DOCUMENT CONTROL PAGE

DOCUMENT CONTROL PAGE Title Title: GUIDELINES FOR THE MANAGEMENT OF CONTINUOUS EPIDURAL INFUSION IN CHILDREN Version: 3 Reference Number: Supersedes Supersedes: All previous versions (1998, 2007) Description of Amendment(s): New hospital contact details applied. New infusion pump details and pressure area care advice applied. Recent evidence applied. Originator or modifier Approval Originated By: Denise Jonas Designation: Lecturer/practitioner in Children s Pain Management Modified by: Denise Jonas Designation: Lecturer/practitioner in Children s Pain Management Approval by: Professional Nurse Forum Sub Committee Approval Date: [if required] Application Delete as necessary All Patients Patients Patients Children only All staff Staff Group (Nursing and medical) Other (Insert) Circulation Issue Date: September 2009 Circulated by: Children s Pain Team Issued to: Nursing and medical staff Review Review Date: September 2011 Responsibility of: Children s Pain Team D. Jonas/ Sept 2009 Page 1 of 16

POLICY CONTROL PAGE (2) CIRCULATION DOCUMENT Circulation List: For Information Central Manchester and Manchester University Hospitals NHS Trust is committed to promoting equality and diversity in all areas of its activities. In particular, the Trust wants to ensure that everyone has equal access to its services. Also that there are equal opportunities in its employment and its procedural documents and decision making supports the promotion of equality and diversity. Refer to section 8 for more detail on undertaking equalities impact assessment. This document must be disseminated to all relevant staff, refer to section 10: Dissemination and Implementation The Policy must be posted on the intranet: Date Posted: D. Jonas/ Sept 2009 Page 2 of 16

Royal Manchester Childrens Hospital GUIDELINES FOR THE MANAGEMENT OF CONTINUOUS EPIDURAL INFUSION IN CHILDREN These guidelines should be used in conjunction with the children s pain management epidural protocols, epidural nursing care-plan and infusion chart. Introduction Continuous epidural infusions are now used routinely for any child with moderate to severe pain 1. An epidural is the administration of local anaesthetic solution (with or without an adjuvant such as Clonidine or Fentanyl). The local anaesthetic is introduced into the epidural space via a dedicated epidural line and infused using a dedicated epidural pump. This specialist technique enables analgesics to infuse close to the spinal nerves where they exert a powerful analgesic effect. Epidural catheters are normally inserted when the child is anaesthetised in theatre by a trained anaesthetist 3. The epidural catheter is sited as close as possible to the dermatome level affected by the pain or operation 2. In an operation in the child s lower abdomen or hips the epidural will normally be sited in the lumbar region. The spinal cord contains opioid receptors, analgesia infused into the epidural space will act directly on these opioid receptors. Lower doses of local anaesthetic and additional opioid provide effective analgesia and minimise complications such as sedation and ileus. Epidural analgesia diminishes the body s stress response to surgery thus reducing recovery time and morbidity. Good quality analgesia is more likely with continuous epidural infusion rather than intermittent bolus doses. Contraindications 2 any child with: Bleeding disorder or low platelets Raised intracranial pressure Systemic or local sepsis Known allergy to local anaesthesia Refusal to consent to insertion of the epidural (child and parents must be made aware that there are other types of pain relief that can be used). Use with caution in children with: Spina Bifida Hypovolaemia Pyrexia. Adverse effects (similar to those in adults) 2,7 Hypotension Local anaesthetic can spread outside the epidural space and block the sympathetic nerves resulting in vasodilation and hypotension. The patient may also complain of nausea. Rarely the epidural can spread above the dermatome level of T 4 blocking the cardio-accelerator nerves leading to bradycardia and hypotension. Bradycardia in patients with thoracic epidural should always be investigated as it is not necessarily associated with blocking of the cardio-accelerator nerves. Respiratory impairment or respiratory depression - opioids can cause a reduction in the sensitivity of the respiratory centre to CO 2 leading to shallow and slow respirations. This is less likely to occur with lipid soluble opioids such as Fentanyl. D. Jonas/ Sept 2009 Page 3 of 16

