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A Self-Directed Learning Module

Third Edition

Epidural Analgesia

U NI V ER SIT Y
HOS PI TA L

O F

W I SC ON SIN

A ND

MA DI SON ,

Copyright , 2000, UW Hospit al and Clinics Autho rit y Board

C LI NI C S
W I

TABLE OF CONTENTS

I.

Introduction

2

II. Content
Section 1
Benefits, Indications, and Contraindications

4

Section 2
Pain Transmission / Modulation

7

Section 3
The Epidural Space

9

Section 4
Epidural Catheter Placement

11

Section 5
Common Opioids and Local Anesthetics

13

Section 6
Nursing Assessment, Documentation, and
Management of Side Effects and Complications

17

Section 7
Patient / Family Teaching

22

Section 8
AP II Pump

23

III. Post-test

24

IV. References

28

First Authored 1997 by:
Susan L. Schroeder, RN, MS
Clinical Nurse Specialist
Department of Nursing
Perission granted to modify or adopt provided written credit given to University of Wisconsin Hospital &
Clinics
Copyright 2000 UWHC Authority Board

UW Hospital and Clinics, Madison, WI
Revised 2000 by:
Deb Gordon, RN, MS
Clinical Nurse Specialist
Department of Nursing
UW Hospital and Clinics, Madison, WI
Sue Deeren RN, MS, NP
Clinical Nurse Specialist
Department of Anesthesiology
University of Wisconsin, Madison, WI
Michael Ford, MD
Assistant Professor
Department of Anesthesiology
University of Wisconsin, Madison, WI
Mark Schroeder, MD
Associate Professor
Department of Anesthesiology
University of Wisconsin, Madison, WI

Produced byrdthe Department of Nursing Resources and Development
3 Ed, Copyright 2000 UW Board of Authority

1
Permission granted to modify or adopt provided written credit given to University of Wisconsin
Hospital & Clinics
Copyright 2000 UWHC Authority Board

INTRODUCTION
Analgesia is now recognized as a significant contributor to
clinical outcomes (1). The goal for pain management is to provide
the best analgesia with the least amount of side effects. Epidural
analgesia is a desirable method of pain relief because it provides
true segmental analgesia with
little or no contribution from
systemic levels of opioids (2). All of
which may lead to excellent
analgesia with minimal side effects (2,3).
Caring for patients who receive epidural analgesia requires
specialized knowledge regarding the placement of the epidural
catheter, management of the(1,3,4,5,6)
therapy, and monitoring for potential
side effects/complications
. This self-directed learning
module is essential information for the nurse clinician who cares
for patients receiving epidural analgesia.

After the completion of this self-directed
learning module, nurse clinicians will be able to:
o Identify the benefits, indications and contraindications for
epidural analgesia.
o Explain the transmission and modulation of pain stimuli as
related to epidural analgesia.
o Identify the spinal cord anatomy as related to the placement of
the epidural catheter.
o List the common medications used for epidural analgesia.
o Identify potential complications from epidural analgesia, the
required monitoring of patients receiving epidural analgesia, and
the specific actions to be taken if a complication occurs.
o Recognize common side effects from epidural analgesia, and list
appropriate actions to be taken in the management of these side
effects.
o Describe required nursing assessment and documentation as related
to epidural analgesia.
o Perform appropriate patient/family teaching for those patients
receiving epidural analgesia.
o Demonstrate the programming and use of the Baxter AP II infusion
Pump.

2
Permission granted to modify or adopt provided written credit given to University of Wisconsin
Hospital & Clinics
Copyright 2000 UWHC Authority Board

M. 2. CNS. CNS. Nursing Staff Development 263-6488. FL. RN. 3. Instructions for use of the self-directed learning module are: 1. Karabella. Nursing Staff Development Kathy Hansen. (1994). Epidural analgesia for Critical Care Nurse. Epidural anesthesia and analgesia: their role in postoperative outcome. Nursing Policy & Procedure 6. D. RN. ASPMN. October. Pasero C. Epidural Analgesia For Acute Pain Management. Naber.. Read the content material. Liu S. August. AP II Programming Guide and/or Baxter AP II video o Attend AP II Pump Inservice Other recommended resources to review (available through Nursing Staff Development. Nursing Staff Development Sue Deeren. (1996) Bowel function recovery after radical hysterectomies: Thoracic epidural bupivacaine-morphine versus intravenous patient-controlled analgesia with morphine: A pilot study. (1998). American Society of Pain Management Nurses self directed learning program. 263-6490): de Leon-Casasola. or pager #7253 3 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board . M. NP. Nursing. Jones. Journal of Clinical Anesthesia. Carpenter RL. RN. 69-83. please contact: Deb Gordon.. 34-40. Complete the post-test. RN. Neal JM. effective pain control. O. (1995). McCaffery M.. & Lema. Anesthesiology 82(6) 1474-1506. (1999). & Halm. CNS.13 Epidural and Intrathecal Analgesia 2. G. Pensacola. Anesthesiology Pain Resource Nurse on your Unit o o • • • For clarification or questions regarding this self-directed learning module.Prior to completing the self-directed learning module: o Review : 1. 8. Providing epidural analgesia: how to maintain a delicate balance. Pasero C. L. Perform return demonstration on the use and programming of the AP II pump to: Deb Gordon. 87-92.

