CLINICAL GUIDELINES ID TAG Epidural Guidelines Dr Damian Scullion and Sr Jane Doyle Speciality / Division: Anaesthetics

Transcription

1 CLINICAL GUIDELINES ID TAG Title: Epidural Guidelines Author: Dr Damian Scullion and Sr Jane Doyle Speciality / Division: Anaesthetics Directorate: ATICS Date Uploaded: 9 th November 2015 Review Date 5 th January 2017 Clinical Guideline ID CG0191

2 Epidural Guidelines SHSCT DR D. Scullion and Jane Doyle Acute Pain Sister 06/01/2014 1

3 Epidural Analgesia Epidural Analgesia is available for postoperative analgesia following major surgery. This is an effective analgesic technique which is not without potential for major adverse complications. All staff involved in the care of patients with epidural analgesia must have appropriate training and guidance to ensure safe delivery and management of these patients. Epidural guidelines provide information on the best practice for the management of epidural analgesia in the adult patient. Epidural analgesia is available for adult patients in the following areas in SHSCT; ICU CAH Recovery/HDU CAH 4 South-Progressive Care Ward CAH 4 North Emergency 3 South Orthopaedic and Trauma Wards Delivery Suite CAH and DHH HDU DHH Definition Epidural analgesia is a superior method of providing sustained and effective pain relief following surgery such as thoracic, orthopaedic surgeries, major abdominal procedures, and in Childbirth. Patients with epidural analgesia can be safely managed at ward level provided that the staff has been appropriately trained and patients are closely monitored. Serious adverse effects such as epidural haematoma are rare but close monitoring should ensure early detection and appropriate intervention. Standardisation of delivery pumps, analgesic prescription, pre-filled local anaesthetic solutions and patient monitoring will optimise patient care and safety. 2

4 Rationale: Promote safe and effective analgesia Objectives: To standardise clinical practice in the provision of epidural analgesia To ensure implementation of the NI recommendations in relation to NPSA alert 21 To deliver safe and effective analgesia Epidural analgesia provides superior pain relief, with improved pulmonary function and earlier return of bowel habit, following some surgical procedures and for certain patients. Indications: Surgery: Thoracic surgery Abdominal and colorectal surgery Lower limb orthopaedic surgery Major vascular surgery, e.g., aortic aneurysm repair Major Urological procedures, e.g. Nephrectomy or Cystectomy Childbirth Trauma: Rib fractures Flail chest Other: Ischaemic pain prior to leg amputation Terminal Illness CONTRAINDICATIONS: Patient refusal Septicaemia Sepsis in planned site of epidural insertion Coagulation disorders- DIC, thrombocytopenia, moderate to severe haemophilia Severe liver disease 3

5 Therapeutic heparinisation Allergy to local anaesthetic Head injury or other medical/drug-induced CNS depression ESTABLISHMENT OF EPIDURAL ANALGESIA The patient must be aware of the options and risks involved with this procedure, and verbal consent obtained by the Anaesthetist prior insertion. Epidural analgesia is established using aseptic technique and only in the following areas: Theatre Recovery area Intensive care An epidural catheter must be inserted by: A Consultant Anaesthetist An Anaesthetist in Training with adequate skills in epidural analgesia Patients must be monitored during epidural insertion and establishment of analgesia. Preparation of Epidural Pumps The Details of the Epidural infusions must be prescribed by an Anaesthetist. An epidural pump may be prepared for use by the following personnel. Acute Pain Team General Recovery trained nursing staff Trauma and Orthopaedic Recovery trained nursing staff ICU trained nursing staff Anaesthetists Preparation and commencement of an Epidural solution/infusion should involve two qualified practitioners. The practitioners should confirm the correct product and line connection have been selected and prepared, and the administration method is correct. 4

6 Dressings The epidural catheter should be held in place with a transparent dressing to allow view of the insertion site, e.g. IV HAND This should only be re-dressed if: Dressing has rolled up and exposed insertion point. Catheter distance to skin has been altered by an Anaesthetist or a member of the Acute Pain Team on Anaesthetist instructions. Dressing should be renewed using aseptic technique. (See Procedures) PRE-FILLED BAGS Pre-filled bags are ordered from pharmacy and stored as per NPSA 21 guidelines in all area where Epidural Analgesia Patients can be cared for. Refer to NPSA guidance on storage of these solutions (1). N.B. No additional drugs should be added to these pre-filled bags. PUMPS FOR EPIDURAL ANALGESIA (CADD Solis Pump) A dedicated lockable and programmable device must be used for epidural analgesia. This pump must NOT be used for any other purpose (NPSA 21) The pump and the extension line must be connected to an epidural catheter via a bacterial filter, this should be clearly labelled as "For Epidural Use Only. The label should be coloured yellow with black text. The pump must only be programmed for epidural infusion by an anaesthetist, a recovery nurse or a pain control nurse who have been trained and deemed competent in the use of the dedicated pump and epidural analgesia. Refer to manufacturer documentation for programming. All pre-filled bags for epidural use should be labelled with a patient identifier i.e. addressograph label and signed by those preparing the infusion. PRESCRIPTION FOR EPIDURAL ANALGESIA 5