Close monitoring of sedation score, respiratory rate, dosage appropriate to the age and weight of the child can minimise this adverse effect. A close indication of impending respiratory depression is increased sedation and reduced respiratory rate. Rarely local anaesthetic can spread above the dermatome level of T 4 blocking motor nerves associated with the diaphragm. Early indications of a high block are that the child complains of numbness in the hands and difficulty in raising their shoulders. Local anaesthetic toxicity accumulation of local anaesthetic is rare but may result in muscle twitching, irritability, excessive sedation, hypotension, convulsions or cardiac arrhythmias. The prolonged ½ life of local anaesthetic drugs renders infants more susceptible to the side-effects of local anaesthetic toxicity, therefore suggested duration of epidural infusion in infants under three months should be a maximum of 48 hours 5,6,7. To minimise the risk of toxicity, epidural catheters are sited as close as possible to the dermatome level that needs to be blocked. This will allow for reduction in volume whilst providing effective analgesia. If toxicity is suspected then stop the epidural infusion and contact the on-call anaesthetist for advice. Dural puncture is a risk associated with the insertion of the epidural catheter. If the needle punctures the dura then cerebral-spinal fluid will leak. The anaesthetist can remove the needle and make a further attempt at a different level or abandon insertion of the epidural. The patient has the potential to develop a postural headache following dural puncture, if this occurs seek advice from the on-call anaesthetist 2. Loss of motor function leg weakness or loss of movement will occur if the motor nerves supplying the legs are blocked. Persistent loss of movement in the feet will increase the risk of the child developing pressure sores. Increased degree of motor weakness when the epidural infusion has been stopped may imply the development of an epidural abscess; seek advice urgent from the on-call anaesthetist if a child is unable to move their feet. Lack of sedation can be problematic in young toddlers, lack of pain due to effective analgesia may prompt the child to try to stand up or move from the bed causing inadvertent disconnection of the epidural catheter. Mild sedation may be required to maintain the continuity of the epidural. Nausea and vomiting this is opioid induced due to stimulation of the chemoreceptor trigger zone in the 4 th ventricle of the brain. Anti-emetics such as Ondansetron and Cyclizine may reduce the effects (See nausea and vomiting protocol). Itching this is normally as a result of activation of the opioid receptors in the spinal cord releasing increased histamine release from mast cells, IV anti-histamine such as piriton are usually effective in reducing the discomfort. Low dose Naloxone may also be used to reduce the effect of the opioid within the body. Urinary retention this may be caused by the epidural directly blocking the bladder nerves but it is usually associated with opiate induced constriction of smooth muscle of the bladder neck. Urinary retention is more common in adolescents 7 ; pre-emptive urinary catheterisation may be necessary 2. Infection bacteria can be introduced into the epidural space from contaminated equipment or drugs or infection can travel up the catheter from the skin. Epidural abscess is rare but any redness around the site, back pain (in a patient who has not undergone spinal surgery); motor block or weakness, tenderness or purulent discharge should be treated seriously. MR scan may be necessary to exclude the presence of an epidural abscess. If the child develops any of these signs contact the anaesthetist on-call for advice 7,9. D. Jonas/ Sept 2009 Page 4 of 16

