PATIENT CARE MANUAL POLICY NUMBER VII-A-15 PAGE 1 OF 3 APPROVED BY: CATEGORY: Vice President and Senior Operating Officer; Rural Health Services & Professional Practice Lead Body Systems; Central Nervous System PURPOSE: POLICY STATEMENT: To identify the educational requirements for patient care providers who care for inpatients with epidural catheters. Covenant Health is committed to ensuring only qualified staff provide direct care to inpatients with epidural catheters. APPLICABILITY This policy and procedure applies Covenant Health, Edmonton Acute Care, patient care providers who are permitted by legislation to dispense or administer medications within their defined scope of practice and who have successfully completed the Certification Module for Epidural/Spinal Analgesia/Anaesthesia. PRINCIPLES: Once patient care provider staff have successfully completed the Certification Module for Epidural / Spinal Analgesia / Anaesthesia, they will be able to: Licensed Practical Nurses, Registered Nurses & Nurse Practitioners: 1. Accurately describe the anatomy of the epidural space and the surrounding structures. 2. Differentiate between the following; - epidural analgesia and epidural anesthesia - epidural analgesia and intrathecal analgesia 3. Identify the difference between lipophilic and hydrophilic opiods, along with the implications on drug action.
PAGE 2 OF 3 4. Describe the advantages of using epidural analgesics for postoperative pain management. 5. Recognize the indicators of catheter migration and the nursing actions required. 6. Discuss the responsibilities of the anaesthesiologist in caring for the patient receiving an epidural analgesic. 7. Explain the expected action and possible side effects of epidural opioids and local anaesthetics. 8. Differentiate between the monitoring requirements when a patient is receiving a combination of opioid and local anaesthetic infusion with or without patient controlled epidural analgesia (PCEA), an opiod alone, or a local anaesthetic alone. 9. Identify the appropriate documentation required for analgesic administration and patient monitoring. In addition, Registered Nurses and Nurse Practitioners with Special Clinical Competency (RNSCC) will be able to: 1. Specify the epidural analgesics and the possible methods of administration that an RNSCC may use. 2. Describe or demonstrate the appropriate steps required for; - initiating an epidural infusion with or without PCEA - maintaining an epidural infusion - titrating an epidural infusion - removal of epidural catheter - appropriate administration of adjuncts. RESPONSIBILITY Covenant Health s patient care leaders will support patient care provider training for epidural catheters. Covenant Health care-providers shall ensure they are qualified and competent to provide pre and post insertion care for patients with epidurals.
PAGE 3 OF 3 RELATED DOCUMENTS/ RESOURCES Covenant Health (Grey Nuns and Misericordia) Certification Module for Epidural/Spinal Analgesia/Anaesthesia. Covenant Health Patient Care Policy/Procedure #VII-A-5, Assessment and Care of the Adult Following Surgery or Procedures Completed Under General, Intraspinal Anaesthetic and/or Regional Nerve Block Covenant Health Patient Care P/P #IV-55, Maintenance of I.V./Hypodermoclysis Equipment REFERENCES References listed in the Covenant Health (Grey Nuns and Misericordia) Certification Module for Epidural/Spinal Analgesia/Anaesthesia.
PATIENT CARE MANUAL PROCEDURE NUMBER VII-A-15 PAGE 1 OF 4 APPROVED BY: CATEGORY: Vice President and Senior Operating Officer; Rural Health Services & Professional Practice Lead Body Systems; Central Nervous System ALERT: When an anticoagulant (eg. heparin infusion, wafarin) is ordered on a patient who has an epidural catheter in place, nursing staff will immediately notify the anesthesiologist on call. 1. Refer to Patient Care Orders. All orders for analgesia, anaesthesia, antiemetics, and sedatives must be ordered by an anaesthesiologist or intensivist. 2. Follow assessment and monitoring requirements as outlined in Covenant Health Patient Care P/P #VII-A-5, Assessment and Care of the Adult Following Surgery or Procedures Completed Under General, Intraspinal Anaesthetic and/or Regional Nerve Block. 3. Document patient vital signs on Pain Assessment Flow Sheet and Guidelines (forms CH-1343, CH-1344, CH-1345, and CH-1346). 4. Place Epidural Alert card above the patient s bed. 5. Ensure a patent intravenous or saline lock is available for 24 hours after the last epidural dose. 6. Ensure all epidural medications and solutions are preservative-free.