7 Three ready mixed solutions for use in epidural infusions are available: 1. Levobupivacaine 1mg/ml with 2 mcg/ml Fentanyl, 250ml bags. 2. Levobupivacaine 1.25mg/ml, 200ml bags. 3. Levobupivacaine 1mg/ml with 5 mcg/ml Fentanyl, 250ml bags. The Epidural solution must be prescribed on the patient s drug chart in accordance with NPSA 21(2007), to include the following: Concentration of levobupivacaine (%) in Normal saline Concentration of Fentanyl (mcg / ml) Total volume in the reservoir bag (`100,200ml or 250 ml) Initial infusion rate e.g. 5 ml/hr Infusion rate range allowed, e.g ml / hr Examples Continuous EPIDURAL infusion prescription LEVObupivacaine 1mg/ml (0.1%) + FENTANYL 2 microgram/ml Sodium chloride 0.9% Start rate. ml/hour Rate (Range).... ml/hour PCEA / Bolus (circle).... ml 250ml infusion Lockout... minute Signature (sign over sticker and Kardex & print name) Start date Stop date Signature Administration: Record of new infusion bag commenced Date Time Volume Rate Pump ID number Signatures Record rate and volume administered at each check, rate change or bolus on epidural section of MEWS Continuous EPIDURAL infusion prescription LEVObupivacaine 1.25mg/ml (0.125%) Sodium chloride 0.9% Start rate. ml/hour Rate (Range).... ml/hour PCEA / Bolus (circle).... ml 200ml infusion Lockout.. minute Signature (sign over sticker and Kardex & print name) Start date Stop date Signature Administration: Record of new infusion bag commenced Date Time Volume Rate Pump ID number Signatures Record rate and volume administered at each check, rate change or bolus on epidural section of MEWS Continuous EPIDURAL infusion prescription Administration: Record of new infusion bag commenced 6

8 Start rate LEVObupivacaine 1mg/ml (0.1%) + FENTANYL 5 microgram/ml Sodium chloride 0.9%. ml/hour Rate (Range).... ml/hour PCEA / Bolus (circle).... ml 250ml infusion Lockout.. minute Signature (sign over sticker and Kardex & print name) Start date Stop date Signature Date Time Volume Rate Pump ID number Signatures Record rate and volume administered at each check, rate change or bolus on epidural section of MEWS The prescribing anaesthetist must also document the following: 1. Level of epidural catheter insertion e.g. L 3/4 2. Distance from skin to epidural space e.g. 5 cm 3. Length of catheter in the epidural space e.g. 2-3 cm This information can be found on the patients anaesthetic record. EPIDURAL SOLUTIONS These are supplied in terminally sterilised infusion bags. These solutions have been approved by SHSCT s Drugs and Therapeutics Committee for continuous use. Combined use of low concentration of local anaesthetic agents and opioid has been shown to provide consistently superior pain relief compared with either of the drugs alone. These pre-prepared bags must be labelled with a yellow sticker with black writing FOR EPIDURAL USE ONLY (NPSA 21) The choice of these solutions is based on efficacy and commercial availability. If an epidural catheter is inserted at an appropriate vertebral level and an appropriate volume of solution is infused, levobupivacaine 1mg/ml with 2 mcg/ml Fentanyl is sufficient to provide good to excellent analgesia for the majority of patients. 7

9 A dedicated pump (CADD-Solis Pump) will be used for epidural analgesia. The epidural line will have a yellow strip and be clearly labelled with a yellow sticker with black writing FOR EPIDURAL USE ONLY (NPSA 21) Each day the Patients with epidural infusions must be reviewed by The Acute Pain Team, the Anaesthetist on call. Or the ICU Team. As a rough guide the average volume of this solution required to maintain analgesia is 10mls/hr. If this solution provides acceptable block height, but inadequate block density, then a solution of plain levobupivacaine may be considered and a PCA (Patient controlled Analgesia) prescribed to run concurrently. The Acute Pain Team liaises with the Anaesthetist to facilitate prompt changes in the required treatment for each patient. (Bleep 1710) Storage of Epidural Solutions: Levobupivacaine 1mg/ml and Fentanyl 2mcg/ml (250mls) should be in a separate control drug cupboard. Levobupivacaine 1mg/ml and Fentanyl 5mcg/ml (250mls) should be in a separate control drug cupboard. Plain levobupivacaine 1.25mgs/ml (200mls) should be stored separately from intravenous fluids in all areas. A separate controlled drug register is available for epidural solutions containing opioids. (NPSA 21 (2007)) PATIENT MONITORING 8

10 Only Registered Nurses must undertake monitoring of patients with Epidural infusions Observations for patients with epidural infusions include: i. AVPU (Tick and score as per Trusts NEWS chart) ii. Respiratory Rate (Record value and score as per Trusts NEWS chart) iii. Pulse Rate (. And score as per Trusts MEWS chart) iv. Blood Pressure (Record and score as per Trusts NEWS chart) v. Temperature (Record and score as per Trusts NEWS chart) vi. Oxygen Device e.g. Nasal specs(n/s), Rusch, Face Mask(F/M), Room Air (R/A) vii. Oxygen Delivered e.g. In litres for N/S, Litres or % F/M. % for Rusch viii. Oxygen Saturation e.g. % as per monitor ix. Nausea Score (0-3 as per Trusts Observation chart) x. Pain Scores on Movement and Rest (0-3 as per Trusts observation chart) The Following observations are recorded on a Supplementary Epidural record sheet xi. Sensory Block Right and Left side (Normal,Weak,Absent) xii. Motor Block Right and Left side (Normal,Weak,Absent) xiii. Site checks. Tick when satisfactory. * - see notes. N/A- not applicable. xiv. Rate of infusion (mls as per pump) xv. Total Volume infused (mls as per pump) xvi. Volume in mls of any Bolus administered by Anaesthetist or Acute Pain Team xvii. Pressure areas must be closely monitored and findings documented in patients nursing notes. A patient must be monitored every 15mins for at least 1 hour 1 hourly for 4 hours 9

