Download 2006-07 Epidural Analgesia Learning Module

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Epidural Analgesia
Independent Learning Module for Registered Nurses
Grande Prairie, Alberta
Revised July 2006
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Table of Contents
Page
I.
Purpose………………………………………………………………………..3
II.
Learner Objectives ……………………………………………………………3
III.
Introduction……………………………………………………………………3
IV.
Anatomy and Physiology of the Epidural Space……………………………...4
V.
Medications Used in Epidural Anesthesia ……………………………………9
VI.
Complications/Precautions…………………………………………………..12
VII.
Patient Education
VIII.
General Guidelines for Care of Patients Receiving
Epidural Analgesia
IX.
References
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I. PURPOSE:
To assist the Registered Nurse in understanding the concepts related to epidural
analgesia in order to provide competent nursing care to patients receiving analgesics
by the epidural route.
II. LEARNER OBJECTIVES:
After completion of this module, the learner will be able to:
1. Explain the anatomy and physiology of the spinal column as it relates to epidural
analgesia
2.
State the actions, doses and side effects of medications used for epidural
analgesia
3. Explain adverse effects related to epidural analgesia and how these effects may be
avoided or treated Describe the nursing care related to assessments and care of the
patient with an epidural catheter
4. Understand how to administer epidural analgesia either by intermittent bolus or
continuous infusion
5. Describe the technique used for removal of an epidural catheter
III. INTRODUCTION:
In certain patients, methods of pain control other than intramuscular, intravenous or oral
medication may be advantageous. One such method is epidural analgesia. This involves
the insertion of a catheter into the epidural space by an anesthetist. Medications (opiods
and/or local anesthetics) may be delivered through this catheter, either via intermittent
blousing or continuous infusion to achieve pain control. Epidural analgesia is very useful
for postoperative pain control.
Advantages:
There are a number of advantages to using epidural analgesia: small amounts of narcotics
can reduce pain significantly for long periods of time; there are few CNS side effects; and
motor function remains intact (if no local anesthetics are used). Because epidural
analgesia provides pain relief with less sedation than other pain control delivery methods,
it allows patients to breathe and cough easier, and mobilize sooner.
Local anesthetics given epidurally act by binding to nerve roots entering and exiting the
spinal cord. By using low concentrations of local anesthetic, sensory pathways may be
blocked but motor fibres remain relatively intact.
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Although serious side effects are rare, they can have serious outcomes when they do
result. Therefore, patients receiving epidural analgesia warrant close monitoring.
Indications:
Epidural analgesia has been used to control many types of pain including that produced
by surgery (thoracic, major abdominal, orthopaedic), trauma (rib fractures), labour and
delivery or disease process (cancer).
Contraindications:
1. Absolute contraindications:
a. Patient refusal
b. Drug allergy
c. Coagulopathy (Platelet count <100,000, elevated PT, PTT, or INR)
d. Local infection at potential insertion site
2. Relative contraindications:
a. Septicemia (as soon as the patient is responding to treatment for
septicaemia, epidural analgesia may be considered)
b. Increased intracranial pressure
c. Hypovolemia
d. Neurological disease
e. Anticoagulation therapy
f. Spinal fractures
Note: The presence of spinal deformities (e.g. scoliosis) is not a contraindication to the
use of epidural analgesia; however, it can make catheter placement difficult.
IV. ANATOMY AND PHYSIOLOGY OF THE EPIDURAL SPACE
The epidural space is a potential space between the vertebral column and the dura matter.
It contains fat, veins, and lymphatics. The spinal nerves also traverse this space.
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Paravertebral block
Epidural block
Peripheral nerve block
Epidurals are usually performed at the L2-L3 or L3-L4 interspaces. At this level the
space between the spineous processes is large, allowing easier passage of the needle.
Also, if the needle inadvertently punctures the dura, the spinal cord will not be affected,
as it ends at L1-L2 in most adults. Inadvertent puncture of the dura would position the
catheter in the subarachnoid rather than the epidural space.