1 BENEFITS Epidural analgesia provides very effective.4. Such procedures include thoracotomies. The following benefits have been found with epidural analgesia: o excellent analgesia(2. and orthopedic surgeries. o Multiple trauma (3.12) o Chronic pain Epidural analgesia can be used in the treatment of patients experiencing an acute exacerbation of Complex Regional Pain Syndrome (CRPS) by producing a sympathetic blockade using a local anesthetic. major upper abdominal.10) o decreased stress response (7) 1. local opioid-related side effects anesthetics can be administered epidurally in order to produce a neural blockade that provides analgesia. AND CONTRAINDICATIONS Section 1 1.2 INDICATIONS FOR EPIDURAL ANALGESIA o Post-operative pain management (3. prolonged segmental analgesia (3). The epidural infusion provides a localized band of analgesia at the site of the incision.6.8.BENEFITS. Epidural analgesia may also be used for the treatment of other types of chronic pain such as cancer pain. and are believed to act synergistically.9) o decreased incidence of pulmonary complications (9) o decreased incidence of venous thrombosis o earlier return of bowel function (8. Local anesthetics and opioids can be used in combination.6) .11) Epidural analgesia appears to be most beneficial for the highrisk surgical patient or for those recovering from extremely large or painful surgical procedures. The localized analgesia helps the patient overcome the pain induced splinting that contributes to the loss of pulmonary function which in turn may lead to atelectasis and pneumonia. (5. The smaller epidural dose of opioids decreases the potential for (3.7) o less sedation (7) o earlier ambulation (8) (7. 4 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board .: rib fractures. This combination allows the concentration of local anesthetics and dose of opioids to be decreased.5.e.6. In addition to opioids.6. Smaller doses of opioids can be used in the epidural route than systemic routes (parenteral or oral) since the opioid is administered more directly to the spinal opioid receptors. i. major abdominal vascular. and allows the patient to participate in physical therapy which is vital in the control of their symptoms. INDICATIONS.6) Epidural analgesia is especially beneficial for patients with chest trauma. This provides improved analgesia.4.3.

4.13) Systemic infection or sepsis may lead to an infection in the epidural space. Staff should be knowledgeable concerning epidural catheter placement. o Decreased level of consciousness (13) Epidural analgesia may be implicated in any progression of central nervous system dysfunction.14). increases the chance of cerebellar or tentorial herniation due to the loss of CSF.*Note: see summary ASRA consensus 14 statement next page Anticoagulation therapy and neuraxial anesthesia used together increase the risk of epidural hematoma which may lead to serious adverse effects such as permanent paralysis.13) A localized infection at the site of insertion may lead also to an infection in the epidural space.5.4.5. (1.6. Anticoagulation therapy should not be initiated or changed without first advising the Acute Pain Service. 5 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board . o Lack of qualified nursing care to monitor patients for side effects and complications (1.4.5. (6) o Increased intracranial pressure An inadvertent dural puncture when trying to locate the epidural space in a patient with increased intracranial pressure.3 CONTRAINDICATIONS TO EPIDURAL ANALGESIA Epidural analgesia is contraindicated in the presence of: o Anticoagulation therapy (3.6.6.14) o Coagulopathies Patients experiencing coagulopathies are at an increased risk for an epidural hematoma. epidural medications. o A localized infection at the insertion site of the epidural catheter (4. Also pain management by epidural analgesia requires accurate reports of pain levels by patient.6.6.13.5.1. and the possible side effects and complications from epidural analgesia. o Systemic infection (4.5.13.15) Epidural analgesia should only be used in hospital units where the staff has received adequate training.

by themselves. LOW MOLECULAR WEIGHT HEPARIN LMWH increases the risk of spinal hematoma.*SUMMARY OF THE AMERICAN SOCIETY OF REGIONAL ANESTHESIA'S CONSENSUS STATEMENTS ON NEUAXIAL ANESTHESIA AND ANTICOAGULATION14 ORAL ANTICOAGULANTS For patients on chronic oral anticoagulation. 6 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board . antiplatelet drugs. It is recommended that indwelling catheters be removed prior to initiation of LMWH. If used. and heparin. Prolonged therapeutic anticoagulation appears to increase the risk of spinal hematoma formation. especially if combined with other anticoagulants or thrombolytics and neuraxial blocks should be avoided in this clinical setting. and the infusion should be limited to drugs minimizing sensory and motor blockade.5 at the time of catheter removal. STANDARD HEPARIN Subcutaneous (mini-dose) prophylaxis is not considered a contraindication to using neuraxial techniques. and longer if the INR was >1. the anticoagulant therapy must be stopped and the prothrombin time (INR) measured prior to initiation of neuraxial block. enoxaparin 1mg/kg twice daily) will require longer delays (24 hours). Neurological testing of sensory and motor function should be performed routinely during epidural analgesia for patients on warfarin therapy. A single-dose spinal anesthetic may be the safest neuraxial technique and needle placement should occur at least 10-12 hours after a dose of LMWH. These medications include aspirin. The risk of neuraxial bleeding may be reduced by delaying the heparin injection until at least one hour after the block or catheter placement. The catheter should be removed 1 hour before any subsequent heparin administration or 2-4 hours after the last heparin dose. or timing of the neuraxial catheter removal. appear to represent no added significant risk for the development of spinal hematoma in patients having epidural or spinal anesthesia. FIBRINOLYTIC AND THROMBOLYTIC DRUGS Patients receiving concurrent heparin with fibrinolytic and thrombolytic drugs are at high risk of adverse neuraxial bleeding during spinal or epidural anesthesia and should be cautioned against receiving spinal or epidural anesthetics except in highly unusual circumstances. Timing of catheter removal is of paramount importance and should be delayed for at least 10-12 hours after a dose of LMWH. Patients receiving higher doses of LMWH (e. Subsequent doses of LMWH should be administered at least 2 hours or longer after catheter removal. there do not seem to be specific concerns as to the timing of a single shot or catheter technique in relationship to the dosing of NSAIDs. At this time. These checks should be continued after catheter removal for at least 24 hours. since needle placement occurs during peak anticoagulant therapy. postoperative monitoring. nonsteroidal anti-inflammatory drugs (NSAIDs). The concurrent use of medications that affect other components of the clotting mechanisms may increase the risk of bleeding complications for patients receiving oral anticoagulants. The decision to perform a neuraxial block must be made on an individual basis and if performed extreme vigilance of the patient's neurologic status is warranted. Neuraxial techniques should be avoided in patients administered a dose of LMWH two hours preoperatively (general surgery patients).g. and do so without influencing the prothrombin time and INR. neurologic monitoring should be performed at least every 2 hours or more frequently. ANTIPLATELET DRUGS Antiplatelet drugs.