Staff training All nursing staff caring for a child receiving epidural analgesia must have attended a formal training session provided by the children s pain team 4. Epidural bags and rates can only be changed by staff who have attended a formal training session and been formally assessed as competent by a trained assessor. Competent staff may only change a rate on the epidural infusion if they have discussed the change first with a member of the pain team or the on-call anaesthetist. Any problems with the epidural infusion should be always directed to a member of the pain team, a consultant anaesthetist or the on-call anaesthetist 3. Equipment required to commence Epidural infusion Hospira Gemstar Epidural infusion pump 4. Pulse oximeter with age appropriate size probe and apnoea alarm if child under 6 months of age. Dedicated epidural infusion set with yellow line through infusion giving set 3,4. Resuscitation equipment in area where the child will be nursed. Yellow epidural observation chart Epidural infusion prescribed as per protocol on child s pink prescription sheet. (See red pain manual for protocol) Prescribed bag of epidural fluid and additive if necessary. Children s division drug additive label if additive is used. Intravenous Naloxone, Piriton and Ondansetron must be available in the ward/unit medicine cupboard where the child is nursed. Epidural infusion bags Three types of epidural infusion bags are used within Royal Manchester Children s Hospital: Type of Local Anaesthetic Strength Additive Levobupivacaine 0.125% (1.25mg/ml) None Levobupivacaine 0.125% (1.25mg/ml) Clonidine 1.5 micrograms per ml Levobupivacaine 0.1% (1mg/ml) Fentanyl 2 micrograms per ml All drugs given via the epidural route must be preservative free. Assessment of child Epidural analgesia is normally considered for moderate to major surgery requiring pain relief for more than 24 hours. The anaesthetist will consider the benefits and risks of providing epidural analgesia for each individual child prior to surgery. Parents and child should be given full explanation of epidural analgesia including the risks, benefits and side effects. A leaflet entitled Epidural Infusion Information for Parents and carers is available to reinforce any verbal information given 2. The ultimate responsibility for the epidural infusion remains with the individual anaesthetist who inserts the epidural catheter 2. The child s temperature, pulse, respirations and blood pressure should be recorded before the child goes to theatre to provide a baseline by which to compare future observations. The child should be examined to check for any abnormal limb weakness or loss of sensation to prevent present problems from being associated with the use of the epidural. The nurse will explain the pain assessment tool to the child and parent to ensure that they understand how to use the tool in the postoperative period 3. D. Jonas/ Sept 2009 Page 5 of 16

Action Pre-operative Assessment 1 The anaesthetist will discuss the use of an epidural infusion with child and parents for management of their child s pain. 2 The parents and child (if appropriate) will be given an epidural infusion information leaflet 3. Preparation of the area 3 The child s bed will be prepared with a pulse oximeter. Suction and oxygen at the bedside will also be checked. Infants under 6 months of age will require both pulse oximeter and apnoea alarm. Naloxone will be available on the ward/unit area. Ondansetron and Piriton will be available on the ward/unit area. Theatre Management 4 The epidural will be inserted by a trained anaesthetist using a full aseptic technique. Masks, gloves and gown must be used 3. The epidural must be secured with a clear dressing and mefix tape. The remaining epidural catheter should be taped up the child s back to the shoulder using mefix 3. The filter must be intact and secured to the epidural catheter between two pieces of clear dressing eg. Tegaderm 3. The connection will be secure but remain visible. The catheter must have a yellow epidural label attached 4. 5 A dedicated for epidural use only pump (Hospira Gemstar) and epidural line (yellow) will be used at all times; no Rationale To obtain the child and parents co-operation and ensure they are adequately informed. To reinforce verbal information given by the anaesthetist. This ensures that the child is nursed in a safe environment, where appropriate monitoring is available and safety measures are undertaken 3. To reverse the effects of the Fentanyl (if added to the infusion solution) should respiratory depression occur. To reduce the incidence of nausea and vomiting or itching associated with the use of Fentanyl. To minimise the risk of complications. To minimise the risk of infection. This ensures that nursing staff are able to see where the epidural enters the skin and be able to check for migration of the catheter, leakage or bleeding. The use of the filter reduces the risk of infection whilst securing the remaining epidural catheter reduces the risk of kinking. The securing of the filter to the catheter with clear dressing will prevent inadvertent disconnection of the filter and minimise infection. To ensure safe programming of the pump and to exclude mistakes made by human error. D. Jonas/ Sept 2009 Page 6 of 16

