Monitoring Practices Following Epidural Analgesics for Pain Management: A Follow-Up Survey

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1 36 Journal of Pain and Symptom Management Vol. 14 No. 1July 1997 Original Article Monitoring Practices Following Epidural Analgesics for Pain Management: A Follow-Up Survey Margaret R. Muir, RN, MSN, Frederick L. Sullivan, RN, MSN, Guy Dear, MB, BCh, and Brian Ginsberg, MB, BCh Acute Pain Service, Department of Anesthesiolog); Duke University Medical Centeg, Durham, North Carolina, USA Abstract Indwelling epidural catheters are commonly used in pain management. There is much literature on the risks and benefits of this therapy, but there is no consensus on a standard, cost-effective method of monitoring these patients, nor on the types of analgesics or methods of drug deliver),. The purpose of this paper is to examine clinical practices of pain management nurses belonging to the American Society of Pain Management Nurses (ASPM'V). A total of 202 members responded to a follow-up survey on their institutions' use of epidural catheters. Although there were numerous variations in practice, certain similarities and themes regarding drug choice, patient monitoring, and health care providers involved with the care of this patient population are evident. J Pain Symptom Manage 1997;14: U.S. Cancer Pain Relief Committee, Key Words Epidural, ASPIVIN, monitoring, respiratory depression Introduction Epidural analgesics are commonly used in the management of both acute and chronic pain states. The popularity of epidural analgesics is due not only to effective analgesia but to a reduction in morbidity and mortality following surgical procedures) -4 These beneficial effects have been acknowledged by the Agency for Health Care Policy and Research (AHCPR), which recommended that epidural therapy become an essential element of pain management. The Acute Pain Management Address reprint requests to: Dr. Brian Ginsberg, Duke Medical Center, Department of Anesthesiolo~,, Box 3094, Durham, NC 27710, USA. Accepted for publication: October 18, Guideline Panel of that agency recommends that "any hospital in which abdominal or thoracic operations are routinely performed offer patients postoperative regional anesthetic, epidural or intrathecal opioids, PCA infusions, and other interventions requiring a similar level of expertise. ''5 In a landmark publication, Ready et al. described the experience of the acute pain team at the University of Washington's hospital in Seattle. 6 In this paper, they described how patients had been monitored for side effects on regular wards following epidural analgesics, with safe outcomes. As part of that regimen, patients were monitored hourly by the nursing staff to maintain effective analgesia and adequate respiratory status. Many hos- U.S. Cancer Pain Relief Committee, /97/$17.00 Published by Elsevier, New York, New York PII S (97)

2 Vol. 14 No. 1 July 1997 Practices Following Epidural Analgesics 37 pitals now routinely send their patients to general floors (versus intensive care units) while utilizing epidural analgesics. Despite the many benefits of epidural analgesia, the risks associated with their use, including respiratory depression, remain a concern. There is no consensus, however, on a standard, costeffective method of monitoring patients with epidural catheters to prevent the inherent risks of respiratory depression. In July 1994, Sullivan et al. published a survey detailing monitoring practices of 42 institutions using epidural analgesia. 