Download LEARNING PACKAGE Epidural 2012

Readings for
Epidural Education
Course for Nurses
ACUTE PAIN MANAGEMENT SERVICE
CHRISTCHURCH HOSPITAL
BOOKLET TO BE READ IN CONJUNCTION WITH
Canterbury DHB Policy and Procedure Manual
Epidural Standard and Procedures –
Post Operative Patients
Volume 12, Fluid and Medication Manual
The Department of Nursing
Christchurch Hospital
Developed by:
Richard Craig
Clinical Nurse Specialist, APMS
Updated March 2012-02-29
CONTENTS
INTRODUCTION .............................................................................................................................. 3
LEARNING OBJECTIVES................................................................................................................ 4
ASSESSMENT CRITERIA: SURGICAL CONTEXT ...................................................................... 4
ADVERSE EFFECTS OF ACUTE PAIN .......................................................................................... 5
Adverse Physiological Effects of Acute Pain ........................................................................... 5
ASSESSING PAIN IN ADULTS & CHILDREN .............................................................................. 6
Figure One: Verbal Analogue Scale ........................................................................................ 6
Figure Two: Visual Scale for Children.................................................................................... 7
INTRODUCTION TO EPIDURAL ANALGESIA INFUSIONS ...................................................... 8
Table One: Uses of Epidural Analgesia Anaesthesia .............................................................. 8
BENEFITS OF EPIDURAL INFUSIONS ......................................................................................... 9
INDICATIONS FOR USE OF EPIDURAL INFUSION ................................................................... 9
CONTRAINDICATIONS FOR USE OF EPIDURAL INFUSION ................................................... 9
EPIDURAL INSERTION ANALGESIA (EIA) TECHNIQUE ....................................................... 10
TO CONTACT THE ACUTE PAIN MANAGEMENT SERVICE ................................................. 10
SPINAL ANATOMY ....................................................................................................................... 11
Figure Three: Vertebral column ............................................................................................. 12
Figure Four: Spinal anatomy ................................................................................................ 12
DEPTH TO SPACE MEASUREMENT OF EPIDURAL CATHETER .......................................... 13
Figure Five: Epidural Catheter ............................................................................................... 14
NURSING MANAGEMENT OF CHILDREN RECEIVING EPIDURAL INFUSION ................. 15
COMMON DRUGS USED IN EPIDURAL INFUSIONS .............................................................. 16
Local Anaesthetic (LA)
Mechanism of Action ............................................................................................................. 16
Table Two: Nerve Fibre Class, Size and Function ................................................................ 17
Bupivacaine ............................................................................................................................ 17
Figure Six: Bromage Scale ..................................................................................................... 19
Ropivacaine ............................................................................................................................ 20
Opioid Agents
Fentanyl .................................................................................................................................. 20
Alpha Agonist
Adrenaline .............................................................................................................................. 20
Clonidine ................................................................................................................................ 21
Opiate Antagonists
Narcan (naloxone) .................................................................................................................. 21
Vasopressers
Ephedrine ................................................................................................................................ 21
Table Three: Epidural Drugs Adults ...................................................................................... 23
Table Four: Epidural Drugs Children.................................................................................... 24
RESCUE REGIME RECOMMENDED BY APMS ........................................................................ 25
PROCEDURES FOR NURSING MANAGEMENT ....................................................................... 26
PROMOTING MOBILISATION ..................................................................................................... 27
PATIENT CONTROLLED EPIDURAL ANALGESIA : AN INTRODUCTION
TO TECHNIQUES AND GUIDELINES ......................................................................................... 29
ASSESSING DERMATOME SENSORY BLOCK LEVELS ......................................................... 30
Figure Seven: Dermatome Chart ............................................................................................ 32
“BRIDGING” FROM THE EPIDURAL .......................................................................................... 32
Figure Eight: Flow on Analgesia Post EIA ............................................................................ 33
Epidural Complications……………………………………………………………………..34
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Prepared by Richard Craig, Clinical Nurse Specialist,
APMS for Department of Nursing, Christchurch Hospital,
Canterbury District Health Board
Last Updated 2012-02-29
Page 1
INTRODUCTION
Welcome to the Epidural Education Course.
Please read the information provided carefully taking special note of the learning
objectives. You will not be tested on anything that is not included in these objectives.
I have endeavoured to ensure that the material enclosed is as up to date and relevant as
possible. However, as I‟m sure you‟ll appreciate; these modalities are subject to change
and consequently will need modification from time to time as appropriate.
This booklet is to be read in conjunction with:
Canterbury DHB Policy and Procedure Manual
Post operative patients
Volume 12 Fluid and Medication Manual
Department of Nursing
Christchurch Hospital
This is available via the intranet, if you do not have access to the intranet manual copies
are available in the Medical Library.
Finally, please feel free to direct to me any comments or suggestions you may have
regarding these readings.
Richard Craig
Clinical Nurse Specialist
Acute Pain Management Service
March 2012
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Prepared by Richard Craig, Clinical Nurse Specialist,
APMS for Department of Nursing, Christchurch Hospital,
Canterbury District Health Board
Last Updated 2012-02-29
Page 2
LEARNING OBJECTIVES
The Registered Nurse (RN) will be able to:
a)
Describe the basic spinal anatomy relating to epidural infusion analgesia.
b)
State his/her role in the management of a patient with an epidural analgesia infusion

conduct a comprehensive assessment of patient‟s pain

assessing dermatome sensory block levels

patient assessment and documentation

mobilisation

potential complications and the appropriate nursing intervention of these

when and how to contact the APMS [Canterbury DHB, Christchurch Hospital
Policy]
c)
Paediatrics : state five differences in the care of children with epidural infusions
d)
Outline the care related to an epidural catheter including

assessment of the dressing/site and documentation

potential complications and the appropriate nursing intervention

outline the procedure for removal of the epidural catheter.
e)
Review drugs commonly used in epidural analgesia and therapeutic action associated
pharmacokinetics

state three drugs commonly used in epidural analgesia and their therapeutic action

state two useful adjuvants, and their therapeutic action

state two drugs used as reversal agents in epidural infusion, and their expected
action, precautions.
f)
Demonstrate operational competence with the epidural infusion pump.
g)
Provide comprehensive patient education (refer to Appendix C)

care of adults

care of children
ASSESSMENT CRITERIA: SURGICAL CONTEXT
For a RN to be successful the RN must:

Read the Canterbury DHB, Christchurch Hospital Policy document Volume 12, Fluid
and Medication Manual Epidural Standard – Post Operative Patients. This is available
via the internet – if you do not have access to the internet manual copies are available in
the Medical Library.

