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Chronic Refractory Angina

 Nursing Guidance for Paravertebral Block

 

These Guidance recommendations have been produced in accordance with the NHS Executive publication "Clinical Guidelines" (May 1996) and incorporate those standards produce by the King's Fund for evidence based clinical practice.

Produced for the National Refractory Angina Centre. 
E-mail Dave.Trenbath@ccl-tr.nwest.nhs.uk

 

Accompanying medical chapters

  1. TENS

  2. Patient Counselling 

  3. Stellate Ganglion Block

  4. Paravertebral block

  5. Spinal Cord Stimulation

  6. High Thoracic Epidural 

  7. Intrathecal pumpSynchromed

  8. Intrathecal pump Algomed

 

Definition

The administration of local anaesthetic into the Paravertebral space to block the thoracic sympathetic ganglion. It is considered if stellate ganglion block fails to adequately ameliorate symptoms.


Treatment contract 

It is essential that from the very beginning there is complete agreement made about the aims of treatment, between the patient their carers and the treatment team. The actual aim being to improve the patient and carers quality of life by reducing the effect of angina but it should be emphasised that as with all treatments for chronic refractory angina pectoris Paravertabral block cannot cure the problem. At all stages of the treatment, expectations must be discussed to ensure that the patient and carers expectations on pain relief are not unrealistic and unachievable.

Patients on Anticoagulant Therapy

There are different indications for anticoagulation in cardiac patients, which can be stratified into low-risk e.g. atrial fibrillation with no previous embolic history; and high-risk groups e.g. metal valve replacement, when considering the temporary interruption of their warfarin.
In the low risk group, anticoagulants can be stopped until the INR is <1.4. This usually takes three days. In the high-risk group the "therapeutic window" must be tightly controlled to minimise the embolic risks to the patient without exposing them to the risk of haematoma. The medical team looking after the patient must closely monitor the control of the anticoagulant.

Recommendation for infection control

The procedure should be carried out in a clean area/room, using aseptic technique.

Skin preparation

The skin should be visibly clean before any skin preparation. An antiseptic skin preparation of either alcoholic chlorhexidine or alcoholic povidone Ò iodine solution should be applied to the insertion site and surrounding area vigorously, using gauze swabs rather than cotton wool. The skin must be allowed to dry before proceeding in order to ensure decontamination of the skin is effective.

Equipment

  1. Chlorhexidine or equivalent skin cleansing agent.

  2. Local anaesthetic 2% Lignocaine. 

  3. 0.5% Bupivacaine for infusion rate to be decided by the doctor.

  4. Normal saline 20mls.

  5. 10ml and 20ml syringe.

  6. Blue 19g and green 21g needles.

  7. Sterile dressing pack.

  8. Epidural catheter pack with filter, which includes - Tuohy needle, obturator, low friction syringe, filter, and extension lead.

  9. Occlusive dressing.

  10. Venflon for venous access.

  11. Phenylephrine or Methoxamine should be available.

Observation of the patient pre procedure

Base line observation of the blood pressure, pulse, temperature and respiratory rate will be taken.

Procedure &  Rationale

  1. The procedure will be explained to the patient. To ensure that the patient understands the procedure and have given written consent. 

  2. An electrocardiograph is performed before therapy as a routine base line procedure.

  3. The patients back is prepared with cleaning solution To reduce risk of infection.

  4. Patient to sit on a hard surface with arms resting on a pillow and head on arms To allow identification of the spinous, for patient comfort and prevent sudden movements.

  5. Give the patient support and encouragement. Observing and reassuring the patient throughout the procedure is very important.

Doctor/Nurse action 

  1. The skin and subcutaneous spaces are infiltrated with local with local anaesthetic. To reduce discomfort felt by the patient on insertion of Tuohy needle.

  2. The Tuohy is introduced between 5cm lateral to the midline at the level of T3-T4. The needle is advanced until the 'give' costotransverse ligament is felt and the needle enters the paravertebral space. A negative aspiration must be obtained before injection of local aneasthetic.

