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Epidural Analgesia (EA)
Lo Ah Chun
APN
OTS & Pain Management
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Learning objectives:
Nurses will be able to:
1. Describe the basic anatomy relating to EA
2. State his/her role in the management of a patient
with an epidural infusion
3. Outline the care related to an epidural catheter.4. Demonstrate operational competence with the
epidural infusion pump
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EA guideline The HAHO Medication Safety Committed has
established guideline on Safe Handling of EpiduralAnalgesia with effective from 1st March 2009
which is approved by the Central Committee on
Quality and Risk Management with advisory panelinputs from the COC (Anaesthesiology) and COC
(Nursing). With respect to this guideline we would
like to implement with effective from 1st May 2009
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Medical error : potential fatal results
Preparation of Epiduralinfusion syringe
(centrally supplied by
Pharmacy to the ward.(only Ropivacaine
0.15% with Fentanyl
2g/ml A/V)
Name: English
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Anaesthesiologist will draw up first syringe of epidural
mixture in OT or K9
Subsequent top-up syringes will be centrally supplied by
Pharmacy to the ward. (only Ropivacaine 0.15% with
Fentanyl 2g/ml in Normal Saline 0.9% available ) The epidural drugs are all supplied in pre-filled Terumo BD
50ml syringes, with yellow label on the syringes.
No refrigeration of drugs & keep in room temperature &discard after 24hrs
Stick bright yellow labels to drug syringes as well as
extension tubings to alert all staffs against parenteral routes.
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Medical error: potential fatal results
Administration of
epidural infusion
Epidural drug
Wrong route
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Medical error : potential fatal results
Administration of
epidural infusion
Wrong route
Intravenous
drug
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EA service would be initiated only by
anaesthesiologist inside OT or labor ward.
Key points in EA guideline
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Only dedicated syringe pumps are labeled with
FOR EPIDURAL INFUSION ONLY would be
used
Fresenius Kabi
Terumo Syringe Pump
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Preparation of the Epidural Solution:
The anaesthetist should check prescription and drug
regimen with a trained staffs.
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Mixing of EA Infusion
0.15% Ropivacaine + 2g/ml Fentanyl
Draw up 38 ml of normal saline + 10 ml of 0.75%Ropivacaine + 2 ml Fentanyl (100 microgram) into a
50ml syringe Terumo
43 ml N/S
100 microgram/ml Fentanyl
0.75% Ropiacaine 5ml
Terumo syringe
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Labelling: Label the epidural infusion syringe with drug regime,
patients name and prominent warning label
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Immediately prior administration All EA infusion must be prescribed on delegated PinkMAR epidural charts which are only a/v in OT and labor
wards, and they are chopped with FOR EPIDURAL USEONLY on the top. The infusion regimes would also be
chopped
MEDICATION ADMINISTRATION RECORD EPIDURAL DRUG PRESCRIPTION SHEET
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Immediately prior administration Anaesthetist + Another trained staff
5 Rights
Right patient
Right timeRight drug
Right dose
Right route
Cross-checks with documentation
MEDICATION ADMINISTRATION RECORD EPIDURAL DRUG PRESCRIPTION SHEET
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Immediately prior administration
Another trained staff
Independently verify patient identification
Confirm that correct epidural product, lineconnection, administration method and pump
settings
Both Sign
MEDICATION ADMINISTRATION RECORD EPIDURAL DRUG PRESCRIPTION SHEET
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Administration: Yellow coloured set and EPIDURAL labels near
all the connectors from the infusion syringe to
the antibacterial filter
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Important !!