Attend the epidural study day run by the Acute Pain Service at the PDU
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Canterbury District Health Board
Last Updated 2012-02-29
Page 3
1.
ADVERSE EFFECTS OF ACUTE PAIN
1.1 Adverse Physiological Effects of Acute Pain
Respiratory - pain leads to muscle splinting with decreased total volume (TV), vital
capacity (VC), Functional Residual Capacity (FRC) and alveolar ventilation. Resulting
atelectasis causes venous admixture, hypoxia and hypercapnia. Inability to cough leads
to retention of secretions and increased disposition to lobular collapse with resultant
infection.
Cardiovascular – pain causes sympathetic overactivity resulting in tachycardia,
hypertension, increased peripheral vascular resistance, cardiac load  CO and oxygen
consumption. Myocardial ischaemia and infarction may result in a susceptible patient.
Regional blood flow is also altered and cerebral blood flow may be compromised.
Skeletal muscle spasm – reflex activity leads to muscle spasm which will increase pain
thereby setting up a vicious cycle. Immobility will potentiate the incidence of DVT and
pulmonary embolus. Venous aggregation and increased platelet aggregation adds to
this problem.
Gastrointestinal and genitourinary – increased sympathetic activity leads to increased
secretions and sphincter tone. This can result in decreased intestinal motility and
gastric dilation.
Hormonal – pain is one of the factors causing hormonal response to injury. Increased
ADH and aldosterone lead to sodium and water retention. Increased cortisol and
Adrenaline leads to hypoglycaemia. There are many other hormonal disturbances.
1.2 Adverse Psychological Effects of Acute Pain
Unrelieved pain results in anxiety and sleeplessness. This results in another vicious
cycle with anxiety resulting in increased pain. The effects of decreased anxiety have
been demonstrated in many studies. Patients who have good preoperative explanations
have been found to require fewer opiates in the postoperative period.
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Prepared by Richard Craig, Clinical Nurse Specialist,
APMS for Department of Nursing, Christchurch Hospital,
Canterbury District Health Board
Last Updated 2012-02-29
Page 4
2.
ASSESSING PAIN IN ADULTS AND CHILDREN
The regular assessment of pain levels is fundamental to pain management. The tool for
adult pain level assessment adopted by the APMS is the verbal analogue scale. A
visual scale can be used for children.
Verbal Analogue Scale
The patient rates his/her pain according to the scale using numbers related to
descriptive words denoting varying intensities of pain. The patient chooses the number
that most nearly describes the pain they are experiencing. It is important that the
patient scores his/her pain both at rest and on activity. The goal is to control the pain so
that the patient can perform activities, eg physiotherapy, coughing, comfortably within
pain boundaries acceptable to them.
5
Excruciating
Pain
4
Severe
Pain
3
Painful
2
Moderate
Discomfort
1
Mild
Discomfort
0
No pain
Figure One: Verbal Analogue Scale
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Canterbury District Health Board
Last Updated 2012-02-29
Page 5
Figure Two: Visual Scale for Children
Present knowledge tells us of the multiplicity of mechanisms that need to be blocked to
effect good analgesia. In some instances certain mechanisms can be pre-emptively
blocked before pain is initiated. However, in the majority of cases there is a need to
treat pain as it arises using a variety of pharmacologic and non pharmacologic, regional
and non regional means in an attempt to shut each pain pathway/mechanism „door‟ and
so keep the pain from getting through.
Different surgical procedures require different approaches to pain management. Most
can be managed using relatively simple measures. Others require more advanced
techniques of analgesia.
The APMS objective is to be comprehensive in applying the variety of approaches in a
way which is appropriate for each and every situation.
These situations refer broadly to three aspects:
1. Type and site of surgery.
2. Severity of pain.
3. Degree of rehabilitation required.
When considering the more simple, non advanced techniques we traditionally use a
variety of pharmacologic agents usually considered under the categories of mild
analgesia, non steroidal anti-inflammatory drugs (NSAIDS), opioid and non opioid
analgesics and adjuvant agents. These will often be used in combination to achieve
multimodal/mechanism analgesia. For instance, many patients will receive regular
Paracetamol as a background analgesic while receiving, and after completion of,
opioids and advanced analgesia techniques. NSAIDS may also be used in this way.
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APMS for Department of Nursing, Christchurch Hospital,
Canterbury District Health Board
Last Updated 2012-02-29
Page 6
3.
INTRODUCTION TO EPIDURAL ANALGESIA
Epidural Infusions are used most commonly for postoperative and obstetric analgesia.
Less common applications are for trauma, pre-amputation and cancer pain as well as
selected chronic pain states.
Agents are
i) Combination (such as low concentration local anaesthetic (LA), and opioid
The preferred option is the combination infusion technique. It has been found that by
using a combination of agents their concentration and side effects can be minimised
while still producing excellent analgesia. Integral to this success is the placement of the
catheter in the epidural space at a level as close to the mid dermatome for the surgical
incision as possible.
Epidural Infusion Analgesia (EIA) for postoperative analgesia, is administered by
trained staff. The AIM is to provide effective analgesia using ward-based epidural
infusion in selected patients.
Table One: Uses of Epidural Analgesia
Acute postoperative pain
Intrathoracic surgery
Abdominal surgery
Lower limb orthopaedic surgery
Vascular surgery
Urological procedures
Chronic pain
Terminal illness
Obstetrics
Local anaesthetic freezes sensory
and motor nerves of the uterus and
vagina
During operative procedures
Appropriate for individuals
undergoing surgery who would not
be suitable for a general
anaesthetic, ie those with major
cardiovascular, respiratory and
metabolic problems.
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Canterbury District Health Board
Last Updated 2012-02-29
Page 7
4.
BENEFITS OF EPIDURAL ANALGESIA INFUSIONS
Epidural analgesia is an effective method of pain relief in a variety of situations.
Benefits include:













5.
INDICATIONS FOR USE OF EPIDURAL INFUSIONS




6.
Effective analgesia
Avoids the need for intramuscular (IM) injections
Decreased nausea and vomiting
More effective respiratory function
No significant depression of conscious level
Better compliance with dressing changes, physiotherapy and orthopaedic passive
movement devices.
More rapid post operative mobilisation.
Lower deep vein thrombosis (DVT) rate.
Improved wound perfusion
Faster return in bowel function
Less nursing time checking controlled drugs (efficient use of nursing resource)
Decreased length of stay, earlier discharge from hospital
Earlier weaning time from mechanical ventilation.
For major abdominal/thoracic surgery
Some pelvic/lower limb orthopaedic procedures
Surgical inpatients with severe respiratory disease.
Where Patient Controlled Analgesia (PCA) may be inappropriate, or as an adjuvant
to PCA.
CONTRAINDICATIONS FOR USE OF EPIDURAL
INFUSIONS





