EPIDURAL ASSESSMENTRebecca M Humphreys, BSN, RNUnit Based Educator, 5 EastSt. Lukes Health System, Boise

WHAT IS EPIDURAL ANALGESIA?The administration of opioids/anesthetics via a catheter in the epidural space for pain management. The epidural catheter is inserted by an anesthesiologist or primary physician.

TERMINOLOGYIntraspinal- into the spine, either epidural or intrathecalEpidural - the potential space above the dura mater Intrathecal- the subarachnoid space. The cerebrospinal fluid surrounds the spinal cord here. Spinal - same as intrathecalSubarachnoid = spinal = intrathecal

EPIDURAL INSERTION

EPIDURAL CATHETER PLACEMENT

ASSESSMENTMaintain IV access for a minimum of 4 hours following last epidural dose or discontinuation of the epidural catheter. Keep Naloxone (Narcan) 0.4mg available until 4 hours following last dose.

ASSESSMENTAssess and document the following parameters:Respiratory status: rate, depth and oxygen saturation upon initiation, then every 30 minutes x 2, then every 1 hour x12 hours, and then every 2 hours x12 hours, then every 4 hours. Assess in 4 hours and as needed after epidural discontinuation. If a bolus is administered then assess every 30 minutes X 2 then return to previous assessment times. Use a continuous pulse oximeter monitor for patients on a continuous infusion unless provider constantly at bedside. May place patient on continuous pulse oximeter per nursing judgment.

ASSESSMENTSedation scale upon initiation, then every 30 minutes x 2, then every 1 hour x 12 hours, then every 2 hours x 12 hours, then every 4 hours until epidural discontinued. If a bolus is administered then assess every 30 minutes X 2 then return to previous assessment times. Pain scale, heart rate and BP upon initiation, then every 30 minutes x 2, then every 4 hours on non-obstetrical patients.

Motor and sensory function every 4 hours and prior to first ambulation and 4 hours after catheter discontinued. Two (2) persons will assist patient out of bed the first time and thereafter until full motor function has returned. Use caution when transferring /moving patient to assure catheter does not become dislodged.

ASSESSMENTEpidural assessment for hematoma every 4 hours until 12 hours after the catheter has been removed. Assess for:severe back painleg weakness or numbnessincontinence of stool and/or urineCatheter insertion site for displacement, leakage, kinking, redness, fluid or bleeding every 4 hours and prior to bolus administration Bladder distention, frequency, and urgency. Evaluate ability to void within 4 to 6 hours of discontinuation of epidural catheter. Nausea and vomiting especially related to movement. Document at least every 4 hours until epidural discontinued. Itching. Document at least every 4 hours until epidural discontinued.

Why?

CAUTIONS!Do not give anticoagulants (other than low dose heparin) until 2 hours after the epidral catheter has been discontinued.No other CNS depressants are to be given without the written order of the anesthesiologist, this includes medications like muscle relaxants.

WHEN TO CALL:Notify anesthesiologist or physician managing epidural if:Respiratory rate

REMOVALRemoval of Epidural Catheter:Epidural catheters are discontinued on the order from a physician. Check with physician managing the epidural if patient has received anticoagulant.Have patient roll head and shoulders caudally (knee to chest or fetal position). This helps to expose back, slightly separate vertebrae, and ease catheter removal. Wash hands.Don Gloves.Grasp catheter close to skin and remove slowly, pulling steadily.Observe for presence of metal or blue plastic tip. If not present, notify anesthesiologist or physician managing the catheter.Cover insertion site with a band-aid.Document procedure and assessment of insertion site.

