updates on acute pain management

7/27/2019 Updates on Acute Pain Management

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Epidural Analgesia (EA)

Lo Ah Chun

APN

OTS & Pain Management


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Learning objectives:

Nurses will be able to:

1. Describe the basic anatomy relating to EA

2. State his/her role in the management of a patient

with an epidural infusion

3. Outline the care related to an epidural catheter.4. Demonstrate operational competence with the

epidural infusion pump


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EA guideline The HAHO Medication Safety Committed has

established guideline on Safe Handling of EpiduralAnalgesia with effective from 1st March 2009

which is approved by the Central Committee on

Quality and Risk Management with advisory panelinputs from the COC (Anaesthesiology) and COC

(Nursing). With respect to this guideline we would

like to implement with effective from 1st May 2009


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Medical error : potential fatal results

Preparation of Epiduralinfusion syringe

(centrally supplied by

Pharmacy to the ward.(only Ropivacaine

0.15% with Fentanyl

2g/ml A/V)

Name: English


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Anaesthesiologist will draw up first syringe of epidural

mixture in OT or K9

Subsequent top-up syringes will be centrally supplied by

Pharmacy to the ward. (only Ropivacaine 0.15% with

Fentanyl 2g/ml in Normal Saline 0.9% available ) The epidural drugs are all supplied in pre-filled Terumo BD

50ml syringes, with yellow label on the syringes.

No refrigeration of drugs & keep in room temperature &discard after 24hrs

Stick bright yellow labels to drug syringes as well as

extension tubings to alert all staffs against parenteral routes.


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Medical error: potential fatal results

Administration of

epidural infusion

Epidural drug

Wrong route


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Medical error : potential fatal results

Administration of

epidural infusion

Wrong route

Intravenous

drug


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EA service would be initiated only by

anaesthesiologist inside OT or labor ward.

Key points in EA guideline


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Only dedicated syringe pumps are labeled with

FOR EPIDURAL INFUSION ONLY would be

used

Fresenius Kabi

Terumo Syringe Pump


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Preparation of the Epidural Solution:

The anaesthetist should check prescription and drug

regimen with a trained staffs.


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Mixing of EA Infusion

0.15% Ropivacaine + 2g/ml Fentanyl

Draw up 38 ml of normal saline + 10 ml of 0.75%Ropivacaine + 2 ml Fentanyl (100 microgram) into a

50ml syringe Terumo

43 ml N/S

100 microgram/ml Fentanyl

0.75% Ropiacaine 5ml

Terumo syringe


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Labelling: Label the epidural infusion syringe with drug regime,

patients name and prominent warning label


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Immediately prior administration All EA infusion must be prescribed on delegated PinkMAR epidural charts which are only a/v in OT and labor

wards, and they are chopped with FOR EPIDURAL USEONLY on the top. The infusion regimes would also be

chopped

MEDICATION ADMINISTRATION RECORD EPIDURAL DRUG PRESCRIPTION SHEET


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Immediately prior administration Anaesthetist + Another trained staff

5 Rights

Right patient

Right timeRight drug

Right dose

Right route

Cross-checks with documentation



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Immediately prior administration

Another trained staff

Independently verify patient identification

Confirm that correct epidural product, lineconnection, administration method and pump

settings

Both Sign



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Administration: Yellow coloured set and EPIDURAL labels near

all the connectors from the infusion syringe to

the antibacterial filter


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Important !!

Only the trained nurse can care the patient

with epidural continuous infusion

Attend the training session


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Epidural Analgesia

Administration of analgesics

into epidural space

Exert a powerful analgesic

effect

One of the most effective

techniques for acute pain

management


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Anatomy of Epidural Analgesia


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Anatomy of Epidural Analgesia


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Level of incision determine level of

insertion

High Thoracic (T4 7)

Thoracotomy, oesophagectomyMid/low thoracic (T8 10)

Gastrectomy, neprectomy, colectomy

Lumbar (L2 4)

Lower limb operation

Caudal: Sacral levelLower limb to lower abdominal region


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Indications of EA :a. Acute postoperative pain:

