epidural infusion analgesia for adults fileepidural infusion analgesia for adults version 3 page...

EPIDURAL INFUSION ANALGESIA FOR ADULTS

Version 3

Page Number

of 17

Date Authorised

January 2015


REF NO: PMD 01/15 v3

KEY WORDS (To assist in searching for the Guideline on the Intranet – suggested minimum 10 words )

Epidural Infusion Post-op pain management, adult pain management, central neuraxial block, local anaesthetic

AUTHOR AUTHOR’S LINE MANAGER RATIFIED BY

Name: Karen Williams Name: Gill Nixon Name:

P MacDowall

Title: Acute pain specialist nurse

Title: Lead Clinical Specialist Nurse for Acute Pain Management.

Title: Chair Evidence Based Guidelines Group

INITIATING DIRECTORATE DATE RATIFIED Anaesthetics

January 2015

TARGET AUDIENCE REVIEW DATE Critical care units, general theatres, gynaecology theatres, wards 10, 11, 15, gynaecology ward.

January 2018

CLINICAL GUIDELINE

The governing principles outlined within this document are fully supported in every respect by the Clinical Governance Sub-Committee.

All members of staff are required to adhere to the principles involved as outlined within this document, together with any related procedures, which are enabled by this guideline.

This guideline was produced in consultation with: Dr Shiva Tripathi (Lead consultant for acute pain management)

Sr. Louise Gracie (Ward manager, surgical directorate)

Dr Anna Bewlay (Consultant anaesthetist) Sr. Kate Sutherland (Acute pain specialist nurse) Sr. Linda Martin (Acute pain specialist nurse) Nital Panchal (Pharmacist)

Sr. Ruth Palliser (Acute pain specialist nurse) Dr Sangeeta Sharma (Consultant anaesthetist)

GROUP OR COMMITTEE APPROVED BY: (This will involve local or specialist group review / scrutiny using a body of expertise and knowledge who have confirmed that the document is fit for purpose. Where no such relevant body exists for the approval of a document approval may be obtained from those individuals or groups involved in the consultation process).

DEFINITION OF CLINICAL GUIDELINES Clinical Guidelines are evidence based systematic statements to assist practitioners and patients in making decisions about appropriate health care for specific clinical circumstances.

Lancashire Teaching Hospitals

NHS Foundation Trust


Version 3

Page Number

of 17

Date Authorised

January 2015

1. Full Guideline Title

All adult patients requiring epidural infusion for analgesia

2. Adaptation

Updated LTHTR guideline May 2012 EBG12/11 VI

3. Guideline Aim

Epidural analgesia will be delivered in a safe and effective manner in the ward environment

4. Disease/condition/target population

Anaesthetists Patients Nursing Staff

5. Body of Guideline

EPIDURAL DEFINITION: The administration of a weak solution of local anaesthetic and / or opioid into the epidural space to provide segmental (dermatomal) pain relief, ideally without the loss of other sensations or movements. This may be administered as a bolus injection or by continuous infusion. Anaesthetists will see elective patients prior to surgery, either in pre op assessment clinic or on the day of surgery. An explanation of the technique including possible side effects and other analgesic options available should be explained to patient. Verbal consent will be obtained. Ward staff must be deemed competent in caring for patients receiving epidurals by the ward manager. The manager holds responsibility for arranging training for their staff in the use of epidurals. Ward staff must attend an epidural training session on induction to the ward, complete their epidural competency and receive annual updates on epidurals. Patients with epidurals should only be sent to a ward where the staff are familiar and competent with the management of epidurals. Staff should be familiar with the acute pain guidelines and hospital resuscitation policies. Each clinical area that uses epidural pumps will possess their own epidural key, which will be kept with the controlled drug (CD) keys on each ward. Acute pain nurses bleep no 2436. Out of hours bleep on call anaesthetist 3333 (RPH site), Chorley site bleep pain nurse 4701 or anaesthetist on call for critical care (bleep 4445).

