Acute Pain Management: Epidural Analgesia

1. Acute Pain Management: Epidural Analgesia Laura Yontz, BSN, MPH, CPAN PACU presentation

2. Objectives • Describe the anatomy, physiology, pharmacology, and complications related to the analgesia techniques. • Initiate nursing interventions to ensure optimal care. • Recognize emergency situations.

3. 50% of patients report that their pain relief was inadequate. • Polomana, R (2008). Perspectives on pain management in the 21st century. Journal of Perianesthesia Nursing (23)1: 4-13.

4. Acute Pain Management Training Not a major portion of professional healthcare education

5. NC State Board of Nursing • Ongoing competence of nurses • Keep the public safe

6. Advisory Statement • Written protocol • Appropriate training • Supervised practice • Written approval within agency.

7. Epidural Analgesia • Low volume, high risk • How do you stay competent? • How do you provide safe care?

8. Epidural Analgesia • Success rate of 70% Viscusi, E. (2007) Emerging treatment modalities: Balancing efficacy and safety. Am J Health – Syst Pharm. 64: 6-10. • Catheters placed for procedures associated with significant pain • Krenzischek, D. (2008) Pharmacotherapy for acute pain: Implications for practice. JOPAN 23(1):28-42

9. Contraindications • Absolute: • Patient refusal • Allergy • Infections at insertion site • Systemic infection • Acute symptomatic hypovolemia • Probable • Coagulopathy • Spinal deformities • Neurological diseases • Increased ICP

10. Anatomy • Epidural space • Contains; • Blood vessels • Fat • Nerves

11. Anatomy • Analgesics delivered through a needle into the epidural space • Catheter threaded into space

12. Method of Administration • Bolus • Continuous • PCEA

13. Characteristics of Epidural Drugs • Close to receptor sites. • Small doses effective • Cross dura mater into CSF, then into spinal cord to receptor sites.

14. Characteristics (cont.) Lipid soluble Water soluble • Fentanyl, sufentanil • Readily dissolve in epidural fat; move quickly into CSF, then into spinal tissue. • Rapid onset of action: 5 minutes • Shorter duration of action • Morphine, hydromophone • Do not traverse fatty dura mater as quickly • Once in CSF tend to stay there; eventually move into spinal tissue • Longer onset of action: 30-60 minutes • Longer duration of action

15. Local Anesthetics • Bupivicaine , ropivicaine • Used in combination with opioids • Moderate to fast acting: 5-20 minutes • Long duration of action: up to 12 hours • Work synergistically to provide better pain relief at lower doses

16. Side effects Pain management Nausea and vomiting • Vital signs • Pain behaviors • Analgesic history • Acceptable levels • Breakthrough pain • Common reaction • Treated with metoclopramide

17. Side effects (cont.) • Respiratory depression • RR less than 8 breaths/minute • Oxygen sat less than 90% • Decreased LOC

18. Side effects (cont.) • Urinary retention • Assess for distention • Foley catheter • Itching • Treated with benadryl

19. Side effects (cont.) Inadvertent IV infusion Rare side effects • Cardiotoxicity • Neurotoxicity • Abscess • Epidural hematoma • Caudal equina syndrome • Catheter migration • Sympathetic blockade • Allergic reaction • Local anesthetic toxicity

20. Local Anesthetic Toxicity Signs and symptoms Use of Test Dose • Ringing in ears • Numbness around the mouth • Metallic taste • Seizures, twitching • Coma, respiratory arrest • 3cc of 2% lidocaine with 1:200,000 of epi • In epidural space – no change in vital signs • In epidural vein – increase in BP, HR within 20-40 seconds.

21. Nursing Responsibilities • Monitor vital signs • Assess level of sedation • Monitor side effects • Emergency equipment • Know your institution’s protocols

22. 50% of patients report that their pain relief was inadequate. • Polomana, R (2008). Perspectives on pain management in the 21st century. Journal of Perianesthesia Nursing (23)1: 4-13.

23. Summary • Epidural analgesia safe and effective when monitored. • Patient receives stable, consistent pain relief. • Patient satisfaction increases. • Nurse responsible for providing safe, competent care for patients.

