1st day epidural presentation2-4

8/18/2019 1st Day Epidural Presentation2-4

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Dr.Fatma AL Dammas

Epidural Analgesia


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OBJECTIVES

Identify the anatomy and physiology of

the spinal column in relation to the

placement of an epidural catheter.

Identify the nursing responsibilities in

caring for a patient receiving epiduralanalgesia.


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DEFINITIONS

EPIDURAL=administration of medication

into epidural space

INTRATHECAL=administration of

medication into suarac!noid space


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"#ER#IE$

"F THE

%PINAL ANAT"&'


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SPINAL CORD

Located and protected (it!in )erteralcolumn

E*tends from t!e foramen ma+num to

lo(er order ,st

L, -adult %/ -0ids %C taper to a firous and 1 conus

medullaris Ner)e root continue e2ond t!e conus1

cauda e3uina %urrounded 2 t!e menin+es4

-dura4arac!noid 5pia mater.


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VERTEBRAL COLUMN

#erteral columnProtects t!e spinal cord 5 consists of

67 cer)ical 6,/ t!oracic

68 lumar

68 caudal or sacral fused into

one 6918 cocc2+eal fused one one

cocc2*


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The ligaen!s

"#$supraspin%usligaen!

&'$In!erspin%us

ligaen!(a$ligaen!u

)la*u


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EPIDURAL SPACE

Potential space

:et(een t!e dura mater4lui+amentum

fla)um &ade up of )asculature4 ner)es4 fat and

l2mp!atic

E*tends from foramen ma+num to t!esacrococc2+eal li+ament


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INDICATIONS

T!e o;ecti)e of epidural anal+esia is

to relie)e pain.

&a;or sur+er2

Trauma -< ris

Palliati)e care -intractale pain

Laour and Deli)er2


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CONTRAINDICATIONS

Patient refusal no(n aller+2 to opioid or local

anest!etic Infection>ascess near t!e proposed

in;ection site %epsis

Coa+ulation disorder H2potension > !2po)olemia %pinal deformit2>increased ICP


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Pa!ien! assue a si!!ing %r side+l,ing

p%si!i%n -i!h !he 'a#. ar#hed !%-ard !he

ph,si#ian$/elp !% spread !he *er!e'raeapar!


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/eigh! %) sens%r,'l%#.

Lu'ar+T0

Th%ra#i#+T&


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Epidural Analgesia


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INSERTION OF EPIDURAL

CAT/ETER

Positionin+ of patient

T!e site is dependent upon t!e area of

pain

Fi*in+ t!e cat!eter Incision Le)el

T!oracic T91T?

Upper ado T?1T@

Lo(er ado T@1T,

Pel)ic T@1T,

Lo(er e*tremit2 L,1L9


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EPIDURAL CAT/ETERS

Ideal Placement -adult ,1,/ cm at t!e

s0in

Epidural cat!eters !a)e mar0in+s t!atindicate t!eir len+t!.

= t!ere is a mar0 at t!e tip of t!e cat!eter = t!e ,st sin+le mar0 up t!e cat!eter is 8cm

= doule mar0 up t!e cat!eter is , cm

= triple mar0 on t!e cat!eter is ,8 cm = four mar0 to+et!er indicate /cm

A c!an+e in dept! of t!e cat!eter indicates mi+ration

eit!er into or out of t!e epidural space.


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CAT/ETER MI1RATION

Cat!eter mi+ration into a lood )essel in t!e

epidural space or suarac!noid space

rapid onset L"C

Decrease loss of sensor2 or motor loss

-marcain

To*icit2

Profound !2potension


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DRU1S

"ne of t!e most important factors

influencin+ dru+ asorption andioa)ailailit2 is t!e dru+ %"LU:ILIT'

T!e more lipid solule rapid onset 5

s!orter duration


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MEDICATION COMMONL2 USED

"PI"ID%1Fentan2l B&orp!ine -affect t!e pain transmission at t!e

opioid receptors

L.A.1:upi)acaine-marcaine

-in!iits t!e pain impulse

transmission in t!e ner)es (it!

(!ic! it comes in contact


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MET/ODS OF ADMINISTRATION

:"LU% -FENTAN'L4 DURA&"RPH

C"NTINU"U% INFU%I"N-&ARCAINEBFENTAN'L

All dru+s administered epidural s!ould e

preser)ati)e free.

All epidural opioids s!ould e diluted (it! normalsaline prior to intermittent olus administration.


