EPIDURAL ANALGESIA Munroe Regional Medical Center

EPIDURAL ANALGESIA Munroe Regional Medical Center
Organizational Development 1.0 Contact Hour Developed by: Connie Kingsley RNC CCRN Updated by : Bill Peoples RN June 2006

OBJECTIVES Identify the anatomical location of the epidural space
Explain insertion of epidural catheters Discuss the indications, advantages & disadvantages of epidural analgesia Differentiate the pharmacologic effects of narcotics and local anesthetics in the epidural space Identify assessment parameters the RN must observe, in the patient receiving epidural analgesia

INDICATIONS FOR EPIDURAL ANESTHESIA
Anesthesia via the epidural route is indicated for treatment of pain in the sacral, lumbar, or thoracic areas. Common surgical and medical procedures that may utilize epidural anesthesia include: Cholecystectomy Thoracoscopy Hysterectomy Arthroplasty Lung volume reduction Radical nephrectomy AAA repair Minor pediatric surgery Treatment of chronic pain and its use in palliative care have shown the epidural route a viable option in pain management.

FOR EPIDURAL ANESTHESIA
Contraindications FOR EPIDURAL ANESTHESIA Epidurals are not for everyone. Patients should be assessed for the following absolute and relative contraindications prior to any consideration for epidural anesthesia: ABSOLUTE RELATIVE Systemic anticoagulation Hypovolemic shock Active infection near catheter site Heart failure Aortic stenosis History of 2nd-3rd degree heart block without a pacemaker Patients must also be able to give informed consent and cooperate/tolerate positioning necessary to insert the catheter.

Nurses have long been challenged to manage the postoperative patient’s pain while minimizing the adverse side effects of pain medications. To achieve pain relief comfort measures, the nurse has utilized psychological support and pharmaceutical agents. Continuous epidural analgesia is another tool available to the medical team to manage the postoperative patient’s pain. As with all pain management strategies, careful assessment and prompt intervention is of utmost importance.

Continuous epidural analgesia is indicated as a pain management therapy following major thoracic surgery, abdominal surgery, or lower extremity surgery. Epidural analgesia blocks transmission of the pain signal at the level of the spinal cord and provides pain relief. The use of epidural analgesia has been shown to blunt the surgical stress response, improve postoperative pulmonary function, decrease the incidence of postoperative thrombosis, as well as to provide better analgesia during ambulation, coughing and other activity.

The use of epidural opioids and local anesthetic medications has been shown to decrease postoperative complications and decrease the length of hospital stay thereby decreasing costs. A significant benefit to the patient receiving continuous epidural opioids and/or local anesthetics is stable consistent pain relief that avoids the peaks and valleys associated with other pain control methods. This consistent pain relief translates into increased compliance to postoperative care plans and increased customer satisfaction.

Some disadvantages to the use of epidural analgesia include the inability to control pain of all surgical procedures due to the location of the stimulus (i.e. craniotomies), the risk of epidural hematoma in the patient on anticoagulant therapies, and the higher level of expertise required of the physician and nurse caring for this patient.

Insertion and management of epidural catheters for postoperative pain management is provided only by anesthesia providers at your facility. The rationale for this policy is that the specialized expertise of anesthesia providers in regional anesthesia techniques, provides the best clinical resource for our patients receiving this form of therapy. Prior to insertion of the epidural catheter, informed consent is obtained by the anesthesia provider (Certified Registered Nurse Anesthetist (CRNA), MDA-Medical Doctor of Anesthesia) The role of the RN in the informed consent process is to provide appropriate forms, witness the patient’s signature and facilitate communication between the patient and anesthesia provider.

Ideal catheter placement for continuous epidural
The choice of spinal level for epidural catheter placement is predicated on “centering” the injection site at the level of maximal surgical stimulus. The suggested epidural catheter placement site for various surgical procedures is given on the next slide.

Ideal catheter placement for continuous epidural

Insertion of the epidural catheter begins with positioning the patient in either the lateral decubitus or sitting/dangling position in the bed. The goal of positioning is to open the spaces between the vertebrae in order to ease insertion of the catheter. The choice of positioning is determined by patient condition and/or anesthesia provider.

