QUICK REFERENCE GUIDE · Web viewIf analgesia is inadequate (pain score of 2 or 3, patient verbalizing discomfort), check the epidural catheter is still in situ and increase the infusion

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CONTINUOUS EPIDURAL INFUSIONS MANAGEMENT POLICY

Version 9.1

Name of responsible (ratifying) committee Formulary & Medicines Group

Date ratified 20 July 2017

Document Manager (job title) Acute Pain Sister

Date issued 20 August 2018

Review date 31 July 2021

Electronic location Clinical Policies

Related Procedural Documents See section 8 of this policy

Key Words (to aid with searching)Pain management; epidural anaesthesia; epidural catheter; continuous epidural infusion; anticoagulant; cardiac arrest; hypotension

Version TrackingVersion Date Ratified Brief Summary of Changes Author

9.1 08/02/2019 - Appendix D Observation Chart updated -

9 20/07/2018 - Removal of first sentence in quick reference guide.- Reference to naloxone guideline in section on management of complications.- For pruritus treatment order of medications amended and addition that ondansetron is not licensed for pruritus.- change of wording of management of inadequate analgesia to titrate infusion to an appropriate dose.

Charly Bellis

8 21/07/2017 Remove from Vital PAC and addition of recording of observations on Epidural Observation Chart, change of naloxone policy, remove ephedrine, add ondansetron for pruritus, change to time of catheter removal to not less than 4 hours preceding the next dose LMWH (from 2 hours), new prescription charts, restructure process

Charly Bellis

7 16/01/2015 Inclusion of updated Patient Information Leaflet (September 2014). New Trust template

Libby Burton Smith

Continual Epidural Infusions Management Policy Version: 9.1Issue Date: 20 August 2018Review Date: 31 July 2021 (unless requirements change) Page 1 of 24

Working together to drive excellence in care for our patients and communities

our patients and communities

CONTENTS

QUICK REFERENCE GUIDE................................................................................................................3

1. INTRODUCTION............................................................................................................................4

2. PURPOSE......................................................................................................................................4

3. SCOPE...........................................................................................................................................4

4. DEFINITIONS.................................................................................................................................4

5. DUTIES AND RESPONSIBILITIES................................................................................................4

6. PROCESS......................................................................................................................................5

7. TRAINING REQUIREMENTS.........................................................................................................9

8. REFERENCES AND ASSOCIATED DOCUMENTATION..............................................................9

9. EQUALITY IMPACT STATEMENT.................................................................................................9

10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS.....................................11

EQUALITY IMPACT SCREENING TOOL...........................................................................................12

APPENDIX A: PATIENT LEAFLET......................................................................................................14

APPENDIX B: EPIDURAL PRESCRIPTION CHART..........................................................................19

APPENDIX C: PCEA PRESCRIPTION CHART..................................................................................21

APPENDIX D: EPIDURAL OBSERVATION CHART..........................................................................23

APPENDIX E: PROTOCOL FOR MANAGEMENT OF ABNORMAL NEUROLOGICAL SIGNS IN CONNECTION WITH EPIDURAL ANALGESIA..................................................................................25


QUICK REFERENCE GUIDE

For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.

1) Continuous Epidural infusions should only be managed on either surgical wards that are

covered by the Acute Pain Service and where staff have attended the mandatory acute pain study day or on the Maternity Unit where they will be managed by midwives and the duty maternity anaesthetist.

2) The Acute Pain Service or after hours the 2nd on-call anaesthetist (bleep 1622) should be contacted for advice about epidurals and their management.

3) If the patient is suffering from unusual/unexpected dense block then the management of abnormal neurological signs in connection with epidural analgesia guideline must be followed.

4) All surgical patients with a continuous epidural infusion must have regular observations (pulse, blood pressure), pain and sedation scores and block recorded on Epidural Observation Chart and acted upon when necessary.


1. INTRODUCTION

Indications: Epidural analgesia is an efficacious method of providing postoperative pain relief or for the control of labour pain.

