Continuous Epidural Infusions Management Policy

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CONTINUOUS EPIDURAL INFUSIONS MANAGEMENT POLICY

Version / 9
Name of responsible (ratifying) committee / Formulary & Medicines Group
Date ratified / 20 July 2017
Document Manager (job title) / Acute Pain Sister
Date issued / 20 August 2018
Review date / 31 July 2021
Electronic location / Clinical Policies
Related Procedural Documents / See section 8 of this policy
Key Words (to aid with searching) / Pain management; epidural anaesthesia; epidural catheter; continuous epidural infusion; anticoagulant; cardiac arrest; hypotension

Version Tracking

Version / Date Ratified / Brief Summary of Changes / Author
9 / 20/07/2018 / - Removal of first sentence in quick reference guide.
- Reference to naloxone guideline in section on management of complications.
- For pruritus treatment order of medications amended and addition that ondansetron is not licensed for pruritus.
- change of wording of management of inadequate analgesia to titrate infusion to an appropriate dose. / Charly Bellis
8 / 21/07/2017 / Remove from Vital PAC and addition of recording of observations on Epidural Observation Chart, change of naloxone policy, remove ephedrine, add ondansetron for pruritus, change to time of catheter removal to not less than 4 hours preceding the next dose LMWH (from 2 hours), new prescription charts, restructure process / Charly Bellis
7 / 16/01/2015 / Inclusion of updated Patient Information Leaflet (September 2014). New Trust template / Libby Burton Smith

CONTENTS

QUICK REFERENCE GUIDE

1.INTRODUCTION

2.PURPOSE

3.SCOPE

4.DEFINITIONS

5.DUTIES AND RESPONSIBILITIES

6.PROCESS

7.TRAINING REQUIREMENTS

8.REFERENCES AND ASSOCIATED DOCUMENTATION

9.EQUALITY IMPACT STATEMENT

10.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

EQUALITY IMPACT SCREENING TOOL

APPENDIX A: Patient Leaflet

APPENDIX B: Epidural Prescription Chart

APPENDIX C: PCEA Prescription Chart

APPENDIX D: Epidural Observation Chart

APPENDIX E: Protocol For Management Of Abnormal Neurological Signs In Connection With Epidural Analgesia

QUICK REFERENCE GUIDE

For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.

1)Continuous Epidural infusions should only be managed on either surgical wards that are covered by the Acute Pain Service and where staff have attended the mandatory acute pain study day or on the Maternity Unit where they will be managed by midwives and the duty maternity anaesthetist.

2)The Acute Pain Service or after hours the 2nd on-call anaesthetist (bleep 1622) should be contacted for advice about epidurals and their management.

3)If the patient is suffering from unusual/unexpected dense block then the management of abnormal neurological signs in connection with epidural analgesia guideline must be followed.

4)All surgical patients with a continuous epidural infusion must have regular observations (pulse, blood pressure), pain and sedation scores and block recorded on Epidural Observation Chart and acted upon when necessary.

1.INTRODUCTION

Indications: Epidural analgesia is an efficacious method of providing postoperative pain relief or for the control of labour pain.

2.PURPOSE

This policy is to guide staff in the use of continuous epidural infusions. It is not designed to restrict or limit professional judgment and decision-making

3.SCOPE

This policy is applicable to those surgical areas supported by the acute pain service and applies to staff who have attended the Acute Pain Study Day and have a signed competency. If this is not the case then the patient must be moved to another ward or clinical area where this can occur.

It also applies to the Labour ward on the Maternity Unit

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

4.DEFINITIONS

Epidural analgesia is the introduction of local anaesthetics and/or opioids, into the epidural space, via an indwelling catheter. The epidural space lies between the dura mater and the bones (spinous process) and ligaments (interspinous ligament and ligamentum flavum) of the vertebral canal.

