Transcript PAIN MANAGEMENT

Epidural Analgesia
Dr.Fatma AL Dammas
OBJECTIVES

Identify the anatomy and physiology of
the spinal column in relation to the
placement of an epidural catheter.

Identify the nursing responsibilities in
caring for a patient receiving epidural
analgesia.
DEFINITIONS

EPIDURAL=administration of medication
into epidural space
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INTRATHECAL=administration of
medication into subarachnoid space
OVERVIEW
OF THE
SPINAL ANATOMY
SPINAL CORD
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Located and protected within vertebral
column
Extends from the foramen magnum to
lower border 1st L1 (adult) S2 (kids)
SC taper to a fibrous band - conus
medullaris
Nerve root continue beyond the conuscauda equina
Surrounded by the
meninges,(dura,arachnoid &pia mater.)
VERTEBRAL COLUMN
Vertebral column
Protects the spinal cord & consists of
‫٭‬7cervical
‫٭‬12 thoracic
‫٭‬5 lumbar
‫٭‬5 caudal or sacral fused into
one
‫٭‬4-5 coccygeal fused one bone
coccyx
The ligaments
1c.supraspinous
ligament
2b.Interspinous
ligament
3a.ligamentum
flavum
EPIDURAL SPACE
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Potential space
Between the dura mater,luigamentum
flavum
Made up of vasculature, nerves, fat and
lymphatic
Extends from foramen magnum to the
sacrococcygeal ligament
INDICATIONS

The objective of epidural analgesia is
to relieve pain.
Major surgery
Trauma (# ribs)
Palliative care (intractable pain)
Labour and Delivery
CONTRAINDICATIONS
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Patient refusal
Known allergy to opioid or local
anesthetic
Infection/abscess near the proposed
injection site
Sepsis
Coagulation disorder
Hypotension / hypovolemia
Spinal deformity/increased ICP
Patient assume a sitting or side-lying
position with the back arched toward the
physician.Help to spread the vertebrae
apart
Height of sensory
block
Lumbar-T4
Thoracic-T2
Patients with epidural catheters may
shower, as long as the dressing is
intact.
Epidural Analgesia
INSERTION OF EPIDURAL
CATHETER
Positioning of patient
 The site is dependent upon the area of
pain
 Fixing the catheter
Incision
Level

Thoracic
Upper abdo
Lower abdo
Pelvic
Lower extremity
T4-T6
T6-T8
T8-T10
T8-T10
L1-L4
EPIDURAL CATHETERS

Ideal Placement (adult) 10-12 cm at the
skin

Epidural catheters have markings that
indicate their length.
= there is a mark at the tip of the catheter
= the 1st single mark up the catheter is 5cm
= double mark up the catheter is 10 cm
= triple mark on the catheter is 15 cm
= four mark together indicate 20cm
A change in depth of the catheter indicates migration
either into or out of the epidural space.
CATHETER MIGRATION
Catheter migration into a blood vessel in the
epidural space or subarachnoid space
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rapid onset LOC
Decrease loss of sensory or motor loss
(marcain)
Toxicity
Profound hypotension
CATHETER MIGRATION
Out of the epidural space
 ineffective analgesia
 no analgesia
 drugs deposited into soft tissue.
DRUGS

One of the most important factors
influencing drug absorption and
bioavailability is the drug SOLUBILITY

The more lipid soluble rapid onset &
shorter duration
MEDICATION COMMONLY USED

OPIOIDS-Fentanyl +Morphine
(affect the pain transmission at the
opioid receptors)
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L.A.-Bupivacaine(marcaine)
(inhibits the pain impulse
transmission in the nerves with
which it comes in contact)
METHODS OF ADMINISTRATION
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BOLUS (FENTANYL, DURAMORPH)
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CONTINUOUS INFUSION(MARCAINE+FENTANYL)
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All drugs administered epidural should be
preservative free.
All epidural opioids should be diluted with normal
saline prior to intermittent bolus administration.
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EPIDURAL LOCAL
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Bupivacaine (marcaine)
Mechanism of Action

Bupivacaine (marcaine)
- local anaesthetic works as an
analgesic (subanesthetic dose)
- inhibiting impulse transmission in
the nerve fibers
- sensory nerves are blocked first
before the motor fibers
- sensory fibers carrying the pain is
blocked before those carrying heat
cold touch and pressure.
EPIDURAL LOCAL
ANESTHETIC(MARCAINE)
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Onset 10-15 minutes
Duration- 4 hrs+ after a bolus or after
infusion is stopped
Marcaine(0.0625%-0.125%-0.25%)
Extend of spread influenced by volume
and position of patient
OPIOIDS
Mechanism of action-distribution

Vascular uptake by blood vessels in the
epidural space
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Diffusion through dura into CSF to spinal
cord to the site of action.

