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Pre-reading about Epidural Analgesia for Children. Royal Children’s Hospital Melbourne Australia. What is epidural analgesia?. - PowerPoint PPT Presentation
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Pre-reading about Epidural Analgesia for Children
Royal Children’s HospitalMelbourne Australia
What is epidural analgesia?• Epidural analgesia is a regional
analgesic technique where locally administered agents such as local anaesthetics (often in conjunction with opioids or clonidine) are used to block pain pathways in the spinal cord or spinal nerve roots
Children's Pain Management Service, RCH, Melbourne
Why use an epidural?• Advantages:
• excellent analgesia is possible
• improved post-operative mobility
• improved respiratory function
• reduced use of opioids• improved peripheral
circulation• decreased endocrine and
metabolic response to stress
• Disadvantages:• degree of practice & skill
required• extra supervision needed• possibility of
complications• analgesia not always
totally effective
Indications for epidural analgesia• Major surgery• Prevention of specific complications
• eg muscle spasm following orthopaedic surgery
• Improvement of surgical outcomes• eg improved blood supply following
skin flap grafts• To minimise the use of opioids
Children's Pain Management Service, RCH, Melbourne
Contraindications to epidurals(Some are relative contraindications only)• Allergy or hypersensitivity to amide
anaesthetics• Bleeding disorders or use of anti-coagulants• Infection - locally or systemically• Spinal abnormality or previous spinal surgery• Patients at risk of compartment syndrome• Patients at risk of neurological complications• Inadequate staffing on ward
Children's Pain Management Service, RCH, Melbourne
What to tell children/parents
• Sensations to expect• eg numb and heavy legs, tingling, or no sensation
• Pain relief • eg often complete, but may be partial
• Monitoring required• regular BP, HR, RR, Temp, SpO2
• Urinary catheter may be required• usually only if lumbar epidural
Children's Pain Management Service, RCH, Melbourne
How local anaesthetics work• Local anaesthetics block nerve
impulses in sensory, motor and autonomic nerve fibres
• The sensory nerve fibres respond to pain, temperature, touch and pressure
Children's Pain Management Service, RCH, Melbourne
Drugs used in epidurals• Short-acting local anaesthetics:
Lignocaine• Medium/Long-acting local
anaesthetics:Levobupivacaine
Ropivacaine• Other drugs:
AdrenalineClonidineOpioids
Children's Pain Management Service, RCH, Melbourne
Adding opioids to epidurals• Opioids are added to local
anaesthetic to enhance analgesia• Lipid soluble drugs have a more
rapid onset, act more locally and are shorter lasting
• Lipid solubility:fentanyl > hydromorphone>morphine
Children's Pain Management Service, RCH, Melbourne
Spinal vs Epidural vs Caudal• Different techniques are used
depending on the type of surgery and the need for postoperative analgesia
Children's Pain Management Service, RCH, Melbourne
Spinal• Drugs are administered into the
intrathecal space• Usually a ‘single shot’ prior to surgery,
but the catheter can be left in situ• Local anaesthetic +/- opioid may be
used• Duration of single dose of opioid is
variable (eg morphine 4-24 hours), thus risk of delayed respiratory depression
Children's Pain Management Service, RCH, Melbourne
Anatomy of the spinal space• Intrathecal space situated between
the pia and arachnoid mater (also called spinal or subarachnoid space)
• Contains CSF, the spinal cord, spinal nerves and blood vessels
• Subarachnoid space ends at the second sacral vertebra
• The spinal cord ends at L1/2 (adults) or L3/4 (neonates)
Children's Pain Management Service, RCH, Melbourne
Children's Pain Management Service, RCH, Melbourne
As appears in McCaffrey M, Pasero C: Pain: Clinical Manual, p218, 1999, Mosby, Inc.
Epidural• Drugs are administered into the
epidural space• Drug infuses thru to CSF/spinal nerves• Local anaesthetic +/- opioid or
clonidine may be used• The epidural catheter is usually left in
situ and an infusion or boluses of analgesic solution are given
Children's Pain Management Service, RCH, Melbourne
Anatomy of the epidural space• Epidural space is between ligamentum
flavum and the dura mater• Contains fat, blood vessels and
connective tissue (the spinal nerves pass through epidural space)
• Epidural space extends from the foramen magnum to the coccyx
Children's Pain Management Service, RCH, Melbourne
Children's Pain Management Service, RCH, Melbourne
As appears in McCaffrey M, Pasero C: Pain: Clinical Manual, p216, 1999, Mosby, Inc.
