grey nuns and misericordia sites certification

September 2010 of 35

GREY NUNS and MISERICORDIA SITES

CERTIFICATION MODULE

for

EPIDURAL / SPINAL ANALGESIA /

ANAESTHESIA

CERTIFICATION PROGRAM FOR THE ADMINISTRATION OF POSTOPERATIVE ANALGESICS THROUGH AN EPIDURAL CATHETER BY A REGISTERED NURSE WITH SPECIALIZED CLINICAL

COMPETENCY (RN SCC) & LICENSED PRACTICAL NURSE

ACKNOWLEDGEMENTS:

Adapted from: University of Alberta/Capital Health Authority “Certification Program for the Administration of Postoperative Analgesics Through a Percutaneous Epidural Catheter by a Registered Nurse with Specialized Clinical Competency”. Caritas Module Review/Revisions January 2003, March/2005,

Review & Approval: Dr. R. Gregg, Chief of Anaesthesiology; Sylvia Treloar, RN, BScN, ONC © Clinical Nurse

Educator; Janie-Rae Crowley, RN, BScN, Recovery Room Coordinator; Sharon Dawson, RN, BScN, MES, March 2009.

Adaptations by: Colleen Kasa, RN, BScN., Clinical Nurse Educator; Jodi Normandeau, RN, Clinical

Nurse Educator; Georgia Barry, RN, BScN. June 2010


Addendum to the Epidural Peripheral Nerve Block Certification Package (2014) While reviewing the package for certification/recertification for Epidural/Regional Nerve Blocks, we noticed several items that we would like to clarify/bring to your attention.

1. In several places, the package discusses the role of the LPN. ( Page 3 #3 and #5b, Page 14, section 3, 3) At this time, LPN’s cannot be part of an independent double check with epidural medications. However, when an LPN receives a patient with an epidural into her/his care; the LPN must ensure that the correct medication is infusing at the correct rate, that all of the equipment is in order and that the site is intact.” However, when the drug is changed, or when the rate is changed, 2 RNSCC’s are responsible to do the independent double check as this is not in the scope of practice for the LPN.

2. Several surgeons have been ordering the foley catheter be removed prior to the discontinuation of the epidural catheter. A review of the literature supports this practice if the epidural catheter is a thoracic placement. Quoting Day, Rene et al., 2010, “Conscious awareness of bladder filling occurs as a result of the sympathetic neuronal pathways that travel via the spinal cord to the level of T10 through T12. Initiation of voiding occurs when the efferent nerve pelvic nerve, which originates in the S2-S4 area.” McCaffery and Pasero, 2010, also support the early removal of foley catheters for patients that have a thoracic epidural catheter for post-operative pain management. Varadhan et al (2010), Enhanced Recovery After Surgery: The future of Improving Surgical Care, also encourages the early removal of the foley catheter with a thoracic epidural catheter. Therefore, if the surgeon orders the foley be removed and the patient has a thoracic epidural catheter, it is reasonable to remove the catheter even though the epidural is insitu. Please note that patients with a lumbar epidural will potentially have more difficulty voiding because of the specific placement of the catheter in relation to the enervation required for awareness of bladder filling and emptying.

3. When assessing the dermatomes in the lower extremities, it is acceptable to either name the anatomical position of the ie, block or to state the dermatome. (ie mid thigh or L3-4)

4. Just a reminder (page 18) that assessments are best performed determining the level on one side of the patient’s body and then moving to the other side of the bed to assess the other side of the patient’s body. Please remember to document the method of determining the dermatome.(ie. Ice or light touch). This provides consistency of communication.

5. Dr. Knight, Chief of Anesthesiology at the Misericordia has requested that nursing always give information about a patient’s fluid status when requesting a bolus for a low blood pressure. For example, whether the patient has already received boluses and when and what the patient’s fluid balance is.

6. The anesthetists at the Misericordia have decided that they are not comfortable with nursing staff reconnecting the epidural catheters in the event it becomes disconnected. The potential for contamination of the catheter and introduction of bacteria into the catheter with a resulting epidural abcess is too great a risk. Therefore, if an epidural catheter does become disconnected, do not reconnect as per the manual, cover the catheter tip with a sterile gauze and call anesthesia for further direction and orders. References 1. Pasero, Chris and McCaffery, Pain Assessment and Pharmacologic

Management. Mosby Elsevier. St. Louis. 2011. Pages 428and 502. 2. Day, Rene et al. Textbook of Canadian Medical-surgical Nursing. Lippincott

Williams and Wilkins. Philadelphia. 2010. Page 1411. 3. Varadhan, Krishna et al. Enhanced Recovery After surgery: The Future of

Improving Surgical Care. Critical Care Clin 26(2010) 527-547.


TABLE OF CONTENTS

INTRODUCTION PROGRAM OBJECTIVES SECTION I ANATOMY - DIAGRAMS EPIDURAL ANAESTHESIA VS. ANALGESIA INDICATIONS/CONTRAINDICATIONS SECTION II SPINAL AND EPIDURAL MEDICATIONS ADVANTAGES OF OPIOID AND LOCAL ANESTHETIC EPIDURAL COMBINATION

OPIOIDS LOCAL ANAESTHETICS METHODS OF ADMINISTRATION ADVANTAGES OF PCEA SECTION III RESPONSIBILITIES OF THE ANAESTHESIOLOGIST RESPONSIBILITIES OF THE RN SCC RESPONSIBILITIES OF THE LPN PATIENT AND FAMILY TEACHING SECTION IV ASSESSMENT OF A PATIENT RECEIVING EPIDURAL ANALGESIA

PAIN CONTROL SEDATION / RESPIRATORY HEMODYNAMICS MOTOR STRENGTH / SENSATION EMERGENCY SITUATIONS UNWANTED SIDE EFFECTS OF EPIDURAL/INTRATHECAL OPIOIDS UNWANTED SIDE EFFECTS OF LOCAL ANAESTHETICS

SECTION V GENERAL EPIDURAL CATHETER AND SITE CARE

PREPARATION FOR AN EPIDURAL INFUSION MAINTAINING AN EPIDURAL INFUSION TITRATING AN EPIDURAL INFUSION REMOVAL OF EPIDURAL CATHETER

APPENDIX I REPLACING EPIDURAL CONNECTOR

CHECKING CATHETER PLACEMENT APPENDIX II ASRA GUIDELINES FOR NEURAXIAL BLOCKS AND

ANTICOAGULANT THERAPY APPENDIX III GLOSSARY REFERENCES


INTRODUCTION 1. Rationale of the certification program Epidural opioids and Local anaesthetics have an important role in postoperative pain

management for patients undergoing major surgical procedures. Traditionally, anaesthesiologists were responsible for the administration of opioids and Local anesthetics for postoperative analgesia. This practice can be problematic as it relies on the availability of the anaesthesiologist.

Having a RN with SCC administer a variety of epidural analgesics can:

• allow quicker response to patient’s pain management needs • provide more options for drug delivery best suited to each patient.