With the use of different opiods and local anesthetics, most epidurals are performed in
the thoracic region. If used in the thoracic spine, a band of analgesia may be obtained a
few segments above and below the catheter site. Because of this, patients may have a
numb chest or abdominal wall, but normal sensation and muscle strength in the legs. If
inserted lower in the lumbar spine, the legs may be anesthetized.
Highly lipid-soluble opiods (fentanyl, sulfenta) are more readily dissolved in fatty tissue,
and easily penetrate the dura/arachnoid membranes and the spinal tissue, thus having a
rapid onset of action. In addition, they are more dependent on catheter location for
optimal segmental effect due to their limited ability to spread in the CSF. The principle
routes of clearance of epidurally administered opiods are through rapid vascular
absorption or through slow rosteral diffusion in the CSF with elimination at the arachnoid
granulations. Thus, lipophilic opiods have a rapid onset of action but a limited duration.
Hydrophilic agents (morphine and hydromorphone) have difficulty penetrating the
membranes as, and diffuse more slowly. Therefore, the onset of pain relief is slower.
Hydrophilic opiods tend to accumulate in the CSF (aqueous solution), and are transported
rosterally to higher spinal levels eventually being eliminated at the arachnoid
granulations. Since hydrophilic opiods have a greater ability for dermatomal spread than
the lipophilic, this enables them to provide analgesia for larger areas. So, hydrophilic
opiods have a slower onset of action and a longer duration.
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Meperidine
Fentanyl
Morphine
The insertion is often performed midline so as to avoid puncture of the large epidural
veins that lie laterally in the epidural space, and thus inadvertent intravascular injection of
the epidural drug.
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The epidural needle is inserted between the spineous process, through the Ligamentum
Flavum and into the epidural space. A small plastic epidural catheter is then passed
through the needle and threaded 3-6 cm upwards. The needle is then removed and the
catheter securely taped to the skin.
Most epidural catheters are approximately 100 cm long and 19 gauge. The catheters have
centimetre markings at the distal end to assist in deciding how far to insert the catheter.
There is a black tip on the distal end. Ensure the tip is intact when removed.
A filter may be added to the proximal end of the catheter to ensure no small particles (e.g.
glass) are introduced into the epidural space. All medications should be drawn up using
a filtered needle in case no filter is used on the line.
Nerves:
The size of the nerve fibre influences its sensitivity to local anesthetics. Local anesthetics
block nerve conduction in small nerve fibres faster and at lower concentrations than in
large fibres. The pain fibres are one of the smallest. Sensitivity to cold is very similar in
size, with sensitivity to touch being larger and the nerves that influence motor power the
largest. This is why a patient can have good pain control with sometimes no sensory
block to cold and the ability to ambulate.
The anesthetist should always be called for a sensory or motor block that is rising, e.g. if
a patient returns to the nursing unit with a block at T6 and now it is at T4. Blocks that are
vague and present intermittently are caused by the low concentrations and are not a
concern if the patient has good pain control.
Dermatomes:
The portion of the skin innervated by each spinal nerve or spinal cord segment is called a
dermatome. Spinal nerves are responsible for sympathetic, sensory and motor responses
along the dermatomes. By identifying the surface area that is anesthetized using ice or an
alcohol swab, the sensory level of the block can be determined. Remember that pain is
the easiest modality to block, so movement and sensation of touch are not adequate signs
of return of normal nerve function. Cold sensation is the last to return, so checking
sensation with ice gives the most accurate assessment of block level. The dermatomes of
the body follow an orderly head to toe sequence:
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How Epidural Opiods Work:
Opiod uptake after epidural injection may follow at least 4 different routes:
 Diffusion through the dural membrane of the spinal root cuff into the CSF and to
the dorsal horn of the spinal cord and the brain
 Possible direct transfer from the epidural space to the spinal cord via spinal
radicular arteries
 Vascular uptake into the bloodstream
 Diffusion into surrounding lipophilic tissues that lack opiod receptors
Epidural opiods have no effect on motor function. The analgesic effect is mainly confined
to segmental spread across the spinal nerves that correspond to the site of entry into the
epidural space.