Hypovolaemia
Infection
Coagulopathy
Raised intracranial pressure
Patient refusal
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Canterbury District Health Board
Last Updated 2012-02-29
Page 8
7.
EPIDURAL INSERTION ANALGESIA (EIA) TECHNIQUE
The epidural catheter is inserted pre-operatively by the Anaesthetist using standard
techniques for both the insertion and fixation of the catheter. The special Epidural
Infusion Analgesia Treatment Sheet QMR0221 (Adult) or QMR0166 (Child) will be
filled out and delivered to Recovery for preparation of the pump and the infusion
solution.
Commencement of Epidural Infusion1
Before discharge from Recovery the epidural infusion and other methods of pain relief
will be adjusted to achieve maximum analgesia and effectiveness of block.
The analgesia infusion solution will be prescribed and made up from premixed bags. It
is delivered using the epidural specific volumetric Gemstar Pump to the epidural
catheter. These pumps have the facility to deliver a bolus of drug. The system is closed
apart from bag changes or technical problems (rare).
The rate of infusion remains as prescribed by the Anaesthetist or APMS. Changes
within the rate set will occur if required, after checking the patient‟s vital signs and
dermatome level.
The APMS reviews its patients at least once a day and monitors the ongoing infusion.
All EIA patients will be on regular Paracetamol for basal/background analgesia
during and following EIA (unless contraindicated).
NB: It is particularly important that the patient receives no additional doses of opioid
drugs for the duration of the infusion. Such doses/drugs should not be prescribed
except after consultation with a member of the APMS.
TO CONTACT THE APMS AT CHRISTCHURCH HOSPITAL/CWH –
GYNAECOLOGY WARD
In hours:
APMS Nurse CWH(Gynaecology)
Beep 8170
APMS Nurse(ChCh Hospital)Beep 8114
Duty Anaesthetist
Beep 8120
After hours: On call Anaesthetic Registrar Beep 8212
or on call Anaesthetist via telephone office
APMS Nurse hours:
Monday – Friday
Saturday
Sunday
1
0800-1630 hours
0800-1400 hours
0800-1200 hours
Rarely Epidurals may be commenced in Intensive Care Unit, or in Ward (chest trauma).
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Last Updated 2012-02-29
Page 9
8. SPINAL ANATOMY
The human spinal column consists of 33 individual vertebrae referred to by their location:
(1)
7 Cervical
(2)
12 Thoracic
(3)
5 Lumbar
(4)
5 caudal or sacral (fused into one bone, the sacrum)
(5)
4 coccygeal (fused into one bone, the coccyx).
Vertebrae consist of an anterior body, the laminae that protect the lateral spinal cord and
spinous processes that project outwardly and posteriorly from the laminae. The vertebrae
become larger as they descend in the vertebral column. The bones of the laminae are bound
together by a number of ligaments (eg the dense ligamentum flavum).
The spinal cord is located within and protected by the bony vertebral column and connective
tissue (meninges). It is a continuous structure extending from the foramen magnum to
approximately the first or second lumbar (L1-L2) vertebral interspace. The subarachnoid
space (also called the intrathecal space in the caudal part of the spine) surrounds the spinal
cord, separated by the pia mater. The subarachnoid space is filled with clear, colourless
cerebrospinal fluid (CSF) that continually circulates and bathes the spinal cord. The dura is
composed of the arachnoid and dura mater membranes and separates the epidural space from
the subarachnoid space.
The epidural space is a potential space filled with vasculative, fat and a network of nerve
extensions. No fluid is in the epidural space; a true space is created when volume or air is
injected into it.
The fact that the epidural space is a potential space has implications for nurses. Although
injecting large amounts of air is not recommended, small amounts such as tiny bubbles within
the infusion tubing when therapy is initiated, are not considered dangerous. In addition,
because the epidural catheter is in a space and not a blood vessel, a continuous epidural
infusion may be stopped for hours and restarted without concern that the catheter has become
occluded.
However crystallisation of the saline within the epidural catheter can occur when catheters
are unused for prolonged periods. In these cases weekly or bi-weekly irrigation is
recommended.
At each vertebral body level, nerve roots exit from the spinal cord bilaterally. Specific skin
surface areas are innervated by a single spinal nerve or group of spinal nerves. These skin
areas are called dermatomes.
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Fig 3. Vertebral column. The human spinal column consists of
33 individual vertebrae referred to by their locations: (1) 7
cervical, (2) 12 thoracic, (3) 5 lumbar, (4) 5 caudal or sacral
(fused into one bone, the sacrum) and (5) 4 coccygeal (fused into
one bone, the coccyx). At each vertebral body level, nerve roots
exit from the spinal cord bilaterally. Specific skin surface areas
are innervated by a single spinal nerve or group of spinal nerves.
Fig 4. Spinal anatomy The spinal cord is a continuous
structure extending from the foramen magnum to approximately
the first or second lumbar (L1-L2) vertebral interspace. The
subarachnoid space (also called the intrathecal space in the
caudal part of the spine) surrounds the spinal cord, separated by
the pia mater.
The subarachnoid space is filled with
cerebrospinal fluid (CSF) that continually circulates and bathes
the spinal cord. The dura is composed of the arachnoid and dura
mater membranes and separates the epidural space from the
subarachnoid space. The epidural space is a potential filled with
vasculature, fat and a network of nerve extensions.
From Salerno E, Willens J. Pain management handbook, p 441, St Louis, 1996,
Mosby
From Thibodeau GA Patton KT: Anatomy & Physiology, p 463 ed 3, St Louis,
1996, Mosby
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Last Updated 2012-02-29
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9. DEPTH TO SPACE MEASUREMENT OF EPIDURAL
CATHETER
When the epidural is first inserted by the Anaesthetist both the depth to space
measurement and the catheter mark at skin are noted and recorded under insertion
details at the top of the first page of the adult epidural infusion analgesia treatment
sheet (QMR0221), or the inside page of the Paediatric Epidural Infusion Sheet
(QMR0166).
Depth to space is the distance from the skin to the epidural space.
The epidural catheter has a series of markings upon it as illustrated in Figure Four.
The “catheter mark at skin” is exactly that, ie whatever mark is nearest to the skin entry
point.
The amount of catheter within the epidural space is calculated by subtracting the depth
to space from the catheter mark at skin.
If the epidural catheter inadvertently moves out of position then this can be deduced by
the fact that the catheter mark at skin will be different from the one recorded initially.
Also for the occasions when the APMS “pull back” or alter the length of the catheter
within the epidural space, it is important to calculate the depth to space.
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Key:
4 marks together
= 20 cm
3 marks together
= 15 cm
2 marks together
= 10 cm
Catheter tip is coloured and blunted
Figure Five: Epidural Catheter
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10. NURSING MANAGEMENT OF CHILDREN RECEIVING
EPIDURAL INFUSION
Notes prepared by Dr Peter Kempthorne