2. PURPOSE

This policy is to guide staff in the use of continuous epidural infusions. It is not designed to restrict or limit professional judgment and decision-making

3. SCOPE

This policy is applicable to those surgical areas supported by the acute pain service and applies to staff who have attended the Acute Pain Study Day and have a signed competency. If this is not the case then the patient must be moved to another ward or clinical area where this can occur. It also applies to the Labour ward on the Maternity Unit

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

4. DEFINITIONS

Epidural analgesia is the introduction of local anaesthetics and/or opioids, into the epidural space, via an indwelling catheter. The epidural space lies between the dura mater and the bones (spinous process) and ligaments (interspinous ligament and ligamentum flavum) of the vertebral canal.

The epidural catheter is 40cm long, has 1cm markings to 15cm and then 1 at 20cm and a blue tip at the insertion end

The concept of the continuous infusion of bupivacaine combined with fentanyl is to saturate the pain receptors in the spinal cord whilst interrupting transmission of painful stimuli from sensory nerves

Wessex Pain Score is: - 0 = no pain on movement, 1 = mild pain on movement, 2 = moderate pain on movement and 3 = severe pain on movement.

Sedation (CNS) score is – A = Alert, V = Voice, P = Pain and U = Unresponsive

PCEA is the abbreviation for Patient Controlled Epidural Analgesia..‘Top-ups’ is the term used for a bolus dose of local anaesthetic via the epidural catheter

5. DUTIES AND RESPONSIBILITIES

Where an anaesthetist is involved in a patient’s care, it is his/her responsibility (not that of a surgeon) to seek consent for anaesthesia, having discussed the benefits and risks. The insertion of the epidural catheter is the responsibility of the anaesthetist. The continued care of the patient is the responsibility of the surgical team and ward staff in collaboration with The Acute Pain Service. The 2nd on-call Anaesthetist has responsibility for epidurals out of hours. The maternity duty anaesthetist and midwifery staff are responsible for the management of epidurals on the labour ward.


Only anaesthetists or other Health Care Professionals who have established their competency should perform top-ups

6. PROCESS

ACTION RATIONALE1. PRE-OPERATIVELYThe patient should be seen by the anaesthetist preoperatively and fully informed of the procedure and the risks and benefits of the epidural and continuous infusion.

If the patient is assessed to be suitable for PCEA, then he/she must be introduced to the concept of PCEA and shown the equipment that will be used. This is complemented and reinforced by nursing staff.

A patient information leaflet should be given to the patient (Appendix A)

Professional courtesy and decreasing pre- and post-operative anxiety and pain. To help the patient in the consent decision process. Establish need for epidural analgesia and identify risk factors, need for further investigations, contraindications or technical difficulties of epidural technique.

To ensure patient understands how to use the PCEA device.

To support the consent process

2. IN THEATRE

If the patient is receiving prophylactic low molecular weight heparin (LMWH) the catheter must not be inserted within 12 hours of the last dose. If the patient is receiving a therapeutic dose of LMWH the catheter must not be inserted within 24 hours of the last dose – this applies to concurrent anticoagulants used in accordance with Trust VTE guidelines

All patients must have patent IV access while the infusion is running and a urinary catheter should be inserted in theatre, and removed only after the return of normal sensation.

An anaesthetist using aseptic technique will site the epidural catheter. It is then connected via a 0.22 micron bacterial filter to the continuous infusion pump.

The catheter is secured at the site by a sterile clear dressing and secured up to the shoulder with a clear dressing or Mepore.

A gauze pad is placed under the filter and secured to the shoulder of the patient.

The catheter is attached to a McKinley bodyguard 545 epidural pump with the

To minimize the risk of an epidural haematoma, the American Society of Regional Anaesthesia (ASRA) guidelines on central nerve block and LMWH (Low Molecular Weight Heparin) should be followed.

Emergency IV access for fluids and/or drugs. The local anaesthetic can cause the patient to lose bladder sensation/control.

To reduce incidence of infection.

To prevent migration of catheter.

To prevent a pressure area/irritation.

A dedicated pump and line will decrease the risk of confusion between epidural, intravenous


designated epidural line and yellow colour-coded extension. Ready-to-use bags of bupivacaine 0.1% with or without fentanyl 2 microgram/ml will be used.

