SELF – LEARNING MODULE ADDED NURSING COMPETENCY FOR MONITORING AND CARE OF THE PATIENT RECEIVING NEURAXIAL ANALGESI

1. SELF – LEARNING MODULEADDED NURSING COMPETENCYFOR MONITORING AND CARE OF THE PATIENT RECEIVING NEURAXIAL ANALGESIA Originally developed by Susan Warman, BN., Helen Gourlay,BN/MN. ,and Janet Walker, BN. January 1997 Revised Dec 2005 by Nancy Schuttenbeld -Acute Pain Nurse for RVH, Reviewed by Dr. Rick Chisholm, Anesthesiology, Marie Chase- Learning Services.

2. POLICY • Registered Nurses (RN’s) are required to be certified in the • monitoring and Care of the Patient receiving Neuraxial Analgesia. STANDARDS • The RN will: • Complete the Self – Learning Module on Monitoring and Care of the Patient receiving Neuraxial Analgesia. • Attend the in service on Neuraxial Analgesia and complete a written exam with a passing mark of 85%. • Demonstrate application of knowledge in the care of the patient receiving neuraxial analgesia.

3. PURPOSE • Patients have a right to the best pain relief possible. The Acute Pain Service (APS) at River Valley Health (RVH) involves a team of anesthesiologists and an acute pain service nurse who implement and maintain acute pain management for surgical and non-surgical patients. • Neuraxial analgesia (subarachnoid bolus or epidural opioid / local anesthetic) is used in the management of acute post- operative and post- traumatic pain. Post–intraspinal opioids serve as an effective way to manage and control acute pain by providing: • A controlled method of pain relief. • 2. Safe delivery of intraspinal medications to patients.

4. Post – Intraspinal Opioids • Category:Added Nursing Competency • Policy: • The patient will be cared for on a nursing unit that can meet the total needs of the patient most appropriately ie. medical status, hemodynamic monitoring and nursing care requirements. • Patients receiving intraspinal opioids will be cared for by RN’s certified in the added nursing competency on the general med/surg units, PACU, obstetrical service and ICU. • Patients receiving epidural analgesia with anaesthesia (ie. Marcaine) whether intermittently or by continuous infusion will be cared for by certified RNs in ICU, PACU or Labor and Delivery. • Administration of bolus medication via the epidural catheter is a medical responsibility. RN’s may prepare, hang and initiate medication for continuous epidural infusion. (See Nursing Policy & Procedure re: Perth Hospital). • Removal of the epidural catheter is a medical responsibility but may be removed by the acute pain nurse at the DECRH and RN’s in Perth who are certified for this function (with a physician’s order). • Pain management of the patient while receiving intraspinal analgesia is the responsibility of the Acute Pain Service (APS) of the Department of Anesthesia in collaboration with the attending physician, RN’s and other appropriate health team members. The patient will be assessed daily by an anesthesiologist. • An anesthesiologist is responsible for ensuring that repeat bolus doses are administered. (See updated nursing policy & procedure re: Perth hospital). • A pain flow sheet will be used for patients on the APS at the DECRH.

5. Standards • In collaboration with other appropriate health team members: the anesthesiologist will determine if the patient is a suitable candidate for intraspinal opioids. • The Department of Anesthesia at the DECRH will keep a registry in the OR for patients receiving intraspinal opioids including patient unit, date and time of initial administration, frequency and time of top-ups and date of removal of epidural catheter. • Patient transfers to an alternate unit will be reported to the Department of Anesthesia immediately. • Certified RN’s caring for the patient will follow the established protocol for patients monitoring and guidelines for response to complications or emergency situations. • Emergency equipment must be immediately available and functioning. This includes O2 and suction, pulse oximetry, ambu bag and mask, and Naloxone. • Documentation will reflect date, time, medication, dosage, route of administration and patient response. • Data Source • Neuraxial Analgesia/ Post- Intraspinal Opioid Physician Orders 06.6000-64-(05/06)D • Anesthesia Record (7500-39) • Patient Notes • Original date: March 1993 • Revised: January 1997, April 2003, August 2005

6. Learning Objectives • Following completion of the self-learning module, the RN will: • Understand the physiology of pain transmission • Understand the anatomy of the subarachnoid and epidural space and the actions of local anesthetics at this level • State the indication for epidural opioid analgesia and subarachnoid opioid analgesia. • Identify the common opioids used for epidural analgesia. • Identify potential complications of neuraxial analgesia and state actions to be taken if side effects / complications occur. • Identify the nursing care for a patient receiving medications via bolus and continuous epidural infusion or subarachnoid bolus. • Identify indications for the use, dosage and implications for Naloxone. • Complete the test and Performance Criteria checklist of skills for care and monitoring of a patient receiving neuraxial analgesia.