Only the trained nurse can care the patient
with epidural continuous infusion
Attend the training session
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Epidural Analgesia
Administration of analgesics
into epidural space
Exert a powerful analgesic
effect
One of the most effective
techniques for acute pain
management
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Anatomy of Epidural Analgesia
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Anatomy of Epidural Analgesia
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Level of incision determine level of
insertion
High Thoracic (T4 7)
Thoracotomy, oesophagectomyMid/low thoracic (T8 10)
Gastrectomy, neprectomy, colectomy
Lumbar (L2 4)
Lower limb operation
Caudal: Sacral levelLower limb to lower abdominal region
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Indications of EA :a. Acute postoperative pain:
Intrathoracic surgery
Abdominal surgery
Lower limb orthopaedic surgery
Vascular surgery
Urological procedures
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b. Chronic pain -- terminal illness
c. Obstetrics -- Local anaesthetic freezes sensory and
motor nerves of the uterus and vagina
d. During operative procedures Patients unfit for GAe.g. those with major cardiovascular, respiratory and
metabolic problems
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Contraindications of EA
Patients refusal Coagulation disorders
Anatomical difficulties / abnormalities of vertebral
column Local or systemic sepsis
Anticoagulation therapy
Raised intracranial pressure Hypovolaemia
Uncooperative patients
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Advantages of Post-operative EA
Potential to provide excellent analgesia
Continuation of intra-operative therapy
Less systemic side effects compared to IV narcotic
infusions
Reduction in pulmonary complications, DVT, graft
thrombosis etc
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Disadvantages of EAA. Side effects from the drugs
a. Local Anaesthetics:
Hypotension, Lower limb weakness and
numbness, Incontinence, Diarrhoea
b. Opioids: Nausea, Pruritus, Urinary retention, Sedation,
Respiratory Depression
B. Catheter related complications Nerve Injury, Epidural Haematoma, Infection
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Complications of EA
Accidental dural puncture
post dural puncture headache
typically frontal, exacerbated by movement or
sitting upright, associated with photophobia,
nausea and vomiting, and relieved when lying flat
Epidural haematoma
May lead to compression of the spinal cord
paraplegia Infection
Failure of block
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Complications of EA
Hypotension
Inadvertent high epidural block
Difficulty in talking drowsiness
difficulty breathing
Local anaesthetic toxicity light-headedness, tinnitus, circumoral tingling ornumbness and a feeling of anxiety or "impendingdoom", followed by confusion, tremor,
convulsions, coma and cardio-respiratory arrest Total spinal
profound hypotension, apnoea, unconsciousness
and dilated pupils
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Setting Up Epidural Infusion
The infusion regimes have been used :
Ropivacaine 0.15 % + 2 ug/ml fentanyl at 0-12 mls/hr
Bupivacaine 0.0625% + 3.3 ug/ml Fentanyl at 0-12
mls/hr
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Modes of Delivering of EA
1. Epidural Infusion
Continuous
Patient Controlled (PCEA)
2. Intermittent administration of
opioid drugs into epidural space
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Epidural Analgesia (EA)EA can be safely managed provided that the following
are considered:
Regular follow up
Education of nursing personnel
Suitable protocols are adhered In-house acute support service
Continuing review
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Preparation for EA pre-operatively
1. The responsible anaesthetistshould discuss the risks, benefits
and alternatives about EA with thepatient prior to the theatre & givepatients and families leaflets &obtain consent for the procedure
2. The nursing staff should explainthe epidural procedure to the
patient.
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3. The following baseline observations should be
recorded before the patient goes to theatre e.g. T/
HR / RR / BP/ P
4. Report any abnormal sensation/limb weakness to
the anaesthetist & record down prn
5. Nurses should ensure that patient understands self-
report tools for pain assessment e.g. NRS /VAS
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Numeric Rating Scale
0 = No pain 10 = Worst pain imaginable
0 1 2 3 4 5 6 7 8 9 10
No Pain Worst pain imaginable
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Faces Rating Scale for children
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Care of EA in ward1. Resuscitation drugs including Atropine, Ephedrine
andNaloxone should be available
2. Heat packs or warming pads shall not be used on
areas where sensation is affected by the epidural
analgesia.