11 2 hourly thereafter If stable commence 4 hourly observations (or as per NEWS frequency) Following Rate Increase or Bolus Recommence observations to 15mins for 1 hour If stable 4 hourly or as per MEWS frequency All Registered Nurses must have attended training in pain and pump management before undertaking responsibility for these patients (NPSA 21). PATIENT TRANSFER BETWEEN DEPARTMENTS Both nurse transferring responsibility and nurse accepting responsibility for the patient must verify and record this information in the patients nursing notes or the relevant transfer documentation (NPSA 21). This information should include: 1. Epidural is prescribed correctly 2. Pump setting and ID no. are verified and recorded 3. Volume of drug infused / remaining is documented IV access must be maintained throughout the duration of epidural analgesia. Oxygen must also be available. Naloxone must be readily available. Anti emetics should be prescribed. Adjunct analgesia e.g. IV paracetamol should be prescribed. Observations must be clearly recorded on the Trusts EWS chart and The supplementary Epidural record sheet. Qualified nursing staff ONLY must record EWS and related observations on these patients. CARE OF THE PATIENT WITH EPIDURAL ANALGESIA 10

12 Patients with epidural analgesia should be nursed in:- Intensive Care Recovery/High dependency Unit Surgical Ward 4 North and 4 South, 3South and Orthopaedic and Trauma Ward with adequate nursing levels, where nursing staff deemed competent in the care of patients with epidural analgesia are on duty in a 24 hour period. Patients with epidural infusions should be nursed in close proximity to the nursing station or in exceptional circumstances as indicated by the prescribing Anaesthetist. Ward nurses that have been trained and deemed competent in the use and care of epidural analgesia can increase or decrease the delivery rate of the epidural infusion within the prescription range. All adjustments must be verified and recorded by a second competent nurse or doctor. Epidural insertion site, sensory block and motor function must be monitored and findings documented for at least 24 hours after removal of the epidural catheter. Any persistent or new deterioration in motor function or skin insertion site abnormality must be reported immediately to the Acute Pain Team or Anaesthetist on call. EPIDURAL BOLUS ADMINISTRATION There are two techniques by which local anaesthetic +/- an opioid can be administered by the epidural in situ. 1. Bolus administered via the epidural pump using the prescribed solution titrated up to a maximum of 10mls. 11

13 2. Top-up using an ampoule of a more concentrated local anaesthetic solution and / or an opioid. The following people are permitted to administer a Bolus (1) Anaesthetists Acute Pain Sisters Recovery Staff Intensive Care Unit Staff The following people are permitted to administer a Top-up (2) Anaesthetists INDICATIONS FOR EPIDURAL BOLUS ADMINISTRATION Missed segment Sensory blockade below level of wound Unilateral blockade Pain score unacceptable Re-establishment of epidural analgesia REMOVAL OF EPIDURAL CATHETER Should be coordinated by the Acute Pain Sister No epidural catheter should be removed without considering when anticoagulants were last administered. Appropriately experienced nursing staff are encouraged to remove epidural catheters once the epidural infusion has been discontinued. Ideally an epidural should be removed between 10.00hrs and 14.00hrs. If after 14.00hrs administration time of anticoagulant should be adjusted to ensure 8 hours have elapsed since removal of epidural. 12

14 In general terms this should be viewed as equivalent to changing a wound dressing with similar preparations made and sterile precautions taken. (See Procedures) The epidural catheter should not be removed if; 1. The patient has an abnormal coagulation screen or low platelet count (<80,000). 2. The last dose of prophylactic Enoxaparin was administered less than 8 hours ago. 3. The patient has a suspected postdural puncture headache. 4. The patient has a suspected epidural haematoma. 5. If the patient is on Enoxaparin 40 mgs twice daily, then catheter should be removed 24 hours following administration of the last dose. The next dose of Enoxaparin should be delayed for at least 4 hours after catheter removal. If in doubt seek advice from Acute Pain Team/ Anaesthetist on call. ACCIDENTAL REMOVAL OF EPIDURAL CATHETER If this occurs in close proximity of last dose of Enoxaparin the patient should be closely observed for any signs of epidural haematoma. NB: Motor and sensory blockade must be assessed at 2 hourly intervals for 12 hours after removal of the catheter. LEAKING/PARTIAL DISLODGEMENT EPIDURAL CATHETER If this occurs and analgesia is satisfactory the epidural infusion can be continued provided that there is no evidence of local infection or risk to the surrounding skin. If analgesia is 13

15 inadequate, alternative analgesia should be promptly implemented and the catheter removed at an appropriate time (re: last dose of Enoxaparin). Analgesia should be adjusted appropriately following discontinuation of epidural analgesia. DISPOSAL OF EPIDURAL SOLUTION When the epidural is being disposed of the volume remaining in the bag should be recorded and verified by two competent nurses and recorded (as per Hospital Policy for Disposal of Opioid ) in the wards Controlled Drug Record Book. Disposal should comply with hospital protocol. The pump should be cleaned and returned to Hospitals main Recovery Unit. COMPLICATIONS ASSOCIATED WITH EPIDURAL ANALGESIA Respiratory depression- Inform Anaesthetist/ DR have Naloxone ready. Nausea and vomiting - Give anti emetic. Hallucinations -Omit opioid from epidural. Pruritis - Consider use of Chlorphenamine. Urinary retention - Patient is usually catheterised for duration of infusion, once epidural is removed and catheter removed observe and record urinary function. Other complications include: Hypotension Bradycardia Epidural Catheter Migration Local anaesthetic toxicity Total Spinal Postdural puncture headache Epidural haematoma Epidural abscess 14

16 HYPOTENSION Definition: Unacceptable reduction in systolic or mean arterial blood pressures. Usually defined as fall of over 20% from pre-operative values or systolic pressure below the level expected for the age and condition of patient. Background: Epidural analgesia causes vasodilation in any area of the body where there is analgesia. Usually this vasodilation benefits the patient by improving blood flow and reducing the risk of venous thrombosis If the vasodilation caused by the epidural causes hypotension, then logically the only treatment required should be to increase the intravenous fluids. However: In some patients excess intravenous fluid may lead to pulmonary oedema. Prolonged low blood pressures may place newly formed bowel anatomises at risk of ischaemia. IT IS NOT THE ROLE OF THE ACUTE PAIN TEAM TO INFLUENCE THE FLUID MANAGEMENT OF SURGICAL PATIENTS. Stopping the epidural infusion will cause a rise in blood pressure as the patient begins to experience pain. It will take at least an hour for the epidural to start to wear-off and for the blood pressure begin to rise. Stopping the epidural should only be a last resort. If the surgical team are concerned that the blood pressure is too low, despite what they consider adequate fluid resuscitation, Anaesthetist on call should be contacted. Stop epidural. Contact Anaesthetist on call Bleep 1130 Possible causes: Hypovolaemia (dehydration, haemorrhage) Change in posture e.g. sudden change from supine to sitting position High / extensive epidural block 15