6. Clinical Algorithms

INDICATIONS FOR USE: postoperative pain after thoracic, lower limb, vascular, major abdominal or pelvic surgery, chest trauma, pre amputation, palliative care and obstetrics (See Obstetric Epidural Analgesia for Labour Guideline, 2014). BENEFITS: gold standard analgesia due to fewer side effects than parenteral opioids. The main benefits are:-

Less sedating

Less nausea and vomiting

Improvement of postoperative pulmonary function

Increased blood flow to lower extremities

Improves wound healing

Enhances gastric motility

Reduces post operative risk of myocardial infarction

Reduces stress response to surgery


Version 3

Page Number

of 17

Date Authorised

January 2015

CONTRAINDICATIONS: Absolute – patient refusal, coagulopathy, treatment with anticoagulation (see below), related allergy, thrombocytopenia ( platelet count < 100x109/l although consideration may be given to an epidural dependent upon risk with a platelet count of 75 – 100 x 109/), uncorrected hypovolaemia, raised intracranial pressure, sepsis, insufficient numbers of trained staff who have completed their epidural competency, lack of suitable conditions for insertion. Relative – patients receiving non-steroidal anti-inflammatory drug (NSAIDS) or aspirin, immunocompromised patients, dural tap, back pain or previous trauma, mechanical difficulties in inserting catheter, some neurological conditions. With regards to contraindications the anaesthetist will make the decision based on risk to the patient. Risk is a continuum that runs from ‘normal risk’ to ‘very high risk’. There should always be consideration of an individual patient’s circumstances. There may be circumstances in which, although the use of a regional technique for a patient is a risk the alternative for this patient may expose them to even greater risk. Experienced clinicians should be involved in decisions about whether or not to perform a regional anaesthetic technique on a patient with abnormal coagulation and the patient with capacity should be given all the information he/she needs to make an informed choice. Advice should then be sought from the consultant anaesthetist on call. ANTICOAGULATION: The epidural must be sited at least 12 hours after a prophylactic dose of low molecular weight heparin (LMWH) Removal of epidural – should be at least 12 hrs after last dose of LMWH Next dose of LMWH should be given at least 4 hrs after removal of epidural For patients receiving Rivaroxaban (Total hip and knee replacements) and other factor Xa inhibitors ( see appendix 3) INSERTION: All epidurals will be inserted using strict aseptic technique in line with the hospital aseptic non touch technique – ANTT procedure (LTHTR, 2013) including hand washing, the use of sterile gloves, sterile gown, hat, mask, appropriate skin preparation and sterile drapes around the injection site. Chlorhexidine 0.5% with 70% isopropyl alcohol is used for skin preparation. (The Association of Anaesthetists of Great

Britain and Ireland (AAGBI). Lidocaine 1% is used for the skin and subcutaneous tissues prior to insertion of the epidural to ensure comfort. 16G or 18G epidural sets are available as are longer needles for obese patients. Once sited the epidural is taped in place with adhesive dressings (for example a dedicated “lock-it” dressing covered by a transparent adhesive dressing such as C-view and then a window of mefix).

Epidural local anaesthetic used is bupivacaine 0.125% with or without fentanyl 2mcg/4mcg per ml. The following are guides only and can be used to determine rate - lumbar catheter 0-15ml, thoracic catheter 0 -10 ml/hr.


Version 3

Page Number

of 17

Date Authorised

January 2015

All patients with an epidural must have a urinary catheter inserted. PROGRAMMING THE PUMP AND PRESCRIPTION OF EPIDURAL: The pump must be programmed by the anaesthetist in theatre. Only a designated pump for epidurals must be used in combination with a dedicated epidural giving set. This is specifically designed with a yellow line by the manufacturers and follows national guidance. The anaesthetist must prescribe the infusion on the prescription chart. Ward staff will renew bags as required in line with the hospital aseptic non touch technique – ANTT procedure (LTHTR, 2013). When changing bupivacaine and fentanyl bags nurses should follow ‘LTHTR, Medicines management policy 2013. Bags containing bupivacaine only should also be checked by 2 nurses with the prescription chart. Plain bupivacaine bags must be stored in a location that is away from the storage of intravenous fluids. Bags containing fentanyl should be stored in the CD cupboard.

Epidural prescription adhesive labels are available in theatres and should be used where possible. (available from pharmacy). BEFORE DISCHARGE FROM RECOVERY THE FOLLOWING CRITERIA MUST BE MET:

At least 20 mins since last bolus

Pain score 0-1 on movement

Bromage score of 1 (see appendix 1 )

Systolic blood pressure (BP) >80mm Hg (this is obviously dependent on many factors, take advice from anaesthetist)

Heart rate < 100

Respiratory rate >8

Sedation score 0-1

Urine output 0.3ml/kg/hr (see any parameters set by anaesthetist)

Oxygen saturations > 94% with oxygen ( if required) At least one set of observations must be charted on the epidural daily management record chart prior to discharge.

