CHAPTER: Medication Administration Guidelines DUE FOR REVIEW: October 2018 ENDORSEMENT DATE: October 2015 AMENDMENT DATE/S:

St Vincent’s Hospital Melbourne Epidural Analgesia Infusions | Page 1 of 4

St. Vincent’s Hospital (Melbourne) Caritas Christi Hospice

St. George’s Health Service Prague House

EPIDURAL ANALGESIA INFUSIONS Dosing, Administration and Monitoring Guidelines

Protocol purpose and related documents

To provide guidance on the dosing, administration and monitoring of Epidural Analgesia Infusions, including Patient Controlled

Epidural Analgesia (PCEA).

Current protocols, policies and guidelines that may relate include:

Epidural Abscess protocol

Special Analgesia Nursing Observations policy

Epidural and Paravertebral Analgesia Protocols

Management Of Antithrombotic Agents In The Perioperative Period guideline

Clonidine medication management guideline

Prescribing requirements and restrictions

The order should be written by an Anaesthetist on the Analgesia Infusion Treatment Sheet (SV 754) specifying the background

infusion rate, bolus volume, and lockout period and the pump will be programmed accordingly.

Indication

Post-operative analgesia

Pain conditions where the pain can be managed by central blockade (e.g. fractured ribs, complex regional pain

syndrome, bony metastases)

Dosage and Administration

Medications used for epidural analgesia comprise a local anaesthetic e.g. ropivacaine/bupivacaine with or without an opioid

analgesic e.g. fentanyl. Clonidine or adrenaline can be added to any of the above to improve the quality of analgesia (see

Clonidine - for Pain Management medication management guideline).

These are administered NEAT (without dilution). The rate of infusion will be dictated by individual anaesthetic prescription as

found on the Analgesia Infusion Treatment sheet (SV 754). Examples of usual rates for these infusions would be 5-15mL/hr and

bolus doses 5-10mL with a lockout of 20-30minutes. Prescriptions are individualised according to the patient and surgical

incision.

Commercially available solutions used at SVHM:

Ropivacaine 0.2% (2 mg/mL), 200 mL Polybag

Ropivacaine 0.2% (2 mg/mL) + Fentanyl 2 microg/mL (400 microg /200 mL), 200 mL Polybag

Ropivacaine 0.2% (2 mg/mL) + Fentanyl 4 microg/mL (800 microg /200mL), 200mL Polybag

Bupivacaine 0.125%, 200 mL Polybag – limited stock - Only to be used if ropivacaine is unsuitable.

Not commercially available but made by Pharmacy:

Bupivacaine 0.2%, 0.25%, 200 mL ‘Plain’

The Pharmacy Department will prepare any anaesthetic solutions that are not commercially available. This includes

the addition of clonidine or adrenaline to epidural infusions ordered on the wards. Orders must be received during

Pharmacy working hours otherwise contact the on-call anaesthetist who will prepare the infusion solution.

CHAPTER: Medication Administration Guidelines DUE FOR REVIEW: October 2018 ENDORSEMENT DATE: October 2015 AMENDMENT DATE/S:

St Vincent’s Hospital Melbourne Epidural Analgesia Infusions | Page 2 of 4

Additives are NOT permitted to an epidural analgesia infusion bag unless authorised by the Department of Anaesthesia and

Acute Pain Medicine protocol. Additions will be made by the Pharmacy Department or the on-call anaesthetist (see above).

Common dose ranges for additions:

Clonidine – 300 to 450 microg /200 mL epidural infusion.

Adrenaline – 400 microg /200 mL epidural infusion.

Transitional analgesia following catheter removal:

IM/IV opioids can be given 1 to 2 hours after ceasing epidural infusions containing fentanyl

IV Patient Controlled Analgesia (PCA) analgesia can be commenced at the same time the epidural is ceased

Oral opioids e.g. oxycodone, can be given at the same time the epidural is ceased /removed or as soon as patient has

discomfort.

Adjuvant analgesia such as paracetamol, tramadol and NSAID’s (e.g. celecoxib) – there is no restriction on when these

can be administered. If there are no contraindications, these may be given in addition to the opioid patient controlled

analgesia and oral opioids.

The Acute Pain Service should be notified immediately if the transitional analgesia is inadequate.

Administration

Infusion Pump: All epidural infusions must be given via a REM Bodyguard pump (with a locked box if contains opioid).