17 Epidural catheter migration into subdural (intrathecal) space Epidural catheter migration into a blood vessel Sepsis MANAGEMENT OF HYPOTENSION (N.B Keep the bed flat, do not apply foot up tilt) 1) Stop epidural infusion if patient is symptomatic 2) Place patient supine or in the lateral recovery position if there is any concern about the patient's airway or level of consciousness is depressed. 3) Rapidly infuse mls of colloid? 4) Give 100% O2 by face mask 5) Have EPHEDRINE at patient's bedside (with 10 mls water for injection) 6) Get Medical Assistance, i.e. ward doctor and/or on-call anaesthetist Bleep ) Monitor the following: blood pressure, pulse, respiratory rate, AVPU (conscious level) every 5 minutes until there is sustained improvement in blood pressure and level of consciousness. BRADYCARDIA This may occur when local anaesthetic given by thoracic epidural blocks the cardio-accelerator fibres (T2-6). Bradycardia requires treatment if it is associated with hypotension or patient symptoms of postural hypotension dizziness, light-headedness, nausea. MANAGEMENT OF BRADYCARDIA 1. Stop epidural infusion 2. Place the patient supine or in recovery position 3. Have atropine mcgs ready to give IV if blood pressure does not improve or the patients symptoms worsen. 4. Contact Acute Pain Team and/or Anaesthetist on call for further management. It may be feasible to continue epidural analgesia at a lower infusion rate. 16

18 EPIDURAL CATHETER MIGRATION This should be suspected if the patient develops; Severe hypotension. Signs of local anaesthetic toxicity. Breathing difficulties. Extensive sensory and profound motor block. MANAGEMENT OF SUSPECTED CATHETER MIGRATION 1. Stop the epidural infusion 2. Contact the Anaesthetist on call and Acute Pain Team immediately. LOCAL ANAESTHETIC TOXICITY This can occur if the epidural catheter migrates into an epidural blood vessel or an excessive dose of local anaesthetic is given for epidural top-up. Symptoms of local anaesthetic toxicity include patient awareness of the following: Metallic taste in mouth or circum-oral numbness Anxiety Dizziness Shaking / shivering Tinnitus (ringing in ears) Signs of local anaesthetic toxicity a) Convulsion with respiratory depression b) Severe hypotension c) Bradycardia d) Respiratory arrest with cyanosis and loss of consciousness d) Cardiac rhythm disturbance e) Cardiac arrest MANAGEMENT OF LOCAL ANAESTHETIC TOXICITY 1. Stop administration of epidural solution / local anaesthetic. Inform Anaesthetist immediately 2. Airway, give 100% oxygen 17

19 3. Breathing, ventilate lungs if necessary with bag, mask reservoir bag 4. Circulation, IV access 5. Treat hypotension with IV fluids - Hartmann s solution or a plasma expander by rapid infusion and have IV ephedrine at bed side 6. Monitor and record ECG, SpO2, blood pressure, respiratory rate, pulse, AVPU every 5 minutes until there is sustained improvement in blood pressure and level of consciousness. TOTAL SPINAL This may occur when more than 3mls of a local anaesthetic, has accidentally entered the subarachnoid space. Symptoms and signs: a) Severe hypotension and bradycardia b) Breathing difficulty c) High sensory blockade d) Profound weakness in legs and arms e) Decrease in SpO2, cyanosis f) Loss of consciousness g) Respiratory, followed by cardiac arrest MANAGEMENT OF TOTAL SPINAL 1. Stop administration of epidural solution 2. Airway, give 100% oxygen, intubate as soon as possible 3. Breathing, ventilate lungs if necessary with bag, mask reservoir bag 4. Contact Anaesthetist on call immediately 5. Circulation, IV access 18

20 6. Treat hypotension with IV fluids - Hartmann s solution or a plasma expander by rapid infusion and have IV ephedrine at bedside 7. Monitor and record ECG, SpO2, blood pressure, respiratory rate, pulse, AVPU every 5 minutes until there is sustained improvement in blood pressure and level of consciousness 8. Patient will require transfer to ICU for ventilation and inotropic support POSTDURAL PUNCTURE HEADACHE (PDPH) This may occur within minutes of attempted epidural insertion, during epidural analgesia infusion or within 48 hours of removing the epidural catheter. It is due to leakage of cerebrospinal fluid through a hole or tear in the dura mater. Typically the headache is frontal or occipital with neck and shoulder pain, exacerbated by sitting or standing and relieved by lying down. There may be associated nausea and vomiting and photophobia. MANAGEMENT OF PDPH 1. Contact the prescribing Anaesthetist, Acute Pain Team or Anaesthetist on call if a PDPH is suspected. 2. If epidural catheter is in situ let it remain so until patient has been seen by prescribing Anaesthetist, or instructed otherwise. 3. Maintain good hydration and administer paracetamol +/- NSAID if not contraindicated. 4. Check the patient s blood white cell count, especially if he / she is pyrexic, to exclude infection. 19

