GREY NUNS and MISERICORDIA SITES CERTIFICATION MODULE. for EPIDURAL / SPINAL ANALGESIA / ANESTHESIA

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1 GREY NUNS and MISERICORDIA SITES CERTIFICATION MODULE for EPIDURAL / SPINAL ANALGESIA / ANESTHESIA CERTIFICATION PROGRAM FOR THE ADMINISTRATION OF POSTOPERATIVE ANALGESICS THROUGH AN EPIDURAL CATHETER BY A REGISTERED NURSE WITH SPECIALIZED CLINICAL COMPETENCY (RN SCC) & LICENSED PRACTICAL NURSE ACKNOWLEDGEMENTS: Adapted from: University of Alberta/Capital Health Authority Certification Program for the Administration of Postoperative Analgesics Through a Percutaneous Epidural Catheter by a Registered Nurse with Specialized Clinical Competency. Covenant Module Review/Revisions January 2003, March/2005, September 2016 Review & Approval: D. Hardy, Acting Chief of Anesthesiology; Sylvia Treloar, RN, BScN, ONC ; Janie- Rae Crowley, RN, BScN; Sharon Dawson, RN, BScN, MES, March Adaptations by: Colleen Kasa, RN, BScN. CMSN ; Jodi Normandeau, RN; Georgia Barry, RN, BScN. June Colleen Kasa, RN, BScN. CMSN ; Sylvia Treloar, RN, BScN; Anne Le, RN, BScN; Karen Murphy, RN, BScN. CMSN ; Krista Aasman, RN, DN; Jayne Young, RN, BScN; November January 15,

2 INTRODUCTION 3 RN CERTIFICATION LPN CERTIFICATION PROGRAM OBJECTIVES LEARNING MODULE OBJECTIVES SECTION I 5 VERTEBRAL COLUMN SPINAL ANATOMY Diagram EPIDURAL NEEDLE PLACEMENT Diagram EPIDURAL ANESTHESIA VS. ANALGESIA DERMATONES Diagram INDICATIONS / CONTRAINDICATIONS FOR EPIDURAL ANALGESICS SECTION II 10 SPINAL AND EPIDURAL MEDICATIONS ADVANTAGES OF OPIOID AND LOCAL ANESTHETIC EPIDURAL COMBINATION OPIOIDS LOCAL ANESTHETICS METHODS OF ADMINISTRATING MEDICATION FOR NEURAXIAL ANALGESIA PATIENT CONTROLLED EPIDURAL ANALGESIA (PCEA) SECTION III 13 RESPONSIBILITIES OF THE ANESTHESIOLOGIST PATIENT AND FAMILY TEACHING SECTION IV 15 ASSESSMENT OF PATIENTS RECEIVING EPIDURAL ANALGESICS PAIN CONTROL SEDATION SCALE / RESPIRATORY HEMODYNAMICS MOTOR STRENTH / SENSATION EMERGENCY SITUATIONS CATHETER MIGRATION POTENTIAL SIDE EFFECTS OF EPIDURAL/INTRATHECAL OPIODS POTENTIAL SIDE EFFECTS OF EPIDURAL LOCAL ANESTHETCIS SECTION V 24 GENERAL EPIDURAL CATHETERS AND SITE CARE PREPATION FOR STARTING AN EPIDURAL INFUSION MAINTINING AN EDPIDURAL INFUSION TITRATING A CONTINUOUS EPIDURAL INFUSION REMOVAL OF EPIDURAL CATHETER (RN SCC) REFERENCES 28 APPENDIX I APPENDIX II APPENDIX III REPLACING EPIDURAL CONNECTOR. CHECK CATHETER PLACEMENT ANTICOAGULATION GUIDELINES FOR NEURAXIAL OR PERIPHERAL NERVE PROCEDURES. ASRA (American Society of Regional Anesthesia) GUIDELINES GLOSSARY January 15,

3 INTRODUCTION Epidural opioids and local anesthetics have an important role in postoperative pain management for patients undergoing major surgical procedures. Anesthesiologists are responsible for the administration of opioids and local anesthetics for postoperative analgesia. Health Care Professionals (HCP) monitoring patients with an epidural require additional knowledge pertaining to epidural pumps, analgesia and anesthesia to safely care for these patients. RN certification includes: self-study package successful completion of a written exam demonstration of epidural pump programming successful demonstration of assessment, documentation, and verification of pump settings one satisfactory supervised demonstration of an epidural catheter removal in a simulated or clinical setting Only RN with SCC may; Initiate, titrate and change out medication with or without Patient Controlled Epidural Analgesia (PCEA) Remove an epidural catheter as ordered by Anesthesiology, ensuring that the American Society of Regional Anesthesia (ASRA) guidelines are followed for patients who are receiving anticoagulants. LPN certification to monitor includes: self-study package successful completion of a written exam successful demonstration of assessment, documentation, and verification of pump settings It is the HCP responsibility to maintain competency and skill level, to safely care for patients with epidural and spinal analgesia and anesthesia January 15,

4 PROGRAM OBJECTIVES HCP must have the knowledge and skill required to: Administer pharmacy prepared epidural opioids and local anesthetics through an indwelling epidural catheter (RN only) Assess and monitor patients receiving epidural opioids and local anesthetics through an indwelling epidural catheter Correctly perform verification of the settings in the infusion pump Identify the appropriate documentation required for analgesic administration and patient monitoring Identify and report abnormal findings to charge nurse or anesthetist, as appropriate LEARNING MODULE OBJECTIVES Health Care Professionals practice within their scope, as licensed by their professional body and Health Professions Act (HPA), and having completed program specific education The HCP will be able to: Describe the anatomy of the epidural space and the surrounding structures Differentiate between the following: o epidural analgesia and epidural anesthesia o epidural analgesia and intrathecal analgesia Identify the difference between lipophilic and hydrophilic opioids, along with the implications on drug action Describe the advantages of using epidural analgesics for postoperative pain management Recognize the indicators of catheter migration and the nursing actions required Discuss the responsibilities of the anesthesiologist in caring for the patient receiving an epidural analgesic Explain the expected action and possible side effects of epidural opioids and local anesthetics Differentiate between the monitoring requirements when a patient is receiving a combination of opioid and local anesthetic infusion with or without PCEA, an opioid alone, or a local anesthetic alone Describe or demonstrate the appropriate steps required for: o maintaining an epidural infusion o titrating an epidural infusion January 15,