Uptake by the fat in the epidural space.
Morphine (Duramorph/Astramorph)
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Hydrophilic(water soluble)
Slow to diffuse across the dura on to the
spinal cord
Can cause late respiratory depression
Monitor respiratory status for 12 hrs after
the last dose of duramorph
Duration 6 hrs+
Broad spread
Fentanyl (preservativefree)
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Lipophilic(fat soluble)
Crossess the dura rapidly
Rapid onset of action(segmental)
Decreased risk of late respiratory
depression
Onset 5-20 mins
Duration 2-4hrs
Excellent for breakthrough pain
Opioid pharmacology
Opioid pharmacology
•Peak plasma concentration after
po = 1 hour
SC,IM = 30MINS
IV
= 6MIN
•Half- life at steady state
PO,PR,SC,IM,IV =3-4 H.
Adverse Effects -Opioids
Sedation and resp.depression- IV narcan
 N/V-Opioids stimulate the chemoreceptor trigger zone
primperan
 Pruritus- diphenhydramine or narcan (low dose)
 Urinary retention- low dose narcan and /or
catheterization
 Slowing of GI motility
 Hypotension

Respiratory Depression
May occur
Early
Delayed
R/D is relatively uncommon.
Risk factors
recent IV or IM narcotics
large dose
recent CNS depressants (anesthetic ,etc)

ASSESSMENT OF THE SEDATION
LEVEL
None
Alert
1
Mild
Easily aroused
2
Moderate
Difficult to arouse
or RR <10 notify
APS pg2789
3
Severe
Unresponsive or RR
<8. notify APS2789
0
Motor and Sensory Assessment
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Motor assessment
Sensory assessment:
* Use ice in the tip of a glove
* Start in upper neck and move down
thorax bilaterally assessing all
potential dermatomes
* Level of block is where intensity of cold
changes or the cold sensation is absent
* assess the dermatomes below the pelvis
Assessment of motor block
Bromage Score
Motor and Sensory Assessment
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Motor assessment
Sensory assessment:
* Use ice in the tip of a glove
* Start in upper neck and move down
thorax bilaterally assessing all
potential dermatomes
* Level of block is where intensity of cold
changes or the cold sensation is absent
* assess the dermatomes below the pelvis
Sensory assessment
Adverse Effects L.A
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Hypotension-assess intravascular
volume status
-no trendelenberg
positioning
Teach patient to move
slowly from a lying
position to sitting to
standing position.
Treatment
 fluids
Cont.
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Temporary lowerextremity motor or
sensory deficits.
Tx: lower the rate or
concentration.
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Urine retention
Tx: catheter
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Local anesthetic
toxicity (neurotoxicity)
Tx: stop infusion.

