Annual Anesthesia Education

1. Annual Anesthesia Education Principles in Obstetrical Anesthesia: 2014 “Pain relief during labor and delivery is an essential part of good obstetrical care.” Obstetrics 6th Ed.: Normal and Problem Pregnancies. 2012

2. Epidural Education…why? The Dept of Health states: The Registered Nurse must receive instructions in and demonstrate competence in the following: • Epidural Anatomy and Physiology • Indications and Contraindications to epidural anesthesia • Potential adverse reactions • Maintenance of the catheter and/or infusion device and related equipment. • Pharmacology and pharmacokinetics of commonly used analgesia medications • Nursing care responsibilities as defined and approved by institutional policy

3. What can we do as RN’s with Epidurals??? • The Washington State Dept. of Health DOH) has some requirements in place that, when all of these requirements are met, nurses can care for epidural infusion devices. General Requirements: • Written policy, procedures and nursing guidelines for patient monitoring, drug administration and management, which are immediately available for review and implementation.

4. General Requirements from DOH • The epidural catheter is placed by a licensed anesthesia provider who assumes responsibility for ensuring proper placement and monitors initial test dose of the medication. A licensed anesthesia provider must be available as define by institutional policy, to manage any complication which might arise when the RN is monitoring the epidural. • The RN assumes responsibility for pt. care only after the anesthesia provider who placed the catheter has verified correct placement, the patients’ vital signs are stable and analgesia level is established and stabilized. • Only RN’s with the appropriate education, knowledge, skills and supervised clinical practice are allowed to administer and manage medications for epidural anesthesia.

5. DOH (Non-PCEA) or Continuous Pump Infusion Rules: • Insertion, initial injection or re-injection of the continuous infusion of epidural catheters for anesthesia or analgesia for the obstetrical patient in labor may ONLY be performed by the anesthesia provider. • The obstetrical nurse may assist in maintaining the continuous epidural infusion by replacing empty infusion syringes or bags with pre-packaged solutions. The obstetrical nurse may stop the infusion as needed. The obstetrical nurse may remove the catheter upon direction of the anesthesia provider. • The obstetrical nurse may not adjust the rate of infusion of the continuous epidural infusion and may not administer a bolus of medication or adjust the pump to provide a bolus dose.

6. DOH PCEA (Parturient Controlled Epidural Analgesia) Infusion Rules: The obstetrical nurse may assist in monitoring of PCEA when the following safeguards are in place: • Written criteria for patient selection and patient education in the use of the PCEA pump. • Only a credentialed anesthesia provider performs the insertion and initial injection of the epidural catheter and will remain present until all VS are stable. • The anesthesia provider activates and programs the PCEA pump with proper dosing and lockout procedures. • The anesthesia provider attaches the epidural catheter to the PCEA pump. • The anesthesia provider is “readily available” to deal with the complications and institute proper interventions.

7. WHO wants an EPIDURAL??? Most women have thought about pain options during labor. Some choose more natural methods, while others choose to have medicinal intervention. Most women who desire to have an epidural will qualify to get one except for…

8. Contraindications: • Coagulation disorders • Local infection at the site of injection • Maternal hypotension and shock • Non-reassuring FHR pattern requiring immediate birth • Maternal inability to cooperate • Allergy to local anesthetics • Last dose of low molecular weight heparin within 12 hours

9. Definitions: • Obstetrical anesthesia encompasses all techniques used by anesthesiologists, nurse anethtists and obstetricians to alleviate the pain associated with labor and delivery: • GENERAL ANESTHESIA • NEURALAXIAL ANESTHESIA (spinal, epidural or combined spinal/epidural ) • LOCAL ANESTHESIA (paracervical, local infiltration, pudundal block • PARENTRAL ANESTHESIA

10. Pain Pathways: • Pain during the first stage of labor results from a combination of uterine contractions and cervical dilation. • Painful sensations travel from the uterus through visceral afferent (sympathetic) nerves and enter the spinal cord through the posterior segments of thoracic spinal nerves 10, 11 and 12. • During the second stage of labor, additional painful stimuli are added as the fetal head distends the pelvic floor, vagina and perineum.

11. Pain Pathways: • The sensory fibers of sacral nerves 2,3 and 4 (pudendal nerves) transmit painful impulses from the perineum to the spinal cord during the second stage and also during any repair.

12. PAIN-STRESS-PAIN!! • The process of labor involves significant pain and stress for most women. • The maternal and fetal stress response to the pain of labor has been difficult to assess! • But we do know…that maternal psychological stress can detrimentally affect uterine blood flow and fetal acid-base status.

13. Opioid Analgesia: • Opioids can be given intermittently by IM or IV routes. • All opioids provide sedation and a sense of euphoria, but their analgesic effect in labor is limited. • All opioids also cross the placenta, decreased beat to beat variability and can increase the likelihood of respiratory depression at birth. • Some common opioids to use in labor are: Demerol, Nubain, Stadol and Fentanyl

14. 2 kinds of EPIDURALS Defined: Standard Epidural: Involves the injection of a local anesthetic agent (e.g., lidocaine or bupivacaine) and an opioid analgesic agent (e.g., morphine or fentanyl) into the lumbar epidural space. • The injected agent gradually diffuses across the Dura into the subarachnoid space, where it acts primarily on the spinal nerve roots and to a lesser degree on the spinal cord and paravertebral nerves. Combined Spinal Epidural: Offers advantages of both the epidural and spinal techniques as it provides rapid onset pain relief and minimal blockade to the laboring woman.

15. Neuraxial Analgesia: Neuraxial analgesic and anesthetic techniques (spinal, epidural or a combination) use local anesthetics to provide sensory as well as various degrees of motor blockage over a specific region of the body.

