THE BIG BAD SCARY EPIDURAL (isn’t so bad once you get to know it….)

ONCE upon a time, a nurse was assigned to care for a patient with an epidural, which struck terror into her heart……

REVIEW: HOW DOES AN EPIDURAL WORK? Epidural analgesia is a form of regional anesthesia involving infusion of drugs through a catheter placed into the epidural space. The tip of the tube lies near the nerves transmitting pain sensations at the place where the nerves enter the backbone. The injection can cause both a loss of sensation (anesthesia) and a loss of pain (analgesia), by blocking the transmission of signals through nerves in or near the spinal cord.

Epidural infusions are used most commonly for postoperative pain control (thoracic, abdominal, and lower extremity procedures) and obstetric analgesia. Less common applications are for management of traumatic pain (rib fractures), pre-amputation, and cancer pain, as well as selected chronic pain states.

It is typical to get a block level from 1-2 dermatomes above the level of placement to 2-3 dermatomes below the level of placement. The epidural catheter is placed at a level which will provide maximal coverage for the injury or surgical incision:

True or False: Nursing staff are allowed to change the rate of an epidural infusion

Directions to change the pump rate are attached to each pump, and will walk you through the steps:

The code needed to make programming changes to the pump is located on the back of the pump – it is the zip code typed in backwards:

True or False: Nursing staff are not allowed to prime epidural tubing

A small amount of air is not problematic; generally speaking if it makes it past the pump sensors, it’s small enough to not worry about – there is an inline filter in the tubing. If the air amount is large enough to make the pump alarm (i.e. bag has run dry), you may need to disconnect the tubing from the patient and prime the tubing (follow directions located on all pumps).

Avoid the need to prime tubing by NEVER changing the bag volume on the programming screen. This tells the pump what the bag size is (always 250 ml within our system) and has nothing to do with the volume of fluid actually in the bag. NO YES

Remember, minimizing the number of breaks in a closed system is the best way to reduce the risk of contamination.

True or False: Nursing staff are allowed to change epidural tubing

According to the “Epidural Analgesia Management Protocol,” in compliance with CDC guidelines, the epidural tubing does not need to be changed on the days IV tubing is changed (Weds/Sun). However, nurses are allowed to change the tubing if it becomes necessary to do so (broken tubing, other mechanical problem).

True and False. It depends….. True or False: My patient has an epidural, so I can’t give them additional narcotic pain medicine. True and False. It depends…..

If the epidural solution contains narcotics, then you should only give additional narcotics which have been ordered or approved by an Anesthesia provider. If the epidural solution contains no narcotic (ropivacaine or bupivacaine only), then the primary team should order additional pain medications to supplement the epidural, and you should give them as needed.

My patient’s epidural dressing has some drainage under it My patient’s epidural dressing has some drainage under it. When should I call Anesthesia? At the earliest sign of any drainage If the drainage looks purulent If there is a large amount of frank bleeding If there is a moderate amount of clear drainage under the dressing, but the patient’s pain seems well controlled If there is a moderate amount of clear drainage under the dressing, and the patient’s pain has increased

It’s not unusual for patients to experience some drainage under their epidural dressing – because the medication is infusing into a small space, occasionally some of the fluid backs out along the catheter and collects under the dressing. If there is some drainage and pain remains well controlled, it’s a pretty good bet that things are okay. However, if the patient has increasing complaints of pain in addition to increased drainage, it could mean the catheter has migrated out.   A small amount of blood may ooze from the insertion site and appear to track along the coiled catheter; if there appears to be frank bleeding or if you notice signs of infection (purulent drainage, red or tender site), APS should be notified.

True or False: Nurses can change epidural dressings

The epidural dressing should only be changed by an Anesthesia provider The epidural dressing should only be changed by an Anesthesia provider. If the edges seem loose or in danger of rolling up, you may reinforce the dressing. However, if the site is compromised (insertion site is exposed) or if there is significant leaking at the site, the epidural may need to be removed, and Anesthesia should be called to evaluate the site.

Where should I chart about my patient’s epidural? Patient assessment should be completed according to the guidelines in the “Epidural Analgesia Management Protocol.” Document your findings within the “Epidural” section of the “Pain/Sedation Management” band of IVIEW:

True or False: Benadryl is the best medication to give patients who have itching related to epidural narcotics

The itching is resulting from an opioid receptor reaction, not a histamine reaction. Nubain is an opioid agonist-antagonist analgesic, which means that in addition to having the benefit of providing some additional analgesia, it is the most effective means of relieving opioid-induced pruritis.

QUESTIONS???? Contact the Acute Pain Service RN’s: Nick Glascock, pager 256-8797 glascockn@health.missouri.edu Kay Smith, Pager 256-8853 smithkj@health.missouri.edu