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EPIDURAL LOCAL

:upi)acaine -marcaine


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Me#hanis %) A#!i%n

:upi)acaine -marcaine 1 local anaest!etic (or0s as an

anal+esic -suanest!etic dose

1 in!iitin+ impulse transmission in t!e ner)e fiers

1 sensor2 ner)es are loc0ed first

efore t!e motor fiers1 sensor2 fiers carr2in+ t!e pain is

loc0ed efore t!ose carr2in+ !eat

cold touc! and pressure.


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EPIDURAL LOCAL

ANEST/ETIC3MARCAINE)

"nset ,1,8 minutes

Duration1 9 !rsB after a olus or after

infusion is stopped &arcaine-.?/81.,/81./8

E*tend of spread influenced 2 )olume

and position of patient


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OPIOIDS

&ec!anism of action1distriution

#ascular upta0e 2 lood )essels in t!e

epidural space

Diffusion t!rou+! dura into C%F to spinalcord to t!e site of action.

Upta0e 2 t!e fat in t!e epidural space.


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M%rphine 3Dura%rph4As!ra%rph5

H2drop!ilic-(ater solule

%lo( to diffuse across t!e dura on to t!e

spinal cord Can cause late respirator2 depression

&onitor respirator2 status for ,/ !rs after

t!e last dose of duramorp! Duration ? !rsB

:road spread


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Fen!an,l 3preser*a!i*e)ree5

Lipop!ilic-fat solule

Crossess t!e dura rapidl2

Rapid onset of action-se+mental Decreased ris0 of late respirator2

depression

"nset 81/ mins Duration /19!rs

E*cellent for rea0t!rou+! pain


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Ad*erse E))e#!s +Opi%ids

%edation and resp.depression1 I# narcan N>#1"pioids stimulate t!e c!emoreceptor tri++er one

primperan Pruritus1 dip!en!2dramine or narcan -lo( dose Urinar2 retention1 lo( dose narcan and >or

cat!eteriation %lo(in+ of I motilit2 H2potension


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Respira!%r, Depressi%n

&a2 occur

Earl2

Dela2edR>D is relati)el2 uncommon.

Ris0 factors

recent I# or I& narcotics

lar+e dose

recent CN% depressants -anest!etic 4etc


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ASSESSMENT OF T/E SEDATION

LEVEL

None Alert

, &ild Easil2 aroused

/ &oderate Difficult to arouse

or RR G, notif2AP% p+/7@

%e)ere Unresponsi)e or RR

G@. notif2 AP%/7@


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M%!%r and Sens%r, Assessen!

&otor assessment %ensor2 assessment

J Use ice in t!e tip of a +lo)e J %tart in upper nec0 and mo)e do(n

t!ora* ilaterall2 assessin+ all

potential dermatomes

J Le)el of loc0 is (!ere intensit2 of coldc!an+es or t!e cold sensation is asent

J assess t!e dermatomes elo( t!e pel)is


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Assessen! %) %!%r 'l%#.

:roma+e %core


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M%!%r and Sens%r, Assessen!

&otor assessment %ensor2 assessment

J Use ice in t!e tip of a +lo)e J %tart in upper nec0 and mo)e do(n

t!ora* ilaterall2 assessin+ all

potential dermatomes

J Le)el of loc0 is (!ere intensit2 of coldc!an+es or t!e cold sensation is asent

J assess t!e dermatomes elo( t!e pel)is


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Sens%r, assessen!


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Ad*erse E))e#!s L$A

H2potension1

1assess intra)ascular

)olume status

1no trendelener+

positionin+

Teac! patient to mo)e

slo(l2 from a l2in+

position to sittin+ to

standin+ position.

Treatment

fluids


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C%n!$ Temporar2 lo(er1

e*tremit2 motor orsensor2 deficits.

T* lo(er t!e rate or

concentration.

Urine retention

T* cat!eter

Local anest!eticto*icit2 -neuroto*icit2

T* stop infusion.

Resp. insufficienc2

T*stop infusion

1 A:C-, o/

call for !elp

1 Assess spread

and

!ei+!t of loc0

1 Alt.anal+esia


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OT/ER COMPLICATIONS

Headac!e -dural

puncture

T* s2mptomatic

treatmentAutolo+ous lood

patc!

Infection nausea and

)omitin+.