Resp. insufficiency
Tx:stop infusion
- ABC(100% o2
call for help)
- Assess spread
and
height of block
- Alt.analgesia
OTHER COMPLICATIONS
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Headache (dural
puncture)
Tx: symptomatic
treatment
Autologous blood
patch
Infection
nausea and
vomiting.
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Intravenous
placement of catheter
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Subdural placement of
catheter
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Haematoma
EPIDURAL
ANALGESIA(GUIDELINES)
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Collect items
Assess patient
Inspect site
Wash hands
Aspiration test – Glucose test
Administer
Document
Evaluate the outcome
POLICIES
1. Placement of epidural catheters is performed by the
anesthetist in the Operating Room .
2. All patients must have a patent IV access for the
duration of epidural therapy and for 12 hours after the
catheter is removed.
3. The Acute Pain Service (APS) / Anesthesiologist will
be responsible for ordering all epidural analgesia.
4. When the nurse receives a patient with a continuous
epidural infusion, the RN must follow every order on
the order sheet.
4.1. If there is any query about the orders, if any of
the orders are not filled in and/or if there is no date
and time and/or signature, contact the anesthetist
who wrote the order.
6. Epidural Medications
6.1. No medications, other than those offered by the Acute
Pain Service (APS), are to be administered into the epidural line
6.2. Do not use agents from a multiple dose vial. Most multidose vial medications contain preservatives, which can cause
intra-spinal neurotoxicity
6.3. Do not use alcohol or alcohol based products near the
epidural catheter. Alcohol is neurotoxic and can damage the
nerves.
6.4. Return any medications that are unclearly labeled, cloudy
or contain particulate matter to pharmacy.
6.5. Return any unused used syringes and cassettes to
pharmacy
7. Local anesthetic must not be given as a bolus via the epidural
catheter by the nurse.
8. The APS / anaesthetist must be notified if pain is not well
controlled by the epidural infusion.
9. No other narcotic drug will be administered to the patient by any
other route unless ordered by the anesthetist / APS .
10. All monitoring information and assessments must be
documented on the Continuous Epidural Infusion Flowsheet
11. Patient monitoring will be done as outlined for 12 hours after the
discontinuation of the epidural infusion and after removal of
epidural catheter, whether it is opioids or local anesthetic which
has been infused.
11.1.Assess pain scores, blood pressure, heart rate,
sedation level, respiratory and sensory levels, and motor
function every 15 mins x1h, every 1 hour x 4 hours and then
every 4 hours until 12 hours after the infusion is discontinued.
12. Motor functions of patients receiving local
anesthetic via epidural catheter must be
assessed by an RN.
13. To assess the height of sensory block, use
the ice technique.
14. All epidural catheters must be identified with
the label “Epidural Catheter” at the access
hub, to prevent inappropriate use of the
catheter.
15. Dressing changes are done only when necessary, by nurses
who have been trained in proper techniques of dressing change
in present of APS .
16. The administration set (including the 0.22 micron filter) will be
changed every 72 hours and the tubing labeled with the date
and time of change.
Dressing Changes and Removal of Epidural Catheters
EQUIPMENT/MATERIALS
Dressing Change
Sterile 4 x 4 gauze x 2 packages
Povidone-lodine swabs sticks x 3 packages
Large Transparent dressing x 1
Sterile gloves x 2 pair
Transparent tape
Dressing Changes:
Dressings should not be changed unless it is absolutely
necessary, however, they may be changed if:
1. the dressing is wet due to oozing from the
puncture site
2. the dressing has become loose
Dressing Changes:
PROCEDURE
1. Gather all equipment and supplies.
2. Explain the procedure to the patient.
3. Position patient on bed.
4. Wash hands.
Open the sterile gloves, transparent dressing
4x 4 gauze package.
Dressing Changes:
5. Put on sterile gloves. With a finger tip, apply
gentle pressure over the catheter insertion site
and slowly peel back the opsite dressing using
extreme care.
6. Remove gloves and dispose soiled dressing and
gloves into garbage bin.
7. Wash hands and put on second pair of sterile gloves.
8. Supporting the catheter with one hand, clean the
Insertion site with povidone-iodine swabs, moving
from center to periphery of site. Allow to dry.
Dressing Changes:
9. Loop the catheter, and fix
using transparent dressing.
10. Gently run finger over
catheter and dressing.
11. Fix catheter along back and
over shoulder .
12. Document dressing change
and observations on
Nursing Record.
Epidural Catheter Removal:
1. Removal of the epidural catheter must be ordered by
the APS physician.
2. Low Molecular Weight Heparin (LMWH): Catheter
removal should be delayed until 12 hours after a
dose of LMWH. If LMWH is to be continued, it should
not be resumed until at least 4 hours after catheter
removal.
3. Standard Heparin Therapy: Catheter removal should
be delayed until 6 hours after a dose of standard
heparin. If standard heparin is to be continued, it
should not be resumed until 2 at least 2 hours after
catheter removal.
Removal of the epidural catheter
