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Care of the patient receiving local anesthesia
PERIOP BRIEFING
GUIDELINE FIRST LOOK
Care of the patient receiving local anesthesia Leslie Bourdon, Managing Editor
T
he new “Guideline for care of the patient receiving local anesthesia”1 provides guidance for the perioperative RN caring for a patient who is receiving local anesthesia by injection, infiltration, or topical application, and covers patient assessment, patient monitoring, recognition and treatment of local anesthetic systemic toxicity (LAST), assessment for local anesthetic allergies, and patient care documentation. Although local anesthesia is deemed to be safe and effective, in rare occurrences, it may contribute to a toxic systemic or allergic reaction. The guideline provides information to help perioperative nurses recognize the signs and symptoms of LAST and allergic reaction to a local anesthetic and understand the necessary treatment protocols for such events. The following are highlights from the new guideline.
Patient assessment and monitoring The perioperative RN should perform a preoperative nursing assessment for patients who will be receiving local anesthesia to help identify allergies and comorbid conditions that may affect absorption of the local anesthetic; acquire baseline measures of vital signs, pain, and anxiety; and evaluate the patient’s level of consciousness.1 The patient assessment should include a review of allergies and sensitivities, age, height, weight, body mass index, current medications, medical history, baseline cardiac and respiratory status, and other elements. Information obtained during the preoperative assessment can help identify underlying conditions (e.g., cardiac, hepatic, renal) that may increase a patient’s risk of developing LAST. The guideline recommends using a physical acuity assessment tool to determine patient acuity because such a tool provides an objective, consistent method to assess acuity. The American Society of Anesthesiologists Physical Status Classification system is a common tool used to determine patient acuity that concisely describes patient condition criteria and is familiar to surgeons, anesthesia http://dx.doi.org/10.1016/S0001-2092(15)00068-X
P10 | Periop Briefing
professionals, and nurses. Based on the patient assessment, procedure type, and the health care organization policy, the perioperative RN should determine the personnel needed to implement the plan of care, with a minimum of one perioperative RN circulator dedicated to each patient undergoing an operative or other invasive procedure who should be present during that patient’s entire intraoperative experience. “It is very important to take into consideration the patient’s acuity, level of anxiety, and the complexity of the procedure when determining the number of personnel needed for the care of a patient receiving local anesthesia without the presence of an anesthesia care provider,” said Mary Ogg, MSN, RN, CNOR, perioperative nursing specialist at AORN and lead author of the guideline. “A healthy, extremely anxious person classified as a P1 per the ASA system may need an additional RN to monitor and alleviate the patient’s anxiety.” The perioperative RN should monitor and document the patient’s physiological and psychological responses, identify nursing diagnoses, and implement appropriate nursing interventions.1 Monitoring the physiological and psychological status of patients may contribute to early detection of potential complications. For example, changes in cardiac rhythm and rate, blood pressure, and mental status may be early indicators of LAST. Specific guidance is provided in the guideline for what should be included in baseline patient monitoring and documentation (e.g., pulse, blood pressure, respiratory rate) and intraoperative and postoperative patient monitoring and documentation (i.e., level of pain, anxiety, consciousness).