other infusion device must be used 3,4. The epidural pump must be programmed by and checked by two IV & epidural competent members of theatre staff or an anaesthetist. The pump will be programmed to include both minimum and maximum infusion rates according to the child s weight, based on the epidural protocol 4. The prescription will be written according to protocol. (See red pain manual for protocols) 6 The infusion will be made up following aseptic non-touch technique (ANTT) principles according to the prescription or using a pre-prepared bag available from pharmacy. The bag will be correctly labelled using a children s division drug label. The preparation will be made according to the Trust drug policy and management of controlled drugs policy following ANTT principles. 7 The yellow epidural infusion observation chart must be commenced as soon as the epidural infusion is connected to the child. Observations must be recorded at a minimum of hourly. The anaesthetist must complete all sections of the yellow observation form before the child leaves theatre 3. A minimal acceptable blood pressure will be also recorded on the epidural form. An epidural care plan (see appendix 1) should be commenced and attached to the child s notes. 8 The recovery nurse/oda must document a least one set of observations before the child leaves theatre. 9 The recovery nurse/oda must ensure that the child s pain is controlled before To ensure that the amount of local anaesthetic is based upon the child s weight and to avoid toxicity and other adverse effects. To ensure that the IV preparation is as clean as possible. (Infusion bags prepared at ward/theatre level expire after 48 hours). To indicate what concentration of additive is in the bag and to enable the nurse to check the concentration against the prescription at the start of the shift. To ensure that the child s safety is maintained and the protocol adhered to. To provide accurate documentation of insertion of the epidural catheter. To provide parameters for the nursing staff when considering intervention for hypotension. To provide consistent documentation in the child s nursing care plan. To provide a baseline of observations prior to the child leaving theatre. To ensure maximum comfort for the child. Anaesthetists are readily available in theatre D. Jonas/ Sept 2009 Page 7 of 16

they leave theatre. Pain will be assessed using an age appropriate pain assessment tool 2. 10 If further analgesia is required in the form of bolus dose of local anaesthetic or bolus dose of opiate then the child must remain in recovery for at least a further 20 minutes. 11 The recovery nurse/oda and ward nurse must check the prescription, epidural bag, labelling and programming of the pump before the child leaves recovery. The ward nurse will check that all the documentation has been completed in particular the yellow epidural observation form. Care of the child - Observations 12 All observations must be undertaken and recorded hourly. All sections of the epidural infusion observation chart must be completed. 13 The child s respiratory rate and sedation score will be recorded at minimum hourly. Minimum respiratory rates are a guide; they don t take into account respiratory effort or depth of respiration. The child will indicate signs of increased sedation alongside a reduction in respirations. 14 The child will be monitored continually using a saturation monitor and the readings recorded hourly. 15 The child s heart rate will be recorded hourly should additional analgesia need to be given. To assess the effectiveness of any additional analgesia before the child leaves theatre. To ensure that the prescription is written according to protocol. For the nurse to accept accountability for the epidural infusion and pump. Any errors made can be rectified before the child leaves theatre. At each shift change two nurses must undertake the same checking of the pump, epidural bag and prescription. To maintain accurate records and to provide the nurse with essential information regarding the insertion and site of the epidural catheter. To detect early signs of the adverse effects of the epidural infusion. To detect early signs of increased sedation or impending respiratory depression. If respiratory rate below level for child s age or sedation score of 4 then stop infusion and contact on-call anaesthetist. If respiratory depression suspected then follow Event Protocol (see red pain manual). Respiratory depression usually has a slow progressive onset rather than a sudden event. To detect signs of respiratory depression and in accordance with the protocol. To indicate possible increases in levels of pain due to increased heart rate. Or to detect possible local anaesthetic toxicity due to bradycardia. D. Jonas/ Sept 2009 Page 8 of 16