How Epidural Local Anesthetics Work:
Local anesthetics block pain impulses just before they enter the dorsal horn of the spinal
cord. The extent of the block depends on the dose. If you have a unilateral block,
sometimes turning the patient with the unaffected side down will even out the block. Low
concentrations are used for epidural analgesia to provide sensory block with minimal
motor block. Not everyone will experience a sensory block. This is okay as long as
pain is blocked. Remember with local anesthetics, pain is blocked first, then sensory and
finally motor nerve fibres.
Epidural opiods are more effective when used in combination with a local anesthetic to
produce a synergistic analgesic action and reduce the required dose and side effects
associated with either the local anesthetic or opiod alone.
V. MEDICATIONS USED IN EPIDURAL ANALGESIA
Physiology of Pain:
Pain is a warning signal that stimulates the body to respond to prevent further injury.
Noxious substances are released in response to tissue damage that initiates nociceptive
transmission. Afferent nerve fibres respond to the nociceptive stimuli peripherally, and
relay this information to the spinal cord. Most of the nociceptive input enters the spinal
cord through the dorsal horn.
In the dorsal horn, nociceptive neurotransmitters (e.g. substance “P”) are released in
response to the nociceptive input, which activate the second-order dorsal horn neurons.
The activation of the second order neurons result in:
 Spinal reflex responses such as acute vasoconstriction, muscle spasms, and
increased sensitization of nociceptors
 Activation of the ascending tracts which transmits the nociceptive input to several
regions within the brain
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The modulation of nociceptive input occurs at several sites including the opiod receptors
located in the dorsal horn, and at opiod receptors located supraspinally in such areas as
the cortex, hypothalamus and periaqueductal area. Neuropeptides such as enkelphalin
molecules (endogenous opiods) bind with the opiod receptors to modulate nociceptive
input. Exogenous (administered) opiods work in a similar fashion. These opiod receptors
provide the means by which the spinal opiods are able to modulate pain transmission.
Narcotics:
Epidural analgesics can be administered either by intermittent bolus injection or by
continuous infusion. Narcotics administered by the epidural route include preservative
free morphine (Epimorph), fentanyl citrate, meperidine (Demerol), or Sufentanil
(Sufenta). Preservative free morphine is used for epidural analgesia, as the preservative in
regular morphine is potentially neurotoxic.
Mechanism of Action:
The action of narcotics given epidurally is NOT due to systemic absorption. Epidural
narcotics diffuse slowly from the epidural space across the dura and arachnoid
membranes into the CSF.
Narcotics are thought to block substance “P” by binding with the opiate receptors in the
dorsal horns of the spinal cord thus blocking transmission of pain impulses to the cerebral
cortex. The amount of opiod needed to provide a given level of analgesia is much smaller
when administered via a spinal route. This is due to the opiod being deposited in close
proximity to the spinal cord opiod receptor sites. This reduces dose requirements, and
improves the selectivity of spinal analgesia, which provides for excellent analgesia with
little associated sedation or respiratory depression. When comparing 24 hour dose
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requirements of parenteral vs. epidural morphine, it has been found to be a
sequential 10-fold decrease i.e.: 50-70mg of parenteral morphine = 5-7mg of
epidural morphine.
Pain relief from epidural narcotics is variable due to the lipid solubility, which affects the
onset and duration of action.
Table 1
Narcotic
Peak
(min)
90-120
Duration
Bolus Dose
Infusion Rate
Epimorph
Onset
(min)
30-90
6-24 hrs
3-5mg
0.2-1.0mg/hr
Fentanyl
Sufentanil
Meperidine
5-15
5-10
5-10
10-20
10
10-20
4-6 hrs
2-4 hrs
68 hrs
50-200mcg
10-60mcg
10-40mg
50-100mcg/hr
5-15mcg/hr
5-20mg/hr
Morphine:
Epimorph is the most common analgesic administered through the epidural route.
Morphine given via the epidural route has a long duration of action with few CNS side
effects and no sensory or motor impairment. As a result, postoperative patients who have
received epidural morphine are generally comfortable, alert and able to move about
freely.