5 Anatomy: The spinal canal contains the spinal cord (or cauda equina below L2), the cerebral spinal fluid (CSF), the membranes surrounding the spinal cord, and the epidural space. In adults, the spinal cord ends at L1-L2. Only the remaining nerve roots or cauda equina continue on and exit the spinal canal at the appropriate lumbar or sacral vertebrae. Vertebral Column Spinal Anatomy January 15,

6 The spinal cord, cauda equina and brain are surrounded by CSF and the entire contents are covered by a watertight fibrous membrane called the dura. This is the outermost of three membranes surrounding the spinal cord and brain. Outside the dura but still within the spinal canal is the epidural space. This space contains the spinal nerves as they exit, blood vessels, and fatty tissue. Epidural Needle Placement Neuraxial (Intraspinal): Neuraxial refers to spaces and potential spaces surrounding the spinal cord into which medications can be administered; i.e. epidural and (spinal) intrathecal / subarachnoid. Spinal Anesthesia: This is an injection of anesthetic solutions intrathecally into the subarachnoid space producing sensory, motor and autonomic blockade of the nerve roots and spinal cord. The anesthesiologist inserts a needle through the dura into the intrathecal (subarachnoid) space of the spinal cord. Local anesthetics are injected directly into the CSF to produce the desired nerve blockade. Opioids can also be injected intrathecally to produce analgesia post operatively; e.g. single shot morphine for longer action or fentanyl for short duration. Because of the proximity to the opioid receptors in the dorsal horn, very small doses of opioids are needed for control of pain. January 15,

7 Epidural Anesthesia: The anesthesiologist carefully introduces a needle through the thoracic or lumbar vertebral interspaces into the epidural space, but NOT through the dura and subarachnoid. Anesthetic solutions can be introduced into the epidural space. In addition, a small catheter can be passed and left in place for continued analgesia medications. Inadvertent dural puncture during insertion below L1 will not hit the spinal cord. At levels above L1, unintended dural puncture during catheter insertion carries a risk of spinal cord injury. Epidural Analgesia: The epidural catheter is threaded through a needle and into the epidural space. The needle is then removed and the catheter is taped to the skin, allowing analgesics to be administered during the postoperative period. The epidural catheter is placed as close as possible to the dermatomes that need analgesia following the surgical procedure. Medications diffuse through the epidural space, across dura mater into the CSF where they attach to opioid receptors in the dorsal horn of the spinal cord. Some of the medication is also absorbed by blood vessels and/or taken up by the fat in the epidural space. Epidural analgesia can be achieved with lower doses compared to systemic (IV) doses that are administered by anesthesiologist during anesthesia. Factors affecting the degree of dermatomal spread or the targeted amount of numbness of certain sensory nerves are: catheter placement, concentration of local anesthetics, and the lipid solubility of the opioid medications. The catheter typically stays in for hours and is removed by the RN with SCC following an order from the anesthesiologist. Prior to epidural removal, the RN with SCC must ensure that the ASRA guidelines are followed for patients who are receiving anticoagulants. January 15,

8 Dermatomes Used in the assessment of spinal and epidural anesthesia and epidural analgesia when local anesthetics are administered. Nerve roots in the spinal cord skin innervate the skin in continuous sensory bands that look like stripes. Each sensory stripe or dermatome corresponds to a specific nerve root. January 15,

9 Indications and Contraindications for Epidural Analgesics Advantages of Epidural Administration: excellent analgesia minimal sedation long duration of action facilitate early ambulation avoid repeated injections (I.M, S.C.) few hemodynamic effects Insertion of an epidural catheter would be contraindicated for the followingreasons: patient refusal known drug allergy coagulopathy (may be a risk of epidural hematoma) infection at the insertion site Possible contraindication (but not absolute) would include: presence of a spinal abnormality or injury sepsis hypovolemia neurological problems bowel perforations January 15,

10 Spinal and Epidural Medications -- Opioids and Local Anesthetics Both opioids and local anesthetics can be used alone or in combination for desired analgesic effect. Because the two classes of drugs work synergistically, they are often used together to treat acute pain. Advantages of Opioid and Local Anesthetic Epidural Combination better analgesic at lower doses than opioid alone fewer side effects improved GI function reduced cardiovascular, pulmonary and infectious complications better mobility, ( long term as well ) less nausea less fatigue decreased surgical stress response Opioids Opioids are defined as a naturally occurring, synthetic or semi-synthetic drugs exerting opium-like effects by attaching to special receptors in the spinal cord and brain with resulting pain relief. Opioids by any route work by attaching to special receptors in the posterior dorsal horn area of the spinal cord and are believed to inhibit release of a neurotransmitter called Substance P. As a result, the transmission of painful impulses upward to the brain is reduced or modified. Epidural opioids act primarily at the level of the spinal cord, and less so at the level of the brain stem. In this way epidural opioids can produce excellent analgesia with little associated sedation or respiratory depression. Over time, usually 4-6 hours (but as many as 12 hours) after injection, hydrophilic medications within the CSF slowly spreads toward the brain stem. At the same time the drug is absorbed into the blood vessels in the epidural space and circulated systemically. It crosses the blood brain barrier and potentially causes an increase in concentration in the CSF bathing the respiratory centre. Although rare, this delayed onset and slow progression of respiratory depression with excessive sedation must be anticipated. January 15,

