SELF DIRECTED LEARNINGPACKAGE: PAIN

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SDLP Pain

Module 2: Epidural/Spinal Analgesia Page 1 of 66 October 2020

GIPPSLAND HEALTH SERVICES CONSORTIUM

SELF DIRECTED LEARNINGPACKAGE:

PAIN

MODULE 2: EPIDURAL/SPINAL

ANALGESIA

CPD 5 POINTS: RN 6 POINTS: RM

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Acknowledgments/Copyright/Disclaimer

3 Introduction

4 Anatomy & Physiology

5 Overview of Epidural & Spinal Analgesia

9 Epidural Analgesia

13 Medications used in Epidurals

16 Key Principles of Care

19 Patient Assessment : Observation &

Frequency

23 Assessment of Motor & Sensory Block

25 Key Nursing & Midwifery Considerations

29 Management of Adverse Events & Side

Effects

36 Checklist of Care : Patient receiving

Epidural Analgesia

51 Giving an Epidural Bonus

52 Troubleshooting Table

54 Spinal Analgesia with Intrathecal Opioid

55 Midwifery care of the woman with epidural

analgesia: Key Principles of Care

57

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ACKNOWLEDGEMENTS

This Self Directed Learning Package was adapted from Epidural Management Learning Package & Competency - Goulburn Valley Health and Epidural Management Self-Directed Learning Package – Bass Coast Health

Approved by the Gippsland Region Nurse Educators Group July 2009 & updated by Sarah Pearse-Clarke LRH and Robyn Godbold GRNMEC January 2014. Peer review & midwifery component Rosemary Parker LRH. Updated as part of new Pain SDLP 2020- Deb Kennedy perioperative educator LRH, Pain Team LRH & Barbara Dann BCH, WGHG & SGH midwife.

COPYRIGHT

Wherever possible permission has been obtained for reproduction of materials and images and the compilers acknowledge the rights of the copyright holder in all reproduced materials which are referenced on the page or in the reference notes.

DISCLAIMER

The information in this learning package is intended to be a guide only and Health Care Professionals should be aware of the policies and procedures of their

employing organisation.

This learning package consists of current best practice at the time of publication, October 2020 however it should be noted that changes in the medical and nursing field can occur quite rapidly therefore it is up to the individual to ensure they are accessing current information.

NAVIGATION TOOLS & TERMINOLOGY

Critical areas of practice & key points

*

Please refer to local guideline while you are working through this section

Escalation Protocol

“The protocol that sets out the organisational response required for different levels of abnormal physiological measurements or other observed deterioration.” (ACSQHC, 2017)

Rapid Response System

The protocol set out by organisation in order to obtain emergency assistance in response to severe deterioration it is included as part of escalation protocol. (ACSQHC, 2017)

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INTRODUCTION

This is a learning package only and clinicians should refer to their own organizational policy and procedures to direct their practice. Please ensure you have access to these documents as you undertake this SDLP

Once you have completed the reading of this SDLP you will need to complete the online quiz on your Kineo/ReHSeN e-learning portal. If this does not appear under your learning TAB, please contact your education department so they can get this allocated to you. There is one quiz for midwives and one for nurses.

AIM

The purpose of this self-directed learning package is to provide education for Nurse’s & Midwives so that they are able to safely and effectively care for patients receiving Epidural/Spinal Analgesia.

LEARNING OUTCOMES

On completion of this package including assessments the learner will be able to:

 Provide comprehensive patient and carer/family education

 Describe the basic anatomy of the spine, spinal nerves and epidural/subarachnoid (spinal) space

 State his/her role in the management of a patient with an epidural/spinal analgesia and or infusion

 Conduct a comprehensive assessment of patient who has an epidural/spinal in progress including sensory and motor block assessment

 Understand assessment and precautions with mobilisation

 Understand adverse reactions, potential complications and initiate the appropriate nursing interventions

 Ability to escalate care/initiate rapid response system according to Hospital protocol in response to adverse reactions/complications

 Outline the care related to an epidural catheter dressing/site

 Outline the procedure for discontinuing infusion and removal of the epidural catheter.

 Have sound knowledge of the drugs commonly used in epidural/spinal analgesia

 Demonstrate operational competence with the epidural infusion pump and the management of epidural infusions.

 For midwives: to understand the implications for practice in the care of a labouring woman

Please Note: Training and competency requirements will be determined by your employee Health Service.

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ANATOMY & PHYSIOLOGY

Spine

The spine is divided into 5 sections: 1. Cervical C1-C7 2. Thoracic T1-T12 3. Lumbar L1-L5 4. Sacral S1-S5 5. Coccyx (Martini 2006)

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Spinal Cord

The spinal cord extends form the foramen magnum to L1and is protected by vertebrae, ligaments, meninges and CSF.

The meninges are the 3 layers that run continuously around the spinal cord and brain

 Dura mater: outer layer

 Arachnoid mater: middle attached to dura

 Pia mater: inner layer (Nagelhout, 2017) Dividing the meninges are spaces or potential spaces

Epidural: potential space between ligamentum flavum and the dura mater

Subdural: potential space between dura and arachnoid mater

Spinal/intrathecal/subarachnoid: space between the arachnoid and the pia mater and contains CSF (Nagelhout, 2017)

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Spinal Nerves

The spinal nerves emerge through the intervertebral spaces along the spine. The area of skin innervated by a given spinal nerve is called a dermatome. (Sawhney, 2012)There are 31 paired spinal nerves leaving the spinal column.

After leaving the spine the nerves now form the peripheral nervous system. The peripheral nervous system contains 3 types of nerves

 Autonomic: regulates involuntary body functions, cardiac muscle, smooth muscle and glands

 Sensory: conducts sensory impulses from the periphery, pain temperature pressure touch

 Motor: conducts impulses to muscles (Harris, 2010)

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Overview of Epidural & Spinal Analgesia/Anaesthesia

Epidural and Spinal analgesia is: the administration of drugs (local anaesthetic/opioid) into the epidural or spinal space bathing the spinal nerves and/or cord providing analgesia/anaesthesia depending on drug, doses & volumes used. They are often referred to collectively as neuraxial blockade/analgesia

 Epidural

 Spinal +/- intrathecal narcotic

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Epidural

The epidural space is a potential space that lies between the ligamentum flavum

and the spinal meninges, specifically the dura mater.

It extends from the foramen magnum (base of the skull) to the sacrococcygeal ligament (sacrum), and it contains fatty (adipose) tissue.