PRACTICE CHANGECONTINUOUS EPIDURAL

picture of me giving medT-CONNECTOR WILL BE PLACED ON THE END OF YELLOW EPIDURAL TUBING INTO HUB OF EPIDURAL CATHTO GIVE BOLUS WITH CONTINUOUS:SCRUB T-CONNECTOR PORT FOR 2 MINUTES WITH BETADINEDO NOT USE ALCOHOLDAB WITH 2X2 IF WETUSING 25G 5/8 NEEDLE ON SYRINGE MEDICATION, INSERT NEEDLE INTO PORTSLOWLY INJECTREMOVE ACTIVE SAFETY NEEDLEDISCARD IN SHARPS QUESTIONS? CONTACT:KIM KRUTZ krutzk@slhs.orgRAQUEL HANSEN - hansenr@slhs.org, 1-1505

6/2010

BOLUS DOSINGBOLUS DOSING (Not for the pregnant/laboring patient)Administer a bolus dose for breakthrough pain while receiving continuous infusions using the T-connector. Use preservative-free medication and preservative free normal salinePreservative-free vials are to be discarded after a single useDraw up opioid dose:Add the preservative free normal saline, if necessary Assess insertion site for:Excessive drainageCatheter integritySigns and symptoms infection, redness, pain, or swelling.Cleanse T-connector injection cap:Scrub with povidone-iodine prep-pad. NEVER USE ALCOHOL WITH EPIDURAL CATHETERS. Allow to dry for 2 minutes.Wipe with sterile 2x2 after 2-minute dry time has elapsed.Attach empty syringe and check for placement of line by gently aspirating for blood or CSF.Insert an empty 3-ml syringe with 25-gauge, 5/8-inch needle through the dry, prepped injection cap and aspirate. Little (< 0.5ml) or no fluid should return from the epidural space.If no fluid aspirated, remove the needle and syringe from the epidural catheter cap.If bloody fluid or clear fluid > 0.5 ml aspirated, STOP. Do not re-inject the aspirate. Withdraw the needle and notify the anesthesiologist, CRNA or physician managing the catheter.Attach syringe with medication and administer slowly. You should feel some resistance as you inject; however, if you are unable to inject the medication, call the physician. Resume infusion.Document medication given.

WHAT IF YOU SEE THIS?

CASE STUDY: MRS. GREEN - 12 HOURS POST HIP REPLACEMENT Its 2 AM, Mrs. Green had Morphine 2 mg epidural at 1 AM. She appears to be sleeping.Her respiratory rate is 10/min.She does not wake up when you call her name.

WHAT WOULD YOU DO?StimulateTurn off continuous infusionCheck O2 saturationCall RTStart oxygenGive Narcan 0.4 IVP

CASE STUDY MR. JONES65 year old man with colon resection.Bolus of Morphine given by anesthesia 5 MG.Continuous epidural with Morphine at 0.5 mg/hr8 hours post op- Rates pain as 8

What would you assess?What do you think Mr. Jones needs to have his pain relieved?Do you need to call the doctor?

MR. JONESAssess pain Assess AbdomenVital signsMedicate for breakthrough pain (fentanyl) sterile techniqueConsider increasing continuous morphineCall MD if order is needed or pain may be caused by a complication.Nonpharmacologic pain measures

QUESTIONS?

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**Terminology can be confusing. Epidural space is actually subcutaneous tissue above the dura mater.Spinal cord surrounded by cerebral spinal fluid (The intrathecal or subarachnoid space)3 layers of meninges protect the cord and CSF (pia mater, arachnoid mater, dura mater)Epidural (above the dura)*The patient is placed on their side with the chin tucked and the knees pulled up to help round the back and thus open a wider space between the vertebrae for easier access.This is the same position the patient is placed in for catheter removal and for spinal tap (LP) for CSF specimen collection to rule out meningitis.*Visual of epidural catheter placement.*These are hives. That would indicate an allergic reaction.What should you assess?(ABC, VS, Extent of hives)What actions would you take?Stop drug, treat, hives with antihistamine, epinephrine if ABC impaired, IV access, O2)*Ask groupwhat should you do?Stimulate.Try to wake up-is she sleeping or is she sedated?O2sat?

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