Epidural Analgesia (EA)

Lo Ah Chun APN OTS & Pain Management

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Learning objectives:
Nurses will be able to:
1. Describe the basic anatomy relating to EA 2. State his/her role in the management of a patient with an epidural infusion 3. Outline the care related to an epidural catheter. 4. Demonstrate operational competence with the epidural infusion pump

EA guideline
The HAHO Medication Safety Committed has established guideline on Safe Handling of Epidural Analgesia with effective from 1st March 2009 which is approved by the Central Committee on Quality and Risk Management with advisory panel inputs from the COC (Anaesthesiology) and COC (Nursing). With respect to this guideline we would like to implement with effective from 1st May 2009

Medical error : potential fatal results

Preparation of Epidural infusion syringe (centrally supplied by Pharmacy to the ward. (only Ropivacaine 0.15% with Fentanyl 2g/ml A/V)
Name: English

 Anaesthesiologist will draw up first syringe of epidural mixture in OT or K9 Subsequent top-up syringes will be centrally supplied by Pharmacy to the ward. (only Ropivacaine 0.15% with Fentanyl 2g/ml in Normal Saline 0.9% available ) The epidural drugs are all supplied in pre-filled Terumo BD 50ml syringes, with yellow label on the syringes. No refrigeration of drugs & keep in room temperature & discard after 24hrs Stick bright yellow labels to drug syringes as well as extension tubings to alert all staffs against parenteral routes.

Medical error: potential fatal results

Administration of epidural infusion

Wrong route

Epidural drug
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Medical error : potential fatal results

Administration of epidural infusion

Wrong route

Intravenous drug
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Key points in EA guideline

EA service would be initiated only by anaesthesiologist inside OT or labor ward.

Only dedicated syringe pumps are labeled with FOR EPIDURAL INFUSION ONLY would be used
Terumo Syringe Pump

Fresenius Kabi
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Preparation of the Epidural Solution:

The anaesthetist should check prescription and drug regimen with a trained staffs.
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Mixing of EA Infusion
0.15% Ropivacaine + 2 g/ml Fentanyl Draw up 38 ml of normal saline + 10 ml of 0.75% Ropivacaine + 2 ml Fentanyl (100 microgram) into a 50ml syringe Terumo

Terumo syringe

100 microgram/ml Fentanyl

43 ml N/S

0.75% Ropiacaine 5ml 11

Labelling:
Label the epidural infusion syringe with drug regime, patients name and prominent warning label

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Immediately prior administration

All EA infusion must be prescribed on delegated Pink MAR epidural charts which are only a/v in OT and labor wards, and they are chopped with FOR EPIDURAL USE ONLY on the top. The infusion regimes would also be chopped

MEDICATION ADMINISTRATION RECORD EPIDURAL DRUG PRESCRIPTION SHEET13

Immediately prior administration

Anaesthetist + Another trained staff
5 Rights Right patient Right time Right drug Right dose Right route Cross-checks with documentation
MEDICATION ADMINISTRATION RECORD EPIDURAL DRUG PRESCRIPTION SHEET 14

Immediately prior administration

Another trained staff
Independently verify patient identification Confirm that correct epidural product, line connection, administration method and pump settings

Both
Sign
MEDICATION ADMINISTRATION RECORD EPIDURAL DRUG PRESCRIPTION SHEET 15

Administration:
Yellow coloured set and EPIDURAL labels near all the connectors from the infusion syringe to the antibacterial filter

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Important !!
Only the trained nurse can care the patient with epidural continuous infusion Attend the training session

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Epidural Analgesia
Administration of analgesics into epidural space Exert a powerful analgesic effect One of the most effective techniques for acute pain management

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Anatomy of Epidural Analgesia

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Anatomy of Epidural Analgesia

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Level of incision determine level of insertion