2. RN SCC Certification includes:

• self study package • successful completion of a written exam, oral testing of knowledge and

demonstration of skill • one satisfactory supervised demonstration of an epidural catheter removal in

a simulated or clinical setting • instruction for the epidural pump.

3. LPN Certification to Monitor includes:

• self study package • successful completion of a written exam • successful demonstration of assessment, documentation, and independent

double check of pump. 4. Recertification must be done on an annual basis. 5. Program Theory Content Goal

• The Registered Nurse with specialized clinical competency successfully completing certification will have the knowledge and skills required to:

a) Administer pharmacy prepared epidural opioids and local anaesthetics

through an indwelling percutaneous epidural catheter; b) Safely remove an epidural catheter as ordered by Anaesthesiology,

ensuring that guidelines are followed for patients who are receiving low molecular weight heparin (LMWH), SC/IV heparin or Coumadin.

• The Licensed Practical Nurse will have the knowledge and skills required to:

a) Assess and monitor patients receiving epidural Opioids and local anesthetics through a percutaneous epidural catheter.

b) Correctly perform independent double checks of the infusion pump and effectively document findings on appropriate documentation;


PROGRAM OBJECTIVES The Licensed Practical Nurse/ Registered Nurse will be able to: 1. Describe the anatomy of the epidural space and the surrounding structures. 2. Differentiate between the following:

- epidural analgesia and epidural anaesthesia - epidural analgesia and intrathecal analgesia

3. Identify the difference between lipophilic and hydrophilic opioids, along with the

implications on drug action. 4. Describe the advantages of using epidural analgesics for postoperative pain

management. 5. Recognize the indicators of catheter migration and the nursing actions required. 6. Discuss the responsibilities of the anaesthesiologist in caring for the patient

receiving an epidural analgesic. 7. Explain the expected action and possible side effects of epidural opioids and local

anaesthetics. 8. Differentiate between the monitoring requirements when a patient is receiving a

combination of opioid and local anaesthetic infusion with or without patient controlled epidural analgesia (PCEA), an opioid alone, or a local anaesthetic alone.

9. Identify the appropriate documentation required for analgesic administration and

patient monitoring. The Registered Nurse with special clinical competency in addition will be able to: 1.. Specify the epidural analgesics and the possible methods of administration that an

RN SCC may use. 2, Describe or demonstrate the appropriate steps required for:

- initiating an epidural infusion with or without PCEA - maintaining an epidural infusion - titrating an epidural infusion - removal of epidural catheter - appropriate administration of adjuncts


SECTION I

Anatomy:

The spinal canal contains the spinal cord (or cauda equina below L2), the cerebral spinal fluid (CSF), the membranes surrounding the spinal cord, and the epidural space. In adults, the spinal cord ends at L1-L2. Only the remaining nerve roots or cauda equina continue on and exit the spinal canal at the appropriate lumbar or sacral vertebrae. The spinal cord, cauda equina and brain are surrounded by CSF and the entire contents are covered by a watertight fibrous membrane called the dura. This is the outermost of three membranes surrounding the spinal cord and brain. Outside the dura but still within the spinal canal is the epidural space. This space contains the spinal nerves as they exit, blood vessels, and fatty tissue.

Spinal Anesthesia:

Is achieved through an injection of anesthetic solutions into the intrathecal space producing sensory, motor and autonomic blockade of the nerve roots and spinal cord. The anaesthesiologist inserts a needle through the dura into the intrathecal (subarachnoid) space of the spinal cord. Local anaesthetics are injected directly into the CSF to produce the desired nerve blockade. Opioids can also be injected intrathecally to produce analgesia post operatively; eg. single shot Morphine for longer action or Fentanyl for short duration. Because the proximity to the opioid receptors in the dorsal horn, very small doses of opioids are needed for control of pain.

.Epidural Anesthesia:

The anesthesiologist carefully introduces a needle through the thoracic or lumbar vertebral interspaces into the epidural space, but not through the dura and subarachnoid. Anesthetic solutions can be introduced into the epidural space. In addition, a small catheter can be passed and left in place for continued analgesia medications.

Inadvertent dural puncture during insertion below L1 will not hit the spinal cord. At levels above L1, unintended dural puncture during catheter insertion carries a risk of spinal cord injury, although, actual incidence of complications reported is similar to catheters placed in the lower lumbar region.

Epidural Analgesia:

The epidural catheter is threaded through a needle and advanced 8-10cm towards the head. The needle is then removed and the catheter is taped to the skin, allowing analgesics to be administered during the postoperative period. The epidural catheter is placed as close as possible to the dermatomes that need analgesia following the surgical procedure.


SECTION I (continued)

Medications diffuse through the epidural space, across dura mater into the CSF where they attach to opioid receptors in the dorsal horn of the spinal cord. Some of the medication is also absorbed by blood vessels and/or taken up by the fat in the epidural space. Epidural analgesia can be achieved with lower doses than the anesthesiologist uses during anesthesia. Factors affecting the degree of dermatomal spread or the targeted amount of numbness of certain sensory nerves are: catheter placement, concentration of local anaesthetics, and the lipid solubility of the opioid medications. The catheter typically stays in for 48-72 hours and is removed by the RN SCC following an order from the anaesthesiologist. The RN SCC must ensure prior to removal that guidelines are followed for patients who are receiving LMWH, SC/IV heparin or coumadin.

Neuraxial (Intraspinal)

Neuraxial refers to spaces and potential spaces surrounding the spinal cord into which medications can be administered; i.e. epidural and (spinal) intrathecal/ subarachnoid.


I SECTION I (continued)

Vertebral Column

Spinal Anatomy Epidural Needle Placement



Dermatomes

Used in the assessment of spinal and epidural anesthesia and epidural analgesia when local anaesthetics are administered. Nerve roots in the spinal cord skin innervate the skin in continuous sensory bands that look like stripes. Each sensory stripe or dermatome corresponds to a specific nerve root.



Indications and Contraindications for Epidural Analgesics Advantages of Epidural Administration

• excellent analgesia • minimal sedation • long duration of action • facilitate early ambulation • avoid repeated injections (I.M., S.C.) • little hemodynamic effects

Insertion of an epidural catheter would be contraindicated for the following reasons:

• patient refusal • known drug allergy • coagulopathy (may be a risk of epidural hematoma) • infection at the insertion site

Possible contraindication (but not absolute) would include:

• presence of a spinal abnormality or injury • sepsis • hypovolemia • neurological problems • bowel perforations


I SECTION II

Spinal and Epidural Medications-- Opioids and Local anaesthetics

Both opioids and local anaesthetics can be used alone or in combination for desired analgesic effect. Because the two classes of drugs work synergistically, they are often used together to treat acute pain.