7. POST - INTRASPINAL OPIOID PROTOCOL • 1. In ICU, PACU and L&D • –monitor vital signs as per unit routine • –discharge as per unit discharge criteria • On General Units • -After initial bolus, monitor V/S as per post operative routine and respiratory rate • and sedation score q 2 hours X 24 hours than q 4 hrs or more frequently if patient • condition warrants. • -For continuous infusion, monitor vital signs q 4 hours. • -Following administration of subsequent bolus doses, respiratory rate and sedation • score q 1 h X 12 hrs. • Inspect catheter site every shift and document. Notify acute pain nurse or anesthesiologist • if catheter insertion site shows signs of leakage, infection or bleeding. Reinforce site. • If respiratory rate <8/min and/or sedation score is ≥3, implement the following: • Rouse patient and encourage to breathe • Start pulse oximetry and check pulse and BP • Administer O2 by mask at 5L/min • Notify Acute Pain Service or anesthesiologist on call • If unresponsive, Rx Naloxone 0.1mg IV, repeat q 3 min prn until patient • responsive and respiratory rate 8 or greater. • No supplemental opioids or sedatives unless approved by the anesthesiologist. • Notify anesthesiologist before patient is started on Warfarin, LMWH, or a Heparin infusion. • 7. Maintain IV access for 12 hours after last intraspinal bolus or discontinuing infusion. • 8. Assess motor function regularly. • 9. Activity and diet in accordance with attending physician’s orders. • 10. Side effects: • Nausea /vomiting- Rx as ordered by anesthesiologist • Pruritus- Rx as ordered by anesthesiologist • Urinary retention- catheterize once in/out: if repeat needed- use foley • catheter. Ortho patients follow ortho standing orders • 11. For breakthrough pain (score 4 or more) – Rx as ordered by anesthesiologist. • Report off unit transfers to the Anesthesia Department so that the registry can be • kept current.

8. Sedation Score • S -Normal sleep – easily roused • 0 -Alert - awake • 1 - Drowsy – occasionally drowsy, easily roused • 2 - Drowsy – repeatedly drowsy, easily roused • 3 -Very drowsy – difficult to rouse • 4 -Unresponsive • *Pain Score • 0-No pain • 2 -Mild pain – moves easily • 4 -Discomforting – moves with difficulty • 6 -Distressing – unable to move • 8 -Horrible • 10 -Worst imaginable (excruciating) • In RVH, use the 0 – 10 numeric rating scale for pain intensity assessment whenever possible. In cases where an alternate scale is used, it is imperative that the patient’s record indicate which scale is being used.

9. Theory • Neuraxial is defined as pertaining to the cerebrospinal axis. Epidural opioid /local anesthetic administration and subarachnoid opioid administration are two alternative postoperative pain control techniques. Together they are referred to as neuraxial opioid analgesia. • The spinal cord is covered by three meninges (membranes). • Diagram: Spinal Anatomy –as appears in McCaffery M., Pasero,C.Pain: Clinical Manual (2nd Ed.) 1999. Mosby, Inc., p.216. • Pia Mater –Innermost layer that adheres to the surface of the spinal cord and brain. It contains many blood vessels to supply the spinal cord. • Arachnoid Mater – Middle transparent layer. It is separated from the pia mater by the CSF filled subarachnoid space. • Dura Mater – The strong, tough outer layer that consists of dense, fibrous connective tissue. • Epidural Space – The potential space that lies between the dura mater and the vertebral canal and extends from the cranium to the sacrum. This space contains blood vessels, fat and connective tissue. • Subarachnoid Space – is located between the arachnoid and the pia mater. This area contains cerebrospinal fluid (CSF). It is also called the spinal or intrathecal space. In general, it only requires 1/10 of the dose of medication used in the epidural space.

10. Pain TransmissionUnderstanding of the transmission of pain is essential to the management of pain. There are three main types of pain: Acute pain, cancer pain and chronic nonmalignant pain. Pain is also classified by pathophysiology as nociceptive pain (stimuli from somatic and visceral structures) and neuropathic pain (stimuli abnormally processed by the nervous system).Nociceptive pain is normal processing of stimuli that damages normal tissue or has the potential to do so, if prolonged. This pain is usually responsive to nonopioids and or opioids. Acute pain is mainly nociceptive and is classified as either somatic (referring to pain of the musculoskeletal system) or visceral pain (referring to pain arising from the body’s internal organs).Nociception is the term used to describe how pain becomes conscious. Four basic processes are involved: Transduction = The sensation of pain by cell damage or injury.Transmission = Occurs in the dorsal horn of the spinal cord (substance P is released here).Perception= This is how we interpret the pain (a conscious experience).Modulation= Refers to changing or inhibiting pain impulses. (response to pain) Substance “P” foun4. Modulation3. Perception2. Transmission1. Transductiond in the dorsal horn.Narcotics such as morphine are thought to bind to opiate receptors in the dorsal horn. This blocks substance P and as a result blocks the transmission of pain.When opiates are delivered into the epidural space the drug moves slowly across the meninges, through the CSF and finally to the opiate receptors in the dorsal horn – the pain relief results from the drug levels in the spinal cord.Delivering the narcotic to the opiate receptors in the spinal cord assists in decreasing the side effects that occur when using other routes of parenteral narcotics. The duration of action is longer as the narcotic must diffuse out of the CSF to the bloodstream and then be eliminated as usual by the liver and kidneys. Monitoring for LATE side effects should continue up to 12 hours post injection. Most of the late side effects you will see are thought to be due to spread through the CSF to the brain (rostral spread).Venous, CSF and epidural spaces lie within close proximity. If a bolus dose of a medication is inadvertently injected intravenously or intrathecally (CSF) the effects of the narcotic will be more profound.