and increased sensitization of nociceptors. Afferent Nerve: A nerve that transmits impulses from the periphery toward the central nervous system. This is where several responses to pain occur including the perception of pain. Noxious stimulus: A stimulus that is damaging or potentially damaging to body tissue. Modulation: The process whereby nociceptive transmission is (16. muscle spasms. Nociceptor: A nerve receptor that is preferentially sensitive to noxious or potentially noxious stimuli.17) . Most of the nociceptive input enters the spinal cord through the dorsal horn (16. 7 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board .18) . The activation of the second order neurons results in: 1) spinal reflex responses such as acute vasoconstriction. and 2) activation of the ascending tracts which transmits the nociceptive input to several regions within the brain (16. and the emotional and behavioral responses. In the dorsal horn. Noxious substances which are released in response to damaged tissue initiate the nociceptive transmission.17. the absence of pain in response to a stimulus that normally would be painful. Nociception: The process of encoding a painful sensation. nociceptive neurotransmittors are released in response to the nociceptive input which activate the second-order dorsal horn neurons. and relay this information to the spinal cord.18).PAIN TRANSMISSION MODULATION OF PAIN Section 2 Definition of terms: Pain: An unpleasant sensory and emotional experience associated with the actual or potential tissue damage. Analgesia: Pain relief. Afferent nerve fibers respond to the nociceptive stimuli peripherally. modified through a number of influences o o • • The body’s response to pain is protective in nature. Pain is a warning signal to which the body responds to prevent further injury.

Neuropeptides such as enkephalin molecules (endogenous opioids) bind with the opioid receptors to modulate nociceptive input.19) . hypothalamus and periaqueductal area. Exogenous (administered) opioids work in a similar fashion. These opioid receptors provide the means by which spinal opioids are able to modulate pain (18. (See diagram 1) transmission 8 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board .The modulation of nociceptive input occurs at several sites including the opioid receptors located in the dorsal horn. and at opioid receptors located supraspinally in such areas as the cortex.

13). 2) the arachnoid mater. The vertebral column is stabilized by ligaments.21). and is located between the bony vertebral canal and the outer surface of the dura mater. The ligamentum flavum is the structure through which the epidural needle and catheter must pass when being inserted to reach the epidural space (2). (See Diagrams 2 & 3) The epidural space contains fat which surrounds and pads the spinal cord. Opioids administered into the epidural space diffuse across the meninges and CSF to receptors in the dorsal horn of the spinal cord. They are: 1) the dura mater. and contains the cerebral spinal fluid (CSF) (20. and 3) the pia mater which adheres tightly to the spinal cord and brain. 9 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board . The subarachnoid space is the area that lies between the arachnoid and pia mater. Moving towards the spinal cord from the epidural space are the membranes or meninges that cover the spinal cord. This fat functions as a ‘depot’ for opioids and local anesthetics when these medications are administered for epidural analgesia (4.THE EPIDURAL SPACE Section 3 The epidural space is a ‘potential space’ that contains fatty tissue and blood vessels.

10 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board .

6. (See diagram 4) The epidural catheter is placed in a centrally located interspace so that all of the affected dermatomes would receive the benefits of the infusion (22. The catheter and tubing should be clearly labeled as ‘EPIDURAL CATHETER’ (3. the epidural catheter is placed by a physician with the patient in the sitting or lateral fetal position. Proper placement of the catheter is verified by the physician through aspiration of the catheter and a small test dose of a local anesthetic.22 micron filter is attached between the catheter and the infusion tubing. Once proper placement of the catheter is confirmed.EPIDURAL CATHETER PLACEMENT Section 4 A dermatome is the area of skin and soft tissue that is innervated by a single spinal nerve root. the catheter is secured with tape and an occlusive. transparent dressing. A . The extra length of the catheter is then brought up over the shoulder. Under aseptic conditions. 11 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board .23). and secured with tape along its length.13).

or caudal spaces. Most often thoracic catheters are placed for the management of upper abdominal and thoracic sites of pain. If lumbar catheters are placed for upper abdominal or thoracic sites. However lumbar catheters may also be placed for these sites. Lumbar and caudal catheters are generally used for lower abdominal or lower extremity sites (22. a larger dose/volume of opioid may be needed. (See Diagram 5) 12 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board .23). lumbar.Epidural catheters may be placed either in the thoracic.

