pre-reading about epidural analgesia for children

Pre-reading about Epidural Analgesia for Children

Royal Children’s HospitalMelbourne Australia

What is epidural analgesia?• Epidural analgesia is a regional

analgesic technique where locally administered agents such as local anaesthetics (often in conjunction with opioids or clonidine) are used to block pain pathways in the spinal cord or spinal nerve roots

Children's Pain Management Service, RCH, Melbourne

Why use an epidural?• Advantages:

• excellent analgesia is possible

• improved post-operative mobility

• improved respiratory function

• reduced use of opioids• improved peripheral

circulation• decreased endocrine and

metabolic response to stress

• Disadvantages:• degree of practice & skill

required• extra supervision needed• possibility of

complications• analgesia not always

totally effective

Indications for epidural analgesia• Major surgery• Prevention of specific complications

• eg muscle spasm following orthopaedic surgery

• Improvement of surgical outcomes• eg improved blood supply following

skin flap grafts• To minimise the use of opioids


Contraindications to epidurals(Some are relative contraindications only)• Allergy or hypersensitivity to amide

anaesthetics• Bleeding disorders or use of anti-coagulants• Infection - locally or systemically• Spinal abnormality or previous spinal surgery• Patients at risk of compartment syndrome• Patients at risk of neurological complications• Inadequate staffing on ward


What to tell children/parents

• Sensations to expect• eg numb and heavy legs, tingling, or no sensation

• Pain relief • eg often complete, but may be partial

• Monitoring required• regular BP, HR, RR, Temp, SpO2

• Urinary catheter may be required• usually only if lumbar epidural


How local anaesthetics work• Local anaesthetics block nerve

impulses in sensory, motor and autonomic nerve fibres

• The sensory nerve fibres respond to pain, temperature, touch and pressure


Drugs used in epidurals• Short-acting local anaesthetics:

Lignocaine• Medium/Long-acting local

anaesthetics:Levobupivacaine

Ropivacaine• Other drugs:

AdrenalineClonidineOpioids


Adding opioids to epidurals• Opioids are added to local

anaesthetic to enhance analgesia• Lipid soluble drugs have a more

rapid onset, act more locally and are shorter lasting

• Lipid solubility:fentanyl > hydromorphone>morphine


Spinal vs Epidural vs Caudal• Different techniques are used

depending on the type of surgery and the need for postoperative analgesia


Spinal• Drugs are administered into the

intrathecal space• Usually a ‘single shot’ prior to surgery,

but the catheter can be left in situ• Local anaesthetic +/- opioid may be

used• Duration of single dose of opioid is

variable (eg morphine 4-24 hours), thus risk of delayed respiratory depression


Anatomy of the spinal space• Intrathecal space situated between

the pia and arachnoid mater (also called spinal or subarachnoid space)

• Contains CSF, the spinal cord, spinal nerves and blood vessels

• Subarachnoid space ends at the second sacral vertebra

• The spinal cord ends at L1/2 (adults) or L3/4 (neonates)



As appears in McCaffrey M, Pasero C: Pain: Clinical Manual, p218, 1999, Mosby, Inc.

Epidural• Drugs are administered into the

epidural space• Drug infuses thru to CSF/spinal nerves• Local anaesthetic +/- opioid or

clonidine may be used• The epidural catheter is usually left in

situ and an infusion or boluses of analgesic solution are given


Anatomy of the epidural space• Epidural space is between ligamentum

flavum and the dura mater• Contains fat, blood vessels and

connective tissue (the spinal nerves pass through epidural space)

• Epidural space extends from the foramen magnum to the coccyx



As appears in McCaffrey M, Pasero C: Pain: Clinical Manual, p216, 1999, Mosby, Inc.

Caudal• Drugs are administered into the

caudal epidural space• Local anaesthetic +/- adrenaline +/-

opioid +/- clonidine may be used• Adrenaline or clonidine may be added

to the local anaesthetic for a longer lasting block

• In neonates epidurals may be inserted at caudal level and threaded up to thoracic level


Anatomy of the caudal space• Caudal space is well below the

termination of the spinal cord• Caudal space lies within the sacral

bone (which is not fully ossified in children)

• It is accessed via the sacrococcygeal membrane at level of sacral hiatus (S5-coccyx)


Epidural set

• The 18G and 19G PortexTM epidural kits can be distinguished by the colour of the hub on the filter and the size of the epidural catheter

