CENTRAL IOWA HEALTHCARE Marshalltown, Iowa CARE OF PATIENT POLICY & PROCEDURES Policy Number: 4.84 Subject: Policy: Purpose: Continuous Epidural Analgesia Acute or chronic pain relief provided to a patient by way of a catheter placed into the epidural space for site specific pain control will be initiated and modified by Anesthesia. Pain control will be assessed and management of the epidural catheter will be responsibility of a Registered Nurse. To establish guidelines for assessment and for monitoring a patient receiving continuous epidural analgesia for spinal canal drug administration thus bypassing the blood-brain barrier. Additional Information: 1. Initiation of epidural/intrathecal analgesic therapy will be only by Anesthesia. 2. IV access will be maintained during the course of therapy and 24 hours after last dose of medication. 3. Naloxone will be available in Pyxis for any patient receiving epidural analgesia. Use of naloxone will require cautious considerations: a. use may bring on severe difficult to control pain b. naloxone induced sympathetic stimulation may lead to hypertension, tachycardia, ventricular dysrhythmias, pulmonary edema, cardiac arrest. c. Opioid withdrawal syndrome. 4. Bolus doses are only available by physician order. 5. Other systemic analgesics will be added at the discretion of the Anesthesia to individualize the comfort/function goal to maximize recovery activities. 6. Unwanted effects may be minimized by repositioning, distribution of epidural medication may be altered with change in spinal column alignment. 7. Most common complication is numbness and leg weakness, requiring physician notification and medication titration. Itching, nausea and respiratory depression may occur. 8. Unwanted effects requiring Anesthesia and/or attending physician notification may signify spinal canal hematoma, epidural infection, or systemic absorption of local anesthetic: a. lower extremity weakness b. lower extremity loss of sensation c. respiratory depression d. hypotension e. urine retention indicating lost perception of bladder stimuli f. ringing ear noises g. circumoral numbness h. slow speech i. irritability j. seizure activity k. metallic taste
Continuous Epidural Analgesia, Page 2 Equipment: 9. Information required when notifying Anesthesia should include nature of the problem, vital signs, dermatome level representing effected area and infusion pump settings. 10. Should a separation in infusion line to catheter occur, never reattach. Call Anesthesia. 1. Epidural PCA infusion with key. 2. Prescribed anesthetic solution in bag. 3. Tubing for epidural PCEA pump. 4. Analgesic order sheet, patient chart. 5. Form MR-015 6. Cardiac monitor, pulse oximetry, blood pressure monitor 7. Narcan available in Pyxis. Procedure Key Points 1. For in-room insertion, prepare to assist. 1. Information regarding insertion helps minimize a. Properly identify patient anticipation anxiety. b. Explain procedure c. Explain possible complications d. Explain use of pain scale 2. Obtain signed consent. 3. Organize and assemble equipment a. Pharmacy prepared medication solution bag b. Epidural insertion kit and tray c. Patient monitors 4. Position patient as requested by Anesthesia, 4. Anticipate position to best expose spinal either knee-chin side lying position or landmarks. sitting on edge of bed leaning over bedside table. 5. Confirm the correct medication and infusion 5. Verification by two registered nurses are rate as per policy 4:19 (PCA Infusion) with required with initiation of analgesia IV therapy. another RN. 6. Prime tubing of special epidural kit after 6. Check priming sequence of infusion device in attaching to medication bag. use. 7. Assist Anethesia to connect primed tubing after insertion into infusion pump. 8. Tape all connections on catheter tubing. 8. Taping may prevent disconnection and Label tubing clearly: EPIDURAL moreover prevent accidental administration of INFUSION. drugs into the epidural line. 9. Start infusion. 9. For epidural catheters established in the OR, verify appropriateness of settings, tape over connections and label EPIDURAL INFUSION. 10. Using MR-015, establish a baseline assessment for continual monitoring epidural catheter use. Notify Anesthesia should changes in assessment data develop. 10. Monitored parameters a. VS b. pulse ox c. pain rating d. sedation level e. dermatome level effect
Continuous Epidural Analgesia, Page 3 f. motor function g. urine output NOTE: Pain rating of 3 or less is typically desirable. 11. Dermatome level is tested with alcohol swab. Stimulation in a systematic pattern from head to toe using diagram Figure 2-3 of MR-015 pinpoints level of anethesia and analgesia. Record using C2 through S5 designations on MR-015 flow sheet. (Epidural Catheter Flow Sheet) 12. Assess insertion site appearance, ensure transparent dressing is intact. 13. Monitor for signs of epidural catheter displacement. 14. Monitor for signs of epidural catheter migration. Consult Anesthesia if symptoms develop. 15. Evaluate patient status and pain control every hour for 4 hours, then every 2 hours for 4 hours, then every 4 hours. 16. Reevaluate every hour for 4 hours with any infusion dosage change. 11. The alcohol swab will lose coolness sensation on the skin. Dermatomes are specific skin surface areas innervated by a single spinal nerve or group of spinal nerves. 12. Transparent dressing allows for inspection of drainage. Small amount dried blood may be expected; moisture or blood tinged fluid under dressing should be unexpected. 13. Inadequate pain relief or loss of pain control or no pain reduction with increasing opioid use may indicate displacement. Consult Anesthesia if changes develop. 14. Confirmation of migration involves aspiration from epidural catheter of CSF or free-flowing blood. Symptoms may include: a. unexplained increase in opioid induced side effects b. sensory or motor block or both c. inadequate or assymetrical pain releif d. signs local anesthetic toxicity e. circumoral numbness f. ringing ear noises g. slow speech h. irritability i. metallic taste 15. See MR-015. 16. Motor strength and sensory loss may indicate large motor nerve fiber involvement. Notify physician. Documentation: 1. MR-015 Epidural Catheter flow sheet a. respiratory rate b. VS c. level of consciousness d. urine output e. pain scale f. level of anesthesia using dermatomes g. motor function h. infusion rate i. medication
Continuous Epidural Analgesia, Page 4 j. pulse oximetry k. dressing integrity and insertion site 2. CPSI pharmacy for medication and concomitant analgesics 3. Patient response: assessment and nursing notes Originated by: Intensive Care Effective date: April 03 Authorized by: Anesthesia 7/09 Authorized by: Chief Nursing Officer Date Revision date: 6/07, 3/09, 7/09 Review date: 6/04, 4/17 Distribution: ICU, PACU, WCC, M/S/T/P References: Atlas of Regoinal Anesthesia, 2 nd ed. Katz, J. Appleton & Lange 1994 Providing Epidural Analgesia, Nursing 99, Aug. 1999. pp 34-39 Nursing Procedures, Springhouse Corp. Epidural Administration of Analgesics. pp. 258-261 4th Edition 2004. T:\Data\Policies\CAREPT\cpt4.84r1crk.doc