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3. Assist/observe patient with ambulation prn
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4. Ward nurse should check the followings upon initial
set-up; at the beginning of each shift/work period;For syringe changes; anytime tubing is
reconnected after disconnection.
a. Ensure delegated EA pump proper running
b. Ensure proper labelling of catheter
c. Check for dislodgement of catheter dailyd. Ensure no misconnection of epidural catheter
e. Check any oozing of insertion site
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5. Ensure EA catheter is taped along the back
Tapping is made around four corner of Tegaderm dressing to
reinforce the dressing. (eg Hyperfix or Mefix)
The remainder of the catheter is taped up the patients back
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6. Ensure EA catheter & filter are securely fixed
The filter is securely taped to the upper chest wall (near clavicle)
Any loose catheter tubing should be carefully coiled and taped
securely to the chest wall or shoulder
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7. Ward nurses should make sure that only delegated
infusion pump & delegated Pink MAR form areused for EA infusion
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8. Ward nurses should check the drug being administered
corresponding to the prescription & Nursing Instructionssheet, APS Prescription & Observation Records should
be completed appropriately
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9. Nursing Observation & record BP/HR/ RR record
hourly for the first 24 hours, then Q4h if stable.
If hypotension occurs, IV fluid support / slow
down the infusion rate/ Vasopressors, Rule outother causes of hypotension e.g. surgical
complications (bleeding)
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10. If the patient develop respiratory depression
Give 100% oxygen and manual ventilation if apnoea.
Inform Surgeon and Pain team / on call Anaesthetist IV Naloxone 0.1 mg, repeat every 2-3 minutes up to a
total of 0.4 mg as required
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11. Observation and record : sedation score
If the patient has a sedation score of > / = 2,
Contact on Pain Team or on call Anaesthetist
The sedation score is :
0 Awake, alert
1 Slight drowsy2 Very drowsy, rousable
3 Unrousable
S Sleeping, rousable
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12. Observation and record : pain score
Use self-report wherever possible.
Identify the type & location of pain Reposition & reassurance the patient
Rule out other cause of increasing or unresolved
pain e.g. surgical complications & contact thesurgeons or pain team / on call anaesthetist
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rescue
13 Observe & record motor Score (refer to APS
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13. Observe & record motor Score (refer to APS
Prescription& observation charts)
0 No leg weakness, full
extension, can raise extendedleg off bed
1 Unable to raise extended legbut able to flex knee and
ankle
2 Unable to raise extended legor flex knee but able to moveankle
3 Unable to flex knee, ankle orfoot
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14. Check & record lower Limb (s) Numbness
Use self-report wherever possible.
Identify the Right leg or Left leg whenever possible.
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15. Assess & record sensory Level
Assess the patients response to T change, apply an
ice pack or WariActiv spray to the skin surface.
Bilateral assessment of the block should be made.
If the block extends cephalad (i.e. towards the head)
to T3 or T4, the responsible anaesthetist must be
notified.
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Upper Dermatome Level
Lateral and AnteriorUpper Thigh
L2
GroinT12-L1
UmbilicusT10
XiphisternumT6
Nipple LineT4Sternal AngleT2
Reference of Dermatome Levels
T4
T10
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16. Observation and record: Nausea & vomiting
If the patient complaining of nausea or vomiting:
Aspirate nasogastric or gastrostomy tube if appropriate
IM / IV Maxolon 10mg Q8H
Side effect
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17. Observation and record: intake and output
If the patient has a palpable bladder or bladder
discomfort:
Contact the on call anaesthetist
Contact the surgeons to determine if the patient needs
to be catheterized. Documentation
The amount drained should be recorded.