Blood vessels, lymphatic vessels, and spinal nerves pass through the epidural space. (Sawhney 2012)

The epidural needle is inserted between the vertebra into the epidural space without puncturing the dura. A catheter is then inserted down the needle into the epidural space for administration of drugs. The epidural needle is then removed & the catheter is left insitu.

The exact insertion level of the epidural needle is determined by the type of surgery or procedure being performed. It is inserted at a level appropriate for the dermatome which will cover the midpoint of the surgical wound or the uterus (in labour). The epidural drugs will spread to a range of segments above and below the insertion point.

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Spinal/Subarachnoid/Intrathecal

The sub arachnoid space is located between the arachnoid mater and the pia mater and contains cerebrospinal fluid (CSF). The spinal cord extends from the brain to the level of L1-L2. When anaesthetic drugs +/- opioids are injected into this space it is called a spinal anesthetic. If opioids are used it is referred to as spinal anesthetic with intrathecal opioid (morphine or fentanyl).

A finer (diameter) needle is used for insertion of spinal anaesthetic and the dura is punctured. Correct positioning of the needle is determined by the presence of CSF at the hub of the needle. Much smaller doses of drugs are used via this method than are with epidural administration as they spread more easily in the CSF (ANZCA, 2019) Analgesia onset is more rapid, reliable and effective. (Shatil, 2019)

Summary of differences between Spinal and Epidural Anaesthesia Spinal Epidural Mechanism of action Nerve roots blocked as they pass

through CSF

Nerve roots blocked outside the subarachnoid space (CSF)

Administration site Lower lumbar below termination of spinal cord

Lumbar or thoracic

Dose comparison of drugs Smaller dose & volume Larger dose & volume

Administered via Needle Catheter

Ongoing dosage No Yes

Speed of onset Rapid, intense motor and sensory block more likely to lead to

hypotension

Gradual less dense blockade, if hypotension usually more gradual (Nagelhout, 2017)

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Combined Spinal/Epidural (CSE)

A combined spinal/epidural (CSE) combines the two methods. An epidural needle is inserted into the epidural space. A finer spinal needle is then inserted down the epidural needle puncturing the dura so the tip of the needle sits in the

spinal/subarachnoid space. Drugs are injected into the space and the spinal needle is removed. The epidural catheter is then threaded down the epidural needle into the epidural space for administration of ongoing analgesia. (Up to Date 2020)

Needles for combined spinal/epidural:

Spinal needle

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EPIDURAL ANALGESIA

How an epidural works

Epidural analgesia is a central neural block which is used primarily for surgical anaesthesia, obstetric analgesia and post-operative pain relief. The degree of effect covers a wide range from analgesia with minimal motor block to dense anaesthesia with full motor block.

Epidural analgesia is the administration of analgesic drugs into the epidural space via an epidural catheter, providing pain relief by bathing the spinal nerves as they run through the epidural space. It can be placed at thoracic or lumbar level.

Effective analgesia is achieved when local anaesthetics and opioids are combined because they work synergistically to provide better pain relief with fewer adverse reactions. (Summers, 2019)

The underlying principle is to provide effective analgesia to patients without causing excessive motor block (weakness) or sensory deficit (numbness) during and following various surgical procedures, post-operative or during labour and childbirth. Epidural analgesia may be administered as an

 Intermittent injection: with the epidural drugs being administered as a bolus when required without a background infusion.

 Continuous infusion: where a dose range is delivered continuously, following an initial bolus.

 Patient Controlled Epidural Analgesia PCEA: Where the patient is able to activate a metered dose (small bolus) of epidural medication on demand within set limits via specialized device, following an initial bolus dose. PCEA may sometimes have a low dose background continuous infusion.

Please refer to your local protocols in terms of PCEA. Separate training may be required. You may need to complete local training and clinical competency around this.

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Indications for epidural analgesia

 Anaesthesia for surgery chest, abdomen and lower limbs



Postoperative analgesia after thoracic, abdominal, bowel, spinal or lower limb surgery.



Pain relief post trauma e.g. # ribs.



Analgesia for some types of chronic pain.



Obstetric analgesia – during labour and birth.

Contraindications for Epidural Infusion (maybe absolute or relative)

 Client refusal.

 Any documented previous allergic reactions to any of the medications that may be administered.

 Coagulation disorders

 Therapeutic anticoagulation (relative follow local protocols)

 Uncorrected severe hypovolaemia.

 Actual or anticipated serious maternal haemorrhage

 Significant hypotension.

 Recent head injury or head trauma or CNS disease. Any clinical signs of raised intracranial pressure.

 Neurological disease (relative)

 Stenotic valvular heart disease

 Foetal distress (consider need for urgent caesarean)

 Serious infection: infection at site, sepsis or bacteraemia.

 History of spinal deformity, surgery or disease (relative) (Nagelhout, 2017)

Benefits of Epidural Analgesia

 Patient comfort – a well-managed epidural infusion results in excellent analgesia.

 Patient is mentally more alert (drugs administered locally not systemically)

 Reduces systemic side effects of opioids, such as nausea and vomiting and decreased bowel motility.

 Increased ability to deep breath, cough and mobilise. This is especially pertinent after abdominal or thoracic surgery as it aids rehabilitation and decreases side effects such as chest infections and deep vein thrombosis.

 Post-operative analgesia following bowel surgery with the benefits listed above.

 Decreased stress response to surgery by decreasing pain and consequently sleep disturbances.

 Shorter hospital stays (optimal pain management)

 Lowers BP in pre-eclampsia

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Limitations of Epidural Analgesia

 Requires specialist skills: medical & nursing/midwifery

 Takes time to insert epidural catheter

 Epidural analgesia may not be effective when there is pain from multiple sites.

 Adverse side effects, associated with epidural insertion and/or administration of epidural drugs, may limit the effectiveness of epidural analgesia

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MEDICATIONS USED IN EPIDURALS

*

Before completing this section find out what drugs are commonly used in

your health service for epidural analgesia and how they are prepared & stored for safety i.e. polybag, premix

Local Anaesthetics

Bupivacaine (Marcain) & Ropivacaine (Naropin) are the local anaesthetics of choice for an epidural infusion and have a longer duration of action (4 to 7 hours) than other local anaesthetic agents.

Lignocaine (Xylocaine) may be used in epidural anaesthesia (fast action but shorter duration)

Adrenalinemay be used in combination with thelocal anaesthetic to potentiate the action of local anaesthetic drugs.

The effect of the local anaesthetic depends on

 Choice of drug

 Volume of drug: larger volume greater spread within the epidural space

 Concentration of drug: rapidity of onset & density of block

 Additives: adrenaline will speed up action

Opioids

Fentanyl is lipid soluble and has a quick onset (5 to 15 minutes) but a short duration of action (2 to 3 hours).