11 The opioids used for spinal anesthesia / or epidural analgesics are: morphine hydromorphone (Dilaudid ) fentanyl (Sublimaze ) The onset and duration of opioid action will depend on the solubility property of the drug. Lipophilic or more fat-soluble opioids are absorbed quicker and have a shorter duration of action. Hydrophilic opioids are more water-soluble, thus have a slower onset but a longer duration of action. This will in turn affect how the drug will be administered and the duration of patient monitoring. Epidural Opioid Solubility Onset of Action Duration of Action morphine more hydrophilic minutes 6-24 hours hydromorphone more hydrophilic minutes 6-18 hours Fentanyl more lipophilic 5-15 minutes 2-4 hours Local Anesthetics In lower concentrations than given for spinal anesthesia, epidural local anesthetic act by blocking some impulses without blocking larger fibers that transmit motor functions. Ideally post surgical patients experience numbness over the surgical incision area but with little to no motor and sensation deficits to lower limbs. Therefore ambulation with less pain is possible. The epidural Local anesthetics most commonly infused for postoperative analgesia are: bupivacaine (Sensorcaine, Marcaine ) ropivacaine (Naropin) Local anesthetics are administered by an infusion pump for postoperative analgesia. In dilute amounts, an epidural local anesthetic can block painful sensory input at the nerve root prior to reaching the spinal cord. This will produce relief along the affecteddermatomes. Typically, there may be some numbness in and around the incision or targeted area. January 15,

12 Methods of Administering Medication for Neuraxial Analgesia The duration of pain anticipated is considered in determining the best method for pain control. 1. Clinician Administered Bolus Direct Intrathecal injection by an anesthesiologist Direct epidural injection by an anesthesiologist Epidural injection into an epidural catheter by anesthesiologist. (The disadvantage to this method is there is no steady level of analgesia long term. Peak and trough of side effects and pain) 2. Continuous Epidural Infusion Continuous rate delivered by infusion pump through epidural catheter 3. Patient Controlled Epidural Analgesia (PCEA) Patient uses a hand control to deliver a bolus dose via an infusion pump into the epidural catheter PCEA can be used alone or in conjunction with a continuous epidural infusion to supplement the basal rate The concept of patient controlled epidural analgesia (PCEA) has been adapted from intravenous patient controlled analgesia IV PCA. With PCEA, a basal infusion rate keeps the patient comfortable with analgesia, however, the patient can self-administer a bolus dose for breakthrough pain if the basal infusion is insufficient, for example when turning and ambulating. Advantages of PCEA: More timely pain relief More control for the patient Convenience for the nurse and patient to reduce the time required obtaining and administering required supplemental boluses January 15,

13 Inserting the epidural catheter Responsibilities of the Anesthesiologist Administering the first dose of epidural opioid Providing a written order for the opioid route, dose and frequency before the patient leaves the recovery room Patient specific blood pressure parameters must be ordered with local anesthetic Providing written orders for epidural infusions with or without PCEA, opioids alone, local anesthetic alone or combination of both - including titration rates and adjuncts as needed Being available for consultation if questions or problems develop (anesthesiologist on call) Monitoring the patient on a daily basis Ordering any supplemental systemic opioids. Patients on epidural opioids do not usually receive opioids by another route Provide a written order for removal of epidural catheter, noting specific instructions for patient on anticoagulant(s) If indicated, systemic opioids are ordered by the anesthesiologist and not by the attending service (exception is in critical care, the intensivist may order opioids in addition to anesthesiologist) Once the epidural catheter is removed, analgesic and adjunct orders can be obtained from the attending service unless otherwise indicated January 15,

14 Patient and Family Teaching The patient, family or significant other should be instructed about the use of intraspinal analgesic and/or anesthetic agents for pain management. The patient teaching should include instruction on: Catheter placement, purpose, and common complications that may be experienced and the need to immediately report complications Pain management regimen including action of intraspinal analgesic and/or anesthetic and side effects that may be experienced Need for immediate and early reporting of pain. Instruct the patient how to use a pain intensity scale to report the pain Need for immediate reporting of any side effects. Emphasize the importance of reporting any changes in respiration, level of sedation and movement or sensation in lower extremities Who will administer and monitor intraspinal medication Activity level. It is recommended that HCPs complete a functional assessment (see Appendix VII) prior to mobilizing patient. Due to the superior level of pain control that may be experienced with intraspinal narcotic and/or anesthetic, the patient may have a tendency to overdo activity. Caution patient to begin slowly and restrict patient's activity to that which is appropriate relative to the underlying condition. If a local anesthetic infusion is in use instruct the patient to obtain assistance with mobilization on the first time out of bed When intraspinal pain management is discontinued, prepare the patient for the variation in pain control that may be experienced during the transition (Olsson, leddo, & Wild, 1989) January 15,

