Professional Documents
Culture Documents
Dr.Fatma AL Dammas
OBJECTIVES
DEFINITIONS
EPIDURAL=administration of medication
into epidural space
INTRATHECAL=administration of
medication into subarachnoid space
OVERVIEW
OF THE
SPINAL ANATOMY
SPINAL CORD
VERTEBRAL COLUMN
Vertebral column
Protects the spinal cord & consists of
7cervical
12 thoracic
5 lumbar
5 caudal or sacral fused into
one
5-4 coccygeal fused one bone
coccyx
The ligaments
1c.supraspinous
ligament
2b.Interspinous
ligament
3a.ligamentum
flavum
EPIDURAL SPACE
Potential space
Between the dura mater,luigamentum
flavum
Made up of vasculature, nerves, fat and
lymphatic
Extends from foramen magnum to the
sacrococcygeal ligament
INDICATIONS
CONTRAINDICATIONS
Patient refusal
Known allergy to opioid or local
anesthetic
Infection/abscess near the proposed
injection site
Sepsis
Coagulation disorder
Hypotension / hypovolemia
Spinal deformity/increased ICP
Height of sensory
block
Lumbar-T4
Thoracic-T2
Epidural Analgesia
INSERTION OF EPIDURAL
CATHETER
Positioning of patient
The site is dependent upon the area of
pain
Fixing the catheter
Incision
Level
Thoracic
Upper abdo
Lower abdo
Pelvic
Lower extremity
T4-T6
T6-T8
T8-T10
T8-T10
L1-L4
EPIDURAL CATHETERS
CATHETER MIGRATION
Catheter migration into a blood vessel in the
epidural space or subarachnoid space
CATHETER MIGRATION
DRUGS
OPIOIDS-Fentanyl +Morphine
(affect the pain transmission at the
opioid receptors)
L.A.-Bupivacaine(marcaine)
(inhibits the pain impulse
transmission in the nerves with
which it comes in contact)
METHODS OF ADMINISTRATION
CONTINUOUS INFUSION(MARCAINE+FENTANYL)
EPIDURAL LOCAL
Bupivacaine (marcaine)
Mechanism of Action
Bupivacaine (marcaine)
- local anaesthetic works as an
analgesic (subanesthetic dose)
- inhibiting impulse transmission in
the nerve fibers
- sensory nerves are blocked first
before the motor fibers
- sensory fibers carrying the pain is
blocked before those carrying heat
cold touch and pressure.
EPIDURAL LOCAL
ANESTHETIC(MARCAINE)
OPIOIDS
Mechanism of action-distribution
Morphine (Duramorph/Astramorph)
Hydrophilic(water soluble)
Slow to diffuse across the dura on to the
spinal cord
Can cause late respiratory depression
Monitor respiratory status for 12 hrs after
the last dose of duramorph
Duration 6 hrs+
Broad spread
Fentanyl (preservativefree)
Lipophilic(fat soluble)
Crossess the dura rapidly
Rapid onset of action(segmental)
Decreased risk of late respiratory
depression
Onset 5-20 mins
Duration 2-4hrs
Excellent for breakthrough pain
Opioid pharmacology
Opioid pharmacology
Peak plasma concentration after
po = 1 hour
SC,IM = 30MINS
IV
= 6MIN
Half- life at steady state
PO,PR,SC,IM,IV =3-4 H.
Respiratory Depression
May occur
Early
Delayed
R/D is relatively uncommon.
Risk factors
recent IV or IM narcotics
large dose
recent CNS depressants (anesthetic ,etc)
Alert
Mild
Easily aroused
Moderate
Difficult to arouse
or RR <10 notify
APS pg2789
Severe
Unresponsive or RR
<8. notify APS2789
Motor assessment
Sensory assessment:
* Use ice in the tip of a glove
* Start in upper neck and move down
thorax bilaterally assessing all
potential dermatomes
* Level of block is where intensity of cold
changes or the cold sensation is absent
* assess the dermatomes below the pelvis
Motor assessment
Sensory assessment:
* Use ice in the tip of a glove
* Start in upper neck and move down
thorax bilaterally assessing all
potential dermatomes
* Level of block is where intensity of cold
changes or the cold sensation is absent
* assess the dermatomes below the pelvis
Sensory assessment
Hypotension-assess intravascular
volume status
-no trendelenberg
positioning
Teach patient to move
slowly from a lying
position to sitting to
standing position.
Treatment
fluids
Cont.
Urine retention
Tx: catheter
Local anesthetic
toxicity (neurotoxicity)
Tx: stop infusion.