Morphine is hydrophilic and has a longer time to onset (30 to 60 minutes) and duration action (up to 24 hours)

(Sawhney, 2012)

Hydromorphone is more hydrophilic (water soluble) than fentanyl but more lipophilic than morphine. The onset of action for hydromorphone ranges from 15 to 30

minutes, and duration of action is up to 18 hours.

Fentanylis usually the opioid used in epidurals. It has been chosen because it has high lipid solubility. This gives it several advantages:

• It works rapidly because it penetrates nerve tissue easily.

• It has relatively short mode of action because it is rapidly removed from the systemic circulation and taken up by fat.

• When given via the epidural route it is less likely to cause respiratory depression because it is easily absorbed into the local nerve tissue.

Epidural anaesthesia vs. epidural analgesia

While epidural analgesia is used to manage pain, epidural anaesthesia is used to provide anaesthesia for surgical procedures.

Epidural anaesthesia includes the loss of sensation and motor function as well as the management of pain, and involves the administration of local anaesthetics and/or opioids into the epidural space at a larger dose than what’s administered to achieve epidural analgesia. (Sawhney, 2012)

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How local anaesthetic works in epidurals

Local anaesthetics affect spinal nerve roots by binding to sodium channels and preventing the influx of sodium ions into the nerve cells. This prevents generation of action potentials and interrupts conduction of nerve impulses, so the pain “message” can’t be transmitted along the spinal nerves. (Sawhney, 2012)

• Autonomic - are the smallest and will be blocked first [sympathetic blockade] causing vasodilation, sweating and heat loss. Results in drop in blood pressure (BP), postural hypotension, warm dry periphery, and compensatory vasoconstriction in the upper limbs

• Sensory - In order from small to larger they are pain, temperature, touch, pressure, and proprioception. Pain and temperature nerves are approximately the same size so pain and temperature nerve block will occur simultaneously and therefore can be checked by temperature testing.

• Motor - Results in loss of motor power within the blockade segment if the concentration of LA is high enough. E.g. a thoracic block should only affect the thoracic and abdominal muscles/myotomes innervated by the thoracic nerves. Lumbar epidurals will affect the lower limbs more. This is very important when considering mobilisation. The extent of the motor block can be assessed by use of the Bromage Scale (this will be discussed later in the package)

(Craig, 2012)

How opioids work in epidurals

Opioids administered into the epidural space work by binding to opioid receptors in the dorsal horn of the spinal cord to block transmission of the pain message to the brain. Opioids have no effect on sympathetic, sensory, or motor nerve fibres. The onset of action depends on the lipid (fat) solubility of the opioid. The more lipid soluble the opioid is, the faster it passes through the epidural space to bind to opioid receptors. (Sawhney, 2012)

Fentanyl is considered to be a lipid soluble opioid. As such it is taken up more readily by the neural tissues at the particular epidural level where it is injected.

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KEY PRINCIPLES OF CARE

Refer to your own hospitals Policy & Procedure manual for

information on the equipment required, insertion instructions and the roles and responsibilities of all involved.

RESPONSIBILITY

Nurse & Midwife - Who has undertaken an epidural education & competency

program. (ANZCA, 2014)

 Checking consent, patient identification and allergies

 Preparation of equipment

 Monitors & maintains surgical aseptic technique during preparation, insertion and all interventions

 Care and management of the patient undergoing epidural anaesthesia, including monitoring of vital signs & escalation of care as required

 Documentation of all monitoring and care given in accordance with protocols.

 Preparation of fluids and medications for administration in accordance with

o Hospital policy & Procedure

o Scope of practice/competency

o Legal & regulatory requirements for drug administration

o Maintenance of aseptic technique (CGHS, 2010)

Midwife - Who has undertaken an epidural education & competency program.

(ANZCA 2014)

 As above &

 For the care and management of the woman having epidural analgesia in labour ward

 To document all monitoring and care given in accordance with protocols.

PROCEDURE & EQUIPMENT

Infection prevention & control principles

Insertion of an Epidural requires application of a “surgical aseptic technique” utilising a “critical aseptic field” (utilising full barrier precautions)

& strict adherence to the five moments of hand hygiene. (NHMRC, 2019)

Epidural Equipment (refer to your local hospital policy and procedure) At bedside:

 Oxygen & Suction equipment

 Monitoring equipment

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Drugs:

Available & valid order as per epidural chart/record

 Naloxone: Rx of respiratory depression

 Ephedrine: Rx of hypotension

 Metaraminol (aramine): Rx of hypotension

Please refer to local administration and monitoring guidelines when these drugs are used. A protocol for the management of hypotension and respiratory depression may be included as part of this.

*

Please review the epidural management chart at your health service

Resuscitation Trolley:

Including O² supply, suction equipment, self-inflating bag, face mask, intubation equipment, defibrillator & supply of intra-lipid readily available for treatment of LA toxicity (Kasson, 2017)

CTG Machine

All labouring women having an epidural require continuous CTG monitoring as per RANZCOG guidelines (2019) with a consistently good trace i.e. no periods with loss of contact. If the quality of the trace is questionable a foetal scalp electrode should be applied if possible. (RANZCOG, 2019)

Instructions:

Prior to Epidural

Nursing/Midwifery staff responsibilities:

 Consultation in patient selection.

 Informing patient of basic procedural details in conjunction with anaesthetist

 Document baseline observations prior to procedure.

 Preparation of equipment.

 Ensure patient IV access & patency

Insertion of Epidural:

 Procedure is undertaken in Operating Suite / Labour Ward

 A Nurse/Midwife must be present throughout the procedure

 If a Syntocinon infusion is in progress, this does not need to be paused during the procedure as long as high quality CTG monitoring can be continued (SCV 2018) *Please refer to local guideline and instructions of treating MO

 Baseline observations should be taken including pulse, blood pressure, respiratory rate and foetal heart rate (if applicable).

 Intravenous line is inserted prior to the epidural insertion and an IV fluid bolus may be given prior to insertion

 Assist patient into anaesthetists preferred position with back curved. Either sitting over heart table or lying on left side.

 Monitor and maintain asepsis during setup, procedure & ongoing management

 Monitor the patient’s responses throughout the insertion procedure

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 Skin prep is applied and allowed to dry, sterile drapes are applied

” Skin preparation should be conducted in such a manner that agents used for skin preparation are unable to contaminate drugs or equipment used

for neural blockade”(ANZCA, 2014 pp2)

Alcohol preparations are neurotoxic (alcoholic chlorhexidine & alcoholic betadine skin preparations)

If equipment or drugs are contaminated by skin prep, they must be discarded. To prevent contamination separate skin prep from other equipment & drugs used in epidural insertion.