If being used for PCEA an appropriately configured and programmed pump with patient handset should be used. There is pre-determined regime (See Appendix C).

The drug type, rate of infusion, level of the epidural and the length of the epidural catheter at skin should be recorded on the epidural prescription chart Appendix B

and other Local Anaesthetic infusions.

A background infusion is likely to provide adequate analgesia, but to prevent the risk of overdose a maximum should be set at 8-12 mls/hour.

To enable correct assessment of effectiveness and possible change of position of epidural catheter and to ensure details appear in patients notes

3. NURSING CARE AND OBSERVATIONS

Monitor respiratory rate, sedation score and pain score on Vital Pac hourly for the first 12 hours, 2 hourly for the next 12 hours and then 4 hourly. Continue for 4 hours once epidural has been removed/turned off. Midwives follow local guidelines.Pain scores, blood pressure and pulse as per standard operating procedures.All patients with a continuous epidural infusion should have 2 litres of oxygen via nasal specks unless otherwise indicated.

Pain scoring must be documented to establish whether or not the treatment is effective. The effects of the local anaesthetic on the sympathetic nerves can exacerbate hypotension. Respiratory depression is a side effect of fentanyl.

Sensory level and motor block function should be monitored hourly for the 12 hours and then four hourly. Patients should be able to move toes and have sensation above T4 or nipples. These must be recorded on the dedicated lilac epidural observation chart.(Appendix D)

Patients can get up out of bed and mobilize once motor function has been assessed as adequate.

Local anaesthetic can affect the tone and power of the lower limbs. Pressure area care is important, as most patients will have a degree of sensory loss in lower limbs.

The epidural catheter must be kept clean under a sterile dressing and the site inspected daily for signs of infection or movement.

Bacterial filter must be kept intact. Epidural catheters will normally remain insitu for a maximum of 4 days, unless otherwise indicated. The decision to continue an epidural infusion beyond 4 days should be taken by the Acute Pain Service or an anaesthetist.

Some epidurals tend to leak slightly, however if it is working it should remain in situ.

To reduce the risk of infection and ensure that the infusion is sited correctly.

The filters have a licence from the manufacturers for 96 hours use.

Risk assessment shows there is a higher risk in removing an epidural compared with allowing a slightly leaking but functioning epidural to continue.


4. MANAGEMENT OF COMPLICATIONS

If respiratory rate is less than 8 and/or sedation score is 3, inform duty surgical team, turn infusion off, give naloxone 40 mcg IV (prescribed on epidural chart) every 1 minute and O2 100% via self inflating bag.Call cardiac arrest team and hand ventilate if respiratory arrest occurs.

If local anaesthetic toxicity is suspected, follow the drug therapy guideline – Management of severe local anaesthetic toxicity.

If systolic blood pressure is less than 90mmHg give 500ml of an appropriate IV fluid over 15 minutes (prescribed on epidural chart). A surgical opinion is required to exclude/correct hypovolaemia.

Inform surgical team.If blood pressure continues to be low, an anaesthetic review is required for possible transfer to a high care unit for a metaraminol infusion.

For pruritus consider chlorphenamine or ondansetron and/or change the infusion to plain Bupivacaine.

If the epidural catheter becomes disconnected from the patient side of the bacterial filter, the epidural must be removed. If it becomes disconnected from the infusion side of the filter it can be reconnected. Do not clean the filter with anything, especially not alcohol.

For nausea and vomiting refer to Drug Therapy guideline- post operative nausea and vomiting- treatment in adults. If severe consider changing infusion to plain bupivacaine.

If analgesia is inadequate (pain score of 2 or 3, patient verbalizing discomfort), check the epidural catheter is still in situ and increase the infusion rate as necessary in accordance to pain. Recommence hourly observations. If pain remains excessive after an hour ring the Acute Pain Team during office hours or the 2nd on call anaesthetist after hours.

If the patient is suffering from unusual/unexpected dense block then the management of abnormal neurological signs in connection with epidural analgesia guidelines should be followed (Appendix D and E)

Opioids can affect the central nervous system causing euphoria, sedation and respiratory depression. Fentanyl may be distributed to the CNS after vascular uptake or CSF transfer.