15 Assessment of Patients Receiving Epidural Analgesics Specific monitoring is required for patients receiving epidural analgesics or spinal anesthesia. The monitoring required addresses the potential for side effects and depends on which analgesic or combination of analgesics used. The Adult Inpatient Pain Assessment and Analgesic Monitoring Flow Sheet is used to document the patients pain score, sedation scale, side effects, motor strength, sensation level and pump program. This form is to be added to the patient s chart when the epidural analgesic is initiated or if a spinal anesthetic has been given. Monitoring is based on the procedure VII-A-5, Assessment and Care of the Adult Following Surgery or Procedures Completed Under General, Intraspinal Anesthetic and / or Regional Nerve Block unless otherwise ordered. These are applicable for the use of a combination of an epidural opioid and local anesthetic per infusion with or without PCEA, epidural or intrathecal opioids alone, or epidural local anesthetic alone. For example, if an epidural infusion of combined Bupicavaine and Fentanyl were to be used, monitoring for both opioids and local anesthetics would be required, unless otherwise ordered by the anesthesiologist. 1.0 Pain Control -- Patient Assessment As pain is subjective it is recommended to obtain the patient s functional goal, a selfreport from the patient. You may use a visual analogue scale (pain ruler) if available or obtain a verbal report from the patient using a 0-10 numeric scale. Explain to the patient that 0 means no pain and 10 would be the worst pain imaginable. Ask the pain score at rest and during activity (e.g. coughing, ambulating). Remember that the number reported must be relevant to how the patient perceives that value. For example, some patients may consider a score of 5/10 too much pain while another may report being quite comfortable until 8/10. If possible, ask the patient to provide you with a number representing the level of pain that is no longer acceptable. This can be your reference to help evaluate the effect of the pain control provided. Patients must be comfortable enough to cooperate with care. The Functional Goal; the score in which the patient determines that they can ambulate comfortably, is documented on the Pain Assessment Flow Sheet at the top left corner. Inadequate analgesia Assess the level of pain during waking hours at least EVERY4 hours and proceed with nursing intervention. If the anesthesiologist has given a bolus dose of epidural local anesthetic, check the BP and pulse rate EVERY5 minutes x 3 times, then EVERY 15 minutes x 1 time (including a sensory level and motor function check at this time). If no problems are noted, resume the previous monitoring schedule. January 15,

16 2.0 Sedation Scale, Respiratory - Patient Assessment The patient should be easy to rouse (sedation score 2) and have a respiratory rate (RR) of at least 10 breaths/ minute. Note the depth of the respirations. If the patient is sleeping, he/she should respond to a gentle touch on the shoulder or being called by name. You do not need to fully waken the patient. As respiratory depression is often associated with increasing sedation, it is important to determine that the patient easily rouses. NOTE: Respiratory rate alone is not a reliable indicator of respiratory depression. Refer to the sedation scale when asked to assess the level of consciousness or provide a sedation score. Assess respiratory rate (RR) and sedation score according to guidelines for the Adult Inpatient Pain Assessment and Analgesic Monitoring Flow Sheet Those more at risk for developing respiratory depression are the elderly (especially after thoracic or upper abdominal procedures), any patient receiving systemic opioids (PO, IV, IM, SC), concurrent use of CNS depressants (drugs such as sedatives), or any patient becoming increasingly sedated (with or without increased respirations). When a patient is receiving epidural analgesia, orders for other analgesics and adjuncts must be ordered by Anesthesia / Intensivist. Ensure IV access, naloxone and oxygen is immediately available on the unit Keep these available following the last dose and for 24 hours after infusion of opioids is discontinued IF respiratory depression is suspected: Rouse the patient, encourage deep breathing, administer oxygen, raise head of bed, stay with the patient while someone calls Anesthesia, and administer naloxone (Narcan ) as ordered. (Check the epidural order sheet for a standing naloxone order.) If naloxone is needed, notify Anesthesia. Naloxone should be given slowly over two minutes while you observe the patient's response (it should be titrated to effect). If given too fast it can precipitate severe pain and increase sympathetic activity leading to hypertension, tachycardia, ventricular arrhythmias, pulmonary edema and cardiac arrest. A disadvantage of naloxone is that analgesia will also be reversed and pain will return. Naloxone is a short acting opioid antagonist. Observe for recurrent symptoms of respiratory depression beyond thirty minutes after drug is given. Refer to naloxone parenteral drug monograph. January 15,

17 3.1 Hemodynamics - Patient Assessment Take Blood Pressure and pulse according to the Adult Inpatient Pain Assessment and Analgesic Monitoring Flow Sheet - Guidelines. E.g. Intraspinal (CH-1344), Continuous Epidural (CH-1345) and Regional Nerve Block (CH-1346). Local anesthetics can block sympathetic nerve fibers as well as blocking sensory pain fibers. With sympathetic blockade, venous pooling of blood in the extremities can result in postural hypotension. Hypotension is accentuated if there is also a postoperative fluid volume deficit. If clinically significant hypotension occurs: Notify Anesthesia if: The patient is very dizzy, light-headed or faint More than a 30mm Hg drop in systolic BP A pulse that is less than or more than 25% from baseline A systolic BP of less than 90mm Hg or parameter ordered by anesthesia Hypotension bolus check Epidural Analgesia Patient Care Order. Frequently in post-operative patients the fluid balance is altered. Ongoing assessments of the intake and output are needed to determine the factors influencing a in BP &/or P. Opioid only epidurals do not often lead to hypotension look for other causes (i.e. hemorrhaging at surgical site) Ensure that ephedrine is immediately available on the patient care unit. This may be required for hypotension not resolved by fluid replacement. Ephedrine is a sympathomimetic drug used for severe hypotension. (See doctor s orders regarding administration.) Refer to ephedrine parenteral drug monograph. For the first ambulation, check the BP lying, sitting and standing allowing 3-5 minutes between position changes. Perform a functional assessment. Have the patient sit for a few minutes before changing positions and monitor for complaints of being dizzy, lightheaded or faint. If postural hypotension develops, lay the patient down, elevate the legs; if BP is still below parameters, call anesthesiologist. If the first ambulation is well tolerated, all three positional BP s do not need to be repeated. You would then resume regular blood pressure monitoring as ordered. If the local anesthetic infusion rate is increased or a bolus dose of local anesthetic is given by the anesthesiologist, check the BP lying, sitting and standing on next ambulation. January 15,