16 The child s blood pressure will be recorded hourly. Record blood pressure every 5 minutes for 30 minutes following bolus dose of local anaesthetic solution. In order to take prompt action if blood pressure falls below parameter set by anaesthetist by the administration of a prescribed fluid bolus of 0.9% sodium chloride. In addition observe for hypotension as a direct result of the addition of Clonidine in the epidural solution. 17 The child s pain will be assessed and documented hourly using a pain assessment tool 2. 18 The child s legs and feet will be monitored for normal movement and sensation if the epidural sited is affecting the lumbar and lower thoracic dermatomes. The child s hands, arms and shoulders will be monitored for normal movement and sensation if the epidural sited is affecting the upper thoracic dermatomes. The child s skin will remain intact. 19 The child will be observed hourly for signs of nausea & vomiting 20 The child will be observed for signs of itching or urine retention. Children receiving Fentanyl epidural infusions are at risk of developing opiate To ensure that the analgesia is effective and the child s pain is controlled. Contact on-call anaesthetist if pain is: uncontrolled, pain score of 7 or more, or pain score of more than 4 for 3 consecutive hours, Anaesthetist will need to assess child as an epidural bolus may need to be administered. Reposition child if pain only on one side to encourage spread of the block over the body. Prevent motor block and the development of pressure sores. Dense motor block is more common in lumbar epidurals. To aid detection of neurological complications developing 3. To detect early signs of excessive blockade and possible impending respiratory impairment. Observe skin prominences 3 hourly. In order to take prompt action to reduce the discomfort of nausea and vomiting by use of anti-emetics. To detect early sings of adverse effects of Fentanyl (if added to the infusion) and take appropriate action by administering antihistamines or reduction in infusion rate. If administration of anti-histamines ineffective then contact on-call anaesthetist. Intractable itching may necessitate the removal of Fentanyl from the infusion. Urinary catheterisation may be necessary if the nerves surrounding the bladder area are D. Jonas/ Sept 2009 Page 9 of 16

induced urinary retention. 21 Contact on-call anaesthetist if child develops a postural headache (pain increases when child is sat upright), Contact on-call anaesthetist if child develops loss of motor function or paralysis. 22 The rate and volume of the epidural infusion will be recorded hourly affected. Opioids can cause relaxation of the detrusor muscle and thus an increase in bladder capacity. If urinary catheterisation is required then the catheter should remain in situ until the epidural has been stopped. This may be due to dural tap and require specialist intervention. This may be due to impending nerve damage. To ensure accurate recording of amount child has received. To detect early errors with pump failure. (Use in conjunction with Trust IV fluid chart). If pump appears faulty, stop infusion, contact pain team or on-call contact on-call anaesthetist to reprogram a new pump. Send the faulty pump to medical engineering, labelled and with maintenance order. 23 The epidural catheter and filter will be checked hourly 3. The epidural site in the child s back will be checked at for any leakage or bleeding at least three hourly and when moving the child. 24 Any changes to epidural by anaesthetist or any actions taken to minimise complications must be recorded in the child s notes or care plan. 25 Do not nurse child head down (even if hypotensive). Nurse child with head up with at least a 45 0 angle. There should be adequate supervision of the child with the epidural infusion especially when they move out of bed. To ensure complete connection and that the epidural infusion line remains patent. To minimise the risk of infection. To ensure that the dressing remains intact. (Do not remove or change the dressing) Leakage from the site does not always necessitate the removal of the epidural 2. If pain is well controlled then the leakage should be observed and documented on the child s notes or care plan. To maintain accurate and legal records. Epidural fluid will gravitate in the body towards the respiratory nerves if the patient is nursed head down and increases the risk of respiratory depression. Change of position promotes healing but the safety of the child must be always considered. Care must be taken when D. Jonas/ Sept 2009 Page 10 of 16