(See Diagram 6 and refer to Table 1) Table 1 DRUG EPIDURAL OPIOIDS LIPID SOLUBILITY (25) ONSET DURATION Morphine 1 30 .24).3. The principle routes of clearance of epidurally administered opioids are through rapid vascular absorption or through slow rostral diffusion in the CSF with elimination at the arachnoid granulations. and diffuse more slowly. 6 . agitation. drug metabolism does not influence the spinal opioids’ duration of action. Meperidine is metabolized in the liver to normeperidine. epidural myoclonus. their duration of action is longer. this enables them to provide analgesia for larger areas. easily penetrate the dura/arachnoid membranes and the spinal tissue. Unlike systemically administered opioids.24).13. lipophilic opioids have a rapid onset of action but a limited duration (2. and convulsions meperidine infusions are at low doses and normeperidine toxicity is not a problem.24 hours Hydromorphone 10 15-30 6 . an intermediate lipophilic opioid. Thus. Hydrophilic opioids tend to accumulate in the CSF. Meperidine. Additionally since hydrophilic opioids spread rostrally and linger longer in the CSF. Therefore the onset of pain relief is slower. (25) .8 hours 13 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board . Generally though. Conversely lipophilic opioids are limited in their ability to spread throughout several dermatomes due to their rapid penetration of spinal membranes and tissue. So hydrophilic opioids have a slower onset and a longer duration (2.10 min.1 EPIDURAL OPIOIDS o Onset and duration of analgesia A spinal opioid’s ability to dissolve in fat (lipid solubility) influences its onset and duration of action.18 hours Meperidine 30 5 . 6 . a CNS neurotoxic metabolite which can produce irritability. Caution must be used with prolonged or high doses of meperidine. such as morphine and hydromorphone. has a moderate onset of action and duration. tremors. Lipophilic opioids such as fentanyl.COMMON OPIOIDS AND LOCAL ANESTHETICS Section 5 5. and are transported rostrally to higher spinal levels eventually being eliminated at the arachnoid granulations. Since hydrophilic opioids have a greater ability for dermatomal spread than the lipophilic. thus having a rapid onset of action. or with use in the elderly or patients with impaired renal or hepatic function. have difficulty penetrating the membranes.60 min. Hydrophilic drugs (water soluble).13.

This is due to the opioid being deposited in close proximity to the spinal cord opioid receptor sites. 14 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board . epidural vs.Fentanyl 800 5 min.6 hours o Potency of epidural opioid analgesia The amount of opioid needed to provide a given level of analgesia is much smaller when administered per spinal route. 4 . and improves the selectivity of spinal analgesia. Effective doses of opioids when administered intrathecally are even smaller due to the medication being deposited even closer to the receptor sites. This reduces dose requirements. When comparing 24 hour dose requirements of parenteral vs.

: 50 .e.70 mg of parenteral morphine = 5 mg of epidural morphine = 0.5 mg intrathecal morphine (26). 15 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board .intrathecal morphine. it has been found to be a sequential 10 fold decrease i.

the progressive rostral spread may lead to potentially serious complications and/or mild side effects as discussed below. A typical dose of nalpuphine for pruritis is 2.5-5.26).4. Fortunately. This may occur up to 24 hours later. IM. Urinary retention occurs most often but not exclusively in young males and is less likely with thoracic epidurals.5. Thus explaining why antihistamines may provide effective treatment (13.3.6) the CSF to the chemoreceptor trigger zone in the brainstem .24) .26). Another pruritus management option is to administer a mixed opioid agonist-antagonist such as nalpuphine (Nubain). 5.27. Nalpuphine antagonizes mu opioid receptors which are thought to be associated with respiratory depression and pruritus and stimulates opioid kappa receptors. ‘Early-onset respiratory depression’ may occur though due to the rapid uptake and circulation to the brainstem respiratory center (2. With the use of lipophilic opioids. This is similar to parenteral administration. the incidence is reduced after repeated doses. This occurs in about 17% of post-operative patients. The risk of respiratory depression is greatly increased if systemic opioids (IV. and extended dermatomal spread. similar to patients receiving parenteral opioids (6. It has been reported to occur due to the relaxation of the bladder detrusor muscle (13. and can often be managed with antiemetics Pruritus is frequently noted with epidural opioids.2 LOCAL ANESTHETICS 16 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board .4. ‘Early respiratory depression’.5. higher potency.28) . The alterations in spinal and trigeminal nerve processing modulation of nociceptive(29) input is interpreted at a higher level as an itch.26). which produces analgesia.o Side effects of epidural opioid analgesia While the ability of hydrophilic opioids to remain in the CSF does provide some advantages such as prolonged duration. A recent study indicates that there maybe changes in the spinal efferent outflow. the ‘delayedonset respiratory depression’ is less likely to occur due to the decreased tendency of lipophilic opioids to have a rostral spread. but it may reflect (26. causing histamine to be released at peripheral sites. usually of the face and chest.6. soon after administration.13. ‘Delayed-onset respiratory depression’ occurs due to the rostral spread of the opioid via the CSF to the brainstem respiratory center. occurs mainly due to the vascular absorption and circulatory redistribution to the brain. A rash is not normally detected.0 mg IV q6 hours PRN. The cause for pruritus is not clearly understood. Respiratory depression with a hydrophilic opioid such as morphine may occur at two distinct times. Nausea and vomiting are also related to rostral spread of the opioid in (2. or PO) are co-administered with epidural opioids.