7 This article was based on a small sample of members of the American Society of Pain Management Nurses (ASPMN). The purpose of this paper is to expand on the scope of that survey and to determine how institutions clinically manage patients using epidural analgesics. Profiles of modern pain services are also explored. Methods The American Society of Pain Management Nurses (ASPMN) is a 6-year-old organization of members who work in pain management. These nurses represent acute, chronic, and combined pain services. This professional group provided a convenient source to obtain data regarding clinical trends of pain management practices. The fourth annual ASPMN meeting was held in Chicago, Illinois (April 1994) and was attended by 450 nurses. Two hundred and two ASPMN members completed a six-page, 36-item survey designed to provide data about epidural pain management and trends in pain services (Appendix A). Not all of the nurses who were surveyed completed every question, and the number of respondents indicated for each question is presented in parentheses. Resu/ts Demographic Data Of 202 respondents, 98% (N = 193) represented pain nurses working in the United States and 0.2% (N= 3) were from other countries. For the purpose of this paper, data ~dll reflect respondents of the United States. The majority of the nurses, 89% (N-- 180), worked for a hospital and only 6% (N = 13) worked Service Table 1 Service and Use of Epidurals Percentage (N) General surgery 88% (160) Orthopedic 81% (147) Thoracic 81% (147) Obstetrics 70% (127) Urology, 63% (114) Gynecolo~" 59% (106) Pediatrics 25% (46) Plastics 15% (28) Other 23% (42) for a freestanding pain clinic. Fifty-two percent (N = 99) represented hospitals of 400 beds or less, 36% (N= 71) worked in hospitals of beds, and 12% (N = 23) were from hospitals of 800 beds or more. Forty-eight percent (N = 95) of institutions were privately owned, 34% (N = 68) were community-based hospitals, and 7% (N = 13) were freestanding pain clinics; one hospital was a veterans administration medical center. Of 181 respondents, 88% (N = 160) of respondents indicated that their institution utilized epidural opioids in general surgery patients. Epidural analgesia was used by 82% (N = 149) in orthopedics, 81% (N = 147) in thoracic surgery, 70% (N= 127) in obstetrics, 63% (N= 114) in urology, 59% (N-- 106) in gynecology, 25% (N = 46) in pediatrics, 15% (N= 28) in plastics, and 23% (N= 42) in medicine (Table 21). Profile of Pain Service Of 197 respondents who use epidurals, 34% (N= 83) were from an acute pain service, 31% (N= 75) were from a chronic pain service, and 34% represented a combined (acute and chronic) pain service. Thirty-one percent (N = 58) of the respondents reported that their pain services used epidural catheters for greater than 5 years; 29% (N = 56) have used them for 4-5 years, 34% (N = 65) used epidurals for 2-3 years, and 5% (N = 11) used epidurals for less than 1 year. The composition of acute pain services varied. Respondents reported that the professionals included pain management nurses (76%, N = 146), anesthesiologists (78%, N-- 158), pharmacists (22%, N = 44), psychologists (10%, N = 20), and primary care physician (6%, N = 12). Respondents reported that the professionals in the chronic pain services included

3 38 Muir et al. Vol. 14No. 1July 1997 Table 2 Drugs Commonly Used for Bolus and Patient-Controlled Epidural Analgesia Hospital size Less than 400 beds beds Over 800 beds N=99 N=71 N=23 PCEA Bolus PCEA Bolus PCEA Bolus Drug Morphine 30(30) 39(39) 32(23) 46(33) 22(5) 30(7) Meperidine 3(3) 5(5) 10(7) 10(7) 13(3) 4(1) Fentanyl 32(32) 33(33) 32(23) 38(27) 30(7) 2(6) Fentanyl 9(9) 2(2) 8(6) 3(2) 17(4) 4(1) mixture PCEA, patient-controlled epidural analgesia. nurses (76%, N= 155), anesthesiologists (78%, N = 158), pharmacists (23%, N = 46), psychologists (52%, N = 105), and primary care physicians (21%, N = 41). Profile of Methods of Epidural Drug Delivery Epidural drugs can be administered by three different modalities. For the purpose of this paper, bolus method is defined as an intermittent injection of a opioid and/or local anesthetic into the epidural space via an epidural catheter. A continuous infusion method is where a catheter is connected to a device that delivers a constant infusion of drug. The third method is patient-controlled epidural analgesia (PCEA), in which the patient has the capability to dose their own catheter, which may or may not have a continuous infusion delivered simultaneously. Drug delivery often differs depending on whether the patient has an epidural for acute or chronic pain, but this survey did not differentiate by