Strict aseptic technique is utilized during insertion of the epidural catheter as infection and/or abscess can cause significant complications for the patient. After the patient is prepped and draped, local anesthetics are administered into the skin of the insertion site and a small bore spinal needle, usually 20G, is inserted by the anesthetist or anesthesiologist into the epidural space. The role of the RN during insertion of the catheter includes assuring patient safety during the positioning, monitoring vital signs including SaO2, and assuring comfort and sedation.

The epidural space is located within the spinal canal outside the dura mater. The epidural space contains fat, blood vessels and spinal nerves.

Spinal Anatomy and Epidural Placement.
Intrathecal (subarachnoid) space Spinal Anatomy and Epidural Placement.

Insertion of epidural catheters
Find landmark for catheter insertion

Injection of local anesthetic

Placement of larger bore needle

Advance introducer

Loss of resistance syringe

Advance towards the epidural space

Loss of resistance is reached

Check for CSF, to rule out intrathecal placement

Administration of “test dose”

Advance epidural catheter

Remove needle when catheter is in place

Epidural catheter and etched epidural needle (A)
A marked epidural catheter being threaded through an etched epidural needle ( A and B). This arrangement enables one to determine the distance a catheter is threaded into the epidural space. The distance at which loss of resistance is achieved is noted on the epidural needle, thus determining the distance between the skin and the epidural space. The epidural catheter is then threaded through the needle until a length of 4 to 5 cm is advanced into the epidural space. After removal of the epidural needle, the catheter is withdrawn until 2 to 4 cm of catheter length remains within the epidural space. This measurement is determined by adding 2 to 4 cm to the number of centimeters representing the skin-to-epidural space distance. For example, if loss of resistance is attained at 5 cm and the epidural catheter is withdrawn to the 8-cm mark, then 3 cm of catheter remains within the epidural space.

Attach hub with luer lock – for medication instillation.

After the catheter has been threaded into the epidural space, the anesthesia provider will inject a test dose of epinepherine to assure proper placement. Expected effects of test dose include changes in heart rate and blood pressure, as well as, change in sensation below the level of insertion. Other effects can include but are not limited to: respiratory depression, palpitations, headache and dizziness. After correct catheter placement is confirmed, a transparent stabilizing dressing will be applied. The transparent dressing enables the nursing staff to assess the insertion site for signs of infection and/or dislodgement.

What is an epidural blood patch?
In the event that the dura mater tears during insertion, cerebrospinal fluid (CSF) could leak into the epidural space. This “wet tap” will likely cause a severe headache whenever the head becomes elevated. The patient should be kept supine and the anesthesia provider notified. Treatment could include IV fluids and caffeine, analgesics, or the administration of an epidural blood patch by the anesthesia provider. Figure The epidural blood patch technique is a common one. (Adapted From Mulroy [13].)

What is an epidural blood patch?
The epidural blood patch technique involves the following steps: Identify the epidural space at the site of the original dural puncture or 1 – 2 spaces caudal. Aseptically withdraw 20 ml of the patient’s blood via venapuncture. Slowly inject the blood into the epidural space until the patient complains of pressure or pain in the legs, buttocks, back, or head. Do not inject over 20 ml. Have the patient remain supine for approximately 20 minutes. Have the patient avoid valsava maneuvers for the next 24 hrs. Figure The epidural blood patch technique is a common one. (Adapted From Mulroy [13].)

Epinephrine test dose response
There is always the risk of unintentionally injecting local anesthetic into an epidural vein with an epidural needle or catheter, thereby causing systemic local anesthetic toxicity. The intravenous epidural test dose uses the hemodynamic effects of epinephrine to identify when such unintentional intravenous placement has occurred. Injection of 15 µg of epinephrine into an epidural vein consistently elevates the heart rate by 30% within 30 seconds, in the normal patient. The epidural test dose is not effective in patients who are taking beta blockers, women who are experiencing labor contractions at the time of test dose injection, or in some circumstances when patients are receiving high MAC levels of inhalational general anesthetics. The ease of detecting a positive epinephrine intravenous test dose with the use of pulse oximetry or digital pulse counters is illustrated on the next slide.