WARD STAFF TO CHECK THE FOLLOWING WHEN RECEIVING PATIENT BACK FROM THEATRE: Blood or fluid loss, fluid replacement, epidural rate, any boluses given, other analgesia in recovery, height of block (should not be above T4 – nipple level). Observations must be charted on the vital signs observation chart with relevant observations on the epidural daily management record.

OBSERVATIONS ON RETURN TO THE WARD FROM THEATRE RECOVERY: Observations should be documented on the vital signs observation chart hourly for 12 hours, then 4 hourly. Increase frequency of observations if there is a clinical need. Heart rate, BP, respiratory rate, oxygen saturation and percentage of oxygen, pain score, sedation score, nausea score, NEWS, total volume infused from pump, pump infusion rate ml/hr, record patient temperature 4 hourly. Monitor urine output hourly for the duration of the epidural. If epidural is discontinued immediately post-surgery, hourly observations need to be continued for 6 hours then revert back to 4 hourly observations if clinically stable.

NB inform pain team if patient complains of headache whilst epidural in situ. If out of hours inform 2nd on - call anaesthetist bleep 3333. (At CDH call anaesthetist on call for critical care bleep 4445).


Version 3

Page Number

of 17

Date Authorised

January 2015

Epidural Daily Management Record (appendix 4): NB. Vital sign observations – HR, RR, BP, saturations etc are made as usual on the vital signs

observation chart.

On the EPIDURAL DAILY MANAGEMENT RECORD chart 4 hourly:

• Height of block: - Numbness of epidural must not go above nipple level. Test the block with steret on left and right sides. (see appendix 2). If the block height is higher than nipple level follow actions recommended on the chart

Leg strength (Bromage score ): - Purpose of assessing leg strength is to ensure that any numbness or motor block is temporarily caused by the epidural infusion and not caused by underlying pathology of epidural abscess, haematoma or nerve damage. The leg strength needs to be grade 1 or less.

Record this 4 hourly on chart.

Check and record pressure areas.

Check site and dressing dry and intact

Check epidural line intact.

Ensure that each recording is initialled at end.

Document removal of catheter and leg strength 2 hours after removal and give the patient an

epidural leaflet. BOLUS DOSES: If an anaesthetist or acute pain nurse administers a bolus, observations of BP, RR, sedation

score/pain score are required as follows: Every 5 mins for 15 mins Every 15 minutes for next hour, then as condition allows back to routine observations.

ADJUSTING THE INFUSION RATE: If pain is well controlled after major surgery, Bromage score is 1 (i.e. patient has free movement of legs and feet) and height of the epidural block is not above nipple level then the rate does not need to be adjusted. However, for inadequate analgesia, increase the rate by 2ml at a time up to the maximum prescribed rate. For example:

Patient has epidural prescribed at 0-10ml/hr.

The rate is 6mls/hr and the patient’s pain score is 2-3.

Increase the epidural by 2ml to 8ml /hr.

Review patient at 20 minutes and again at 40 minutes.

Ensure paracetamol and a non-steroidal anti-inflammatory is given (NSAID) if this is appropriate for patient

Patient may also require a bolus of epidural (from pain nurses or anaesthetist)

If pain score cannot be maintained at less than 2 seek advice from pain team or on call anaesthetist

TROUBLE SHOOTING THE EPIDURAL:

PAIN AT UPPER END OF WOUND

Consider increasing rate as above

Ensure paracetamol given 1g qds IV/O/PR (4-6hrly)

Consider NSAID if no contraindications

If above fails then need to ask pain team /anaesthetist to bolus epidural


Version 3

Page Number

of 17

Date Authorised

January 2015

PAIN AT LOWER END OF WOUND

Consider sitting patient upright if BP allows

Increase rate (be aware of motor block)

Ensure paracetamol given. Consider NSAID if no contraindications

May need to ask pain team/anaesthetist to bolus UNILATERAL BLOCK

Consider tilting patient onto painful side to promote distribution of local anaesthetic solution

Ensure paracetamol given

Consider NSAID if no contraindications

Change for plain bupivacaine epidural and PCA

If the patient is in critical care, refer to intensivist to consider withdrawing catheter by 1 cm or resiting if within 24 hours of surgery.