High Thoracic (T4 7) Thoracotomy, oesophagectomy Mid/low thoracic (T8 10) Gastrectomy, neprectomy, colectomy Lumbar (L2 4) Lower limb operation Caudal: Sacral level Lower limb to lower abdominal region
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Indications of EA :
a. Acute postoperative pain: Intrathoracic surgery Abdominal surgery Lower limb orthopaedic surgery Vascular surgery Urological procedures

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b. Chronic pain -- terminal illness

c. Obstetrics -- Local anaesthetic freezes sensory and motor nerves of the uterus and vagina d. During operative procedures Patients unfit for GA e.g. those with major cardiovascular, respiratory and metabolic problems

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Contraindications of EA
Patients refusal Coagulation disorders Anatomical difficulties / abnormalities of vertebral column Local or systemic sepsis Anticoagulation therapy Raised intracranial pressure Hypovolaemia Uncooperative patients
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Advantages of Post-operative EA
Potential to provide excellent analgesia Continuation of intra-operative therapy Less systemic side effects compared to IV narcotic infusions Reduction in pulmonary complications, DVT, graft thrombosis etc

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Disadvantages of EA
A. Side effects from the drugs a. Local Anaesthetics: Hypotension, Lower limb weakness and numbness, Incontinence, Diarrhoea b. Opioids: Nausea, Pruritus, Urinary retention, Sedation, Respiratory Depression B. Catheter related complications Nerve Injury, Epidural Haematoma, Infection
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Complications of EA
Accidental dural puncture post dural puncture headache typically frontal, exacerbated by movement or sitting upright, associated with photophobia, nausea and vomiting, and relieved when lying flat Epidural haematoma May lead to compression of the spinal cord paraplegia Infection Failure of block
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Complications of EA
Hypotension Inadvertent high epidural block Difficulty in talking drowsiness difficulty breathing Local anaesthetic toxicity light-headedness, tinnitus, circumoral tingling or numbness and a feeling of anxiety or "impending doom", followed by confusion, tremor, convulsions, coma and cardio-respiratory arrest Total spinal profound hypotension, apnoea, unconsciousness and dilated pupils 29

Setting Up Epidural Infusion

The infusion regimes have been used : Ropivacaine 0.15 % + 2 ug/ml fentanyl at 0-12 mls/hr Bupivacaine 0.0625% + 3.3 ug/ml Fentanyl at 0-12 mls/hr

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Modes of Delivering of EA
1. Epidural Infusion Continuous Patient Controlled (PCEA) 2. Intermittent administration of opioid drugs into epidural space

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Epidural Analgesia (EA)

EA can be safely managed provided that the following are considered: Regular follow up Education of nursing personnel Suitable protocols are adhered In-house acute support service Continuing review

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Preparation for EA pre-operatively

1. The responsible anaesthetist should discuss the risks, benefits and alternatives about EA with the patient prior to the theatre & give patients and families leaflets & obtain consent for the procedure 2. The nursing staff should explain the epidural procedure to the patient.

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3. The following baseline observations should be recorded before the patient goes to theatre e.g. T/ HR / RR / BP/ P 4. Report any abnormal sensation/limb weakness to the anaesthetist & record down prn 5. Nurses should ensure that patient understands selfreport tools for pain assessment e.g. NRS /VAS

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Numeric Rating Scale 0 = No pain 10 = Worst pain imaginable

0 1 2 3 4 5 6 7 8 9 10

No Pain

Worst pain imaginable

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Faces Rating Scale for children

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Care of EA in ward
1. Resuscitation drugs including Atropine, Ephedrine and Naloxone should be available 2. Heat packs or warming pads shall not be used on areas where sensation is affected by the epidural analgesia.

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3.

Assist/observe patient with ambulation prn

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4.

Ward nurse should check the followings upon initial set-up; at the beginning of each shift/work period; For syringe changes; anytime tubing is reconnected after disconnection. Ensure delegated EA pump proper running Ensure proper labelling of catheter Check for dislodgement of catheter daily Ensure no misconnection of epidural catheter Check any oozing of insertion site

a. b. c. d. e.

