Erector spinae plane (ESP) catheters for analgesia for rib fractures (Raigmore only)
ESP catheters can be used as part of a multi-modal analgesic approach in the management of patients with acute pain from rib fractures. Please see “Rib fracture pathway” section for advice on assessing, scoring and referral of patients for consideration of an ESP catheter.
The catheters are inserted in theatres by the anaesthetists. Patients will return to the ward with the catheter secure over one shoulder and connected to an On-Q elastometric pump. Infusions are started when the patient leaves theatre.
The prescription should be documented in the Kardex with a box to indicate the time when a new pump will need attached. This should be at 36 hours from the time of commencing the infusion to enable time to prepare and attach a new filled On-Q pump.
These pumps should not run out overnight - If this is likely to be the case please mark an earlier time in daytime hours to facilitate obtaining a new infusion pump.
Monitoring of patients and nursing care
- The On-Q pump will be started by the anaesthetist inserting the catheter. The volume of the On-Q pump is 400 mL. These run a fixed rate of 10 mL/hr of 0.125% levobupivacaine
- A blue wound catheter chart must be completed
- All observations should be carried out as per routine practice
- Intravenous access must be maintained at all times.
- In addition to the ESP catheter infusion, regular analgesia should be administered
When the pump is empty
The pump will last for 40 hours; however, most catheters are usually in for a minimum of 48 to 72 hours and so the pump will usually need to be replaced at least once. The replacement pumps can be obtained from main theatres and filled by a member of the anaesthetic team. Catheters can remain in for up to 5 days, however, if the catheter site is healthy and the patient is still getting significant benefit, a decision will be made by the anaesthetist or pain team to continue for another 24 hours.
Removal of ESP catheters
- Daily reviews by Acute Pain Team and decision for removal will be decided by the team.
- Catheters can remain in place for up to 5 days if still effective and no signs of local infection
- Catheters will be removed by ward nurse and must be documented
- Please make decisions to step down from regional analgesia at the beginning of a day. The catheter can be clamped off for 2 to 4 hours before removal.
If patient is still managing pain well, the catheter can be removed.
If the patient is in sufficient pain to interfere with coughing, deep breathing or mobilizing, then the catheter should be continued for at least a further 24 hours and may require a bolus on restarting the infusion.
- Patients should not be sent home on the same day the infusion is stopped and catheter removed. This is to allow time to exclude complications and ensure oral analgesia is optimised.
Trouble shooting On-Q pumps
If called in to see patient in pain:
Always make sure patient is on multimodal analgesia (providing no contraindications) ie: paracetamol / NSAID / PCA / when required opiate
- Check pump connected and not empty.
- Check catheter site to exclude malposition or gross leakage.
- Patient habitus, height, and position / number of rib fractures may mean that some patients experience breakthrough pain after the initial local anaesthetic bolus. Some patients may require additional boluses down the ESP catheter to re-establish the block.
- If catheter site healthy and intact, bolus 20 mL of 0.125% Levobupivacaine in a sterile fashion (similar standard of sterility to epidural top-up required). Re-connect the On-Q Infusion. You must be available for the next 15 minutes for the unlikely occurrence of local anaesthetic toxicity.
- Boluses should only given by an anaesthetist or member of the acute pain team.
- Please document the bolus dose on the front of the Kardex. Re-connect the On-Q Infusion.
- Maximum number / frequency of top-ups:
Two per day of 20mL 0.125% levobupivacaine at least 8 hours apart.
- If no improvement:
- In hours: refer to emergency anaesthetist for consideration of catheter re-site
- Out of hours: Abandon catheter and optimise oral / IV / PCA analgesia
ESP: Erector spinae plane
NSAID: Non-steroidal anti-inflammatory drug
PCA: Patient controlled analgesia