Resp. insufficiency
Tx:stop infusion
- ABC(100% o2
call for help)
- Assess spread
and
height of block
- Alt.analgesia
OTHER COMPLICATIONS
Headache (dural
puncture)
Tx: symptomatic
treatment
Autologous blood
patch
Infection
nausea and
vomiting.
Intravenous
placement of catheter
Subdural placement of
catheter
Haematoma
EPIDURAL
ANALGESIA(GUIDELINES)
Collect items
Assess patient
Inspect site
Wash hands
Aspiration test Glucose test
Administer
Document
Evaluate the outcome
POLICIES
1. Placement of epidural catheters is performed by the
anesthetist in the Operating Room .
2. All patients must have a patent IV access for the
duration of epidural therapy and for 12 hours after the
catheter is removed.
3. The Acute Pain Service (APS) / Anesthesiologist will
be responsible for ordering all epidural analgesia.
6. Epidural Medications
6.1. No medications, other than those offered by the Acute
Pain Service (APS), are to be administered into the epidural line
6.2. Do not use agents from a multiple dose vial. Most multidose vial medications contain preservatives, which can cause
intra-spinal neurotoxicity
6.3. Do not use alcohol or alcohol based products near the
epidural catheter. Alcohol is neurotoxic and can damage the
nerves.
6.4. Return any medications that are unclearly labeled, cloudy
or contain particulate matter to pharmacy.
6.5. Return any unused used syringes and cassettes to
pharmacy
EQUIPMENT/MATERIALS
Dressing Change
Sterile 4 x 4 gauze x 2 packages
Povidone-lodine swabs sticks x 3 packages
Large Transparent dressing x 1
Sterile gloves x 2 pair
Transparent tape
Dressing Changes:
Dressings should not be changed unless it is absolutely
necessary, however, they may be changed if:
1. the dressing is wet due to oozing from the
puncture site
2. the dressing has become loose
Dressing Changes:
PROCEDURE
1. Gather all equipment and supplies.
2. Explain the procedure to the patient.
3. Position patient on bed.
4. Wash hands.
Open the sterile gloves, transparent dressing
4x 4 gauze package.
Dressing Changes:
5. Put on sterile gloves. With a finger tip, apply
gentle pressure over the catheter insertion site
and slowly peel back the opsite dressing using
extreme care.
6. Remove gloves and dispose soiled dressing and
gloves into garbage bin.
7. Wash hands and put on second pair of sterile gloves.
8. Supporting the catheter with one hand, clean the
Insertion site with povidone-iodine swabs, moving
from center to periphery of site. Allow to dry.
Dressing Changes:
9. Loop the catheter, and fix
using transparent dressing.
10. Gently run finger over
catheter and dressing.
11. Fix catheter along back and
over shoulder .
12. Document dressing change
and observations on
Nursing Record.
PROCEDURE
1. The APS staff should be notified if the patient is
receiving anticoagulant.
2, Gather all equipment and supplies.
3. Explain the procedure to the patient.
4. Position the patient side-lying or sitting with the back
exposed and arched out.
Flexion of the back widens the vertebral space,
allowing for easy withdrawal of the catheter
5. Stop the epidural pump.
14. Maintain IV access for 12 hours after the last dose of opioid is given
15. Document epidural catheter removed in the
nursing record.
Include date, time, condition of catheter, and site and
patients tolerance of the procedure.
16. Obtain co signature of a second nurse to witness
waste of narcotic (if required)
17. Clean pump thoroughly and return to Recovery Room Level 2.
REMMEMEBER
STAFF NURSE
RESPONSIBILITIES
1. Upon receiving patient check for:
1.1. IV cannula
1.2. urinary catheter
1.3. epidural catheter length (if visible)
1.4. if dressing is intact
1.5. doctors order
1.6. ongoing epidural infusion bag
STAFF NURSE
RESPONSIBILITIES
2. Assess and monitor as indicated on epidural
flowsheet.
3. Notify APS or on call anaesthetist any untoward
complications, emergency , side effects or inadequate
relief related to therapy.
3.1 pager 2113 aps anaesthetist weekdays 0730
1600
3.2 pager 2789 aps nurse weekdays 0730 1600
3.3 pager 3540 maternity on call anaesthetist 1630
0730 daily and weekends
STAFF NURSE
RESPONSIBILITIES
4. Certified nurse should connect the new bag.
5. CN are allowed to increase or decrease the infusion rate based
on the rate ordered or patients pain response from ongoing
infusion.
6. Infusions:
6.1. if used : discard with the presence of other witness or
staff.
6.2. if not used: Incident report and send back to pharmacy.
7. Keep patent IV access and continue to monitor for 12 hours
after removing the epidural catheter.
8. Inform APS team or on call anesthetist if patients is on
anticoagulant.