Advantages of Opioid and Local Anesthetic Epidural Combination • better analgesic at lower doses than Opioid alone • fewer side effects • improved GI function • reduced cardiovascular, pulmonary and infectious complications • better mobility, ( long term as well ) • less nausea • less fatigue • decreased surgical stress response

Opioids

Opioids are defined as a naturally occurring, synthetic or semi-synthetic drugs exerting opium-like effects by attaching to special receptors in the spinal cord and brain with resulting pain relief. The term ‘narcotics’ tends to be applied to a much broader spectrum of drugs that can produce ‘insensibility’ or ‘stupor’ (usually classed as drugs of abuse). Opioids by any route work by attaching to special receptors in the posterior dorsal horn area of the spinal cord and are believed to inhibit release of a neurotransmitter called ‘Substance P’. As a result, the transmission of painful impulses upward to the brain is reduced or modified. Epidural opioids act primarily at the level of the spinal cord, and less so at the level of the brain stem. In this way epidural opioids can produce excellent analgesia with little associated sedation or respiratory depression. Over time, usually 4-6 hours (but as many as 12 hours) after injection, the morphine within the CSF slowly spreads upward toward the brain stem (Rostral effect). At the same time the drug is being taken up into the spinal cord, and being greatly diluted as it slowly mixes with the CSF. Due to this absorption and dilution of the morphine in CSF, the amount remaining has minimal effects by the time it reaches the brain stem. There is rare occasion when the morphine concentration is high enough to cause excess sedation and serious respiratory depression. Although rare, this delayed onset and slow progression of respiratory depression with excessive sedation must be anticipated.


SECTION 2 (continued)

RN SCC’s do NOT administer intrathecal medications

The opioids used for spinal anesthesia /or epidural analgesics are: • epidural morphine • hydromorphone (Dilaudid®) • fentanyl (Sublimaze®) • meperidine (Demerol®)

The onset and duration of opioid action will depend on the solubility property of the drug. Lipophilic or more fat-soluble opioids are absorbed quicker and have a shorter duration of action. Hydrophilic opioids are more water-soluble, thus have a slower onset but a longer duration of action. This will in turn affect how the drug will be administered and the duration of patient monitoring.

Local Anaesthetics

In lower concentrations than given for spinal anesthesia, epidural Local Anesthetic act by blocking some impulses without blocking larger fibers that transmit motor and sensory functions. Ideally post surgical patients experience numbness over the surgical incision area but with little to no motor and sensation deficits to lower limbs. Therefore ambulation without pain is possible. The epidural Local anaesthetics most commonly infused for postoperative analgesia are:

• bupivacaine (Sensorcaine®, Marcaine®) • ropivacaine (Naropin)

Local anaesthetics can be administered by RN SCC’s via infusion pump (Gemstar) for postoperative analgesia. In dilute amounts, an epidural local anaesthetic can block painful sensory input at the nerve root prior to reaching the spinal cord. This will produce relief along the affected dermatomes. Typically, there may be some numbness in and around the incision or targeted area. Monitoring for side effects will follow a standard schedule (as below) unless otherwise ordered by Anaesthesia.

RN SCC’s do NOT administer epidural bolus injections of Local anaesthetics!

Epidural Opioid Solubility Onset of Action Duration of Action morphine more hydrophilic 15-60 minutes 6-24 hours hydromorphone more hydrophilic 15-30 minutes 6-18 hours Fentanyl more lipophilic 5-15 minutes 2-4 hours meperidine more lipophilic 5 minutes 2-12 hours


SECTION 2 (continued)

Methods of Administering Medication for Neuraxial Analgesia

The duration of pain anticipated is considered in determining the best method for pain control. 1. Clinician Administered Bolus

⇒ Direct Intrathecal injection by an anaesthesiologist ⇒ Direct epidural injection by an anaesthesiologist ⇒ Epidural injection into an epidural catheter by anesthesiologist. (The

disadvantage to this method is there is no steady level of analgesia long term. Peak and trough effect of side effects and pain)

2 Continuous Epidural Infusion ⇒ Basal rate delivered by infusion pump through epidural catheter

3 Patient Controlled Epidural Analgesia (PCEA) [At this time, PCEA option is

only available at the MCH] ⇒ Patient uses a hand control to deliver a bolus dose via an infusion pump into

the epidural catheter ⇒ PCEA can be used alone or in conjunction with a continuous epidural infusion

to supplement the basal rate

The concept of patient controlled epidural analgesia (PCEA) has been adapted from intravenous patient controlled analgesia IV PCA. With PCEA, a basal infusion rate keeps the patient comfortable with analgesia, however, the patient can self administer a bolus dose for breakthrough pain if the basal infusion is insufficient, for example when turning and ambulating.

Advantages of PCEA:

• More timely pain relief • More control for the patient • Convenience for the nurse and patient to reduce the time required obtaining and

administering required supplemental boluses


I

SECTION III Responsibilities of the Anaesthesiologist:

1. Inserting the epidural catheter.

2. Administering the first dose of epidural opioid.

3. Providing a written order for the opioid route, dose and frequency before the patient leaves the recovery room.

4. Providing written orders for epidural infusions with or without PCEA, opioids alone, local anaesthetic alone or combination of both - including titration rates and adjuncts as needed.

5. Being available for consultation if questions or problems develop (anaesthesiologist on call).

6. Monitoring the patient on a daily basis.

7. Ordering any supplemental systemic opioids. Patients on epidural opioids do not usually receive opioids by another route. If indicated, systemic opioids are ordered by the anaesthesiologist and not by the attending service (exception is in critical care, the intensivist may order opioids in addition to anesthesiologist).

8. Providing a written or oral order for removal of epidural catheter, noting specific instructions for patient on anticoagulant.

Once the epidural catheter is removed, analgesic orders can be obtained from the attending service unless otherwise indicated.

Responsibilities of the RN SCC:

Under the direction of the Anaesthesiologist: 1. Maintain a continuous epidural infusion.

2. Titrate an epidural infusion within ordered limits.

3. Remove an epidural catheter in adherence to guideline by the Department of

Anaesthesia regarding patients on anticoagulants. 4. Perform independent co-check and co-sign for solution or dosage changes.

5. Provide patient and family teaching about the use of intraspinal analgesia/

anaesthetic for pain management.


SECTION III (continued)

Responsibilities of the LPN:

Under the direction of the Anesthesiologist: 1. Maintain a continuous epidural infusion.

2. Assess, monitor and document the health status of the patient with a

continuous epidural infusion.

3. Perform independent co-checks.

4. Report any untoward effects of the continuous epidural infusion to the Nurse in Charge.

5. Provide patient and family teaching about the use of intraspinal analgesia/ anaesthetic for pain management.

Patient and Family Teaching

The patient, family or significant other should be instructed about the use of intraspinal analgesic and/or anesthetic agents for pain management. The patient teaching should include instruction on:

1. Catheter placement, purpose, and common complications that may be

experienced and the need to immediately report complications. 2. Pain management regimen including action of intraspinal analgesic and/or

anesthetic and side effects that may be experienced. 3. Need for immediate and early reporting of pain. Instruct the patient how to use

a pain intensity scale to report the pain. 4. Need for immediate reporting of any side effects. Emphasize the importance of

reporting any changes in respiration, level of sedation and movement or sensation in lower extremities.