RESPIRATORY DEPRESSION:

Possible causes:

Opioid in CSF reaching the brainstem (always associated with sedation)

Local anaesthetic block can rise and therefore affect respiratory muscles

Assess patient by Airway, Breathing, Circulation, Disability, Exposure (ABCDE) process SEDATION:

Possible causes:

Opioid in CSF reaching brainstem

Opioid absorbed into blood stream

Assess patient by Airway, Breathing, Circulation, Disability, Exposure (ABCDE) process IF RESPIRATORY RATE < 8 AND/OR SEDATION SCORE 2: Stop infusion and seek urgent advice from nurse in charge/medical team/acute pain team/ on call anaesthetist

Give oxygen at 15 litres via a non-rebreathe mask (as per oxygen policy)

Commence pulse oximetry.

Ensure naloxone available – 0.4mg(1ml) and 3ml of normal saline in syringe – give 0.1mg (1ml) increments until respiratory rate >12/min and sedation score less than 2

Check sedation score and BP

Respiratory depression and sedation are not usually caused by the epidural, other causes should be considered. Assess patient by Airway, Breathing, Circulation, Disability, Exposure (ABCDE) process

BRADYCARDIA:

This can be caused if the level of local anaesthetic travels above the level of nipple level and it can affect the sympathetic nerve supply to the heart which produces a bradycardia and may cause hypotension. If patient is bradycardic and sensory level of block is at or above nipple level:

Sit patient up

Reduce rate of epidural by 50%

Inform surgical team and request a review of patient


Version 3

Page Number

of 17

Date Authorised

January 2015

Assess patient by Airway, Breathing, Circulation, Disability, Exposure (ABCDE) process

HYPOTENSION:

If systolic blood pressure is below 80mmHg contact the surgical team and request a review of the patient. There may be several causes and the patient needs to be assessed surgically. Do not draw the conclusion that the epidural is the cause. Action

Give oxygen 15 litres/min via non rebreathe mask

If systolic blood pressure < 80mmHg lie patient flat with legs elevated on pillows

Do not tilt bed head down as this may cause epidural block to rise and affect respiratory muscles

Infuse 250-500mls sodium chloride 0.9% stat and reassess. Consider further 250-500mls sodium chloride 0.9%. This may need to be reduced in elderly patients and those with cardiac problems. Seek advice from surgical team.

Check blood pressure, urine output and fluid balance

Consider potential surgical complications. Inform surgical team/acute pain team

If the patient does not respond to a fluid challenge and leg elevation, ensure ephedrine is available - 30mg diluted to 10ml and give 1ml by slow intravenous injection every minute until BP restored.

If urine output is less than 0.3-1ml/kg/hr for 2 hours inform senior nurse or surgical team

For the duration of an epidural an intravenous infusion should be maintained

In most cases hypotension will be corrected by fluid replacement. If medical staff make the decision to stop epidural and replace with PCA please ensure that they first seek advice from either the pain team or 2nd on anaesthetist on bleep 3333. It is more beneficial to change the epidural to plain (if there is still some residual function with it) and reduce the rate rather than abandon it completely

Assess patient by Airway, Breathing, Circulation, Disability, Exposure (ABCDE) process

MOTOR BLOCK: Possible causes:

Migration of catheter into subarachnoid space causing a larger volume of analgesia to enter the CSF

Epidural abscess

Epidural haematoma Slight motor weakness of the legs or trunk muscles may be inevitable to achieve adequate sensory block. Thoracic epidural analgesia should not cause profound leg weakness but lumbar epidurals sometimes cause motor block. Increasing leg weakness usually means the infusion rate is too high, however it may also mean that the patient is developing an epidural haematoma or abscess, if associated with other signs and symptoms. Leg strength should be assessed 4 hourly whilst epidural in situ and be recorded at 6 hours post removal of epidural. This must be recorded on the daily management record. Action:

Aim for Bromage score of 1(Appendix 1). Use the table to assist in the assessment of leg strength for each leg. (This is found on the epidural daily management record).