21 5. If the headache does not settle spontaneously within hours an epidural blood patch may be considered performed by an Anaesthetist in theatre. EPIDURAL HAEMATOMA This rare complication is most likely to occur in patients who are on high dose heparin therapy or in patients with a clotting disorder, e.g. This may occur during epidural infusion or after removal of the epidural catheter. Signs: (any or all of these signs may be present) a) Severe backache b) Localised tenderness in area of the epidural catheter insertion site c) Fever d) Elevated white cell count e) Pain in legs f) Persistent weakness in legs MANAGEMENT OF SUSPECTED EPIDURAL HAEMATOMA Contact the prescribing Anaesthetist, Acute Pain Team or the Anaesthetist on-call to see the patient urgently, if this diagnosis is suspected urgent MRI should be discussed with a senior Radiologist. If the diagnosis is confirmed, the patient should have the haematoma evacuated surgically within 4-6 hrs of diagnosis, to avoid permanent neurological deficit. EPIDURAL ABSCESS This is rare complication may result from contamination at the time of epidural catheter insertion or by blood borne spread of endogenous organisms. 20

22 Signs: (any or all of these signs may be present) a) Back pain b) Fever c) Leucocytosis d) Persistent weakness in legs MANAGEMENT OF SUSPECTED EPIDURAL ABSCESS Contact the prescribing Anaesthetist, Acute Pain Team or the Anaesthetist on-call to see the patient urgently, if this diagnosis is suspected, then discuss with senior Radiologist on duty. This diagnosis should be confirmed or excluded by MRI patient must be checked for metal/clips. Urgent surgical evacuation of confirmed abscess may be indicated. Procedures Associated with Epidural Analgesia: ADMINISTRATION OF A BOLUS DOSE VIA THE EPIDURAL PUMP Only those Acute Pain Nurses, Recovery Nurses, Intensive care unit Nurses and Anaesthetic staff can administer a bolus dose via the epidural delivery pump. OBJECTIVES 1. Ensure patient safety 2. Standardise the technique of administering a bolus dose via the epidural pump 3. Maintain optimal analgesia PROCEDURE 1. A top-up will only be indicated for the following situations: a. Missed segment b. Sensory blockade below level of wound c. Unilateral blockade d. Pain score unacceptable 2. A bolus can only be administered if the patient s clinical observations state the following; a. Sedation score (AVPU A/V) b. Normal/stable motor function c. Sensory blockade below 5 th thoracic vertebrae on both right and left side 21

23 of the body d. Vital signs within acceptable range e. Intravenous fluids in progress f. Adequate urinary output 3. Inform the anaesthetist on-call of these findings 4. Refer to manufacturer instructions for administering a bolus via the dedicated epidural delivery pump 5. Titrate bolus until analgesic effect to a maximum of 10mls 6. Check blood pressure, pulse and motor function at 5 minute intervals during the procedure 7. Monitor vital signs, including motor and sensory blockade, pain and sedation scores at 15 minute intervals for at least 1 hour, then resume normal observation frequency 8. If analgesia is still inadequate anaesthetist on-call must be contacted for further advice and instructions. CHANGE OF DRESSING The dressing over the epidural/intrathecal exit site needs to fulfil the following three functions: 1. To help secure the epidural/intrathecal catheter. 2. To minimize the risk of infection. 3. To minimize the risk of infection. 4. To allow observation of the site without disturbing the dressing A transparent moisture responsive occlusive dressing (e.g. Tegaderm or Opsite IV 3000 ) fulfils these functions. Opsite IV 3000 has been found to perform well as an epidural catheter fixation product (Lawler & Anderson 2002). The epidural/intrathecal site should be inspected daily and the dressing changed at least once weekly or more frequently if there is any serous discharge from the site. Equipment 1. Sterile dressing pack. 2. Skin cleaning agent, e.g. chlorhexidine in 70% alcohol. 22

24 3. Transparent occlusive dressing. Procedure Action 1Explain and discuss the procedure with the patient. 2Wash hands with soap and water. Clean trolley (or plastic tray in the community) with chlorhexidine in 70% alcohol with a paper towel. 3Position the patient comfortably on their side or sitting forward so that the site is easily accessible without undue exposure of the patient. 4Prepare trolley or tray with sterile field and cleaning solution. 5Remove old dressing and place in disposable bag. 6Wash hands with bactericidal handrub. 7Observe site for any signs of infection such as redness, swelling or purulent discharge. If any of these are present contact the hospital anaesthetic/pain team for advice. 8Clean site with skin-cleaning agent (chlorhexidine in 70% alcohol) 9Apply transparent occlusive dressing over the whole area. 10Ensure that the patient is comfortable. 11Dispose of all material in the clinical waste bag. 12Wash hands with soap and water. Rationale To ensure that the patient understands the procedure and gives his/her valid consent (DH 2001: C; NMC 2006b: C). To minimize cross-infection (Preston 2005: C). To provide a clean working surface (Parker 2004: E). To maintain the patient's dignity and comfort. This is especially important when carers are attending to an area that is not visible to the patient (Chapman & Day 2001: E). To minimize risk of infection and ensure equipment available (Preston 2005: C). To prevent cross-infection (E). To minimize the risk of microbial contamination (E). To ensure careful monitoring of site to minimize the chance of any infection (Royal College of Anaesthetists 2004: C). To minimize the risk of infection (Mimoz et al 1999: R 1b; Kinirons et al. 2001: R 1b; Hebl 2006: R 5). To anchor the epidural/intrathecal catheter, minimize the risk of infection and allow observation of the epidural/intrathecal site (Burns et al. 2001: R 1b; Royce et al. 2006: E). To prevent environmental contamination (Preston 2005: C). To reduce the risk of cross-infection (Preston 2005: C). 23