The epidural is placed while the child is asleep. A dose is given that will cover the
surgery and then a more dilute solution is run as an infusion. The solution is the same
as that used for adults.
Ropivacaine 2mg/ml with 2mcg/ml of Fentanyl
Occasionally this will be changed later to decrease a side effect, eg motorblock.
The infusion rate ranges between 0.2 and 0.5 mls/kg/hr
The epidural infusion is useful for children of all ages and the general principles
discussed in the adult section apply to children. The biggest differences are:
1. The young child cannot give good information for assessment of level.
2.
Children below the age of about eight show no hypotension associated with
sympathetic blockade. They are already fully vasodilated unless there is shock so
the administration of a sympathetic blockade does not cause hypotension.
3.
The greater activity of young children means that extra care is needed with
securing the epidural catheter.
4.
The younger and more active the child, the more likely that local anaesthetic will
leak out around the catheter. This does not mean that the block is ineffective but it
does lead to loosening of the dressing etc. The other effect is that the infusion rate
may have to be increased to 0.5 ml/kg/hr to cope with the leak. Rates above this in
the presence of excessive leak should be avoided in case the leak later stops
causing a rise in the level of blockade.
5.
The main person to turn to for help with the epidural in a child is one of the
Paediatric Anaesthetists, preferably the one who placed the epidural or the Acute
Pain Service Nurse. (Beep 8114). At night the Anaesthetic Registrar (Beep 8212)
may be available but is likely to be busy. The Paediatric Anaesthetist on call is
more likely to be available. In the case of a dangerous problem call the Paediatric
Registrar or the ICU Registrar immediately.
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11. COMMON DRUGS USED IN EPIDURAL INFUSIONS
The epidural space is used because it allows drugs to be injected near to the spinal cord
and the nerves surrounding it. When opioids are administered epidurally, pain relief is
produced by the drug that is present in the spinal cord and not that in the plasma. The
drug diffuses slowly into the subarachnoid space and then passes to opioid receptors in
the dorsal horn of the spinal cord.
Opioid analgesics are thought to block the release of substance P when they bind to
opioid receptors in the dorsal horn therefore blocking the transmission of pain impulses
to the cerebra cortex.
Epidural administration of opioids has a more prolonged effect since the drug must
diffuse out of the CSF into the blood before it can be excreted via the liver and kidneys.
The analgesic effect is mainly confined to segmented spread across the spinal nerves
that correspond to the site of entry into the epidural space.
Local anaesthetics block the conduction of nerve impulses while narcotics only
interfere with pain impulses.
The most common opioid used in epidural analgesia is Fentanyl. At Christchurch
Hospital Fentanyl is usually combined with a local anaesthetic such as Ropivacaine as
this combination has been reported to produce a synergistic effect and reduce the
incidence of side effects.
11.1 Local Anaesthetic (LA)
Mechanism of Action
Local anaesthesia works by pharmacologically blocking the nerve supply to a certain
part of the body. This is achieved by reversibly interrupting the conduction of impulses
along nerve fibres.
The nerve axon has a membrane through which sodium ions (Na+) and potassium ions
(K+) can pass. When no messages travel along these nerve fibres, they are said to be in
a resting state. In the resting state the fibres are polarised, and have higher
concentrations of Na+ outside the cells and higher concentrations of K+ inside.
Generation of a nerve impulse (termed “propagation”) involves a depolarisationrepolarisation wave travelling along the nerve fibre.
Depolarisation is caused by a flow of Na+ from outside the membrane of a nerve fibre
through sodium channels to the inside. This ionic imbalance is rectified by ionic
„pumps‟, which allow more K+ to flow out of the nerve fibre thus resulting in a
repolarisation. Repolarisation is the reverse of depolarisation, with more K+ flowing
out of the nerve fibres than Na+ in.
Each depolarisation-repolarisation that occurs causes an adjacent depolarisation, which
propagates the depolarisation-repolarisation wave along the nerve fibre.
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Regional anaesthetics prevent nerve depolarisation by preventing the sodium channels
from opening. This effectively blocks nerve impulse progagation.
There are a number of different types of nerve fibres which vary in size and function
Table Two: Nerve Fibre Class, Size and Function
Class
A-alpha (A)
Size
Largest
A-beta (A)
A-gamma (A)
A-delta (A)
B
C (unmyelinated)
Smallest
Function
Motor, proprioception (position
sense)
Touch/pressure, motor
Muscle spindle tone
Pain/temperature
Preganglionic autonomic
Pain/temperature
The ease with which a nerve fibre is blocked by a given concentration of local
anaesthetic drug depends on its critical blocking length (the length that must be
exposed to the drug in order for the nerve to become blocked) and on the accessibility
of the nerve membrane binding site to the blocking agent. It has always been taught
that smaller diameter nerve fibres are more easily blocked than larger diameter fibres.
In fact, the actual diameter of the fibre is not itself important. However, the smaller
diameter fibres have the smallest critical blocking length and are more easily accessed
and blocked by local anaesthetic solutions. Nerve blockade is also frequency
dependent; that is, active nerve fibres are more easily blocked than inactive ones.
B fibres tend to be blocked before C fibres. This is probably because C fibres are
usually arranged in Remak bundles, which may hamper diffusion of the local
anaesthetic solution, and/or because the critical blocking length of B fibres is quite
short.
As the effect of any nerve block wears off, recovery of movement may precede
recovery of sensation or sympathetic nerve function. This is of particular importance
following epidural of spinal anaesthesia, when a patient may appear to have normal
motor function yet may have incomplete return of sensation and a residual sympathetic
block that leads to postural (orthostatic) hypotension.
Bupivacaine
(Marcain)
0.125%
Used to effect a variable neural block usually including sympathetic, sensory and
possibly motor nerves. This differential block pattern relates to the concentration of the
LA with the motor nerve block requiring a higher concentration and the sympathetic
nerves the least. The ideal is to block at least the pain pathways (will mean the more
sensitive sympathetic nerves are blocked as well) while leaving the motor nerves
unblocked.
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The effects of the various nerve blocks:
Sympathetic nerves: Vasodilation, sweating and heat loss. Results in drop in blood
pressure (BP), postural hypotension, warm dry periphery, and compensatory
vasoconstriction in the upper limbs.
Sensory nerves:
[Have a range of sizes for the various modalities.] In order
from small to larger they are pain, temperature, touch, pressure, and proprioception
requiring increasing concentration of LA to effect blockade. Again, a wide variable
block of some or all of these fibres may be present.

