns

ix. The order to discontinue the CPNB catheter must be obtained prior to removal

x. Use a licensed professional with demonstrated competency to remove the CPNB catheter,

noting organizational policies and state laws. The patient or family member may remove

the CPNB catheter only if ordered and only after being instructed

xi. The nurse should verify the end of the catheter is intact after removal

xii. Document findings and treatments

b. For upper extremity nerve blocks

i. Use sling until sensory/motor function returns

ii. Assess for Horner’s syndrome (ipsilateral pupillary constriction, hoarseness, nasal

congestion or conjunctival hyperemia)

iii. Assess for signs and symptoms of pneumothorax (respiratory distress, hypoxemia,

hypotension, or tachycardia)

c. For lower extremity nerve blocks, CFNB and FNB

i. Instruct not to bear weight without the use of a knee immobilizer if ordered by physician

ii. Assess for muscle strength prior to ambulation

iii. Ambulation may need to be supervised or restricted until quadriceps function intact

iv. Implement fall prevention strategies

1. Apply gait belt or other assistive devise(s)

2. Lock and lower bed

3. Apply non-slip footwear

4. Emphasize that the patient is never to get up without help

5. Position call light within reach or stay with the patient


v. Dangle to rule out orthostatic hypotension

vi. Use a team approach with two or more staff to transfer a patient with CPNB

vii. Encourage use of the unaffected limb to direct movement

viii. Avoid asking the patient to pivot or turn with the anesthetized leg (unable to perform)

ix. Limit time up to reduce muscle fatigue

x. Educate patient and staff about the increased fall risk and document

(ASA, 2012) (Level V), (Brull, McCartney, Chan, & El-Beheiry, (2007) (Level III), (Capdevila, et al., 2005) (Level III),

(Graber &Kraay, 2010) (Level III), (McCamant, 2006) (Level VI), (Woodard, 2009) (Level V).

Diagnostic Tests These diagnostic tests are ordered and utilized for the insertion and placement of PNB and CPNB by the

Anesthesiologist.

Ultrasonography is a diagnostic technique in which high-frequency sound waves are directed at internal body

structures, and a record is made of the wave pulses as they are reflected back through the tissues. The different

acoustic densities differentiate between solid and cystic structures and thereby form an “image” of what organ

being studied (Pagana&Pagana, 2002) (Level V).

Nerve stimulator is a medical device in which a stimulation needle is placed sufficiently close to the target nerve,

predefined electrical pulses generate muscle contractions at motor efferent fibers and electrically elicited

paresthesias at sensory afferent fibers. During this procedure, direct contact of the injection needle with the nerve

is intentionally avoided. The nerve stimulator is intended only for the pre-operative localization of nerves; under no

circumstances may it be used on a patient during surgery. (B. Braun Medical, 2009) (Level V).

Risk Factors and Association Complications 1. Neurological complications

a. Injury or anesthetic blockade of adjacent structures

b. Mechanical trauma to the nerve by needle or intrafascicular injection

c. Neuronal ischemia

d. Inadvertent needle placement into unwanted locations

e. Neurotoxicity of local anesthetics

f. Foot drop

g. Phrenic nerve palsy, usually effected unilaterally

i. May report difficulty breathing or shortness of breath

ii. Lung sounds may be diminished on the affected side

2. Hematoma

3. Infection

4. Falls

5. Drug error

6. Local anesthetic systemic toxicity (LAST)

a. Symptoms progress from tachycardia and hypertension to ringing in the ears, metallic taste in the

mouth, numbness of lips, twitching of the eyes and lips and seizures


(Clifford, 2011) (Level V), (Marcus, 2005) (Level V), (Blumenthal, et. al., 2006) (Level IV), (Brull, McCartney, Chan, &

El-Beheiry, 2007) (Level III),(Erickison, Louis,& Naughton, 2009) (Level V), (Gupta, Dhulkhead, Divekar,&Gupta,

2009) (Level V),(Cornish, et. al., 2007) (Level IV).

Education – Patient & Family: 1. Inform patient to expect feelings of numbness and tingling in the recovery period

2. Inform patient that postsurgical pain will return once the block resolves

3. Teach patient to protect any areas with altered sensation (with movement, heat, cold)

4. Inform patient that pain will return once nerve block wears off and to notify the nurse to ensure adequate

pain control

5. Explain side effects and contraindications of medications and use the teach-back method for patient/family

understanding

6. Instruct patient for signs and symptoms of infection including temperature of more than 101.5 F, redness,

drainage from the catheter site, excessive swelling or bleeding of the operative extremity, and pain that is

not relieved with medication or rest

7. Patients discharged home with a CPNB infusion pump

a. Strongly recommend a caregiver be present for the duration of the local anesthetic infusion and be

available while the catheter is in use

b. Provide patients with verbal/written instructions and contact numbers in which to call immediately

if:

i. The catheter site displays signs of infection

ii. The extremities show signs and symptoms of compartment syndrome

iii. The patient shows symptoms of local anesthetic toxicity

c. Provide detailed directions regarding use of the infusion pump, including how to stop the infusion,

catheter site care, and removal to patient/caregiver.

d. Instruct patient to call provider if the motor and sensory effects do not resolve in 36 hours

8. Block specific teaching

a. Femoral blocks

i. Instruct patient not to get out of bed without assistance

ii. Instruct patient to use brace or remain NWB until quadriceps function is fully returned

iii. Have patient demonstrate proficiency with assistive devices prior to discharging home

b. Brachial Plexus blocks

i. Instruct patient to pad areas near the ulnar and radial nerves

ii. Use of a sling until sensory and motor function returns is recommended

(McCamant, 2006) (Level V), (Iflo, 2004) (Level VI).