Epinephrine test dose response

The epidural catheter tubing must be correctly labeled and have no injection ports.
This prevents inadvertent administration of solutions and/or medications into the epidural space. At your facility you may use special yellow striped tubing and large yellow labels that read “EPIDURAL CATHETER”.

Only anesthesia providers are allowed to inject solutions into the epidural catheter at most institutions; and the RN is responsible for maintaining the system and administering prescribed medications via an infusion pump only. The RN will monitor and maintain the continuous epidural infusion according to the inserting practitioners orders. Due to the risk of injury (paralysis) to the patient from the instillation of preservative containing solutions, only the pharmacy and/or the anesthesia provider should mix solutions for administration through the epidural catheter. Always follow your institution’s policy and procedure

Medications administered through the epidural catheter can be grouped into two categories, opioids and local anesthetics. These medications can be given incidentally or more commonly are given in combination. Epidural medications provide pain relief by diffusing into the CSF (cerebrospinal fluid) in the spinal/subarachnoid space and acting on the spinal cord and nerve roots to block conduction of pain stimulus to the brain. The areas of the body in which the conduction of the pain stimulus is blocked/altered depend upon the spinal level at which the epidural medication is administered, the specific medication administered, and the concentration of the medication administered.

This is why epidural analgesia has been referred to as “painting the fence”. “Painting the fence” or segmental blockade can be achieved for a particular dermatome range yet spares the dermatome levels below the range. For example, pain relief can occur in the abdomen yet the lower extremities will be spared of anesthetic effects thereby encouraging ambulation.

This is in stark contrast to spinal/subarachnoid medication administration that provides sensory and motor block from the injected dermatome down. The RN can accurately report the effect of the medication by referring to the effected dermatome.

T10 dermatome affects sensation at the level of the umbilicus
For example: T10 dermatome affects sensation at the level of the umbilicus L2 dermatome affects sensation at the level of the thigh L3 dermatome affects sensation at the level of the knee The use of a standard reference facilitates communication between practitioners. Now that we know where the effect will be (dermatome level), what is the expected effect?

Epidural spreads in segmental fashion
Epidural anesthesia classically spreads in a segmental fashion in both caudal and cephalad directions from the injection site. Sacral anesthesia is frequently slower in onset or even incomplete because of the thickness of the sacral nerve roots. Attachment of the dura to the foramen magnum limits anesthetic spread beyond the cervical regions. The dermatomal spread of analgesia as a function of time and type of local anesthetic is illustrated on the next slide.

Epidural spreads in segmental fashion
Figure Epidural anesthesia classically spreads in a segmental fashion in both caudad and cephalad directions from the injection site. Sacral anesthesia is frequently slower in onset or even incomplete because of the thickness of the sacral nerve roots. Attachment of the dura to the foramen magnum limits anesthetic spread beyond the cervical regions. The dermatomal spread of analgesia as a function of time and type of local anesthetic is illustrated. (From Bromage [16].)

Cardiovascular changes with epidural anesthesia
Cardiovascular changes associated with epidural anesthesia are largely the result of which spinal cord segments are anesthetized. When thoracic sympathetic segments (T1-5) are blocked, the result is decreased sympathetic output to the heart. This is manifested by decreased heart rate, decreased contractility, and increased myocardial oxygen supply in those patients with ischemic myocardium. Blockade of lumbar spinal segments (L1-4) results in diminished systemic vascular resistance and, consequently, lower blood pressure.

Cardiovascular changes with epidural anesthesia

Opioids produce segmental analgesic effect of the dermatomes near the catheter tip. Side effects of epidurally administered opioids include respiratory depression, urinary retention, sedation, pruritus (itching), nausea and vomiting. Opioids commonly administered in the epidural space are Morphine (Duramorph), Fentanyl, and Sufentanil. See Table below for common doses, onset and duration of the effect. Drug Dose Onset Duration Morphine mg/hr 45-60 minutes 6-8 hours Fentanyl 35-70 ug/hr 10-20 minutes 3-6 hours Sufentanil 10-21ug/hr