18 4.1 Motor Strength and Sensation -- Patient Assessment In most major nerve blocks, the autonomic nerve fibers affected - first to last - by local anesthetics are: 1) superficial pain 2) touch 3) temperature 4) motor function 5) pressure 6) proprioception (awareness of body or extremity position) Motor Strength Patients receiving an epidural local anesthetic may experience motor weakness and have difficulty with weight bearing. Review functional assessment prior to ambulation. Assess Motor Function according to the Adult Inpatient Pain Assessment and Analgesic Monitoring Flow Sheet Have the patient flex their knees and ankles and document on the Adult Inpatient Pain Assessment and Analgesic Monitoring Flow Sheet. If +3 motor block present, stop the local anesthetic infusion and contact the anesthesiologist. Assess motor function prior to ambulation using a transfer belt upon first ambulation and as necessary, two person standby. Sensation The sensory fibers for temperature are similar to the pain fibers and are affected by a local anesthetic. Document the levels of sensory block in relation to the affected dermatomes (see dermatome chart on the Adult Inpatient Pain Assessment and Analgesic Monitoring Flow Sheet) or describe in relation to some anatomical point in the nursing notes. The epidural order sheet will designate the acceptable level of sensory loss. This level may vary somewhat, depending on the level of catheter insertion. If numbness occurs in the face, neck, hands or arms, or exceeds the level designated on the order sheet; stop the infusion and notify Anesthesia. Excessive sensory block may interfere with cardiac and respiratory function. Reposition the patient frequently and observe for potential skin breakdown especially in pressure areas affected by the local anesthetic as the patient may have decreased sensation. There are slight variations of determining the sensory level between the Grey Nuns and the Misericordia, depending on Anesthesia preferences. January 15,

19 At the Grey Nuns Hospital to determine the level of sensory loss, use cold touch bilaterally (ice is recommended); alternating between the left and right side. Light touch with a cotton swab may also be used. Touch an area with the ice or swab where you would expect normal sensation (e.g. hand or face) and the patient should respond that it feels cold. Then starting above the targeted level of block, assess across bilaterally. Ask the patient to report any sensation changes or if sensation is no longer felt. The level at which perception changes is the upper level of sensory block. Then determine the lower level of the block on both sides using the ice or swab below the targeted area and working upwards until a change or absence in sensation is perceived. At the Misericordia Hospital to determine the level of sensory loss, use light touch with a cotton swab. The assessments are most accurately performed by assessing the entire right side and then the entire left side of the patient s body. Touch an area with the cotton swab where you would expect normal sensation (e.g. forehead or cheek). Then starting above the targeted level of the block, move down the dermatomes until the patient reports a change in the sensation. The level where the sensation changes is the upper level of the sensory block. To determine the lower level of the block, start the testing below the targeted area and work upwards until there is a change or absence of sensation. Move to the other side of the patient and test the dermatomes on that side of the body. Document the levels of sensory block in relation to the affected dermatomes (see dermatome chart on the Adult Inpatient Pain assessment and Analgesic Monitoring Flow Sheet. (CH 1343) or describe in relation to an anatomical point, (e.g. Mid-thigh). If the specific dermatome cannot be determined definitively, use ice to determine if the patient can recognize a change in temperature. However, if ice is used, document that in the nursing notes that was the method of testing. Emergency Situations: notify Anesthesia STAT! Initiate emergency measures O2, provide airway support if required elevate HOB monitor vital signs frequently initiate Code Blue response if required Rapid Decrease in Level of Motor Strength and Sensation Report any rapidly evolving neurological deficit to anesthesia immediately as this may be due to a neurological injury (egg. epidural hematoma) and is considered an emergency. Observations indicating a deficit may include: abnormal sensation, numbness, tingling, decrease movement, muscle weakness, or back pain. This needs prompt treatment to prevent permanent neurological damage. January 15,

20 Catheter Migration Always be alert for symptoms indicative of catheter migration. If you suspect catheter migration, stop the infusion, contact Anesthesia STAT and call Attending, RRT and/or Code Blue. 1) intravascular migration Local anesthetic infusing into a blood vessel could result in systemic toxicity and subsequent adverse effects; outlined in the table below Early Characteristics Mid-Characteristics Late Characteristics Metallic taste Tinnitus Dysphoria Confusion Agitation Dizziness Mouth numbness Somnolence which may progress to seizures Cardiac / Respiratory arrest Coma 2) intrathecal migration a rapid increase in motor weakness or sensory block. Doses of local anesthetic intended for epidural use would result in profound motor or sensory block if inadvertently administered into the intrathecal space January 15, 2018

21 Excessively High Sensory Block Excessively high sensory block may interfere with cardiac and respiratory function. POTENTIAL SIDE EFFECTS OF EPIDURAL / INTRATHECAL OPIOIDS Unwanted Effect Cause and Comments Assessment What to Report Respiratory Depression & Sedation Post-operative Nausea and Vomiting Pruritis Urinary retention A in rate & depth of respirations from baseline, rather than just a number. Sedation determine if caused by opioid, likely cause if just started on opioids or dose. Prolonged sedation can lead to respiratory depression. Action and duration of long acting opioids must be considered in monitoring patients. E.g. Morphine peaks about 12 hr post administration. Often considered to be as debilitating as pain. Slow steady titration helps nausea. Adjustments to diet and activity may be used. Relaxation techniques may help. Higher incidence with intraspinal morphine than other opioids. Thought to be due to cephalad migration of the opioid in CSF and interaction in the medulla. Sometimes generalized all over the body but can be localized on face and neck. Epidural analgesics delivered close to the dermatones near the micturation centre, located in the lumbar segments of the spinal cord. The combination of epidural local anesthetics and opioids can cause relaxation of the detrusor muscle. An opioid-induced increase in sphincter tone can make urination difficult. The central effects of Resp rate and sedation score; Q 30 min x 2 times Q 1 hr x 12 hr Q 2 hr x 12 hr Then Q 4 hr until 12 hr post last dose or discontinued Sedation scale: 0 = none (awake & alert) 1= mild (occasionally drowsy) 2 = moderate (frequently drowsy easy to rouse) 3 = severe (somnolent) S = sleep (normal sleep) Possibility of aspiration Tension on sutures Fluid and electrolyte imbalance intracranial & intraocular pressures If antihistamine (Benadryl) given monitor sedation scale as this can cause drowsiness along with the opioid Regularly assess for bladder distention; in and out or urinary catheterization if needed Resp rate less than 10 and decreased depth Difficult to arouse Sedation Scale greater than or equal to 2 Need for Naloxone notify Anesthesia Sudden change in sedation can be a sign of catheter migration. Notify anesthesia STAT Consider decreasing dose for prolonged sedation Antiemetics (monitor increased sedation) Consider decreasing the opioid dose Consider adjunct and Local Anesthetic for pain control Persistent urinary retention January 3,

