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Epidural Analgesia

Debra Lashley- Faria

NR321 Week 6

Tracy Swanston

December 4, 2009
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Epidural Analgesia

Analgesia is now recognizedas a significant contribution to clinical outcomes. The goal for pain
management is to provide the best analgesia, with the least amount of side effects. General Anesthesia
is a desirable method of pain relief, as it provides true segmental analgesia with little or no contribution
for systemic levels of opiods, all of which may lead to excellent analgesia with minimal side effects.

 Benefit:
 Less sedation
 Earlier ambulation
 Decreased incidence of pulmonary complications
 Excellent analgesia
 Decreased incidence of venous thrombosis.
 Earlier return of bowel function
 Decreased stress response.

Indication:

Post operative Pain Management.

This is especially beneficial for increased high rish surgical patients, or, for tose recovering from
extremely large or painful surgical procedure. E.g. Thoracotomies, major abdominal vascular and
orthopedic surgeries. The epidural infusion provides a localized band of analgesia at site of incision.

Epidural analgesia should only be used in hospital units where staff has adequate training. They should
be knowledgeable concerning epidural catheter placement, epidural medications and possible side
effects and complications.
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Contraindications to Epidural Analgesia:

Decreased level of consciousness may be implicated in any progression of central nervous system
dysfunction.

Systemic infection. Systemic infectionor sepsis may lead to an infection in the epidural space.

Increased intracranial pressure. When trying to locate the epidural space in a patient with raised
intracranial pressure, it increases the chance of cerebellar or tentorial herniation due to loss of central
spinal fluid.

Most important: Lack of qualified nursing care to monitor patients for side effects and complications.

Central nervous system toxicity may occur secondary to analgesic overdose. It presents as excitation and
may be preceded by numbness of the tongue and mouth and other symptoms.

Potentially life-threatening respiratory depression can occur due to opioid overdose and is potentially
lethal. The clinician in chare of the patient’s care should be notified immediately if the patient’s
respiratory rate falls below normal. The clinician may prescribe the opiod antagonist to be administered
in small increments., so that the blood opiate levels are not inadvertently decreased to a level that
causes pain to return.

Decreased pain relief, increased sedation, and/or decreased respiratory rate may occur, indicating
catheter migration.

Blood or clear fluid may leak from the catheter entry site if the catheter tip has become blocked. Slow or
stop the infusion .
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Epidural Analgesia has its advantages, as it gives the ability to be awake during the operation, especially
in labor, and the ability to avoid complications of general anesthesia. Prior to the procedure, as
physicians, it must be documented regarding your drug allergies, medication taken, any core measures
illness,e.g. asthma, pacemaker hypertension diabetes mellitus to name a few.

Epidural analgesia can cause both anesthesia (1.e., a loss of sensation) and analgesia(i.e., a loss of pain)
by blocking the transmission of signals from nerves in or near th spinal cord to the brain.

It is most suitable for surgical procedures involving the thorax,abdomen,pelvis and lower limbs because
the epidural space is increasingly more difficult to access as one ascends the spine. It is less commonly
used for analgesia for the neck or arms and is not possible following cranial surgery because sensory
innervations for the head are intertwined with the cranial nerves.

Drugs commonly used for pain control via ppost-operative epidural analgesia, are combinations of an
opioid and a local anesthetic such as bupivacaine and ropivacaine. The different mechanisms of the two
types of drugs create a synergy that yields effective pain control and minimizes the potential for toxicity
from a large dose of a single agent.

It is imperative that professionals are knowledgeable about the epidural analgesia and its use in the
postoperative setting, so that we can accurately assess patients’ need.

Complications are rare but no procedure is completely free of risk.

In the United States, 10-20% of all cancer patients do not achieve adequate pain relief or experience
significant side effects while receiving treatment within the Worl Health Organization(WHO) ladder
recommendations and guidelines for pain management. Pain management with an epidural can provide
acceptable pain relief to many of these patients(Coyne,2003).

Few large-population clinical investigations have evaluated the incidence of epidural catheter-related
infections. One meta-analusis of studies prior to 2005 found that incidence rates for infectious
complications range from3.7 to 7.2 cases per 100,000 patients for spinal anesthesia-associated
menengits, and from 0.2 to 83 incidences per 100,000 for regional anesthesia-associated epidural
abscesses.(Schulz-Stubner, et al.,2008)
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References.

1. Bird,A & Wallis, M (2002). Nursing knowledge and assessment skills in the management of
patients receiving analgesia via epidural infusion. Journal of Advanced Nursing, 40(5), 522-531.
2. Black, C., & Schofield, P. (2008). Invasive procedures for the management of pain. Journal of
Community Nursing. 22 (5), 4, 6, 8.
3. Conlon, N.P. Shaw, A. D., & Grichnik, K.P. (2008). Postthoracotomy paravertebral analgesia: Will
it repace epidural analgesia? Anesthesiology Clinics, 26(2), 369-380

4. Coyne, P.J.(2003). When the World Health Organization analgesic therapies ladder fails: The role
of invasive analgesic therapies. Oncology Nursing Forum, 30(5), 777-783.
5. Dawson, S. @001). Epidural catheter infections. Journal of Hospital infections., 47(1), 3-8.
6. Drug administration. (2009). In J. P. Kowalak (Ed), Lippincott’s nursing procedures (5 th ed., pp.
329-332). Philadelphia, PA: Lippincott Williams & Wilkins.
7. Hong, J. Y., & Lim, K. T. (2008). Effect of preemptive epidural analgesia on cytokine response and
postoperative pain in laparoscopic radical hysterectomy for cervical cancer. Regional Anesthesia
and Pain Medicine., 33(1), 44-51.
8. Keck, S., Glennon, C., & Ginsberg, B. (2007). DepoDur extended-release epidural morphine:
Reshaping postoperative care: What perioperative nurses need to know. Orthopaedic Nursing,
26(2), 86-95.
9. Kitcatt, S. E. (2006). Caring for the patient with an epidural in the recovery unit. British Journal of
Anaesthetic and Recovery Nursing, 7(4), 41-43.
10. Lau, W. C., & Eagle, K. A. (2008). Medical evaluation of the surgical patient. In A. S. Fauci, D. L.
Kasper, D. L. Longo, E. Braunwald, S. L. Hauser, & J. L. Jameson (Eds.), Harrison’s principle of
internal medicine (17th ed., pp. 49-53). NY: McGraw Hill.
11. Miller, R. D. (2006). Anesthesia. In G. M. Doherty, & L. W. Way (Eds). Current surgical diagnosis
& treatment (12th ed., pp. 170-182). NY: McGraw-Hill.
12. Murdoch, J. (2005). Ensuring prompt diagnosis and treatment of epidural abscess. Nursing
Times, 101(20), 36-38.
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13. Nishimori, M., Ballantyne, J.C. & Low, J. H. (2006). Epidural pain relief versus systemic opiod-
based relief for abdominal aortic surgery. Cochrane Database of Systematic Reviews, (3).
14. Nishimori, M., Ballantyne, J. C.., & Low., J. H. (2006). Epidural pain relief versus systemic opioid-
based relief for abdominal aortic surgery. Cochrane Database of Systematic Reviews, (3),

Database Nursing Refernce Center.

Evidence-Based Care Sheet

By Kathleen Walsh, RN, BSN, CCRN.

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