diagnosis. Of 189 respondents, 53% (N= 100) reported that their institutions used the bolus method; 93% (N = 176) reported use of continuous infusions, and 41% (N = 79) reported use of PCEA. Of the 53% (N= 100) of respondents from institutions that utilized the bolus method, 84% (N = 82) reported use of morphine, 68% (N = 66) reported use of fentanyl, 31% (N = 30) reported use of hydromorphone, 14% (N = 14) reported use of meperidine, and 15% (N = 15) reported use of sufentanil. Table 2 depicts the most commonly used bolus method drugs in relation to the corresponding size of institution. The health-care provider most likely to bolus the catheter was a member of the anesthesiology team (82%, N = 132). The pain management nurse was the next most likely to bolus a catheter (45%, N= 71). Table 3 depicts other health care professionals who bolus epidural catheters according to hospital size. Forty-one percent (N = 79) of the respondents reported that their institutions utilized patient-controlled epidural analgesia (PCEA). The most commonly used drug was fentanyl 79% (N = 63), followed by morphine 75% (N = 60), and a mixture of local anesthetic and opioid 70% (N = 56). Table 2 reflects the PCEA drugs used according to hospital size. Of the respondents from institutions that used continuous infusions, 73% (N-- 129) reported use of local anesthetics, 80% (N = Table 3 Professionals Who Bolus Catheters According to Hospital Size Less than 400 beds beds Over 800 beds Size % (N) % (N) % (~) Professional Pain RN 25(39) 15(24) 5 (8) Anesthesiologist 47(75) 26(42) 9 (15) Staff RN 13(20) 12(19) 0.6(10) Primary MD 1 (2) 7(1) 0.6(10)

4 Vol. 14 No. 1 July 1997 Practices FoUowing Epidural Analgesics 39 Table 4 Concentrations of Bupivicaine and Fentanyl Used in Continuous Infusions [Bupivicaine and Fentanyl Combination (N = 89)] Fentanyl 2 lag 5 lag 10 lag >10 lag Bupivicaine < > ) reported use of opioids; and 94% (N = 165) reported use of a combination of opioids and local anesthetics. The concentrations of local anesthetics most commonly used are depicted in descending order in Table 4. Bupix4caine and fentanyl was the most common drug combination. If an opioid was used alone, it was most commonly fentanyl at 10 g/ml. Seventy-three percent (N= 168) of the respondents reported that their institutions locked up the opioid infusion in some safety, anti-diversion device attached to the pump, and 27% (N = 46) reported that their institutions left the drug freestanding as it is infused. Monitoring Practices of Patients with Epidural Catheters A number of hospitals utilized hourly sedation and respiratory rate monitoring for the duration of epidural analgesia (Table 5). Following thoracic analgesia, the number of respondents reporting institutions that provided this frequent level of monitoring was 22% (N = 28) for a continuous infusion and 13% (N = 17) for the bolus technique. The corresponding values following lumbar catheter placement were 18% (N= 31) for an infusion and 11% (N= 19) for the bolus administration. Eighty-seven percent (N = 112) of respondents reported that their hospitals monitored their patients hourly for the first 12 hr following thoracic epidural drug delivery; this included 56% (N= 72) of the continuous infusion group and 31% (N = 40) from the bolus group. Forty-four percent (N = 77) of the respondents reported that their institutions monitored lumbar level catheters with continuous infusions every 1 hr for the first 12 hr, and 26% (N= 45) reported that bolus lumbar catheters are monitored for the first 12 hours (Table 5). After an initial 4 hr of moni- toring, however, 47% (N= 61) of the respondents from institutions employing continuous infusion thoracic epidural reported an advance to every-2-hr monitoring or less. Eighteen percent (N= 23) reported that bolus thoracic epidural catheters were monitored every 2 hr or greater after an initial 4-hr monitoring. Sixty-five percent (N = 84) of respondents from institutions that used epidurals, regardless of level, reported monitoring every 2 hr or greater after the first 4 hr of therapy. Fifty-six