Local anesthetics administered into the epidural space provide excellent analgesia but may produce sympathetic blockage resulting in vasodilation and hypotension. Motor blockade can inhibit the patient’s ability to stand and/or ambulate. Commonly used local anesthetics include lidocaine, bupivacaine and ropivacaine. See Table on the next slide for onset and duration of effect. Note: the dose and effects of local anesthestics are dependent on the concentration of the medication (i.e., Lidocaine 0.5%, 1%, 2%) and/or the presence of epinephrine in the solution. Epinephrine increases the duration of the blockade.*

DRUG ONSET DURATION Lidocaine 15 min 80 – 180 min Bupivacaine 10 – 20 min 60 – 240 min Ropivacaine 20 – 30 min 60 – 90 min

Administering a combination of opioids and local anesthetic agents maximizes the benefits of both classes of drugs. The synergistic effects of the local anesthetic on the concomitantly administered opioids decreases the required dose of each drug classification, thereby decreasing the incidence of adverse side effects from either drug classification.

Nursing care of the patient with a continuous epidural infusion includes: education of the patient and family, assessment of the level of pain relief and sensory/motor blockade, and identification of complications of therapy. Notification of the anesthesia provider managing the epidural infusion and prompt intervention if adverse effects occur, are the responsibilities of the RN caring for this patient. The most common adverse effects are nausea, pruritus, and urinary retention.

Other Complications of Epidural Analgesia can include:
Epidural Hematoma Treatment Immediate notification of anesthesiologist Neurosurgery consult CT scan SURGICAL EVALUATION EMERGENTLY (Paralysis may be reversible if evacuated <6 hours) Signs/Symptoms Severe back pain Lower extremity parlysis Paresthesia Change in sensory and/or motor function without definable cause

Epidural Hematoma. Arrow indicates large spinal mass at posterior lateral L3-L4 level, associated with severe narrowing of spinal canal.

Catheter Migration into the Intrathecal Space
Other Complications of Epidural Analgesia can include: Catheter Migration into the Intrathecal Space Treatment Immediate notification of anesthesiologist Emergency intervention to correct cause and symptoms Signs/Symptoms Nausea, decreased BP, new loss of motor function without definable cause

Catheter Migration into the Epidural Vein Signs/Symptoms Ringing in the ears Metallic taste in the mouth Peri-oral tingling Feeling of impending doom Treatment STOP THE INFUSION Notify the anesthesiologist immediately

Catheter Migration into the Subcutaneous Tissue / Complete Catheter Dislodgement Signs/Symptoms Pain No sensory/motor dysfunction Treatment Notify anesthesiologist

Respiratory Depression
Other Complications of Epidural Analgesia can include: Respiratory Depression Signs/Symptoms Respiratory rate <8 per minute, pulse oximeter <90%, decreased LOC

Respiratory Depression
Other Complications of Epidural Analgesia can include: Respiratory Depression Treatment Prevent by careful sedation assessment & proper dosing under the direction of the anesthesiologist Attempt to rouse the patient Assess the integrity of the airway & quality of respirations while stopping the infusion Encourage deep breathing and/or assist breathing by use of an ambu bag and/or oxygen Notify the anesthesiologist Narcan 0.4 mg as directed by the anesthesiologist. Dilute the Narcan 0.4/10ml saline. Administer IV very slowly until effect is noted. Giving too much Narcan or administering it too fast may lead to hypertension, tachycardia, ventricular arrthymias, and or difficulty relieving pain. Assure suction is available when administering Narcan, as nausea & vomiting are also side effects of this medication

Sympathetic Blockade Signs/Symptoms Decreased B/P Decreased HR (rare) Treatment Lay patient flat with legs elevated Notify anesthesiologist Fluid bolus/ephedrine as directed by anesthesiologist only, closely monitor effect

Toxicity of Local Anesthetic Drugs
Other Complications of Epidural Analgesia can include: Toxicity of Local Anesthetic Drugs Signs/Symptoms – specific to individual drug General signs/symptoms – lightheadedness, numbness of lips and tongue, visual/auditory disturbances, muscle twitches, unconsciousness, seizures, coma, respiratory arrest, PR/QRS elongation, bradycardia, sinus arrest Treatment Prevention/identification of allergies Symptom recognition Notification of anesthesiologist Stop epidural infusion Supportive measures