Dose requirements vary more with age than with size: elderly people require lower doses.
The usual dose range for Epimorph is 3-5mg every 6-12 hrs. The dose range for chronic
pain may be higher and more variable as opiate receptors in the dorsal horn and in the
brain may become tolerant to opiods.
Demerol:
Demerol may also be administered epidurally. It is more lipid soluble than morphine.
Refer to Table 1 for dosage and duration of action.
Fentanyl:
Fentanyl has high lipid solubility. It acts more rapidly than morphine but has a shorter
duration of action. Continuous infusions of fentanyl are preferred to intermittent boluses
because of its short duration. Catheter location is important. At a steady rate, slow
elimination from tissues can result in a long half-life and accumulation leading to late and
prolonged sedation and respiratory depression. Fentanyl may also be given in
supplemental boluses for relief of breakthrough pain when morphine infusions need to be
titrated upward.
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Sufentanil:
Sufenta is 2X more lipid soluble than fentanyl. A continuous infusion is preferred
because of its short duration. Catheter location is important. Analgesia and side effects
are similar to fentanyl, but less likely to accumulate. It is more sedating than other
opiods.
Local Anesthetic Agents:
Dilute solutions of local anesthetics may be used to provide analgesia by blocking
conduction of pain impulses as they pass through the nerve roots. The number of pain
impulses blocked depends on the dose of the local anesthetic used. High concentrations,
such as during surgical anaesthesia, block all pain receiving neurons. Low concentrations
block only a portion of neurons.
Bupivicaine (Marcaine)
Bupivicaine is the most commonly used local anesthetic in epidurals. It is an amide local
anesthetic that is about 4X as potent as Lidocaine. It has a slower onset, but longer
duration than lidocaine. The duration can be increased by the addition of epinephrine.
Ropivicaine
Ropivicaine resembles bupivicaine in potency. It’s main advantages are that it produces
less motor blockade while maintaining analgesia and that is less toxic – it binds less to
cardiac tissue, which makes it more suitable for cardiac patients.
Table 2
Local
Anesthetic
Bupivicaine
Ropivicaine
Infusion
2.5-15mg/hr
2.5-15mg/hr
VI. COMPLICATIONS/PRECAUTIONS
RESPIRATORY/CIRCULATORY
1. Respiratory Depression
The incidence of respiratory depression related to epidural analgesia is only
approximately 1%. The risk of respiratory depression is greater in elderly patients,
especially following upper abdominal or thoracic surgery. Patients receiving parenteral
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narcotics in addition to epidural doses are also at great risk for developing respiratory
depression.
Respiratory depression with a hydrophilic opiod such as morphine may occur at 2 distinct
times. Early onset respiratory depression (soon after admission) occurs mainly due to
the vascular absorption and circulatory redistribution to the brain. Peak period for early
onset respiratory depression is 1 hour after the administration of the epidural bolus. This
is similar to parenteral administration. Delayed onset respiratory depression occurs due
to the rosteral spread of the opiod via the CSF to the brainstem respiratory centre. This
may occur up to 24 hrs later.
With the use of lipophilic opioids, the delayed onset respiratory depression is less likely
to occur due to the decreased tendency of lipophilic opiods to have rosteral spread. Early
onset respiratory depression may occur due to the rapid uptake and circulation to the
brainstem respiratory centre.
Prevention/Treatment:
Watch for decreased level of consciousness. Monitor respiratory status and be aware that
although the respiratory rate may stay the same, respirations may become shallow in
depth therefore not providing an adequate tidal volume.
Caution must be used when administering other CNS depressants in conjunction with
agents given epidurally. The additive effects may produce dangerous respiratory
depression. Narcotics or CNS depression ordered by other routes must not be
administered except under the order of the anesthetist responsible for the epidural
analgesia.
Patients receiving epidural analgesia post operatively should become more alert as their
anesthetic wears off and not become drowsy with epidural analgesia. Level of
consciousness needs to be assessed with these patients and any somnolence reported to
the anesthetist. It is important to assess the patient who is sleeping or appears
inappropriately drowsy to determine if the patient can be easily roused. For the sleeping
patient, it is adequate to quietly call out the patient’s name or use gentle tactile stimulus.