moving the child from the bed into a chair to avoid dislodging or pulling out the epidural catheter. 26 Always check the epidural site after moving the child 27 Nursing staff should actively encourage the use of supplementary analgesia such as Paracetamol whilst the child is receiving the epidural infusion. NSAIDs such as Ibuprofen or Diclofenac may also be given if prescribed by child s medical team 6. Other opiates such as Codeine, or morphine should not be used if Fentanyl is infusing in the epidural solution. Sedatives should not be used if Clonidine is infusing in the epidural solution however opiates may be used with Clonidine if prescribed by consultant anaesthetist. Management of epidural disconnection the filter 28 If the epidural catheter becomes inadvertently disconnected from the filter proximal to the patient then the following action should be taken 3. a. If the connection has been immediately witnessed then the two ends must be wrapped in a sterile towel, stop the infusion and contact the on-call anaesthetist. The anaesthetist using an aseptic technique will then clean both ends with an alcohol wipe, cut the end of the catheter with sterile scissors and reconnect the filter to the epidural catheter. The connection must be then secured with a clear dressing eg. Tegaderm. b. If the disconnection has not been witnessed and the patient can be safely managed with alternative analgesia then the epidural must be removed. c. If the on-call anaesthetist considers that it may be difficult to manage the child s pain by any other method then the on-call To ensure that the epidural catheter has not been dislodged. Paracetamol used in addition to local anaesthetic provides optimum plasma levels of another analgesic thus a reduction in epidural rate without breakthrough pain is more successful. Additional opioids will only increase the risk of respiratory depression if used in conjunction with an epidural containing Fentanyl. Additional sedatives will increase the risk of respiratory depression if used in conjunction with an epidural containing Clonidine. Disconnection from the filter creates a major route for infection to travel into the epidural space. Securing the filter connection with a clear dressing will minimise disconnection. If the disconnection has not been witnessed then the catheter end should be considered contaminated and the epidural removed. Epidural catheters are frequently inserted into high risk patients where use of intravenous opioids may compromise their respiratory status. Removal of an epidural in D. Jonas/ Sept 2009 Page 11 of 16

anaesthetist must contact the consultant anaesthetist on-call, to discuss the risks and benefits of reconnecting the epidural. Changing epidural bags 29 Pre-prepared replacement bags of epidural solutions with Fentanyl will be available made up from pharmacy Clonidine can be added by the on-call anaesthetist, recovery staff or a member of the pain team following ANTT procedure. All epidural bags made up using ANTT procedure expire after 48 hours. 31 The epidural bag will be changed following ANTT principles. Epidural giving sets must be changed after 48 hours. When changing or discontinuing bags of epidural solution two IV competent staff will witness and document on the yellow observation form the discarding of any surplus epidural solution into a burn bin 2. The nurse when caring for a child with an epidural infusion must check that there are sufficient epidural bags in the unit/ward for the intended duration of the epidural. Replacement bags must be ordered from pharmacy. Discontinuing the epidural infusion 32 The epidural infusion will be discontinued when the child s pain is controlled with other analgesia usually 2-5 days. This depends on the age of the child and severity of the procedure. All spinal surgery patients will have their epidural removed on the 3 rd postoperative day. 33 Remove the epidural catheter using a aseptic technique 2. Remove epidural dressing tape humanely. Slowly pull out the catheter applying gentle tension. Place a small spot plaster over the entry site on the child s back. such a child may cause an increased risk. Any decision to leave an epidural catheter in a child that has previously become disconnected must be documented in the child s notes by the anaesthetist. To minimise the risk of infection. To minimise human error when making up epidural bags containing an additive. To minimise the risk of infection To minimise the risk of infection To ensure correct disposal of unused epidural solution. To ensure that the child receives continual analgesia. To ensure replacement epidural bags are available over weekend periods. To ensure that the epidural is not discontinued inappropriately and the child pain is continued to be managed effectively. To minimise infection, the risk of infection increases the longer the epidural catheter remains in the skin 2. To minimise infection to the child and the nurse. To prevent any discomfort to the child. D. Jonas/ Sept 2009 Page 12 of 16

Examine the catheter tip to ensure that the whole catheter is removed 7. Send tip of catheter to microbiology laboratory. Document removal on the yellow epidural form and in the child s notes or care plan. 34 If Fentanyl has been added to the epidural infusion then the child must continue to have their observations of blood pressure, heart rate and respirations recorded hourly for at least 6 hours from discontinuation of the epidural infusion. 35 Any children receiving daily low molecular weight heparin (LMWH) or Enoxaparin. The epidural catheter must be removed a minimum of 10-12 hours after the previous dose of heparin. A subsequent dose can then be given a minimum of 2 hours after the removal of the epidural catheter 2. To ensure that the epidural catheter is removed intact. To ensure that any infection is identified and treated with the appropriate medication. To provide accurate records. Fentanyl remains active within the epidural space and the tissues for up to 6 hours after the infusion has been discontinued. Children undergoing anticoagulant therapy are at increased risk of bleeding into the epidural space and surrounding tissues or development of a spinal haematoma when the epidural catheter is removed. D. Jonas/ Sept 2009 Page 13 of 16

