patient group direction (pgd) for the administration of local anaesthetics and corticosteroids by...

7/31/2019 Patient Group Direction (PGD) For the Administration Of Local Anaesthetics and Corticosteroids BY TENDAYI MUTSO

1/18

Patient Group Directions For The Adminstration Of Steroid Injections

PATIENT GROUP DIRECTION FOR THE ADMINSTRATION/ASPIRATION OF

STEROID INJECTIONS AND LOCAL ANAESTHETICS

By:

TENDAYI MUTSOPOTSI BSc. HPT (Hons) MSc. ORTHO-MED MCSP MSOM


2/18


PATIENT GROUP DIRECTION FOR THE ADMINSTRATION/ASPIRATION OF

STEROID INJECTIONS AND LOCAL ANAESTHETICS

Introduction

This PGD has been drawn up using the recommendations set out in A Clinical Guideline for the use

of Injection Therapy by Physiotherapists by the Association of Chartered Physiotherapists inOrthopaedic Medicine (ACPOM), endorsed by the Chartered Society of Physiotherapy (CSP) 1999,

and from injection techniques in Orthopaedic and Sports Medicine by Saunders 2001.

Since 1995 injection therapy has fallen within the scope of practice for those physiotherapists who

have undertaken appropriate, recognised training. Current practice is restricted to the injection ofintra-articular and peri-articular conditions of the upper and lower extremities only.

The training courses currently recognised as providing best practice are those which result in a

Diploma in Injection Therapy. These are either run by the Association of Chartered Physiotherapists

in Orthopaedic Medicine, The Society of Orthopaedic Medicine or in conjunction with institutions of

Higher Education.

Under certain circumstances, for example where physiotherapists are specialised, training may be

provided within the Chelsea and Westminster Hospital Foundation Trust, by the referring

Orthopaedic Consultant. This training will identify competency for specific injections. Such training

combined with use of this protocol (which is predominantly derived from best practice within

physiotherapy ) should ensure safe and effective practice of injection therapy by physiotherapists

within the Trust.

Physiotherapists authorised to administer injection therapy

Named therapists within the Trust are authorised to administer injection therapy (see appendix A).This will also include taking responsibility for the supply and administration of medicines (See

appendix B).

Staff need to have attended the Chelsea and Westminster Hospital Foundation Trust anaphylaxis

training programme and be up to-date with mandatory cardio pulmonary resusitation (CPR) training.

Rationale/Scope

Subject to all conditions and criteria listed below, appropriately trained and authorised

physiotherapists will administer an appropriate injection to patients following the clinical procedures

within this protocol. This allows the delivery of healthcare provision without the prescription from a

named doctor.

ALL PATIENT GROUP DIRECTIONS WILL BE SUBJECT TO REGULAR REVIEW IN LINE

WITH CURRENT CLINICAL PRACTICE

Date of overall review of this document- July 2015


3/18


PATIENT GROUP DIRECTIONS

FOR THE ADMINSTRATION OF STEROID INJECTIONS

Patient Group Direction

Page

Epinephrine 1:1000 injection

Triamcinolone ecetonide sterile aqueous suspension:

Adcortyl 10mg/ml or Kenalog 40mg/ml

Hydrocortisone acetate:

Hydrocortisab 25mg/ml

Depomedrone

40mg/ml

Lidocaine Hydrochloride:

0.5% , 1%, 2% without epinephrine

Marcaine 0.25% , 0.5% without epinephrine

Declaration:

Appendices

1. Clinical condition

Clinical condition to be treated Arthritis, Bursitis, Capsulitis, Synovitis, Tendinitis, Tenosynovitis

Entrapment neuropathy

Ganglia

Ligamentous injury

Criteria for inclusion For peripheral intra-articular/peri-articular administration in adults (18 years and

over) not presenting with any contraindication.

Criteria for exclusion Patients with an absolute contraindication are excluded. Medical approval must be

sought where a caution exists.