The patient need not be awakened, but should respond to these stimuli.
Assess sedation and respiratory rate (including depth) q1h x 4, q2h x 10, then q4h until
12 hours after last dose. The depth of respiration is more of an indicator of adequate
respiration than is rate.
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Sedation Score:
0 (none)
1 (mild)
2 (moderate)
3 (Severe)
4 (normal)
Awake, alert
Occasionally drowsy, easy to arouse
Frequently drowsy, easy to arouse
Somnolent, somewhat difficult to arouse
Normal sleep, easy to arouse
2. Hypotension
During epidural analgesia as pain relief occurs, levels of circulating catecholamines
decrease, and if the patient has an underlying fluid volume deficit, hypotension may
occur.
In addition, if local anesthetic agents are used as part of the medication regime,
sympathetic nerve fibres may be blocked as well as sensory pain fibres. With sympathetic
blockade, venous pooling in the extremities can result in postural hypotension and is
accentuated when there is also a fluid volume deficit.
Prevention/Treatment
Assess for surgical causes. Monitor fluid balance and replace fluid volume as necessary
to maintain adequate blood pressure. The “rule of thumb” for fluid resuscitation is
20mL/kg. Elevating the legs may be of benefit, but DO NOT place the patient in
Trendelenburg as this may spread the block. For the first ambulation and any time the
infusion is increased or a bolus dose of local anesthetic is given by the anesthetist, check
the blood pressure in lying, sitting, and standing positions. Prior to ambulating, instruct
the patient to progress slowly from gradually increasing head to sitting to standing and
not to ambulate unassisted for the first couple of times. USE A TRANSFER BELT.
If necessary, a sympathomimetic agent such as Ephedrine may be required to improve
hypotension caused by sympathetic blockade.
MECHANICAL
1. Disconnection of Epidural Catheter
The most common cause for discontinuation of epidural analgesia is catheter
disconnection. Catheter disconnection occurs at the connection to the epidural catheter
adapter, which results in contamination of the proximal end of the catheter.
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After the physician secures the epidural catheter into the catheter adapter, the catheter
adapter connection should be taped to eliminate the chance of catheter disconnection. If
the catheter becomes inadvertently disconnected or contaminated, a nurse may replace
the connector using the following procedure:
a) Obtain a sterile epidural connector.
b) Assemble a sterile dressing tray with sterile scissors and providone iodine.
c) If the catheter has been disconnected for less than 8 hrs, proceed with
reconnection:
a. Using sterile technique, clean the outside of the catheter with providone
iodine for approximately 25 cm (5 inches). Allow to dry.
b. Wipe catheter with a sterile 4x4 to avoid contamination of the epidural
space and irritation of the nerves with providone iodine.
c. Cut 12 cm from the catheter and attach the sterile connector to the new
end of the catheter. Tape the connection.
d) If unsure how long the catheter has been disconnected, or if signs of infection are
present, notify anesthetist.
2. Occlusion of Catheter
Occlusion of the catheter can be caused by over-tightening of the epidural catheter
connector, kinking of the catheter above or beneath the skin, or tubing in the pump being
pinched off.
Prevention/Treatment
If difficulty is encountered with injection, first inspect the pump and tubing (if
applicable) to determine a cause, then inspect the visible part of the catheter tubing. The
connection can be loosened if too tight, but ensure that it is not so loose that the
connector will come apart. Tape the connection to ensure accidental disconnection does
not occur.
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3. Migration of the Catheter
The epidural catheter could migrate into a vein, into the subarachnoid space, or fall out.
Prevention/Treatment
The catheter must be aspirated before epidural drugs are administered. If the return is
bloody, it may indicate the catheter has entered a blood vessel. A small amount (less than
0.5 cc) of clear fluid aspirate is normal, but if clear fluid flows freely into the syringe, it
may be CSF. The anesthetist is responsible for determining the proper location of the
catheter.