The epidural catheter is 40cm long, has 1cm markings to 15cm and then 1 at 20cm and a blue tip at the insertion end

The concept of the continuous infusion of bupivacaine combined with fentanyl is to saturate the pain receptors in the spinal cord whilst interrupting transmission of painful stimuli from sensory nerves

Wessex Pain Score is: - 0 = no pain on movement, 1 = mild pain on movement, 2 = moderate pain on movement and 3 = severe pain on movement.

Sedation (CNS) score is – A = Alert, V = Voice, P = Pain and U = Unresponsive

PCEA is the abbreviation for Patient Controlled Epidural Analgesia.

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‘Top-ups’ is the term used for a bolus dose of local anaesthetic via the epidural catheter

5.DUTIES AND RESPONSIBILITIES

Where an anaesthetist is involved in a patient’s care, it is his/her responsibility (not that of a surgeon) to seek consent for anaesthesia, having discussed the benefits and risks.

The insertion of the epidural catheter is the responsibility of the anaesthetist. The continued care of the patient is the responsibility of the surgical team and ward staff in collaboration with The Acute Pain Service. The 2nd on-call Anaesthetist has responsibility for epidurals out of hours. The maternity duty anaesthetist and midwifery staff are responsible for the management of epidurals on the labour ward.

Only anaesthetists or other Health Care Professionals who have established their competency should perform top-ups

