1st Day Epidural Presentation2-4
Transcript of 1st Day Epidural Presentation2-4
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Dr.Fatma AL Dammas
Epidural Analgesia
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OBJECTIVES
Identify the anatomy and physiology of
the spinal column in relation to the
placement of an epidural catheter.
Identify the nursing responsibilities in
caring for a patient receiving epiduralanalgesia.
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DEFINITIONS
EPIDURAL=administration of medication
into epidural space
INTRATHECAL=administration of
medication into suarac!noid space
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"#ER#IE$
"F THE
%PINAL ANAT"&'
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SPINAL CORD
Located and protected (it!in )erteralcolumn
E*tends from t!e foramen ma+num to
lo(er order ,st
L, -adult %/ -0ids %C taper to a firous and 1 conus
medullaris Ner)e root continue e2ond t!e conus1
cauda e3uina %urrounded 2 t!e menin+es4
-dura4arac!noid 5pia mater.
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VERTEBRAL COLUMN
#erteral columnProtects t!e spinal cord 5 consists of
67 cer)ical 6,/ t!oracic
68 lumar
68 caudal or sacral fused into
one 6918 cocc2+eal fused one one
cocc2*
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The ligaen!s
"#$supraspin%usligaen!
&'$In!erspin%us
ligaen!(a$ligaen!u
)la*u
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EPIDURAL SPACE
Potential space
:et(een t!e dura mater4lui+amentum
fla)um &ade up of )asculature4 ner)es4 fat and
l2mp!atic
E*tends from foramen ma+num to t!esacrococc2+eal li+ament
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INDICATIONS
T!e o;ecti)e of epidural anal+esia is
to relie)e pain.
&a;or sur+er2
Trauma -< ris
Palliati)e care -intractale pain
Laour and Deli)er2
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CONTRAINDICATIONS
Patient refusal no(n aller+2 to opioid or local
anest!etic Infection>ascess near t!e proposed
in;ection site %epsis
Coa+ulation disorder H2potension > !2po)olemia %pinal deformit2>increased ICP
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Pa!ien! assue a si!!ing %r side+l,ing
p%si!i%n -i!h !he 'a#. ar#hed !%-ard !he
ph,si#ian$/elp !% spread !he *er!e'raeapar!
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/eigh! %) sens%r,'l%#.
Lu'ar+T0
Th%ra#i#+T&
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Epidural Analgesia
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INSERTION OF EPIDURAL
CAT/ETER
Positionin+ of patient
T!e site is dependent upon t!e area of
pain
Fi*in+ t!e cat!eter Incision Le)el
T!oracic T91T?
Upper ado T?1T@
Lo(er ado T@1T,
Pel)ic T@1T,
Lo(er e*tremit2 L,1L9
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EPIDURAL CAT/ETERS
Ideal Placement -adult ,1,/ cm at t!e
s0in
Epidural cat!eters !a)e mar0in+s t!atindicate t!eir len+t!.
= t!ere is a mar0 at t!e tip of t!e cat!eter = t!e ,st sin+le mar0 up t!e cat!eter is 8cm
= doule mar0 up t!e cat!eter is , cm
= triple mar0 on t!e cat!eter is ,8 cm = four mar0 to+et!er indicate /cm
A c!an+e in dept! of t!e cat!eter indicates mi+ration
eit!er into or out of t!e epidural space.
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CAT/ETER MI1RATION
Cat!eter mi+ration into a lood )essel in t!e
epidural space or suarac!noid space
rapid onset L"C
Decrease loss of sensor2 or motor loss
-marcain
To*icit2
Profound !2potension
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DRU1S
"ne of t!e most important factors
influencin+ dru+ asorption andioa)ailailit2 is t!e dru+ %"LU:ILIT'
T!e more lipid solule rapid onset 5
s!orter duration
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MEDICATION COMMONL2 USED
"PI"ID%1Fentan2l B&orp!ine -affect t!e pain transmission at t!e
opioid receptors
L.A.1:upi)acaine-marcaine
-in!iits t!e pain impulse
transmission in t!e ner)es (it!
(!ic! it comes in contact
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MET/ODS OF ADMINISTRATION
:"LU% -FENTAN'L4 DURA&"RPH
C"NTINU"U% INFU%I"N-&ARCAINEBFENTAN'L
All dru+s administered epidural s!ould e
preser)ati)e free.
All epidural opioids s!ould e diluted (it! normalsaline prior to intermittent olus administration.
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EPIDURAL LOCAL
:upi)acaine -marcaine
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Me#hanis %) A#!i%n
:upi)acaine -marcaine 1 local anaest!etic (or0s as an
anal+esic -suanest!etic dose
1 in!iitin+ impulse transmission in t!e ner)e fiers
1 sensor2 ner)es are loc0ed first
efore t!e motor fiers1 sensor2 fiers carr2in+ t!e pain is
loc0ed efore t!ose carr2in+ !eat
cold touc! and pressure.
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EPIDURAL LOCAL
ANEST/ETIC3MARCAINE)
"nset ,1,8 minutes
Duration1 9 !rsB after a olus or after
infusion is stopped &arcaine-.?/81.,/81./8
E*tend of spread influenced 2 )olume
and position of patient
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OPIOIDS
&ec!anism of action1distriution
#ascular upta0e 2 lood )essels in t!e
epidural space
Diffusion t!rou+! dura into C%F to spinalcord to t!e site of action.
Upta0e 2 t!e fat in t!e epidural space.
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M%rphine 3Dura%rph4As!ra%rph5
H2drop!ilic-(ater solule
%lo( to diffuse across t!e dura on to t!e
spinal cord Can cause late respirator2 depression
&onitor respirator2 status for ,/ !rs after
t!e last dose of duramorp! Duration ? !rsB
:road spread
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Fen!an,l 3preser*a!i*e)ree5
Lipop!ilic-fat solule
Crossess t!e dura rapidl2
Rapid onset of action-se+mental Decreased ris0 of late respirator2
depression
"nset 81/ mins Duration /19!rs
E*cellent for rea0t!rou+! pain
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Ad*erse E))e#!s +Opi%ids
%edation and resp.depression1 I# narcan N>#1"pioids stimulate t!e c!emoreceptor tri++er one
primperan Pruritus1 dip!en!2dramine or narcan -lo( dose Urinar2 retention1 lo( dose narcan and >or
cat!eteriation %lo(in+ of I motilit2 H2potension
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Respira!%r, Depressi%n
&a2 occur
Earl2
Dela2edR>D is relati)el2 uncommon.
Ris0 factors
recent I# or I& narcotics
lar+e dose
recent CN% depressants -anest!etic 4etc
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ASSESSMENT OF T/E SEDATION
LEVEL
None Alert
, &ild Easil2 aroused
/ &oderate Difficult to arouse
or RR G, notif2AP% p+/7@
%e)ere Unresponsi)e or RR
G@. notif2 AP%/7@
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M%!%r and Sens%r, Assessen!
&otor assessment %ensor2 assessment
J Use ice in t!e tip of a +lo)e J %tart in upper nec0 and mo)e do(n
t!ora* ilaterall2 assessin+ all
potential dermatomes
J Le)el of loc0 is (!ere intensit2 of coldc!an+es or t!e cold sensation is asent
J assess t!e dermatomes elo( t!e pel)is
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Assessen! %) %!%r 'l%#.
:roma+e %core
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M%!%r and Sens%r, Assessen!
&otor assessment %ensor2 assessment
J Use ice in t!e tip of a +lo)e J %tart in upper nec0 and mo)e do(n
t!ora* ilaterall2 assessin+ all
potential dermatomes
J Le)el of loc0 is (!ere intensit2 of coldc!an+es or t!e cold sensation is asent
J assess t!e dermatomes elo( t!e pel)is
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Sens%r, assessen!
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Ad*erse E))e#!s L$A
H2potension1
1assess intra)ascular
)olume status
1no trendelener+
positionin+
Teac! patient to mo)e
slo(l2 from a l2in+
position to sittin+ to
standin+ position.
Treatment
fluids
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C%n!$ Temporar2 lo(er1
e*tremit2 motor orsensor2 deficits.
T* lo(er t!e rate or
concentration.
Urine retention
T* cat!eter
Local anest!eticto*icit2 -neuroto*icit2
T* stop infusion.
Resp. insufficienc2
T*stop infusion
1 A:C-, o/
call for !elp
1 Assess spread
and
!ei+!t of loc0
1 Alt.anal+esia
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OT/ER COMPLICATIONS
Headac!e -dural
puncture
T* s2mptomatic
treatmentAutolo+ous lood
patc!
Infection nausea and
)omitin+.
Intra)enous
placement of cat!eter
%udural placement ofcat!eter
Haematoma
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EPIDURAL
ANAL1ESIA31UIDELINES5
Collect items
Assess patient
Inspect site
$as! !ands
Aspiration test K lucose test
Administer
Document E)aluate t!e outcome
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POLICIES
1. Placement of epidural catheters is performed by theanesthetist in the Operating Room .
2. All patients must have a patent IV access for theduration of epidural therapy and for 12 hours after the
catheter is removed.
. !he Acute Pain "ervice #AP"$ % Anesthesiologist &ill
be responsible for ordering all epidural analgesia.
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'. (hen the nurse receives a patient &ith a continuous
epidural infusion) the R* must follo& every order onthe order sheet.