It is possible, although rare, for the epidural catheter to migrate through the dura into the
intrathecal space. Because intrathecal drug doses are approximately 1/10th of epidural
doses, profound complications can result. If the patient becomes unusually drowsy,
difficult to rouse, or has a sudden increase in motor weakness or sensory block:






Stop the infusion
Apply O2 @ 10 litres per mask
Check the vital signs and block level
Call the anesthetist immediately
Have Ephedrine and Narcan brought to the bedside
Stay with the patient
GI/RENAL
1. Urinary Retention
Urinary retention is a side effect related to epidural analgesia. It is seen more commonly
in males and usually occurs in the first 24-48 hours. The cause is unclear but may be
related to a block of acetylcholine resulting in relaxed bladder detrusor muscle or due to
motor/sensory blockade if local anesthetic agents are used.
Prevention/Treatment
Monitor urinary output. In-and-out catheterization may be ordered. Usually if the patient
requires a 2nd in-and-out catheterization, a Foley catheter is considered.
2. Nausea and Vomiting
Because patients are often nauseated postoperatively due to related illness or slowed GI
function, it may be difficult to differentiate nausea related to epidural analgesia. Nausea
related to epidural analgesia usually begins 4-6 hours after medication bolus and is
exacerbated by movement. This side effect is no more common with epidural
administration of narcotics than with systemic administration.
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Prevention/Treatment:
Nausea may be relieved with antiemetics such as metoclopramide or dimenhydrinate. Use
care when administering antiemetics with CNS depressant properties.
NEUROLOGICAL/OTHER
1. Pruritis
Pruritis is a common side effect related to epidural analgesia, resulting in itching around
the head and neck not associated with rash or wheals.
This side effect is not entirely related to histamine release but may also relate to the
spread of opiates into the trigeminal nerve area.
Prevention/Treatment:
Comfort measures such as cool packs and lotions are helpful. Dimenhydramine or
naloxone may be indicated.
Small doses of naloxone may reverse the side effects of pruritis quite well without
reversing the analgesic effect of the opiod.
Be aware that drugs with CNS side effects must only be ordered by the anesthetist to
avoid risk of CNS depression and apnea due to compounding drug effects.
2. Infection
Infection may occur superficially at the insertion site, or bacteria may colonize inside the
catheter with the potential for causing meningitis.
Prevention/Treatment:
Monitor for signs of disconnection, leakage and infection with each dose of medication or
at least q12hr. Maintain strict aseptic technique when preparing/injecting solutions or
changing the injection cap. If an injection cap falls off or becomes contaminated, replace
with a sterile white replacement cap.
A filter needle must be used to draw up any medication administered epidurally.
3. Impaired Physical Mobility
Patients receiving epidural opiods have no sensory or motor deficits and often feel so
much pain relief that they may need to be cautioned to pace their activities so as not to
overexert themselves postoperatively.
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Motor Block: This is caused by the local anesthetic, not the opiod. It is more common
with bupivicaine than ropivicaine, but at low concentrations is less likely with either. The
incidence is higher in the lumbar epidural. The goal is no motor blockade.
Prevention/Treatment:
Assess motor strength regularly and prior to ambulation of patient. Advise patient not to
ambulate alone for the first couple of times. Assist patient to turn q1-2hrs to decrease the
potential for skin breakdown.
If there is some motor blockade, the anesthetist may decrease the local anesthetic
concentration, change the solution, or decrease the rate of the infusion. If the patient
with a stable epidural infusion experiences an increase in sensory or motor blockade
without a change in the solution, turn off the infusion and call the anesthetist. This
could indicate catheter migration into the intrathecal space where epidural doses
are now 10 X more potent.
4. Local Anesthetic Toxicity
If local anesthetic is injected at a rapid rate directly into a blood vessel, the high plasma
concentration may result in direct toxicity. CNS toxicity presents as excitatory
phenomena (tinnitus, metallic taste, numbness around the mouth, tremor, and jitteriness),
with the most profound symptom being seizure.