Absolute Contraindications

Known hypersensitivity to local anaesthetic or steroidSuspicion of infection in the joint or elsewhere

Local sepsis over the injection site

Acute haemarthrosis

Recent trauma

Into a prosthetic joint

Reluctant patient

Pregnancy or breast feeding

Tendon bodies

Adjacent osteomyelitis

Oral antifungal medication (amphotericin and imidazoles)

Exposure to chicken pox if previously uninfected

CautionImmunosupression, drugs or disease

Anticoagulant therapy, increased monitoring required


4/18


Bleeding disorder

Poorly controlled diabetes, increased monitoring required

Anxious/ psychogenic patient

Liver disease

Unstable joint

Ciclosporin treatment, monitoring requiredAction if excluded Patients who are excluded will be offered alternative appropriate management which

may include Physiotherapy.

Action if declines Patients who do not wish to receive injection therapy will be offered alternative

appropriate management which may include Physiotherapy.

Drug Interactions Antibacterials: erythromycin inhibits metabolism of steroid.

Anticoagulant effect of warfarin possibly altered.

Antidiabetics: antagonism of hypoglycaemic effect.

Antiepileptic drugs including barbiturates accelerate metabolism of steroid (reduced

effect).

Antifungals: increased risk of hypokalaemia with amphotericin,imidazoles inhibit metabolism of steroid.

Ciclosporin: plasma ciclosporin concentration increased by high dose

methylprednisolone (risk of convulsions)

2. RecordsThe following should be recorded in the patients records.

Name of drug

Dose given Date given

Route given

Any advice or warnings given to the patient

Any adverse drug reactions occurring after administration

Signature of Physiotherapist administering drug

Consent form signed by the patient and Physiotherapist

The referring Medical Practitioner will be forwarded a copy of the Injection treatment including drugs

used and dose

3. Treatment procedure

The following procedure is good practice and based on guidelines from Injection techniques in

orthopaedic and sports medicine Saunders 2002.

Prepare the patient

Injection checklist completed (Appendix D JM and HT checklist)

Patient placed in a comfortable, supported position

Injection site exposed Allergy to plaster checked


5/18


Prepare

equipment

Drugs checked for name, dosage an expiry dates

Collect syringe and needles for drawing up infiltration

Collect alcohol swab, plaster, cotton wool and sharp box

Prepare site

Position limb to make site accessible

Mark skin by applying pressure to injection site

Clean site with alcohol

Allow to dry

Assemble equipment

Wash hands

Open vials

Draw up drugs, steroid first, using sterile needle

Discard needle into sharps box

Apply fresh sterile needle of correct size for infiltration

Injection technique

Stretch skin and insert needle perpendicular to skin in order to avoid painful skin puncture

Angle needle towards site of lesion to obtain correct placement

Draw back on plunger to ensure needle tip is not in blood vessel and to check for the presence

of sepsis Administer injection as either a bolus into joints/bursa or as a peppering technique for tendons

or ligaments

Withdraw needle rapidly while applying firm pressure with cotton wool to minimise bleedingand reduce chance of skin de-pigmentation or fat atrophy

Discard syringe and needle immediately into sharps box to prevent needle stick injury

Apply plaster/alternative to prevent tracking of infection and bleeding onto clothes

Aftercare

Injection therapy record to be completed (Appendix D ?) Patient waits for 20 minutes to ensure no adverse reaction

Patient advised on home management and follow up appointment arrangement

Patient satisfaction form can be given to patient (Appendix E)

Anaphylaxis

In the event of an anaphylactic reaction, Chelsea and Westminster Hospital Foundation Trust

anaphylaxis procedure should be followed (Appendix F). Physiotherapists therefore need to have

undergone the C&W anaphylaxis training programme.

4. Documentation


6/18


All

documentation including the injection check

list to be added to the patients current physiotherapy or medical records and reference to procedure

made within these records sufficient to enable audit trail.

Any adverse reaction or patient incident must be reported through the Trust incident reporting

procedure and to ACPOM, if the physiotherapist is a member.

5. Professional Responsibility

1. The Physiotherapist will ensure he/she has completed successfully the relevant training (Diploma in

Injection Therapy or equivalent) and is competent in all aspects of administration, including cautions and

contra-indications. He/she will attend regular training updates including Anaphylaxis management.

2. The Physiotherapist will have due regard for the CSPs Code of Conduct, Scope of Professional Practice,Clinical Guidelines for the use of Injection therapy by Physiotherapists and Safe Systems of work for

Injection Therapy.

6. RECOMMENDED MEDICINES

6.1

Name of medicine Epinephrine 1:1000

Legal status Prescription only medicine.