 The doctor will inject local anaesthetic into the skin and subcutaneous tissue and then insert epidural needle through to the epidural space.

 In the labouring woman, it is important that the needle and catheter are inserted in between contractions. During contractions the epidural veins become distended and an inadvertent bloody tap may occur. It is important to instruct the patient that they must alert the anaesthetist to the onset and easing of contractions.

 Anaesthetist will confirm loss of resistance (this confirms placement in the epidural space) as the needle passes through the ligamentum flavum into the epidural space.

 Patient must be kept as still as possible during this time to minimise the risk of inadvertent dural puncture or serious injury to spinal nerves

 The needle is then aspirated to detect any blood/CSF. If negative, the epidural catheter can be introduced.

 Once the catheter is inserted, the needle is removed and a filter is attached to the distal end of the catheter. Attach securement device appropriate to the size of epidural catheter at the site of insertion. The insertion site is dressed with clear occlusive dressing and the edges of the dressing secured with sleek or fixamul. The rest of the catheter is then secured up the patient’s back to their shoulder with sleek or fixamul. Secure to shoulder on opposite side to the IV cannula (safety & to facilitate line reconciliation).

The dressing should allow for easy visibility of insertion site

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 A test dose of local anaesthetic is given by the anaesthetist whilst assessing for any sensory or motor changes. Correct placement of the catheter in the epidural space is indicated by no noticeable effects of the test dose.

 If after 5 minutes there are no complications from the test dose the full dose is given.

 The pregnant woman should then be positioned on her left or right side, either flat or in a semi – reclining position (still on her side), all other patients are positioned supine. All patients have their head elevated on at least one pillow. Change of position may be necessary to assist spread of the anaesthetic agent. Follow anaesthetist direction in relation to positioning.

 Patient observations are recorded and any problems recorded and reported.

Post Insertion

The Nurse/Midwife must remain with the patient for the next 30 minutes at least, whilst the block becomes effective. (ANZCA 2014)

 Vigilant patient assessment according to Hospital guidelines (this will be covered later in SDLP)

 After 30 minutes the effectiveness of the block and the upper limit of the block should be tested with ice (or a cold pack) and the level noted and recorded. (Procedure described in subsequent section of the SDLP)

 The patient can then be placed in any favoured position, avoiding the supine

position in pregnant women.

 If the epidural catheter is inserted and infusion commenced in the operating suite the patient must be stabilised prior to transfer to the ward.

Epidural insertion equipment

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PATIENT ASSESSMENT - OBSERVATIONS & FREQUENCY

Close observation and timely and appropriate interventions in response to abnormal or concerning findings is critical area of patient safety when caring for someone who has an epidural insitu.

*

Please refer to local guideline while you are working through this section, the

following information is a guide only, follow your local observation regimen.

*

Please review the epidural management chart at your health service, noting

parameters for escalation of care

Initial observations

 Pulse, respiration, blood pressure, foetal heart rate (continuous CTG), level of pain & level of sedation are recorded frequently (generally 5 minutely) in the initial period following insertion or bolus doses (or until stable) (ANZCA, 2014). ANZCA recommend this for 30 minutes

Motor and sensory function (will be discussed in more detail on subsequent pages) should be measured during this initial period (at 30 minutes).

These observations are documented on an epidural infusion chart. (ANZCA, 2014)

 Monitoring of patient’s temperature should also be carried out as per hospital guidelines (at least 4 hourly)

 Pulse oximeter and ECG monitoring should be available. (ANZCA, 2014) This frequency of observations is repeated following bolus doses or increases in infusion rates or change of drug concentration/dosage.

Ongoing observations

 Observations then continue at frequent intervals according to local protocol, observation frequency may need to alter in response to abnormal findings. An example of monitoring requirements is tabled on the next page.

 Obstetric patients’ in labour will continue to have observations at half hourly intervals for duration of labour & continuous foetal monitoring. (RANZCOG 2019)

 Level of anaesthesia dermatome level & motor blockshould be checked 4-6 hourly or more frequently if changes to rate or bolus doses or if clinically indicated.

 After epidural infusion is discontinued observations shall be done at least four hourly and IV access shall be maintained for a minimum of four hours

 If epidural morphine has been used observation regimen should continue for 24 hours.

 Monitor urine output. In most cases, an indwelling catheter will be insitu, if not encourage patient to empty bladder at least 2 hourly

Reportable parameters are also noted on an epidural infusion chart and anaesthetist should be contacted immediately of changes in vital signs outside these parameters.

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The following table is a guide only observation frequency will depend on local guideline; observation frequency needs to be responsive to abnormal findings

Baseline observations should be obtained prior to commencement of procedure

 Pulse, BP, respirations, temp, pain & sedation score

Observation Initial observation

Ongoing observation Labouring Woman

Post Epidural Pulse 5 min for 1/2 hr ½ hourly for 2 hours ½ hourly 4 hourly

BP 5 min for 1/2 hr ½ hourly for 2 hours ½ hourly 4 hourly

Resp 5 min for 1/2 hr ½ hourly for 2 hours ½ hourly 4 hourly

Temp 4 hourly 4 hourly 4 hourly 4 hourly

FHR Continuous Continuous Continuous

Pain 5 minutely ½ hourly for 2 hours ½ hourly 4 hourly

Sedation 5 minutely ½ hourly for 2 hours ½ hourly 4 hourly

Motor at 20-30 mins ½ hourly till block established then 4-6 hourly

½ hourly till block established then 4-6 hourly

Till normal motor function returns

Sensory at 20-30 mins ½ hourly till block established then 4-6 hourly

½ hourly till block established then 4-6 hourly

Till normal motor function returns

SpO2 continuous Intermittent ½hourly for 2 hours

Intermittent ½ hourly

4 hourly

ECG If indicated If indicated If indicated If indicated

PAIN ASSESSMENT

Comprehensive assessment of pain is a critical component of ongoing patient assessment & will determine ongoing management

Level of pain is monitored to determine efficacy of analgesia but may also be a key indicator in the development of complications.

MEASURING SEDATION

Sedation scoring is used primarily to assess the effect of opioid analgesia.

The level of a patient’s sedation is measured according to their level of wakefulness and their ability to respond to verbal commands. (ACSQHC, 2017)

There will be a sedation score guideline on your epidural infusion observation record. Please refer to this and to the appropriate reporting parameters.