Recognizing and treating LAST or an allergic reaction According to the guideline, perioperative RNs should know the local anesthetic being used and understand its indications for use, contraindications,
desired effects, and adverse effects. More specifically, the perioperative RN should understand the local anesthetic’s recommended dose and onset and duration of action. Local anesthetics have different durations of action and adding a vasopressor (e.g., epinephrine) delays absorption by constricting the blood vessels and prolongs the effect. Before administration of a local anesthetic, the perioperative RN should verify correct dosing parameters and identify the patientspecific maximum dose through consultation with the health care organization’s medication formulary, a pharmacist, or a physician or by referencing the product information sheet or other published material.1 “Knowing the maximum dose of a particular local anesthetic that a patient should receive is important because if you exceed that dose, it could result in LAST,” said Ogg. Although rare, LAST can occur in less than one minute after a single injection of a local anesthetic and can be fatal.2 The perioperative RN should know the symptoms of LAST (e.g., metallic taste, numbness of the tongue and lips, auditory changes) and the guideline provides a comprehensive list of symptoms. Evidence indicates that LAST occurs as serum levels of the local anesthetic increases and symptoms may present as central nervous system or cardiovascular system complications or both.2 Early recognition and treatment of LAST is critical and initial treatment should focus on airway management because hypoxemia and acidosis intensify the effects of LAST. If LAST does occur, the perioperative RN should complete the following actions: • “call for help, • help maintain the airway, • ventilate with 100 percent oxygen, • assist with basic or advanced cardiac life support, • be prepared to establish or assist with IV access, and • be prepared to assist with administration of 20 percent lipid emulsion therapy.”1,p519 The guideline cites evidence that supports the use of lipid emulsion therapy for treating LAST, including a review of case reports in which lipid emulsion was used for both bupivacaine-related and non-bupivacaine-related LAST and effectively
© AORN, Inc, 2015
resolved symptoms for patients with LAST.3 The perioperative RN should also recognize the signs and symptoms of an allergic reaction to a local anesthetic (e.g., anxiety, bronchospasm, dizziness). Allergic reactions to local anesthetics occur in less than 1 percent of patients who receive a local anesthetic.4 Evidence indicates other substances should be investigated as a cause of hypersensitivity reactions to local anesthetics,5 including a study that found 80 percent of reactions among 43 patients with a suspected allergy to amide-type local anesthetic agents (e.g., lidocaine, bupivacaine) were caused by the antiseptic, which contained parabens, rather than the lidocaine.6 Paraben additives, which are commonly found in cosmetics and hair products, can contribute to a sensitization and pose a risk of developing a local anesthetic allergy. “Some personal care products may predispose you to have an allergic reaction to a local anesthetic,” said Ogg. “Paraben is a preservative in shampoos, cosmetics, and lotions, so you might develop a sensitivity to paraben, which is also a preservative used in local anesthetics.” In addition, evidence shows that previous exposure to lidocaine can contribute to lidocaine hypersensitivity, and over-the-counter lidocaine products (e.g., anti-hemorrhoidal products) could be a source of lidocaine exposure and sensitization.7
Patient education and policies and procedures The guideline states that the perioperative RN should educate patients who are undergoing local anesthesia about the perioperative care experience. Patient education should include the anticipated sequence of events before, during, and immediately following the procedure; instructions for completing a pain level assessment; the process for requesting additional pain relief during and after the procedure; and reporting postoperative signs and symptoms to a designated health care provider.1 Policies and procedures for caring for patients receiving local anesthesia should be developed, periodically reviewed, revised, and made readily available in the practice setting. The guideline states that a multidisciplinary team should develop policies and procedures for caring for patients
March 2015 Vol 101 No 3 • Periop Briefing | P11
PERIOP BRIEFING
LOCAL ANESTHESIA
PERIOP BRIEFING
LOCAL ANESTHESIA
receiving local anesthesia without monitoring by an anesthesia professional. Such policies and procedures should include elements such as patient assessment criteria; personnel qualifications, competencies, and certifications; staffing requirements; and monitoring. References 1. Guideline for care of the patient receiving local anesthesia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:513-524. 2. Di Gregorio G, Neal JM, Rosenquist RW, Weinberg GL. Clinical presentation of local anesthetic systemic toxicity: a review of published cases, 1979 to 2009. Reg Anesth Pain Med. 2010;35(2):181-187. 3. Ozcan MS, Weinberg G. Update on the use of lipid emulsions in local anesthetic systemic toxicity: a focus on differential efficacy and lipid emulsion as part of advanced cardiac life support. Int Anesthesiol Clin. 2011;49(4):91-103. 4. Batinac T, Sotošek Tokmadžić V, Peharda V, Brajac I. Adverse reactions and alleged allergy to local
P12 | Periop Briefing
anesthetics: analysis of 331 patients. J Dermatol. 2013;40(7):522-527. 5. Harboe T, Guttormsen AB, Aarebrot S, Dybendal T, Irgens A, Florvaag E. Suspected allergy to local anaesthetics: follow-up in 135 cases. Acta Anaesthesiol Scand. 2010;54(5):536-542. 6. Saito M, Abe M, Furukawa T, et al. Study on patients who underwent suspected diagnosis of allergy to amide-type local anesthetic agents by the leukocyte migration test. Allergol Int. 2014;63(2):267-277. 7. Amado A, Sood A, Taylor JS. Contact allergy to lidocaine: a report of sixteen cases. Dermatitis. 2007;18(4):215-220.
RE CORD E D W E B I N AR Watch the “Guideline for Perioperative Practice: Local Anesthesia” webinar to learn more about patient assessment and monitoring, recognition and treatment of LAST, assessment for local anesthetic allergies, and documentation of patient care. Register at: http://www.aorn.org/Member_Apps/Product/ Detail?productID=9061.
