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Third Edition
Epidural Analgesia
U NI V ER SIT Y
HOS PI TA L
O F
W I SC ON SIN
A ND
MA DI SON ,
C LI NI C S
W I
TABLE OF CONTENTS
I.
Introduction
II. Content
Section 1
Benefits, Indications, and Contraindications
Section 2
Pain Transmission / Modulation
Section 3
The Epidural Space
Section 4
Epidural Catheter Placement
11
Section 5
Common Opioids and Local Anesthetics
13
Section 6
Nursing Assessment, Documentation, and
Management of Side Effects and Complications
17
Section 7
Patient / Family Teaching
22
Section 8
AP II Pump
23
III. Post-test
24
IV. References
28
1
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INTRODUCTION
Analgesia is now recognized as a significant contributor to
clinical outcomes (1). The goal for pain management is to provide
the best analgesia with the least amount of side effects. Epidural
analgesia is a desirable method of pain relief because it provides
true segmental analgesia with
little or no contribution from
systemic levels of opioids (2). All of
which may lead to excellent
analgesia with minimal side effects (2,3).
Caring for patients who receive epidural analgesia requires
specialized knowledge regarding the placement of the epidural
catheter, management of the(1,3,4,5,6)
therapy, and monitoring for potential
side effects/complications
. This self-directed learning
module is essential information for the nurse clinician who cares
for patients receiving epidural analgesia.
2
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BENEFITS, INDICATIONS,
AND CONTRAINDICATIONS
Section 1
1.1
BENEFITS
o Chronic pain
Epidural analgesia can be used in the treatment of patients
experiencing an acute exacerbation of Complex Regional Pain
Syndrome (CRPS) by producing a sympathetic blockade using a
local anesthetic. This provides improved analgesia, and allows
the patient to participate in physical therapy which is vital in
the control of their symptoms. Epidural analgesia may also be
used for the treatment of other types of chronic pain such as
cancer pain.
4
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1.3
o Coagulopathies
Patients experiencing coagulopathies are at an increased risk for
an epidural hematoma.
o Decreased level of consciousness (13)
Epidural analgesia may be implicated in any progression of
central nervous system dysfunction. Also pain management by
epidural analgesia requires accurate reports of pain levels by
patient.
o Systemic infection (4,5,6,13)
Systemic infection or sepsis may lead to an infection in the
epidural space.
o A localized infection at the insertion site of the epidural
catheter (4,5,6,13)
A localized infection at the site of insertion may lead also to
an infection in the epidural space.
(6)
5
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PAIN TRANSMISSION
MODULATION OF PAIN
Section 2
Definition of terms:
Pain: An unpleasant sensory and emotional experience associated
with the actual or potential tissue damage.
Afferent Nerve: A nerve that transmits impulses from the periphery
toward the central nervous system.
Analgesia: Pain relief, the absence of pain in response to a
stimulus that normally would be painful.
Noxious stimulus: A stimulus that is damaging or potentially
damaging to body tissue.
Nociceptor: A nerve receptor that is preferentially sensitive to
noxious or potentially noxious stimuli.
Nociception:
7
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9
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12
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COMMON OPIOIDS
AND LOCAL ANESTHETICS
Section 5
5.1
EPIDURAL OPIOIDS
EPIDURAL OPIOIDS
LIPID SOLUBILITY
(25)
ONSET
DURATION
Morphine
30 - 60 min.
6 - 24 hours
Hydromorphone
10
15-30
6 - 18 hours
Meperidine
30
5 - 10 min.
6 - 8 hours
13
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Fentanyl
800
5 min.
4 - 6 hours
15
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LOCAL ANESTHETICS
16
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5.4
18
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NURSING ASSESSMENT,
DOCUMENTATION, AND MANAGEMENT
OF SIDE EFFECTS AND COMPLICATIONS
Section 6
6.1
(13)
Noting:
1. The location of the epidural catheter
2. Initial preop opioid bolus dose, if given and when
3. Medication(s) ordered and the infusion rate
4. Specific recommendations for patient assessment
5. Orders to treat potential side effects/complications
6. When to notify the Anesthesiology Acute Pain Service
Notify by using the P-A-I-N pager ( # 7 2 4 6 )
6.2
(3,5,13)
Assessment:
Assess the patients pain rating using patientspecific pain scale (e.g. 0-10)
every 4 hours while awake, both at rest and with
activity
Documentation: Document patients pain ratings on Pain Management
flow sheet (UWHC #48)
Management:
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6.3
(2,3,4,5,6,13,22,31,35,36)
Management:
4 and / or
21
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o Nausea / Vomiting
(2,3,4,5,6,13,22,31)
(2,3,4,5,6,13,22,31)
(2,3,4,5,6,13,22,31)
(4,6,13,32,34)
(3,4,5,13,30,31)
6.4
o Epidural abscess
(4,5,6,13,21,37)
(6,13,21,35,38)
(6,13)
(5,13)
(The catheter may migrate into the blood vessels of the epidural
space, causing the medications to be delivered systemically)
Assessment: Assess the
Assess the
analgesia may occur
due to the
systemically
Assess the
toxicity such as
dizziness,
seizures
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6.5
o Dressing care:
Notify the Acute Pain Service to reinforce or
change the dressing.