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ASSESSMENT OF MOTOR & SENSORY BLOCK

In relation to epidural the dermatome levels and the Bromage scale assess two distinct aspects of the analgesia. The dermatome levels are used to assess sensory block whilst the Bromage scale assesses the motor block.

They are part of the initial and ongoing assessment of the patient with an epidural.

SENSORY BLOCK ASSESSMENT

Performed to map the epidural sensory block upper & lower level (Barwon Health, 2016)

What is a dermatome?

An area on the surface of the body innervated from a single spinal nerve root.

Key dermatome landmarks C3 Neck C5 Clavicles T4 Nipples T7 Xiphoid T10 Navel L1 Groin L4 Knee L5 Dorsum of foot S1 Lateral ankles (Cross, 2006)

C5-T1: perform dermatome assessment on arms

Why assess dermatome levels?

Assessment of dermatome levels enable caregivers to assess the extent of sensory block associated with epidural analgesia.

The local anaesthetic blocks the conduction of impulses into and out of the nerves. When lower concentrations of local anaesthetic are used, there will be a sensory block with minimal or no motor block. Pain and temperature nerves are blocked at the same time. Nurses/Midwives can therefore use a piece of ice to detect which nerve roots at the spinal level are covered with local anaesthetic. Thus, loss of temperature sensation to COLD is used to determine analgesic block height (sensory block height).

Key indicators of dermatome levels

T4 Mid sternum (nipple line).

Sensory blocks above this level represent a high or extensive block. This level of block has the potential for cardiovascular and respiratory instability.

This may signal excessive local anaesthetic and sympathetic block, indicating a need for reducing or stopping the epidural infusion.

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When to access dermatome levels

 Initially following commencement of epidural (according to local protocols) & frequently till block established

 Usually 4-6 hourly once epidural established & at shift handover

 If patient shows signs of other complications: e.g. difficulty breathing, arm weakness tingling fingers

 If the patient develops significant hypotension

 If patient has severe pain

 Prior to changes in infusion rate

 Prior to bolus and following bolus (@ 30 minutes’ post bolus) (Monash Health 2016)

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High Sensory Block

If the sensory block level exceeds the acceptable height charted on the epidural infusion chart by the Anaesthetist

 Escalate care and cease infusion if indicated

 Increase your vital sign recordings.

Low sensory block

If the block is below the level of the wound or desired area

 Increase the epidural infusion rate (within the parameters prescribed) and notify the anaesthetist.

 The patient will usually need to have a “top up” bolus dose administered.

Patchy” Sensory Block

If the blocked area is becoming poorly defined or “patchy”

 Notify the anaesthetist and increase the epidural infusion rate (within the parameters prescribed).

 “Patchy” blocks are usually an early sign that the patient is going to lose their dermatome block levels altogether and a bolus dose is required.

Unilateral Block

When only one side has sensory loss, this is called a unilateral block. This is usually caused by the epidural catheter moving off to one side and there are some strategies we can employ to try and compensate for this.

 Obviously if the side that is well blocked is also the location of the surgical procedure and the patient has no pain then the fact the block is unilateral is of no real concern, however this won’t always be the case.

 Turn the patient onto their painful side (the side that is not being blocked); gravity can sometimes help spread the local anaesthetic across. The patient will probably also need a bolus dose to be administered. (Craig, 2012)

Steps to carry out a dermatome assessment:

1. Patient Explanation – inform the patient that you would like them to tell you

when they feel a change in temperature and/or sensation as the ice is moved along their body.

2. Ice Test – using ice, in a thin glove, touch the patient’s chest or face. This

effectively shows the patient what is ‘baseline’ cold.

3. Utilising a Dermatome chart for reference points – systematically advance

the ice over the dermatomes of each side of the patient’s body on either side of the midline Determine where the patient can feel ‘nothing’, touch only’ or ‘cold’. Start at the patient’s feet and move the ice upward in three to four cm increments at a time

4. The dermatome below where the patient feels the cold sensation is the

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5. Changes in sensation – document the upper and lower level of the block for

each side of the body using the dermatome chart as a map.

6. Take appropriate action – if the block level is too low or too high.

7. Assessment should be done bilaterally, one side at a time. (Loader, 2011)

MOTOR BLOCK ASSESSMENT

Motor block assessment using the Bromage scale assesses the patient’s ability to move their lower limbs. During an operation it is desirable for patients to have a motor block, postoperative or in labour it is not. The patient is asked to move their legs and the result is graded according to the table below. (Faculty of Pain Medicine, 2010)

Bromage scale

http://www.frca.co.uk/article.aspx?articleid=100316

An increase in the degree of block (motor weakness) may be indicative of excessive drug administration but could also indicate the development of more serious complications

 Migration of catheter

 Epidural haematoma

 Epidural abscess

(Faculty of Pain Medicine, 2010)

Grade Criteria Degree of block

I Free movement of legs and feet Nil (0%)

II Just able to flex knees with free movement of feet Partial (33%)

III Unable to flex knees, but with free movement of feet Almost complete (66%)

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KEY NURSING/MIDWIFERY CONSIDERATIONS Infusion pumps & lines

LINE RECONCILIATION - Where all tubes and catheters are traced from patient to infusion source. Should be done at the change of each shift, at handover to different departments, prior to a bolus and when changing lines or poly bag/infusion syringe.

 The use of a single chamber infusion pump is mandatory for epidural infusion. (ANZCA, 2014)

 Key pad to infusion pump must be locked once dose entered.

 The epidural catheter should be taped to the opposite shoulder to the arm the IV line is in

 The infusion pump should be situated and managed from the opposite side to the intravenous infusion.

 Only yellow coloured epidural lines with no injection ports for accidental access are to be used. (ANZCA, 2014)

 Burettes must not be added to infusion line

 These lines are generally available in the Operating Suite and Labour Ward.

 Dosing must be set hourly i.e. if the rate is 10mls per hour, the volume to be infused is set at 10mls.

Labelling

 Some hospitals require a label above the patients bed (check your hospitals policy). All epidural infusion labelling must be routinely checked each shift

 Dedicated epidural infusion labels must be attached and clearly visible on

 The infusion bag/syringe

 The line above the infusion pump if polybag used

 The line below the infusion pump close to the filter

 The infusion pump itself (ANZCA, 2014)

Labelling must comply with ACSQHC (2015) “National standard for user applied labelling of injectable medicines fluid and lines”. https://www.safetyandquality.gov.au/

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Yellow epidural line (no injection ports)

Observation of epidural catheter & site

 Epidural catheter line and filter should be observed regularly for integrity.

