Continuous nerve blocks at home

What is a peripheral nerve block?

A peripheral nerve block is a way to treat and prevent pain after surgery. Your child's anesthesiologist injects medication near the nerves that supply the area where your child will have surgery. This numbing medication, called a local anesthetic (ropivacaine), is long-acting and temporarily "freezes" the area.

Anesthesiologists use nerve blocks to:

• Reduce pain after surgery.
• Decrease the need for pain medications and their side effects, such as nausea, vomiting, itching, sleepiness and constipation.
• Allow better rest following surgery.
• Make it easier to take part in physiotherapy.

Types of nerve blocks at CHEO

After your child is asleep or sedated, the anesthesiologist uses an ultrasound machine to see the nerve and inserts a needle to inject medication near it.

1. Single-shot nerve block

A single-shot nerve block is a one-time injection that helps control your child's pain for 6 to 18 hours.

2. Continuous nerve block

A continuous nerve block allows your child to receive numbing medication continuously after the initial injection. The medication is delivered through a small tube (catheter) connected to a disposable pump that lasts up to 48 hours.

Before your child goes home, the team will connect the catheter to a small pump filled with numbing medication. We will provide instructions for caring for the pump and managing your child's pain. You do not need to return to the hospital to remove the pump.

Continuous nerve blocks last as long as the medication is infusing through the pump and continue working for 6 to 18 hours after the infusion stops.

The anesthesiologist and surgeon will discuss which type of nerve block your child will receive before surgery. More than one nerve may need to be blocked for pain relief.

What happens when the nerve block wears off?

Your child should be able to move their limb normally within 6 to 18 hours after a single-shot nerve block or after a continuous nerve block infusion stops. Feeling in the limb will also return.

Follow-up after surgery for children receiving a continuous nerve block

• If your child is admitted to hospital, the pain team will visit them.
• If your child is discharged home, you will receive a daily follow-up phone call.

Pain medications at home

To prevent pain, give your child pain medication before the nerve block begins to wear off completely. Follow the instructions from your surgeon in your child's After Visit Summary, which you will receive before leaving the hospital.

• Even if the nerve block is working, your child may need additional pain medication.
• You may need to give pain medication if your child's pain score is greater than 4 on a scale of 0 to 10, where 0 means no pain and 10 means the worst possible pain.
• It is easier to control pain when medication is given early, as soon as your child can drink.
• For single-shot nerve blocks, we recommend giving a dose of pain medication at bedtime because the nerve block may wear off during the night.

Watch for constipation: If your child is taking opioid pain medication, it may be helpful to give them RestoraLAX or Lax-A-Day. These products are available without a prescription. Ask your pharmacist if you have questions.

Are there any side effects or risks?

It is normal for the affected area to feel numb or heavy. These sensations will go away once the nerve block wears off.

Risks associated with nerve blocks are rare and include:

• The nerve block not working.
• Nerve damage that may cause numbness or tingling.
• Bleeding or hematoma.
• Infection.
• Local anesthetic toxicity.

Possible side effects caused by the local anesthetic

• Ringing or buzzing in the ears.
• Numbness or tingling around the mouth.
• Metallic taste in the mouth.
• Lightheadedness or dizziness.
• Blurred or double vision.

Possible side effects of specific nerve blocks

Your anesthesiologist will confirm which nerve block your child received and provide any special instructions.

• ☐ Interscalene nerve block (neck injection): May cause a feeling that your child cannot take a full breath, arm weakness, hoarseness, a droopy eyelid and/or a pinpoint pupil on the blocked side.
• ☐ Femoral block (groin injection): May cause leg weakness.
• ☐ Popliteal fossa (sciatic) block (injection behind the knee or thigh): May cause foot weakness.
• ☐ Pectoral blocks: May rarely cause pneumothorax (collapsed lung).