On the pump, Select Epidural, and then select the correct epidural protocol from the pump menu as prescribed on the

Analgesia Infusion Treatment Sheet (SV754). These pumps are used for all epidural and peripheral nerve infusions and

will be primed and set up in PACU prior to the patient being transferred to the wards. If a patient is transferred to the

ward with the REM Bodyguard pump the Acute Pain Service (APS) team will see the patient 2-3 times daily and the APS

nurses will educate the ward nurses caring for the patient on how to use and alter the pump if required.

Tubing: The tubing for epidural infusions must not contain any accessible injection ports and should be colour-coded

(yellow stripe) or clearly labelled as ‘EPIDURAL INFUSION’.

PCEA (Patient Controlled Epidural Analgesia): the patient must clearly understand how to use the button for ‘wound

pain’ and to report numbness or tingling in the arms or hands. Orders will specify the background infusion rate, bolus

volume, and lockout period and the pump will be programmed accordingly.

Special Precautions and Contraindications

Anticoagulation: Epidural needle placement is contraindicated in therapeutically anticoagulated patients.

Patients receiving Heparin sodium or Low Molecular Weight Heparins (LMWH) require short-term medication

discontinuation prior to epidural needle insertion. Patients receiving oral anticoagulants require the anticoagulant to be

withheld for the appropriate number of days and bridging anticoagulation with LMWH/Heparin sodium to be started

prior to surgery/the epidural needle insertion - See the Epidural and Paravertebral Analgesia Protocol, and the

Management of Antithrombotic Agents in the Perioperative Period guideline.

o Manipulation of epidural catheter can ONLY be done by an Anaesthetic trainee or Anaesthetic Consultant

o Caution in patients with renal impairment – prolongs effect of LMWH

o Acute Pain Service must be notified before commencing IV unfractionated heparin in patients with an epidural

catheter

o For removal of epidural catheter - see Epidural and Paravertebral policy

Pregnancy and Breastfeeding - Medication dependent. Contact medicines information pharmacist for advice (4359).

Removal of epidural catheter

Removal of epidural catheter: Can ONLY be performed on written order of an anaesthetist. See the Epidural and Paravertebral

Analgesia Protocol and the Management of Antithrombotic Agents in the Perioperative Period guideline.

CHAPTER: Medication Administration Guidelines DUE FOR REVIEW: October 2018 ENDORSEMENT DATE: October 2015 AMENDMENT DATE/S:

St Vincent’s Hospital Melbourne Epidural Analgesia Infusions | Page 3 of 4

Monitoring

Refer to Special Analgesia Nursing Observation Policy ,

Special Analgesia Chart (SV 167) , and

Epidural and Paravertebral Analgesia Policy

PCEA – the patient must clearly understand how to use the button for ‘wound pain’ and to report numbness or tingling in

the arms or hands.

Adverse Effects and Overdose

Overdose: Signs and Symptoms of local anaesthetic or opioid toxicity see Reportable Observations section on the Special

Analgesia observation chart (SV 167) and Epidural and Paravertebral Analgesia Policy

Adverse Effects: See Special Analgesia Nursing Observations Policy and Special Analgesia Observation chart (SV167) under

Standard Orders and Reportable observations.

Drug Interactions (1, 2, 3, 4, 5)

Ropivacaine & Bupivacaine

When using ropivacaine as a single dose or for <24hours treatment, studies did not indicate any clinically relevant drug

interactions. If repeated administration or a long-term infusion is given, avoid potent CYP1A2 and CYP3A4 inhibitors such as

fluvoxamine and ketoconazole, as these may increase ropivacaine levels.

Other local anaesthetics and amide type Class III antiarrythmic drugs (eg/ amiodarone, mexiletine, lignocaine : consider ECG monitoring as cardiac effects may be additive

Clonidine - see the Clonidine medication management guideline for interactions

Adrenaline

Beta –blockers: (especially non-selective e.g. propanolol) may result in severe hypertension followed by reflex bradycardia

(even when used with a LA).

MAOIs: may inhibit the metabolism of adrenaline, increasing the risk of arrhythmias, hypertension and vasoconstriction.

Use combinations cautiously, monitoring ECG, BP and haemodynamic parameters.

TCAs: may also inhibit the metabolism of adrenaline (see above), however this is less likely to occur when used with LA.