The epidural catheter is secured with adhesive
strips and covered with
a clear adhesive dressing. Manipulation of the
dressing may dislodge
the epidural catheter from the epidural space. It
is best if a member of
the Acute Pain Service attends to the dressing so
that assessment of
the position of the catheter is noted.
(5,6)
6.6
(31)
The Acute Pain Service will remove the epidural catheter. The
decision to stop the epidural infusion and remove the epidural
catheter is made by either the Acute Pain Service or the
patients primary physicians. The Acute Pain Service will
remove the epidural catheter.
If an epidural catheter is removed accidentally, place the
catheter and attached dressing into a plastic bag and label
with the patients name. The APS will inspect the catheter to
ensure it was removed without breakage.
6.7
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AP II PUMP
Section 8
1.
Review
and/or view
Baxter
Development
2.
3.
For more information, or for additional copies of this SelfDirected Learning Module, please call Nursing Staff Development at
263-6490.
28
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III. POST-TEST
True or False (Please record your answers on the answer sheet
provided)
_____ 1.
Exogenous opioids bind with
modulate the nociceptive
transmission.
opioid receptors to
_____ 2.
Fat in the epidural space functions as a depot for
the opioids and local anesthetics.
_____
3.
Lipophilic opioids such as fentanyl, when
administered epidurally, have a rapid onset and a long
duration of action.
_____
4.
Morphine, when administered epidurally, has a slower
onset but a longer duration of action when compared to
fentanyl.
_____
5.
The dose of an opioid administered epidurally is
about the same as a parenteral dose.
_____
6.
Common side effects of epidural opioids are nausea,
pruritus, and urinary retention.
_____
7.
If the epidural catheter dressing is loose, the
nurse should reinforce the area with tape and a new
occlusive dressing.
_____
8.
A sudden increase in a patients sedation level may
be due to the migration of the epidural catheter into the
subarachnoid space.
_____ 9.
All medications administered epidurally must be
preservative-free.
_____ 10.
The epidural catheter insertion site should be
assessed every 8 hours for tenderness, swelling, erythema,
or drainage.
29
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every 2 hours
every 4 hours
every hour
one time this shift
d.
32
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a.
also assess the epidural infusion pump and tubing for problems
such as kinked
tubing, and assess the catheter site for catheter displacement
or leakage
b.
just notify the Acute Pain Service
c.
wait another hour and reassess patient
d.
just notify the Surgical Service
18.
the
the
the
the
Surgical Service
anesthesiologist who inserted the epidural catheter
Acute Pain Service in the morning
Acute Pain Service
33
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On your unit is a 42 year old female who is S/P (R) Thoracotomy, and
had an epidural catheter inserted at the interspace T 6 preoperatively.
She is receiving an infusion of Meperidine 2mg/ml and Bupivacaine 0.1% at
6cc/hr. Today (POD#1), you are to start to ambulate the patient. She
denies incisional pain, numbness or heaviness in her legs. She does tell
you that when she sat up in bed this am she felt very dizzy.
19.
bed
b.
check for orthostatic changes in the patients heart rate and
blood pressure
c.
just notify the Surgical Service
d.
none of the above
20. On POD#3, the surgeons request that the epidural catheter be
discontinued. The nurse
should:
a.
b.
c.
catheter
d.
34
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IV. REFERENCES
1. Macintrye, P.E. & Ready,L.B. (1996). Acute pain: significance
and assessment. In P.E. Macintrye & L.B. Ready, Acute Pain
Management A Practical Guide (pp.1-12). London:
W.B.
Saunders.
2. VadeBoncouer, T.R. & Ferrante, F.M. (1993). Epidural and
subarachnoid opioids. In F.M. Ferrante & T.R. VadeBoncouer
(Eds.), Post-operative Pain Management (pp.279-303).
New York: Churchill Livingstone.
3. Grichnik, K. & Ginsberg, B. (1992). Epidural analgesic for
patients recovering from surgery. In R. Sinatra, A. Hord, B.
Ginsberg, & L. Preble (Eds.), Acute Pain Mechanism and Management
(pp.243-252). St. Louis: Mosby-Year Book.
4. Pasero C. (1998). Epidural Analgesia For Acute Pain Management.
American Society of Pain Management Nurses self directed learning
program. ASPMN, Pensacola, FL.
5. Pasero C., & McCaffery M. (1999). Providing epidural analgesia:
how to maintain a delicate balance. Nursing, August, 34-40.
6. Naber, L., Jones, G., & Halm, M. (1994). Epidural analgesia for
effective pain control. Critical Care Nurse, October, 69-83.