PAGE 2 OF 4 1.0 PRE-INSERTION CARE OF PATIENT 1.1 Explain procedure to patient. 1.2 Ensure signed consent form is in patient care record. Refer to Patient Care P/P #V-25, Patient Consent for Specific Procedures 1.3 Establish peripheral IV, if not in situ. Check patient care orders for solution and rate. 1.4 Attach patient to blood pressure device and pulse oximetry. 1.5 Ensure oxygen and suction available and functional. 1.6 Obtain baseline BP, pulse and respirations. If patient s sensory and/or motor function has been affected by a previous illness or injury, establish normal baseline for that patient. 1.7 Position patient (dependent on anaesthesiologist s preference). 1.7.1 Lateral Fetal Position chin on chest, knees pulled toward chest and back arched like a cat. 1.7.2 Sitting Up feet on stool, bent over hugging pillow with chin to chest. 1.8 Reassure patient and assist anaesthesiologist as required (i.e. to landmark iliac crest, reposition patient, etc.) NOTE: Some patients may feel a transient sharp shooting pain down the leg when the catheter is inserted from the catheter contacting a nerve root. 2.0 POST-INSERTION CARE OF PATIENT 2.1 Once catheter is in situ, place dressing over insertion site and appropriate adhesive tape over the catheter from insertion site dressing to shoulder.
PAGE 3 OF 4 2.2 Anaesthesiologist will: connect hub and filter; assess catheter placement; and administer test dose. NOTE: The test dose is administered to confirm catheter placement. If catheter placement is the subarachnoid space, the patient will feel a warm tingling sensation down the leg, usually within five minutes. If a test dose containing epinephrine is inadvertently injected into a vein, the patient will have an increase in pulse almost immediately and possibly an increase in BP. 2.3 Monitor pulse and BP q 2 minutes during test dose or as ordered by anaesthesiologist. Following test dose: q 5 minutes x 15 minutes q 15 minutes x 45 minutes or as ordered by anaesthesiologist. 2.4 Ensure all connections (catheter/hub/filter) are taped. For intermittent bolus injection, connect an Interlink injection cap to primed filter. Filter should be flushed with 0.3 ml preservative-free normal saline. for continuous infusion, connect primed administration set and filter to catheter injection cap. Set administration rate as ordered. 2.5 Complete documentation. 3.0 EPIDURAL MEDICATION ADMINISTRATION 3.1 Intermittent Opioid Injection (if no continuous epidural infusion) (Applies to ICU / RR ONLY) 3.1.1 Explain procedure to patient. 3.1.2 Prepare analgesic for administration. Draw up analgesic with a filter straw in 10 ml syringe, then replace filtered needle or straw with blunt cannula.
PAGE 4 OF 4 3.1.3 If a dead-end cap is on end of catheter/filter, use aseptic technique to remove it and attach an interlink injection cap. Discard deadender. 3.1.4 Thoroughly cleanse injection cap of epidural catheter with povidone-iodine swab. NURSING ALERT: Do not use alcohol to prepare the injection cap. Alcohol may cause spinal cord damage. 3.1.5 Allow povidone-iodine to dry for two full minutes, then wipe with sterile dry gauze to avoid injecting disinfectant into the epidural. 3.1.6 To check for placement, insert blunt cannula of empty 3 ml syringe. Gently aspirate plunger of syringe. Observe. When aspirating there should be no fluid or less than 0.5 ml of clear fluid. NURSING ALERT: Observe catheter for fluid color when aspirating. If > 0.5 ml fluid or blood tinged fluid is aspirated, DO NOT inject analgesic or fluid aspirated. Catheter may be misplaced. Save fluid to show anaesthesiologist. Notify the anaesthesiologist. 3.1.7 Remove blunt cannula and syringe from injection cap and dispose in garbage. 3.1.8 Insert syringe of medication and slowly inject analgesic. 3.1.9 Slowly flush catheter with 0.5 ml normal saline (preservative free). 3.1.10 Ensure catheter is labelled Epidural Only, to prevent inadvertent IV bolus administration. 3.1.11 Monitor as described in 2.3.