When to call for help

Call 613-737-7600, press 0 and ask for the Anesthesiology resident on call to be paged if your child has any of the following:

• Increased anxiety, shortness of breath, difficulty breathing, shaking and/or tremors.
• Signs of infection, such as redness, swelling, pain or discharge at the catheter insertion site.
• Abnormal, intense pain at the surgical site or anywhere else on the blocked limb. This most often means the nerve block is not working, but in very rare cases it may be a sign of nerve damage.
• Numbness lasting longer than 24 hours after a single-shot nerve block or after removal of the continuous catheter.

Who to call

During the first 72 hours after surgery: For pain related to surgery, call 613-737-7600, press 0 and ask for the Anesthesiology resident on call to be paged.

After 72 hours: For other questions or concerns, or pain-related concerns after 72 hours, contact your surgeon's clinic or go to your nearest emergency department.

Taking care of your child at home

Because your child cannot feel the frozen limb, you will need to take special care to protect it from injury.

• Always support and protect the frozen limb. Raising it on a pillow may help reduce pain.
• Keep the limb in a comfortable position.
• Make sure nothing is pressing on the frozen limb.
• Protect the limb from extreme heat and cold. Your child may not feel temperature or other sensations normally.
• Avoid excessive activity involving the frozen limb. Your child cannot feel or control it normally while it is frozen.
• Take precautions to prevent injury. Make sure your child wears a sling or uses crutches if ordered by the surgeon.
• Do not allow your child to put weight on a numb leg or use a numb arm for support.

Caring for the injection site

Check the nerve block injection site for leaking, redness or discharge over the next two days.

Continuous nerve block pump care at home

• If your child's pain is not controlled, check the tubing for closed clamps or kinks. Also check that there is medication in the pump.
• Keep the dressing over the catheter clean and dry. A small amount of clear or pink-coloured drainage under the dressing is normal. Leakage is not a concern if pain control is good.
• Do not change the dressing. The catheter is not stitched in place and could come out if the dressing is removed. If needed, reinforce the dressing with a large Tegaderm.
• Your child cannot shower or take a tub bath while the catheter is in place. A sponge bath is okay.
• Follow your surgeon's activity restrictions.
• Refer to the pump instruction manual for information on checking infusion status.
• Do not drop the pump or allow it to get wet. If your child is using ice for comfort, keep it away from the lower part of the pump tubing.
• The pump delivers the nerve block medication automatically. You cannot adjust the infusion.
• The medication infuses very slowly. It may take more than 24 hours before you notice a change in the size or appearance of the pump. The pump will gradually collapse as it empties.
• If your anesthesiologist decides that your child needs the infusion for longer than 48 hours, you may need to return to CHEO for a pump replacement.

Removing the catheter

You will remove the dressing and catheter at home. Your anesthesiologist will tell you when to do this.

Any remaining numbness should go away within 24 hours after the catheter is removed.

How to remove the catheter

1. Gently lift the adhesive dressing covering the catheter insertion site. Remove any remaining tape.
2. Grasp the catheter as close as possible to where it enters the skin and gently pull it out. This should not cause discomfort or resistance. A small amount of blood or fluid drainage is normal.
3. If you feel resistance or the catheter stretches, STOP. Continuing to pull could break the catheter. Wait 30 to 60 minutes and try again. If you still have trouble removing it, call the Anesthesiology resident on call.

After removing the catheter

1. Hold pressure over the insertion site for one minute using a sterile gauze pad. Apply a bandage. You may remove the bandage later that day.
2. Check the tip of the catheter for a black dot. This confirms that the entire catheter was removed.
3. Use an alcohol swab to remove any remaining surgical soap or adhesive from the skin near the site.
4. Throw the catheter, tubing and pump in the garbage. Do not try to remove any remaining medication.

If your child experiences persistent weakness, numbness, tingling or other abnormal sensations for more than one week after surgery, contact your surgeon. They can alert the anesthesia team if needed.

Questions?

Questions about nerve blocks or general anesthesia before the procedure

Pre-Anesthesia Clinic
613-737-7600, ext. 2522
Or contact the Pre-Anesthesia nurse through MyChart.

Questions about your child's surgery or procedure

Orthopedic Clinic (C4)
613-737-7600, ext. 2407

Plastic Surgery Clinic (C6)
613-737-7600, ext. 2325