Pruritis Signs/Symptoms Uncontrollable itching Treatment Benadryl 25 mg IV Q4H or medicate as ordered by anesthesiologist If pain is well controlled and side effects continue; consider reducing the dose under the direction/order of the anesthesiologist

Nausea Treatment Reglan 10mg IV Q6H or medicate as ordered by the anesthesiologist Signs/Symptoms Vomiting, complaints of nausea

Break through pain Signs/Symptoms Exhibits signs of pain (restlessness, RR, BP, HR) Complains of pain Treatment BEWARE – DO NOT GIVE OTHER ORAL OR PARENTAL NARCOTICS WITHOUT THE EXPRESS ORDER OF THE ANESTHESIOLOGIST. Notify the anesthesiologist Toradol 15 to 30 mg IV Q6H if approved by surgeon Manual bolus of epidural medication by CRNA/Anesthesiologist Titrate epidural infusion/administer pump bolus as directed in the critical care areas & cardiovascular unit

Limited Mobility Treatment Identify cause of defect (see prior slides) Notify anesthesiologist if condition new OOB with assist if approved by attending surgeon Head of Bed elevated degrees Signs/Symptoms Secondary to sensory/motor blockage and/or orthostatic hypotension

Urinary Retention Signs/Symptoms I > O, has not voided in 5 hrs complains of urgency without results Treatment Assessment of bladder by palpation/percussion Notify surgeon Possible foley catheter insertion as directed Strict I & O Consider decreasing infusion rate under the direction of the anesthesiologist if pain is well controlled

Infection / epidural abscess (rare)
Other Complications of Epidural Analgesia can include: Infection / epidural abscess (rare) Signs/Symptoms 1 to 3 days postoperatively complain of back pain, fever, flaccid paralysis followed by spastic paralysis, sensory/motor changes, WBC on CBC, nuchal rigidity Treatment Prevent with proper aseptic technique & site assessment Surgical evacuation of abscess Antibiotics

Managed properly, continuous epidural infusions provide excellent pain relief without limiting the patient’s involvement in postoperative activities that prevent complications due to pain and immobility. Diligent assessment, planning and evaluation of patient responses to medical and nursing interventions are the responsibility of the RN caring for this patient. Your facility has routine epidural/spinal physician orders to aide in the assessment and planning of care of these patients. Following, is an example of the routine epidural orders you may see.

Standing orders are frequently used to provide consistency of care between patients utilizing epidural analgesia.

A sample schedule for routine assessment parameters for the patient receiving epidural analgesia follows. Your patients’ assessment schedule should be based on the specific medications received, physician orders and the individual patient response. More frequent assessments may be indicated following dose/infusion rate increases and/or patient response to therapy. Please use this schedule as an aide to guide you in interpreting your physician orders.

Sample Assessment Schedule
Parameter Frequency per routine orders Alteration may indicate BP Q1h X 2 then Q2h Increased BP may = pain Decreased BP may = catheter migration into spinal space Sepsis Surgical bleeding Pulse Increased HR may = pain Hypovolemia Anxiety Respiratory rate and depth Q 1h X 24h then Q2h Respiratory rates < or = 8 per min is an indication to STOP the INFUSION

Immediate nursing actions should include: Assessment of airway integrity & quality of respirations while stopping the infusion, encourage deep breathing and/or assist breathing as necessary, and notify the anesthesiologist per policy. Narcan may be ordered to reverse opioid induced respiratory depression. Risk of respiratory depression continues after the epidural infusion is stopped. The anesthesia provider will order for how many hours after the epidural medication is discontinued; close respiratory monitoring must be performed.

If patient is unable to void or is incontinent, notify surgeon.
Dressing checks Q2h If the transparent dressing becomes wet, SHUT OFF THE INFUSION, cover with a sterile dressing and notify the anesthesiologist. If the dressing becomes loose, the RN may reinforce it. Check your facility’s policy to determine if only the anesthesiologist or CRNA may perform dressing changes. Assess for signs of infection with each dressing check. I & O Continuous If patient is unable to void or is incontinent, notify surgeon. IV access During & 24h after d/c gtt Maintain IV access for emergency medications.

