A Clinical Guideline
· To provide nursing staff with guidance and education in the use of axillary tunnel catheters
· To provide the patient with effective analgesia, in a safe and risk-reduced manner
· To ensure compliance with local, state, federal, legal and professional requirements
The brachial plexus forms behind the clavicle by the union of nerve roots C5-T1, and then divides into terminal nerves to supply sensation and motor function to the scapula, clavicle, shoulder, arm, forearm, wrist and hand. It does not supply the skin over the shoulder nor the skin on the inner, upper aspect of the arm.
The catheter enters the skin just beside sternocleidomastoid muscle and is placed down behind the clavicle to sit just lateral to the gap between the first rib and clavicle, within the connective tissues surrounding the brachial plexus.
Axillary tunnel catheters may be used for any procedures on the upper extremity. It may provide prolonged pain relief, or prolonged sympathectomy
Catheters are secured using OpsiteÔ or similar dressing and taped against the base of the patient’s neck. The catheter is labeled and date and time of insertion noted. It is connected to a device that can administer a bolus of local anaesthetic.
20 ml 0.25% bupivacaine with 1:400,000 adrenalin via the catheter every 6 hours is a standard order.
· Prepare the drug according to the prescription, following Hospital Infection Control Policy
· Follow the Hospital procedures for checking the patient prior to administering a drug
· Ensure that intravenous access is patent
· Check the catheter sites for dressing integrity, signs of infection, catheter dislodgement, presence of filter and cap.
· Monitor with pulse oximeter during top-up
· Using clean non-sterile gloves and employing a no-touch technique, clean the filter cap with alcohol swab and allow to dry.
· Remove the cap, affix the syringe and gently aspirate the line.
· Inject 3 ml 0.25% bupivacaine with 1:400,000 adrenalin down the catheter over 1 minute. Observe for adverse reaction (cf below).
· Inject 17 ml 0.25% bupivacaine with 1:400,000 adrenalin down the catheter over1-2 minutes.
· Monitor for leakage during topup.
· Replace the cap.
· Monitor for onset of analgesia over 15 minutes. Check vital signs at 5 and 15 minutes.
· Document administration.
Removal of Axillary Tunnel Catheter:
· Usually at day 3 or 4 postoperatively
· Aseptic technique
· Applying gentle traction, pull catheter out and check intact.
· Cover puncture site with non-occlusive dressing
· Document removal in patient records.
· Catheter dislodgement
· Catheter blockage
· Insertion site infection
· Insertion site leakage
· Local anaesthetic toxicity:
mild – feeling of vagueness, numbness of lips and tongue
moderate – convulsions
severe – cardiac arrest
In Case of Adverse Reaction:
Treat initial symptoms in accordance with emergency protocols
Lipid rescue as required – Recovery hold a supply in the Local Anaesthetic Block Trolley