6.PROCESS

ACTION / RATIONALE
1. PRE-OPERATIVELY
The patient should be seen by the anaesthetist preoperatively and fully informed of the procedure and the risks and benefits of the epidural and continuous infusion.
If the patient is assessed to be suitable for PCEA, then he/she must be introduced to the concept of PCEA and shown the equipment that will be used. This is complemented and reinforced by nursing staff.
A patient information leaflet should be given to the patient (Appendix A) / Professional courtesy and decreasing pre- and post-operative anxiety and pain. To help the patient in the consent decision process. Establish need for epidural analgesia and identify risk factors, need for further investigations, contraindications or technical difficulties of epidural technique.
To ensure patient understands how to use the PCEA device.
To support the consent process
2. IN THEATRE
If the patient is receiving prophylactic low molecular weight heparin (LMWH) the catheter must not be inserted within 12 hours of the last dose. If the patient is receiving a therapeutic dose of LMWH the catheter must not be inserted within 24 hours of the last dose – this applies to concurrent anticoagulants used in accordance with Trust VTE guidelines
All patients must have patent IV access while the infusion is running and a urinary catheter should be inserted in theatre, and removed only after the return of normal sensation.
An anaesthetist using aseptic technique will site the epidural catheter. It is then connected via a 0.22 micron bacterial filter to the continuous infusion pump.
The catheter is secured at the site by a sterile clear dressing and secured up to the shoulder with a clear dressing or Mepore.
A gauze pad is placed under the filter and secured to the shoulder of the patient.
The catheter is attached to a McKinley bodyguard 545 epidural pump with the designated epidural line and yellow colour-coded extension. Ready-to-use bags of bupivacaine 0.1% with or without fentanyl 2 microgram/ml will be used.
If being used for PCEA an appropriately configured and programmed pump with patient handset should be used. There is pre-determined regime (See Appendix C).
The drug type, rate of infusion, level of the epidural and the length of the epidural catheter at skin should be recorded on the epidural prescription chart Appendix B / To minimize the risk of an epidural haematoma, the American Society of Regional Anaesthesia (ASRA) guidelines on central nerve block and LMWH (Low Molecular Weight Heparin) should be followed.
Emergency IV access for fluids and/or drugs. The local anaesthetic can cause the patient to lose bladder sensation/control.
To reduce incidence of infection.
To prevent migration of catheter.
To prevent a pressure area/irritation.
A dedicated pump and line will decrease the risk of confusion between epidural, intravenous and other Local Anaesthetic infusions.
A background infusion is likely to provide adequate analgesia, but to prevent the risk of overdose a maximum should be set at 8-12 mls/hour.
To enable correct assessment of effectiveness and possible change of position of epidural catheter and to ensure details appear in patients notes
3. NURSING CARE AND OBSERVATIONS
Monitor respiratory rate, sedation score and pain score on Vital Pac hourly for the first 12 hours, 2 hourly for the next 12 hours and then 4 hourly. Continue for 4 hours once epidural has been removed/turned off. Midwives follow local guidelines.
Pain scores, blood pressure and pulse as per standard operating procedures.
All patients with a continuous epidural infusion should have 2 litres of oxygen via nasal specks unless otherwise indicated. / Pain scoring must be documented to establish whether or not the treatment is effective. The effects of the local anaesthetic on the sympathetic nerves can exacerbate hypotension. Respiratory depression is a side effect of fentanyl.
Sensory level and motor block function should be monitored hourly for the 12 hours and then four hourly. Patients should be able to move toes and have sensation above T4 or nipples. These must be recorded on the dedicated lilac epidural observation chart.(Appendix D)
Patients can get up out of bed and mobilize once motor function has been assessed as adequate. / Local anaesthetic can affect the tone and power of the lower limbs. Pressure area care is important, as most patients will have a degree of sensory loss in lower limbs.
The epidural catheter must be kept clean under a sterile dressing and the site inspected daily for signs of infection ormovement.
Bacterial filter must be kept intact. Epidural catheters will normally remain insitu for a maximum of 4 days, unless otherwise indicated. The decision to continue an epidural infusion beyond 4 days should be taken by the Acute Pain Service or an anaesthetist.
Some epidurals tend to leak slightly, however if it is working it should remain in situ. / To reduce the risk of infection and ensure that the infusion is sited correctly.
The filters have a licence from the manufacturers for 96 hours use.
Risk assessment shows there is a higher risk in removing an epidural compared with allowing a slightly leaking but functioning epidural to continue.
4. MANAGEMENT OF COMPLICATIONS
If respiratory rate is less than 8 and/or sedation score is 3, inform duty surgical team, turn infusion off, give naloxone 40 mcg IV (prescribed on epidural chart) every 1 minute and O2 100% via self inflating bag.
Call cardiac arrest team and hand ventilate if respiratory arrest occurs.
If local anaesthetic toxicity is suspected, follow the drug therapy guideline – Management of severe local anaesthetic toxicity.
If systolic blood pressure is less than 90mmHg give 500ml of an appropriate IV fluid over 15 minutes (prescribed on epidural chart). A surgical opinion is required to exclude/correct hypovolaemia.
Inform surgical team.
If blood pressure continues to be low, an anaesthetic review is required for possible transfer to a high care unit for a metaraminol infusion.
For pruritus consider chlorphenamine or ondansetron and/or change the infusion to plain Bupivacaine.
If the epidural catheter becomes disconnected from the patient side of the bacterial filter, the epidural must be removed. If it becomes disconnected from the infusion side of the filter it can be reconnected. Do not clean the filter with anything, especially not alcohol.
For nausea and vomiting refer to Drug Therapy guideline- post operative nausea and vomiting- treatment in adults. If severe consider changing infusion to plain bupivacaine.
If analgesia is inadequate (pain score of 2 or 3, patient verbalizing discomfort), check the epidural catheter is still in situ and increase the infusion rate as necessary in accordance to pain. Recommence hourly observations. If pain remains excessive after an hour ring the Acute Pain Team during office hours or the 2nd on call anaesthetist after hours.
If the patient is suffering from unusual/unexpected dense block then the management of abnormal neurological signs in connection with epidural analgesia guidelines should be followed (Appendix D and E) / Opioids can affect the central nervous system causing euphoria, sedation and respiratory depression. Fentanyl may be distributed to the CNS after vascular uptake or CSF transfer.
Local anaesthetic toxicity is a rare complication of epidural analgesia.
Sympathetic block can lead to hypotension. However with the low concentration of local anaesthetic used on the general wards, significant hypotension is unlikely unless the patient is also hypovolaemic.
Pruritus is a well-known side effect of opioids and occurs more frequently in association with spinal or epidural administration.
Micro-organisms introduced up-stream of the filter will be removed by it.
Alcohol is neurotoxic and should therefore not be used for cleaning.
5. MANAGEMENT OF A PATIENT FOLLOWING A ‘TOP-UP’
Blood pressure and respiratory rate must be checked every 5 minutes for first 20 minutes, then half hourly for next 2 hours. If the patient becomes hypotensive see section 4. Block levels should be done hourly for first 4 hours and then 4 hourly. / High doses and stronger concentrations of local anaesthetic can lead to a sympathetic block. A bolus of opiate can lead to an increase in sedation.
6. REMOVAL OF EPIDURAL CATHETER
Trained nursing staff may remove epidural catheters. The date, reason for removal and whether the tip was present should be documented on the epidural prescription chart (Appendix B).
Only send the tip to microbiology for culture if there is any suspicion of infection.
If the patient is receiving low molecular weight heparin (LMWH) the catheter must be removed not less than 12 hours after a dose and not less than 4 hours preceding the next dose.
Patients who are to have a continuous epidural infusion must not be prescribed rivaroxaban and should have a LMWH prescribed instead. Rivaroxaban can be prescribed at 1800 hours the day following the removal of the epidural catheter. If a patient is inadvertently given rivaroxaban the epidural catheter must not be removed less than 24 hours after a dose, nor less than 6 hours before the next dose. / The catheter tip provides evidence of whether the infusion site was infected.
To minimize the risk of a spinal haematoma the American Society of Regional Anesthesia (ASRA) guidelines on central nerve block and LMWH (Low Molecular Weight Heparin) should be followed.
ASPECT OF CARE / OUTCOMES / EXPECTED STANDARD / TARGET / SOURCE OF DATA COLLECTION
Record keeping / 100% of patients will have correctly filled in prescription and observation charts / Acute Pain Service will review documentation daily, within their working hours.
Adverse incident reporting / 100% of all incidents reported to risk management are discussed at mortality and morbidity meetings. / Summary of incidents reported to risk department and anaesthetic department critical incident reporting system.