'.1. If there is any +uery about the orders) if any of
the orders are not filled in and%or if there is no dateand time and%or signature) contact the anesthetist
&ho &rote the order.
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6. Epidural Medications
,.1. *o medications) other than those offered by the AcutePain "ervice #AP"$) are to be administered into the epidural line
,.2. -o not use agents from a multiple dose vial. ost multi/dose vial medications contain preservatives) &hich can cause
intra/spinal neuroto0icity
,.. -o not use alcohol or alcohol based products near theepidural catheter. Alcohol is neuroto0ic and can damage thenerves.
,.'. Return any medications that are unclearly labeled) cloudyor contain particulate matter to pharmacy.
,.. Return any unused used syringes and cassettes topharmacy
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. 3ocal anesthetic must not be given as a bolus via the epiduralcatheter by the nurse.
4. !he AP" % anaesthetist must be notified if pain is not &ell
controlled by the epidural infusion.
5. *o other narcotic drug &ill be administered to the patient by anyother route unless ordered by the anesthetist % AP" .
16. All monitoring information and assessments must bedocumented on the 7ontinuous 8pidural Infusion 9lo&sheet
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11. Patient monitoring &ill be done as outlined for 12 hours afterthe discontinuation of the epidural infusion and after removal ofepidural catheter) &hether it is opioids or local anesthetic &hichhas been infused.
11.1.Assess pain scores) blood pressure) heart rate)sedation level) respiratory and sensory levels) and motorfunction every 1 mins 01h) every 1 hour 0 ' hours and thenevery ' hours until 12 hours after the infusion is discontinued.
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12. otor functions of patients receiving local
anesthetic via epidural catheter must be
assessed by an R*.
1. !o assess the height of sensory bloc:) use
the ice techni+ue.
1'. All epidural catheters must be identified &ith
the label ;8pidural 7atheter< at the accesshub) to prevent inappropriate use of the
catheter.
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1. -ressing changes are done only &hen necessary) by nurses
&ho have been trained in proper techni+ues of dressing change
in present of AP" .
1,. !he administration set #including the 6.22 micron filter$ &ill be
changed every 2 hours and the tubing labeled &ith the date
and time of change.
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Dressing Changes and Re%*al %) Epidural Ca!he!ers
8=>IP8*!%A!8RIA3"
Dressin+ C!an+e
"terile ' 0 ' gau?e 0 2 pac:ages
Povidone/lodine s&abs stic:s 0 pac:ages3arge !ransparent dressing 0 1
"terile gloves 0 2 pair
!ransparent tape
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Dressing Changes6
-ressings should not be changed unless it is absolutely
necessary) ho&ever) they may be changed if@
1. the dressing is &et due to oo?ing from the
puncture site
2. the dressing has become loose
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Dressing Changes6
PR"CEDURE
1. ather all e+uipment and supplies.
2. 80plain the procedure to the patient.
. Position patient on bed.
'. (ash hands.
Open the sterile gloves) transparent dressing
'0 ' gau?e pac:age.
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Dressing Changes6
. Put on sterile gloves. (ith a finger tip) apply
gentle pressure over the catheter insertion site
and slo&ly peel bac: the opsite dressing using
e0treme care.
,. Remove gloves and dispose soiled dressing and
gloves into garbage bin.
. (ash hands and put on second pair of sterile gloves.
4. "upporting the catheter &ith one hand) clean the
Insertion site &ith povidone/iodine s&abs) moving
from center to periphery of site. Allo& to dry.
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Epidural Ca!he!er Re%*al6
1. Removal of the epidural catheter must be ordered bythe AP" physician.
2. 3o& olecular (eight Beparin #3(B$@ 7atheterremoval should be delayed until 12 hours after a doseof 3(B. If 3(B is to be continued) it should not beresumed until at least ' hours after catheter removal.
. "tandard Beparin !herapy@ 7atheter removal shouldbe delayed until , hours after a dose of standardheparin. If standard heparin is to be continued) itshould not be resumed until 2 at least 2 hours aftercatheter removal.
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Removal of the epidural catheter
'. Beparin Infusion@ !he coagulation status of the
patient receiving heparin infusion should be
assessed. !he heparin infusion shall be stopped for ,
hours prior to catheter removal) and not resumed forat least 2 hours after the catheter is removed.
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PROCEDURE
1. !he AP" staff should be notified if the patient is
receiving anticoagulant.
2) ather all e+uipment and supplies.
. 80plain the procedure to the patient.
'. Position the patient side/lying or sitting &ith the bac:
e0posed and arched out.
Flexion of the back widens the vertebral space,
allowing for easy withdrawal of the catheter
. "top the epidural pump.
, ( h h d P t t il l
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,. (ash hands. Put on sterile gloves.
. ently remove tape and dressing.
4. inspect catheter site for redness) s&elling ordrainage.