Storage Store as stock items in a lockable cupboard at room temperature.

Dose Epinephrine injection comes as a single-dose pre-filled automatic injection device-

Epi-pen

Route/method Injected into the thigh intramuscularly using the automatic injection device

Frequency Used only in the management of an anaphylactic shock

Total dose number Epinephrine injection comes as a single-dose pre-filled automatic injection device-

Epi-pen

Suggested regime In the event of an impending or anaphylactic shock. This is a medical emergency with

symptoms of an itchy sensation progressing rapidly to facial or glossal swelling. The

CSP suggest the following regime:

-Stop delivery of drug

-Summon Medical Help

-Admisnter the adrenaline

-Adminster cardiopulmonary resuscitation


7/18


Triamcinolone Acetonide:

Name of medicine Triamcinolone Acetonide: Adcortyl 10mg/ml or Kenalog 40mg/ml in 1ml vials or5ml vials



Dose Maximum dose per Consultation is 40mg.

Route/method Injection of Steroids with/ without Lidocaine via Intra-articular, Periarticular,Intrabursal, and Tendon Sheaths administration only

Frequency Allow at least a two-week interval between repeat injections into the samelesion.The standard recommendation is forosteoarthritic joints where no other therapyis effective is once every 3 -6 months.

Any patient that requires injection as often as once per month should be referred to

the appropriate medical or orthopaedic specialists for adequate management andmonitoring

Total dose number A maximum number of three injections per lesion are acceptable.

Advice to Patient The patient will be given information about the injection including:

Nature of their condition

Details of the proposed treatment and alternatives

Nature of the drugs to be given

Contraindications to injection

Possible adverse effects, incidence and management including contacts during and

outside working hours

Likely benefits

Warning about possible post injection pain

Plans for follow-up and after care including relative rest

The patient will be observed for indications of any immediate post-injection adverse

reactions for at least 30 minutes

A written information sheet will be given to the patient

6.2 Methylprednisolone (Depo-Medrone):

Name of medicine Methylprednisolone (Depo-Medrone)- 40-120 mg/ml 1 ml, 2 ml, 3ml vialsintermediate to long lasting and least soluble




Route/method with or without Lidocaine Hydrochloride/Marcaine prior to injection.

Frequency Allow at least a two-week interval between repeat injections into the same


8/18


lesion.The standard recommendation is forosteoarthritic joints where no other therapy

is effective is once every 3 -6 months.Any patient that requires injection as often as once per month should be referred tothe appropriate medical or orthopaedic specialists for adequate management andmonitoring









Likely benefits


Plans for follow-up and after care including relative restThe patient will be observed for indications of any immediate post-injection adverse



6.3 Hydrocortisone:

Name of medicine Hydrocortisone acetate (Hydrocortistab) 25mg/ml - 1 ml AMPOULES.Considered to be more soluble and shorter acting, recommended for tendon sheaths




Route/method with or without Lidocaine Hydrochloride/Marcaine prior to injection.

Frequency Allow at least a two-week interval between repeat injections into the samelesion.The standard recommendation is forosteoarthritic joints where no other therapy

is effective is once every 3 -6 months.Any patient that requires injection as often as once per month should be referred tothe appropriate medical or orthopaedic specialists for adequate management andmonitoring








outside working hoursLikely benefits



9/18






6.4 Local Anaesthetics:

Name of medicine Lidocaine hydrochloride -AMPOULES of0.5% (2 ml), 1% (2 ml), or 2% (2 ml or5ml) - without adrenaline.

Marcaine- AMPOULES of 10ml



DoseMaximum dose per Consultation

Lidocaine 0.5% solution - 20ml, 1% solution 10ml, 2% solution - 5ml.

Marcaine 0.25% solution- 20ml, 0.5% solution- 15ml

The doses listed for Lidocaine Hydrochloride are for healthy adult of medium

built and should produce only relief of pain and loss of skin sensation for theduration of the half life which is estimated to be between 1 2 hours and forMarcaine is 2.7 hours

Route/method Local infiltration with or without steroid

Frequency Allow at least a two-week interval between repeat injections into the samelesion.