Caudal• Drugs are administered into the
caudal epidural space• Local anaesthetic +/- adrenaline +/-
opioid +/- clonidine may be used• Adrenaline or clonidine may be added
to the local anaesthetic for a longer lasting block
• In neonates epidurals may be inserted at caudal level and threaded up to thoracic level
Children's Pain Management Service, RCH, Melbourne
Anatomy of the caudal space• Caudal space is well below the
termination of the spinal cord• Caudal space lies within the sacral
bone (which is not fully ossified in children)
• It is accessed via the sacrococcygeal membrane at level of sacral hiatus (S5-coccyx)
Children's Pain Management Service, RCH, Melbourne
Epidural set
• The 18G and 19G PortexTM epidural kits can be distinguished by the colour of the hub on the filter and the size of the epidural catheter
• 18G kit has blue hub• 19G kit has white hub
Children's Pain Management Service, RCH, Melbourne
Securing epidural catheters• Accidental or deliberate removal of
the epidural catheter by children can be a problem
• The use of non-allergenic tape to secure the epidural catheter to the skin and covering all vulnerable points of disconnection from children’s fingers will decrease the likelihood of premature dislodgement
Children's Pain Management Service, RCH, Melbourne
Epidural insertion site
• A sterile sponge is often applied at the insertion site to soak up any leaking epidural solution
• An occlusive clear dressing is placed over the sponge
Children's Pain Management Service, RCH, Melbourne
Taping the epidural catheter
• The epidural catheter must be securely taped to the skin
• A ‘window’ is made with the tape to allow viewing of the insertion site and catheter markings
Children's Pain Management Service, RCH, Melbourne
Prevention of disconnection
• The filter hub must be firmly screwed on to the epidural catheter to prevent accidental disconnection
• If the hub is screwed on too tightly the catheter may be occluded
Children's Pain Management Service, RCH, Melbourne
Securing the epidural filter
• The epidural filter must be securely taped to the upper chest wall in a comfortable position
Children's Pain Management Service, RCH, Melbourne
Securing the epidural filter
• Any loose catheter should be coiled and taped securely to prevent kinking and disconnection
Children's Pain Management Service, RCH, Melbourne
Where will the epidural be inserted?• The level of insertion is determined
by the site of surgery and the desired number of dermatomes to be blocked
• Ideally the catheter tip should lie level with the middle dermatome (when local anaesthetics are being infused)
Children's Pain Management Service, RCH, Melbourne
Thoracic epidurals• Thoracic epidurals are used for
surgical procedures of the upper abdomen or chest wall
• They may be combined with IV opioids (nurse controlled infusion or PCA) to provide optimal analgesia
Children's Pain Management Service, RCH, Melbourne
Lumbar epidurals• Lumbar epidurals are used for
orthopaedic, urological, general surgical procedures below the umbilicus
• They may be combined with IV opioids to provide optimal analgesia
Children's Pain Management Service, RCH, Melbourne
Caudal epidurals• Caudals are used for surgical
procedures below umbilicus (generally sacral, perineal, lower limb and lower abdominal surgery)
• Caudals are the most frequently used block in children
• Most commonly given as a ‘single shot’
Children's Pain Management Service, RCH, Melbourne
Post-operative epidural management• Observation of vital signs• Assessment of analgesia• Detection of side effects• Early detection of major
complications• Pressure area care
Children's Pain Management Service, RCH, Melbourne
Assessing sensory blockDermatomes:• Dermatomes are areas of skin that are
primarily innervated by a single spinal nerve
• Pain and temperature nerve fibres are similarly affected by local anaesthetic drugs, thus changes in temperature perception indicate the area where the epidural is working
Children's Pain Management Service, RCH, Melbourne
Children's Pain Management Service, RCH, Melbourne
Why check dermatomes?• To ensure the epidural/caudal is
covering the patient’s pain• To ensure the block is not too
extensive, which may increase the risk of complications
Children's Pain Management Service, RCH, Melbourne
Pressure areas
• If the epidural block is very dense the patient will not be able to move, will have no sensation of pressure or pain and may develop pressure areas
• Meticulous pressure area care is vital
Children's Pain Management Service, RCH, Melbourne
Nerve compression• Superficial nerves (eg common
peroneal nerve) are vulnerable to damage from unrecognised pressure due to decreased sensation
• It is vital that during regular pressure area care special attention is made to ensure nerve compression is avoided
Children's Pain Management Service, RCH, Melbourne
Assessing motor block• Motor nerves (as well as sensory
nerves) may be affected by local anaesthetics
• Assessing the motor function of legs and feet can give an indication of the degree of motor nerve blockade
Children's Pain Management Service, RCH, Melbourne
Children's Pain Management Service, RCH, Melbourne
Why check for motor block?• To detect the onset of
complications eg epidural haematoma or abscess
• To ensure the patient can move their legs to prevent pressure areas
• To ensure the patient is safe to ambulate
Children's Pain Management Service, RCH, Melbourne
Causes of breakthrough pain• Epidural catheter kinked or dislodged• Epidural catheter disconnected at filter• Epidural block is unilateral on the wrong
side • Insufficient epidural infusion rate to
cover desired dermatomes• The epidural catheter tip is situated too
high or too low in the epidural space
Children's Pain Management Service, RCH, Melbourne
Causes of breakthrough pain cont.• Surgical complications
• eg compartment syndrome, haemorrhage, sepsis, peritonitis
• Tight plaster +/- swelling• Full bladder +/- urinary retention• Urinary catheter or drains
obstructed or occluded
Children's Pain Management Service, RCH, Melbourne
Causes of breakthrough pain cont.
ALWAYS be concerned if the pain is remote to the surgical site:• get an URGENT review!
Children's Pain Management Service, RCH, Melbourne
Managing breakthrough painIf the patient complains of pain or appears to be in pain:• Check catheter at insertion site for leaking• Is the epidural still in situ?• Check at connection of catheter and filter for
disconnection/leaking• Check the epidural catheter position is the
same as stated on prescription• Give an epidural bolus as charted
Children's Pain Management Service, RCH, Melbourne
Managing breakthrough pain cont.• Assess dermatomes on both sides• Assess severity and location of
pain• Consider surgical review if risk of
surgical complications• Call Children’s Pain Management
Service for review
Children's Pain Management Service, RCH, Melbourne
Children's Pain Management Service• The Children's Pain Management
Service supervises all patients with epidural analgesia at the Royal Children's Hospital
• CPMS can be contacted at all times on pager 5773
Children's Pain Management Service, RCH, Melbourne
Finally…Optimal pain management is the right of all patients and the responsibility of all health professionals
Children's Pain Management Service, RCH, Melbourne
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