Pain and temperature fibres are approximately the same size so pain fibre block can
be checked by temperature testing.

Complete block will remove pressure sense so regular 2 hourly position
changes are necessary to avoid pressure areas developing eg blisters on heels.

Sensory blockade is recorded by the regular documentation of upper and lower
dermatome levels.
Motor nerves:

Results in loss of motor power within the blockade segment if the concentration of
LA is high enough. Eg a thoracic block should only effect the thoracic and
abdominal muscles/myotomes innervated by the thoracic nerves.

Lumbar epidurals will affect the lower limbs more. This is very important when
considering mobilisation.

The extent of the motor block can be assessed by use of the Bromage scale for
motor blockade in the lower limbs.
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Bromage Scale
0
No Block
0%
1
Partial
33%
2
Almost complete
66%
3
Complete
100%
Full flexion of knees and feet
possible
Just able to flex knees, still full
flexion of feet possible.
Unable to flex knees. Still flexion of
feet.
Unable to move legs or feet.
Figure Six: Bromage Scale
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Ropivacaine (Naropin)
2 mg/ml
Of a similar structure and potency to Bupivacaine, Ropivacaine has a similar onset and
duration of action to Bupivacaine but is less cardiotoxic. In concentrations producing
comparable analgesia, it results in less motor blockade than Bupivacaine.
11.2 Opioid Agents
for example
Fentanyl
(Sublimaze)
2mcg/ml
Affect antinociception by their action at opioid receptors at nerve root, spinal cord and
brain stem sites. Does not block the other modalities as described above under LA
block so there is no effect on BP or muscle function. However, they can cause nausea,
vomiting, itch, urinary retention and respiratory depression. The risk of respiratory
depression, although very rare, necessitates the regular monitoring and recording of
respiratory rate and more importantly sedation levels. Fentanyl is considered to be a
relatively lipid soluble opioid. As such it is taken up more readily by the neural tissues
at the particular epidural level where placed. Over time it will eventually spread
through the CSF towards the brain stem where the respiratory centre is located. More
water soluble opioids such as morphine will spread more rapidly within the CSF
because they are not absorbed so readily by neural tissue.
11.3 Alpha Agonist
for example
Adrenaline
(Epipine)
0.2ml 1:1000
Has two effects:

