Epidural Analgesia Guidelines by ipx46851


									            Epidural Analgesia

            Date:         January 2008

            Ref :         PCD004

            Vers :        3

Policy Profile
Policy Reference Number       PCD004
Version                       3
Status                        Approved
Trust Lead                    Director of Nursing/Acute Pain Team
Implementation Date           September 2005
Last Review Dates             January 2008
Next Formal Review            September 2009
Approval Record

Policy Tracker
Consultation                                                   Date
Epidural Analgesia Guidelines                            January 2008
Ref: PCD004 (v3)                                      Status: Approved

Contents                                          Page No
Role of Anaesthetist and the Acute Pain Nurse     3

Role of Nursing and Midwifery Staff               3

Patient Care                                      4

Absolute Contraindications for use of Epidurals   4

Relative Contraindications                        4

Monitoring the Patient                            4

Management of postdural puncture headache         5

Rare Complications of Epidural Analgesia          6

Dartford & Gravesham NHS Trust                                 2
Epidural Analgesia Guidelines                                                January 2008
Ref: PCD004 (v3)                                                          Status: Approved

Epidural analgesia is the administration of agents into the epidural space in the spine
to relieve pain. Pharmacological agents used in epidural analgesia include local
anaesthetics, opioids or a combination of both. A fine bore PVC catheter is inserted
peri-operatively into the epidural space and administers either bolus only or
continuous infusion or a combination of both into the space. The intensity of the
block will depend on the volume and concentration of the drug, the site of the
catheter and the position of the patient. Infusions are titrated using an infusion pump.

Both nursing and medical staff should make daily considerations of the
appropriateness of continuing an epidural.

Patients with Epidurals may be nursed across the trust in the Intensive Care Unit,
High Dependency Unit, Surgical wards, Post Anaesthetic Care Unit. Nursing staff
within these areas have received training and competent to care for patients with this
method of post operative analgesia. Nursing staff within these areas have received
training and are competent to care for patients with this type of post operative

Role of the Anaesthetist and the Acute Pain Nurse
It remains the responsibility of the anaesthetic staff to support staff on the wards
caring for patients with Epidurals. Ward staff will be trained to undertake the day-to-
day management of epidurals. The Acute Pain Nurse will be available Monday to
Friday between 8.00-4.00 p.m. for advice and assessment of patients. Medical
support is also provided on a daily basis by the anaesthetic team. Out of these hours
the Anaesthetist on call will be available. The acute pain team will visit patients with
epidurals at least daily until the epidural has been discontinued. If a patient comes to
the ward via ITU/HDU, with an epidural infusion the ward needs to inform the pain
team to initiate daily reviews.

The initial Epidural settings are checked by two members of staff. The senior
checker must be a Doctor, Operating Department Practitioner or a qualified
nurse. The second person can be any of the above. Recovery nurses should
also check the pump.

Role of Nursing and Midwifery Staff
Under the UKCC’s Scope of Professional Practice (1992) nurses should maintain
and improve their professional knowledge and experience in caring for patients.
Keeping in line with the NHS Plan (2000) nurse’s midwives and therapists will be
empowered to undertake a range of clinical tasks, which will require practitioners to
constantly update their knowledge and expertise. Nurses caring for patients with
epidurals should attend a theoretical teaching programme and have undertaken
clinical competency and demonstrate that they are competent in using infusion
delivery pumps. In house training for epidural pumps will be arranged through the
Acute Pain Nurse.

At the beginning of each shift and when a different nurse takes over the care of
the patient, a qualified nurse must check the pump settings to ensure the
setting is the same as the prescription chart.

The Acute Pain team will communicate any changes regarding the patients
pain management to the qualified nurse responsible for that patients.

Dartford & Gravesham NHS Trust                                                     3
Epidural Analgesia Guidelines                                                January 2008
Ref: PCD004 (v3)                                                          Status: Approved

The registered nurse must be aware of and demonstrate their accountability,
including their own abilities and limitations when caring for a patient who is
receiving continuous epidural analgesia.

Patient Care
Patients with epidural infusions require support and explanation. It will be the
responsibility of the Acute Pain Team to ensure that patients receive information of
the procedure. Nursing staff should also be made aware of the plan, so that pre-
operative Fragmin/Clexane and Heparin can be omitted. A trained nurse must
escort patients who are going for investigations such as x-rays whilst an
epidural is insitu.

Unless contraindicated by the type of surgery or the patient is experiencing heavy
legs (dense weakness) the patient should sit up in bed post epidural.

The Acute Pain team will communicate any changes regarding the patient pain
management to the qualified nurse responsible for that patient.

Absolute Contraindications for use of Epidurals:
   Patient Refusal
   Infection at Puncture site
   Allergy to local anaesthetics
   Coagulopathy (bleeding tendency)
   Uncorrected hypovolemia
   Active neurologic disease
   Unstable spinal fractures

Relative Contraindications:
   Spinal column deformities, laminectomy, or low back pain
   Severe backaches or headaches
   Patient unable to co-operate
   Stable neurologic disease

Monitoring the Patient
In addition to performing routine postoperative observations (RR, BP and HR)
observations specific to epidural analgesia should be made and recorded as
specified on the epidural assessment chart.