5. Who will administer and monitor intraspinal medication. 6. Activity level. Due to the superior level of pain control that may be experienced

with intraspinal narcotic and/or anesthetic, the patient may have a tendency to overdue activity. Caution patient to begin slowly and restrict patient's activity to that which is appropriate relative to the underlying condition. If a local anesthetic infusion is in use instruct the patient to obtain assistance with mobilization on the first time out of bed.

7. When intraspinal pain management is discontinued, prepare the patient for the

variation in pain control that may be experienced during the transition (Olsson, leddo, & Wild, 1989).


SECTION IV

Assessment of Patients Receiving Epidural Analgesics

Specific monitoring is required for patients receiving epidural analgesics or spinal anesthesia. The monitoring required addresses the potential for side effects, depends on which analgesic or combination of analgesics used. The Adult Inpatient Pain Assessment and Analgesic Monitoring Flow Sheet CH-1343 April 2008 acts as a documentation sheet and also provides a summary of required monitoring. This sheet should be added to the patient’s chart when the epidural analgesic is initiated or if a spinal anesthetic has been given. Monitoring is based on the procedure VII-A-5, Assessment and Care of the Adult Following Surgery or Procedures Completed Under General, Intraspinal Anesthetic and / or Regional Nerve Block unless otherwise ordered. These are applicable for the use of a combination of an epidural opioid and local anaesthetic per infusion with or without PCEA, epidural or intrathecal opioids alone, or epidural local anaesthetic alone. For example, if an epidural infusion of combined bupicavaine and fentanyl were to be used, monitoring for both opioids and Local anaesthetics would be required, unless otherwise ordered by the anaesthesiologist.

1.0 Pain Control -- Patient Assessment As pain is subjective it is preferred to obtain a self-report from the patient. You may

use a visual analogue scale (pain ruler) if available or obtain a verbal report from the patient using a 0-10 numeric scale. Explain to the patient that ‘0’ means no pain and ‘10’ would be the worst pain imaginable. Ask the pain score at rest and during activity (eg. coughing, ambulating). Remember that the number reported must be relevant to how the patient perceives that value. For example, some patients may consider a score of 5/10 ‘too much pain’ while another may report being quite comfortable until 8/10. If possible, ask the patient to provide you with a number representing the level of pain that is no longer acceptable. This can be your reference to help evaluate the effect of the pain control provided. Patients must be comfortable enough to cooperate with care.

Inadequate analgesia – Assess the level of pain during waking hours at least Q4 hours and proceed with nursing intervention.

If the anaesthesiologist has given a bolus dose of epidural Local Anesthetic, check

the BP and pulse rate Q5 minutes x 3 times, then Q 15 minutes x 1 time (including a sensory level and motor function check at this time). If no problems are noted, resume the previous monitoring schedule.


SECTION IV (continued)

2.0 Sedation Scale, Respiratory - Patient Assessment

The patient should be easy to rouse (sedation score ≤ 2) and have a RR of at least 10 breaths/ minute. Note the depth of the respirations. If the patient is sleeping, he/she should respond to a gentle touch on the shoulder or being called by name. You do not need to fully waken the patient. As respiratory depression is often associated with increasing sedation, it is important to determine that the patient easily rouses. NOTE: Respiratory rate alone is not a reliable indicator of respiratory depression.

Refer to the sedation scale when asked to assess the level of consciousness or provide a sedation score. Assess respiratory rate (RR) and sedation score according to guidelines for the Adult Inpatient Pain Assessment and Analgesic Monitoring Flow Sheet CH-1343 Respiratory depression – Those more at risk for developing respiratory depression are the elderly (especially after thoracic or upper abdominal procedures), any patient receiving systemic opioids (PO, IV, IM, SC), concurrent use of CNS depressants (drugs such as sedatives), or any patient becoming increasingly sedated (with or without respirations). When a patient is receiving epidural analgesia, orders for other analgesics and adjuncts must be ordered by Anesthesia / Intensivist. Ensure there is an IV access, naloxone and oxygen (at the bedside or immediately available on the unit). Keep these available following the last dose or stopped infusion of opioid for 24 hours.

IF clinically significant respiratory depression is suspected: • Rouse the patient, encourage deep breathing, administer oxygen, stay with the

patient while someone calls Anaesthesia, and administer naloxone (Narcan®) as ordered. (Check the epidural order sheet for a standing naloxone order.)

• If naloxone is needed, notify Anesthesia. Naloxone should be given slowly over

two minutes while you observe the patient's response (it should be titrated to effect) if given too fast it can precipitate severe pain and increase sympathetic activity leading to hypertension, tachycardia, ventricular arrhythmias, pulmonary edema and cardiac arrest. A disadvantage of naloxone is that analgesia will also be reversed and pain will return. Naloxone is a short acting opioid antagonist. Observe for recurrent symptoms of respiratory depression beyond thirty minutes after drug is given.



3.0 Hemodynamics - Patient Assessment

Blood pressure and pulse are taken as prescribed in the postoperative orders when the epidural opioid is used alone. If an epidural infusion contains a mixture of opioid and local anaesthetic, refer to the monitoring requirements for a local anaesthetic. Local anaesthetics can block sympathetic nerve fibers as well as blocking sensory pain fibers. With sympathetic blockade, venous pooling of blood in the extremities can result in postural hypotension. Hypotension is accentuated if there is also a postoperative fluid volume deficit. Take Blood Pressure and pulse according to the Adult Inpatient Pain Assessment and Analgesic Monitoring Flow Sheet CH-1343 guidelines. If clinically significant hypotension occurs:

• Notify House staff / Anesthesia if: – the patient is very dizzy, light-headed or faint – more than a 30mm Hg drop in systolic BP – a pulse or more than 25% from baseline – a systolic BP of less than 90mm Hg

• Hypotension Bolus – check Doctor’s Orders. Frequently in post operative

patients the fluid balance is altered. Ongoing assessments of the intake and output are needed to determine the factors influencing a ↓ in BP &/or ↑P. Opioid only epidurals do not lead to hypotension – look for other causes.

• Ensure that ephedrine is immediately available on the patient care unit. This

may be required for hypotension not resolved by fluid replacement. Ephedrine is a sympathomimetic drug used for severe hypotension. (See doctor’s orders regarding administration.)

• For the first ambulation, check the BP lying, sitting and standing allowing 3-5

minutes between position changes. Have the patient sit for a few minutes before changing positions and monitor for complaints of being dizzy, light-headed or faint. If postural hypotension develops, lay the patient down, elevate the legs, stop the infusion, and call the anaesthesiologist.

• If the first ambulation is well tolerated, all three positional BP’s do not need to

be repeated. You would then resume regular blood pressure monitoring as ordered. If the local anaesthetic infusion rate is increased or a bolus dose of local anaesthetic is given by the anesthesiologist, check the BP lying, sitting and standing on next ambulation.



4.0 Motor Strength and Sensation -- Patient Assessment

The autonomic nerve fibers affected - first to last - by local anaesthetics are: 1) touch 2) pain 3) motor 4) pressure 5) proprioception (awareness of body or extremity position).