vasoconstriction (limits the vascular uptake of agents used); and

antinociception.
The latter is achieved at a local spinal cord level by neurotransmitter/receptor
interaction. It augments the analgesic action of the other agents. Adrenaline containing
LA is useful when giving a test or top-up dose to check if the catheter is in a vein. This
will be indicated by an immediate and significant tachycardia.
NB: Adrenaline is not required to be added when using Ropivacaine.
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Clonidine
(Catapres)
150ug/ml
Analgesia results from its action at alpha receptors in spinal cord dorsal horn. Systemic
absorption can cause hypotension. Is a useful addition to the analgesic armamentarium
especially as a top up agent for resistant pain.
11.4 Opiate Antagonists
for example
Narcan (naloxone)
0.4 mg/ml ampoule
Indications:
An opioid antagonist counteracts the effects of opiates. Given alone it has no clinically
useful effects. Reverses respiratory depression, but maintains some analgesia.
Problems/Side Effects:
1.
Short duration of action (< 1 hour), therefore risk of renarcotisation.
2.
Produces withdrawal in narcotic tolerant/dependent people.
3.
Can produce vomiting and emergence of delirium.
Rare Complications:

Significant cardiovascular function with/ without prior narcotisation.

Reported include systemic hypertension

Pulmonary oedema

Ruptured cerebral aneurism

Atrial and ventricular arrhythmias.
Administered as prescribed
Note:
Reversal with Narcan can herald a return of patient‟s pain.
11.5 Vasopressors
for example
Ephedrine (Ephedrine Sulphate)
30mg/ml
Acts as a Vasoconstricter and a cardiac accelerant.
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Hypotension ± bradycardia
 May be secondary to sympathetic block of epidural
 Hypovolaemia
 A vasovagal response
 Postural
 Rarely LA toxicity
 A medical complication
Medical Staff treat according to the cause, eg Ephedrine 5mg IV for hypotension from
sympathetic block, volume expansion for hypovolaemia, etc.
Do not automatically assume hypotension is due to epidural block alone.
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EPIDURAL LOCAL ANAESTHETICS
Category
Drug
Local
Anaesthetic
Bupivacaine
0.125%
100ml polybag
200ml polybag
Local
Anaesthetic
Ropivacaine
2mg/ml
Recommended
Dose
Use 200ml
polybag at rate
prescribed
Use 200ml
polybag at rate
prescribed
Route
via epidural line
via epidural line
Authorisation
Infusion
prescription
Adult epidural
infusion
analgesia sheet
(QMRO221)
Infusion
prescription
Adult epidural
infusion
analgesia sheet
(QMRO221)
INTRAVENOUS ANTAGONISTS AND VASOPRESSORS (ADULTS)
Opiate
Antagonist
Narcan
(Naloxone)
0.4mg/ml
0.1mg and
repeat as
necessary
Intravenously
Vasopressor
Ephedrine
30mg/ml
5mg and repeat
as necessary
Intravenously
Adult epidural
infusion
analgesia sheet
(QMRO221)
Medical staff
authorisation
only
Table Three
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DRUGS USED WITH CHILDREN
Category
Local
Anaesthetic
Drug
Ropivacaine 200 ml
polybag premixed
with Fentanyl
2mcg/ml
Recommended
Dose
Use 200ml
polybag at rate
prescribed
Route
Epidural
Opioid
Agents
Fentanyl 2mcg/ml
(already premixed in
bag)
2mcg/ml
NB for children
under 6 months
of age 1mcg/ml
is sometimes
prescribed
Epidural
Alpha
Agonist
Clonidine
150mcg/ml
150mcg
1.5mcg/ml
Epidural (add to
bag)
Opiate
Antagonist
Narcan (Naloxone)
0.4mg/ml
Dose is
approximately
0.1mg IV and
0.04mg/kg IM
Intravenously
or
Intramuscularly
Simple
analgesic
Paracetamol
Route as
prescribed
Authorisation
Infusion
Prescription
Paediatric
epidural
analgesia
infusion sheet
(QMRO166)
As prescribed by
Anaesthetist on
Paediatric
epidural
analgesia
infusion sheet
(QMR0166)
As prescribed by
Anaesthetist on
Paediatric
epidural
analgesia
infusion sheet
(QMR0166)
As prescribed by
Anaesthetist on
Paediatric
epidural
analgesia
infusion sheet
(QMR0166)
Dose as
prescribed by
medical staff
(usually 20mg
per Kg)
Table Four
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12. RESCUE REGIME RECOMMENDED BY APMS
Applies mainly to NON PCEA infusions ie INTRAVENOUS opioid use if On Call /
Duty Anaesthetist unable to come immediately and administer an Epidural Top Up.
Procedure/Guidelines to follow for break through pain when Duty / On Call
Anaesthetist is unable to come and perform an epidural top up:
1.
Leave epidural running.
2.
Contact on-call/Duty Anaesthetist ASAP
3.
Discuss situation, plus details of IV Opioid prescription, if charted, on MR4
4.
After being authorised, use the IV Opioid prescription charted on MR4.
5.
If there is no IV Opioid rescue regime charted in the MR 4 it will need to be.
Recommended guidelines for a rescue regime to be charted would be:
a)
Contact appropriate Medical Staff (ie Duty House Surgeon)
b)
Appropriate dose of IV Morphine or Pethidine (Morphine is the preferred agent
unless contraindicated).
c)
Adult Dose: 0.5 – 2 mg Morphine or 10-20 mg Pethidine IV prn every 5
minutes to analgesia and respiratory rate > 10. After this IV
Opioid loading monitor respiratory rate and sedation score at 20
minute intervals until epidural is reassessed.
NB: At the time of the epidural being assessed, if an epidural top-up is given be aware
that this may accentuate the effect of the IV opioid previously given and special
vigilance is required to note respiratory depression/arrest.
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13. PROCEDURES FOR NURSING MANAGEMENT
Refer to:
Epidural Standards and Procedures, Post Operative Patients
“Nursing Procedures Volume 12”
For ease of reference, this is reproduced as Appendix A
Other useful policy references :
Pressure Area Prevention – Canterbury DHB, Christchurch Hospital “Nursing Procedures
Volume E”
Procedure for Anti-embolic Stockings
Canterbury DHB, Christchurch Hospital “Nursing Procedures Volume 6E”
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14. PROMOTING MOBILISATION
Mobilisation maximises rehabilitation from surgery.
The effects of EIA relating to mobilisation are:
 The degree of motor block will depend on the extent and density of the block. A
thoracic epidural effecting only the thoracic segments should not cause significant
weakness in the legs.
 A lumbar epidural commonly will, as well as possibly blocking the bladder function
requiring the placement of a urinary catheter.
 The sympathetic block will cause vasodilation below the block so postural
hypotension will occur.
 Block of proprioception will result in unsteadiness through lack of position sense.
 Postural hypotension may be confused with hypotension caused by
hypovolaemia.
Keeping the above in mind, proceed as follows:
 Check the sensory level including position sense.
 Check muscle power around the knee and ankle using the Bromage Scale.
 Check there is no hypovolaemia either from overt or concealed blood loss.
 Examine the patient for evidence of sympathetic block (warm, dry feet).
 Record a supine Blood Pressure.
 If this is considered adequate proceed to gently sit the patient up and repeat the BP
noting any change from that of supine.
If no postural hypotension:
Proceed to mobilise and if at
any stage the patient becomes
symptomatic of low BP, assume
the supine position and reassess.
If there is postural hypotension:
A systolic drop of more than 20-30 mm Hg and
the patient is symptomatic (weak and
lightheaded etc) then you may not be able to go
on to the erect position. Return the patient
supine. If there is no significant postural
hypotension in the sitting position then proceed
to stand the patient and repeat the BP.
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 Remember that even if there is no problem with postural hypotension, the patient
may still need to be supported during mobilisation if there is a block of the
proprioceptive nerve fibres and two nurses may be required for this support.
If there are any questions about mobilisation consult the APMS.
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15. PATIENT CONTROLLED EPIDURAL ANALGESIA
(PCEA) : AN INTRODUCTION TO TECHNIQUES AND
GUIDELINES
Philosophy
PCEA in some respects is quite different to Intravenous Patient Controlled Analgesia.
With IV PCA the patient is instructed to push the button before a painful procedure
occurs, eg mobilising physiotherapy, in other words in anticipation of pain occurring or
becoming worse. Whereas with PCEA the patient is instructed not to push the button
unless pain is actually present. The rationale for this is we don‟t want the patient using
the PCEA mode frequently and possibly increasing the height of the dermatome block
level if it is not necessary.
Rationale
Our current pumps have a PCEA function and its introduction has been intended. This
will be consistent with other centres practice, maximise the efficiency of this modality
and hopefully reduce the call-out top up rate.
Patient Selection
At the commencement this will be determined by the APMS. The reasoning for this is
to introduce this new modality in a controlled-as-possible way. This will make things
as comfortable as possible for all involved. Later when familiarity is achieved the
selection and commencement process will be relaxed.
For instance, at first, we will most likely commence PCEA following the Pain Round
the morning after surgery if the patient is stable and an appropriate candidate.
Set up and Monitoring
As per PCEA GUIDE laminated chart attached to the epidural stand.
Essentially the monitoring is the same as with an EIA with the exception that the
dermatomes will be determined 2 hourly and not 4 hourly “if the parameters have been
stable” (this may be relaxed back to 4 hourly in the future, all going well). The
observations required are detailed in the EIA Treatment Sheet (QMRO221).
The overall technique will require familiarisation from a number of perspectives. For
instances, noting the frequency of PCEA “injections” (and “attempts”) as a basis for
increasing the infusion rate if necessary.
History button will reveal injection/attempts (record and document these along with Q2
hourly recordings.
Injection/attempts shift total should be “zeroed” at the end of each eight hour shift (use
reset  1. reset shift).
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16. ASSESSING DERMATOME SENSORY BLOCK LEVELS
The Anaesthetist will have charted on the Epidural Infusion Analgesia Treatment Sheet,
QMR0221 what they deem to be an acceptable height for the dermatome block level.
This will often differ slightly from patient to patient depending usually on the type of
surgery performed and the insertion level of the epidural catheter. For example patients
undergoing a thoracic procedure will have a high epidural catheter insertion whereas
patients undergoing say an orthopaedic procedure will have a low epidural catheter
insertion.
As a general rule of thumb, the higher the epidural catheter insertion point, the higher
the sensory block will rise although this is influenced by the rate at which the infusion
is being delivered.
There are several points that are important to note about dermatome block levels and
their measurement.
Firstly, always use ice to measure the sensory block level, NOT pinprick or pinch. Ice
is ideal because pain and temperature fibres are approximately the same size and pain
fibre block can be checked by temperature testing. There have been some cases
documented in the literature where pinprick and pinch testing have resulted in severe
skin damage manifesting 24-36 hours later (especially in elderly patients where skin
tends to be fragile and easily bruised).
Before assessing the level of the block the patient needs to have a comparison of
sensation. Press the ice against the patient‟s inside wrist or cheek so they will be able
to determine the difference in sensation from cold to numbness.
Unilateral Block
Test both sides of the patient‟s body with the ice, when one side only has sensory loss,
this is called a unilateral block. This is usually caused by the epidural catheter moving
off to one side and there are some strategies we can employ to try and compensate for
this. Obviously if the side that is well blocked is also the location of the surgical
procedure and the patient has no pain then the fact the block is unilateral is of no real
concern, however this won‟t always be the case.
Turn the patient onto their painful side ie the side that is not being blocked, gravity can
sometimes help spread the local anaesthetic across. Also inform the APMS or Duty
Anaesthetist as the patient will probably need a “top up” bolus dose to be administered.
Another strategy the APMS or Duty Anaesthetist may employ is to pull the epidural
catheter back slightly (usually 1 or 2 cm) which may resolve the problem however to do
this necessitates taking the epidural catheter dressing down which is not done lightly.
Pulling the epidural catheter back is also one of the instances where the importance of
“Depth to Space” measurement (page 14) becomes relevant.
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High Sensory Block
If the sensory block level exceeds the acceptable height charted on the Epidural
Infusion Sheet by the Anaesthetist then the patient should be sat up as this may drop the
block level to some degree and the APMS or duty Anaesthetist notified regarding
orders to decrease or possibly cease the infusion. Watch your vital sign recordings.
Low Sensory Block
If the block is below the level of the wound increase the epidural infusion rate (within
the parameters prescribed) and notify the APMS or Duty Anaesthetist. The patient will
almost certainly need to have a “top up” bolus dose administered.
“Patchy” Sensory Block
If he blocked area is becoming ill defined or “patchy” notify the APMS or Duty
Anaesthetist. Increase the epidural infusion rate (within the parameters described).
“Patchy” blocks are nearly always an early sign that the patient is going to lose their
dermatome block levels altogether and the APMS usually administers a “top up” bolus
dose.
General