22 opioids and motor and sensory blockade can interfere with perception of bladder fullness and the patient s attention to bladder stimuli. from McCaffery M., Pawero, C.: Pain: Clinical Manual, copyright 1999, Mosby, Inc. January 3,

23 POTENTIAL SIDE EFFECTS OF EPIDURAL LOCAL ANESTHETICS Unwanted Effect Sensory and/or motor deficit Cause and Comments Assessment What to Report Many factors, including vertebral location of the epidural catheter, local anesthetic dose, and variability in patient response, can result in patients experiencing unwanted sensory and/ or motor deficit. The lower the level of intraspinal catheter placement, the lower the affected dermatome. Sensory deficit: Do assessments according to guidelines and ordered parameters. Motor deficit: Perform functional assessments prior to ambulation. Complete assessments according to guidelines and ordered parameters. Ask patients to remain in bed if they are unable to bear weight. Provide assisted ambulation PRN. Complete loss of sensation in a skin area Muscle weakness, inability to move extremities or bear weight Numbness and tingling in areas distant to the nociceptive site Changes in sensory or motor deficit from last assessment (e.g. a lower location or increased intensity) Unresolved deficits after changes in therapy have been made Local Anesthetic toxicity Adverse hemodynamic effects (Hypotension) Toxicity can result from vascular uptake or injection or infusion of local anesthetic directly into the systemic circulation. Elderly patients may be at higher risk for toxicity from accumulation because most have a decreased ability to clear Local Anesthetics. Because Local Anesthetics block nerve fibers, they affect the sympathetic nervous system and cause vasodilatation. Mild hypotension is common. Some patients receiving intraspinal local anesthetics experience significant hypotention and bradycardia, especially when rising from a prone position or after large dose increases or boluses. Thoracic placement of the epidural catheter is associated with fewer hemodynamic disturbances. Assessments completed according to guidelines and ordered parameters. Assess for and ask patients about signs of local anesthetic toxicity: circumoral tingling and numbness, ringing in ears, metallic taste, slurred speech, irritability, twitching, seizures, cardiac dysrhythmias. Stop local anesthetic administration if signs are present. Regular assessment of HR and BP, including orthostatic blood pressure before ambulation until dose is stabilized and it is clear that bradycardia and hypotension are not problems. Signs of local anesthetic toxicity Symptomatic hypotension and/or bradycardia Persistent hypotension and/or bradycardia Symptomatic orthostatic hypotension May be duplicated for use in clinical practice. From McCaffery M, Pasero C: Pain: Clinical Manual, pp Copyright 1999, Mosby, Inc. January 3,

24 General Epidural Catheter and Site Care 1. Observe the dressing and area over the insertion site at least twice per shift and prn for presence of: signs of infection (inflammation, tenderness, purulent drainage) leakage of CSF or bleeding Ensure the tape is dry and secured Do not remove the tape or change the epidural dressing as the catheter is not sutured into place. Edges to the dressing or tape may be reinforced as needed. Don t dislodge catheter. Contact Anesthesia if any problems noted. Assess overall skin integrity particularly with patients experiencing decreased sensation. 2. The catheter should have a label EPIDURAL close to the injection port or clearly visible on the infusion tubing at all times. Use the epidural tubing recommended by the manufacturer of the pump with a 0.2 micron filter, without any additional injection ports. 3. A label with the date of tubing change should be on catheter tubing. Epidural tubing must be changed every 96 hours. 4. If the connector detaches and the end of the catheter is exposed, protect the end of the catheter immediately with sterile 4x4 gauze. Contact Anesthesiologist for further instructions. The anesthesiologist may request that the connector be replaced. RN SCC s certified for epidural analgesics can replace the connectors as per the procedure in the Appendix 1. The catheter may also be ordered to be removed. In that case, check the Anticoagulation Guidelines for Neuraxial or Peripheral Nerve Procedures; check the time the last dose of anticoagulant was administered. Catheter removal may need to be postponed to prevent potential bleeding. Note: Removal of the epidural catheter may be done by an; RN with SCC Anesthesia/Intensivist (usually 2-3 days after insertion) Note: Anesthesiology must provide a written order prior to the removal of the epidural catheter for all patients receiving anticoagulants. Follow the ASRA Guidelines (Appendix II) to determine when the subsequent doses of anticoagulants may be given. If there are any questions or concerns, contact Anesthesiology. January 3,

25 Preparation for Start of an Epidural Infusion on a Patient Care Unit Most times the epidural infusion will have already been initiated in the OR/RR. There may be occasions where this needs to be initiated on a general care unit. 1. Obtain an epidural pump and manufacturers tubing. The tubing should NOT have any extra injection ports 2. Label the infusion tubing with DATE and EPIDURAL tags (epidural tubing should be changed every 96 hours) 3. Check the epidural order and contact pharmacy for the medication bag if the anesthesiologist has not already prepared and labeled a solution bag (air should be removed during preparation of the bags) 4. The RN may initiate infusion and/or change the premixed medication bag following the test dose given by anesthesia and written orders. HCP performing within their scope must perform an Independent double-check and sign with initiation, solution change or rate change. RN SCC check catheter placement prior to initiation (refer to Appendix I) and document on the patient record 5. Documentation on the Adult Inpatient Pain Assessment and Analgesic Monitoring Flow Sheet include Initial Set Up; Drug, Concentration, Pump #, Start Date / Time 6. The Medication Administration Record (MAR) to be signed by both the nurse initiating and the nurse completing the independent double check Maintaining an Epidural Infusion As defined by post-surgical epidural policy, RN SCC s may administer analgesics per epidural infusion by attaching a prepared medication bag and adjust the rate of the infusion as ordered by Anesthesia. Loading doses through the pump are only given by Anesthesia & RN SCC in Post Anesthetic Recovery Room 1. At the start of each shift, verify and review the pump program by checking that the Medication bag label matches the information programmed into the pump and the patient care order i.e. Prescribers original order or documentation recorded on the Pain Assessment Flow Sheet 2. Check to see if the pump is running and that all connections are secure. Check the epidural line is labelled with Epidural, High Alert and Date labels 3. Check the epidural site, looking for any problems such as CSF leakage, every8h adorn 4. Document pain assessment, record drug, rate, cumulative volume and dose taken (shift total) absorbed on the Adult Inpatient Pain Assessment and Analgesic Monitoring Flow Sheet 5. Change the tubing and the medication bags every 96 hours as required. All epidural January 3,

