A Clinical Guideline

Aim:         
·      To provide nursing staff with guidance and education in the use of rectus sheath 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


Scientific Background:

The anterior branches of spinal segmental nerves T6-T11  innervate the rectus abdominis muscle and the skin of the abdominal wall over the rectus abdominis muscle, i.e., the midline.

Rectus sheath catheters are placed by the surgeon or pain specialist within the sheath of the rectus abdominis muscle, through which course the anterior branches of the  spinal segmental nerves T6-T11. One catheter is placed on each side.


Indications:
·      Mid-line laparotomy incisions

·      Pfannenstiel incision - in combination with infiltration of the lateral wound margins with local anaesthetic to block the lateral cutaneous branches.

Site:
Catheters are secured using Opsite or similar dressing and taped to the abdominal wall. The catheter is labeled and date and time of insertion noted.


Prescription:
20 ml 0.25% bupivacaine with 1:400,000 adrenalin via each catheter every 6 hours is a standard order.


Top-up technique:
·      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 each catheter over 1 minute. Observe for adverse reaction (see below).

·      Inject 17 ml 0.25% bupivacaine with 1:400,000 adrenalin down each catheter over1-2 minutes.

·      Monitor for leakage during top-up.

·      Replace the cap.

·      Repeat the process for the second catheter.

·      Monitor for onset of analgesia over 15 minutes. Check vital signs at 5 and 15 minutes.

·      Document administration.
 

Removal of Rectus Sheath Catheters:
·      Usually at day 3 or 4 postoperatively

·      Use aseptic technique

·      Applying gentle traction, pull the catheter out and check it is intact

·      Cover puncture site with non-occlusive dressing

·      Document removal in patient records.


Potential complications:
·      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


Copyright PBC 2007.