Some nerves are less readily blocked than others due to their size and extent of myelination. tremors. dizziness. Systemic side effects primarily involve the central nervous or cardiovascular systems (30. Cardiovascular systemic toxicity is initially noted by hypotension which may be transient but this may progress to profound hypotension. By combining both in the epidural infusion. myocardial depression eventually resulting in cardiac arrest and death (32. site of injection. This may progress to an excitatory phase with symptoms such as shivering. muscle twitching. nerve roots as they return to the spinal column Local anesthetics may differ according to: 1) potency. epidural administration of a local anesthetic can lead to high blood concentrations of local anesthetics causing symptoms of systemic local anesthetic toxicity. The initial symptoms of CNS toxicity are lightheadedness.31). and then generalized convulsions. has a high anesthetic potency. 3) duration of activity. However. the most common local anesthetic used in continuous epidural infusions.13. and will also provide adequate sensory analgesia with minimal blockade of motor function (28). Patients receiving epidural local anesthetic should be kept well hydrated and monitored regularly for changes in lower extremity motor strength and orthostatic hypotension. This is the development of an acute tolerance to the drug. The term ‘differential block’ is used to describe this phenomenon. Local anesthetics are relatively free of side effects. metallic taste.34). This generally provides better analgesia with fewer side effects (2. a decreased concentration of the local anesthetic and a lower dose of the opioid may be possible. CNS depression may follow resulting in a respiratory arrest. a prolonged duration of action. while motor and other sensory functions may be unaffected.Dilute local anesthetics when injected on or near a nerve will result in the blockade of some nerve conduction. A number of factors influence the blood concentrations of local anesthetics such as the dose of the drug. 2) speed of onset. Local anesthetics administered epidurally interrupt the nociceptive input at the (28) .3 OPIOID AND LOCAL ANESTHETIC COMBINATIONS Opioids and local anesthetics are believed to act synergistically. speed of the injection. A phenomenon called tachyphylaxis may also occur with the administration of local anesthetics. The coadministration of epidural local anesthetics and opioids has been found to prevent the occurrence of tachyphylaxis. higher concentrations of local anesthetics will provide an increased motor block (possibly limiting ambulation) and/or a sympathetic blockade (resulting in resting or orthostatic hypotension). and ringing in the ears.33). 5. Although rare. and 4) ability to cause a differential blockade of sensory and motor fibers (26). the drug becomes less effective. Bupivacaine. The exact mechanism for this is still unclear (28). or inadvertent injection directly into the blood vessels. This may result in the absence of pain. 17 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board .

1% (1mg/ml).5.4 COMMON EPIDURAL INFUSION Common Opioid Concentrations Morphine 50 mcg/ml Hydromorphone 10mcg/ml Fentanyl 2-5mcg/ml Meperidine 2mg/ml 5.5mg/ml) Ropivacaine 0.05% (0. Bupivacaine 0.5 Common Local Anesthetics Concentrations Bupivacaine 0.2% (2mg/ml) COMMON INFUSION RATES 5-14 cc/hour 18 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board .

AND MANAGEMENT OF SIDE EFFECTS AND COMPLICATIONS Section 6 6. notify the Acute Pain Service prior to starting the sedative. both at rest and with activity Documentation: Document patient’s pain ratings on Pain Management flow sheet (UWHC #48) Management: Notify the Acute Pain Service of inadequate analgesia 19 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board . Initial preop opioid bolus dose.1 GENERAL PATIENT MANAGEMENT o Maintain IV access while receiving epidural analgesia and for 8 hours following the last administration of medication.13) o Epidural medications should be sterile.26) o Do not use alcohol on the epidural catheter or infusion tubing (6. Medication(s) ordered and the infusion rate 4.2 ASSESSMENT OF ANALGESIA LEVEL (3. DOCUMENTATION. o Review Epidural Physician Orders (13) Noting: 1. If the patient is anxious.NURSING ASSESSMENT. and needs a sedative. It may be prudent to stop the epidural infusion and provide analgesia through another route. o No other opioid or CNS depressant should be administered to a patient receiving epidural opioids due to the increased risk of respiratory depression. 0-10) every 4 hours while awake. Specific recommendations for patient assessment 5. and designated for intraspinal use.g. (6. preservative-free (due to the neurotoxicity of preservatives). Anticoagulation therapy increases the risk of epidural hematoma. Orders to treat potential side effects/complications 6. agitated. When to notify the Anesthesiology Acute Pain Service Notify by using the P-A-I-N pager ( # 7 2 4 6 ) 6.24) due to the potential for neurotoxicity. (3. o No anticoagulation therapy should be initiated or changed before notifying the Acute Pain Service.13) Assessment: Assess the patient’s pain rating using patientspecific pain scale (e. The location of the epidural catheter 2. if given and when 3.5. Timing of catheter placement and removal is of paramount importance in the presence of anticoagulation therapy.