Local anaesthetic toxicity is a rare complication of epidural analgesia.

Sympathetic block can lead to hypotension. However with the low concentration of local anaesthetic used on the general wards, significant hypotension is unlikely unless the patient is also hypovolaemic.

Pruritus is a well-known side effect of opioids and occurs more frequently in association with spinal or epidural administration.

Micro-organisms introduced up-stream of the filter will be removed by it.

Alcohol is neurotoxic and should therefore not be used for cleaning.


5. MANAGEMENT OF A PATIENT FOLLOWING A ‘TOP-UP’

Blood pressure and respiratory rate must be checked every 5 minutes for first 20 minutes, then half hourly for next 2 hours. If the patient becomes hypotensive see section 4. Block levels should be done hourly for first 4 hours and then 4 hourly.

High doses and stronger concentrations of local anaesthetic can lead to a sympathetic block. A bolus of opiate can lead to an increase in sedation.

6. REMOVAL OF EPIDURAL CATHETER

Trained nursing staff may remove epidural catheters. The date, reason for removal and whether the tip was present should be documented on the epidural prescription chart (Appendix B).

Only send the tip to microbiology for culture if there is any suspicion of infection.

If the patient is receiving low molecular weight heparin (LMWH) the catheter must be removed not less than 12 hours after a dose and not less than 4 hours preceding the next dose.

Patients who are to have a continuous epidural infusion must not be prescribed rivaroxaban and should have a LMWH prescribed instead. Rivaroxaban can be prescribed at 1800 hours the day following the removal of the epidural catheter. If a patient is inadvertently given rivaroxaban the epidural catheter must not be removed less than 24 hours after a dose, nor less than 6 hours before the next dose.

The catheter tip provides evidence of whether the infusion site was infected.

To minimize the risk of a spinal haematoma the American Society of Regional Anesthesia (ASRA) guidelines on central nerve block and LMWH (Low Molecular Weight Heparin) should be followed.

ASPECT OF CARE / OUTCOMES

EXPECTED STANDARD / TARGET

SOURCE OF DATA COLLECTION

Record keeping 100% of patients will have correctly filled in prescription and observation charts

Acute Pain Service will review documentation daily, within their working hours.

Adverse incident reporting 100% of all incidents reported to risk management are discussed at mortality and morbidity meetings.

Summary of incidents reported to risk department and anaesthetic department critical incident reporting system.


7. TRAINING REQUIREMENTS

Only anaesthetists trained in this technique should initiate this type of postoperative pain relief.

Only nurses who have their IV and Epidural competency (Appendix ) should care for these patients with support from the Acute Pain Service and the Anaesthetic Department. Midwives are responsible for the care of ladies on the labour ward in conjunction with the maternity duty anaesthetist.

Matrons/Senior Nurses will ensure that nurses caring for patients with epidurals have achieved their competency in agreement with the Acute Pain Service.

8. REFERENCES AND ASSOCIATED DOCUMENTATION

Please note that some references/links within policies may be to internal documentation that are not externally accessible – ie. they are located on the Trust’s intranet

Acute Pain Management: Scientific Evidence. Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Fourth Edition 2015.

Best Practice In The Management of Epidural Analgesia In The Hospital Setting. Faculty of Pain Medicine of The Royal College of Anaesthetists. November 2010.

ASRA Guidelines. Anticoagulation 3rd Edition 2010.

Drug Therapy Guideline - Naloxone for the treatment of opioid overdose in adults.

Drug therapy guideline – Local anaesthetic toxicity (severe) management

Drug Therapy Guideline - Postoperative nausea and vomiting – treatment in adults.

Bridging guidelines for peri-operative management of existing anticoagulation in surgical & invasive procedures (Adults)

9. EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy has been assessed accordingly

Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace. Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.