Addendum to the Epidural Peripheral Nerve Block Certification Package (2014) While reviewing the package for certification/recertification for Epidural/Regional Nerve Blocks, we noticed several items that we would like to clarify/bring to your attention. 1. In several places, the package discusses the role of the LPN. ( Page 3 #3 and #5b, Page 14, section 3, 3) At this time, LPN s cannot be part of an independent double check with epidural medications. However, when an LPN receives a patient with an epidural into her/his care; the LPN must ensure that the correct medication is infusing at the correct rate, that all of the equipment is in order and that the site is intact. However, when the drug is changed, or when the rate is changed, 2 RNSCC s are responsible to do the independent double check as this is not in the scope of practice for the LPN. 2. Several surgeons have been ordering the foley catheter be removed prior to the discontinuation of the epidural catheter. A review of the literature supports this practice if the epidural catheter is a thoracic placement. Quoting Day, Rene et al., 2010, Conscious awareness of bladder filling occurs as a result of the sympathetic neuronal pathways that travel via the spinal cord to the level of T10 through T12. Initiation of voiding occurs when the efferent nerve pelvic nerve, which originates in the S2 S4 area. McCaffery and Pasero, 2010, also support the early removal of foley catheters for patients that have a thoracic epidural catheter for post operative pain management. Varadhan et al (2010), Enhanced Recovery After Surgery: The future of Improving Surgical Care, also encourages the early removal of the foley catheter with a thoracic epidural catheter. Therefore, if the surgeon orders the foley be removed and the patient has a thoracic epidural catheter, it is reasonable to remove the catheter even though the epidural is insitu. Please note that patients with a lumbar epidural will potentially have more difficulty voiding because of the specific placement of the catheter in relation to the enervation required for awareness of bladder filling and emptying. 3. When assessing the dermatomes in the lower extremities, it is acceptable to either name the anatomical position of the ie, block or to state the dermatome. (ie mid thigh or L3 4) 4. Just a reminder (page 18) that assessments are best performed determining the level on one side of the patient s body and then moving to the other side of the bed to assess the other side of the patient s body. Please remember to document the method of determining the dermatome.(ie. Ice or light touch). This provides consistency of communication. 5. Dr. Knight, Chief of Anesthesiology at the Misericordia has requested that nursing always give information about a patient s fluid status when requesting a bolus for a low blood pressure. For example, whether the patient has already received boluses and when and what the patient s fluid balance is. 6. The anesthetists at the Misericordia have decided that they are not comfortable with nursing staff reconnecting the epidural catheters in the event it becomes disconnected. The potential for contamination of the catheter and introduction of bacteria into the catheter with a resulting epidural abcess is too great a risk. Therefore, if an epidural catheter does become disconnected, do not reconnect as per the manual, cover the catheter tip with a sterile gauze and call anesthesia for further direction and orders. References 1. Pasero, Chris and McCaffery, Pain Assessment and Pharmacologic Management. Mosby Elsevier. St. Louis. 2011. Pages 428and 502. 2. Day, Rene et al. Textbook of Canadian Medical surgical Nursing. Lippincott Williams and Wilkins. Philadelphia. 2010. Page 1411. 3. Varadhan, Krishna et al. Enhanced Recovery After surgery: The Future of Improving Surgical Care. Critical Care Clin 26(2010) 527 547.