GUIDELINE FIRST LOOK
Care of the patient receiving local anesthesia Leslie Bourdon, Managing Editor
T
he new “Guideline for care of the patient receiving local anesthesia”1 provides guidance for the perioperative RN caring for a patient who is receiving local anesthesia by injection, infiltration, or topical application, and covers patient assessment, patient monitoring, recognition and treatment of local anesthetic systemic toxicity (LAST), assessment for local anesthetic allergies, and patient care documentation. Although local anesthesia is deemed to be safe and effective, in rare occurrences, it may contribute to a toxic systemic or allergic reaction. The guideline provides information to help perioperative nurses recognize the signs and symptoms of LAST and allergic reaction to a local anesthetic and understand the necessary treatment protocols for such events. The following are highlights from the new guideline.
Patient assessment and monitoring The perioperative RN should perform a preoperative nursing assessment for patients who will be receiving local anesthesia to help identify allergies and comorbid conditions that may affect absorption of the local anesthetic; acquire baseline measures of vital signs, pain, and anxiety; and evaluate the patient’s level of consciousness.1 The patient assessment should include a review of allergies and sensitivities, age, height, weight, body mass index, current medications, medical history, baseline cardiac and respiratory status, and other elements. Information obtained during the preoperative assessment can help identify underlying conditions (e.g., cardiac, hepatic, renal) that may increase a patient’s risk of developing LAST. The guideline recommends using a physical acuity assessment tool to determine patient acuity because such a tool provides an objective, consistent method to assess acuity. The American Society of Anesthesiologists Physical Status Classification system is a common tool used to determine patient acuity that concisely describes patient condition criteria and is familiar to surgeons, anesthesia http://dx.doi.org/10.1016/S0001-2092(15)00068-X
P10 | Periop Briefing
professionals, and nurses. Based on the patient assessment, procedure type, and the health care organization policy, the perioperative RN should determine the personnel needed to implement the plan of care, with a minimum of one perioperative RN circulator dedicated to each patient undergoing an operative or other invasive procedure who should be present during that patient’s entire intraoperative experience. “It is very important to take into consideration the patient’s acuity, level of anxiety, and the complexity of the procedure when determining the number of personnel needed for the care of a patient receiving local anesthesia without the presence of an anesthesia care provider,” said Mary Ogg, MSN, RN, CNOR, perioperative nursing specialist at AORN and lead author of the guideline. “A healthy, extremely anxious person classified as a P1 per the ASA system may need an additional RN to monitor and alleviate the patient’s anxiety.” The perioperative RN should monitor and document the patient’s physiological and psychological responses, identify nursing diagnoses, and implement appropriate nursing interventions.1 Monitoring the physiological and psychological status of patients may contribute to early detection of potential complications. For example, changes in cardiac rhythm and rate, blood pressure, and mental status may be early indicators of LAST. Specific guidance is provided in the guideline for what should be included in baseline patient monitoring and documentation (e.g., pulse, blood pressure, respiratory rate) and intraoperative and postoperative patient monitoring and documentation (i.e., level of pain, anxiety, consciousness).
Recognizing and treating LAST or an allergic reaction According to the guideline, perioperative RNs should know the local anesthetic being used and understand its indications for use, contraindications,
desired effects, and adverse effects. More specifically, the perioperative RN should understand the local anesthetic’s recommended dose and onset and duration of action. Local anesthetics have different durations of action and adding a vasopressor (e.g., epinephrine) delays absorption by constricting the blood vessels and prolongs the effect. Before administration of a local anesthetic, the perioperative RN should verify correct dosing parameters and identify the patientspecific maximum dose through consultation with the health care organization’s medication formulary, a pharmacist, or a physician or by referencing the product information sheet or other published material.1 “Knowing the maximum dose of a particular local anesthetic that a patient should receive is important because if you exceed that dose, it could result in LAST,” said Ogg. Although rare, LAST can occur in less than one minute after a single injection of a local anesthetic and can be fatal.2 The perioperative RN should know the symptoms of LAST (e.g., metallic taste, numbness of the tongue and lips, auditory changes) and the guideline provides a comprehensive list of