They recover sensation in the reverse order. 1. Motor Strength – Patients receiving an epidural local anaesthetic may

experience motor weakness and have difficulty with weight bearing. Assess Motor Function according to the Adult Inpatient Pain Assessment and Analgesic Monitoring Flow Sheet CH-1343 guidelines

• Have the patient flex their knees and ankles and document on the Adult Inpatient Pain Assessment and Analgesic Monitoring Flow Sheet CH-1343 . If unable to flex a joint, stop the local anaesthetic infusion and contact the anaesthesiologist.

• Assess motor function prior to ambulation and remain on 2 person standby

using a transfer belt upon first ambulation and as necessary. 2. Sensation – The sensory fibres for temperature are similar to the pain fibres and

are affected by a local anesthetic.

To determine the level of sensory loss use light touch bilaterally, alternating left to right. If specific sensory level cannot be determined - use ice or an alcohol swab to check for a change in cold perception (use alcohol only in areas where skin integrity is intact). Touch an area with the alcohol or ice where you would expect normal sensation (eg. hand or face) and the patient should respond that it feels cold. Then, starting above the targeted level of block, move the ice or alcohol swab downward. Ask the patient to report when they no longer feel the cold or when the sensation changes from cold. (Sometimes the patient detects a change in sensation rather the absence of cold.) The level at which perception changes is the upper level of sensory block. Then determine the lower level of the block on both sides by using the ice or alcohol below the targeted area and working upwards until there is a change or absence in cold sensation. Document the levels of sensory block in relation to the affected dermatomes (see dermatome chart on the Adult Inpatient Pain Assessment and Analgesic Monitoring Flow Sheet CH-1343) or describe in relation to some anatomical point in the nursing notes. Try using the ice rather than alcohol if a level is difficult to detect.



The epidural order sheet will designate the acceptable level of sensory loss.

This level may vary somewhat, depending on the level of catheter insertion. If numbness occurs in the face, neck, hands or arms, OR exceeds the level designated on the order sheet, stop the infusion and notify Anaesthesia. Excessive sensory block may interfere with cardiac and respiratory function.

• Reposition patient frequently and observe for potential skin breakdown

especially in pressure areas affected by the local anaesthetic as the patient may have decreased sensation.

Emergency Situations: notify Anaesthesia STAT!

• Initiate emergency measures – o O2, provide airway support if required o elevate HOB o monitor vital signs frequently o initiate Code Blue response if required

Rapid Decrease in Level of Motor Strength and Sensation

Report any rapidly evolving neurological deficit to anaesthesia immediately as this may be due to a neurological injury (eg. epidural hematoma) and is considered an emergency. Observations indicating a deficit may include: abnormal sensation, numbness, tingling, movement, muscle weakness, or back pain. This needs prompt treatment to prevent permanent neurological damage.

Catheter Migration

Always be alert for symptoms indicative of catheter migration. If you suspect catheter migration, stop the infusion and contact Anaesthesia. a. intravascular migration – early characteristics are: a metallic taste, tinnitus and

dysphoria, mid characteristics are: confusion, agitation, dizziness and mouth numbness; late characteristics are: somnolence which could progress to seizures, coma and cardiac / respiratory arrest. Local anaesthetic infusing into a blood vessel could result in systemic toxicity and subsequent adverse effects.

b. intrathecal migration – a rapid increase in motor weakness or sensory block.

Doses of local anaesthetic intended for epidural use would result in profound motor or sensory block if inadvertently administered into the intrathecal space.

Excessively High Sensory Block Excessively high sensory block may interfere with cardiac and respiratory function.



POTENTIAL SIDE EFFECTS OF EPIDURAL OPIOIDS

Unwanted Effect Cause and Comments Assessment What to Report

Respiratory Depression

&

Sedation

A decrease in rate & depth of respirations from baseline, rather than just a number.

Sedation – determine if caused by opioid, likely cause if just started on opioids or dose increased. Prolonged sedation can lead to respiratory depression.

Action and duration of long acting opioids must be considered in monitoring patients. E.g. Morphine peaks about 12 hrs post administration.

Resp rate and sedation score

Q 30 min x 2 times Q 1 hour x 12 hours Q 2 hours x 12 hours

Then Q 4 hour until 12 hrs. post last dose or discontinued

Sedation scale

0 = none (awake & alert) 1= mild (occasionally drowsy) 2 = moderate (frequently drowsy easy to rouse) 3 = severe (somnolent) S = sleep (normal sleep)

• Resp rate less than 10 and decreased depth

• Difficult to arouse • Sed. Scale ≥ 2 • Need for Narcan / notify

Anaesthesia • Sudden change in sedation

can be a sign of catheter migration. Notify anesthesia STAT

• Consider ↓ dose for prolonged sedation

Post operative Nausea and Vomiting

Often considered to be as debilitating as pain. Slow steady titration helps ↓ nausea. Adjustments to diet and activity may be used. Relaxation techniques may help.

Possibility of aspiration

Tension on sutures

Fluid and electrolyte imbalance

↑ intracranial & intraocular pressures

• Antiemetics (monitor increased sedation)

Pruritis Higher incidence with intraspinal morphine than other opioids. Thought to be due to cephlad migration of the opioid in CSF and interaction in the medulla. Sometimes generalized all over the body but can be localized on face and neck.

If antihistamine (Benedryl) given monitor sedation scale as this can cause drowsiness along with the opioid

• Consider decreasing the opioid dose

• Consider adjunct and Local Anesthetic for pain control

Urinary retention

Epidural analgesics are delivered close to the micturation centre, located in the lower segments of the spinal cord. The combination of epidural local anaesthetics and opioids can cause relaxation of the detrusor muscle. An opioid-induced increase in sphincter tone can make urination difficult. The central effects of opioids and motor and sensory blockade can interfere with perception of bladder fullness and the patient’s attention to bladder stimuli.

Regularly assess for bladder distention; in and out or Foley catheterization if needed

• Persistent urinary retention

from McCaffery M., Pawero, C.: Pain: Clinical Manual, copyright 1999, Mosby, Inc.


POTENTIAL SIDE EFFECTS OF EPIDURAL LOCAL ANAESTHETICS

Unwanted Effect Cause and Comments Assessment What to Report

Sensory and/or motor deficit

Many factors, including vertebral location of the epidural catheter, local anaesthetic dose, and variability in patient response, can result in patients experiencing unwanted sensory and/ or motor deficit. The lower the level of intraspinal catheter placement, the lower the affected dermatome.

Sensory deficit:

Every shift, ask patients to point to numb and tingling skin areas (numbness and tingling at the incision site is common and usually normal).

Motor deficit:

Every shift, ask patients to bend their knees and lift the buttocks off the mattress. Most are able to do this without difficulty. Determine patients’ ability to bear weight and ambulate. Ask patients to remain in bed if they are unable to bear weight. Provide assisted ambulation PRN.

• Complete loss of sensation in a skin area

• Muscle weakness, inability to move extremities or bear weight

• Numbness and tingling in areas distant to the nociceptive site

• Changes in sensory or motor deficit from last assessment (e.g. a lower location or increased intensity)

• Unresolved deficits after changes in therapy have been made

Urinary retention

Epidural analgesics are delivered close to the micturation centre, located in the lower segments of the spinal cord. The combination of epidural Local Anesthetics and opioids can cause relaxation of the detrusor muscle. An opioid-induced increase in sphincter tone can make urination difficult. The central effects of opioids and motor and sensory blockade can interfere with perception of bladder fullness and the patient’s attention to bladder stimuli.