We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:

Working together for patientsWorking together with compassionWorking together as one teamWorking together always improving

This policy should be read and implemented with the Trust Values in mind at all timesContinual Epidural Infusions Management Policy Version: 9.1Issue Date: 20 August 2018Review Date: 31 July 2021 (unless requirements change) Page 9 of 24

10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

Minimum requirement to be

monitored

Lead Tool Frequency of Report of Compliance

Reporting arrangements Lead(s) for acting on Recommendations

Evidence of completed

training and competency by staff involved in

the care of patients with continuous

epidural infusions

Acute Pain Service

Acute Pain Service registers

Ongoing Policy audit report to:Acute Pain Service

Acute Pain Service

Evidence of collection of

adverse incident reports and

discussion at Mortality and

Morbidity Meetings

Acute Pain Service

Self-reporting

tool

Monthly Policy audit report to:Acute Pain Service

Acute Pain Service

This document will be monitored to ensure it is effective and to assure compliance.


EQUALITY IMPACT SCREENING TOOLTo be completed and attached to any procedural document when submitted to the

appropriate committee for consideration and approval for service and policy changes/amendments.

Stage 1 - Screening

Title of Procedural Document: Continuous Epidural Infusions Management Policy

Date of Assessment 18 July 2018 Responsible Department

Acute Pain Service

Name of person completing assessment

Charly Bellis Job Title Acute Pain Sister

Does the policy/function affect one group less or more favourably than another on the basis of :

Yes/No Comments

Age No

Disability No

Gender reassignment No

Pregnancy and Maternity No

Race No

Sex No

Religion or Belief No

Sexual Orientation No

Marriage and Civil Partnership No

If the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2

More Information can be found be following the link below

www.legislation.gov.uk/ukpga/2010/15/contents

Stage 2 – Full Impact Assessment

What is the impact Level of Mitigating Actions Responsible


http://www.legislation.gov.uk/ukpga/2010/15/contents

Impact (what needs to be done to minimise / remove the impact)

Officer

Monitoring of Actions

The monitoring of actions to mitigate any impact will be undertaken at the appropriate level

Specialty Procedural Document: Specialty Governance CommitteeClinical Service Centre Procedural Document: Clinical Service Centre Governance CommitteeCorporate Procedural Document: Relevant Corporate Committee

All actions will be further monitored as part of reporting schedule to the Equality and Diversity Committee

APPENDIX A: Patient Leaflet


Information about Your Anaesthetic and Pain Control after Surgery

Information for patients

Specialist SupportIf you require this leaflet in another language, large print or another format, please contact the Health Information Centre Tel: (023) 9228 6757, who will advise you.Preparing yourself for surgeryIf you smoke, giving up or cutting down can reduce the risk of breathing problems.If you have loose teeth or loose crowns, you should see your dentist to reduce the risk of damage to your teeth during your anaesthetic. Any long-standing medical problem such as diabetes, asthma or high blood pressure, should be checked by your GP, if you have not been recently.

Before coming into hospitalBefore your surgery you will usually see a nurse at a pre-assessment clinic, or be called at home to discuss your:-• Health and any medical problems,• any allergies/sensitivities,• regular medicines - including herbal remedies.• and to decide if you require any tests eg blood taking or heart tracing (ECG).

You will also be given instructions about taking your normal medicines; you can normally continue to take them as usual on the morning of your operation unless told not to do so.You should ask questions about what to expect.

On the day of your operationFastingThe hospital should give you clear instructions about the latest time you are allowed to eat and drink before your operation. It is important to follow these. If you have food or drink inyour stomach during your anaesthetic it is possible to vomit and cause damage to the lungs.

IllnessIf you feel unwell when you are due to come into hospital, please contact the ward for advice. It may be safer to cancel your surgery and wait until you are fully fit. Occasionally we


can only decide you are not well enough to go ahead, once you have come in and been examined.

The AnaesthetistAnaesthetists are fully qualified doctors with specialist training. They are responsible for giving your anaesthetic and for your wellbeing and safety throughout your surgery. Youwill meet your anaesthetist before your operation. They will ask you questions about your health, previous anaesthetics and usual medicines. They may need to examine your chestwith a stethoscope and examine your neck and mouth. They will explain the anaesthetic to you and what pain relief is suitable so you can discuss the options. Please ask questionsand tell them of any worries you may have.