• 18G kit has blue hub• 19G kit has white hub


Securing epidural catheters• Accidental or deliberate removal of

the epidural catheter by children can be a problem

• The use of non-allergenic tape to secure the epidural catheter to the skin and covering all vulnerable points of disconnection from children’s fingers will decrease the likelihood of premature dislodgement


Epidural insertion site

• A sterile sponge is often applied at the insertion site to soak up any leaking epidural solution

• An occlusive clear dressing is placed over the sponge


Taping the epidural catheter

• The epidural catheter must be securely taped to the skin

• A ‘window’ is made with the tape to allow viewing of the insertion site and catheter markings


Prevention of disconnection

• The filter hub must be firmly screwed on to the epidural catheter to prevent accidental disconnection

• If the hub is screwed on too tightly the catheter may be occluded


Securing the epidural filter

• The epidural filter must be securely taped to the upper chest wall in a comfortable position


Securing the epidural filter

• Any loose catheter should be coiled and taped securely to prevent kinking and disconnection


Where will the epidural be inserted?• The level of insertion is determined

by the site of surgery and the desired number of dermatomes to be blocked

• Ideally the catheter tip should lie level with the middle dermatome (when local anaesthetics are being infused)


Thoracic epidurals• Thoracic epidurals are used for

surgical procedures of the upper abdomen or chest wall

• They may be combined with IV opioids (nurse controlled infusion or PCA) to provide optimal analgesia


Lumbar epidurals• Lumbar epidurals are used for

orthopaedic, urological, general surgical procedures below the umbilicus

• They may be combined with IV opioids to provide optimal analgesia


Caudal epidurals• Caudals are used for surgical

procedures below umbilicus (generally sacral, perineal, lower limb and lower abdominal surgery)

• Caudals are the most frequently used block in children

• Most commonly given as a ‘single shot’


Post-operative epidural management• Observation of vital signs• Assessment of analgesia• Detection of side effects• Early detection of major

complications• Pressure area care


Assessing sensory blockDermatomes:• Dermatomes are areas of skin that are

primarily innervated by a single spinal nerve

• Pain and temperature nerve fibres are similarly affected by local anaesthetic drugs, thus changes in temperature perception indicate the area where the epidural is working


Why check dermatomes?• To ensure the epidural/caudal is

covering the patient’s pain• To ensure the block is not too

extensive, which may increase the risk of complications


Pressure areas

• If the epidural block is very dense the patient will not be able to move, will have no sensation of pressure or pain and may develop pressure areas

• Meticulous pressure area care is vital


Nerve compression• Superficial nerves (eg common

peroneal nerve) are vulnerable to damage from unrecognised pressure due to decreased sensation

• It is vital that during regular pressure area care special attention is made to ensure nerve compression is avoided


Assessing motor block• Motor nerves (as well as sensory

nerves) may be affected by local anaesthetics

• Assessing the motor function of legs and feet can give an indication of the degree of motor nerve blockade


Why check for motor block?• To detect the onset of

complications eg epidural haematoma or abscess

• To ensure the patient can move their legs to prevent pressure areas

• To ensure the patient is safe to ambulate


Causes of breakthrough pain• Epidural catheter kinked or dislodged• Epidural catheter disconnected at filter• Epidural block is unilateral on the wrong

side • Insufficient epidural infusion rate to

cover desired dermatomes• The epidural catheter tip is situated too

high or too low in the epidural space


Causes of breakthrough pain cont.• Surgical complications

• eg compartment syndrome, haemorrhage, sepsis, peritonitis

• Tight plaster +/- swelling• Full bladder +/- urinary retention• Urinary catheter or drains

obstructed or occluded


Causes of breakthrough pain cont.

ALWAYS be concerned if the pain is remote to the surgical site:• get an URGENT review!


Managing breakthrough painIf the patient complains of pain or appears to be in pain:• Check catheter at insertion site for leaking• Is the epidural still in situ?• Check at connection of catheter and filter for

disconnection/leaking• Check the epidural catheter position is the

same as stated on prescription• Give an epidural bolus as charted


Managing breakthrough pain cont.• Assess dermatomes on both sides• Assess severity and location of

pain• Consider surgical review if risk of

surgical complications• Call Children’s Pain Management

Service for review


Children's Pain Management Service• The Children's Pain Management

Service supervises all patients with epidural analgesia at the Royal Children's Hospital

• CPMS can be contacted at all times on pager 5773


Finally…Optimal pain management is the right of all patients and the responsibility of all health professionals


pre-reading about epidural analgesia for children

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