Intra)enous

placement of cat!eter

%udural placement ofcat!eter

Haematoma


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EPIDURAL

ANAL1ESIA31UIDELINES5

Collect items

Assess patient

Inspect site

$as! !ands

Aspiration test K lucose test

Administer

Document E)aluate t!e outcome


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POLICIES

1. Placement of epidural catheters is performed by theanesthetist in the Operating Room .

2. All patients must have a patent IV access for theduration of epidural therapy and for 12 hours after the

catheter is removed.

. !he Acute Pain "ervice #AP"$ % Anesthesiologist &ill

be responsible for ordering all epidural analgesia.


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'. (hen the nurse receives a patient &ith a continuous

epidural infusion) the R* must follo& every order onthe order sheet.

'.1. If there is any +uery about the orders) if any of

the orders are not filled in and%or if there is no dateand time and%or signature) contact the anesthetist

&ho &rote the order.


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6. Epidural Medications

,.1. *o medications) other than those offered by the AcutePain "ervice #AP"$) are to be administered into the epidural line

,.2. -o not use agents from a multiple dose vial. ost multi/dose vial medications contain preservatives) &hich can cause

intra/spinal neuroto0icity

,.. -o not use alcohol or alcohol based products near theepidural catheter. Alcohol is neuroto0ic and can damage thenerves.

,.'. Return any medications that are unclearly labeled) cloudyor contain particulate matter to pharmacy.

,.. Return any unused used syringes and cassettes topharmacy


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. 3ocal anesthetic must not be given as a bolus via the epiduralcatheter by the nurse.

4. !he AP" % anaesthetist must be notified if pain is not &ell

controlled by the epidural infusion.

5. *o other narcotic drug &ill be administered to the patient by anyother route unless ordered by the anesthetist % AP" .

16. All monitoring information and assessments must bedocumented on the 7ontinuous 8pidural Infusion 9lo&sheet


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11. Patient monitoring &ill be done as outlined for 12 hours afterthe discontinuation of the epidural infusion and after removal ofepidural catheter) &hether it is opioids or local anesthetic &hichhas been infused.

11.1.Assess pain scores) blood pressure) heart rate)sedation level) respiratory and sensory levels) and motorfunction every 1 mins 01h) every 1 hour 0 ' hours and thenevery ' hours until 12 hours after the infusion is discontinued.


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12. otor functions of patients receiving local

anesthetic via epidural catheter must be

assessed by an R*.

1. !o assess the height of sensory bloc:) use

the ice techni+ue.

1'. All epidural catheters must be identified &ith

the label ;8pidural 7atheter< at the accesshub) to prevent inappropriate use of the

catheter.


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1. -ressing changes are done only &hen necessary) by nurses

&ho have been trained in proper techni+ues of dressing change

in present of AP" .

1,. !he administration set #including the 6.22 micron filter$ &ill be

changed every 2 hours and the tubing labeled &ith the date

and time of change.


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Dressing Changes and Re%*al %) Epidural Ca!he!ers

8=>IP8*!%A!8RIA3"

Dressin+ C!an+e

"terile ' 0 ' gau?e 0 2 pac:ages

Povidone/lodine s&abs stic:s 0 pac:ages3arge !ransparent dressing 0 1

"terile gloves 0 2 pair

!ransparent tape


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Dressing Changes6

-ressings should not be changed unless it is absolutely

necessary) ho&ever) they may be changed if@

1. the dressing is &et due to oo?ing from the

puncture site

2. the dressing has become loose


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Dressing Changes6

PR"CEDURE

1. ather all e+uipment and supplies.

2. 80plain the procedure to the patient.

. Position patient on bed.

'. (ash hands.

Open the sterile gloves) transparent dressing

'0 ' gau?e pac:age.


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Dressing Changes6

. Put on sterile gloves. (ith a finger tip) apply

gentle pressure over the catheter insertion site

and slo&ly peel bac: the opsite dressing using

e0treme care.

,. Remove gloves and dispose soiled dressing and

gloves into garbage bin.

. (ash hands and put on second pair of sterile gloves.

4. "upporting the catheter &ith one hand) clean the

Insertion site &ith povidone/iodine s&abs) moving

from center to periphery of site. Allo& to dry.


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Epidural Ca!he!er Re%*al6

1. Removal of the epidural catheter must be ordered bythe AP" physician.

2. 3o& olecular (eight Beparin #3(B$@ 7atheterremoval should be delayed until 12 hours after a doseof 3(B. If 3(B is to be continued) it should not beresumed until at least ' hours after catheter removal.

. "tandard Beparin !herapy@ 7atheter removal shouldbe delayed until , hours after a dose of standardheparin. If standard heparin is to be continued) itshould not be resumed until 2 at least 2 hours aftercatheter removal.