Usual dose is 100mcg IV given over 1 minute. cooperative to tranquil (normal patient’s baseline without sedation) 3 = Quiet. UWHC Sedation Scale: = Normal sleep 1 = Anxious. check the patient’s oxygen saturation level • Naloxone is an opioid antagonist that reverses the effects of opioids.5.3 ASSESSMENT AND MANAGEMENT OF SIDE EFFECTS o Increased sedation / respiratory depression (2. agitated.6. preferably by the same nurse during each shift.36) An increased sedation level will occur prior to respiratory depression Assessment: Assess sedation level/respiratory rate every hour for the first 24 hours. Stop the epidural infusion 2. sluggish response to increasingly vigorous stimuli 6 = Unresponsive to painful stimuli N If the sedation score is 5 and the respiratory rate is less than 8 1.4. 20 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board . or restless 2 = Calm.3.6. brisk response to forehead tap or loud verbal stimuli 5 = Asleep. responds to verbal commands 4 = Asleep. Notify the Acute Pain Service 4.22. Administer oxygen. Caution must be taken to give it slowly because naloxone may cause cardiopulmonary symptoms such as ventricular tachycardia and pulmonary edema.31. then every 4 hours. Administer naloxone* as ordered on the Epidural Physician orders 3. Documentation: Document levels on the Pain Management flow sheet Warning: Do not administer systemic opioids or CNS depressants without approval of the Acute Pain Service.35. drowsy. Management: 4 and / or Notify the Acute Pain Service of a sedation score of respiratory rate less than 10.5 minutes until the symptoms have been reversed.13. The dose may need to be repeated every 3 .

21 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board .• Patients should be monitored closely after naloxone administration because respiratory depression may recur due to the short half-life of naloxone (55 minutes). Repeat boluses or constant infusion may be necessary.

o Pruritus (2.3.22.6. Notify the Acute Pain Service if changes are greater than 20% from baseline.6. Assess for other possible causes and treat as appropriate. The Acute Pain Service recommends not to routinely discontinue the foley while the patient is still receiving a lumbar epidural infusion.4. The risk of urinary retention is greater in men and with lower (lumbar or caudal) catheter placement.13. o Sensory / Motor function loss (3.31) Assessment: Assess the patient for changes in sensory/motor function at least every 4 hours and more frequently if there are changes. o Urinary retention (2.5.6. o Orthostatic hypotension (4.31) Management: The patient may have a foley catheter placed.13. Management: Do not ambulate the patient if the patient complains of weakness.4. and notify the Acute Pain Service if the pruritus persists or becomes more severe.31) Management: Administer diphenhydramine (antihistamine) or nalbuphine (opioid agonist-antagonist) as ordered prn.30.4.13.22.o Nausea / Vomiting (2.5. Assess for other possible causes and treat as appropriate. and to bend their knees and lift the buttocks off the mattress.3. Ask the patient to point to numb and tingling skin areas.5.3.32.31) Management: Administer anti-emetics as ordered.34) Assessment: Assess BP and HR every 4 hours Assess for orthostatic changes prior to ambulating Management: Ensure adequate hydration and fluid replacement. or be straight catheterized prn.6. and notify the Acute Pain Service if the nausea/vomiting persists.5. or numbness/tingling in lower extremities Notify the Acute Pain Service of changes noted in the patient’s sensory/motor function 22 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board .13.13. heaviness. If the patient requies a second straight catheterization consider placing a foley catheter.4.22.

13.35. fever.38) Assessment: Assess the catheter insertion site every 8 hours for pain and or swelling at the site.e. drainage. Assess for changes in sensory/motor function every 4 hours including unexplained back pain. loss of sensory and motor function.6. inadequate small opioid dose being delivered patient for symptoms of local anesthetic lightheadedness. causing an overdose of opioid and local anesthetic) Assessment: Assess the patient for a sudden or progressive increase in side effects such as sedation. swelling.6. bowel or bladder dysfunction. Assess for changes in sensory/motor function every 4 hours. erythema. agitation. hypotension. seizures catheter for blood in the tubing patient’s pain level.13) (The catheter may migrate into the blood vessels of the epidural space.21.including progressive numbness. Management: Notify the Acute Pain Service of any changes noted o Epidural hematoma (6. hypotension Management: Notify the Acute Pain Service immediately o Migration of catheter into epidural vessels (5. 23 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board . causing the medications to be delivered systemically) Assessment: Assess the Assess the analgesia may occur due to the systemically Assess the toxicity such as dizziness. weakness. or neck stiffness.4 ASSESS FOR POTENTIAL COMPLICATIONS OF EPIDURAL ANALGESIA o Epidural abscess (4.13. or bowel and bladder dysfunction Warning: Do not administer Low Molecular Weight Heparin without first advising the Acute Pain Service Management: Notify the Acute Pain Service of these symptoms o Subdural puncture (6.5.: tenderness.37) Assessment: Assess the catheter insertion site every 8 hours for signs of infection i.13) (The catheter may migrate into the subarachnoid space.21.

Management: Notify the Acute Pain Service of any of these changes 24 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board .

31).22. The nurse should discuss the plan and clarify responsibility for 25 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board . The decision to stop the epidural infusion and remove the epidural catheter is made by either the Acute Pain Service or the patient’s primary physicians. 6. Manipulation of the dressing may dislodge the epidural catheter from the epidural space. It is best if a member of the Acute Pain Service attends to the dressing so that assessment of the position of the catheter is noted. o Disconnection of the epidural catheter from the filter.6.5 CATHETER AND DRESSING CARE o Dressing care: Notify the Acute Pain Service to reinforce or change the dressing. The APS will inspect the catheter to ensure it was removed without breakage. The Acute Pain Service will remove the epidural catheter.6) .22) If the catheter or filter is cracked (clear fluid may accumulate under dressing). Do not change or reinforce the dressing (5. Notify the acute pain service immediately (13. place the catheter and attached dressing into a plastic bag and label with the patient’s name. Notify the Acute Pain Service immediately (13.6 DISCONTINUATION OF EPIDURAL CATHETER (31) The Acute Pain Service will remove the epidural catheter. cover the ends with sterile gauze. The epidural catheter is secured with adhesive strips and covered with a clear adhesive dressing.7 TRANSITION TO ALTERNATIVE MODES OF ANALGESIA(30) Studies are lacking and controversy exists over the correct ratios to use when switching opioid-naïve patients from various epidural opioids to parenteral or oral opioids. or if the epidural catheter or filter is cracked: If disconnected. 6. If an epidural catheter is removed accidentally.