 Epidural site checked at least once per shift or when there are any issues with the epidural. Any redness, ooze, swelling or pain is noted and reported to the anaesthetist & vital signs should be checked including temperature. If leaking is observed DO NOT remove the dressing, cover with sterile dressing and notify the anaesthetist.

 Epidural catheters have markings on them to indicate their length from tip of the catheter.

o It is good practice to check the catheter level mark at the insertion site when doing epidural site checks or when catheter migration is suspected.

o Each mark represents one centimetre. Two marks close together represent ten centimetres. Three marks close together indicate fifteen centimetres and so on.

o Check the marking at the insertion site and document.

o This measurement can be compared to the length documented on insertion by the anaesthetist.

Urinary output

Insertion of an indwelling catheter is usually required for the duration of the epidural (Monash Health, 2019)

If urinary catheter is not insitu, monitor urinary output and encourage regular voiding: fluid balance chart

Infection Control Principles

 Strict adherence to five moments of hand hygiene (ACSQHC, 2019)

 Insertion of an epidural should adhere to surgical aseptic technique using a critical aseptic field (NHMRC, 2019)

 Standard aseptic technique should be adhered to when changing poly bags/syringe, setting up infusion or administering bolus injections. (NHMRC, 2019)

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 Bags must be renewed every 24 hours in accordance with Infection Prevention & Control guidelines.

 Injections or infusions must always be administered through bacterial filter, which is attached between the epidural catheter and the infusion tubing.

 In the event of accidental disconnection of line, cover with sterile dressing and contact Anaesthetist in charge of epidural.

Other safety considerations

 A peripheral intravenous cannula must be insitu during the epidural catheterisation and for at least four hours post removal (Monash Health, 2016) Longer if epidural Morphine is used (see local guideline)

 Intake and output is to be monitored for 24 hours to assess adequate bladder function, urinary retention is a complication of both epidural narcotic and local anaesthesia.

 Care with systemic opioid analgesia.

o If required - This must be under direction of anaesthetist caring for patient and vigilant observation for side-effects of opioid analgesia must be undertaken.

o Post epidural requirements around timing of ongoing opioids may differ depending on whether epidural morphine or fentanyl was used.

 Drugs ordered in conjunction with epidural infusions should only be ordered by the Anaesthetist caring for patient.

 Naloxone and administrative equipment should be available at all times. At some hospitals this is at the patient’s bedside please check your hospitals policy on this.

 Resuscitation equipment should be readily available

 Pruritus may occur and a STAT order for Naloxone is often ordered. A small dose of Naloxone may reverse side effects without reducing analgesia. Other measures may be used check your local guideline.

 Heat packs should not be used (risk of burns due to altered sensation)

 Pressure injury assessment and care due to reduced sensation and mobilisation

Escalation of care according to individual hospital escalation protocol when observations vary from desired parameters.

A Nurse or Midwife (in Labour Ward) must be in continuous attendance for the first 30 minutes after insertion and any untoward

occurrence or change in vital signs is noted and reported to the Anaesthetist

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Checking of pump settings, drugs and documentation

Infusion pump settings must be checked by two Nurses/Midwives (current competency in epidural care) when:

 Setting up

 Poly bag/syringe changes

 Bolus dose administration

 Infusion rate is altered

 Change of shift

 Infusion ceased and contents of poly bag discarded

 At handover on discharge from PACU.

These checks should be noted on the observation chart and signed by both Nurses/Midwives.

 Record infusion rate/mgs/hr and volume infused as per guidelines.

Mobilisation of patient & falls prevention

The effects of an epidural infusion relating to mobilisation are

 The degree of motor block: A thoracic epidural affecting only the thoracic segments should not cause significant weakness in the legs. A lumbar epidural may affect the lower limbs more.

 The sympathetic block will cause vasodilation below the block so postural hypotension will occur.

 Some patients while having full motor power to their legs may experience block of proprioception when mobilising. This is an inability to ascertain where their feet are in relation to the ground caused by altered sensation and lack of position sense which leads to unsteadiness. (Some patients describe the sensation as similar to trying to walk on water). It is important to assist these patients with mobilising.

 Patients therefore have an increased risk of falls (update falls risk assessment to align with this)

(Women’s and Newborn Health, 2018)

Prior to ambulation the Medical Officer shall be consulted and an assessment made regarding the patient's ability to walk (Bromage scale)

Walking will require the assistance of two nurses/midwives initially

Blood pressure should be checked prior to ambulation and the patient ambulated slowly as they are still susceptible to hypotension from the sympathetic block. (Women’s and Newborn Health, 2018)

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Documentation

“Contemporaneous records must be kept of events throughout the period of epidural analgesia”.(Faculty of Pain Medicine, 2010 pp. 10)

The following elements must be documented

 Informed consent as per hospital protocol

 Insertion on the epidural infusion order chart (labour ward) or anaesthetic record (theatre)

 Allergies on the epidural infusion chart

 Prescription of the infusion on the epidural infusion chart

 Rate of the infusion on the epidural infusion chart including rate ranges

 Bolus dose on the epidural infusion chart

 PCEA dose & lockout

 Catheter insertion site and level at skin on the epidural infusion chart

 Reportable levels of observations on the epidural infusion chart

 Discontinuation of the epidural on the epidural infusion chart

 Removal of epidural catheter in the patient notes

 Name, signature and contact number or prescribing anaesthetist on the epidural infusion chart. Record of nurse/midwife who made up infusion medications if not using pre prepared polybags or syringes.

 Antidote & protocol for respiratory depression and low blood pressure or decreased conscious state on the epidural infusion chart

 Use of controlled substances in the DD book

 Observations as per hospital policy on the epidural infusion chart

 Administration of bolus doses or rate changes on the epidural infusion chart

 Any reportable events, patient activity, side effects or adverse reactions in the patient notes

 Patient involvement and education on the care plan (as appropriate) and in the patient notes

Removal of epidural catheter

 Must be ordered by the anaesthetist and documented on the epidural order chart for post op epidurals, follow local guideline in relation to labour epidurals following vaginal delivery (generally the midwife can cease these unless otherwise specified)

 “A protocol for catheter removal that relates timing of removal

to the timing of administration of anticoagulant medication, or in the

presence of a coagulopathy should be available” (ANZCA, 2014)

o Follow your local hospital protocol/guideline which will clearly outline timing of removal in relation to administration of anticoagulant medication.

o Ensure instructions for the timing of removal correspond to this & are clearly written on epidural infusion chart

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 Place patient in left lateral or sitting position, with legs drawn up and back curved in a bent forward position.