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Removal of the epidural catheter

'. Beparin Infusion@ !he coagulation status of the

patient receiving heparin infusion should be

assessed. !he heparin infusion shall be stopped for ,

hours prior to catheter removal) and not resumed forat least 2 hours after the catheter is removed.


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PROCEDURE

1. !he AP" staff should be notified if the patient is

receiving anticoagulant.

2) ather all e+uipment and supplies.

. 80plain the procedure to the patient.

'. Position the patient side/lying or sitting &ith the bac:

e0posed and arched out.

Flexion of the back widens the vertebral space,

allowing for easy withdrawal of the catheter

. "top the epidural pump.

, ( h h d P t t il l


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,. (ash hands. Put on sterile gloves.

. ently remove tape and dressing.

4. inspect catheter site for redness) s&elling ordrainage.

If the area is reddened or if there is drainage, notify the

APS physician. Collect surface swabs and catheter tip

for cultures and sensitivity per APS physician! using

aseptic techni"ue.

5. 7lean the catheter insertion site) from centerout&ards)and allo& to air dry.


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16. Apply steady traction to remove catheter. -o not pullvigorously.

If resistance is #et, ask the patient to flex or arch hisback #ore. If resistance re#ains, stop and notify APS.

11. (hen catheter is removed) chec: that tip is intact. If

not) notify AP" immediately.

12. Apply band/aid to the site.

1. Instructions to patients should include@

A. report any pain at the insertion


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1'. aintain IV access for 12 hours after the last dose of opioid is given

1. -ocument epidural catheter removed in the

nursing record.

Include date, ti#e, condition of catheter, and site and

patient$s tolerance of the procedure.

1,. Obtain co signature of a second nurse to &itness

&aste of narcotic #if re+uired$

1. 7lean pump thoroughly and return to Recovery Room 3evel 2.


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1.easure the length of the epidural catheter from epidural spaceto the s:in.


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2.(hat &ill you do to chec: the 7"9 and Clood/ tinged fluid.


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.Bo& you perform a "8*"ORD level assessment using an ice

method.


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method.'.Bo& you perform a O!OR level.


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1.easure the length of the epidural catheter from epidural space tothe s:in.


.Bo& you perform a "8*"ORD level assessment using an ice method.

'.Bo& you perform a O!OR level..(hat &ill you chec: for the site.

,.uidelines for removing epidural catheter for those patients &horeceives anticoagulant.

3O( O387>3AR (8IB! B8PARI*

"!A*-AR- B8PARI* !B8RAPDB8PARI* I*9>"IO*


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.(hat &ill you chec: for the site.


.Cased on your :no&ledge and understanding ho& you &ill do theepidural dressing after preparing all the needed materials.


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.(hat &ill you chec: for the site.


.Cased on your :no&ledge and understanding ho& you &ill do the

epidural dressing after preparing all the needed materials.4. Bo& you &ill remove the epidural catheter.


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REMMEMEBER

STAFF NURSE


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STAFF NURSE

RES!NS"#"$"T"ES

1. >pon receiving patient chec: for@

1.1. IV cannula

1.2. urinary catheter 1.. epidural catheter length #if visible$

1.'. if dressing is intact

1.. doctors order 1.,. ongoing epidural infusion bag

STAFF NURSE


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STAFF NURSE

RES!NS"#"$"T"ES

2. Assess and monitor as indicated on epiduralflo&sheet.

. *otify AP" or on call anaesthetist any unto&ard

complications) emergency ) side effects or inade+uaterelief related to therapy.

.1 pager 211 aps anaesthetist &ee:days 66 E1,66

.2 pager 245 aps nurse &ee:days 66 E 1,66

. pager '6 maternity on call anaesthetist 1,6 E 66 daily and &ee:ends

STAFF NURSE


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STAFF NURSE

RES!NS"#"$"T"ES

'. 7ertified nurse should connect the ne& bag.

. 7* are allo&ed to increase or decrease the infusion rate basedon the rate ordered or patients pain response from ongoinginfusion.

,. Infusions@ ,.1. if used @ discard &ith the presence of other &itness or

staff.

,.2. if not used@ Incident report and send bac: to pharmacy.

. Feep patent IV access and continue to monitor for 12 hoursafter removing the epidural catheter.

4. Inform AP" team or on call anesthetist if patients is onanticoagulant.

'oureMMM $!at did 2ou learn


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1st day epidural presentation2-4

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