Presentation and Storage

Commercially available solutions used at SVHM:

Ropivacaine 0.2% (2 mg/mL) (Ropivacaine Kabi®)Polybag 200mL

Ropivacaine 0.2% (2 mg/mL) + Fentanyl 2 microg/mL (400 microg/200 mL) (Naropin® with Fentanyl) Polybag

Ropivacaine 0.2% (2 mg/mL) + Fentanyl 4 microg/mL (800 microg/200mL) (Naropin® with Fentanyl) Polybag

o Store Ropivacaine Polybags below 25°C. Do not refrigerate. Do not freeze.

Bupivacaine 0.125%, 200 mL Polybag – limited stock - Only to be used if ropivacaine is unsuitable.

Not commercially available but made by Pharmacy if necessary:

Bupivacaine 0.2%, 0.25%, 200 mL ‘Plain’. Expires 48 hours after preparation.

Any local anaesthetic infusion preparation with addition of adrenaline or clonidine added expires 48 hours after preparation

REFERENCES 1. MIMS® Online. Ropivacaine hydrochloride (Ropivacaine Kabi®)0.2% solution for injection 200 mL Product Information.

MIMS Australia 2015, accessed 29/07/15 at https://www.mimsonline.com.au.acs.hcn.com.au/Search.

2. AusDI ®, Bupivacaine hydrochloride (Marcain®) Product Information, AusDI® 2.0r115, 009-2015 Health Communication

Network Limited 2009-2015 accessed 29/09/15 at http://ausdi.hcn.com.au/quickSearch.hcn

3. MIMS® Online. Clonidine hydrochloride (Catapres®) 150microg/mL ampoules, Product Information. MIMS Australia 2015,

accessed 29/07/15 on https://www.mimsonline.com.au.acs.hcn.com.au/Search

CHAPTER: Medication Administration Guidelines DUE FOR REVIEW: October 2018 ENDORSEMENT DATE: October 2015 AMENDMENT DATE/S:

St Vincent’s Hospital Melbourne Epidural Analgesia Infusions | Page 4 of 4

4. AMH 2015 [online]: Australian Medicines Handbook Pty Ltd, accessed online on 24/09/15 at

https://www.amhonline.amh.net.au/

5. Baxter K, Preston C. Stockley's Drug Interactions. London: Pharmaceutical Press accessed 23/09/15 at

http://www.medicinescomplete.com/

6. Acute Pain Management: Scientific Evidence (3rd Edition 2010). Australia and New Zealand College of Anaesthetists and

Faculty of Pain Medicine. Website: www.anzca.edu.au

7. Analgesic Expert Group. Therapeutic Guidelines: Analgesic Version 5. Melbourne: Therapeutic Guidelines Limited; 2007

8. Breivik, H. and G. Niemi (2001). “Does Adrenaline improve epidural bupivacaine and fentanyl analgesia after abdominal

surgery? (comment).” Anaesthesia and Intensive Care 29 (4):436-7.

9. Niemi, G. and H. Breivik (1998). “Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion

of bupivacaine, fentanyl and adrenaline after major surgery. A randomised, double-blind, cross-over study with and without

adrenaline.” Acta Anaesthesiologica Scandanavica 42(8):897-909.

10. Niemi, G. and H. Breivick (2003). “The minimally effective concentration of adrenaline in a low-concentration thoracic

epidural analgesia infusion of bupivacaine, fentanyl and adrenaline after major surgery. A randomised, double-blind dose

finding study.”

Acta Anaesthesiologica Scandinavica 47(4):439-50.

11. Scott, D.A. (2014). Acute Pain Service Manual. Department of Anaesthesia, St Vincent’s Hospital, Melbourne (anaesthetic

access only).

Authorship and Contributor Details

Primary Policy Author(s):

Andrew Stewart Consultant Anaesthetist, Anaesthetics Department

Wendy McDonald Acute Pain Nurse, Anaesthetics Department

Kim Choate Acute Pain Nurse, Anaesthetics Department

Noni Oborne Medicines Information Pharmacist, Pharmacy Department (July 2015)

Gedal Basman Medicines Information Pharmacist, Pharmacy Department (July 2010)

Others Consulted, including Committees:

Medication Guideline Review Group

Head of Department Responsible for policy:

Andrew Cording Chief Pharmacist, Pharmacy Department