16. Standard Epidural: • Definition: A neuraxial anesthetic to provide analgesia during labor, or surgical anesthesia for vaginal or cesarean delivery. • The technique uses a large bore needle to locate the epidural space. • Once the space is located (usually L2-L5), a catheter is inserted through the needle and the needle is removed over the catheter. • After aspirating the catheter, a test dose of local anesthetic with epinephrine is infused to be certain the catheter has not been unintentionally placed in the subarachnoid (spinal) space or in a blood vessel.

17. Standard Epidural: • Intravascular placement will lead to maternal tachycardia due to the epinephrine and rapid onset of sensory and motor block will occur if the local anesthetic is placed in the spinal fluid. • Once these complications have been ruled out, local anesthetic can be given via the catheter that remains in place throughout labor. This is called continuous epidural analgesia. • The patient should be able to move in bed and perceive the impact of the presenting part on the perineum.

18. Epidural Placement Video: • https://www.youtube.com/watch?v=rM1aQC-HAX0&feature=player_detailpage • Video Title: Epidural Spinal Anesthesia—Animation by Cal Shipley, M.D.

19. Combined Spinal Epidural (CSE): • A variant of the epidural technique involves passing a small gauge spinal needle through the epidural needle BEFORE the catheter placement. This combined spinal-epidural (CSE) technique provides more rapid onset of analgesia using a very small dose of opioid or local anesthetic and opioid combination.

21. Commonly Used Analgesia Medications:

22. Adverse Events: Common • Maternal Hypotension (see next slides for details on this very common side effect) • FHR changes (Late/prolonged decels, fetal bradycardia common with CSE). Decreased variability associated with low dose local anesthetic and opioid solutions) • Reduced success in breastfeeding initiation • Headache: May occur after accidental puncture of the Dura (a.k.a. ‘wet tap’). Blood patch will provide immediate relief to 65-90% of patients. • Maternal Fever (hyperthermia): Etiology remains unknown after infection is ruled out.

23. Hypotension: Very Common • Hypotension: Can occur as a result of the effects of local anesthetic agents on sympathetic fibers, which normally maintain blood vessel tone. Hypotension: Defined most often as a systemic blood pressure of less than 100 mm Hg or a 20% decrease from baseline. Occurs in about 10% of spinal or epidural blocks given during labor. Hypotension occurs primarily as a result of the effects of local anesthetic agents on sympathetic fibers, which normally maintain blood vessel tone. Vasodilation results in decreased venous return of blood to the right side of the heart

24. Hypotension Treatment: • Hypotension threatens the fetus by decreasing uterine blood flow. • However, when recognized promptly and treated effectively, few, if any untoward effects accrue to either mother or fetus. Treatment starts with: PROPHYLAXIS • IV access for volume expansion (500-1000 mL’s of a crystalloid IV infusion may blunt the hypotension) and administration of pressors. • LUD (Left Uterine Displacement) to maintain cardiac pre-load. • Administer O2 at 10 liters non-rebreather facemask • Treat per Anesthesia Order Set and Notify Anesthesia

25. Crystalloid Solutions:

26. Hypotension Treatment: If these simple measures do not suffice; then a vasopressor is indicated. The vasopressor of choice is: Phenylephrine in 50-100 mcg increments IV. Ephedrine can also be given in 5-10 mg increments IV. Recent clinical studies have suggested that phenylephrine may be given safely to treat hypotension during neuraxial anesthesia for cesarean delivery and the drug may lead to higher umbilical artery pH values in the fetus and less maternal nausea and vomiting.

27. Adverse Events: RARE • Local Anesthetic Toxicity: S/S—Excitation, bizarre behavior, ringing in the ears and disorientation. • Allergic Reaction • High or Total Spinal Anesthesia: inadvertent placement of the catheter and infusion into the intrathecal space can cause a high spinal block resulting in immediate upper thoracic sensory loss and severe lower extremity motor blockade. The anesthetic agent may ascent intrathecally to the brain stem leading to respiratory paralysis, total autonomic blockage and loss of consciousness • Meningitis (extremely rare)

28. Adverse Events: Rare cont; • Neurologic Injury • Accidental Intravenous Injection: injection of epinephrine and a local anesthetic agent into the epidural vein may lead to systemic toxicity causing almost immediate increased maternal heart rate, palpitations, increased blood pressure, numbness of the tongue or around the mouth, metallic taste, tinnitus, slurred speech, jitteriness or agitation, which may culminate in seizures and cardiac arrest. • Bleeding that can lead to a very rare spinal or epidural hematoma

29. WHAT DO WE DO??? • The nurse must always be prepared by having emergency equipment immediately available, recognize these complications and anticipate the need for cardiopulmonary support. • Know how to get help and the correct procedure for getting emergency help.

31. Post-Epidural Nursing Care: • Maternal Assessments: • VS q 5 mins for at least 15 mins. More or less may be decided by the anesthesia provider. • Level of anesthesia • Pain • Place catheter if unable to void • Asses labor and adequacy of uterine contractions • Fetal Assessments • Continuous while initiation or rebolus then q 5 mins for at least 15 mins. More or less may be decided by the anesthesia or obstetric provider.

32. Pullman Regional Hospital BirthPlace Policy and Order Sets Add links to: • ‘Epidural and Intrathecal Analgesia for Labor and Delivery’. Policy in Anesthesia Policy and Procedures. • Standard Physician Orders: Obstetric Epidural Anesthesia • Standard Physician’s Orders: Obstetric Intrathecal Anesthesia

33. THANK-YOU!! Enjoy this video  https://www.youtube.com/watch?feature=player_detailpage&v=qtR_-MINR1o “How Men React to Labor Pain” on You Tube