7. Liu S., Carpenter R.L., & Neal J.M. (1995). Epidural anesthesia
and analgesia: their role in postoperative outcome.
Anesthesiology, 82(6) 1474-1506.
8. Anderson G., Rasmussen H., Rosenstock C., Bleemer T., Engb/ek J.,
Christensen M., & Ording H. (2000). Postoperative pain control by
epidural analgesia after transabdominal surgery: efficacy and
problems encountered in daily routine. Acta Anaesthesiol
Scand,44, 296-301.
9. Mann C., Pouzeratte Y.,
al., (2000). Comparison
controlled analgesia in
surgery. Anesthesiology
10. Horlocker T.T., Wedel D.J., (1998). Neuraxial block and low
molecular weight heparin: balancing perioperative analgesia and
thromboprophylaxis. Regional Anesthesia Pain Medicine 23 Supp.
11. Liu S.S., Mulroy M.F. (1998). Neuraxial anesthesia and
analgesia in the presence of standard heparin. Regional
Anesthesia Pain Medicine. 23 Supp.
12. de Leon-Casasola, O.A., Karabella, D. & Lema, M.J. (1996).
Bowel function recovery after radical hysterectomies: Thoracic
epidural bupivacaine-morphine versus intravenous patient35
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A pilot study.
Journal of
13. Agency for Health Care Policy and Research (1992). Clinical
Practice Guidelines: Acute Pain Management: Operative or
Medical Procedures and Trauma, Pub. No. 92-0032, Rockville, MD.
14. American Society of Regional Anesthesia. Neuraxial Anesthesia
and Anticoagulation Consensus Statements. American Society of
Regional Anesthesia Consensus Conference, Chicago, Il, May 2-3,
1998.
15. Byas-Smith, M. (1992). Management of acute exacerbations of
chronic pain syndromes. In R. Sinatra, A. Hord, B. Ginsberg, &
L. Preble (Eds.), Acute Pain Mechanism and Management (pp.432444). St. Louis: Mosby-Year Book.
16. Macintrye, P.E. & Ready, L. B. (1996). Epidural and
intrathecal analgesia. In P.E. Macintrye & L.B. Ready, Acute
Pain Management A Practical Guide (pp. 114-151). London: W.B.
Saunders.
17. Ready, L. B. (1990). Spinal opioids in the management of
acute and post-operative pain. Journal of Pain and Symptom
Management, 5 (3), 138-145.
18. Jones, S.J. (1992). Anatomy of pain. In R. Sinatra, A.
Hord, B. Ginsberg, & L. Preble (Eds.), Acute Pain Mechanism and
Management (pp.8-28). St. Louis: Mosby-Year Book.
19. Katz, N. & Ferrante, F.M. (1993). Nociception. In F.M.
Ferrante & T.R. VadeBoncouer (Eds.), Post-operative Pain
Management (pp.17-67). New York: Churchill Livingstone.
20. Willens, J.S. (1996). Introduction to pain management. In
E. Salerno & J. Willens (Eds.), Pain Management Handbook An
Interdisciplinary Approach (pp.3-38). St. Louis: Mosby-Year
Book.
21. Aimone, L.D. (1992). Neurochemistry and modulation of pain.
In R. Sinatra, A. Hord, B. Ginsberg, & L. Preble (Eds.), Acute
Pain Mechanism and Management (pp.29-43). St. Louis: Mosby-Year
Book.
22. Jasinski, D.M. & Snyder, C. J. (1996). Invasive
interventions. In E. Salerno & J.S. Willens (Eds.), Pain
Management Handbook An Interdisciplinary Approach (pp.429-464).
St. Louis: Mosby-Year Book.
23. Paice, J.A. & Buck, M.M. (1993). Intraspinal devices for
pain management. Nursing Clinics of North America, 28 (4), 921935.
24. Lubenow, T. R. (1992). Epidural analgesia: Considerations
and delivery methods. In R. Sinatra, A. Hord, B. Ginsberg & L.
36
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In
35. Olsson, G.L., Reed, B.A., & Vanderveer, B.L. (1992). Nursing
education regarding epidural
and intrathecal opioids. In R.
Sinatra, A. Hord, B. Ginsberg, & L. Preble (Eds.), Acute Pain
Mechanism and Management (pp. 570-584). St. Louis: Mosby-Year
Book.
37
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36. Ready, L.B., Loper, K.A., Nessly, M., & Wild, L. (1991).
Post-operative epidural morphine is safe on surgical wards.
Anesthesiology, 75 (3), 452-456.
37. Ngan Kee, W.D., Jones, M.R., Thomas, P. & Worth, R.J. (1992).
Extradural abscess complicating extradural analgesia for
caesarean section. British Journal of Anaesthesia, 69,
647-652.
38. Metzger, G. & Singbartl, G. (1991). Spinal epidural hematoma
following anesthesia versus
spinal subdural hematoma. Two case
reports. Acta Anaesthesiol Scan, 35, 105-107
38
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Notes:
39
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