26 medication bags should be checked for correct, drug, dose and expiry date. Attaching a new infusion bag requires resetting the reservoir (bag) volume as per pump instructions. Document the changes on the Adult Inpatient Pain Assessment and Analgesic Monitoring Flow Sheet 6. Titrate the infusion rate as ordered by Anesthesia. HCP must co-check and co-sign changes made to the pump programming and document this on the Adult Inpatient Pain Assessment and Analgesic Monitoring Flow Sheet 7. When dose is adjusted, HCP must revert back to initial monitoring schedule 8. Continue to monitor the patient for any adverse effects or uncontrolled pain 9. Assess and document infusion, cumulative and dose taken (shift total) of epidural and PCEA amounts Titrating a Continuous Epidural Infusion 1. In the presence of uncontrolled pain, consider the following: check to see if the pump is operating and if there are any kinks or leaks in the tubing assess the insertion site for any possible problems presence of postoperative complications such as DVT or compartment syndrome requiring treatment of another nature 2. Assess the patient for presence of side effects relevant to the type of analgesic(s) infusing: for infusions containing an opioid check the respiratory rate and sedation score for local anesthetic infusion, check the BP, pulse, motor function and sensory level If any findings are not within the acceptable values, notify the anesthesiologist and do not proceed Identify if adjunctive medications have been administered (e.g. anti-inflammatory, acetaminophen). If not, administer them as ordered and consider their use more regularly if ordered on a PRN basis You may also choose to increase the infusion rate as ordered by the anesthesiologist. Note: Do NOT titrate more often than every 60 minutes (see epidural patient care orders) Staff must revert back to initial monitoring schedule If the infusion is already at the maximum rate, contact the anesthesiologist Refer to the epidural order sheet for further titration information (e.g. time intervals between infusion increments) Document the programming changes on the Adult Inpatient Pain Assessment and Analgesic Monitoring Flow Sheet. An independent double check by a second RN SCC is required. Repeat as required January 3,

27 Removal of Epidural Catheter; RN SCC only NOTE: Orders to remove epidural catheter must be written by the Anesthesiologist. Prior to the removal of the epidural. Review relevant lab results; i.e. platelets, PT, PTT; and anticoagulants must be identified. Follow ASRA guidelines or anesthesiologists order 1. Place patient in lateral fetal or sitting up position. (Hint: Ask patient what position they were in during insertion) 2. Cleanse insertion site with an alcohol free Chlorhexidine solution or povidine iodine or betadine 3. Let site dry for two minutes 4. Wipe area with a sterile 2x2 gauze 5. Pull out catheter using slow continuous pressure and apply steady pressure around site while withdrawing catheter If catheter is difficult to remove have patient arch back If catheter will not move or patient reports pain or resistance is felt, call Anesthesia 6. Check catheter tip is intact, witnessed by a second HCP and include in documentation If catheter or tip not intact call Anesthesia 7. Apply a band aid to the insertion site the site should be checked after catheter removal for oozing, hematoma at the site: o 15 minutes o then 30 minutes o Notify anesthesia if large amounts of oozing or hematoma develops 8. With patient explain there is a low risk of side effects of spinal anesthesia on removal of epidural. Discuss signs and symptoms of: o epidural hematoma e.g. Confusion, altered LOC, weakness on one side o dural leak. Patient may complain of a frontal or occipital headache that is aggravated when upright. A dural blood patch is often performed by the anesthesiologist as treatment 9. Document procedure, patient education, including and contact with anesthesia Independent Double Checks and Verification Two RN s are required to complete an independent double check when the epidural is initiated or titrated An LPN can be a second check and verifier when the epidural is already infusing; such as when coming on shift and checking an existing pump infusion Epidural removal is only performed by an RN with SCC in this skill. RN to check and 27 document black tip is intact on removal