If the area is reddened or if there is drainage, notify the
APS physician. Collect surface swabs and catheter tip
for cultures and sensitivity per APS physician! using
aseptic techni"ue.
5. 7lean the catheter insertion site) from centerout&ards)and allo& to air dry.
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16. Apply steady traction to remove catheter. -o not pullvigorously.
If resistance is #et, ask the patient to flex or arch hisback #ore. If resistance re#ains, stop and notify APS.
11. (hen catheter is removed) chec: that tip is intact. If
not) notify AP" immediately.
12. Apply band/aid to the site.
1. Instructions to patients should include@
A. report any pain at the insertion
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1'. aintain IV access for 12 hours after the last dose of opioid is given
1. -ocument epidural catheter removed in the
nursing record.
Include date, ti#e, condition of catheter, and site and
patient$s tolerance of the procedure.
1,. Obtain co signature of a second nurse to &itness
&aste of narcotic #if re+uired$
1. 7lean pump thoroughly and return to Recovery Room 3evel 2.
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1.easure the length of the epidural catheter from epidural spaceto the s:in.
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1.easure the length of the epidural catheter from epidural spaceto the s:in.
2.(hat &ill you do to chec: the 7"9 and Clood/ tinged fluid.
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1.easure the length of the epidural catheter from epidural spaceto the s:in.
2.(hat &ill you do to chec: the 7"9 and Clood/ tinged fluid.
.Bo& you perform a "8*"ORD level assessment using an ice
method.
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1.easure the length of the epidural catheter from epidural spaceto the s:in.
2.(hat &ill you do to chec: the 7"9 and Clood/ tinged fluid.
.Bo& you perform a "8*"ORD level assessment using an ice
method.'.Bo& you perform a O!OR level.
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1.easure the length of the epidural catheter from epidural space tothe s:in.
2.(hat &ill you do to chec: the 7"9 and Clood/ tinged fluid.
.Bo& you perform a "8*"ORD level assessment using an ice method.
'.Bo& you perform a O!OR level..(hat &ill you chec: for the site.
,.uidelines for removing epidural catheter for those patients &horeceives anticoagulant.
3O( O387>3AR (8IB! B8PARI*
"!A*-AR- B8PARI* !B8RAPDB8PARI* I*9>"IO*
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1.easure the length of the epidural catheter from epidural spaceto the s:in.
2.(hat &ill you do to chec: the 7"9 and Clood/ tinged fluid.
.Bo& you perform a "8*"ORD level assessment using an ice
method.'.Bo& you perform a O!OR level.
.(hat &ill you chec: for the site.
,.uidelines for removing epidural catheter for those patients &horeceives anticoagulant.
.Cased on your :no&ledge and understanding ho& you &ill do theepidural dressing after preparing all the needed materials.
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1.easure the length of the epidural catheter from epidural spaceto the s:in.
2.(hat &ill you do to chec: the 7"9 and Clood/ tinged fluid.
.Bo& you perform a "8*"ORD level assessment using an ice
method.'.Bo& you perform a O!OR level.
.(hat &ill you chec: for the site.
,.uidelines for removing epidural catheter for those patients &horeceives anticoagulant.
.Cased on your :no&ledge and understanding ho& you &ill do the
epidural dressing after preparing all the needed materials.4. Bo& you &ill remove the epidural catheter.
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REMMEMEBER
STAFF NURSE
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STAFF NURSE
RES!NS"#"$"T"ES
1. >pon receiving patient chec: for@
1.1. IV cannula
1.2. urinary catheter 1.. epidural catheter length #if visible$
1.'. if dressing is intact
1.. doctors order 1.,. ongoing epidural infusion bag
STAFF NURSE
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STAFF NURSE
RES!NS"#"$"T"ES
2. Assess and monitor as indicated on epiduralflo&sheet.
. *otify AP" or on call anaesthetist any unto&ard
complications) emergency ) side effects or inade+uaterelief related to therapy.
.1 pager 211 aps anaesthetist &ee:days 66 E1,66
.2 pager 245 aps nurse &ee:days 66 E 1,66
. pager '6 maternity on call anaesthetist 1,6 E 66 daily and &ee:ends
STAFF NURSE
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STAFF NURSE
RES!NS"#"$"T"ES
'. 7ertified nurse should connect the ne& bag.
. 7* are allo&ed to increase or decrease the infusion rate basedon the rate ordered or patients pain response from ongoinginfusion.
,. Infusions@ ,.1. if used @ discard &ith the presence of other &itness or
staff.
,.2. if not used@ Incident report and send bac: to pharmacy.
. Feep patent IV access and continue to monitor for 12 hoursafter removing the epidural catheter.
4. Inform AP" team or on call anesthetist if patients is onanticoagulant.
'oureMMM $!at did 2ou learn
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