symptoms. Evidence indicates that LAST occurs as serum levels of the local anesthetic increases and symptoms may present as central nervous system or cardiovascular system complications or both.2 Early recognition and treatment of LAST is critical and initial treatment should focus on airway management because hypoxemia and acidosis intensify the effects of LAST. If LAST does occur, the perioperative RN should complete the following actions: • “call for help, • help maintain the airway, • ventilate with 100 percent oxygen, • assist with basic or advanced cardiac life support, • be prepared to establish or assist with IV access, and • be prepared to assist with administration of 20 percent lipid emulsion therapy.”1,p519 The guideline cites evidence that supports the use of lipid emulsion therapy for treating LAST, including a review of case reports in which lipid emulsion was used for both bupivacaine-related and non-bupivacaine-related LAST and effectively
© AORN, Inc, 2015
resolved symptoms for patients with LAST.3 The perioperative RN should also recognize the signs and symptoms of an allergic reaction to a local anesthetic (e.g., anxiety, bronchospasm, dizziness). Allergic reactions to local anesthetics occur in less than 1 percent of patients who receive a local anesthetic.4 Evidence indicates other substances should be investigated as a cause of hypersensitivity reactions to local anesthetics,5 including a study that found 80 percent of reactions among 43 patients with a suspected allergy to amide-type local anesthetic agents (e.g., lidocaine, bupivacaine) were caused by the antiseptic, which contained parabens, rather than the lidocaine.6 Paraben additives, which are commonly found in cosmetics and hair products, can contribute to a sensitization and pose a risk of developing a local anesthetic allergy. “Some personal care products may predispose you to have an allergic reaction to a local anesthetic,” said Ogg. “Paraben is a preservative in shampoos, cosmetics, and lotions, so you might develop a sensitivity to paraben, which is also a preservative used in local anesthetics.” In addition, evidence shows that previous exposure to lidocaine can contribute to lidocaine hypersensitivity, and over-the-counter lidocaine products (e.g., anti-hemorrhoidal products) could be a source of lidocaine exposure and sensitization.7
Patient education and policies and procedures The guideline states that the perioperative RN should educate patients who are undergoing local anesthesia about the perioperative care experience. Patient education should include the anticipated sequence of events before, during, and immediately following the procedure; instructions for completing a pain level assessment; the process for requesting additional pain relief during and after the procedure; and reporting postoperative signs and symptoms to a designated health care provider.1 Policies and procedures for caring for patients receiving local anesthesia should be developed, periodically reviewed, revised, and made readily available in the practice setting. The guideline states that a multidisciplinary team should develop policies and procedures for caring for patients
March 2015 Vol 101 No 3 • Periop Briefing | P11
PERIOP BRIEFING
LOCAL ANESTHESIA
PERIOP BRIEFING
LOCAL ANESTHESIA
receiving local anesthesia without monitoring by an anesthesia professional. Such policies and procedures should include elements such as patient assessment criteria; personnel qualifications, competencies, and certifications; staffing requirements; and monitoring. References 1. Guideline for care of the patient receiving local anesthesia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:513-524. 2. Di Gregorio G, Neal JM, Rosenquist RW, Weinberg GL. Clinical presentation of local anesthetic systemic toxicity: a review of published cases, 1979 to 2009. Reg Anesth Pain Med. 2010;35(2):181-187. 3. Ozcan MS, Weinberg G. Update on the use of lipid emulsions in local anesthetic systemic toxicity: a focus on differential efficacy and lipid emulsion as part of advanced cardiac life support. Int Anesthesiol Clin. 2011;49(4):91-103. 4. Batinac T, Sotošek Tokmadžić V, Peharda V, Brajac I. Adverse reactions and alleged allergy to local
P12 | Periop Briefing
anesthetics: analysis of 331 patients. J Dermatol. 2013;40(7):522-527. 5. Harboe T, Guttormsen AB, Aarebrot S, Dybendal T, Irgens A, Florvaag E. Suspected allergy to local anaesthetics: follow-up in 135 cases. Acta Anaesthesiol Scand. 2010;54(5):536-542. 6. Saito M, Abe M, Furukawa T, et al. Study on patients who underwent suspected diagnosis of allergy to amide-type local anesthetic agents by the leukocyte migration test. Allergol Int. 2014;63(2):267-277. 7. Amado A, Sood A, Taylor JS. Contact allergy to lidocaine: a report of sixteen cases. Dermatitis. 2007;18(4):215-220.
RE CORD E D W E B I N AR Watch the “Guideline for Perioperative Practice: Local Anesthesia” webinar to learn more about patient assessment and monitoring, recognition and treatment of LAST, assessment for local anesthetic allergies, and documentation of patient care. Register at: http://www.aorn.org/Member_Apps/Product/ Detail?productID=9061.