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840977523 1 Epidural Analgesia Independent Learning Module for Registered Nurses Grande Prairie, Alberta Revised July 2006 D:\840977523.doc 840977523 2 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 D:\840977523.doc 840977523 3 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. D:\840977523.doc 840977523 4 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. D:\840977523.doc 840977523 5 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. D:\840977523.doc 840977523 6 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. D:\840977523.doc 840977523 7 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: D:\840977523.doc 840977523 D:\840977523.doc 8 840977523 9 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 D:\840977523.doc 840977523 10 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 D:\840977523.doc 840977523 11 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. D:\840977523.doc 840977523 12 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 D:\840977523.doc 840977523 13 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. D:\840977523.doc 840977523 14 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. D:\840977523.doc 840977523 15 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. D:\840977523.doc 840977523 16 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. D:\840977523.doc 840977523 17 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. D:\840977523.doc 840977523 18 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. D:\840977523.doc 840977523 19 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. D:\840977523.doc 840977523 20 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. D:\840977523.doc