percent (N = 39) of respondents from institutions using thoracic epidural catheter reported that their institutions employed electronic devices, such as pulse oximeter and apnea monitor, to monitor patients. Only 32% (N = 52) of respondents reported use of such devices with lumbar catheters (Table 6). This survey did not differentiate monitoring practices of "temporary" versus "permanently" implanted catheters. Fifty-seven percent (N = 93) of the respondents reported that the pain management nurse checks dermatome levels. The other personnel who check dermatome levels were reported to be anesthesiology (68%, N= 110), staff nurses (43%, N= 69), and primary physician (2%, N = 2). Ninety-seven percent (N = 153) of respondents from institutions using lmnbar level catheters and 89% (N = 101) of respondents from institutions using thoracic level catheters reported routine monitoring of patients on general care beds, rather than ICU or step-down beds. Only 8% (N = 13) of respondents from institutions using lumbar catheters and 16% (N = 18) from institutions using thoracic level catheters reported monitoring of patients in ICU or step-down settings (Table 7). The most likely health-care provider to remove the epidural catheter was an anesthesiologist (reported by 79% of the respondents, N= 144). Sixty-three percent (N= 115) of the respondents reported that the pain management nurse removes catheters, and 21% (N = 39) of the respondents reported that the nurses on the floor remove epidural catheters. D/S~/$S/OF/ The purpose of this survey was to determine current clinical practices of institutions in the United States that use epidural analgesics in

5 40 Muir et al. Vol. 14 No. 1July 1997 Frequency Table 5 Patient Monitoring Following Epidural Analgesics Thoracic (N= 196) Continuous % (?v) Q 1 hr duration 22(28) Q 1 hr x 24 hr then Q 2 hr 19(25) Q 1 hr X 12 hr then Q 2 hr 15(19) Q 1 hr x 4 hr then Q 2 hr 9(12) Q 1 hr x 4 hr then Q 4 hr 19(25) Q 2 hr duration 2(2) Q2 hr x 24 hr then Q4 hr 7(9) Q 2 hr x 12 hr then Q4 hr 5(6) Q 4 hr duration 5(7) Bolus % (l~) Continuous % (N) Lumbar (N= 216) Bolus % (N) 13(17) 18(31) 11(19) 11(14) 15(27) 10(17) 7(9) 11(19) 5(9) 2(3) 7(13) 3(5) 10(13) 18(31) 9(16) 1(1) 2(3) 1(1) 1(1) 5(9) 1(1) 2(2) 2(4) 1(1) 2(3) 4(7) 2(3) Q 1 hr duration, monitoring every 1 hour for the duration of the epidural analgesics; Q 1 hr X 24 hr then Q 2 hr, monitoring every 1 hour ['or 24 hours then every 2 hours; Q 1 hr X 12 hr then Q 2 hr, monitoring every 1 hour for 12 hours then every 2 hours; Q 1 hr 4 hr then Q 2 hr, monitoring every 1 hour for 4 hours then every 2 hours; Q 1 hr 4 hr then Q 4 hr, monitoring every 1 hour for 4 hours then every 4 hours; Q 2 hr duration, monitoring every 2 hours for the duration of the epidural analgesics; Q 2 hr x 24 hr then Q 4 hr, monitoring every 2 hours for 24 hours then every 4 hours; Q 2 hr X 12 hr then Q 4 hr, monitoring every 2 hr for 12 hours then every 4 hours; Q 4 hr duration, monitoring every 4 hours for the duration of the epidural analgesics. the management of pain. Clinical practices vary from hospital to hospital, but the majority of institutions rely on the clinical skills of the floor nurses to monitor patients during epidural therapy. One weakness of our survey was that we did not differentiate between the chronic and acute pain patient. Our data did not exclude the chronic pain patient with the permanently implanted epidural catheter. Obviously, monitoring and care of these two patient groups would differ. Anatomical level (thoracic versus lumbar) of catheter placement and ~?e of drug delivery (bolus or continuous method) is a known potential risk factor in rostral spread and respiratory depression, s Despite these potential risks, over 80% of institutions surveyed send patients to a general care bed versus a monitored ICU or step-down unit. This practice was not influenced by level of the catheter or type of drug administered. This observation affirms that many pre~40us studies have demonstrated the safety and efficacy of this form of therapy) '6 On general care floors, patients are not routinely monitored with electronic devices for desaturation or apnea. 