25 REATTACHING AN EPIDURAL CATHETER If agreed by the Anaesthetist an epidural catheter that has dislodged from the bacterial filter can be reattached. This will be decided on an individual basis. OBJECTIVES 1. Ensure patient safety 2. Standardise the technique of reattaching the epidural catheter 3. Maintain optimal analgesia PROCEDURE 1. Reassure the patient and offer simple analgesia if pain is unacceptable. 2. Stop epidural infusion 3. Have available sterile scissors and sterile alcohol wipes. 4. Wash hands and apply sterile gloves. 5. Locate the end of the epidural catheter and bacterial filter. 6. Swab the bacterial filter with a sterile alcohol wipe. 7. Using sterile scissors cut approximately 2cms from the end of the exposed epidural catheter 8. Swab the cut end of the epidural catheter. 9. Re-insert the cut end of the epidural catheter into the bacterial filter and ensure that it is secure. 10. Re-start the epidural infusion. 11. If appropriate administer a bolus dose via the epidural infusion. 12. Record clinical observations as per epidural guidelines. 13. Document disconnection and inform Acute Pain Team to ensure an audit trail is maintained. REMOVAL OF EPIDURAL CATHETER Note: before an epidural/intrathecal catheter is removed it is essential to consider the clotting status of the patient's blood. If the patient is fully anticoagulated a clotting profile must be performed and advice sought from the medical staff as to when the catheter can be removed. If the patient is receiving a prophylactic anticoagulant the following guidelines are recommended (Vandermeulen et al. 1994; Horlocker & Wedel 1998; Rowlingson & Hanson 2005). Low-dose low molecular weight heparin. If this is given once daily the epidural/intrathecal catheter should be removed at least 12 hours after the last injection and several hours prior to the next dose (the timing will depend on the manufacturer's recommended guidelines, e.g. Tinzaparin [Leo Laboratories Ltd] recommend epidural or spinal catheters are removed a minimum of 4 hours before the subsequent dose). Unfractionated heparin. The epidural/intrathecal catheter should be 24

26 removed following local guidelines and the advice of the anaesthetic/pain management team. Equipment Procedure 1. Dressing pack. 2. Skin cleaning agent, e.g. chlorhexidine in 70% alcohol. 3. Occlusive dressing. Action 1Explain and discuss the procedure with the patient. 2Wash hands with bactericidal soap and water or bactericidal alcohol handrub. 3Open dressing pack. 4Wash hands and remove tape and dressing from catheter insertion site. 5Gently, in one swift movement, remove the catheter. Check that the catheter is intact. This can be done by observing that the tip of the catheter is marked blue and that the 1 cm marks along the length of the catheter are all intact. Add to document that catheter removed intact. 6Clean around the catheter exit site using skin cleaning agent. 7Apply an occlusive dressing and leave in situ for 24 hours. The epidural/intrathecal tip may be sent for culture and sensitivity if infection is suspected, or according to local policy. Rationale To ensure the patient understands the procedure and gives his/her valid consent (DH 2001: C; NMC 2006b: C). To minimize cross-infection (Preston 2005: C). To minimize risk of crossinfection (Preston 2005: C). To ensure the catheter is removed intact with the minimum of discomfort to the patient (E). To minimize contamination of site by micro-organisms (E). To prevent inadvertent access of micro-organisms along the tract (E). As per SHSCT protocol- Venous Thromboembolism (VTE) risk Assessment for Adult surgical Patients. Epidural/Spinal analgesia- Placement or removal of catheter should be delayed for 12 hours after administration of enoxaparin. Enoxaparin should not be given sooner than 4 hours after catheter removal. 25

27 Useful Information Sensory Block 26

28 A high epidural block is one at, or above, the T4 dermatome level (nipple line). A HIGH BLOCK is detected by the regular nursing measurement of block height, performed as part of the routine epidural observations. The block height may be different on the left and right hand sides of the patient. For 'midline' operations, e.g. laparotomy, BOTH sides of the patient need to have a block above the wound. It is recommended that both sides of the patient should be checked and any significant difference (more than 2 dermatomes) is recorded. Background: A working epidural infusion will prevent areas of skin from feeling pain or temperature. The area of numb skin is called the blocked area, because pain and cold sensations are 'blocked'. To give adequate analgesia following surgery the skin from at least 2-3 cm above to 2-3 cm below the skin incision should be blocked. With the standard epidural solution, (Levobupivacaine 0.1% & 2mcg/ml Fentanyl), blocked areas will not feel cold sensation. They may feel pressure, rubbing or movement. The lower limit of the block ('lower' meaning towards the feet) is usually irrelevant, as long as it is below the lower end of the skin incision. The upper limit of the block, ('upper' meaning towards the head), is important and must be recorded on the Epidural Observation Chart if it is above T4. Sensory Level Checks Levels are checked using ice to determine if the local Anaesthetic is blocking the sensory nerve pathways. 27

29 Ideally the patient should have altered temperature sensation which covers the area of surgery. The upper dermatome level at which normal temperature sensation can be felt is recorded for each side of the body. If staff cannot establish a level for any reason, as long as the patient is comfortable and their Observations are satisfactory, it is acceptable to mark a tick as long as the ice can be felt at T4 level. Easily remembered dermatomes are: Nipple line Umbilicus Thigh, level with genitals T4 Dermatome T10 Dermatome L2 Dermatome If there is any concern that the block height is rising or falling then it is suggested that a biro or felt tip mark is made on the patients skin or wound dressing indicating the block height. The mark should have the date and time of the assessment written above it, so subsequent comparisons can be made easily. Level of administration Thoracic Thoracic epidural analgesia is common choice for treatment of pain after major abdominal and thoracic surgery. Evidence suggests that administration of local anaesthetic into the thoracic epidural space results in improved bowel recovery. If this analgesia is extended for more than 24 hrs a significant reduction in the incidence of postoperative myocardial infarction is evident. In patients with multiple rib fractures, epidural analgesia has been shown to reduce the incidence of nosocomial pneumonia and indeed the number of ventilator days. Lumbar 28