Remember when measuring dermatome block levels that you are looking for an
upper and lower block level (bilaterally).

If you need to increase or decrease the epidural infusion rate (within prescribed
parameters) do so in multiples of two.

You can nearly always discern if a patient has a good sympathetic block by feeling
their feet. They will feel warm to the touch (vasodilation) and dry (sweat gland
inhibition). Both of these factors are due to the action of the local anaesthetic.

Be very careful with hot drinks etc around patients on epidural infusion. It is easy
for them to unknowingly suffer a severe burn to the blocked area. Heated
wheatbags are particularly dangerous and should never be used on patients with
epidural infusions.

Some patients while having full motor power to their legs may experience block of
proprioception when mobilising. This is an inability to ascertain where their feet
are in relation to the ground caused by altered sensation and lack of position sense
which leads to unsteadiness. (Some patients describe the sensation as similar to
trying to walk on water). It is important to assist these patients with mobilising.

Children present some special challenges in terms of assessing dermatome levels.
It has to be accepted that with the young child and babies dermatome assessment
may not be possible. One strategy that may be useful is to observe for flinch
response to ice.
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cervical
thoracic
lumbar
sacral
Key dermatome levels
Landmark
Little finger
Nipple line
Tip of xiphoid
Umbilicus
Inguinal ligament
Level
C8
T4-5
T7
T10
T12
Significance
Cardiac accelerator fibres (T1-4) blocked
Possibility of cardio-accelerator blockade
Splanchnics (T5-L1) may become blocked
Sympathetic blockade limited to lower limbs
Figure Seven : Dermatome Chart
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17. “BRIDGING” FROM THE EPIDURAL





Leave epidural catheter in situ.
Continue to record regular pain assessments and monitoring.
Feed and mobilise as consistent with post op progress.
Continue with the regular Paracetamol ± NSAID doses already instituted.
Anticipate being able to analgese patient adequately with additional
analgesics/means, unless pain levels declare themselves to be severe. Trend
initially towards regular dosing moving to “prn” as pain subsides,
18. CHANGING THE EPIDURAL INFUSION BAG
19. REMOVAL OF THE EPIDURAL CATHETER
 Remove catheter only on authorisation of APMS/Duty Anaesthetist. The
recommended time for removal for patients receiving anticoagulants (clexane) is 22
hrs from the last dose (ie 2 hours before the next dose.
 The patient must be positioned on their side with back slightly flexed.
 This is an aseptic procedure and the use of sterile gloves is required.
 Catheter is gently and steadily withdrawn NOTE Force should NOT be used. If
resistance is felt, do not continue with the removal and notify APMS or duty
anaesthetist.
 The tip of the epidural catheter should be examined on removal to check for
intactness. Tip is coloured blue and blunted. If catheter not intact notify APMS or
duty anaesthetist.
 If there is any signs of infection/inflammation swab site and send swab and the
Epidural catheter tip for bacteriology culture and notify APMS .
 Document removal of the catheter and any variances (see above point) in the patients
clinical record.
 Clean site with Chlorhexidine solution and apply a sterile dry dressing to the site for
twelve hours-document time for dressing removal in the patients care plan.
20. POTENTIAL COMPLICATIONS- EPIDURAL
ADMINISTRATION ERROR






Dedicated GEMSTAR YELLOW COLUR CODED volumetric pump is the ONLY pump
to be used for the delivery of Epidural Infusions.
Dedicated GEMSTAR YELLOW COLOUR CODED is the ONLY tubing to be used .
Filter is secured at chest by IV 3000 transparent dressing and labelled as EPIDURAL
Secure tubing and filter on opposite side of patients neck to any central line.
Only medications prescribed on the epidural prescription sheets QMR0221 (Adult) or
QMR0166 (children) are to be administered via the epidural .
Two registered nurses must check the drugs to be administered and the correct
programming of the epidural pump.
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RESPIRATORY DEPRESSION AND SEDATION






Dependant on dose and volume of opioids used.
No other opioids are to be given concurrently unless authorised by anaesthetist
Risk of respiratory depression increases with higher thoracic catheter placement
Ensure patient has a patent IV leur in situ for administration of reversal drug if required.
It is recommended that a oxygen at 2lt is charted for a minimum of 24 hrs for all epidural
patients.
Recordings/observations as per epidural infusion treatment sheet.
EPIDURAL HAEMATOMA
 Rare but serious complication.
 May occur at insertion/removal of catheter or at any time during the epidural infusion
 Following authorisation from the APMS the ideal time for removal of epidural catheter
for patients on subcutaneous clexane anticoagulant is 22hrs from the last dose (ie 2 hrs
before the next dose is due).
Any symptomlogy such as swelling at epidural site, back pain, loss of motor power, contact
APMS or Duty Anaesthetist.
EPIDURAL CATHETER MIGRATION
(eg thru the dura into csf/blood vessel)
 Rare
 Rapidly ascending wide dermatome block.
 Vital signs may indicate a decrease in BP pulse and respirations
 STOP epidural infusion
 Contact APMS or Duty Anaesthetist as reversal agents may be required.
EPIDURAL ABCESS
 Rare
 Usually caused by skin staphylococcus tracking up the epidural catheter.
 Higher risk patients are those who are or have been:
immunocompromised/onsteroids/diabetic.
Symptoms.
-Back pain (exquisite to palpation)
-Radiating radicular pain from the spine to the chest
-Pus at epidural site and/or pyrexia
-Loss of bowel or bladder function (late symptom)
-Can be a late presentation after epidural has ceased.
 Diagnosis is through history and physical examination
 Definitive diagnosis is made by MRI scan
Treatment- antibiotic therapy and/or surgical decompression.of spine.
INFECTION AT EPIDURAL SITE


Incidence risk rises after three days of therapy
Exposure of epidural site to air will usually result in infection within 34-36 hrs, site must
be cleaned with chlorhexidine and then redressed
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

After consultation with APMS/Duty Anaesthetist remove epidural catheter if infection at
site present. Swab epidural site for culture and also send epidural catheter tip to lab for
culture. (Clexane dosage timing will be a factor in timing of epidural catheter removal).
Observe epidural site for 3-4 days post removal to ensure healing is occurring (APMS
will also follow up patient post catheter removal).
Preventative Measures:
 Window dressing over site
 Biopatch in situ
 Premixed infusion bags
 Do not disconnect/reconnect epidural tubing
Three day therapy time frame (usually)
HIGH BLOCK
 Any dermatome block above the level prescribed on the QMR0221 EPIDURAL
INFUSION SHEET
 Posture will affect block height level. Sit patient up as this may drop the block level to
some degree.
Contact APMS/Duty Anaesthetist regarding orders to decrease or possibly cease epidural
infusion.
BREAKTHROUGH PAIN
 Check integrity of system
 Unless contraindicated APMS recommend that all adult patients on epidural infusions
have Paracetamol 1gm Q6hrly as prescribed.
 APMS/Duty Anaesthetist to be contacted to assess the patient and to administer a “topup” bolus of epidural solution if required.
 Increase epidural infusion rate as prescribed (recommend increase by 2ml only)
 Patient Controlled Epidural Analgesia may be an option.
Posture may help the block spread (eg turn patient onto side that is sore).
URINARY RETENTION
 Stopping the epidural infusion may resolve the issue.
 Patient may require urinary catheterisation.
NAUSEA AND VOMITING
 This side effect is difficult to isolate as being caused by epidural infusion, antiemetic
therapy is the mainstay of treatment.
PRURITIS
 Can be caused by the opioid in epidural infusion solution, may be mild or severe
For children (upon authorisation) the opioid is usually removed from the infusion solution,
after this the itch usually resolves fairly rapidly. For adults usually pharmacological anti itch
agents are used (eg low dose naloxone)The APMS/Duty Anaesthetist will need to be
involved.
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APMS for Department of Nursing, Christchurch Hospital,
Canterbury District Health Board
Last Updated 2012-02-29
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SENSORY /MOTOR BLOCK
 Usually dependant upon level of epidural catheter placement.
 Bromage scale recordings as per QMRO221 Epidural Infusion Treatment Sheet.
 If a degree of motor blocking is present , pressure area care (esp heels) is paramount to
prevent pressure sores developing
 Some motor impediment treatments the APMS may authorise include discontinuation of
epidural infusion if no resolution after 24 hrs and re-siteing of catheter.
HYPOTENSION
 Common problem post surgery with or without epidural
 Epidurals UNMASK fluid volume status.
 APMS may prescribe IV colloid agents.
LEAKAGE AT SITE
 More common in children than adults. Main problem with leakage is it tends to lift the
epidural site dressing. If patency of dressing becomes a real issue epidural may have to be
abandoned. The best way to remedy a lifting epidural site dressing is to place more IV
3000 dressings over the top of the existing dressing thus securing it down
 Leakage can also be an early sign of epidural failure (mostly in adults).
LOCAL ANAESTHETIC TOXICITY
 Rare
 May occur with inadvertent intravascular administration (eg epidural catheter moves out
of position)
If a patient develops any of the following signs and symptoms (they are usually progressive)
contact APMS/Duty Anaesthetist.