Intrathoracic surgery

Abdominal surgery

Lower limb orthopaedic surgery

Vascular surgery

Urological procedures


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b. Chronic pain -- terminal illness

c. Obstetrics -- Local anaesthetic freezes sensory and

motor nerves of the uterus and vagina

d. During operative procedures Patients unfit for GAe.g. those with major cardiovascular, respiratory and

metabolic problems


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Contraindications of EA

Patients refusal Coagulation disorders

Anatomical difficulties / abnormalities of vertebral

column Local or systemic sepsis

Anticoagulation therapy

Raised intracranial pressure Hypovolaemia

Uncooperative patients


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Advantages of Post-operative EA

Potential to provide excellent analgesia

Continuation of intra-operative therapy

Less systemic side effects compared to IV narcotic

infusions

Reduction in pulmonary complications, DVT, graft

thrombosis etc


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Disadvantages of EAA. Side effects from the drugs

a. Local Anaesthetics:

Hypotension, Lower limb weakness and

numbness, Incontinence, Diarrhoea

b. Opioids: Nausea, Pruritus, Urinary retention, Sedation,

Respiratory Depression

B. Catheter related complications Nerve Injury, Epidural Haematoma, Infection


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Complications of EA

Accidental dural puncture

post dural puncture headache

typically frontal, exacerbated by movement or

sitting upright, associated with photophobia,

nausea and vomiting, and relieved when lying flat

Epidural haematoma

May lead to compression of the spinal cord

paraplegia Infection

Failure of block


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Complications of EA

Hypotension

Inadvertent high epidural block

Difficulty in talking drowsiness

difficulty breathing

Local anaesthetic toxicity light-headedness, tinnitus, circumoral tingling ornumbness and a feeling of anxiety or "impendingdoom", followed by confusion, tremor,

convulsions, coma and cardio-respiratory arrest Total spinal

profound hypotension, apnoea, unconsciousness

and dilated pupils


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Setting Up Epidural Infusion

The infusion regimes have been used :

Ropivacaine 0.15 % + 2 ug/ml fentanyl at 0-12 mls/hr

Bupivacaine 0.0625% + 3.3 ug/ml Fentanyl at 0-12

mls/hr


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Modes of Delivering of EA

1. Epidural Infusion

Continuous

Patient Controlled (PCEA)

2. Intermittent administration of

opioid drugs into epidural space


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Epidural Analgesia (EA)EA can be safely managed provided that the following

are considered:

Regular follow up

Education of nursing personnel

Suitable protocols are adhered In-house acute support service

Continuing review


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Preparation for EA pre-operatively

1. The responsible anaesthetistshould discuss the risks, benefits

and alternatives about EA with thepatient prior to the theatre & givepatients and families leaflets &obtain consent for the procedure

2. The nursing staff should explainthe epidural procedure to the

patient.


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3. The following baseline observations should be

recorded before the patient goes to theatre e.g. T/

HR / RR / BP/ P

4. Report any abnormal sensation/limb weakness to

the anaesthetist & record down prn

5. Nurses should ensure that patient understands self-

report tools for pain assessment e.g. NRS /VAS


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Numeric Rating Scale

0 = No pain 10 = Worst pain imaginable

0 1 2 3 4 5 6 7 8 9 10

No Pain Worst pain imaginable


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Faces Rating Scale for children


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Care of EA in ward1. Resuscitation drugs including Atropine, Ephedrine

andNaloxone should be available

2. Heat packs or warming pads shall not be used on

areas where sensation is affected by the epidural

analgesia.