pain management with the patient’s primary treatment team prior to epidural catheter removal. 26 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board .

and that the staff is eager to provide adequate analgesia. Activity levels expected of the patient while receiving epidural analgesia (1.PATIENT / FAMILY TEACHING Section 7 The patient / family should be informed of the importance of pain management to their well-being.What Everyone Should Know (UWH #4299) • Epidural Analgesia (UWH #4322) 27 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board . 4. The patient / family should be instructed on: 1. The use of pain rating scales 2. The different routes of analgesia administration 3.13) The patient / family should also be given to read: Health Facts For You: • Pain Management ---. The possible side effects of the analgesic and the management of these side effects.

RN Nursing Staff Development Kathy Hansen. 3. RN Anesthesiology Pain Resource Nurse on your unit For more information. Review and/or view Baxter Development the Acute Pain Service Guidelines for use of the pump the AP II video (available through the Nursing Staff office) 2. or for additional copies of this SelfDirected Learning Module. 28 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board .AP II PUMP Section 8 1. RN Nursing Staff Development Sue Deeren. Return demonstration on use and programming of AP II pump to: Deb Gordon. please call Nursing Staff Development at 263-6490. Attend inservice on use of AP II pump.

III. _____ 7. _____ 8. The epidural catheter insertion site should be assessed every 8 hours for tenderness. All medications administered epidurally must be preservative-free. when administered epidurally. when administered epidurally. _____ 5. or drainage. _____ 9. the nurse should reinforce the area with tape and a new occlusive dressing. _____ 10. 29 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board . have a rapid onset and a long duration of action. pruritus. Fat in the epidural space functions as a ‘depot’ for the opioids and local anesthetics. POST-TEST True or False (Please record your answers on the answer sheet provided) _____ 1. A sudden increase in a patient’s sedation level may be due to the migration of the epidural catheter into the subarachnoid space. Morphine. _____ 6. and urinary retention. Common side effects of epidural opioids are nausea. The dose of an opioid administered epidurally is about the same as a parenteral dose. opioid receptors to _____ 2. erythema. Exogenous opioids bind with modulate the nociceptive transmission. _____ 4. swelling. has a slower onset but a longer duration of action when compared to fentanyl. Lipophilic opioids such as fentanyl. _____ 3. If the epidural catheter dressing is loose.

o • • • 30 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board .

This patient should have her respiratory rate and level of sedation checked during your shift tonight: a. At 0100 you note her respiratory rate is 6 / min. b. Prior to this you a fall in blood pressure an increased sedation level increased pain level none of the above 13. may have noticed: a. stop the epidural infusion. should not have received IV Morphine along with the epidural infusion due to the increase risk of respiratory depression.9 The patient is alert.5mg at 0800. The patient had an epidural catheter inserted in the thoracic interspace 4 (T4) at 0700.Case examples with multiple choice questions A 63 year old female was admitted to your unit at 1300 from the PACU following a (R) Thoracotomy for cancer. and received this report: Vital signs have been stable. b. call the Acute Pain Service b. The Acute Pain Service should be notified of inadequate analgesia c. this was appropriate b. An epidural infusion of Morphine 50 mcg/ml and Bupivacaine 0. Your shift started at 2300. d. you assess the patient’s sedation level and rate it a 5.. c. The patient: a. Surgery and her stay in the PACU were without complications. and oriented x3 Epidural is infusing at 7 cc/hr The patient complained of incisional pain earlier. She received both a general anesthetic and an epidural infusion of bupivacaine during surgery. You should: a. currently BP 140/80 HR 88 RR 16 T 37. stimulate the patient and call the Acute Pain Service d.1% was started at 7cc/hr in the PACU. should not have received IV Morphine with the epidural infusion. Upon discovering this patient with a respiratory rate of 6 / min. and the Surgery Service should be notified 31 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board . and received Morphine 2 mg IV at 1400 and 1600 Currently she denies pain 11. and preservative-free Morphine 2. every 2 hours every 4 hours every hour one time this shift 12. d. and notify the Acute Pain Service 14. administer Naloxone as ordered on the Physician Epidural Order sheet. denied pain following the IV Morphine. stop the epidural infusion and monitor the patient c. the patient had received IV Morphine for reports of increased pain. Earlier in the day. c.

none of the above o o • • 32 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board .d.