30 Lumbar epidural analgesia is widely effective at providing analgesia after orthopaedic and vascular operations to the lower limbs, and urology and other pelvic surgery. Managing High Epidural Block Definition: A 'High Block' is defined as loss of cold sensation at, or above, the nipple line (T4). If undetected a High Epidural Block may endanger the patient by paralysing the respiratory muscles. Causes of High Block: 1. Infusion rate too high. 2. Recent top-up. 3. Migration of epidural catheter into the CSF. Signs and Symptoms: Loss of cold sensation at or above nipple line. 'Danger' signs Weakness or numbness in hands or arms. Hypotension. BP below 90mmHg systolic. Nausea (due to hypotension). Shortness of breath. Abnormal bradycardia. Action: If a high block is detected: Stop the epidural infusion. Give Oxygen. Check and record patient observations If any of the 'Danger signs' are present, contact Acute pain Sister / Anaesthetist immediately, who must review patient before restarting pump. Monitor and record patient observations, including, dermatome level every 15mins. When block falls to a safe dermatome level (below T4) restart infusion at the original rate minus 2mls/hr. Continue observations half hourly for 2 hours on the MEWS Chart. 29

31 In order to provide analgesia, an epidural must block the sensation in an area of skin. It is likely that the muscles beneath any blocked area of skin are also weakened by the epidural. Normal quiet respiration is maintained by the diaphragm, heavy breathing also involves the intercostal muscles. Nerves from the cervical region (C3, 4 and 5 dermatomal levels) innervate the diaphragm. The intercostal muscles are innervated by nerves from the corresponding thoracic dermatome; i.e. the 4th intercostal muscle is innervated by the nerve supplying sensation to the nipple. An epidural which blocks any thoracic dermatome will probably weaken the corresponding intercostal muscle and (slightly) reduce breathing capacity. This is usually irrelevant, because the diaphragm does all the work of breathing at rest. If the block rises to the level of C3, 4 and 5 then the diaphragm would also be paralysed and the patient would be unable to breath. The arm is also supplied by nerves coming form the cervical region, so a dangerously high block will result in numb hands or arms. Heart rate may be influenced by thoracic nerves and in some people high block may result in bradycardia. Regular measurement and recording of block height will prevent these life-threatening complications. Ineffective Epidural Analgesia Epidurals can occasionally provide inadequate analgesia. Effective analgesia can usually be re-established with a little effort. No epidural infusion should be discontinued unless every effort has been made to make the epidural work. No Epidural catheter should be removed without considering when anticoagulants were last given. If analgesia is ineffective the following MUST be done: 1. Check epidural infusion pump, epidural site, sensory block and patient observations. 2. Adjust the epidural rate as per drug prescription. 30

32 3. Give supplementary paracetamol, NSAIDS, if indicated on drug kardex. 4. Continue to monitor observations including pain assessment every 15 minutes. 5. If analgesia does not improve within 30 minutes, inform the Acute Pain Team or Anaesthetist on call. 6. The APT or Anaesthetist MUST attend within 1 hour of the call. If the APT or Anaesthetist cannot attend the Nurse should: Stop the epidural infusion. Ask the surgical Doctor on call to prescribe and administer Morphine up to 10mgs intravenously or that amount that is necessary to ensure the patients comfort and safety. 7. The APT or Anaesthetist MUST attempt to re-establish analgesia using the epidural by doing the following: Check catheter for displacement or migration by inspecting and aspirating the catheter. Personally check the height of the block. Administer a bolus/ top-up to re-establish epidural block. If analgesia is re-established then a suitable new infusion rate should be prescribed. If no block is detectable after 15mls of top-up then the catheter is assumed to be displaced and the epidural infusion may be discontinued. DO NOT remove the catheter. If the epidural infusion is abandoned, appropriate alternative analgesia must be prescribed and instituted. If the epidural has contained Fentanyl it is usually safe to administer systemic opiates. The actions taken must be clearly documented in the case notes. 8. Following re-establishment of analgesia, staff must record observations ¼ hourly for 2 hours and if stable 4 hourly. 9. If epidural analgesia is abandoned out of hours the epidural catheter should be removed in accordance with the DISCONTINUING THE INFUSION AND REMOVING THE CATHETER. 31

33 If any member of staff is concerned that the above guidelines are not being followed they should contact the Acute Pain Team or Dr D F Scullion. Securing Filter and Changing an Epidural Catheter Dressing If there is a central line in situ epidural filter must Always be secured to opposite side of this line to avoid accidental administration of drugs. Epidural catheter dressings should only be changed if there is serious danger of the catheter becoming displaced or contaminated. The catheter may be stuck to the dressing and attempts to remove the dressing may result in accidental catheter displacement. It is normal for some fluid to collect around the site where the catheter enters the skin. If the epidural is working and the dressing is otherwise intact this fluid can be ignored. If the dressing requires changing, release any large (>5 ml) collection of fluid prior to the removing old dressing. Attempts to re-secure the dressing should only be made by nursing staff familiar with epidural catheters and confident in managing wounds in an aseptic fashion.(see Procedures) IN ALL CASES OF CONFUSION GIVE OXYGEN AS THE FIRST LINE OF TREATMENT Acute confusion may follow any operative procedure, especially in the elderly. It is unlikely to be due to epidural analgesia. Every attempt should be made to identify and rectify the cause. See below Common causes of confusion. If no serious cause can be found then if at all possible management should be conservative. Reassurance, leaving room lights on and using cot sides may be sufficient. Management should NOT involve any additional sedative drugs. Sedatives are likely to add to confusion, not improve it. 32