The other form of local anesthetic toxicity is cardiac toxicity. This is almost always due
to injection of a large intravascular dose of bupivicaine. The drug causes severe
arrhythmias and cardiac arrest.
Both severe complications of seizure and cardiac arrhythmias are extremely uncommon
if small doses of local anesthetics or local anesthetic infusions are used, since
complications are directly related to the concentration of the drug in the blood.
Prevention/Treatment:
Stop the infusion. Check breathing. Ensure adequate oxygenation by administering high
flow oxygen by mask. Assess vital signs. Stay with the patient. Have the anesthetist
called immediately.
If in cardiac arrest, call a Code Blue and start CPR.
5. Epidural Hematoma
Epidural hematoma can occur due to trauma to an epidural vein by the epidural needle or
the catheter itself. It can happen during insertion or removal. The resultant bleeding puts
pressure on the spinal nerves. Epidural hematoma requires immediate surgical
decompression. The symptoms of hematoma are:
 Weakness and sensory change well past the expected duration of the block
 Severe back tenderness
 Possible changes in bladder and/or bowel continence.
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Prevention/Treatment:
Unless otherwise ordered by the anesthetist:
1. The epidural should not be removed until at least 8-12 hrs after a dose of LMWH
(low molecular weight heparin) or sc heparin has been administered.
2. LWMH or sc heparin should not be given for at least 2 hrs after an epidural
catheter has been removed.
3. The patient should not be started on IV heparin until at least 6 hrs after an
epidural has been removed.
4. If LMWH is considered preoperatively, it should be administered at least 8 hrs
preoperatively, and not started earlier than 2 hrs postoperatively.
5. An RN may not remove an epidural catheter when the patient is fully
anticoagulated (on IV heparin).
6. Patients receiving low dose warfarin therapy must have their prothrombin time
and INR checked prior to removal of the catheter. Notify anesthetist with results
and confirm order to remove the catheter. Document the lab results, the time the
physician notified, and order to remove the catheter.
7. The anesthetist in charge of the epidural must be notified before starting oral
anticoagulants on a patient who has an epidural in situ.
8. NSAIDS (non-steroidal anti-inflammatory drugs) should only be given after
careful consideration to patients who have epidurals who are receiving
anticoagulants.
VII. PATIENT EDUCATION
It is important that patients who may have an epidural catheter are provided with
information about epidural pain management. The patient handout “Epidural Analgesia”
(F0000808) is to be given to the patient and reviewed with the patient prior to the
insertion of an epidural catheter if at all possible (preoperatively), or as soon as possible
after the insertion of an epidural catheter, dependant on the patient’s ability to
comprehend the information provided.
VIII. GENERAL GUIDELINES FOR CARE OF PATIENTS RECEIVING
EPIDURAL ANALGESIA
Complete guidelines for patient care, administration of analgesics via the epidural route,
and the removal of epidural catheters are provided in Procedure #_____ Care of Adult
Patient Receiving Epidural Analgesics. General points to remember are:



Always use a filter needle when drawing up medications.
NEVER use alcohol on an epidural line. It is neurotoxic.
The epidural catheter is NOT sutured in place. Do not remove original dressing:
reinforce the dressing as needed, and ensure the epidural catheter is secured with
tape.
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Any sudden changes in sensory or motor blockade are potential emergencies. Stop
the infusion, stay with the patient, and have the anesthetist notified.
References
Neligan, P. (1999). Local Anaesthetics Tutorial. 4um.com. Retrieved from:
http://www.4um.com/tutorial/anaesth/Locals.htm August 1, 2006.
Queen Elizabeth II Hospital (November 1995, Revised May 2000). Learning Module
on Care of Patient Receiving Epidural Analgesia for Registered Nurses.
Author: Grande Prairie.
University of Wisconsin Hospital and Clinics (2000). Epidural Analgesia. A SelfDirected Learning Module (3rd ed.). UW Hospital and Clinics Authority
Board: Madison.
Williams, B. & Wheatley, R. (July 2000). Epidural analgesia for postoperative pain
relief. The Royal College of Anaesthetists, Bulletin 2.
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