Chapter 10: Pain Medicine 2026

Published: 24/04/2026

10.13 Safe and Effective Implementation of Local Anaesthetic Infusions for Acute Pain

Dr Thomas Walton, Dr Jordan Alfonso

Why do this Quality Improvement Project?

Continuous peripheral nerve blocks (CPNB) (continuous local anaesthetic infusions via perineural, fascial plane or wound infusion catheters) are increasingly used for acute pain management and prevention of chronic postsurgical pain.1, 2  However, the complexity of these techniques introduces multiple potential points of error, necessitating robust systems under the supervision of a specialist inpatient pain service (IPS) to ensure patient safety.  This project is intended to support the introduction of local anaesthetic (LA) infusions and the ongoing monitoring of safe utilisation.

Background

Commonly used postoperatively after major surgery and following trauma, CPNBs are opioid-sparing, provide targeted analgesia, and aid functional recovery.3 The growing use of regional anaesthesia has led to a national focus on identifying and managing associated complications.4 Errors in prescription, pump programming, catheter management, or patient monitoring can cause significant harm, highlighting many opportunities for quality improvement throughout the patient pathway.

Best Practice

Departments of anaesthesia/inpatient pain should ensure that there are designated personnel and clear protocols to support the safe and effective use of CPNBs. Best practice is derived from core principles within the GPAS framework, as well as supplementary guidance from the RCoA/Faculty of Pain Medicine and specialist bodies including Regional Anaesthesia UK (RA-UK).5, 6, 7, 8

  • Monitoring:
    a. Registered nurses with specific training in CPNB supervision and complication management must be present on the ward 24/7
    b.  Ward monitoring should include regular pain scores, motor/sensory function assessment, and monitoring for Local Anaesthetic Systemic Toxicity (LAST)
    c. All patients with CPNBs require daily IPS review (or trained alternative, i.e. anaesthetic/critical care team), including weekend and bank holiday coverage
    d.  The insertion site should be checked daily for leakage, dislodgement, or infection
  • Drugs and Equipment:
    a.  Local anaesthetic pumps and infusion lines should be single-purpose, appropriately coloured/labelled, and conform to national safety standards. All NHS institutions should use the NRFit™ (ISO 80369-6) connector9, 10
    b. Standardised, programmable infusion pumps with preset protocols or restricted programming ranges to minimise errors should be utilised
    c. Standardised prescriptions and pre-printed drug labels for local anaesthetic bags should be employed, with pre-prepared infusions used where available
    d.   Local anaesthetic drugs should be stored separately from intravenous drugs and other infusion bags to prevent accidental wrong route administration
  • Patient education and managing complications:
    a. Patients and families should receive clear verbal and written information about the infusion's purpose, signs of complications (including LAST), and how to seek help
    b. Ward staff should be trained to recognise, manage and escalate potential complications
    c.  A ‘LAST rescue kit’7 (containing 20% lipid emulsion and the Association of Anaesthetists Quick Reference Handbook)11 should be immediately available on all wards managing local anaesthetic infusions, alongside standard advanced life support equipment and a defibrillator.
     

Suggested Data to Collect

Quality improvement (QI) projects can be used to track process and outcome measures to show changes and trends over time after implementation. For patients who have CPNBs in situ consider measuring:
Outcome Measures:
1. Total opioid consumption (e.g. oral morphine milligram equivalents) in the first 48 hours
2. Total time in first 48hours from CPNB catheter insertion where CPNB is not providing effective pain relief
3. Patient satisfaction survey results related to postoperative pain management
4. Qualitative feedback from multidisciplinary staff directly involved in caring for patients with CPNBs in place i.e. nursing staff monitoring patients or physiotherapists mobilising patients.

Process Measures:
1. Percentage of patients receiving a continuous LA infusion who received a relevant information leaflet pre-procedure
2. Percentage of patients with a continuous LA infusion reviewed daily by IPS (or trained alternative)
3. Percentage of patients with CPNB who did not have best practice observations in first 48hours
4. Confirmation of documented weekend IPS service provision
5. Audit of equipment availability: Are dedicated, correctly labelled pumps and NRFit™ disposables available in all relevant clinical areas?
6. Ward-level audit confirming separate and secure storage of LA infusion bags from IV medication

Balancing Measures
1. Incidence of patients with CPNB related complications:
2.  Catheter-related issues (e.g., dislodgement, leakage)
3. Signs or symptoms of LAST
4. Pump programming errors or equipment failure
5.  High Bromage scores (2-3) indicating a reduced ability to mobilise 


Quality Improvement Methodology (Worked example using a Plan-Do-Study-Act cycle)

  • Plan: An audit reveals that while NRFit™ connectors are available, non-NRFit™ disposables are occasionally used in recovery when setting up CPNBs, risking wrong-route errors. The QI goal is 100% compliance with NRFit™ use for all local anaesthetic infusions within one month
  • Do: All non-NRFit™ stock is removed from clinical areas where infusion catheters are inserted. Training is provided for all anaesthetic and recovery staff on the new equipment and rationale. Visual aids are placed by storage cupboards
  • Study: After one month, a spot audit confirms 100% of infusions use correct NRFit™ connectors and tubing. No adverse incidents reported
  • Act: The change is formally adopted into the CPNB safety policy. The stock ordering system is updated to permanently remove old disposables, sustaining improvement.
    Any deviation and use of non-NRFit™ disposables is captured by local safety data, and SIEPS models are used in follow-up.  

References

1.    Weinstein EJ et al. Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children. Cochrane Database Syst Rev 2018
2.    Liang SS et al. Continuous local anaesthetic wound infusion for postoperative pain after midline laparotomy for colorectal resection in adults. Cochrane Database of Systematic Reviews 2019, Issue 10. Art. No.: CD012310. DOI:10.1002/14651858.CD012310.pub2
3.    Niazi AU, Solish M, Moorthy A, et alUse of fascial plane blocks for traumatic rib fractures: a scoping review. Regional Anesthesia & Pain Medicine. Published Online First: 19 March 2025. doi: 10.1136/rapm-2024-106366
4.    RCoA. NAP8: Complications of Regional Anaesthesia. (https://rcoa.ac.uk/research/research-projects/national-audit-projects-n…)
5.    Guidelines for the Provision of Regional Anaesthesia Services  https://rcoa.ac.uk/gpas/chapter-8
6.    European Society of Regional Anaesthesia https://esraeurope.org/guidelines/ 
7.    RAUK Guidelines https://ra-uk.org/resources/guidelines-standards
8.    Faculty of Pain Medicine Clinical Guidelines https://fpm.ac.uk/standards-guidelines/clinical-guidelines
9.    NAP3: Major Complications of Central Neuraxial Block in the United Kingdom. Cook T et al., Br J Anaesth, 2009, vol. 102 (pg. 179-90), DOI: 10.1093/bja/aen360NHS. National Patient Safety Alert: Transition to NRFit™ connectors for intrathecal and epidural procedures, and delivery of regional blocks, NHS England, 2024
10.    Neal J, Woodward C, Harrison T. The American Society of Regional Anesthesia and Pain Medicine Checklist for Managing Local Anesthetic Systemic Toxicity. Reg Anesth Pain Med 2018;43: 150–153
11.    Association of Anaesthetists. Quick Reference Handbook: Guidelines for crises in anaesthesia, 2023G