7.TRAINING REQUIREMENTS

Only anaesthetists trained in this technique should initiate this type of postoperative pain relief.

Only nurses who have their IV and Epidural competency (Appendix ) should care for these patients with support from the Acute Pain Service and the Anaesthetic Department. Midwives are responsible for the care of ladies on the labour ward in conjunction with the maternity duty anaesthetist.

Matrons/Senior Nurses will ensure that nurses caring for patients with epidurals have achieved their competency in agreement with the Acute Pain Service.

8.REFERENCES AND ASSOCIATED DOCUMENTATION

Please note that some references/links within policies may be to internal documentation that are not externally accessible – ie. they are located on the Trust’s intranet

Acute Pain Management: Scientific Evidence. Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Fourth Edition 2015.

Best Practice In The Management of Epidural Analgesia In The Hospital Setting. Faculty of Pain Medicine of The Royal College of Anaesthetists. November 2010.

ASRA Guidelines. Anticoagulation 3rd Edition 2010.

Drug Therapy Guideline - Naloxone for the treatment of opioid overdose in adults.

Drug therapy guideline – Local anaesthetic toxicity (severe) management

Drug Therapy Guideline - Postoperative nausea and vomiting – treatment in adults.

Bridging guidelines for peri-operative management of existing anticoagulation in surgical & invasive procedures (Adults)

9.EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy has been assessed accordingly

Our valuesare the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace.

Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.

We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:

Working together for patients

Working together with compassion

Working together as one team

Working together always improving

This policy should be read and implemented with the Trust Values in mind at all times

Continual Epidural Infusions Management Policy
Version: 9

Issue Date: 20 August 2018
Review Date: 31 July 2021 (unless requirements change) Page 1 of 24

10.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS