SIMPL - Subcutaneous Infusion for Management of Pain using Lidocaine

[Guest guest]

I was wondering if anybody on this group has come across this or

something similar. Control of RSD using subcutaneous lidocine.

http://www.paincenter.com/simpl-rsd.html

A similar protocol is used for neuropathy in cancer patients

I am attaching that protocol from the City of Hope in Southern

California. This was originally developed at the University of Wisconsin.

If somebody has used it, I would be interested in knowing what their

experience with it was.

Rajiv

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______________________________________________________________________________

 CONTINUOUS SUBCUTANEOUS

LIDOCAINE INFUSIONS

Policy

University of Wisconsin Hospital & Clinics

Madison, Wisconsin

 

Developed by:

Debra B. Gordon, RN, MS

Clinical Nurse Specialist, Pain Management

Nursing Resources and Development

 

Distributed by the CITY OF HOPE PAIN RESOURCE CENTER 1999

                                                                           

prc#156

 

POLICY & PROCEDURE

Effective Date:July 1998

  oAdministrative

Manual  oNursing Manual (Red)

  oOther

____________________

Policy #:10.18

  oOriginal  oRevision

Page 1 of 9

Title: Continuous Subcutaneous LidocaineInfusion

 

PURPOSE:

To initiate and maintain a continuous subcutaneous lidocaine infusion for treatment of

neuropathic pain.

POLICY:

The dose and rate of a continuous subcutaneous lidocaine infusion is ordered by the

physician, the appropriate solution prepared by the pharmacist, and the infusion initiated

by the registered nurse.

EQUIPMENT:

Gloves (to be worn by all personnel starting or discontinuing parenteral devices)

MiniMed® Sof-setTM subcutaneous needle model number MMT-111 (CS order

number 1216552)

Micro AVI infusion pump (or Home Health for outpatient use)

AVI administration set

Subcutaneous solution, as prescribed

Tape: Use transparent adhesive dressing, or, if the patient is sensitive to these,

adhesive or non-allergic tape

Skin preparation: Alcohol prep swab

(4-way Stopcock if two sites will be used)

PARTS OF PROCEDURE:

Indications and Contraindications

To place subcutaneous needle and initiate infusion

To maintain site and infusion

Monitoring and documentation

To discontinue site and infusion

Discharge planning

UW Hospital and Clinics

Continuous Subcutaneous

Lidocaine Infusion

Page 2 10.18

PROCEDURE:

A. Indications and Contraindications

Indications: Continuous subcutaneous lidocaine infusions are indicated for

neuropathic pain syndromes with or without other sensory and motor phenomena present. Some

examples include: post-herpetic neuralgia, diabetic painful polyneuropathy, "reflex

sympathetic dystrophy", plexopathy, pain from spinal cord injury and thalamic

syndrome. Only patients who have responded to a test intravenous lidocaine bolus should be

considered for CSCI. This is best done by administering intravenously 100 mg of lidocaine

in double (or single) blind placebo controlled fashion. For more information, contact the

UW Pain Clinic at 263-9550.

Contraindications: Side effects are more pronounced in patients with liver

dysfunction, pulmonary diseases when the predominant problem is carbon dioxide retention,

and congestive heart failure. First and second degree heart conduction blocks could be

aggravated and progress into a higher degree of heart block with lidocaine administration.

Cardiovascular instability and concomitant use of alpha agonists or beta blockers are also

contraindications.

B. To place Subcutaneous Needle and Initiate Infusion

Check the physician's order and solution record, UWH Form 988, for prescribed solution,

volume, additives, and rate of flow.

Usual starting does is 1 mg/kg. Lidocaine should be 4% (40 mg/1 ml) preservative-free

solution in 100 cc minibag.

A single subcutaneous infusion site can usually accept up to 2-3 ml. per hour.

If the infusion must run at more than 2-3 ml/hour, you may use stopcock and two

subcutaneous infusion sets to branch the infusion into two sites. These sites can be

placed as close as 2 inches apart.

2. Determine if the patient has any allergies (sensitivities) to medication, iodine,

tape, etc.

3. Order a micro AVI infusion pump (or CADD pump) and gather other supplies as

needed from Central Supply.

UW Hospital & Clinics

Continuous Subcutaneous

Lidocaine Infusion

Page 3 10.18

 Because of the highly concentrated medication solutions used, it is essential to

use an infusion pump capable of delivering 0.1 ml. increments.