4. Heparin Infusion: The coagulation status of the
patient receiving heparin infusion should be
assessed. The heparin infusion shall be stopped for 6
hours prior to catheter removal, and not resumed for
at least 2 hours after the catheter is removed.
PROCEDURE
1. The APS staff should be notified if the patient is
receiving anticoagulant.
2, Gather all equipment and supplies.
3. Explain the procedure to the patient.
4. Position the patient side-lying or sitting with the back
exposed and arched out.
Flexion of the back widens the vertebral space,
allowing for easy withdrawal of the catheter
5. Stop the epidural pump.
6. Wash hands. Put on sterile gloves.
7. Gently remove tape and dressing.
8. inspect catheter site for redness, swelling or
drainage.
If the area is reddened or if there is drainage, notify the
APS physician. Collect surface swabs and catheter tip
for cultures and sensitivity (per APS physician) using
aseptic technique.
9. Clean the catheter insertion site, from center
outwards,and allow to air dry.
10. Apply steady traction to remove catheter. Do not pull
vigorously.
If resistance is met, ask the patient to flex or arch his
back more. If resistance remains, stop and notify APS.
11. When catheter is removed, check that tip is intact. If
not, notify APS immediately.
12. Apply band-aid to the site.
13. Instructions to patients should include:
A. report any pain at the insertion
14. Maintain IV access for 12 hours after the last dose of opioid is
given
15. Document epidural catheter removed in the
nursing record.
Include date, time, condition of catheter, and site and
patient’s tolerance of the procedure.
16. Obtain co signature of a second nurse to witness
waste of narcotic (if required)
17. Clean pump thoroughly and return to Recovery Room Level 2.
1.Measure the length of the epidural catheter from epidural space
to the skin.
1.Measure the length of the epidural catheter from epidural space
to the skin.
2.What will you do to check the CSF and Blood- tinged fluid.
1.Measure the length of the epidural catheter from epidural space
to the skin.
2.What will you do to check the CSF and Blood- tinged fluid.
3.How you perform a SENSORY level assessment using an ice
method.
1.Measure the length of the epidural catheter from epidural space
to the skin.
2.What will you do to check the CSF and Blood- tinged fluid.
3.How you perform a SENSORY level assessment using an ice
method.
4.How you perform a MOTOR level.
1.Measure the length of the epidural catheter from epidural space
to the skin.
2.What will you do to check the CSF and Blood- tinged fluid.
3.How you perform a SENSORY level assessment using an ice
method.
4.How you perform a MOTOR level.
5.What will you check for the site.
1.Measure the length of the epidural catheter from epidural space
to the skin.
2.What will you do to check the CSF and Blood- tinged fluid.
3.How you perform a SENSORY level assessment using an ice
method.
4.How you perform a MOTOR level.
5.What will you check for the site.
6.Guidelines for removing epidural catheter for those patients who
receives anticoagulant.
LOW MOLECULAR WEIGHT HEPARIN
STANDARD HEPARIN THERAPY
HEPARIN INFUSION
1.Measure the length of the epidural catheter from epidural space
to the skin.
2.What will you do to check the CSF and Blood- tinged fluid.
3.How you perform a SENSORY level assessment using an ice
method.
4.How you perform a MOTOR level.
5.What will you check for the site.
6.Guidelines for removing epidural catheter for those patients who
receives anticoagulant.
7.Based on your knowledge and understanding how you will do the
epidural dressing after preparing all the needed materials.
1.Measure the length of the epidural catheter from epidural space
to the skin.
2.What will you do to check the CSF and Blood- tinged fluid.
3.How you perform a SENSORY level assessment using an ice
method.
4.How you perform a MOTOR level.
5.What will you check for the site.
6.Guidelines for removing epidural catheter for those patients who
receives anticoagulant.
7.Based on your knowledge and understanding how you will do the
epidural dressing after preparing all the needed materials.
8. How you will remove the epidural catheter.
REMMEMEBER
STAFF NURSE
RESPONSIBILITIES
1. Upon receiving patient check for:
1.1. IV cannula
1.2. urinary catheter
1.3. epidural catheter length (if visible)
1.4. if dressing is intact
1.5. doctors order
1.6. ongoing epidural infusion bag
STAFF NURSE
RESPONSIBILITIES
2. Assess and monitor as indicated on epidural
flowsheet.
3. Notify APS or on call anaesthetist any untoward
complications, emergency , side effects or
inadequate relief related to therapy.
3.1 pager 2113 aps anaesthetist weekdays 0730 –
1600
3.2 pager 2789 aps nurse weekdays 0730 – 1600
3.3 pager 3540 maternity on call anaesthetist
1630 – 0730 daily and weekends
STAFF NURSE
RESPONSIBILITIES
4. Certified nurse should connect the new bag.
5. CN are allowed to increase or decrease the infusion rate based
on the rate ordered or patients pain response from ongoing
infusion.
6. Infusions:
6.1. if used : discard with the presence of other witness or
staff.
6.2. if not used: Incident report and send back to pharmacy.
7. Keep patent IV access and continue to monitor for 12 hours
after removing the epidural catheter.
8. Inform APS team or on call anesthetist if patients is on
anticoagulant.
You’re!!! What did you learn?