VAN WERT COUNTY HOSPITAL. Policy/Procedure: Departmental No.: N 11-36A. Issue Date: 7-97 By: Nursing No. of Pages: 6

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1 VAN WERT COUNTY HOSPITAL Policy/Procedure: Departmental No.: N 11-36A Issue Date: 7-97 By: Nursing No. of Pages: 6 Reviewed: 9-14, 8-11, 8-10 Revised: 9-14 Distribution List: All Nursing Departments Concurrence: Anesthesia, Pharmacy Subject: Purpose: To provide safe and effective pain management using epidural route Principle: Epidural Route of Administration 1. When administered into the epidural space, a narcotic analgesic moves across the dura mater through the subarachnoid space into the cerebral spinal fluid. After binding with opiate receptors in the dorsal horn, the analgesic enters the systemic circulation through the epidural veins and is ultimately distributed throughout the body. 2. The greater the narcotic analgesic's lipid solubility, the faster the onset of action and the shorter the duration of pain relief. Highly lipid soluble drugs relieve pain rapidly, but have a short duration. Morphine Sulfate (preservative-free), which has a lower lipid solubility, has a slower onset and a longer duration of action. 3. Drugs administered by epidural routes are absorbed and take effect before being metabolized in the liver, negating the first pass effect. The dosing for epidural route is generally much lower than the equivalent given by the oral route. 4. Epidural narcotics provide long-lasting pain relief with lowered intrathecal cumulative doses. They contribute to improved pulmonary function, decreased metabolic stress response, and enhance early ambulation. May be performed by: 1. A qualified licensed anesthesia provider can: a. insert an epidural catheter b. initiate an epidural injection c. initiate a continuous epidural infusion d. re-bolus an epidural medication e. increase the rate of a continuous infusion f. remove the catheter 2. An RN can: a. monitor the patient and/or fetus b. replace empty infusion bags with newly prepared solution of same concetration c. stop the infusion d. initiate emergency therapeutic measures e. if trained, may remove the catheter (see Nursing P&P N11-36B)

2 Page 2 Equipment: 1. For insertion: a. epidural anesthesia tray (for epidurals) b. spinal anesthesia tray (for intrathecals) c. datascope, pulse oximeter, O2, resuscitative equipment d. for OB, EFM e. sterile gloves f. Betadine 2. For continuous infusion: a. preservative-free medication/saline b. continuous infusion pump device (from PACU) clearly marked EPIDURAL (see Nursing P&P N 7-11).Pump is locked at all times. c. epidural pump tubing (from OB)Clearly marked epidural tubing d. Betadine swabs (DO NOT USE ALCOHOL-IT IS NEUROTOXIC TO THE SPINAL COLUMN) e. non-sterile gloves 3. For intermittent injection/bolus: a. perservative-free medication b. 12cc syringe and filter needle, if needed c. epidural cap (non-vented male Luer-lock cap) d. Betadine swabs (do not use alcohol since it is not preservative-free) e. non-sterile gloves Epidural Medication Preparation: Epidural solutions may be mixed by: a. a pharmacist b. an anesthesia provider Epidural Administration Duties of RN and Anesthesia 1. Two RN's validated to monitor epidural analgesia must verify the drug, dosage, and rate/volume to be administered with the written orders prior to placing medication into the epidural pump. 2. An RN may replace an empty epidural analgesia medication infusion bag into an existing epidural pump. 3. An RN is NOT to irrigate or manipulate the catheter, give a bolus of the medication or change the rate of the infusion. 4. An RN will review settings every shift to verify infusing infusing at prescribed rate. 5. Only anesthesia providers can verify placement of an epidural catheter 6. Anesthesia providers will perform epidural catheter site care-change epidural tubing and caps.

3 Page 3 Policies and General Information: 1. A licensed anesthesia provider shall remain in the hospital at least 30 minutes after insertion of an epidural catheter and shall be readily available for the duration of the infusion. 2. All medications given by epidural route will be preservative-free including normal saline. Procedure: 1. Literature, patient teaching, and consent (form # ) will be the responsibility of the anesthesia provider prior to starting the procedure. 2. Have patient void prior to procedure 3. Start and maintain an IV site during the epidural medication administration and for 4 hours after the epidural is discontinued. Use this line for IV medication, if needed. DO NOT USE THE EPIDURAL LINE AS AN IV LINE. 4. Obtain baseline vital signs, O2 sat. For OB patient, obtain FHR per EFM strip for minimum of 20 minutes and give 500cc bolus of LR prior to procedure. 5. Position patient per anesthesia provider s preference and assist with procedure. 6. Monitor patient as per addendum 1 7. Position patient supine at least 15 min. post procedure, then position of choice. For OB patient, place in low fowlers position for 15 min., then position of choice. Change position a minimum of q 2 hours to decrease risk of unilateral block. 8. When an epidural catheter is not in use, but is to remain in place, a non-vented male Luerlock cap must be in place on the end of the catheter. If twist lock adapter becomes disconnected, cover with sterile 2x2 and notify anesthesia provider. Anesthesia will be responsible to change tubing, caps, etc. Protocol for Monitoring Patients with Epidural Catheter 1. Monitor vital signs, pain level, O2 saturation, LOC, and movement/sensation protocols: a. Baseline prior to insertion of epidural catheter: Blood pressure, pulse, respiration rate, pain level, O2 saturation, LOC, and movement/sensation b. For Epidurals of Fentanyl, Marcaine, and Duramorph: Respiratory rate immediately after initiation of infusion or bolus then q 30 min. x 3 hours then Blood pressure & heart rate per datascope to assess for orthostatic hypotension: q 5 min. x 30 min. after initiation of infusion or bolus then q 30 min. x 3 hours then O2 saturation levels per continuous pulse oximeter to assess for hypoxia: q 5 min. x 15 min. after initiation of infusion or bolus then