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5. Ensure EA catheter is taped along the back

Tapping is made around four corner of Tegaderm dressing to

r ei nfor ce t he dr es s i ng. (eg Hyperfix or Mefix ) The remainder of the catheter is taped up the patients back

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6. Ensure EA catheter & filter are securely fixed

The filter is securely taped to the upper chest wall (near clavicle) Any loose catheter tubing should be carefully coiled and taped securely to the chest wall or shoulder

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7. Ward nurses should make sure that only delegated infusion pump & delegated Pink MAR form are used for EA infusion

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8. Ward nurses should check the drug being administered corresponding to the prescription & Nursing Instructions sheet, APS Prescription & Observation Records should be completed appropriately

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9.

Nursing Observation & record BP/HR/ RR record hourly for the first 24 hours, then Q4h if stable. If hypotension occurs, IV fluid support / slow down the infusion rate/ Vasopressors, Rule out other causes of hypotension e.g. surgical complications (bleeding)

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10.

If the patient develop respiratory depression

Give 100% oxygen and manual ventilation if apnoea. Inform Surgeon and Pain team / on call Anaesthetist IV Naloxone 0.1 mg, repeat every 2-3 minutes up to a total of 0.4 mg as required

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11.

Observation and record : sedation score If the patient has a sedation score of > / = 2, Contact on Pain Team or on call Anaesthetist The sedation score is : 0 Awake, alert 1 Slight drowsy 2 Very drowsy, rousable 3 Unrousable S Sleeping, rousable

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12.

Observation and record : pain score Use self-report wherever possible. Identify the type & location of pain Reposition & reassurance the patient Rule out other cause of increasing or unresolved pain e.g. surgical complications & contact the surgeons or pain team / on call anaesthetist

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rescue

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13.

Observe & record motor Score (refer to APS Prescription& observation charts)

No leg weakness, full extension, can raise extended leg off bed Unable to raise extended leg but able to flex knee and ankle Unable to raise extended leg or flex knee but able to move ankle Unable to flex knee, ankle or foot
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14.

Check & record lower Limb (s) Numbness Use self-report wherever possible. Identify the Right leg or Left leg whenever possible.

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15.

Assess & record sensory Level

Assess the patients response to T change, apply an ice pack or WariActiv spray to the skin surface. Bilateral assessment of the block should be made. If the block extends cephalad (i.e. towards the head) to T3 or T4, the responsible anaesthetist must be notified.

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Upper Dermatome Level

Reference of Dermatome Levels T2 T4 T6 T10 L2 Sternal Angle Nipple Line Xiphisternum Umbilicus Lateral and Anterior Upper Thigh
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T4 T10

T12-L1 Groin

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Observation and record: Nausea & vomiting

If the patient complaining of nausea or vomiting: Aspirate nasogastric or gastrostomy tube if appropriate IM / IV Maxolon 10mg Q8H

Side effect

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17.

Observation and record: intake and output

If the patient has a palpable bladder or bladder discomfort: Contact the on call anaesthetist Contact the surgeons to determine if the patient needs to be catheterized. Documentation The amount drained should be recorded.

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18.

Observation and record: itching Oral / IM / IV Piriton 10 mg Q8H If itching continues to be a problem contact pain team / on call anaesthetist

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Observe & record for systemic LA toxicity

Drowsiness, Dizziness Tinnitus, Numbness of the tongue Anxiety Confusion Muscle twitching ,Convulsions Loss of consciousness, Coma Hypotension Bradycardia cardiac arrest Respiratory arrest ** Contact pain team / on call anaesthetists
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Others observations: Migration of catheter into epidural vessels in the epidural space Causing systematic absorption of medications (systematic toxicity) Observe for inadequate analgesia which may relate to the small opioid dose being absorbed systemically Observe for symptoms of LA toxicity e.g. dizziness, lightheadedness, hypotension, agitation, seizures Notify pain team / on call anaesthetist immediately if theses occurs

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21.