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3. Assist/observe patient with ambulation prn


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4. Ward nurse should check the followings upon initial

set-up; at the beginning of each shift/work period;For syringe changes; anytime tubing is

reconnected after disconnection.

a. Ensure delegated EA pump proper running

b. Ensure proper labelling of catheter

c. Check for dislodgement of catheter dailyd. Ensure no misconnection of epidural catheter

e. Check any oozing of insertion site


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5. Ensure EA catheter is taped along the back

Tapping is made around four corner of Tegaderm dressing to

reinforce the dressing. (eg Hyperfix or Mefix)

The remainder of the catheter is taped up the patients back


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6. Ensure EA catheter & filter are securely fixed

The filter is securely taped to the upper chest wall (near clavicle)

Any loose catheter tubing should be carefully coiled and taped

securely to the chest wall or shoulder


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7. Ward nurses should make sure that only delegated

infusion pump & delegated Pink MAR form areused for EA infusion


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8. Ward nurses should check the drug being administered

corresponding to the prescription & Nursing Instructionssheet, APS Prescription & Observation Records should

be completed appropriately


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9. Nursing Observation & record BP/HR/ RR record

hourly for the first 24 hours, then Q4h if stable.

If hypotension occurs, IV fluid support / slow

down the infusion rate/ Vasopressors, Rule outother causes of hypotension e.g. surgical

complications (bleeding)


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10. If the patient develop respiratory depression

Give 100% oxygen and manual ventilation if apnoea.

Inform Surgeon and Pain team / on call Anaesthetist IV Naloxone 0.1 mg, repeat every 2-3 minutes up to a

total of 0.4 mg as required


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11. Observation and record : sedation score

If the patient has a sedation score of > / = 2,

Contact on Pain Team or on call Anaesthetist

The sedation score is :

0 Awake, alert

1 Slight drowsy2 Very drowsy, rousable

3 Unrousable

S Sleeping, rousable


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12. Observation and record : pain score

Use self-report wherever possible.

Identify the type & location of pain Reposition & reassurance the patient

Rule out other cause of increasing or unresolved

pain e.g. surgical complications & contact thesurgeons or pain team / on call anaesthetist


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rescue

13 Observe & record motor Score (refer to APS


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13. Observe & record motor Score (refer to APS

Prescription& observation charts)

0 No leg weakness, full

extension, can raise extendedleg off bed

1 Unable to raise extended legbut able to flex knee and

ankle

2 Unable to raise extended legor flex knee but able to moveankle

3 Unable to flex knee, ankle orfoot


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14. Check & record lower Limb (s) Numbness

Use self-report wherever possible.

Identify the Right leg or Left leg whenever possible.


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15. Assess & record sensory Level

Assess the patients response to T change, apply an

ice pack or WariActiv spray to the skin surface.

Bilateral assessment of the block should be made.

If the block extends cephalad (i.e. towards the head)

to T3 or T4, the responsible anaesthetist must be

notified.


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Upper Dermatome Level

Lateral and AnteriorUpper Thigh

L2

GroinT12-L1

UmbilicusT10

XiphisternumT6

Nipple LineT4Sternal AngleT2

Reference of Dermatome Levels

T4

T10


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16. Observation and record: Nausea & vomiting

If the patient complaining of nausea or vomiting:

Aspirate nasogastric or gastrostomy tube if appropriate

IM / IV Maxolon 10mg Q8H

Side effect


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17. Observation and record: intake and output

If the patient has a palpable bladder or bladder

discomfort:

Contact the on call anaesthetist

Contact the surgeons to determine if the patient needs

to be catheterized. Documentation

The amount drained should be recorded.


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18. Observation and record: itching

Oral / IM / IV Piriton 10 mg Q8H

If itching continues to be a problem contact

pain team / on call anaesthetist

19 Ob & d f i LA i i


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19. Observe & record for systemic LA toxicity

Drowsiness, Dizziness

Tinnitus, Numbness of the tongue

Anxiety Confusion

Muscle twitching ,Convulsions

Loss of consciousness, Coma Hypotension

Bradycardia

cardiac arrest Respiratory arrest

** Contact pain team / on call anaesthetists

20. Others observations: Migration of catheter into


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20. Others observations: Migration of catheter into

epidural vessels in the epidural space

Causing systematic absorption of medications

(systematic toxicity) Observe for inadequate analgesia which may relate

to the small opioid dose being absorbed systemically

Observe for symptoms of LA toxicity e.g. dizziness,lightheadedness, hypotension, agitation, seizures

Notify pain team / on call anaesthetist immediately if

theses occurs

21 P ti t/ P t/ F il Ed ti di


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21. Patient/ Parent/ Family Education regarding