4 Page 4 Level of consciousness per sedation scale (0-4) on form # : immediately after initiation of infusion or bolus then q 30 min. x 3 hours then Pain level with 0-10 scale (see Hospital P&P N1-19) to assess effect of epidural: q 4 hour during infusion and for 4 hours after infusion discontinued Movement per neurovascular checks per % scale as follows: 0% = no movement of ankles, knees, or legs unable to flex ankles, knees, or raise extended legs 33% = able to flex ankles unable to flex knees, or raise extended legs 66% = able to flex ankles and knees unable to raise extended legs 100% = full movement able to flex ankles, knees, and raise extended legs q 30 min. x3hrs. during infusion and for 4 hours after infusion discontinued change position q1-2 hours to decrease risk of unilateral block assess muscle strength prior to ambulation Sensation per neurovascular checks per neurovascular/cva flowsheet q 30 min. x3hrs. then every four hrs. during infusion and for 4 hours after infusion discontinued change position q1-2 hours to decrease risk of unilateral block Other side effects as noted on form # : q 30 min. x3hrs. then every 4 hrs. during infusion and 4 hours after infusion discontinued c. Activity: 1. change position every 1-2 hrs to decrease risk of unilateral block in semi fowlers position 2. Dangle patient only for the first 24 hrs. of epidural infusion. 3. May transfer patient ( with 2 assists) from bed to chair 24 hrs. after epidural infusing. 4. May ambulate patient 4 hrs after epidural discontinues. 5. Assess muscle strength prior to ambulation. d. Dressing Monitor epidural dressing for fluid leakage every 4 hrs. Reinforce dressing. Do NOT CHANGE dressing. If catheter becomes dislodged or leakage around Insertion site, notify anesthesia. For OB patients: Monitor as per above protocols, plus Continuous EFM

5 Page 5 2. Assess for side effects as per above protocols and NOTIFY anesthesia provider for: a. decreased respirations of 20% of baseline (have Narcan available) b. decreased O2 saturation of less than 90% (provide O2) c. hypotension of 20% of baseline (provide O2, increase IV fluids) d. change from baseline vital signs of + or 20% e. LOC/sedation score of 4 (stop infusion) f. inability to void within 6 hrs.(obtain cath prn order, if needed) g. spinal headache (from opening epidural catheter to air- no patient risk only severe HA) h. pruritis, esp. neck and face (common side effect) (have Narcan and Nubain avaliable as Nubain may be ordered as a continuous infusion) i. nausea and vomiting (have Narcan available) j. break-thru pain (DO NOT give narcotics or sedatives by any route before notifying anesthesia provider) k. change in neurovascular status (movement, sensation), eg: leg pain,weak legs, inability to ambulate l. fever, chills, back pain, stiff neck (risk for meningitis) m. leaking or dislodged epidural catheter (stop infusion) NOTE: Duramorph (morphine) and Sublimaze (fentanyl) s common adverse reactions are: 1) respiratory depression 2) urinary retention 3) pruritis 4) nausea and vomiting Marcaine (bupivacaine) s common adverse reactions are: 1) hypotension 2) decrease in sensation and movement 3. For OB patients, assess and NOTIFY anesthesia provider for: a. any side effect in #2 above b. any non-reassuring FHT pattern Placement of patient with epidural infusion: 1. All epidural infusions can be placed on Telemetry, ICU, INT. and OB. 2. Marcaine pain pump or nerve block patients can be placed on any clinical area. Documentation 1. Nurse s Flow sheet a. date and time of insertion b. name of person inserting epidural catheter 2. Epidural flow sheet (form # ); for OB, Labor flow sheet (form # ) (leave blank if not applicable) Neurovascular/CVA flowsheet. a. medication, solution, and concentration

6 b. infusion rate c. vital signs,o2 saturation, LOC/sedation scale, pain level, movement/sensation, neurovascular checks. FHT as per protocol using key on flow sheet form # N 11-36A Page 6 d. interventions for unrelieved pain e. Catheter sight checks (placement, leaking, redness) q 4 hours f. tubing/cap changes, side effects, nursing interventions 3. MAR a. medication administered b. amount of medication infused per shift c. time d. initials/signature 4. Patient Teaching Record to Include: a. Rationale of procedure b. Patient's understanding of procedure