Follow your institution’s policy and physician’s orders for frequent assessment of patients on epidural medications.

A case study follows which outlines some nursing interventions taken to care for a patient with a continuous epidural infusion for postoperative pain relief.

Case Study Mr. Jones is a 58 year old patient S/P Thoracotomy and Right Upper Lobectomy. On your initial assessment you note that he is Alert & Oriented X 3, restless and curt in responding to your questions. He is receiving Fentanyl 10mcg/ml and 0.125% Marcaine at 6 ml/hr by epidural infusion. He complains of pain that is 8 out of 10 in severity. His vital signs are: BP 154/88, HR 102, RR 24, T 98.6F. The epidural infusion system appears to be intact and the dressing is dry. He moves all four extremities to command and spontaneously.

The Modified Ramsey Scale is used to assess the patient’s level of sedation.
Level 1 = Anxious, agitated or restless Level 2 = Cooperative, oriented and tranquil Level 3 = Responds to command only Level 4 = Brisk response to loud auditory stimulus/glabellar tap Level 5 = Sluggish response to loud auditory stimulus/glabellar tap Level 6 = No response to loud auditory stimulus/glabellar tap According to the Sedation Scale/Modified Ramsey Scale, what is his sedation level? – click on answer below 1 2 3 4 5 6

You notify the anesthesiologist of his breakthrough pain
You notify the anesthesiologist of his breakthrough pain. The anesthesiologist asks you to give a manual bolus of 2 mg morphine through the epidural catheter. According to best practice, you should: - click the box next to the correct answer Call another physician to confirm the order. Follow your institution’s policy re: epidural administration. Tell the physician to come in and do it himself/herself. Give the morphine over 2 min. or longer, using aseptic technique.

You titrate the drip up at a rate of 1 ml Q 15 minutes per policy until you achieve the pain management goal you have set with the patient (usually this is 0 to 1 on the pain scale). One hour later you assess Mr. Jones and find he does not rouse to voice and groans to glabellar tap. His vital signs are: BP 100/70, HR 87, RR 8, O2 sat 86%. You should first: (click the box next to the correct answer) Notify the anesthesiologist Administer Narcan IV Decrease the rate by 1ml every 15 min Assess his airway while stopping the infusion

Your priority intervention would be:
He responds to your treatment and the epidural infusion is continued at a lower rate. Four hours later he denies pain but is restless, scratching himself and suddenly vomits. Your priority intervention would be: (click the box next to the correct answer) Protect his airway during the vomiting Administer antiemetics per MD orders Administer Benadryl for the pruritus per MD order Notify the anesthesiologist PRN (the anesthesiologist may decrease the infusion rate if adverse effects are unresolved).

(click the box next to the correct answer)
Just after this occurs Mr. Jones’ surgeon arrives and tells you to discontinue the epidural infusion. You would: (click the box next to the correct answer) Immediately discontinue the infusion Notify the anesthesiologist of the surgeon’s request Slowly titrate the infusion off to prevent hypertension Initiate IV / IM / PO meds, before discontinuing the infusion

Most patients would not have this many adverse reactions to epidural analgesia. The purpose of this case study was to acquaint you with common adverse reactions to this therapy and the appropriate nursing interventions according to policy and established standards of care. In summary, epidural analgesia provides a safe and effective alternative to conventional oral and parental analgesics for postoperative pain management. Careful patient selection and diligent nursing care of this patient will reward the patient and the healthcare team by providing comfort, decreasing postoperative complications, increasing customer satisfaction and decreasing hospital costs.

Web Resources Additional information is available at the following sites: American Association of Nurse Anesthetists American Society of Anesthesiologists: Pain Relief During Labor and Delivery American Society of Anesthesiologists: Practice Guidelines for Obstetrical Anesthesia

References Schwartz A. “Learning the essentials of epidural anesthesia”. Nursing January. Vol 36 Number 1 World wide web. textbook.com/vat/anatomy.html#video. March 2006 Urden. Stacey. Lough. Thelan’s Critical Care Nursing. Fourth Edition. Mosby pps

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