An epidural abscess or haematoma is a neurosurgical emergency and if a patient complains of severe back pain with or without any neurological deficit to lower limbs an abscess or haematoma must be considered. Any symptoms that would lead you to suspect them require immediate investigation. The


Version 3

Page Number

of 17

Date Authorised

January 2015

patient will need urgent neurosurgical referral by the surgical team. Inform the pain team and 2nd on call anaesthetist. TESTING THE SENSORY LEVEL OF THE EPIDURAL BLOCK: This should be carried out 4hrly and recorded as below or above nipple level on the epidural daily management record. Refer to appendix 2 for guidance on how to the check the sensory block of an epidural. The blocked area must not go higher than nipple level. If patient complains of numb chest above nipple level:

Switch off the epidural

Sit patient upright if possible

Give oxygen at 15 litres via non – rebreathe mask

Check observations (blood pressure, pulse, respiratory rate, oxygen saturation, sedation score)

Contact surgical team and request review of patient

Contact pain team or on call anaesthetist (if out of hours).

IF UNABLE TO MOVE HANDS AND ARMS OR TINGLING SENSATION DOWN ARMS: Action

Switch off epidural infusion

Sit patient upright if possible

Give oxygen at 15 litres via non-rebreathe mask

Check observations (blood pressure, pulse, respiratory rate, sedation score, height of block)

Contact surgical team and request review of patient

Contact pain team or on call anaesthetist (if out of hours).

LOCAL ANAESTHETIC TOXICITY: Causes:

If the local anaesthetic enters systemic circulation

Early signs and symptoms include light-headedness; numbness of mouth, tinnitus, and muscle twitches, leading to unconsciousness, convulsions, coma, and respiratory arrest. In some cases of toxicity, cardiac events may be the first signs.

Action: Depends on the stage and severity of toxicity and requires relevant supportive management at each stage:

Contact surgical team and on call anaesthetist immediately

Oxygen therapy

Intravenous lipid emulsion (intralipid) (Stored in theatre recovery)

Anticonvulsants

Intubation and ventilation

Cardiac resuscitation Each anaesthetic room has guidelines for the management of this. Assess patient by Airway, Breathing, Circulation, Disability, Exposure (ABCDE) process URINARY RETENTION:

Causes:

Opioid affecting bladder reflexes (relaxation of detrusor muscle and increased bladder sphincter tone)


Version 3

Page Number

of 17

Date Authorised

January 2015

Loss of sensation and bladder motor power Action:

Patients with epidurals must have a urinary catheter for the duration of an epidural

PRURITUS: Causes:

May be seen with epidurals containing opioid. Action:

Treat with chlorphenamine 10mg im/sc or 4mgs orally. If patient unable to tolerate itching may need to exchange epidural for plain epidural and PCA.

LEAKAGE FROM THE EPIDURAL CATHETER INSERTION SITE:

This does not always necessitate the need to abandon the epidural. If pain is well controlled, continue the epidural and document leakage (On epidural daily management record). Monitor pain score and if patient experiences moderate to severe pain then they will require a PCA. Contact the acute pain team or 2nd on call anaesthetist if out of hours for advice if needed. Whilst epidural in situ, check insertion site 4hly for any signs of infection. (Record on epidural daily management record). Contact the acute pain team or 2nd on call anaesthetist if out of hours for advice if needed.

HEADACHE: If the patient complains of a headache either whilst the epidural is in situ or after it is removed, please inform the APT or on call anaesthetist out of hours. This may be indicative of a dural puncture caused at the time of insertion.

OCCLUSIVE DRESSING LIFTING OFF:

Do not attempt to remove the original dressing, this may displace or remove the epidural catheter. Place an occlusive, transparent dressing over the existing dressing.

DISCONNECTION OF THE EPIDURAL CATHETER FROM THE ANTIBACTERIAL FILTER : Do not reconnect if disconnection occurs. Remove the epidural catheter and consider alternative analgesia.

PRESSURE AREA CARE: Due to motor and sensory block that may be caused by the epidural, the patient should have pressure areas checked 4 hourly whilst epidural is in situ. (Record on epidural daily management chart). Thoracic epidurals should not cause any motor block and these patients may mobilise around the ward with assistance as long as their general condition allows.

DISCONTINUING THE EPIDURAL:

Epidurals usually remain in situ for 2 – 3 days (5 days for upper GI patients and then may need a PCA) at which time the patient is able to take light diet and fluids. Patients who are on the enhanced recovery pathway may eat sooner and therefore the epidural may be discontinued earlier.