Types of AnaesthesiaGeneral Anaesthesia (GA)This is a combination of medicines, which are given to make you unconscious (asleep), so you do not feel anything and will not be aware of what is going on around you during theoperation. These are usually given through a very small tube (cannula) placed in your hand or arm by the anaesthetist. During surgery the anaesthetist often also gives youanaesthetic ‘vapours’ to breath.

Local Anaesthetics (LA)These are medicines that have a numbing effect, to stop you feeling pain, but do not cause any loss of consciousness.

Local anaesthetic injections can be used alone to numb a small area of the body such as a finger.

Local anaesthetic blocks/spinals and epidurals are used for operations on larger or deeper parts of the body such as your arm or tummy. The types of anaesthetic are often combined – for example an epidural may be given as well as a general anaesthetic, toprovide pain relief after the operation.

SedationThis is normally given to you through a drip in your hand or arm, or sometimes as a gas to breathe in. This is to make you feel relaxed, calmer and a little drowsy, but awake enough totalk. There will be a member of staff that will communicate with you and a monitor will be attached to watch your heart rate and blood pressure. The sedation medicines affect yourmemory for the time you are being given them and many people do not remember anything about their procedure.

Benefits and Risks of AnaesthesiaContinual Epidural Infusions Management Policy Version: 9.1Issue Date: 20 August 2018Review Date: 31 July 2021 (unless requirements change) Page 14 of 24

Serious problems are uncommon in modern anaesthesia and many complex and life saving procedures can be carried out with a high degree of comfort and safety. It is difficult toseparate the risks of the anaesthetic from the risks of the operation and your general health.The risks to you as an individual will depend on:• Whether you have any other illnesses• Personal factors, such as whether you smoke or are overweight• Surgery that is complicated, long or done in an emergency.

Information about your anaestheticAlthough people react differently to medication, some side effects are quite common with anaesthetics, such as• Feeling or being sick• Damage to lips or tongue (usually minor) and a sore throat.• Confusion, memory loss, dizziness, blurred vision, headaches.• Bladder problems, backache, aches and pains.• Itching, bruising and soreness.

Uncommon side effects include• Chest infection• Muscle pains• Slow breathing (depressed respiration)• Damage to teeth• An existing medical condition getting worse• Awareness (becoming conscious during your operation)

Rare or very rare complications include• Equipment failure• Damage to eyes• Serious allergy (reaction) to drugs• Heart attack or stroke• Nerve damage• Death – approximately 5 deaths for every millionanaesthetics in UK.

Pain relief options

1. Oral medicines (taken by mouth) in the form of liquids or tablets.2. Intravenous (IV) medication given straight into your vein.3. Patient Controlled Analgesia (PCA) these are pumps with morphine type drugs that will go straight into your blood stream (vein) and are controlled by you. If you feel sore youpress the button, which is connected to a pump that gives you a dose of painkiller. The PCA is a safe form of pain relief because the pump will prevent you from giving yourself too much. Occasionally the painkiller causes sickness, drowsiness and itching, but these side effects can be treated.


4. Suppositories are small tablets that either you or a nurse will place up your bottom. They work quickly and can be very effective if you are not able to take medicines by mouth.5. Injections either into your thigh, buttock or arm – we do not often use this route.6. Local anaesthetic infusions – e.g. Rectus Sheath Infusion for tummy operations. These are small plastic tubes that are placed under the skin, near the wound during surgery.The tubes deliver numbing medicine to the wound and help with pain relief after your operation. This is a very safe form of pain relief, with a small risk of infection and bruising. The tubes are usually removed 2 to 3 days after your operation.7. Spinals and Epidural infusions are similar injections of a local anaesthetic between the bones in your back, to temporarily numb the nerves to the lower body. A spinal will wear off over 12-24 hours, whereas the epidural involves inserting a very fine plastic tube, through which the local anaesthetic is given continually by a pump. It can be used for several days after surgery to reduce your pain, allow deep breathing/coughing, help you to move more comfortably and aid your recovery. An Epidural is a safe and effective form of pain relief, butcomplications can occur, such as a headache, low blood pressure and heavy legs.

