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Table 1 Selected section of “intermittent bolus of intrapleural analgesia policy document pertaining to delivery of bolus dosing regime and monitoring of the patient” document provided to nursing staff

From: Postoperative pain relief using intermittent intrapleural analgesia following thoracoscopic anterior correction for progressive adolescent idiopathic scoliosis

Delivery of bolus dosing regime
1. Do baseline blood pressure, heart rate, respiratory rate, oxygen saturations, sedation score and pain assessment
2. Position patient operated side up prior to administration of the bolus dose
3. Clamp the thoracic pigtail drain and/or intercostal catheter if in situ
4. Independently double check the pre-programmed bolus against the prescription and patient with a 2nd Registered Nurse
5. Administer the bolus dose (The time of dose delivery is volume dependant and may take as long as 12 minutes to deliver)
6. Continue observations as above every 5 minutes for the next 30 minutes. But after 20 minutes from commencement of bolus delivery, unclamp the pigtail drain and/or intercostal catheter
7. Document and sign the Pain Management Prescription form
8. Observe the drain to ensure patency
9. Position patient in a comfortable position
10. Perform further observations as above after 30 minutes.
11. Then hourly observations until the next bolus is due (excluding the Blood Pressure)
Monitoring of the patient
1. Observations are to be performed as detailed above for delivery of a bolus
2. More frequent observations are required if clinically indicated or as stated in each child’s care plan. Observations include:
· Respiratory rate
· Heart rate
· Blood pressure - not required 1 hour after bolus delivery unless clinically indicated
· Pain score at rest and on movement (not required if the patient is sleeping)
· Continuous oxygen saturations
· Sedation score
· Cumulative dose/deliveries
· Any adverse events
  · Temperature and site check every 4 hours
Adverse events
1. If adverse events occur during a bolus, cease the bolus immediately.
Notify Acute Pain Service (APS)/Anaesthetist for all Adverse Events:
· Horner’s Syndrome – facial palsy, droopy eyelid, red eye, hoarse voice
· Hypotension
· Pneumothorax
· Infection
  · Pain score greater than or equal to 4/10, check catheter, give multi-modal analgesia
· Leaking at the wound - reinforce if sterility maintained
· Disconnected catheter - cease infusion, wrap in sterile gauze keeping the catheter tip below the level of the incision, contact APS and inform Surgical Team of the APS decision )
· Signs and symptoms of local anaesthetic toxicity are:
➢ Facial tingling/numbness
➢ Tinnitus
➢ Metallic Taste
➢ Twitching
➢ Seizures
➢ Apnoea
➢ Hypotension
  ➢ Cardiac arrhythmia/arrest
2. In the event of an emergency (including signs and symptoms of local anaesthetic toxicity)
· Stop the infusion immediately/unclamp chest drain if applicable
· Press emergency button, call emergency number
· Give oxygen/resuscitate if necessary
· Obtain intralipid 20% from Paediatric Intensive Care Unit
  · Notify APS/Anaesthetist