  3. Following insertion of Bupivacaine, the needle is removed and a dressing applied. Occasionally an epidural catheter may be inserted to give a prolonged infusion of local anaesthetic. 

Complications

It is estimated that minor complications occur in less than 5% of cases1 and tend to occur during injection or shortly afterwards. In a large series of patients having mainly perioperative blocks, the main complications were hypotension in 4.6%, vascular puncture in 3.8%, pleural puncture in 1.1% and pneumothorax in 0.5%.2 Accidental extradural or intrathecal injection is rare and due to taking too medial an approach. Total spinal anaesthesia has been reported, with no long-term sequelae.3

Observation for potential side effects post procedure.

Refractory angina patients will be on drug therapies that may cause hypotension and bradycardia in there mode of action. It is therefore important to record the patients blood pressure pulse and respiratory rate prior to the procedure to evaluate base line observations.
Hypotension - check blood pressure every 15 minutes for the first hour and then 1/2 hourly for the next two hours post procedure.
Bradycardia - check blood pressure every 15 minutes for the first hour and then 1/2 hourly for the next two hours post procedure.
Respiratory depression - record respiratory rate, depth and pattern of breathing check blood pressure every 15 minutes for the first hour and then 1/2 hourly for the next two hours post procedure
Inadvertent Epidural anaesthesia - loss of power to the lower torso. Place patient into supine position and call for medical assistance. 
Total spinal anaesthesia - Rapid loss of consciousness with cardiovascular collapse and apnoea = medical emergency - call crash team, institute Cardiopulmonary Resuscitation. Phenylephrine or Methoxamine should be available

Local anaesthetic toxicity - caused by systemic adsorption of local anaesthetic resulting in high blood levels occurring 20-30 minutes after the block. It is characterised by tingling of the lips and tongue, confusion, light headedness, unconsciousness, convulsions and coma. Lie the patient flat and get medical assistance urgently.
Observe infiltration site for haematoma - recent anticoagulant therapy can predispose to haemorrhage into the epidural space.
Nausea or vomiting -side effect of local anaesthetic and hypotension.
Headache - may be caused by accidental puncture of the dura.
Urinary retention - due to parasympathetic block of the sacral level of the spinal cord. 
Observe effectiveness of pain relief following the procedure.

Local Anaesthetic Toxicity

Caused by systemic absorption of local anaesthetic resulting in high blood levels peaking 20-30 minutes after the block4. Toxicity to local anaesthetic is characterised by tingling of the lips, and tongue, confusion, light-headedness, unconsciousness convulsions and coma. 

Discharge


Patients are allowed home later the same day after they have eaten. Driving is discouraged but should they wish to drive themselves home, they must wait at least four hours post procedure and have no visual impairment that could be attributed to HornerÌs syndrome.
The patient records their quality of life on a linear scale and re-evaluates the aims of treatment. If the stellate or paravertebral blocks fails to achieve a satisfactory improvement in quality of life then Spinal Cord Stimulation can be considered. 

Back to nursing guidance
References

  1. Richardson J, Sabanathan S. Thoracic paravertebral analgesia. A review. Acta Anaethesiologica Scandinavica 1995;39:1005-15. 

  2. Lñnnqvist PA, Mackenzie J, Soni AK, Conacher ID. Paravertebral blockade: failure rate and complications. Anaesthesia 1995;50:813-5. 

  3. Gay GR, Evans JA. Total spinal anaesthesia following lumbar paravertebral block: a potentially lethal complication. Anesthesia and analgesia 1971;50:344-8. 

  4. Hardy PAJ, Williams NE. Plasma concentrations of bupivacaine after stellate ganglion block using two volumes of 0.25% bupivacaine plain solution. British Journal of Anaesthesia 1990;65:243-4.
All pages copyright © angina.org. Most recent revision: August 15 2002