Regularly assess for bladder distention; in and out or Foley catheterization if needed

• Persistent urinary retention

Local Anaesthetic toxicity

Toxicity can result from vascular uptake or injection or infusion of local anaesthetic directly into the systemic circulation. Elderly patients may be at higher risk for toxicity from accumulation because most have a decreased ability to clear Local Anesthetics.

Every shift, assess for and ask patients about signs of local anaesthetic toxicity: circumoral tingling and numbness, ringing in ears, metallic taste, slow speech, irritability, twitching, seizures, cardiac dysrhythmias. Stop local anaesthetic administration if signs are present.

• Signs of local anaesthetic toxicity

Adverse hemodynamic effects (Hypotension)

Because Local Anesthetics block nerve fibers, they affect the sympathetic nervous system and cause vasodilatation. Mild hypotension is common. Some patients receiving intraspinal local anesthetics experience significant hypotention and bradycardia, especially when rising from a prone position or after large dose increases or boluses. Thoracic placement of the epidural catheter is associated with fewer hemodynamic disturbances.

Regular assessment of HR and BP, including orthostatic blood pressure before ambulation until dose is stabilized and it is clear that bradycardia and hypotension are not problems.

• Symptomatic hypotension and/or bradycardia

• Persistent hypotension and/or bradycardia

• Symptomatic orthostatic hypotension

may be duplicated for use in clinical practice. From McCaffery M, Pasero C: Pain: Clinical manual, pp. 230-231 Copyright ©1999, Mosby, Inc.


SECTION V General Epidural Catheter and Site Care 1. Observe the dressing and area over the insertion site at least twice per shift prn for

presence of:

• signs of infection (inflammation, tenderness, purulent drainage) • leakage or bleeding Ensure the tape is dry and secured. Do not remove the tape or change the epidural dressing as the catheter is not sutured into place. Edges to the dressing or tape may be reinforced as needed. Don’t dislodge catheter. Contact Anesthesia if any problems noted.

2. The catheter should have a label ‘EPIDURAL’ close to the injection port or clearly visible on the infusion tubing at all times. For epidural infusions, use the appropriate epidural tubing and a 0.22 micron filter without any additional injection ports.

3. A label with the date of tubing change should be on catheter tubing. Epidural tubing

must be changed every 72 hours. 4. If the injection cap comes off, replace it with a sterile Baxter injections site cap with a

white circle (no heparin or priming solution used) using aseptic or ‘no touch’ technique, after cleaning the catheter end, see Appendix 1.

5. If the connector detaches and the end of the catheter is exposed, protect the end of

the catheter immediately with sterile 4x4” gauze. RN SCC’s certified for epidural analgesics can replace the connectors as per the procedure in the Appendix 1.

6. Assess skin integrity particularly with patients experiencing decreased sensation. 7. Removal of the epidural catheter may be done by RN SCC, as ordered by

Anesthesia/Intensivist (usually 2-3 days after insertion). NOTE: Anaesthesiology must be alerted and provide a relevant order prior to the removal of the epidural catheter for all patients receiving low molecular weight heparin, subcutaneous / IV heparin or coumadin. Follow the ASRA Guidelines to determine when the subsequent doses of anticoagulants may be given. If there is any questions or concerns, contact Anesthesiology. Preparation for Start of an Epidural Infusion on a Patient Care Unit Most times the epidural infusion will have already been initiated in the OR/RR. There may be occasions where this needs to be initiated on a general care unit.


SECTION V (continued)

1. Obtain a Gemstar epidural pump, micron filter and tubing from the recovery room.

Use the Gemstar brand tubing with a yellow stripe. The tubing should NOT have any extra injection ports. (Tape over any extra ports if different tubing must be used.)

2. Label the infusion tubing with appropriate date. (Epidural tubing should be changed

every 72 hours. The 0.22 micron filter is used to prevent any bacteria or particulate matter from being infused into the epidural space.) Ensure the epidural catheter is labeled with an ‘EPIDURAL’ tag. Tape connections.

3. Check the epidural order and contact pharmacy for the medication bag if the

anaesthesiologist has not already prepared and labeled a solution bag. (Air should be removed during preparation of the bags.)

4. RN SCC may initiate infusion and/or change the premixed medication bag following

the test dose given by anesthesia. RN SCC must perform an Independent co-check and co-sign of initiation, solution change or rate change. RNSCC should check catheter placement prior to initiation (refer to Appendix 2)

Maintaining an Epidural Infusion As defined by post-surgical epidural policy, RN SCC’s may administer analgesics per epidural infusion by attaching a prepared medication bag and adjust the rate of the infusion as ordered by Anaesthesia. (Loading doses through the pump are only given by Anaesthesia & RN SCC in PARR.) 1. At the start of each shift, verify or review the pump program as per manufacturer

instructions. 2. Check to see if the pump is operating and that all connections are secure. Check

the epidural site, looking for any problems or leakage, q8h and prn.

3. Write pain assessment, record drug, rate and cumulative volume absorbed on the Adult Inpatient Pain Assessment and Analgesic Monitoring Flow Sheet CH-1343.

4. Change the tubing and the medication bags every 72 hours as required. All epidural medication bags should be checked for correct, drug, dose and expiry date. Attaching a new infusion bag requires resetting the container (bag) volume as per pump instructions. Document the changes on the Adult Inpatient Pain Assessment and Analgesic Monitoring Flow Sheet CH-1343

5. Titrate the infusion rate as ordered by Anaesthesia. RN SCC’s or LPN must co-check and co-sign changes made to the pump programming and document this on the Adult Inpatient Pain Assessment and Analgesic Monitoring Flow Sheet CH-1343

6. Monitor the patient for any adverse effects or uncontrolled pain.



7. Assess and document infusion and cumulative PCEA amounts. Titrating a Continuous Epidural Infusion 1. In the presence of uncontrolled pain, consider the following:

• check to see if the pump is operating and if there are any kinks or leaks in the tubing

• assess the insertion site for any possible problems • presence of postoperative complications such as DVT or compartment

syndrome requiring treatment of another nature. 2. Assess the patient for presence of side effects relevant to the type of analgesic(s)

infusing: • for infusions containing an opioid check the respiratory rate and sedation score; • for local anaesthetic infusion, check the BP, pulse, motor function and sensory

level. If any findings are not within the acceptable values, notify the anaesthesiologist and do not proceed.

3. For patient assessment within acceptable parameters, proceed to check the epidural order sheet.

4. Note if adjunctive medications have been administered (e.g. anti-inflammatory,

acetaminophen). If not, administer them as ordered and consider their use more regularly if ordered on a PRN basis.

5. You may also choose to increase the infusion rate as ordered by the

anaesthesiologist. Revert back to initial monitoring schedule. If the infusion is already at the maximum rate, contact the anaesthesiologist. Refer to the epidural order sheet for further titration information (e.g. time intervals between infusion increments).