For planned removal give oral analgesia 30-60 minutes prior to switching off the epidural.

Leave epidural switched off for 4-6 hours. If patient can manage with oral analgesia in this period, then the epidural can be removed. However if the patient’s pain score is 2 or more despite oral analgesia then the epidural may have to be restarted.

An epidural should not remain in situ for more than 5 days unless there are clear clinical indications.

If the white blood cell count and temperature are raised then consideration has to be given to removing the epidural. If the epidural site is swollen or inflamed then the epidural must be


Version 3

Page Number

of 17

Date Authorised

January 2015

removed immediately.

REMOVAL OF THE EPIDURAL CATHETER:

Ensure that leaflet given to patient ‘Post epidural infusion discharge advice’. (available on wards and intranet). Complete leaflet section of epidural daily management record ensuring a signature, time and date are recorded.

LMWH must not have been given in last 12 hours and clotting should be normal (if abnormal seek advice from pain team/anaesthetist)

If the patient is receiving intravenous heparin then this must be stopped for 4 hours and clotting status should be known before removal of epidural catheter.

If patient is receiving therapeutic heparin it may be necessary to wait longer before removing epidural catheter (24 hours). Seek advice from surgical team, pain team or anaesthetist.

There is no need to wean down rate of epidural prior to removal.

A qualified nurse may remove the epidural catheter if she is competent to do so

Patient should lie on side with spine flexed or sat upright with spine flexed (ideally the position the catheter was inserted in).

Using an ANTT technique, apply gentle traction to catheter to remove.

Complete the removal section of the epidural daily management chart ensuring a signature, time and date are recorded.

If the epidural is tunnelled on no account should the catheter be cut. If unsure seek advice from senior nurse/pain team/anaesthetist.

Once removed, examine catheter tip to ensure the blue end is intact, apply an occlusive, transparent dressing to insertion site. This must be kept in place for 48 hours following removal. If the blue end is not intact inform the surgical team immediately and seek an anaesthetic opinion. (bleep 3333)

Report any signs of infection to the surgical team and the acute pain team. Ensure this is documented in medical notes and care pathway/nursing notes/epidural daily management record.

Patient must be assessed for signs of motor block, this is done by recording a bromage score 2 hours after removal of epidural catheter. If bromage is >than 1 contact APS/anaesthetist on call. Complete this section of the epidural daily management chart.

Pain assessment must be continued after discontinuation of epidural.

If there is any doubt about infection of the epidural catheter site, the catheter tip and a wound swab must be sent for culture

Document in medical notes/epidural daily management record re removal of epidural catheter

Continue to observe site 4hly for sign of infection for the first 48hrs after removal.

DISPOSAL OF REMAINING EPIDURAL BAG CONTENTS:

A registered nurse who has undertaken an approved training programme and has been assessed as competent must dispose of the remaining opioid local anaesthetic mixture. This must be witnessed by an approved witness. (The Medicines Management (general) Policy LTHTR, 2013.)

For small volumes (≤ 20ml), the liquid may be disposed of directly onto an absorbent material. e.g. gauze/towel placed inside a sharps bin. When the bin is sent for destruction it should be labelled “Contains mixed pharmaceutical waste and sharps – for incineration’’

For larger volumes (>20ml) the destruction kit must be used to denature the controlled drug (CD).

No volume of CD may be discarded in ward drains.

The amount wasted must be documented on a dedicated page at the back of the CD register (or for those ward areas that undertake this on a regular basis a specific CD destruction register will be used) and on the prescription chart, timed, dated and signed.


Version 3

Page Number

of 17

Date Authorised

January 2015

The pump must then be cleaned as per Trust Policy and returned to recovery

7. Implementation strategy

Through ward managers, practice educators, pain updates and teaching sessions. Critical care flow chart and epidural daily management record available on wards.