References 1. Llewellyn, N,. Moriarty, A. (2007) The national pediatric epidural audit. Pediatric anaesthesia. 17:520-533. 2. Middleton, C. (2006) Epidural Analgesia in Acute pain Management. Whurr Publishers LTD, Chichester. 3. Royal College of Anaesthetists of Great Britain and Ireland (2004) Good practice in the management of continuous epidural analgesia in the hospital setting. RCA, London. 4. National Patient Safety Agency (2007) Safer Practice with epidural injections and infusions. Number 21. London, NSPA Available at www.npsa.nhs.uk 5. Eyres, R. (1995) Local anaesthetic agents in infancy. Paediatric Anaesthesia. 5:213-218. 6. Lloyd-Thomas, A. Howard, R. (1994) A pain service for children. Paediatric Anaesthesia. 4:3-15. 7. Patel, D. (2006) Epidural analgesia for children. Continuing education in anaesthesia, critical care and pain. 6(2):63-66. 8. Chapman, S. Day, R. (2001) Spinal anatomy and the use of opioids Professional Nurse. 16(6):1174-1177. 9. Lin, Y, C., Greco, C. (2005) Epidural abscess following epidural analgesia in pediatric patients. Paediatric Anaesthesia. 15:767-770. D. Jonas/ Sept 2009 Page 14 of 16

Appendix 1 - Royal Manchester Childrens Hospital - Childrens Pain Management - Epidural Nursing Care Plan (To be used in conjunction with the epidural protocol, epidural observation chart, continuous epidural infusion guidelines and EWS) Intravenous access must be maintained at all times for the entire duration of the epidural infusion NAME: PATIENT NUMBER: DOB: WARD CONSULTANT: DATE NUMBER NEED/PROBLEM INTENDED GOAL NURSING INSTRUCTIONS 1 Epidural inserted and infusion in progress 2 Child will be observed in theatre recovery 3 Child will be observed for any complications Safety of child will be maintained, problems identified and action taken Child s pain will be well controlled. Pain assessment score will be 3 or less. Child will be haemodynamically stable To detect and treat any potential complications POTENTIAL PROBLEMS 4 (a) Hypotension Maintain haemodynamic status and maintain systolic blood pressure above minimum level set by anaesthetist. 4 (b) Respiratory impairment or depression from either opiates or high thoracic block 4 (c) Loss of motor function or Child will maintain their respiratory function within normal limits Child s skin will remain intact. Full 1. Observe, monitor and record specific epidural observations on epidural observation chart 2. Epidural pump and bag to be checked against child s prescription sheet at start of each shift. 3. Child will be reviewed daily by on-call anaesthetist or member of children s pain team 4. Consider pre-emptive urinary catheterisation in theatre in children receiving lumbar epidurals 1. Monitor and record observations on recovery chart every 5 minutes for 30 minutes and then every 10 minutes if they remain within normal limits for the child. 2. If additional analgesia bolus is required then child must remain in recovery for further 20 minutes. 3. Record final set of epidural observations on epidural chart prior to discharge from recovery. 4. Check epidural prescription, rate, pump programme, epidural insertion site when handing over to ward/unit nurse. 1. Observations to be recorded at least hourly on epidural chart. 2. All children must have continuous oxygen saturation monitoring. 3. Infants under 6 months must have additional apnoea monitoring 1. Record blood pressure hourly and record blood pressure every 5 minutes for 20 minutes following any bolus dose of epidural analgesia 2. Suspend infusion and inform on-call anaesthetist if systolic blood pressure falls below minimum level set by anaesthetist. 3. Give fluid bolus of 0.9% sodium chloride as prescribed. 4. Resume epidural infusion when blood pressure within normal limits 5. Do not nurse child head down. 1. Ensure child has continuous oxygen saturation monitoring. If SP0 2 drops below level set by anaesthetist or respiratory rate drops below minimum rate for child s age then suspend infusion, give oxygen and contact on-call anaesthetist. Ensure Naloxone is available. 2. Record child s sedation score hourly. If sedation score is 4 then suspend infusion, give oxygen and contact on-call anaesthetist. Consider removal of Clonidine from infusion if used. 3. With high thoracic epidural, if child complains of numbness or tingling in arms or hands then suspend infusion, sit child upright, give oxygen and contact on-call anaesthetist 1. Lower thoracic or lumbar epidural monitor movement in both legs hourly. If no movement in both legs (motor score = 3) then suspend infusion and contact on-call anaesthetist. Loss Epidural nursing Care plan D. Jonas/Aug 2009 Page 15 of 16 REVIEW DATE & SIG. DATE SOLVED & SIG.