6. Document the programming changes on the Adult Inpatient Pain Assessment and

Analgesic Monitoring Flow Sheet CH-1343. A co-check and co-sign is required. 7. Repeat as required.



Removal of Epidural Catheter NOTE: Orders to remove Epidural Catheter must be given by the Anaesthesiologist. Anaesthesia must be alerted prior to the removal of the epidural catheter for all patients receiving low molecular weight heparin, subcutaneous/IV heparin or coumadin. Report relevant lab results; i.e. platelets, PT, PTT. 1. Place patient in lateral fetal or sitting up position. (Hint: Ask patient what the position

during insertion was.) 2. Cleanse insertion site with no alcohol Chlorhexidine solution. Wipe area dry with

2x2. 3. Pull out catheter using slow continuous pressure

• apply steady pressure around site while withdrawing catheter • if catheter is difficult to remove have patient arch back • if catheter will not move or patient reports pain or resistance is felt, call

Anaesthesia 4. Check catheter tip

• if catheter or tip not intact call Anaesthesia. 5. Apply a dressing to the insertion site. The site should be checked after catheter

removal for oozing, hematoma at 15 minutes and 30 minutes following removal. Notify anesthesia if large amounts of oozing or hematoma develops.

6. Discuss signs and symptoms of epidural hematoma with patient. 7. Document procedure including contact with anesthesia An untoward side effect of spinal anesthesia may occur. Headaches may indicate a dural leak. Patient may complain of a frontal or occipital headache that is aggravated when upright. A dural blood patch is often performed by the anaesthesiologist as treatment.


REFERENCES A Self -Directed Learning Module Third Edition Epidural Analgesia, University of

Wisconsin Hospitals and Clinics Madison, WI. 2000, UW Hospital and Clincis Authority Board.

Canadian Anaesthesiologist’s Society (1998) Guidelines for the Use of Neuraxial

Opioids and Continuous Epidural Infusion of Local Anaesthetics and Opioids for Acute Pain Management Draft #3, June 8.

Canadian Anaesthesiologist’s Society (2001) Consensus-Based Guidelines for Acute

Pain Management using Neuraxial Analgesia. Caritas Health Group (2000) The Basics of Epidural/Spinal Analgesia: Module A and

Module B. Capital Health Authority & Caritas Health Group (1997) Regional Analgesia/Anaesthesia

Learning Module. D'Arcy, Y., Using Thoracic Epidural Catheter for Pain Management. Nursing 2004, Vo

34, No.9. pp 18. Drain C. (1994) 3rd Ed. The Post Anesthesia Care Unit A Critical Care Approach to

Post Anesthesia Nursing. W.B.Saunders Co. Philadelphia,PA. Forrest, J. (1998) Acute Pain: Pathophysiology and Treatment. Manticore Publishers. Hambleton, N. (1994) Dealing with the Complications of Epidural Analgesia. Nursing 94,

October, p 55-57. Kreger, C. Spinal Anesthesia and Analgesia. Nursing Management. Jan 2002. pp31-

37. Litwack, K. Ed. (1999) 4th Ed. Core Curriculum for Perianesthesia Nursing Practice.

W.B.Saunders Co. Philadelphia,PA. McCaffery, M and Pasero, C. (1999) Pain Clinical Manual, Second Edition. Mosby, Inc. McCaffery, M and Pasero, C. (1999) Providing Epidural How to Maintain a Delicate

Balance. Nursing 99, Aug. pp 34-39. McNair, N. (1990) Epidural Narcotics for Postoperative Pain: Nursing Implications.

Journal of Neuroscience Nursing, Vol. 22, #5, p 275-279.

Pasero, C. Epidural Analgesia for Postoperative Pain. AJN Oct 2003, Vol. 103, No. 10 pp 62-64.

Pasero, C. Epidural Analgesia for Postoperative Pain, Part 2. AJN Oct 2003, Vol. 103,

No. 11 pp 43-45.


University of Alberta Hospital Site (1992) Certification Program for the Administration of Morphine Through a Percutaneous Epidural Catheter by Specially Trained Registered Nurses. Capital Health Authority.

University of Alberta Hospital Site (2001) Certification Program for the Administration of

Post-Operative Analgesics Through a Percutaneous Epidural Catheter by a Registered Nurse with Specialized Clinical Competency. Capital Health Authority.

Wild, L & Coyne, C. (1992) The Basics and Beyond: Epidural Analgesia. American

Journal of Nursing, April, p 26-34. Snap-lock Adapter. Picture downloaded on May 25, 2007. From:

http://212.68.147.44/ami/dynsiteami/index.asp?ownerId=117&reqPageId=492 (n.d.) Pictures of spinal Anatomy, spinal dermatomes, epidural injection. Downloaded on May

25, 2007. From: http://images.google.com/images (n.d.)


I APPENDIX I

1. Replacing Epidural Connector • If the connector on the catheter slips off, you must first protect the catheter end with

a sterile 4x4” gauze to prevent contamination. Obtain a new connector from Recovery Room or from Epidural Tray. Swab the distal 5 cm of the catheter with a betadine swab. Let dry for 2 minutes. Using sterile scissors cut 4-5 cm off the end of the catheter. Using aseptic technique put the catheter into the connector as per package instructions. It is not necessary to clamp the catheter while changing the injection cap or connector.

Recovery Room will have extra connectors however, check the

unit epidural box first (MCH only).

(example of a connector)

Picture downloaded on May 25, 2007. From: http://212.68.147.44/ami/dynsiteami/index.asp?ownerId=117&reqPageId=492

( 2. Check catheter placement: • Using the empty 3mL syringe with a blunt cannula enter the injection port and

aspirate to check for fluid return to verify catheter placement. Remember that movement by the patient may cause the catheter to migrate into a blood vessel within the epidural space, or puncture through the dura and unintentionally move into the intrathecal space (into CSF).

• When aspirating, little or no fluid should return. A small amount of clear return (less than 0.5mL) may be due to residual medication left in the catheter. Aspirate slowly, observing for the amount of clear fluid return. Take enough time to ensure that clear fluid does not continue to flow into the syringe!

• Abnormal findings during aspiration would be a continued flow of clear fluid greater than 0.5mL indicating catheter migration into CSF or a sanguineous return signaling catheter migration into a blood vessel. If either of these occur, stop and notify the anaesthesiologist. Do not re-inject the fluid withdrawn, as this will be saved to show the anaesthesiologist. Do not inject the epidural medication.


APPENDIX II - ASRA GUIDELINES FOR NEURAXIAL BLOCKS AND ANTICOAGULANT THERAPY

NEURAXIAL BLOCKS (Spinals, Epidurals) and Anticoagulant Therapy

Adapted from the American Society of Regional Anaesthesia and Pain Medicine Consensus Conference, April 2002

NOTE: Concurrent use of two or more drugs from this list INCREASES THE RISK OF BLEEDING COMPLICATIONS For example; a patient on LMWH + Aspirin, or a patient on Plavix (clopidogrel) + Coumadin (warfarin) is at increased

risk compared to either agent alone.