8. Patient Resources

Leaflets- Epidurals for pain relief after surgery, Post epidural infusion discharge advice

9. References

Association of Anaesthetists of Great Britain & Ireland (2013) The Obstetric Anaesthetists’ Association and Regional Anaesthesia UK. Regional anaesthesia and patients with abnormalities of coagulation. Anaesthesia, 68 (9), pp. 966-972 Association of Anaesthetists of Great Britain & Ireland (2010) AAGBI safety guideline: management of severe local anaesthetic toxicity. London, AAGBI. Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (2010) Acute pain management: scientific evidence. 3rd edition. Melbourne, ANZCA. Bombeli, T. and Spahn, D. (2004) Updates in perioperative coagulation: physiology and management of thromboembolism and haemorrhage. British Journal of Anaesthesia, 93 (2), pp.275-87. British Thoracic Society (2008) Guideline for emergency oxygen use in adult patients. London, BTS. Kodali, B. and Oberoi, J. (2011) Management of postoperative pain. In: Basow, D.S (ed). UpToDate. Waltham, UpToDate. Layzell, M. (2008) Current interventions and approaches to postoperative pain management. British Journal of Nursing, 17 (7), pp 414-9. Middleton, C. (2006) Epidural analgesia in acute pain management. Oxford, Wiley-Blackwell. Royal College of Anaesthetists (2010) Best practice in the management of epidural analgesia in the hospital setting. London, RCoA. Royal College of Anaesthetists (2009) NAP 3: Major complications of central neuraxial block in the United Kingdom. London, RCoA. Royal College of Nursing (2010) Standards for infusion therapy. 3rd edition. London, RCN. Slater, R. (2010) Impact of an enhanced recovery programme in colorectal surgery. British Journal of Nursing, 19 (17), pp. 1091-9

10. Companion Documents / Appendices

Epidural competency, management of a patient with continuous epidural analgesia (chart on the wards and intranet). Management of a patient with continuous epidural analgesia (Laminated chart on wards) LTHTR (2013) Competency documentation: care of patient with epidural analgesia. Version 1.

LTHTR (2013) Aseptic Non Touch Technique (ANTT) generic guideline. Version 4. http://lthtr-documents/current/P316.pdf

http://lthtr-documents/current/P316.pdf


Version 3

Page Number

of 17

Date Authorised

January 2015

LTHTR (2013) Oral analgesia in the management of acute pain for adults. Version 4. http://lthtr-documents/current/P73.pdf LTHTR (2014) The resuscitation policy. Version 9.1. http://lthtr-documents/current/P284.pdf LTHTR (2014) Obstetric epidural analgesia during labour. Version 2. http://lthtr-documents/current/P583.pdf LTHTR (2013) The medicines management (general) policy. Version 1.1. http://lthtr-documents/current/P315.pdf LTHTR (2011) Safe delivery of o2 in the acute/ hospital setting. Version 2. http://lthtr-documents/current/P41.pdf LTHTR (2011) Procedure for cleaning and decontamination of patient care items and medical equipment/devices. Version 1.1. http://lthtr-documents/current/P223.pdf








Version 3

Page Number

of 17

Date Authorised

January 2015

Appendix 1 Leg strength (Bromage score):

Grade Criteria

Degree of block

Action

1

Free movement of legs and feet.

Nil (0%) No action, continue observations

2

Just able to flex knees with free movement of feet.

Partial (33%)

Reduce rate by 2ml and continue observations

3

Unable to flex knees, but with free movement of feet

Almost complete

(66%)

Stop epidural. Assess leg strength every 30 minutes up to a maximum of 4 hours. If leg strength does not improve in this time seek urgent review by surgical team. If pain score more than 1 during this time the patient may require a PCA. When bromage score is 2 or less restart epidural at 2 ml less than the previous rate.

4

Unable to move legs or feet

Complete (100%)

Stop epidural Carry out actions as above. If after 4 hours leg strength does not improve seek urgent review by surgical team. Patient will need urgent MRI scan. Inform pain team or 2nd on call anaesthetist out of hours. If pain score more than 1, patient may need PCA.

Appendix 2 Test to make sure the sensory block is not above nipple level (T4) You do not need to determine the actual level of block. You are testing to make sure the patient has normal sensation above T4 (nipple level).This means that the block is less than T4. This must be assessed right and left sides.

Apply a cold stimulus using a steret to the patient’s chest, just below the level of the nipple. (Ethyl spray can also be used as an alternative).The patient should be able to feel the coldness of the steret i.e. there is no block at this level.

On unblocked skin areas the patient will feel the coldness of the steret.

On partially blocked areas the steret will feel slightly cold.

On blocked areas the patient will only be able to feel the touch of the steret and not the cold sensation.