How epidural analgesia works

Opioid/local anesthetic name and side effects

Assessment procedures

Remo al of Epid ral Catheter


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Removal of Epidural Catheter

1. Lie patient on side and curled up if possible

2. Spray with plastic spray & covered with Tegaderm

3. Document the integrity of epidural catheter and

record the time removal of catheter


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Inform pain team on call anaesthetistIf the following situations occurs:

Over sedation

Respiratory depression or respiratory arrest. Disconnection from the filter &Pump occlusion

Displacement / dislodgement/ Break of the epidural catheter

patient has excessive lower limb weakness or numbness,painat insertion site; severe low back pain (signs of epidural /spinal haematoma)

Signs and symptoms of LA toxicity

Wet dressing & oozing of blood at insertion site Signs of catheter site infection, meningitis, or sepsis

Unrelieve N & V & itchiness

Trouble shooting


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Trouble shooting

a. If the epidural catheter is pulled out accidentally:

Reassure the patient. Put a sterile gauze over the entry site.

Keep the epidural catheter.

Contact Pain Team or on call anaesthetist

Documentation

b If h h b di d f h fil


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b. If the catheter becomes disconnected from the filter:

Do not clamp the epidural catheter.

Cover with gauze

Contact Pain Team or on call anaesthetistimmediately

Record the time of disconnection and / or the time of

noticing the disconnection.


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c.If pump occlusion occurs : Stop infusion & reposition the patient prn

Check the filter to ensure no over tightening of

connection. Observe the entry site for any kinking of catheter

under the skin and re-dress if necessary

Check any kinking of the infusion tubing

Check any proper running of the pump

If these interventions are unsuccessful, call pain team/

on call anaesthetist

Documentation

Important information


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p No Narcotics or bolus of LA are given through epidural

unless by pain team / on call Anaesthetist

Hypoxaemia is NOT a reliable early sign of respiratory

depression No injection at the epidural catheter

Catheter to only be removed by pain team / on callanaesthetists

Ensure normal coagulopathy prior to the removal of EA

Adjuvant Analgesics given (Tramadol, Dologesic,Panadol)

IV access should be available throughout the duration ofthe epidural and for 24 hours after it has beendiscontinued.

Patients receiving concomitant anticoagulants are more

at risk for epidural/spinal hematoma after removal of


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at risk for epidural/spinal hematoma after removal of

catheter, so these patients shall be assessed for onset of

signs/symptoms of epidural/spinal hematoma

Stop anticoagulation for 12 hours before removal ofcatheter & resume after 10 hours of removal

Keep monitor vital signs & IV cannula for further 24hours after removal of epidural catheter

Pain Team / on call Anaesthetists will follow up thepatient daily and for 1 more day after removal of EA

catheter

Exchange of empty epidural drug:


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Exchange of empty epidural drug:

Stop the pump

Clamp the tubing

Expel air of the 50 ml syringe

Connect to the epidural tubing

Ensure good sitting of syringe into the pump Start infusion again

** make sure no contamination occurs

** check tubing not connecting to other access before &after changing the syringe

Patient confidentiality


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Patient confidentiality

When return the infusion by porter

False Correct

Anaesthesiologists


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Ward NursePain Nurse

Question & Answer


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Question & Answer


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Pain Nurse: 22551272/ 73069578 (office hour)

On Call Anaesthetist: call operator 0

References


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References

1. Acute Pain Management: Scientific Evidence, ANZCA &Faculty of Pain Medicine / NHMRC, 2nd Edition 2005

2. Macintyre PE, Ready LB. Acute Pain Management: APractical Guide. WB Saunders2nd Edition 2001

3. Scott DA, Blake D, Buckland M, et al. A Comparison of

Epidural Ropivacaine Infusion Alone and in Combinationwith 1, 2, and 4 mg/mL Fentanyl for Seventy-Two Hoursof Postoperative Analgesia After Major AbdominalSurgery. Anesth Analg 1999; 88: 85764

4. Regional Anesthesia in the Anticoagulated Patient Defining the Risks: ASRS Policy Document 1998


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