Serious complications including infection and nerve damage are rare. Long lasting nerve damage with on-going numbness or weakness is very rare indeed, affecting about 1 in 10,000 patients. Your anaesthetist will explain and discuss this in more detail and the pain team will aim to review you on the ward.

The Recovery RoomThis is where you will wake up after your operation, near the operating theatres. Specialist nurses will look after you until you are comfortable and ready to return to the ward. You willbe given painkillers if you need them and treatment for any nausea or sickness. Anxiety will make any pain feel worse, so it is important that you express any worries and ask any questions you may have.

How is pain measured?In Portsmouth Hospitals NHS Trust, we ask our patients to describe the level of pain being felt by using a simple scale 0 = No pain 1 = Mild pain 2 = Moderate pain 3 = Severe painYour scores are then recorded and can hep the doctors and nurses work out the best pain relief method for you. In this hospital, an Acute Pain nursing team and anaesthetists, work alongside the doctors and nurses on the ward to monitor your pain control and aim to visit all the surgical wards each day. The more information you have the better you will be able to cope with the pain. You are the only one who knows how much it hurts! It is important to let the


nurses and doctors know when the painkillers are wearing off and you feel uncomfortable. Do not wait until your pain is unbearable. This is important because having less pain will allow you to move around better and this will help you recover quicker.

Finding out moreSome of the text used in this leaflet is extracted from the Royal College of Anaesthetists’ patient information leaflets ‘Anaesthesia explained’ and ‘You and your anaesthetic’.The Royal College of Anaesthetists and The Association of Anaesthetists have produced a number of useful information leaflets about anaesthesia, which can be accessed via theInternet at www.youranaesthetic.info.

Information we hold about you and your rights under theData Protection ActPlease refer to the booklet ‘Your Healthcare Information – Your Rights! Our Responsibilities! for further guidance.

How to comment on your treatmentWe aim to provide the best possible service and staff will be happy to answer your questions. However, if you have any concerns you can also contact the Patient Experience Service on 0800 917 6039 or E-mail: [email protected]

Consent – What does this mean?Before any doctor, nurse or therapist examines or treats you they must have your consent or permission. Consent ranges from allowing a doctor to take your blood pressure (rollingup your sleeve and presenting your arm is implied consent) to signing a form saying you agree to the treatment or operation. It is important before giving permission that you understand what you are agreeing to. If you do not understand – ask.


APPENDIX B: Epidural Prescription ChartCopies can be obtained from medical photography



APPENDIX C: PCEA Prescription ChartCopies can be obtained from medical photography



APPENDIX D: Epidural Observation ChartCan be obtained from Medical Illustration



APPENDIX E: Protocol For Management Of Abnormal Neurological Signs In Connection With Epidural Analgesia

Introduction

Patients receiving epidural infusions of dilute (0.125 or 0.15%) bupivacaine, do not normally have dense motor block. They should be capable of some sort of movement of their lower limbs e.g. ankle flexion and extension

Significant motor block does not normally persist for more than 4 hours after discontinuing the epidural infusion.

Action

If either of the above occurs, the Acute Pain Service or, outside office hours, the second on-call anaesthetist (bleep 1622) should be contacted immediately. It is the responsibility of the surgical registrar to ensure that this referral takes place.

A suspected epidural haematoma is a MEDICAL EMERGENCY requiring urgent

MRI scan, in order for decompression to be undertaken as early as possible. MRI

scanning is not routinely available at Queen Alexandra Hospital after 1900.

MRI inpatient availability PHT:

Monday – Friday 0900 – 1900 contact radiologist in RAU extension 5270

Saturday and Sunday 0800 – 1900 contact radiologist in RAU extension 5270

During these hours refer directly to radiology for MRI & then liaise with neuro. In UHS

Outside of these hours referred to the Wessex Neurological Centre: Phone 023 8077

7222 or # 6215 and speak to the duty neurosurgeon regarding referral and transfer.

N.B. MRI performed after 1700 on any day will be reviewed by neurosurgery at UHS

and thus they will need to be contacted regarding this.

This protocol has been formally agreed between the Acute Pain Service and Mr N Brook, Consultant Neurosurgeon at Southampton University Hospital.