The catheter insertion site should be covered with a sterile transparent dressing to
detect leaks, haemostasis and whether the catheter has changed position. Observe
for local/systemic signs of infection. The system should be checked for tightness and
security to prevent leaks at least once every eight hours and the filter should be
observed for hairline cracks. To prevent the chances of inadvertent dislodging the
catheter should be secured at the insertion site and to the patient’s back. Any extra
catheter can be coiled and secured with the filter on the upper anterior chest,
shoulder or abdomen.

Pruritis (itching) - is thought to result from the activation of opioid receptors in the
spinal cord. It is common so be aware of signs of patient discomfort such as rubbing,
scratching the arms, face and neck. Monitor the patient for signs of allergic reaction
such as increased temperature, dysponea, or oedema. The nurse should then
inform the Doctor of signs and symptoms.

Dartford & Gravesham NHS Trust                                                     4
Epidural Analgesia Guidelines                                               January 2008
Ref: PCD004 (v3)                                                         Status: Approved

Nausea and Vomiting – the causes of postoperative nausea and vomiting (PONV)
are multi-factorial. Opioids may also induce PONV, which may require treatment with
an anti-emetic. The anti-emetic of choice within this trust is cyclizine.

Urinary Retention – may be due to opioids inhibition of the parasympathetic nervous
system on the bladder. Important actions include palpation of the bladder for
distension, monitoring intake and output closely. Reassurance should also be given
to the patient. Urinary retention usually occurs in the first 24-48 hours and often
resolves spontaneously.

Hypotension – is the most common side effect of epidural analgesia. The aetiology
of the hypotension should be determined. A falling BP associated with an increased
pulse rate; decreasing urine output, loss of skin turgour and a dry mouth should
indicate the need for volume replacement. Volumes should ideally be replaced with
Colloids (plasma substitutes.) Sympathetic blockade by the epidural local anaesthetic
agent commonly causes vasodilatation below the level of block and may result in a
dramatic fall in blood pressure. If systolic falls <85mmHg stop the Epidural infusion,
lay flat – not head down, elevate legs only – give 4litres of O2/min. Contact duty

Respiratory Depression – regular assessment of the level of sedation, the
character of respiration and O2 saturation’s are essential for patients who are
receiving opioid therapy. Over sedation may lead to respiratory depression due to the
absorption of opioids into the circulation. Using a sedation score will enable changes
in the patient’s state of consciousness to be determined. Raising the head end of the
bed may limit cephalad spread of the opioid. Emergency respiratory equipment
should be made immediately available. If RR <8min and sedation score >2 stop the
epidural and call the duty anaesthetist.

Headache – can be one of the most disabling complications after epidural blocks.
The frequency of the headache is related to the size and design of the needle tip
penetrating the dura. The pain is usually located in the occipital region and may be
associated with neck stiffness.

Management of postdural puncture headache
     Give adequate, regular simple analgesics, such as paracetamol or other
     Maintain hydration – regular oral fluids or if the patient is unable to take oral
     fluids then the IV route should be used
     Avoidance of coughing and straining – stool softening agents or laxatives may
     be useful
     Best rest is usually necessary as the headache is worse when the patient is
     sitting upright
     The anaesthetist responsible for the block should be informed. He or she will
     be able to reassure the patient and monitor the response to the simple
     measures as described. If despite these measures the headache persists,
     the anaesthetist may inject 10-20mls of the patient’s blood into the epidural
     space to stop the CSF leak (“epidural blood patch”) This technique is usually
     rapidly effective in 70 to 80 per cent of cases.

Dartford & Gravesham NHS Trust                                                    5
Epidural Analgesia Guidelines                                                January 2008
Ref: PCD004 (v3)                                                          Status: Approved

Rare Complications of Epidural Analgesia –
Catheter Migration
The migration of an epidural catheter into the intrathecal space or into a blood vessel
is a rare occurrence. A sudden loss of effective analgesia could indicate migration of
the catheter into an epidural vein or into the subcutaneous space.

Epidural Haematoma
Puncture of epidural blood during intraspinal needle or catheter placement occurs in
approximately 3% to 12% of patients. Epidural haematomas can occur as a result of
this trauma or spontaneously in patients taking anticoagulants or those with blood
clotting abnormalities.
A spinal epidural haematoma causes compression of the spinal cord.

Signs and Symptoms
Symptoms vary with the amount and location of pressure on the spinal cord and can
cause an abnormal neurological deficit.
 They may include:
   • Severe localised back pain or tenderness
   • Unilateral or bilateral weakness in the arms, legs or trunk or other sensory
   • Incontinence or inability to control the bowel or bladder

Nursing Care

    •    Assess the patients respiratory status and motor function, by testing the
         patients muscle strength
    •    Do this by asking them to resist your movement or to move actively against
         your resistance.
    •    If the patient is suffering from any of the above symptoms then,

Inform Anaesthetist Immediately
If a spinal Epidural Haematoma is suspected the Anaesthetist will make an urgent
referral for an MRI Scan or CT Scan to confirm the presence of a haematoma and
evaluate the extent of bleeding.