6'7 Although the development of respiratory depression is most commonly seen following the use of mot- Table 6 Use of Electronic Monitoring Devices Thoracic Lumbar Equipment (N= 129) (N= 176) Pulse oximeter 28% 27% Apnea monitor 28% 5% phine. 9 We were unable to discern any difference in monitoring practices with the use of epidural morphine versus other opioids. The majority of institutions relied on nursing assessment of respiratory rate and sedation scale every hour for the first 12 hr. Previous studies have clearly shown that patients can experience periods of oxygen saturation less than 90% following epidural opioids, t This potential, however, has not translated into any alteration in clinical practice. Our conclusion is that the majority of institutions utilizing epidural analgesia feel that it is safe when frequent nursing care is used to monitor patients for side effects. A weakness of this survey was the inability to subgroup data (for example, age specific), as respiratory depression is more common at the extremes of age or with concomitant disease, u In addition, we were not able to discern what specific group of patients used the most extensive monitoring. The majority of institutions rely on either an anesthesiologist or resident to bolus epidural catheters. Staff nurses are responsible for bolusing only a small percentage of the epidu- Table 7 Clinical Setting in Which Patients with Epidurals Are Monitored Thoracic Lumbar Setting (N= 114) (N= 158) ICU/step-down umt 15.8% 8.2% General care bed 88.6% 96.8% General care bed after ICU 1.8% 1.3% ICU, intensive care unit.

6 VoL 14 No. 1 July 1997 Practices Following Epidural Analgesics 41 rals. Current economic pressure may change this practice. The limiting factors in the training of staff nurses to administer epidural analgesics has been state regulatory agencies (nursing boards) and various levels of education in the nursing profession. If the trend toward frequent use of epidural analgesia continues, the utilization of the staff nurses to bolus the epidurals may be imperative. The need to train nurses in bolus techniques, however, may be offset by using either continuous infusions or patient-controlled epidural analgesia rather than use of the bolus method. Again, an institution must evaluate the costs associated with owning, operating, cleaning, and storing devices with these features. This survey clearly indicates that there is no single agent primarily used for epidural analgesia. A trend that is apparent from our survey is that hospitals tend to use a low concentration of bupivicaine (~0.125%) combined with a concentration of fentanyl of 5 g/ml or higher, for continuous infusions. Morphine and fentanyl remain the most popular agents for both the bolus method and PCEA. The combination of these agents provide for both a rapid onset of analgesia (fentanyl) and longer duration of pain relief (morphine). Certainly an effective pain service would utilize a multitude of drugs and delivery methods in an attempt to manage pain with the minimum of side effects. A major weakness of this survey was that no quality assurance data were collected and the surveyed nurses were not asked whether or not they felt their guidelines were safe and reasonable for patient care. Further research is needed in examining efficacy and other outcomes with current clinical practice trends. Acknowledgment The authors would like to thank the members of the American Society, of Pain Management Nurses who permitted us to complete this survey and in particular Cindy Brooke. R crc/ e$ 1. Yeager ME Glass DD, Neff RK, Brink-Johnson T. Epidural anaesthesia and analgesia in high risk surgical patients. Anesthesiology 1987;66: Shuhnan M, Sandler AN, BradleyJW, Young PS, Brebner J. Postthoracotomy pain and pulmonary function following epidural and systemic morphine. Anesthesiology, 1984;61: Rawal N, Sjostrand U, Christofferson E. Comparison of intermuscular and epidural morphine for postoperative analgesia in the grossly obese: influence on postoperative ambulation and pulmonary function. Anesth Analg 1984;63: Tuman KJ, McCarthy RJ, March RJ, DeLaria CA, Patel RV, Ivankovich AD. Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery. Anesth Analg 1991;73: Agency for Health Care Policy and Research acute pain management: operative or medical procedures and trauma. Rockx~ille, MD: Public Health Service, US Department of Health and Human Services, 1992:5. 6. Ready LB, Loper KA, Nessly M, Wild L. Postoperative epidural morphine is safe on surgical wards. Anesthesiology' 1991;75: Sullivan FL, Muir MR, Ginsberg B. A survey on the clinical use of epidural catheters for acute pain management. J Pain Symptom Manage 1994;9: Bromage PR, Camporesi E, Durant PAC, Nielson CH. Rostral spread of epidural morphine..~alesthesiology, 1982;56: Bromage PR, Camporesi E, Chestnut D. Epidural narcotics for postoperative analgesia. Anesth Analg 1980;59: Wheatley RG, Somerville ID, Sapsford DJ,Jones JG. Postoperative hypoxaemia: comparison of extradural, i.m. and patienl-controlled opioid analgesia. Br J Analg 1990;64: Stenseth R, Sellevold O, Breivik H. Epidural morphine for postoperative pain: experience with 1085 patients. Acta Anaesthesiol Scand 1985;29: Appendix A Epidural Analgesia Survey Mark (x) all questions that apply to your institution. Specify explanations as indicated throughout the questionnaire. 1. What state/country are you located in? 2. What is the size of your organization? [] beds [] beds [] >800 beds 3. Type of organization where you are employed: [] Private Hospital

7 Morphine Fentanyl Meperidine Butorphanol Lidocaine/Bupivacaine Mixture 42 Muir et al. ~ bl. 14 No. 1July 1997 [] State Hospital [] Community, Hospital [] Veterans Administration/Military [] Freestanding Pain Clinic ( average patients/day) 4. Indicate if you have an organized pain service for: [] Acute Pain [] Chronic Pain [] Combined Service 5. Which of the following are members of the acute pain service? [] Pharmacists [] Anesthesiologist/Residents/CRNAs [] Psychologists [] Physicians (Surgeon, Medical, etc.) 6. ~rhich of the following are members of the chronic pain service? [] Pharmacists [] Anesthesiologists/Residents/CRNAs [] Psychologists [] Physicians (Surgeon, Medical, etc.) 7. You primarily work with [] Acute Pain [] Chronic Pain [] Both 8. Epidurals at your institution are managed by [] Anesthesia Pain Ser~4ce [] Primary Physician (Surgeon, Medical) [] Other; Specify: 9. How long have you been using epidurals for pain management at your institution? [] <1 year [] 2-3 years [] 4-5 years [] >5 years 10. Does your institution use patientcontrolled epidural analgesia? [] Yes [] No 11. If you answered yes to question 10, please rank the agents that you use via patientcontrolled epidural analgesia. (1 = Most commonly used, 8 = Least commonly used, N/A = Not applicable) Hydromorphone Sufentanil of an opioid and local anesthetic; Specify: 12. If you answered yes to question 10, indicate the settings for the two agents that you most commonly use via patient-controlled epidural analgesia. Drug: Bolus dose: Lockout interval: Continuous infusion: Drag: Bolus dose Lockout interval Continuous infusion: 13. Please indicate which services use epidurals for pain management: [] General Surgery/Vascular [] Thoracic/Pulmonary [] Orthopedics [] Urology [] Obstetrics [] Other [] Pediatrics [] Oncology [] Plastics [] Medicine [] Gynecology 14. What is the average number of patients at your institution who have an epidural catheter for acute pain management? [] 1-5 patients/day [] 6-10 patients/day [] patients/day [] patients/day [] >20 patients/day [] Does not apply to our organization 15. What is the average number of patients at your institution who have an epidural catheter for chronic pain management? [] 1-5 patients/day [] 6-10 patients/day [] patients/day [] patients/day [] >20 patients/day [] Does not apply to our organization 16. On average, how long do you leave an epidural catheter in place for acute pain management? [] lday [] 2 days [] 3 days [] 4 days [] 5 days or longer 17. Does your institution use the intermittent bolus technique?