 After removing dressing, gently pull on catheter, if any resistance is felt, get the patient to bend further forward, if the catheter will still not come or patient experiences any pain, referred pain or sensation, cease pulling on catheter and contact the Anaesthetist.

 Following removal cover site with clear occlusive dressing

 The tip of catheter should be examined by 2 Nurses/Midwives to verify completeness – same should be noted on Epidural Chart. Notify Anaesthetist if not complete. (ANZCA, 2014)

 Catheter site should be observed for redness and swelling after removal and once per shift. Temperature should also be attended 4/24, for 24 hours.

Post epidural removal observations

 Observations as per Epidural Chart should continue at least four hourly (see local guideline).

 If morphine has been used, continue observation regimen for 24 hours.

PATIENT AND CARER/FAMILY INVOLVEMENT AND EDUCATION

Patients’ and their carers/family are more relaxed and feel more confident in their care if they understand what is occurring, are encouraged to report changes in their condition and understand what to report to the nursing/midwifery staff

It is the responsibility of the anaesthetist to obtain consent for the insertion of an epidural, but it is a nursing/midwifery responsibility to provide ongoing education and reassurance to promote quality and safe nursing care.

Patients’ should be encouraged to report

 Any increases in their pain or when the pain is becoming uncomfortable

 A cold, numb, heavy, weak or tingling feeling in any area of their body which could indicate their epidural block is too high

 f they have breathing difficulties or tightness in chest

 Any pain or irritation around the insertion site

 If the dressing is coming away

 If they want to ambulate

 If they feel ‘unwell’ so that assessments can be made

 If they can’t move or experience a heavy, numb feeling in parts of their body

 Itchiness from opioid irritation

 Inability to feel when their bladder is full or incontinence (if no IDC in place)

 If they feel drowsy or dopey

 If they feel dizzy or light headed

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Patients’ and their carers/family should be advised

 Escalate care if they have any concerns, all health services have information on how family or carers can initiate this process formally

 That the patient should seek assistance when ambulating due to the possibility of dizziness and unsteadiness and the risk of dislodgement

 Of the assessments the nurse is undertaking to ensure the pain relief is adequate and side effects are minimal

 An IDC may be required because the medication stops the patient being able to feel when they need to void and may lead to retention or

incontinence

 The basic way in which an epidural works and what the patient can expect as far as analgesia, monitoring and how the nurse will ensure quality care

 That the epidural is not designed to completely remove the pain but to make the pain manageable

 If the pain relief is not adequate, then the patient needs to let the nurse know

 Not to touch the insertion site as it can cause dislodgement or infection

 Not to touch the infusion pump

 It is very important to report if the patient becomes drowsy or difficult to rouse

 The medication can cause side effects such as drowsiness, nausea & vomiting, etc. but these can be managed if reported to staff

 The process of discontinuing and removal of the epidural catheter

Epidural Infusion Analgesia Patient Education for Adults

Each health service should provide language and culturally appropriate written and verbal information to all patients who may require epidural analgesia.

*

Please review how this is managed at your health service for both midwifery

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MANAGENT OF ADVERSE EVENTS & SIDE EFFECTS

Epidural analgesia/anaesthesia can cause serious and potentially life threatening complications. Safe & effective management requires a

co-ordinated multi-disciplinary approach (Faculty of Pain Medicine, 2010)

RELATED TO EPIDURAL CATHETER & INSERTION

DURAL PUNCTURE

This situation may arise during epidural catheter insertion. The needle or catheter punctures the dura passing into the subarachnoid space. This causes cerebrospinal fluid to leak out of the subarachnoid space.

Clinical features

This manifests as a severe “postural” headache (‘post dural puncture headache’), usually more severe whilst sitting and standing than when lying down.

 Headache

 neck pain,

 nausea and vomiting,

 photophobia, diplopia

Management

Treatment is centred on

 Timely notification to the anaesthetist/medical officer

 Nursing/midwifery interventions aimed at relieving symptoms

 Lie the patient down in a quiet, darkened room – bed rest

 Administration of PRN medications to relieve headache (e.g. paracetamol) If the headache still persists after this time, or is severe an appropriately skilled medical practitioner may perform an epidural blood patch: a sterile sample of the patients’ blood is obtained and injected into the epidural space under strict aseptic conditions at the same level as the epidural insertion site. This stops the leak of CSF thus relieving symptoms. (Craig, 2012)

CATHETER MIGRATION

The epidural catheter may migrate as a consequence of ordinary movement and activity that the patient undergoes. There are three main ways in which the catheter may migrate and it is important to understand these, along with associative clinical manifestations, so that prompt diagnosis and early treatment may ensue.

 Migration into the subarachnoid space

 Migration into an epidural blood vessel

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a) Migration into the subarachnoid space.

Drugs will now enter into the cerebrospinal fluid and will rapidly cause an extensive block, possibly a TOTAL SPINAL BLOCK. This is an emergency situation as cardiovascular collapse; respiratory arrest and loss of consciousness may follow.

(Faculty of Pain Medicine, 2010)

 Immediate pain relief and motor block in legs, rapidly evident

 Rapid fall in blood pressure

 Bradycardia

 Patient may complain of tingling in arms

 Patient may complain of being unable to move their arms or fingers

 Patient may complain of breathing difficulty

 Patient may become unconscious

Management

 Stop epidural infusion

 Initiate Escalation Protocol/Rapid Response System in response to

clinical deterioration

 In the pregnant woman lay her on her side or in a left lateral tilt, all other patient’s position supine with feet raised, and head slightly elevated.

 Maintain airway and administer 100% oxygen as clinically indicated

 If respiratory arrest occurs ventilate and prepare to intubate

 Give an IV fluid bolus to treat hypotension per local protocol

 Administer emergency drug to treat hypotension as per local protocol

 If bradycardic Rx as per protocol

 If intrapartum continue to manage in line with this

b) Migration into an epidural blood vessel

In this situation, epidural drugs are now being infused directly into a blood vessel and thus directly into the systemic circulation. This may lead to a systemic toxic reaction to local anaesthetic. Local anaesthetic drugs can produce a systemic reaction that may involve the central nervous system (CNS) and/or the cardiovascular system. CNS signs and symptoms will appear before cardiovascular collapse. However, adverse effects involving the cardiovascular system are more serious and more difficult to treat. (Faculty of Pain Medicine, 2010)

See section on Local Anaesthetic Toxicity (page 45) c) Migration out of the epidural space - falls out

This results in inadequate analgesic cover. Re-insertion of the epidural catheter may be necessary or alternative analgesia sought.