Discharge Destination Patients can be discharged to a variety of settings post-operatively with continuous perineural infusion pumps to

include home, extended care facilities or rehabilitation centers. Prolonged perineural infusion does not necessitate

hospitalization. If the patient is going home they will need to demonstrate proficiency with assistive devices

(crutches/walker) and ability to state a plan for dealing with obstacles (e.g., stairs).


It is recommended to have a caregiver present for the duration of the local anesthetic infusion if the patient is

discharged home. The caregiver should be instructed on the post-operative and pain management plan while the

catheter is in use.

Along with standard post-operative instructions, the patient and caregiver should be provided with verbal and

written information to include contact numbers to call immediately if the catheter site displays signs and

symptoms of infection or if the patient has symptoms of local anesthetic toxicity educate the patient/ caregiver to

call 911. Detailed instructionsinclude infusion pump use, expectations regarding surgical block resolution,

breakthrough pain management, and catheter site care. The patient should be instructed to sponge bathe instead

of showering. Instruction on the catheter removal plan should be communicated to include inspection of the

catheter tip at discontinuation.The patient should be instructed not to drive or operate heavy machinery

(McCamant, 2006) (Level V) (Clifford, 2011) (Level VI), (Ilfeld&Enneking, 2005) (Level II), (Sargent &Dunfee, 2005)

(Level V).

Trends and Controversies The use of peripheral nerve blocks may become a mainstay of perioperative pain management.

The multimodal approach for postsurgical pain management is critical to patient recovery with peripheral nerve

blocks. Possible examples include but are not limited to: pharmacological agents (e.g., oral/intravenous/topical)

and non-pharmacological interventions (e.g., distraction/thermal/imagery).

Bupivacaine liposome (Exparel®) is classed as amide anesthetic/analgesic and is approved by the Food and Drug

Administration as a single infiltration into the surgical site to produce post-surgical analgesia. It is not a peripheral

nerve block. It is being used as part of multimodal pain management.

Updates and improvements in technology related to equipment, needles, catheters and infusion pumps may be

made available in the future.

Modification of infiltration techniques may need further research.

Regional anesthesia in children should continue to be monitored.

Another type of peripheral nerve block, the adductor canal block, has recently been studied and is showing

promise in the total knee arthroplasty patient population. Initial research studies show an improvement in pain

control with a decreased motor involvement, thus reducing the fall risk. Future research is needed to compare

adductor canal blocks with femoral nerve blocks.

(Jaeger, et al., 2013) (Level II)


Web Sites

Professionals: www.hssanes.org/for-patients/block-descriptions-femoral.htm

www.usra.ca/sb_femoral

www.nysora.com/files/uploaded/pdfs/continuous_femoral_nerve_block.pdf

www.linkinghub.elsevier.com/retrieve/pii/S0883540304002591

Patient and Family: http://www.webmd.com/pain-management/guide/nerve-blocks

www.hssanes.org/for-patients/block-descriptions-femoral.htm

www.clinicaltrials.gov/ct2/show/NCT00135889


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Appendix: System for Rating the Strength of Evidence

System for Rating the Strength of Evidence

Level I High-quality randomized controlled trial with large sample and statistically significant difference or no

statistically significant difference but narrow confidence intervals Evidence from a systematic review, a

meta - analysis, or an evidence - based clinical practice guideline where only results from randomized

controlled clinical trials were used.

Level II Evidence from at least one well - designed randomized prospective comparative clinical trial. Systematic

review of primarily Level II studies.

Level III

Evidence from well - designed case controlled trials without randomization, comparative studies and

evidence from a systematic review, a meta - analysis, or an evidence-based clinical practice guideline

where results from randomized clinical trials and controlled clinical trials were used. Systematic review

of primarily Level III studies.

Level IV

Evidence from case series and cohort studies. Evidence from well-designed descriptive, qualitative, or

psychometric studies. Evidence from a systematic review, a meta-analysis, or meta-synthesis of

descriptive or qualitative studies.

Level V Evidence from the opinion of authorities or experts.

Level VI Common practice, as documented in clinical articles or nursing textbooks.

Adapted from “Rating System for Hierarchy of Evidence” by Melnyk, B. M., &Fineout-Overholt, E., 2005, Evidence-based

Practice in Nursing & Healthcare: A Guide to Best Practice, p. 10. Copyright 2005 by Lippincott Williams & Wilkins;

“Knowledge-based Initiative” by Devine, E. C., 2007, Knowledge-Based Nursing Initiative Protocol. Unpublished

Manuscript; “The Oxford 2011 Levels of Evidence” by Oxford Centre for Evidence-Based Medicine, 2011. Retrieved from

http://www.cebm.net/mod_product/design/files/CEBM-Levels-of-Evidence-2.1.pdf

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