34 Reasons why an Epidural infusion may cause confusion: 1. Excess opiate: Suspect the diagnosis if the respiratory rate is below 8 breaths per minute and patient appears drowsy with pin-point pupils. 2. Local anaesthetic toxicity from a misplaced epidural catheter. With a misplaced catheter the patient will usually have pain. To exclude local anaesthetic toxicity, stop epidural pump for 20mins. If symptoms do not completely resolve, local anaesthetic toxicity is not the cause. Restart the pump. ( AAGBI- Guidelines for the Management of Severe Local Anaesthetic toxicity 2007 )Appendix 1. Having excluded the analgesic infusion as the cause of confusion, the Primary Medical or Surgical team should be contacted and they should consider other common causes: Common causes of confusion: Blood Glucose: Hypoglycaemia or hyperglycaemia may cause confusion. Hypoxia: If SaO 2 less than 93% give O 2 immediately. Continue O 2 therapy until confusion resolved. Hypoventilation: Hypercapnia: Hypovolaemia/ Hypotension: Sodium: Check respiratory rate. If low, give Naloxone and check arterial blood gasses. Often a consequence of hypoventilation. Check ABG s to confirm diagnosis. Likeliest cause is opiates. Check fluid balance, drains and other losses. Give fluid challenge. If BP fails to respond to fluid consider myocardial insufficiency (e.g. MI) DO NOT STOP THE EPIDURAL UNLESS THE BLOCK IS ABOVE T4 LEVEL. Check electrolytes. High or low sodium may cause confusion. Uraemia: check electrolytes. 33

35 CVA: Disorientation in strange environment: Step-down from Epidural Analgesia Epidural infusions are usually discontinued after 3-4 days and must be removed no later than day 5, unless risk/benefit has been discussed with anaesthetist. The transition from epidural to other analgesia can be difficult and should be planned in advance of stopping the epidural infusion. Some patients will require opiate analgesia following the discontinuation of the epidural. If possible, the step-down analgesia should be planned to avoid problems. The following are recommended: A. Patients able to take oral analgesia: Regular Oral Paracetamol 1grm 6hourly Regular Oral NSAID provided this is not contraindicated B. Patients unable to take oral analgesia: Regular IV Paracetamol 1grm 6hourly Regular IV Parecoxib 40mg12hourly (only if specified by anaesthetist) Plus As required Oral Opiate: Mild to moderate pain: Oral Codeine up to 60mgs 6hourly use with caution following bowel surgery Consider use of mild laxative and advise of constipating effects of regular codeine Moderate to severe pain: IM Morphine solution 5-10mgs 4 hourly Provide adequate anti-emetic cover with same 34

36 Use of oral Prolnged Release Opioids will be at the discretion of the Acute Pain Team Care should be taken on discharge. These patients will require review by GP Co-analgesia with Epidural Analgesia To increase the efficacy of Epidural Infusion, all patients should have co-analgesia prescribed wherever possible. The following drugs and doses are recommended: Simple Analgesics: Paracetamol 1grm IV/orally every 6 hours. Reduce Paracetamol dose in patients under 50kg. Oral paracetamol should be used once oral route is established; however it may in some instances be appropriate to continue IV paracetamol. Consider advice from Acute Pain Team. Non-Steroidal Anti-inflammatory Drugs (NSAIDS): Parecoxib 40mgs IV every 12hours Ibuprofen For Children. In appropriate doses. NSAIDS for post operative use should be indicated by the anaesthetist and the time frame for usage should be limited. References National Patient Safety Agency (2007) Safer Practice Notice 21: Safer Practice with Epidural Injections and Infusions. 35

37 Royal College of Anaesthetists, Royal College of Nursing, Association of Anaesthetists of Great Britain and Northern Ireland, British Pain Society, European Society of Regional Anaesthesia (2004) Good Practice in the Management of Continuous Epidural Analgesia in a Hospital Setting. Association of Anaesthetists Great Britain and Ireland (2006) Controlled drugs in perioperative care Association of Anaesthetists Great Britain and Ireland (2007) Guidelines for the management of severe local anaesthetic toxicity. Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (2005) Acute Pain Management: Scientific Evidence. The Royal Marsden Hospital Manual of Clinical Nursing Procedures, 7 th edition (2008) Wiley-Blackwell NMC The Code- Standards of conduct, performance and ethics for nurses and midwives. SHSCT PGD for Naloxone Appendix 1 Guidelines for the Management of Severe Local Anaesthetic Toxicity 36

38 Signs of severe toxicity: Sudden loss of consciousness, with or without tonic-clonic convulsions Cardiovascular collapse: sinus bradycardia, conduction blocks, asystole and ventricular tachyarrhythmias may all occur Local anaesthetic (LA) toxicity may occur some time after the initial injection Immediate management: Stop injecting the LA Call for help Maintain the airway and, if necessary, secure it with a tracheal tube Give 100% oxygen and ensure adequate lung ventilation (hyperventilation may help by increasing ph in the presence of metabolic acidosis) Confirm or establish intravenous access Control seizures: give a benzodiazepine, thiopental or propofol in small incremental doses Assess cardiovascular status throughout Management of cardiac arrest associated with LA injection: Start cardiopulmonary resuscitation (CPR) using standard protocols Manage arrhythmias using the same protocols, recognising that they may be very refractory to treatment Prolonged resuscitation may be necessary; it may be appropriate to consider other options: o Consider the use of cardiopulmonary bypass if available o Consider treatment with lipid emulsion Treatment of cardiac arrest with lipid emulsion: (approximate doses are given in red for a 70-kg patient) Give an intravenous bolus injection of Intralipid 20% 1.5 ml.kg-1 over 1 min o Give a bolus of 100 ml Continue CPR Start an intravenous infusion of Intralipid 20% at 0.25 ml.kg-1.min-1 o Give at a rate of 400 ml over 20 min Repeat the bolus injection twice at 5 min intervals if an adequate circulation has not been restored o Give two further boluses of 100 ml at 5 min intervals After another 5 min, increase the rate to 0.5 ml.kg-1.min-1 if an adequate circulation has not been restored o Give at a rate of 400 ml over 10 min Continue infusion until a stable and adequate circulation has been restored Remember: Continue CPR throughout treatment with lipid emulsion Recovery from LA-induced cardiac arrest may take >1 h Propofol is not a suitable substitute for Intralipid Replace your supply of Intralipid 20% after use Follow-up action: 37