Version 3

Page Number

of 17

Date Authorised

January 2015

The sensory levels need to be assessed on right and left sides and documented separately on the daily management chart.

If the patient has numbness above T4 contact pain team/anaesthetist on call and do the following :

Switch off the epidural.

Sit patient up if possible.

Give oxygen at 15 litres via non-rebreathe mask.

Check observations (blood pressure, heart rate, respiratory rate, sedation score).

Contact surgical team and request urgent review of patient.

If the patient has no pain and on testing the block you feel that it is not a good block, do not be tempted to switch off the epidural. The patient’s pain is often the better indicator that there is something wrong with the epidural.


Version 3

Page Number

of 17

Date Authorised

January 2015

Appendix 3 RIVAROXABAN and other factor Xa inhibitors Factor Xa inhibitors are now commonly in use for thromboprophylaxis and also in conditions such as atrial fibrillation. There is a risk of epidural haematoma with these medications if central neuroaxial block is performed. Limited data is available. Current advice from The Association of anaesthetists of Great Britain and Ireland is contained within the table taken from their Guidance 2013 “ Patients with Abnormalities of Coagulation “

Elective Hip or knee replacement surgery only:- Rivaroxaban (Xarelto) is a direct inhibitor of activated factor X (anti Xa) and may be given orally for venous thromboprophylaxis in adults after elective hip (THR) or knee (TKR) replacement surgery. Dose and duration of therapy Patients should be prescribed Rivaroxaban 10mg 8 hours post operatively. The first dose and time to be prescribed by the surgeon or Anaesthetist. Continue Rivaroxaban 10mg daily at 6pm for 14 days (TKR) or 35 days (THR) post operatively.

A consultant can stop the rivaroxaban if they feel the risks of complications from this drug outweigh the benefits of giving it. Rivaroxaban does not require therapeutic monitoring.

Epidurals There is a risk of paralysis – monitor neurological signs and wait at least 18 hours after Rivaroxabin dose before removing catheter and do not give next dose until at least 6 hours after catheter removal.

Therefore if patients have an epidural omit the Rivaroxaban the night before the epidural catheter is to be removed. Remove the epidural catheter at 6 am. The next dose of rivaroxaban should be given at 6pm.

Aspirin and Clopidogrel Patients taking aspirin and clopidogrel should have these drugs stopped prior to surgery. These drugs should not be restarted until Rivaroxaban treatment has ceased. Aspirin should be stopped 7 days prior to surgery. Clopidogrel should be stopped 10 days prior to surgery EXCEPT those patients who have drug eluting coronary stents. Under these circumstances advice MUST be taken from the patient’s cardiologist


Version 3

Page Number

of 17

Date Authorised

January 2015

Warfarin Patients taking warfarin should have this stopped five days prior to surgery as per current practice. Such patients should have their warfarin anticoagulation restarted post-surgery with Clexane cover until therapeutic INR is reached. Such patients should NOT be prescribed Rivaroxaban. Contraindications to Rivaroxaban

Active bleeding

Pregnancy

Breast Feeding

Hypersensitivity to active substance or any excipient

Hepatic disease associated with coagulopathy and clinically relevant bleeding risk Cautions in use of Rivaroxaban

Bleeding disorders

Concomitant use of drugs that increase risk of bleeding

Severe hypertension

Active or recent gastrointestinal ulceration

Vascular retinopathy

Recent surgery

Hepatic impairment

Renal impairment – avoid if eGFR<15ml/min

Interactions Strong CYP3A4 & P-gp inhibitors and HIV protease inhibitors: These produce a clinically relevant increase in plasma concentrations of Rivaroxaban and may lead

to an increased bleeding risk. These include: -Ritonavir -Ketoconazole Patients on the above medication should be treated with Enoxaparin as extended thromboprophylaxis. Strong CYPA4 Inducers. These may reduce Rivaroxaban concentrations and therefore reduce effectiveness. These include: - Rifampicin - Phenytoin - Carbamazepine - Phenobarbital Patients on the above medication should be treated with Enoxaparin as extended thromboprophylaxis. St John’s Wort Patients on St John’s Wort should be advised to stop these 5 days preoperatively and advised not to re-start until the Rivaroxaban course is complete.


Version 3

Page Number

of 17

Date Authorised

January 2015

Appendix 4