wait another hour and reassess patient d. This is most likely due to: a. c. c. assess his lower extremities for any further changes in sensory / motor function. He has denied pain at rest. The nurse assesses the patient for any other physical changes and finds none. On Post-op Day (POD)#1. and assess the catheter site for catheter displacement or leakage b. b.1% at 8 cc/hr for pain management. d. d. the local anesthetic in the epidural infusion generalized post-op weakness lying in one position too long during the night development of an epidural abcess Prior to ambulating the patient. and notify the Acute Pain Service of his symptoms i. When patients have inadequate analgesia.e. 15. he reports that his legs feel heavy and areas on his thighs feel numb. and reports a ‘2-3’ pain level with ambulation which he has been satisfied with for the last two days. numbness. you should: a.1% infusing currently at 10 cc/hr. the nurse should notify: a. Currently he is denying pain.A healthy 61 year old male is S/P Colon Resection had an epidural catheter inserted in the T 12 interspace prior to surgery. The nurse should: a. 16. or other changes stop the epidural infusion prior to ambulating the patient not worry about these symptoms notify the Surgical Service o • • • A 29 year old male. b. had an epidural catheter placed at T 9 prior to surgery and is receiving Morphine 50 mcg/ml and Bupivacaine 0. As you prepare to ambulate the patient. In the early hours of POD#3. c. you are to ambulate the patient. the patient reports that over the last 2 hours his pain at rest has increased from ‘0’ to ‘5-6’. and has Morphine 50 mcg/ml and Bupivacaine 0.: heaviness. b. The patient has been progressing very well. On POD#2. just notify the Acute Pain Service c. also assess the epidural infusion pump and tubing for problems such as kinked tubing. 17. the the the the Surgical Service anesthesiologist who inserted the epidural catheter Acute Pain Service in the morning Acute Pain Service o • • • 33 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board . d. just notify the Surgical Service 18. S/P a Total Colectomy-Pouch. he had increased pain so the infusion was increased from 8cc/hr to 10cc/hr.

you are to start to ambulate the patient. Prior to ambulating her. She does tell you that when she sat up in bed this am she felt very dizzy. make sure there is adequate help prior to getting her out of bed b. The nurse should: a. discontinue the catheter remind the Surgical Service to discontinue the catheter should notify the Acute Pain Service. 19. Today (POD#1). the nurse should: a. She is receiving an infusion of Meperidine 2mg/ml and Bupivacaine 0. none of the above 20. She denies incisional pain. On POD#3. catheter d. and had an epidural catheter inserted at the interspace T 6 preoperatively. c. check for orthostatic changes in the patient’s heart rate and blood pressure c. just notify the Surgical Service d. the surgeons request that the epidural catheter be discontinued.On your unit is a 42 year old female who is S/P (R) Thoracotomy.1% at 6cc/hr. who will discontinue the none of the above o • • • 34 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board . numbness or heaviness in her legs. b.

(1998). (1996).. K.. 7.. Ginsberg.243-252). & L.L. Acute Pain Mechanism and Management (pp. F. 8. 34-40. Macintrye. ASPMN. August. (1999).44. FL.. B.M. St. REFERENCES 1. Louis: Mosby-Year Book. L. Nursing. Horlocker T. In F. M.. T. Epidural analgesia for effective pain control. Macintrye & L. Anesthesiology. 433-441.E.M. Wedel D. Carpenter R. Ferrante & T.B. Rasmussen H.R. Karabella. American Society of Pain Management Nurses self directed learning program.1-12). Comparison controlled analgesia in surgery. Pasero C. Pensacola. New York: Churchill Livingstone. Christensen M. 5.F.). 9. Liu S. Saunders. 69-83.M. In P. & Neal J. Sinatra.. Vergne C. de Leon-Casasola.. (1996). 82(6) 1474-1506.E. 11.. Epidural Analgesia For Acute Pain Management. Jones.. & Ording H.L.. O. (2000).. (1992).. & McCaffery M. Pasero C.. Hord.279-303).. Neuraxial anesthesia and analgesia in the presence of standard heparin..B. Naber. & Halm. Mann C.T. Mulroy M. Bleemer T. G. Grichnik.IV.J. & Ginsberg..). Epidural analgesic for patients recovering from surgery. October. In R. (1998).. 4. Bowel function recovery after radical hysterectomies: Thoracic epidural bupivacaine-morphine versus intravenous patient35 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board . Regional Anesthesia Pain Medicine 23 Supp. Rosenstock C. Epidural and subarachnoid opioids. Ready.A.R. Epidural anesthesia and analgesia: their role in postoperative outcome. 12. Anesthesiology Boccara G. et of intravenous or epidural patient the elderly after major abdominal 92(2). Preble (Eds. Post-operative Pain Management (pp. & Ferrante.. & Ready. 3.. (1994). London: W. Pouzeratte Y.J. 10. VadeBoncouer (Eds. 6.S.. Critical Care Nurse. D. 23 Supp. 2. al. A. Anderson G. (2000). Engb/ek J. 296-301. & Lema. M. Acute pain: significance and assessment. Acta Anaesthesiol Scand. (1995). VadeBoncouer. Regional Anesthesia Pain Medicine. Postoperative pain control by epidural analgesia after transabdominal surgery: efficacy and problems encountered in daily routine. P. Peccoux C. Liu S. Providing epidural analgesia: how to maintain a delicate balance.. B. Neuraxial block and low molecular weight heparin: balancing perioperative analgesia and thromboprophylaxis.B. (1993). Acute Pain Management A Practical Guide (pp. (1998).

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P. M.. Jones.R.. G. Extradural abscess complicating extradural analgesia for caesarean section. (1991). 35. Ngan Kee.. 37. K. British Journal of Anaesthesia. (1992). Thomas. Two case reports. 75 (3). G.D. & Worth. & Singbartl. 38. Spinal epidural hematoma following anesthesia versus spinal subdural hematoma. L.B. & Wild..A. 647-652. Loper. Anesthesiology. R. Metzger. L. Nessly. 105-107 38 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board . M. 452-456. Post-operative epidural morphine is safe on surgical wards. Acta Anaesthesiol Scan.36. 69. W. Ready.J. (1991)..

Notes: 39 Permission granted to modify or adopt provided written credit given to University of Wisconsin Hospital & Clinics Copyright 2000 UWHC Authority Board .