Patient/ Parent/ Family Education regarding How epidural analgesia works Opioid/local anesthetic name and side effects Assessment procedures

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Removal of Epidural Catheter

1. Lie patient on side and curled up if possible 2. Spray with plastic spray & covered with Tegaderm 3. Document the integrity of epidural catheter and record the time removal of catheter

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Inform pain team on call anaesthetist

If the following situations occurs: Over sedation Respiratory depression or respiratory arrest. Disconnection from the filter &Pump occlusion Displacement / dislodgement/ Break of the epidural catheter patient has excessive lower limb weakness or numbness,pain at insertion site; severe low back pain (signs of epidural / spinal haematoma) Signs and symptoms of LA toxicity Wet dressing & oozing of blood at insertion site Signs of catheter site infection, meningitis, or sepsis Unrelieve N & V & itchiness
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Trouble shooting
a. If the epidural catheter is pulled out accidentally: Reassure the patient. Put a sterile gauze over the entry site. Keep the epidural catheter. Contact Pain Team or on call anaesthetist Documentation

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b. If the catheter becomes disconnected from the filter: Do not clamp the epidural catheter. Cover with gauze Contact Pain Team or on call anaesthetist immediately Record the time of disconnection and / or the time of noticing the disconnection.

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c. If pump occlusion occurs :

Stop infusion & reposition the patient prn Check the filter to ensure no over tightening of connection. Observe the entry site for any kinking of catheter under the skin and re-dress if necessary Check any kinking of the infusion tubing Check any proper running of the pump If these interventions are unsuccessful, call pain team/ on call anaesthetist Documentation
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Important information
No Narcotics or bolus of LA are given through epidural unless by pain team / on call Anaesthetist Hypoxaemia is NOT a reliable early sign of respiratory depression No injection at the epidural catheter Catheter to only be removed by pain team / on call anaesthetists Ensure normal coagulopathy prior to the removal of EA Adjuvant Analgesics given (Tramadol, Dologesic, Panadol) IV access should be available throughout the duration of the epidural and for 24 hours after it has been discontinued.
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 Patients receiving concomitant anticoagulants are more at risk for epidural/spinal hematoma after removal of catheter, so these patients shall be assessed for onset of signs/symptoms of epidural/spinal hematoma Stop anticoagulation for 12 hours before removal of catheter & resume after 10 hours of removal Keep monitor vital signs & IV cannula for further 24 hours after removal of epidural catheter Pain Team / on call Anaesthetists will follow up the patient daily and for 1 more day after removal of EA catheter
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Exchange of empty epidural drug:

Stop the pump Clamp the tubing Expel air of the 50 ml syringe Connect to the epidural tubing Ensure good sitting of syringe into the pump Start infusion again ** make sure no contamination occurs ** check tubing not connecting to other access before & after changing the syringe
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Patient confidentiality
When return the infusion by porter

False

Correct
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Anaesthesiologists

Pain Nurse

Ward Nurse

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Question & Answer

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Pain Nurse: 22551272/ 73069578 (office hour) On Call Anaesthetist: call operator 0

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References
1. Acute Pain Management: Scientific Evidence, ANZCA & Faculty of Pain Medicine / NHMRC, 2nd Edition 2005 2. Macintyre PE, Ready LB. Acute Pain Management: A Practical Guide. WB Saunders 2nd Edition 2001 3. Scott DA, Blake D, Buckland M, et al. A Comparison of Epidural Ropivacaine Infusion Alone and in Combination with 1, 2, and 4 mg/mL Fentanyl for Seventy-Two Hours of Postoperative Analgesia After Major Abdominal Surgery. Anesth Analg 1999; 88: 85764 4. Regional Anesthesia in the Anticoagulated Patient Defining the Risks: ASRS Policy Document 1998
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