Tinnitus
Light headedness
Visual disturbances
Muscular twitching
Convulsions
Decreased level of consciousness.
POST DURAL PUCTURE HEADACHE
This can occur when during the insertion of the epidural the needle has protruded past the
epidural space and punctured the dura.The hole that has been made in the dura can cause a
significant leaking of the cerebrospinal fluid. It is the leaking of this buffering fluid that can
result in the patient experiencing a severe headache which can be accentuated by posture (ie
sitting forward or standing up).
The hole made in the dura will in most cases heal spontaneously over a period of a few days.
Some will persist longer than this with 99% spontaneously healing within 1-2 weeks.
Treatment
Patients complaining of headache thought to be the result of a dural tap can be prescribed
caffeine tablets 300mg 3-4 hrly prn until the headache subsides.
Patients whose headache are slow to subside or are finding the convalescence restricting can
undergo a “blood patch”. This involves the taking of a sterile sample of approximately 20 mls
of the patients own blood and injecting it into the epidural space at the same level as the
S:\PMHDataLink\Division\SDU\COMMON\Competency Matrix\Self learning packages\epidural manual update march 2012 (2).doc
Prepared by Richard Craig, Clinical Nurse Specialist,
APMS for Department of Nursing, Christchurch Hospital,
Canterbury District Health Board
Last Updated 2012-02-29
Page 35
previous epidural injection. This then creates a patch over the hole in the dura and in the
majority of cases, eliminates the headache.
S:\PMHDataLink\Division\SDU\COMMON\Competency Matrix\Self learning packages\epidural manual update march 2012 (2).doc
Prepared by Richard Craig, Clinical Nurse Specialist,
APMS for Department of Nursing, Christchurch Hospital,
Canterbury District Health Board
Last Updated 2012-02-29
Page 36
APPENDIX C
EPIDURAL INFUSION ANALGESIA – PATIENT EDUCATION
FOR ADULTS
What is an“Epidural”?
An epidural is a method of pain relief where local anaesthetic is injected continuously
through a fine plastic tube which has been placed in the back. The tip of the tube lies near the
nerves transmitting pain sensations at the place where the nerves enter the backbone.
Why have an Epidural?
An epidural infusion can provide you with the best form of pain relief known to us.
Commonly they are associated with childbirth but more recent advances in specialised care
have seen them used in the postoperative setting.
What are the Benefits?
Potentially you will experience superior pain relief, fewer side effects, less drowsiness and be
more clear headed after surgery. Also, epidural infusion pain relief can hasten recovery after
surgery, patients enjoy greater comfort, get well faster and have fewer complications related
to surgery.
What are the Side Effects?
In addition to preventing most of the pain epidurals may create some of the following:

a cold, numb, heavy, weak or tingling feeling on the area where the epidural is working.

A drop in blood pressure and/or heart rate which may cause dizziness especially when
standing.

Itching

Nausea

Inability to sense when the bladder is full; this may require a urinary catheter.
These side effects are expected to wear off when the epidural is discontinued.
How long will I have the Pain for?
This is individual and often depends upon the surgery and your progress. Commonly
epidural infusions remain in progress for 2 to 3 days.
How will I be monitored?
Your nurse will monitor you closely to ensure you get good pain relief and that side effects
are kept to a minimum.
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This is done by:
a) asking you to rate your level of comfort (0) no pain to (5) worst pain imaginable.
b) by taking blood pressure, pulse and other observations which are done regularly while
you are having the epidural.
c) measuring the uppermost level of numbness you may feel which is called the “block
level”. This is usually done with ice. (Refer to chart on back of pamphlet).
d) Determining if you need assistance with moving and prevention of pressure sore
formation.
e) the Acute Pain Service will visit you once a day and together with your nurse ensure you
are as comfortable as possible.
How is it Removed?
After discussion with the pain team the epidural infusion will be stopped. Provided you are
comfortable the plastic tube will be pulled out about six hours later by your nurse. This is
expected to be a quick painless procedure. Should pain occur within that time the epidural
may need to be recommenced for another day or two.
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EPIDURAL INFUSION ANALGESIA – PATIENT EDUCATION
FOR PARENT & CHILD
What is an Epidural
Epidurals traditionally have been associated more with labour and childbirth however in more
recent times have been used to combat post operative pain following certain types of surgical
procedures.
An epidural is a method of pain relief where local anaesthetic is injected continuously
through a fine plastic tube which has been placed in your child‟s back.
The tip of the tube lies near the nerves transmitting pain sensations at the place where the
nerves enter the backbone.
What are the Benefits?
Potentially your child will experience superior pain relief, fewer side effects, less drowsiness
and be more clear headed after surgery. Also epidural infusion pain relief can hasten
recovery after surgery, children enjoy greater comfort, get well faster and have fewer
complications related to surgery.
What are the Potential Side Effects?
Some children may experience a generalised itching. This is usually caused by one of the
opioid drugs used in the epidural infusion solution. It is important to let nursing staff know if
you notice your child is distressed by itch so that treatment can be commenced.
Nausea may be another side effect although this is rare. Should nausea occur it can usually
be treated by removing the opioid component from the epidural infusion solution without
compromising pain relief.
Diminished bladder sensation caused by the local anaesthetic solution may necessitate a
urinary catheter which will be removed following cessation of the epidural infusion.
Numb heavy weak legs may occur again as a result of the local anaesthetic action, this can
usually be resolved by altering the strength of the epidural infusion solution.
How Long will the Epidural Stay in for?
This usually depends upon the type and site of surgery however most children require the
epidural infusion for about 48 hours following surgery.
How Will my Child be Monitored
Your child‟s nurse will monitor your child closely to ensure they get good pain relief and that
side effects are kept to a minimum.
This is done where applicable showing your child a series of faces depicting various stages of
distress and asking them to point to the face which most closely depicts how they are feeling
at the present moment.
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For the very young child we will be looking for non-verbal expressions of pain such as
irritation, crying or restlessness. Your role as a parent is important in the assessment of your
child‟s pain as no one will know your child better than you. Most parents can very quickly
discern when their child is in pain.
The Acute Pain Service will also visit your child at least once a day for the duration of the
epidural infusion and together with the nurse ensure your child is as comfortable as possible
How is the Epidural Removed?
After discussion with the Acute Pain Service the epidural infusion will be stopped. Provided
your child is comfortable the epidural catheter will be pulled out about four hours later by
your child‟s nurse. This is a quick, painless procedure. `
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REFRENCES
Macintyre P.E., Schug S.A., Scott D.A., Visser E.J., & Walker S.M. APM:SE Working
Group of the Australian and New Zealand College of Anaesthetists and Faculty of
Pain Medicine (2010), Acute Pain Management: Scientific Evidence (3rd edition),
ANZCA & FPM, Melbourne.
Mcintyre, P. E., & Schug S. A., (2007). Acute pain management: A practical guide, 3rd Ed,
London: Elsevier.
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Last updated September 2009