28 REFERENCES A Self -Directed Learning Module Third Edition Epidural Analgesia, University of Wisconsin Hospitals and Clinics Madison, WI. 2000, UW Hospital and Clinics Authority Board. Canadian Anesthesiologist s Society (1998) Guidelines for the Use of Neuraxial Opioids and Continuous Epidural Infusion of Local Anesthetics and Opioids for Acute Pain Management Draft #3, June 8. Canadian Anesthesiologist s Society (2001) Consensus-Based Guidelines for Acute Pain Management using Neuraxial Analgesia. Caritas Health Group (2000) The Basics of Epidural/Spinal Analgesia: Module A and Module B. Capital Health Authority & Caritas Health Group (1997) Regional Analgesia/Anesthesia Learning Module. D'Arcy, Y., Using Thoracic Epidural Catheter for Pain Management. Nursing 2004, Vol 34, No.9. pp 18. rd Drain C. (1994) 3 Ed. The Post Anesthesia Care Unit A Critical Care Approach to Post Anesthesia Nursing. W.B.Saunders Co. Philadelphia,PA. Forrest, J. (1998) Acute Pain: Pathophysiology and Treatment. Manticore Publishers. Gustafsson, U. Scott, M. Schwenk, W. Demartines, N. Roulin, N. Francis, N. McNaught, C. MacFie, J. Liberman, A. Soop, M. Hill. Kennedy, R. Lobo, D. Fearon, K. Ljungqvist, O. (2013). Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS ) Society Recommendations. World J Surg. Vol 37. P Hambleton, N. (1994) Dealing with the Complications of Epidural Analgesia. Nursing 94, October, p Kreger, C. Spinal Anesthesia and Analgesia. Nursing Management. Jan pp31 th 37. Litwack, K. Ed. (1999) 4 Ed. Core Curriculum for Perianesthesia Nursing Practice. W.B.Saunders Co. Philadelphia,PA. McCaffery, M and Pasero, C. (1999) Pain Clinical Manual, Second Edition. Mosby, Inc. McCaffery, M and Pasero, C. (1999) Providing Epidural How to Maintain a Delicate Balance. Nursing 99, Aug. pp McNair, N. (1990) Epidural Nagelhout, J. Sass, E. Plaus, K. (2013) 5 th Ed. Nursing Anesthesia. Elsevier Health Sciences. Canada. January 3,

29 Narcotics for Postoperative Pain: Nursing Implications. Journal of Neuroscience Nursing, Vol. 22, #5, p Pasero, C. Epidural Analgesia for Postoperative Pain. AJN Oct 2003, Vol. 103, No. 10 pp Pasero, C. Epidural Analgesia for Postoperative Pain, Part 2. AJN Oct 2003, Vol. 103, No. 11 pp University of Alberta Hospital Site (1992) Certification Program for the Administration of Morphine Through a Percutaneous Epidural Catheter by Specially Trained Registered Nurses. Capital Health Authority. University of Alberta Hospital Site (2001) Certification Program for the Administration of Post- Operative Analgesics Through a Percutaneous Epidural Catheter by a Registered Nurse with Specialized Clinical Competency. Capital Health Authority. Wild, L & Coyne, C. (1992) The Basics and Beyond: Epidural Analgesia. American Journal of Nursing, April, p Snap-lock Adapter. Picture downloaded on Feb 5 th, From: &tbo=u&source=univ&sa=x&ved=0ahukewi_pu3oxehkahxmnjqkhcgnd1oqsaqimw&dp r=1#tbm=isch&q=epidural+snaplock+adapter&imgrc=qywe_6rtlzf3lm%3a Pictures of spinal Anatomy, spinal dermatomes, epidural injection. Downloaded on May 25, From: (n.d.) January 3,

30 1. Replacing Epidural Connector Anesthesia must be notified for an order to replace epidural connector If the connector on the catheter slips off, you must first protect the catheter end with a sterile 4x4 gauze to prevent contamination. Obtain a new connector from Recovery Room or from Epidural Tray. Swab the distal 5 cm of the catheter with a povidine iodine or betadine swab. Let dry for 2 minutes. Using sterile scissors cut 4-5 cm off the end of the catheter. Using aseptic technique put the catheter into the connector as per package instructions. It is not necessary to clamp the catheter while changing the injection cap or connector. Recovery Room will have epidural SnapLock Adapters 2. Check catheter placement: Use an empty 3mL syringe, enter the injection port and aspirate to check for fluid return to verify catheter placement. Remember that movement by the patient may cause the catheter to migrate into a blood vessel within the epidural space or puncture through the dura and unintentionally move into the intrathecal space (into CSF). When aspirating, little or no fluid should return. A small amount of clear return (less than 0.5mL) may be due to residual medication left in the catheter. Aspirate slowly, observing for the amount of clear fluid return. Take enough time to ensure that clear fluid does not continue to flow into the syringe! Abnormal findings during aspiration would be a continued flow of clear fluid greater than 0.5mL indicating catheter migration into CSF or a sanguineous return signaling catheter migration into a blood vessel. If either of these occur, stop and notify the anesthesiologist. Do not re-inject the fluid withdrawn, as this will be saved to show the anesthesiologist. Do not inject the epidural medication. Note: If epidural is ordered not to be used and capped. Cover cap with an occlusive dressing, such as a hydrocolloid and label, Do Not Use. January 3,

31 APPENDIX II ANTICOAGULATION GUIDELINES FOR NEURAXIAL OR PERIPHERAL NERVE PROCEDURES NEURAXIAL BLOCKS (Spinals, Epidurals) and Anticoagulant Therapy Adapted from the American Society of Regional Anesthesia and Pain Medicine Consensus Conference, April 2002 NOTE: Concurrent use of two or more drugs from the list INCREASES THE RISK OF BLEEDING COMPLICATIONS. For example; a patient on LMWH + Aspirin, or a patient on Plavix (clopidogrel) + Coumadin (warfarin) is at increased risk compared to either agentalone. WHEN CAN YOU SAFELY DO NEURAXIAL / PERIPHERAL NERVE PROCEDURES OR GIVE ANTICOAGULANTS? Neuraxial routes include; epidural and intrathecal infusion, implanted intrathecal pumps, and spinal injections Peripheral routes include all peripheral nerve and plexus infusions NOTE: If blood tap / procedure, follow specific instructions from Anesthesia Risk in this document refers to the risk of spinal hematoma (add signs and Sx and consequences) NAT Neuraxial Techniques (i.e. epidurals, spinals) LA Local Anesthetic Prophylactic Dose LMWH = Enoxaparin (Lovenox) 30 mg sc q12h, Dalteparin (Fragmin) 5000 U sc qd, Tinzaparin (Innohep) U/kg sc qd, sc qd Treatment Dose LMWH = Enoxaparin (Lovenox) 1 mg /kg sc q12h or 1.5 mg/kg sc qd, Dalteparin (Fragmin) 120 U/kg sc q12 h or 200 U/kg sc qd, Tinzaparin (Innohep) 175 U/kg sc qd January 3,