24. Thank you for your attention. Any questions?

25. References • Kingsley, C.(2001). Epidural analgesia: Your role. RN 64(4): 9 • Krenzischek, D. (2008). Pharmacotherapy for acute pain: Implications for practice. JOPAN 23(1): s28-42. • Pasero, C. (2003). Epidural analgesia for postoperative pain. AJN 103(10): 62-64 • Pasero, C. (2003). Epidural analgesia for postoperative pain, part 2. AJN 103(11): 43-45

26. References (cont.) • http://www.ncbon.org/content Activities within the scope of practice for the RN/LPN (accessed online March 1, 2008.) • Polomano, C. (2008). Assessment, physiological monitoring, and consequences of inadequately treated acute pain. JOPAN 23(1): s15-27. • Viscusi, E. (2007). Emerging treatment modalities: Balancing efficacy and safety. Am J Health-Syst Pharm. Vol 64, March 15, 2007 suppl 4 (accessed online March 1, 2008 via Cinahl).

27. Central Line Management • Peripheral short catheters • EJ • IJ • Swan introducer • Non-tunneled central catheters • Three port central lines • Can be placed subclavian, jugular, femoral • Includes SG catheter

28. Peripheral Short Catheter • Adults: • Removed every 72 hours • Removed upon suspected contamination, complication, therapy discontinued. • If inserted in emergency, where aseptic technique compromised: replace ASAP, no later than 48 hours. • Limited PV access: can leave >72 hours; need to document reason, assessment of catheter, site, type of therapy required.

29. Removal of short catheter • Remove dressing • Cut sutures if present • Digital pressure applied as catheter is removed • Digital pressure applied until hemostasis obtained. • Occlusive dressing applied to site • Any resistance? Do not use force, notify MD. • Document condition of site and catheter.

30. Non-tunneled catheter • Optimal time for removal is unknown. • Ongoing and frequent monitoring of site and catheter. • Need X-ray confirmation prior to initiation of therapy. • Absolutely no TNA or chemotherapy without X-ray.

31. Non-tunneled catheter, cont. • Sets changed every 96 hours unless designated more often (i.e., TNA) • Luer lock sets • Infusion pumps • Never connect tubing previously connected to another central line or peripheral IV site. Always use new tubing. • During insertion: Notify MD if CP, SOB, palpitaions, tingling down insertion side

32. Removal of non tunneled cath • Patient in supine position • Mask, non-sterile glove: remove old dressing • Open sterile supplies: vaseline gauze, 4x4s • Don sterile gloves • Clean site with 3 alcohol swabs • Remove sutures • Have patient perform valsalva and exhale • Cover site with gauze, hold pressure 3-5 minutes (10 minutes if femoral site • Tape dressing in place

33. Removal of non-tunneled cath • Digital pressure until hemostasis obtained. • Use antiseptic and occlusive dressing. • Document condition of catheter and site. • Dressing changed every 24 hours until site epitheliazed.

34. Air Embolism • Signs and symptoms: • Palpitations • Chest pain • Shortness of breath • Shoulder/low back pain • Cyanosis • Loss of consciousness • If not recognized: shock, cardiac arrest

35. Treatment • Place patient on left side in trendelenburg position to keep air bubble in right side • Vital signs, notify MD, oxygen

36. Brachial Plexus Injury • Indicated by: • Tingling or numbness in hand or arm • Pain shooting down arm • Sudden paralysis of arm • Treatment: • Removal of catheter

37. Pneumothorax • Indicated by: • Sudden chest pain, SOB, dyspnea, resp. difficulty • Cyanosis, subcu emphysema, tachycardia • Persistent cough, diaphoresis • Treatment: • Notify MD • Possible CXR, chest tube • Monitor vital signs, oxygen therapy

38. Other complications • Bleeding • Infection • Catheter fracture, kinks

39. Documentation • All nursing interventions with insertion • Fluid administration, flushes • Set and cap changes, dressing changes • Appearance of site • Blood draws from site • Removal of cath • Cultures, if done

40. References • Infusing Nursing: Standards of Practice • Developed by Infusion Nurses Society, 2006 • Norwood, Maine • www.ins1.org • IV Management and Removal of Temporary Central Venous Catheters • From MCH On-line Policy and Procedures