diminished sensation 4 (d) Inadequate analgesia movement of toes or feet, arms and hands will be maintained Child s pain will be controlled 4 (e) Nausea & vomiting Child will have relief 4 (f) Urinary retention Child will maintain bladder function 4 (g) Itching (Pruritus) Child will have relief 4 (h) Infection Infection will be prevented 4 (i) Loss of epidural catheter or leakage 5 Removal of epidural catheter 6 Observe for further complications Inadequate analgesia or catheter loss will be prevented Child s epidural catheter will be removed safely and intact To ensure no further adverse complications of motor function may indicate severe neurological complication. 2. High thoracic epidural monitor movement in hands, arms and shoulders. If child complains of numbness or tingling in arms or hands then suspend infusion, sit child upright, give oxygen and contact on-call anaesthetist. 3. Observe child s skin and pressure areas 3 hourly. Ensure 3 hourly movement or turning. 1. Assess child s pain hourly on scale of 0-10 using a pain assessment tool (Faces/numerical ladder or FLACC scale. 2. If pain score 7 or more contact on-call anaesthetist. 3. Give 6 hourly Paracetamol 4. Reposition child if pain apparent on only one side of body unilateral or patchy block. 5. Check epidural insertion site 3 hourly. 1. Treat nausea and vomiting according to postoperative nausea and vomiting protocol. 1. Ensure optimum position for micturation. 2. Catheterise child if necessary. 1. Give intravenous Piriton (Chlorpheniramine) as prescribed according to BNFC. 2. Contact on-call anaesthetist if itching persists consider removal of Fentanyl from infusion 1. Epidural bacterial filter will remain in place at all times secured to epidural catheter with Tegaderm. 2. Bacterial filter position will be checked hourly. If disconnection occurs contact on-call anaesthetist and follow disconnection advice in continuous epidural infusion guidelines. 3. Check epidural catheter insertion site 3hourly, if red or inflamed contact on-call anaesthetist. 4. Record child s temperature at least 4 hourly. 1. Check epidural site 3 hourly for any leakage. Contact on-call anaesthetist if excessive leakage around site and child in pain. 2. Protect catheter by ensuring it is kept free from catching on bed sides etc. Take care when moving child around bed or out onto parent s knee or into a chair. 3. Ensure catheter is connected to filter and secured with Tegaderm. 1. The epidural catheter will be removed following ANTT principles. 2. Lie child on their side with spine curved or sit forward in bed or chair. 3. Remove epidural dressing and tape humanely 4. Slowly pull out the epidural catheter, examine the tip to ensure the entire catheter has been removed. Document removal. Send catheter tip to pathology for culture and sensitivity. 5. If child receiving heparin follow advice regarding LMWH in continuous epidural infusion guidelines 1. Continue to record all epidural observations for period of 6 hours post removal or cessation of the epidural infusion if Fentanyl has been administered in the infusion. Please do not hesitate to contact on-call anaesthetist or children s pain team if you have any concerns regarding a child with an epidural catheter in situ. Epidural nursing Care plan D. Jonas/Aug 2009 Page 16 of 16