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18. Observation and record: itching
Oral / IM / IV Piriton 10 mg Q8H
If itching continues to be a problem contact
pain team / on call anaesthetist
19 Ob & d f i LA i i
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19. Observe & record for systemic LA toxicity
Drowsiness, Dizziness
Tinnitus, Numbness of the tongue
Anxiety Confusion
Muscle twitching ,Convulsions
Loss of consciousness, Coma Hypotension
Bradycardia
cardiac arrest Respiratory arrest
** Contact pain team / on call anaesthetists
20. Others observations: Migration of catheter into
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20. Others observations: Migration of catheter into
epidural vessels in the epidural space
Causing systematic absorption of medications
(systematic toxicity) Observe for inadequate analgesia which may relate
to the small opioid dose being absorbed systemically
Observe for symptoms of LA toxicity e.g. dizziness,lightheadedness, hypotension, agitation, seizures
Notify pain team / on call anaesthetist immediately if
theses occurs
21 P ti t/ P t/ F il Ed ti di
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21. Patient/ Parent/ Family Education regarding
How epidural analgesia works
Opioid/local anesthetic name and side effects
Assessment procedures
Remo al of Epid ral Catheter
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Removal of Epidural Catheter
1. Lie patient on side and curled up if possible
2. Spray with plastic spray & covered with Tegaderm
3. Document the integrity of epidural catheter and
record the time removal of catheter
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Inform pain team on call anaesthetistIf the following situations occurs:
Over sedation
Respiratory depression or respiratory arrest. Disconnection from the filter &Pump occlusion
Displacement / dislodgement/ Break of the epidural catheter
patient has excessive lower limb weakness or numbness,painat insertion site; severe low back pain (signs of epidural /spinal haematoma)
Signs and symptoms of LA toxicity
Wet dressing & oozing of blood at insertion site Signs of catheter site infection, meningitis, or sepsis
Unrelieve N & V & itchiness
Trouble shooting
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Trouble shooting
a. If the epidural catheter is pulled out accidentally:
Reassure the patient. Put a sterile gauze over the entry site.
Keep the epidural catheter.
Contact Pain Team or on call anaesthetist
Documentation
b If h h b di d f h fil
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b. If the catheter becomes disconnected from the filter:
Do not clamp the epidural catheter.
Cover with gauze
Contact Pain Team or on call anaesthetistimmediately
Record the time of disconnection and / or the time of
noticing the disconnection.
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c.If pump occlusion occurs : Stop infusion & reposition the patient prn
Check the filter to ensure no over tightening of
connection. Observe the entry site for any kinking of catheter
under the skin and re-dress if necessary
Check any kinking of the infusion tubing
Check any proper running of the pump
If these interventions are unsuccessful, call pain team/
on call anaesthetist
Documentation
Important information
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p No Narcotics or bolus of LA are given through epidural
unless by pain team / on call Anaesthetist
Hypoxaemia is NOT a reliable early sign of respiratory
depression No injection at the epidural catheter
Catheter to only be removed by pain team / on callanaesthetists
Ensure normal coagulopathy prior to the removal of EA
Adjuvant Analgesics given (Tramadol, Dologesic,Panadol)
IV access should be available throughout the duration ofthe epidural and for 24 hours after it has beendiscontinued.
Patients receiving concomitant anticoagulants are more
at risk for epidural/spinal hematoma after removal of
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at risk for epidural/spinal hematoma after removal of
catheter, so these patients shall be assessed for onset of
signs/symptoms of epidural/spinal hematoma
Stop anticoagulation for 12 hours before removal ofcatheter & resume after 10 hours of removal
Keep monitor vital signs & IV cannula for further 24hours after removal of epidural catheter
Pain Team / on call Anaesthetists will follow up thepatient daily and for 1 more day after removal of EA
catheter
Exchange of empty epidural drug:
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Exchange of empty epidural drug:
Stop the pump
Clamp the tubing
Expel air of the 50 ml syringe
Connect to the epidural tubing
Ensure good sitting of syringe into the pump Start infusion again
** make sure no contamination occurs
** check tubing not connecting to other access before &after changing the syringe
Patient confidentiality
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Patient confidentiality
When return the infusion by porter
False Correct
Anaesthesiologists
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Ward NursePain Nurse
Question & Answer
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Question & Answer
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Pain Nurse: 22551272/ 73069578 (office hour)
On Call Anaesthetist: call operator 0
References
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References
1. Acute Pain Management: Scientific Evidence, ANZCA &Faculty of Pain Medicine / NHMRC, 2nd Edition 2005
2. Macintyre PE, Ready LB. Acute Pain Management: APractical Guide. WB Saunders2nd Edition 2001
3. Scott DA, Blake D, Buckland M, et al. A Comparison of
Epidural Ropivacaine Infusion Alone and in Combinationwith 1, 2, and 4 mg/mL Fentanyl for Seventy-Two Hoursof Postoperative Analgesia After Major AbdominalSurgery. Anesth Analg 1999; 88: 85764
4. Regional Anesthesia in the Anticoagulated Patient Defining the Risks: ASRS Policy Document 1998
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