Date post: | 04-Apr-2018 |
Category: |
Documents |
Upload: | physiotherapy-care-specialists |
View: | 217 times |
Download: | 0 times |
of 18
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
7/31/2019 Patient Group Direction (PGD) For the Administration Of Local Anaesthetics and Corticosteroids BY TENDAYI MUTSO
2/18
Patient Group Directions For The Adminstration Of Steroid Injections
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
7/31/2019 Patient Group Direction (PGD) For the Administration Of Local Anaesthetics and Corticosteroids BY TENDAYI MUTSO
3/18
Patient Group Directions For The Adminstration Of Steroid Injections
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
7/31/2019 Patient Group Direction (PGD) For the Administration Of Local Anaesthetics and Corticosteroids BY TENDAYI MUTSO
4/18
Patient Group Directions For The Adminstration Of Steroid Injections
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
7/31/2019 Patient Group Direction (PGD) For the Administration Of Local Anaesthetics and Corticosteroids BY TENDAYI MUTSO
5/18
Patient Group Directions For The Adminstration Of Steroid Injections
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
7/31/2019 Patient Group Direction (PGD) For the Administration Of Local Anaesthetics and Corticosteroids BY TENDAYI MUTSO
6/18
Patient Group Directions For The Adminstration Of Steroid Injections
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
7/31/2019 Patient Group Direction (PGD) For the Administration Of Local Anaesthetics and Corticosteroids BY TENDAYI MUTSO
7/18
Patient Group Directions For The Adminstration Of Steroid Injections
Triamcinolone Acetonide:
Name of medicine Triamcinolone Acetonide: Adcortyl 10mg/ml or Kenalog 40mg/ml in 1ml vials or5ml vials
Legal status Prescription only medicine.
Storage Store as stock items in a lockable cupboard at room temperature.
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
Legal status Prescription only medicine.
Storage Store as stock items in a lockable cupboard at room temperature.
Dose Maximum dose per Consultation is 40mg.
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
7/31/2019 Patient Group Direction (PGD) For the Administration Of Local Anaesthetics and Corticosteroids BY TENDAYI MUTSO
8/18
Patient Group Directions For The Adminstration Of Steroid Injections
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
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 restThe 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
6.3 Hydrocortisone:
Name of medicine Hydrocortisone acetate (Hydrocortistab) 25mg/ml - 1 ml AMPOULES.Considered to be more soluble and shorter acting, recommended for tendon sheaths
Legal status Prescription only medicine.
Storage Store as stock items in a lockable cupboard at room temperature.
Dose Maximum dose per Consultation is 25mg.
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
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 hoursLikely benefits
Warning about possible post injection pain
7/31/2019 Patient Group Direction (PGD) For the Administration Of Local Anaesthetics and Corticosteroids BY TENDAYI MUTSO
9/18
Patient Group Directions For The Adminstration Of Steroid Injections
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
6.4 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
Legal status Prescription only medicine.
Storage Store as stock items in a lockable cupboard at room temperature.
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.
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 givenContraindications 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
7/31/2019 Patient Group Direction (PGD) For the Administration Of Local Anaesthetics and Corticosteroids BY TENDAYI MUTSO
10/18
Patient Group Directions For The Adminstration Of Steroid Injections
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
7/31/2019 Patient Group Direction (PGD) For the Administration Of Local Anaesthetics and Corticosteroids BY TENDAYI MUTSO
11/18
Patient Group Directions For The Adminstration Of Steroid Injections
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)
7/31/2019 Patient Group Direction (PGD) For the Administration Of Local Anaesthetics and Corticosteroids BY TENDAYI MUTSO
12/18
Patient Group Directions For The Adminstration Of Steroid Injections
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:
7/31/2019 Patient Group Direction (PGD) For the Administration Of Local Anaesthetics and Corticosteroids BY TENDAYI MUTSO
13/18
Patient Group Directions For The Adminstration Of Steroid Injections
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
7/31/2019 Patient Group Direction (PGD) For the Administration Of Local Anaesthetics and Corticosteroids BY TENDAYI MUTSO
14/18
Patient Group Directions For The Adminstration Of Steroid Injections
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:
7/31/2019 Patient Group Direction (PGD) For the Administration Of Local Anaesthetics and Corticosteroids BY TENDAYI MUTSO
15/18
Patient Group Directions For The Adminstration Of Steroid Injections
7/31/2019 Patient Group Direction (PGD) For the Administration Of Local Anaesthetics and Corticosteroids BY TENDAYI MUTSO
16/18
Patient Group Directions For The Adminstration Of Steroid Injections
7/31/2019 Patient Group Direction (PGD) For the Administration Of Local Anaesthetics and Corticosteroids BY TENDAYI MUTSO
17/18
Patient Group Directions For The Adminstration Of Steroid Injections
7/31/2019 Patient Group Direction (PGD) For the Administration Of Local Anaesthetics and Corticosteroids BY TENDAYI MUTSO
18/18
Patient Group Directions For The Adminstration Of Steroid Injections