Occasionally, haematomas resolve on their own. However, most need to be
evacuated surgically. Surgery should take place within 12 hours of symptom onset
for the best chance of neurological recovery.

Allergic reaction
Allergic reactions are also a complication epidural analgesia. Nurses should assess
the patient for signs and symptoms of an allergic reaction e.g. respiratory distress,
rash, pruritis, and oedema. The nurse should ensure that the airway is patent and IV
access is readily available.

The epidural space is used as it allows the drug to be injected near to the spinal cord
and the nerves surrounding it. A variety of drugs can be used Morphine,
Diamorphine, Fentanyl, and Bupivicaine. When epidural infusions are in progress
parenteral opioids should be avoided.

The epidural infusion bags currently being used are 250ml bags with Bupivicaine
0.1% and Fentanyl 2mcg/ml in Sodium Chloride (pre-mixed.) The infusion bag is

Dartford & Gravesham NHS Trust                                                     6
Epidural Analgesia Guidelines                                                 January 2008
Ref: PCD004 (v3)                                                           Status: Approved

connected to a special giving set with a filter. This should be labelled with a yellow
‘Epidural’ sticker. Epidural giving sets should not be used for longer than 7 days.
Wasted epidural infusions should be recorded in the CD book/ epidural form or on
the prescription chart as stipulated in the Destruction of Controlled drugs policy.

All of the clinical areas that care for patients with epidurals must stock anti-
emetics, Ephedrine and Naloxone

Continious epidural analgesia must only be administered via a yellow Abbott
Gemstar pump and a dedicated yellow administration set. There are no set
guidelines regarding the frequency, which the epidural giving sets, should be
changed. The portex filter can be used for up to 60 days. The giving set should be
changed if there is known contamination.
The pumps are cleaned prior to being returned to theatre.

Insertion Precautions
It is safe to insert an epidural with patients taking Aspirin or NSAID’s, even though
these drugs are known to effect platelet function. Evidence suggests patients
receiving aspirin and NSAID’s can undergo safe regional anaesthesia
Epidurals can be inserted 6hours following a dose of subcutaneous unfractionated

It is recommended that epidural insertion following a thromboprophylactic dose of low
weight molecular heparin should be delayed by 10-12 hours, at which time the
plasma concentration is at its lowest.

The acceptable upper INR limit for the insertion of an epidural is 1.5.

There is a wide variation in the lowest acceptable level of platelet count reflecting in
different published guidelines, which recommended a range from 50 to 100 × 109 1-1.

If a patient is receiving Xigris – Activated Protein C the presence of an epidural is

Those anaesthetists that perform epidural insertion should adhere to full aseptic
conditions. This should include a formal scrub of the hands and the wearing of a hat,
sterile gown and mask.

Guidelines for the removal of Epidural Catheters
Epidural catheters can be removed by registered nurses who have been trained
to remove epidural catheters. An anaesthetist or the Acute Pain Sister can be
contacted to remove the line. Epidural catheters can also be removed by
registered nurses who are directly supervised by any of the above.

Prior to the removal of epidural catheters you need to check:
    The epidural has been stopped 2 hours before removal
    Alternative analgesia has been prescribed
    No Heparin has been given in the last 8 hours prior removal of catheter
    No Fragmin/Clexane has been given 12 hours prior removal of catheter.
    IV Heparin has been stopped and clotting has returned to normal.

The epidural catheter is checked following removal to ensure that the blue tip is
present. A member of the Acute Pain Team is contacted if this is not present as it
indicates that the catheter may have broken.

Dartford & Gravesham NHS Trust                                                      7
Epidural Analgesia Guidelines                                                      January 2008
Ref: PCD004 (v3)                                                                Status: Approved

Epidural catheter removal is documented in the patient’s nursing notes and includes
a description of the site. This can also be documented on the epidural observation

The epidural site is covered with an occlusive dressing and the site is checked
for redness, swelling and pain two days post removal.

All patients who have epidurals are advised to report any pain at the site or
changes in movement or sensation in their legs during the first two days
following removal of the catheter.

If patients feel any changes in movement or sensation once discharged home
then they should be asked to contact the Acute Pain Sister on ext 8652 or bleep
241 or the Anaesthetic SHO on bleep 242

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Gilbert P, Fulton B, Senthuran S (2002) The Management of Acute Pain Oxford University

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operative prophylaxis and guidelines for regional anaesthesia management Anaesthesiology
analogue 85:874-885

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Madeo M, Samaan A, Alison W, Wilson J, Martin C (1999) Contamination of bags for
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Dartford & Gravesham NHS Trust                                                           8

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