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EPIDURAL HAEMATOMA

This is a haematoma forming within the epidural space that may compress the spinal nerves or cord, causing ischemia and irreversible damage with associative loss of function below the site.This diagnosis must be considered if excessive motor block

does not resolve rapidly after stopping the epidural infusion. (Faculty of Pain Medicine, 2010)

A rare (less than 1 in 150,000) but serious complication, which can occur at insertion/removal of catheter or at any time during the epidural infusion. (Craig, 2012)May be related to anticoagulated patients if insertion and/or removal timing is not followed in relation to the administration of anti-coagulant medication. Follow your local guideline. Knowing the coagulation status of your patient is another important preventative measure.

 Severe localized back pain

 Persistent or increasing motor block (following cessation of infusion)

 Lower limb paresis

 Loss of sphincter tone (urinary and faecal)

 Frank paralysis.

Confirmation of the diagnosis is by CT or MRI scanning

Management

 Stop the infusion

 Notify anaesthetist urgently & escalate care according to Hospital

Escalation protocol/Rapid response

 Treatment involves surgical decompression of the spine

EPIDURAL INFECTION

Epidural infection or abscess is an uncommon complication of epidural catheter insertion. It can, however, hold the same catastrophic results as an epidural haematoma.

 Pyrexia

 Severe localised back pain

 Inflammation around the epidural site, on the patient’s back

 Lower limb weakness

 Loss of sphincter control

 Paralysis is a late sign and often irreversible. (Craig, 2012)

The threat of epidural haematoma is the most important

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Management

 Stop the infusion

Escalation protocol

 Usual treatment involves antibiotic therapy and/or surgical decompression of the spine.

The symptoms are similar to an epidural haematoma and the investigation and urgency is the same.

An epidural haematoma or abscess leads to pressure being placed upon the spinal cord. This can cause irreversible neurological damage; therefore, it is paramount that there is no delay in reporting any of the above symptoms to the anaesthetist. (follow escalation protocol) It is a neurological emergency and quick action may save the patient from

serious and permanent impairment. (Faculty of Pain Medicine,

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RELATED TO EPIDURAL DRUGS

HYPERSENSITIVITY REACTIONS/ANAPHYLAXIS

A rare complication which usually occurs after first injection of drugs

Clinical Features

 Hypotension

 Tachycardia

 Wheezing

 Itchy skin rash

 Rapid swelling of the face and extremities

 GI SYMPTOMS

(University of Pittsburgh, 2013)

Management

 Follow anaphylaxis protocol if severe reaction, administer IM adrenaline 0.5mg

https://www.bettersafercare.vic.gov.au/resources/clinical-guidance/emergency-care/anaphylaxis-adults

 Stop infusion/trigger

OPIOIDS

These include Morphine and Fentanyl. Fentanyl is the opioid of choice used in epidurals at many Health Services in the Gippsland Region. There are a number of side effects associated with the use of opioids.

SEDATION

Sedation is often the most sensitive indication of opioid-induced respiratory depression. (Faculty of Pain Medicine, 2010)

Usually dose related or can be due to the patient receiving concurrent opioid

analgesia via another route, may be due to inadvertent subarachnoid injection (e.g. catheter migration). Epidural opioids do not usually cause sedation. Over sedation differs from normal sleep in that patients are easily roused with normal sleep. (Loader, 2011)

Clinical Features

 Patients may become very drowsy and unrousable. It is important to

regularly assess their level of sedation as part of your observation regimen as outlined previously

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Management

 Follow the instructions on your epidural observation form re the reportable parameters for sedation and escalate care

If associated with respiratory depression, follow protocol for this

RESPIRATORY DEPRESSION

This is usually associated with high doses of opioids however it is possible with any dose of opioids. The risk of respiratory depression is increased if sedatives and other drugs that affect the conscious level are used in conjunction with opioids. This also applies to the period of four hours post epidural catheter removal. If epidural

morphine is used, respiratory depression may occur for up to 24 hours post last dose. (Faculty of Pain Medicine, 2010)

 Excessive sedation as above

 A respiratory rate of < 10/min is reportable.

 Low or normal respiratory rate but decreased tidal volume.

 Pin point pupils

 Possible hypotension

Management

 Stop infusion

 Administer oxygen via mask and maintain airway and ventilation as clinically indicated

 Administer Naloxone 0.1mg (100micrograms) intravenously and repeat every 2-3 minutes. (orders may vary so follow local protocols)

 Maintain more frequent observations until stable - observe for

re-occurrence of respiratory depression, arrhythmias and pain due to reversal following administration of Naloxone

(Monash Health 2019)

GIT DISTURBANCES

Nausea & Vomiting

This may be due to other factors particularly in the post op surgical patient. Nausea and vomiting is a serious post-operative complication. It reduces the patient’s speed of recovery and it is a major complaint of post-operative patients. All patients

receiving epidural should have a minimum of one anti-emetic prescribed on the prn side of the drug chart. (Loader, 2011)

 Nausea and Vomiting – occurs more frequently when opioid analgesia is used. Treat with anti-emetics. If this is ineffective consult anaesthetist.

SELF DIRECTED LEARNINGPACKAGE: PAIN

GIPPSLAND HEALTH SERVICES CONSORTIUM

SELF DIRECTED LEARNINGPACKAGE:

PAIN

MODULE 2: EPIDURAL/SPINAL

ANALGESIA

CONTENTS

Acknowledgments/Copyright/Disclaimer

3

Introduction

4

Anatomy & Physiology

5

Overview of Epidural & Spinal Analgesia

9

Epidural Analgesia

13

Medications used in Epidurals

16

Key Principles of Care

19

Patient Assessment : Observation &

Frequency

23

Assessment of Motor & Sensory Block

25

Key Nursing & Midwifery Considerations

29

Management of Adverse Events & Side

Effects

36

Checklist of Care : Patient receiving

Epidural Analgesia

51

Giving an Epidural Bonus

52

Troubleshooting Table

54

Spinal Analgesia with Intrathecal Opioid

55

Midwifery care of the woman with epidural

analgesia: Key Principles of Care

57

*

INTRODUCTION

ANATOMY & PHYSIOLOGY

Overview of Epidural & Spinal Analgesia/Anaesthesia

EPIDURAL ANALGESIA









MEDICATIONS USED IN EPIDURALS

*

KEY PRINCIPLES OF CARE

*

*

*

*

MANAGENT OF ADVERSE EVENTS & SIDE EFFECTS

RELATED TO EPIDURAL CATHETER & INSERTION

RELATED TO EPIDURAL DRUGS