4. Obtain prescribed solution, check it and added medications against the Solution

Record and/or MD order.

5. Identify the patient; wash hands.

6. Connect administration set to the solution container. Place tubing in the pump and

prime with solution, following the pump instructions. Attach

             subcutaneous

needle to the end of the tubing, and flush with solution.

7. Select site for placement of subcutaneous needle.

a. Any area with a layer of subcutaneous fat is potentially available as an infusion

site. However, consideration should be given to the patient's

preferred lying positions and fat distribution. If there are not contraindications,

choose one of the following four sites: left and right,

between the breast and the clavicle; or right or left on the abdomen.

[Graphic of the anatomical sites could not be reproduced with current software. This

information may be ordered from the City of Hope Pain Resource Center off of the index.]

b. Other sites, such as the upper arms or thighs, or the upper buttocks may also be

appropriate if they fit the individual patient's needs. If these exceptions are to be

utilized, document the reason why.

UW Hospital & Clinics

Continuous Subcutaneous

Lidocaine Infusion

Page 4 10.18

 8. Shave excessive hair if indicated.

9. Prepare the skin using an alcohol prepswab, using a circular motion from the center

outward for at least 30 seconds.

10. Remove the Sof-set from its plastic guard by firmly gripping the wing and sliding

it out. Caution: Do not pull on Sof-set tubing to remove it from the package.

11. Lift the white adhesive tab to remove the Sof-set's adhesive baking and peel it

off.

12. Check to be sure the point of the needle is extended beyond the soft cannula. If it

is not, advance the needle by pushing the needle hub until the needle is visible (see

Figure 2 below).

[Figure 2 and Figure 3 cannot be reproduced with the current software. This information

may be ordered off of the City of Hope Pain Resource Center Index.]

13. Hold the wings on each side with your thumb and middle finger. Use your index

finger to stabilize the top of the plastic needle hub. Flex the wing up as shown in Figure

3 above.

14. Pinch the subcutaneous tissue as you would to give an injection. While holding the

plastic needle hub, insert the needle at a 90° angle straight into the infusion site.

15. Check to be sure that the cannula is fully inserted into the subcutaneous tissue

(see Figure 4 below).

[Figure 4 and Figure 5 cannot be reproduced with current software. This information may

be ordered from the City of Hope Pain Resource Center Index.]

16. Securely hold the Sof-set in place and withdraw the introducer needle (see Figure 5

below). Be sure not to pull the entire Sof-set out of the skin while removing the needle.

Never reinsert the introducer needle into the Sof-set. Reinsertion could cause tearing of

the cannula and result in unpredictable lidocaine flow.

17. Cover the infusion site with a transparent adhesive dressing. Anchor the infusion

set with tape if the patient prefers tape or is sensitive to transparent adhesive

dressing. The infusion site should be left as visible as possible to allow for frequent

checks for redness, swelling, or leakage.

UW Hospital & Clinics

Continuous Subcutaneous

Lidocaine Infusion

Page 5 10.18

 18. Make a loose loop of infusion tubing and anchor with tape to avoid tension on

the site.

19. Discard the needle introducer in your needle discard box.

20. Follow the pump instruction to resume your infusion.

21. Write the time and date of placement of the infusion site on a small piece of

adhesive tape and place it over the tape used to cover the site.

a. The infusion site should be changed approximately 48-72 hours, sooner if

inflammation or leakage occurs.

b. The tape or dressing covering the site may be left in place for the duration of each

infusion set placement.

22. Record in the clinical record: the solution type and additives, the resulting

concentration of medication per ml, and the initial infusion rate and dose. Also note the

placement site.

C. To maintain site and infusion

1. RN is responsible for maintaining the rate of flow as ordered.

2. Change the infusion site every 48-72 hours, or if it develops any redness, leakage,

or swelling.

a. If there are not contraindications, rotate clockwise around these four sites: left

and right, between the breast and the clavicle; followed by right then left on the abdomen

(see Figure 1).

b. Other sites, such as the upper arms or thighs, or the upper buttocks may also be

appropriate if they fit the individual patient's needs. If these exceptions are to be

utilized, document the plan for their use and rotation on the care plan. If possible,

include at least four distinct sites in any plan for rotation to ensure that each site has

adequate time to rest and heal between uses.

c. If tenderness and swelling occurs at the infusion site, change sites and apply warm

compresses to inflamed site.