11. “Spinals” or Subarachnoid Opioid Analgesia • Subarachnoid opioid analgesia is also referred to as “intrathecal” or “spinal”. Intrathecal is defined as within the spinal canal. With subarachnoid analgesia, the opioid is administered directly into the subarachnoid (intrathecal) space. This space is inside the dura/arachnoid and contains the cerebral spinal fluid (CSF). The intrathecal space, containing the CSF that bathes the spinal cord, runs parallel to the epidural space. The dura and arachnoid mater separate the intrathecal and epidural spaces. Subarachnoid opioid analgesia is usually a single administration into the subarachnoid space. Doses for subarachnoid analgesia are much smaller doses than epidural doses, often 1/10 the dose. The risk of infection is a potential complication and therefore catheters are rarely left in place. A subarachnoid bolus may provide analgesia for 6 – 24 hours.

12. Epidural local anesthetics and local anesthetic/opioid admixtures • Local anesthetics administered via the epidural route, block pain signals in the dorsal nerve root before they enter the spinal cord. Sympathetic impulses are also affected resulting in vasodilatation and potentially hypotension. Local anesthetics can potentially block motor nerves as well, resulting in motor weakness. • The body can be mapped according to the sensory and motor innervation derived from the spinal nerve roots. An area whose sensation is supplied by a particular spinal nerve root is called a dermatome. The motor function supplied by a spinal nerve root is called a myotome. Epidural local anaesthetics can result in segmental blocks involving several dermatomes and if potent enough, myotomes as well. Lumbar epidural local anesthetics, because they involve lumbar segments, may cause extremity weakness in addition to sensory loss if the block is dense enough. By using a low concentration of local anaesthetic, sensory pathways may be blocked leaving motor pathways relatively intact. The goal is to provide analgesia WITHOUT motor block to ensure patient safety. Any patient receiving local anaesthetic in the epidural infusion must be cared for in the ICU, PACU or L&D. Motor function and sensory level assessments are completed as per unit routine. • It is imperative to mention that if a patient develops sensory or motor loss following the initiation of an epidural opioid infusion where NO local anaesthetic is used, immediate medical attention is required. See epidural hematoma section, page 11). Notify the APS/anesthesiologist on call stat.

13. Epidural Analgesia • Epidural analgesia refers to insertion or placing a catheter between the dura mater and the vertebral arch. This potential space contains fat, blood vessels and nerves. The opioids diffuse across the dura and subarachnoid space and bind with the receptors in the substantiagelatinosa in the spinal cord. Because the opioid does not cross the blood brain barrier, pain relief results from drug levels in the spinal cord rather than in the plasma, with little central or systemic distribution of the drug. Pain is relieved with smaller doses and therefore less severe side effects, since the drug crosses slowly through the dura mater and is absorbed directly into the CSF and spinal cord and eventually to the opiate receptors in the dorsal horn. • Opioids for Epidural Analgesia • Morphine is a water – soluble (hydrophilic) opioid frequently used for epidural injection. The epidural version of morphine is preservative free. Absence of preservative is vital to avoid irritation or damage to neural structures. Morphine is one of the least lipid soluble of the opiate analgesics and therefore has a slow rate of uptake in the spinal cord and tends to linger longer in the CSF. This means a delayed onset of approximately 30 –60 minutes and prolonged duration of action 12-24 hours. • Fentanyl has a high lipid solubility, which allows it to reach the CSF quite quickly which leads to rapid onset of narcotic effect. • Dilaudid is often used for continuous infusion because of its greater concentration.

14. Epidural Infusions: • DRUG • ONSET • DURATION • Morphine • 30-60 minutes • *Up to 24 hrs • Fentanyl • 10-15 minutes • *4-5 hrs • Dilaudid • 10-20 minutes • *6-17 hrs