DRUG CLASS PRE-OP POST-OP EPIDURAL CATHETER REMOVAL Unfractionated Heparin (UFH) Prophylactic doses* eg. 5000 U sc q 8-12 hours

• NOT a contraindication to NAT • Check platelets if greater than 4 days of heparin pre-op • Risk may be reduced if first dose held until after catheter is placed.

• Check platelets if greater than 4 days of heparin.

Unfractionated Heparin (UFH) Treatment doses* eg. IV infusion

• Prolonged IV heparin therapy pre-op = increased risk (avoid NAT) • Avoid NAT if patient has other coagulopathies. • Delay start of heparin therapy until one hour after needle placement.

• Monitor carefully for early detection of any motor block (especially if catheter placement was difficult or bloody). • Physician to consider minimizing LA concentration.

• If patient is already on heparin, remove catheter 2-4 hours after last dose of heparin. • If patient is to start heparin, wait at least one hour after catheter is removed before starting heparin.

Low Molecular Weight Heparin (LMWH) eg. Enoxaparin (Lovenox) Dalteparin (Fragmin) Tizaparin (Innohep) * see below for dosing

• For treatment doses, Neuraxial block should be at least 24 hours after last LMWH dose. • Avoid NAT if patient recived LMWH within two hours pre-op. • For prophylactic doses: Neuraxial block should be at least 10-12 hours after last LMWH dose.

• BID dosing; first LMWH dose minimum of

24 hours post-op and only if adequate hemostasis.

• QD dosing; first dose 6-8 hours post-op,

second dose minimum 24 hours later.

• If blood present in needle or catheter at time of placement (traumatic insertion) delay LMWH for 24 hours post-op.

• BID dosing; catheter must be removed

before starting LMWH therapy (minimum two hours before first dose)

• QD dosing; catheter may remain in during

LMWH therapy remove catheter a minimum of 10-

12 hours after last dose subsequent dose may be given a

minimum of two hours after catheter removal

Oral Anticoagulants eg. warfarin (Coumadin) nicoumalone (Sintrom)

• For patients on chronic warfarin; D/C 4-5 days pre-op check INR pre-op

• For patients newly starting

• Check INR QD and before catheter removal.

• If INR greater than 3, inform physician (withhold or reduce

• Check INR before removal. • INR should be less than 1.5 before catheter is removed. • Sensory and motor assessments to


DRUG CLASS PRE-OP POST-OP EPIDURAL CATHETER REMOVAL warfarin;

check INR if first dose given greater than 24 hours pre-op or if two doses given pre-op

oral anticoagulant dose) continue at least 24 hours post catheter removal, longer if INR greater than 1.5 at time of removal.

Antiplatelet Medications eg. ASA (Aspirin, Novasen, etc.) NSAIDS (eg. ketorolac (Toradol), ibuprofen, dislofenac, indomethacin, naproxen) Clopidogrel (Plavix) Ticlopidine (Ticlid) GPIIb/IlIa Inhibitors (abciximab, eptifibatide, tirofiban) * list is not exhaustive – if unsure, check CPS or call Pharmacy

• NOTE: PTT/INR do NOT measure platelet function; normal PTT/INR does NOT indicate that NAT are safe in patients receiving antiplatelet medications. • NSAID monotherapy does not increase risk; however, risk is increased when used in combination with other agents in this chart (eg. LMWH + NSAID) medications.

• NSAIDs: No specific timing restrictions on catheter removal.

• D/C clopidogrel (Plavix) seven days pre-op. • D/C ticlopidine (Ticlid) 14 days pre-op. • Physician to assess if patient received GPIIb/lIIa inhibitors within 48 hours pre-op.

• •

Thrombolytic Therapy eg. tenecteplase (TNKase), alteplase (tPA), reteplase (rPA), streptokinase, others

CONTRAINDICATED Patient should be questioned pre-op to check for history of receiving these agents.

• If emergency use of thrombolytic has occurred, intensive monitoring will be required. Obtain detailed monitoring orders from physician.

• No definitive recommendations; extreme caution required.

Fondaparinux (Arixtra) CONTRAINDICATED no NAT

• No specific guidelines available.

Herbal Medications • Obtain history of herbal medication use pre-op. • Safety data lacking; discontinuance of herbals not mandatory.

• No specific guidelines available.

Other Agents: Lepirudin (Refludan) Ancrod (Viprinex) Antithrombin III Argatroban Danaparoid

• Safety is unknown. • No specific guidelines available.

• ‘Risk” in this document refers to the risk of spinal hematoma (add signs and Sx and consequences) • ‘NAT’ – Neuraxial Techniques (i.e. epidurals, spinals) • ‘LA’ – Local Anaesthetic


• Prophylactic Dose LMWH = Enoxaparin (Lovenox) 30 mg sc q12h, Dalteparin (Fragmin) 5000 U sc qd, Tinzaparin (Innohep) 50-75 U/kg sc qd, 3500-4500 sc qd

• Treatment Dose LMWH = Enoxaparin (Lovenox) 1 mg /kg sc q12h or 1.5 mg/kg sc qd, Dalteparin (Fragmin) 120 U/kg sc q12 h or 200 U/kg sc qd, Tinzaparin (Innohep) 175 U/kg sc qd


APPENDIX III AFFERENT Conducting towards the center or specific site of reference. ANAESTHESIA Loss of feeling or sensation. ANALGESIA Relief of pain without loss of consciousness. BLOOD PATCH Treatment for inadvertent dural puncture and subsequent leakage of CSF.

Approximately 10mLs of patient’s blood is drawn from the peripheral vein and injected into the epidural space.

CHOROID PLEXUS Vascular fringe-like folds in the pia mater in the third, fourth and lateral

ventricles of the brain; concerned with formation of CSF. COAGULOPATHY Any disorder of blood coagulation. EPIDURAL INJECTION Injection into the epidural space outside the dural sac. HYDROPHILIC Readily absorbed in aqueous solution. INTRATHECAL / Injection into the subarachnoid space around the spinal cord. SPINAL INJECTION LIPOPHILIC Readily absorbed in fatty tissues. OPIOID Opioids are defined as a naturally occurring, synthetic or semi-synthetic drugs

exerting opium-like effects by attaching to special receptors in the spinal cord and brain with resulting pain relief.

PARENTERAL By subcutaneous, intramuscular, intrasternal or intravenous injection - not

through the alimentary canal. ROSTRAL Toward the rostrum (beak), or simply toward the brain. This may mean

superior (in relation to the spinal cord areas) or anterior/ventral (in relationship to brain areas).

SUBSTANCE ‘P’ Potent vasoactive substance; a sensory neurotransmitter involving pain, touch

and temperature. SYMPATHETIC NERVOUS Part of the autonomic nervous system; regulates basic SYSTEM physiological functions responsible for the ‘fight-or-flight’ response. Clinically

this is manifested by pupillary dilation, increased heart rate, increased blood pressure, bronchial dilation, peripheral vasoconstriction, etc.

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