UW Hospital & Clinics

Continuous Subcutaneous

Lidocaine Infusion

Page 6 10.18

 3. Change administration set and Y extension set every 72 hours.

4. Check infusion site a minimum of one time each shift for redness, swelling, or

leakage. Change the infusion site to the next planned location should any of these occur.

a. Check the site more frequently (at least 2 times per shift) if an infusion site is

receiving more than 2 ml per hour. Poor absorption of fluid and medication is more prone

to appear when an infusion site approaches or surpasses 2-3 ml per hour, or in the

presence of inflammation.

b. If the infusion site surpasses 3 ml/hour, use stopcock and two subcutaneous infusion

sets to branch the infusion into two sites. These sites can be placed as close as 2 inches

apart, but place further apart if tubing length and patient anatomy allows.

c. As the dosage nears the 2 ml/hr limit for each site, consider obtaining order to

change to a more concentrated solution.

D. Monitoring and Documentation

1. D4/4 General Purpose Flowsheet (UWH#30) for continuous SQ lidocaine infusion should

be utilized for monitoring patient pain ratings, BP & P, side effects, and drug usage.

a. Side effects to monitor and document include:

Mild (at serum levels 3-8 mcg/ml): numbness and tingling in fingers and toes,

perioral numbness and paresthesias, metallic taste in the mouth, ringing in the ears,

lightheadedness and dizziness.

Moderate (at serum levels 8-12 mcg/ml): nausea, vomiting, true vertigo,

decreased hearing, tremor, scotoma, blood pressure changes, increase or decreased heart

rate

Severe (at serum levels > 12 mcg/ml): drowsiness, disorientation, muscle

twitching, convulsions, coma and cardiovascular collapse

UW Hospital & Clinics

Continuous Subcutaneous

Lidocaine Infusion

Page 7 10.18

 2. If any side effects occur: stop infusion, obtain BP & Pulse, pain rating,

associated symptoms assessment, and obtain blood sample for serum lidocaine level. The

treating physicians, including the house staff should be informed immediately.

3. Under physician order, the infusion may be restarted once side effects have resolved

30-60 minutes later at the rate that was previously well tolerated without side effect, or

at the 20% smaller dose.

4. Document every four (4) hours after the infusion in initiated.

5. Obtain serum lidocaine levels every 8 hours, or more frequently depending on

patients' responses (effects on pain and side effects).

E. To discontinue site and infusion:

1. To discontinue infusion:

a. Turn off pump and discontinue site as below.

b. Waste any remaining drug and document the date and time in the Pharmacy prn kardex.

2. To discontinue site:

Turn off pump. Loosen tape, and pull the infusion set straight out with a swift motion.

Hold a 2x2 gauze over the site with pressure for 30 seconds. Check site, if there is

leakage of fluid, repeat the pressure till the site is dry. There is no need to dress the

site if the skin is intact. If there is any excoriation, dress the site with triple

antibiotic ointment and gauze until healed.

F. Discharge planning

1. If the patient will be discharged on a continuing infusion, contact Chartwell at

831-8555 at least two days prior to discharge. They will arrange for a pump or another

Home Infusion vendor and/or continuing home health service as appropriate to the

patient/family needs and insurance requirements.

REFERENCES:

UWHC Health Facts for You #5314, Continuous Subcutaneous Lidocaine for Pain Management

UW Hospital & Clinics

Continuous Subcutaneous

Lidocaine Infusion

Page 8 10.18

 Backonja, M, and Gombar, KA (1992). Response of central pain syndromes to

intravenous lidocaine. Journal of Pain and Symptom Management, 7(3), 172-178.

Glazer, S, and Portenoy, RK (1991). Systemic local anesthetics in pain control. Journal

of Pain and Symptom Management, 6(1), 30-39.

DEVELOPED BY:

Deb Gordon, RN, MS, Pain Patient Care Team

Pam Schedler, RN, MS, Case Manager

Arnold, RN, Chartwell

Sue ewicz, RN, Chartwell

REVIEWED BY:

Miroslav Backonja, MD, Neurology

, RN, MS, Pain Clinic

Nursing Patient Care Procedures Committee, March 1998

Nursing Executive Council, June 1998

 

______________________________________

Judith Broad, PhD, RN

Senior Vice President, Nursing