8 Fentanyl Meperidine Butorphanol Lidocaine/Bupivacaine Opioids Opioids <116 Fentanyl Butorphanol Lidocaine/Bupivacaine Vol. 14 No. 1 July 1997 Practices Following Epidural Analgesics 43 [] Yes [] No 18. If yes, what levels are the epidural catheters placed for the bolus technique? [] Thoracic [] Lumbar [] Caudal 19. If yes to question 17, please rank the opioids/local anesthetics that are most commonly used to bolus epidurals. (1 = Most commonly used, 8 = Least commonly used, N/A = Not applicable) Morphine Hydromorphone Sufentanil Other; Specify: 20. What health-care professinals are responsible for bolusing epidurals at your institution? [],Amesthesiologist/Anesthesia Residents/ CRNAs [] Staff Nurse (RN) [] Physicians (Surgeons, Medical) 21. Does your institution use the continuous epidural infusion technique? [] Yes [] No 22. What levels are epidural catheters placed for continuous epidural infusions? [] Thoracic [] Lumbar [] Caudal 23. If your institution uses the continuous epidural infusions, rank the following agents used. (1= Most common, 3 = Least common, N/A = Not applicable) Local anesthetics and local anesthetic 24. If local anesthetic agents are used for continuous infusions, rank the local anesthetics that are used most commonly at your institution: (1 = Most commonly used, 6 = Least commonly used, N/A = Not applicable) or % bupivacaine 116 or % bupivacaine 18 or 0.125% bupivacaine 14 or 0.25% bupivacaine >14 or 0.25% bupivacaine other; Specify: 25. If a combination of opioids and local anesthetics are used for continuous infusions list the agents and concentrations primarily used: 1 Local Anesthetic: Concentration: Opioid: Concentration: 2 Local Anesthetic: Concentration: Opioid: Concentration: 26. If opioids alone are used for continuous infusions, rank the opioids that are used most commonly at your institution: (1 = Most commonly used, 7 = Least commonly used, N/A -- Not applicable) Morphine Meperidine Sufentanil Hydromorphone Other; Specify: 27. What health-care professionals are responsible for pulling out epidural catheters on completion of epidural therapy? [] Anesthesiologist/Anesthesia Residents/ CRNAs [] Staff Nurse (RN) 28. Indicate if your institution routinely sends patients with a lumbar level epidural catheter to (select one): [] ICU/step-down unit only [] General Care Bed Unit [] General Care Bed Unit after hours in ICU/step-down unit 30. Indicate if your institution requires patients with an epidural catheter to use the following equipment? Pulse Oximetry Apnea Monitor Pediatrics [] [] Thoracic level [] [] Lumbar Level [] [] 31. Mark the patient monitoring for both thoracic and lumbar epidurals that is most comparable to your institution. Respiratory rate and sedation scale checks are monitored:

9 44 Muir et al. Vol. 14 No. 1July 1997 Frequency/Duration Q 1 hr for duration of therapy Qlhr 24hr, thenq2hr Q1 hr 12hr, thenq2hr Q1 hr x 4hr, then Q2hr Q1 hr 4hr, thenq4hr Q 2 hr duration of therapy Q2 hr x 24hr, thenq4hr Q2hr 12hr, thenq4hr Q 4 hr duration of therapy c = Continuous; B - Bolus Thoracic Lumbar Epidural Epidural C B C B 32. For continuous epidural infusions containing opioids, does your institution require that the epidural solution be in a locked apparatus versus freestanding? [] Yes [] No 33. Who is responsible for checking dermatome levels of patients with epidural catheters? [] Anesthesiologist/Anesthesia Residents/ CRNAs [] Staff Nurse (RN) [] Physicians (Surgeons, Medical) 34. Are patients allowed to ambulate with an epidural catheter (Y, Yes; N, No)? Opioid Local Anesthetic Lumbar level [] [] Thoracic level [] [] 35. What other information would you like to know about epidural pain management? THANK YOU FOR YOUR TIME!!