Nature of the drugs to be givenContraindications to injection



Likely benefits







10/18


This Patient Group Direction for use in *please tick as appropriate

Chelsea & Westminster Hospital Foundation Trust Kensington PCT

Management of the patient group direction

a. The group direction developed by: Tendayi Mutsopotsi

b. Is Authorised by :-

Job Title Name Signed Date

Orthopeadic Consultant Surgeon Mr. Andrew Sankey

Senior Pharmacist

(Pharmaceutical Advisor)

Executive Nurse

The Physiotherapists named below, being employees of the above Organisation are Authorised to

administer Depomerone 40mg/ml,Triamcinolone Acetonide ( Adcortyl 10mg/ml, Kenalog 40mg/ml)

and Hydrocortisone 25mg/ml

We agree to administer the above drug in accordance with this Patient group Direction

Physiotherapist Job Title Signed Date

Tendayi Mutsopotsi Extended Scope Practitioner


11/18


Acknowledgement

This protocol has been adapted (with permission) from

References

CSP (2001). A Clinical Guideline for the use of injection therapy by physiotherapist .

HSC 2000/026 Patient Group Directions

British National Formulary (BNF 43 March 2002)

A.C.P.O.M (1999). A Clinical Guide for the use of Injection Therapy by physiotherapists.

Genovese, M C (1998)Joint and Soft Tissue Injection: A Useful Adjuvant to Systemic and Local Treatment,Postgraduate Medicine: Symposium: Rheumatologic Diseases, Vol. 103, No 2.

Pharmacia Ltd (2001)Drug Information Update: Depo-Medrone with Lidocaine, http://emc.medicine.org.uk/emc

Roberts W N (2000) Intraarticular and soft tissue steroid injections: What agent(s) to inject and how frequently?UpToDate Version 8.1. (American Rheumatology CD or on Line)

Saunders, S (2002) Patient Group Direction Proforma, The Association of Chartered Physiotherapists inOrthopaedic Medicine (ACPOM).

Saunders, S, Cameron, G (1997)Injection Techniques in Orthopaedic and Sports Medicine, Philadelphia (W.BSaunders company Ltd).

Kesson,M, Akins,E, Davies, I(2002) Musculoskeletal Injection Skills,Edinburgh (Butterworth-Heinemann)


12/18


INJECTION THERAPY PATIENT INFORMATION

What to Expect Post Injection

1. Injected area may ache more for the first 24-48 hours. 2. Your face may become flushed.3. You may have trouble sleeping the night after injection.4. If you are diabetic the injection may cause blood sugar to increase.5. Area injected may become numb and remain numb for 24-48 hours.6. Injected area may seem more swollen for the first day past injection.

CALL THE ME OR THE CLINIC IF THE FOLLOWINGSYMPTOMS OCCUR:


13/18


1. Trouble breathing or swallowing.2. Skin rash.3. Develop a fever of 100 o or more.4. Injected area becomes red or inflamed

Useful Contact Numbers:

Physiotherapy Department:

Therapist:

Injection Therapy Consent Form

Patient Ref. No: Name:

D.O.B: .Gender M/F: ..

Absolute Contraindications:

Yes No Yes NoSuspicion of infection (anywhere) Damaged / broken skin at site

Hypersensitivity to injections Previous allergic reaction

Prosthetic joint Haemarthrosis

Taking oral corticosteroids < 18 years of age

Unable to rest for 48 hours (including driving) Pregnancy / breast feeding

Recent live vaccination (avoid for 2/52 post live vacine) Recent trauma

Planned surgical procedure in next 4/52 (includingdental)

Unstable joint

Taking warfarin and no INR (haematology)

Precautions:Yes No Yes No Yes No


14/18


Diabetic Bleeding disorder Immunosupressed

Taking anticoagulants (eg. warfarin)INR < 2

Needle phobia

Warnings of side effects given:

Yes Yes Yes

Facial flushing Menstrual irregularity Impaired diabetic control (check control)

Allergic reaction Post injection flare-up Skin depigmentation / fat atrophy

Infection Possible tendon rupture

Diagnosis:

Injection site and approach:

Injection composition and prescription:

Analgesic: Batch: Expiry:

Corticosteroid: Batch: Expiry:

Patient advised to wait 30 minutes post injection? Yes

Clinicians name: Signature: Date:

Patients name: Signature: Date:

Date of procedure:


15/18



16/18



17/18



18/18


patient group direction (pgd) for the administration of local anaesthetics and corticosteroids by...

Documents