Epidural Analgesia Procedure Patient Age Group: ( ) N/A (X) All Ages ( ) Newborns ( ) Pediatric ( ) Adult

Applies to: UNM Hospitals Responsible Department: Acute Pain Svc Revised: 12/2016

Title: Epidural Analgesia Procedure Patient Age Group: ( ) N/A (X) All Ages ( ) Newborns ( ) Pediatric ( ) Adult

DESCRIPTION/OVERVIEW This procedure outlines the clinical responsibilities and standardized care for patients receiving epidural analgesia. Epidural analgesia is the administration of local anesthetic agents and/or adjuvants and/or opioids into the epidural space via an epidural catheter for the management of pain. Epidural analgesia may be administered in the thoracic, lumbar, or caudal regions of the spine as clinically indicated and appropriate.

* All items noted with an asterisk denote the need to refer to Labor and Delivery unit-specific variations. Please refer to addendum re: Care of the Obstetric Epidural Analgesia Patient

REFERENCES  American Society of Anesthesiologists. (2009). Practice Guidelines for the Prevention, Detection, and Management of Respiratory Depression Associated with Neuraxial Opioid Administration, Anesthesiology, 110, (2), 1-13.  American Society for Pain Management Nursing, (2007). Position Statement “Registered Nurse Management and Monitoring of Analgesia by Catheter Techniques” Pain Management Nursing, 8 (2), 48-54.  Association of Women’s Health, Obstetric and Neonatal Nurses. (2012). Nursing care of the woman receiving regional analgesia/anesthesia in labor (Evidence-Based Clinical Practice Guideline). Washington, DC: Author  Association of Women’s Health, Obstetric and Neonatal Nurses. (2014). Role of the registered nurse (RN) in the care of the pregnant woman receiving analgesia and anesthesia by catheter techniques (Position Statement). Washington, DC: Author.  Barash, Paul G. (2013) Clinical Anesthesia. 7th Ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.  Horlocker, T., Wedel, D., Rowlingson, J., et al. (2010). Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy, American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Regional Anesthesia and Pain Medicine, 35 (1), 64-101.  Pasero, Chris, & McCaffery, Margo. (2011). Pain Assessment and Pharmacologic Management. St. Louis: Mosby.  Schreiber, Mary L. (2015) Nursing care considerations: the epidural catheter. Medsurg nursing, 24(1) 273-76.  St. Marie, Barbara, ed. (2010). American Society for Pain Management Nurses. Core Curriculum for Pain Management Nursing (2nd ed.). Kendall Hunt Publishing Co.

AREAS OF RESPONSIBILITY Division of Nursing, Department of Anesthesiology and Critical Care, Department of Inpatient Pharmacy, Department of Rehabilitation Services

______Title: Epidural Analgesia Owner: Acute Pain Service Effective Date: 1/2017 Page 1 of 13 PROCEDURE This procedure is not to be used as a substitute or replacement for independent clinical assessment and judgment. Interventions may be changed, with Anesthesia Care Provider approval, to meet individual patient needs based upon condition and assessment data. 1. Indications: To safely provide analgesia to patient populations for which adequate analgesia is important but impractical or unattainable with other routes of analgesia administration 2. Contraindications (not an inclusive list): 2.1 Absolute 2.1.1 Patient refusal 2.1.2 Allergy to ordered epidural medication 2.1.3 Infection at the (proposed) puncture site 2.1.4 Uncorrected hypovolemia 2.1.5 Increased ICP (intracranial pressure) 2.2 Relative 2.2.1 Coagulopathy 2.2.2 Platelet count < 100,000 2.2.3 Lack of patient cooperation 2.2.4 Unstable neurologic disease 2.2.5 Fixed cardiac output states 2.2.6 Sepsis 2.2.7 Hypertension 2.2.8 Severe anatomic abnormalities of the spine 2.3 Controversial 2.3.1 Inadequate (anesthesia provider) training/experience 2.3.2 Elaborate tattoos at the needle insertion site 2.3.3 Positioning that compromises respiratory status 2.3.4 Non-communicative/anesthetized patient 2.3.5 Previous back surgery 2.3.6 Complicated surgeries with major blood loss

3. Placement and Administration 3.1 The epidural catheter is placed by an anesthesia care provider into the epidural space using sterile technique. Analgesic administration may be by continuous infusion, (with or without an epidural patient-controlled component, i.e. PCEA) and/or clinician-administered bolus. 3.2 Continuous infusions are administered via a calibrated, locked, infusion pump. Either a single agent or a combination of drugs may be utilized. Any and all substances entering the epidural space must be preservative-free. Nothing is ever to be added to an epidural medication bag or infusion after preparation by a pharmacist. 3.3 The Acute Pain Service (APS) RN and other registered nurses with verified competency may increase or decrease the infusion rate and/or make changes to PCEA setting as ordered by anesthesia care providers. (* For care of the epidural patient in Labor and Delivery, please refer to ‘Care of the Obstetric Epidural Analgesia Patient’ addendum.) 3.4 Combination solutions (such as local anesthetics with opioids and/or adjuvants) are synergistic, reducing the required amounts (and side effects) of each type of drug used. 3.4.1 Medication bags for infusion are to be obtained from the pharmacy and appropriately labeled as per pharmacy policy to include final concentrations of each component. 3.4.2 Appropriate pump infusion tubing without injection ports will be used for medication delivery. It is preferable to use pump tubing with yellow coloration to denote medication delivery via the epidural route. Pump tubing will be changed by

______Title: Epidural Analgesia Owner: Acute Pain Service Effective Date: 1/2017 Page 2 of 13 anesthesia care providers or APS RN only and does not need to occur more frequently than every 96 hrs unless tubing becomes damaged or contaminated. 3.4.3 The epidural catheter itself will be labeled as such. If the catheter is of the design that contains a metal coil, it is not considered to be safe in the MRI environment. If a patient with an indwelling epidural catheter is to undergo an MRI, the appropriate (adult vs pediatric) APS must be notified/consulted prior to the patient entering the MRI environment. 3.4.5 Appropriate signage denoting the patient is receiving epidural analgesia should be at the head of the bed or otherwise clearly visible. These signs may be obtained from the APS RN or printed (see attachment) on yellow paper then laminated. 3.4.6 Each nursing unit qualified to care for epidural analgesia patients will be responsible for keeping a key for the medication delivery pumps in the unit’s Automated Medication Management System (AMMS). The unit director or designee will be responsible for this. Replacement keys may be obtained from the Department of Pharmacy. 3.4.7 Every effort must be made to preserve the sterility of the closed delivery system. If there is a break in sterility, wrap the ends of the two portions of the system at the break/disconnect with sterile 4x4 gauze and notify the appropriate APS immediately.

4. Management 4.1 Epidural Analgesia infusions will be initiated by providers in the Department of Anesthesia or the APS RN. 4.2 The APS will manage the epidural analgesia of patients receiving epidural infusions related to acute pain until the epidural catheter is removed. Thereafter, the APS will be available for additional consultation as requested by the primary team. 4.3 The primary service as well as the APS will be notified with changes in the patient’s condition, including side effects to medications and/or complications. The APS can be reached by pager at any time whenever there are patient concerns. If the patient is in the care of the Chronic Pain Service, that service will manage the epidural analgesia. 4.4 The disposition of patients receiving epidural analgesia therapy is to units where nurses are competent in caring for patients receiving epidural analgesia, emergency equipment/ medications are readily available, oxygen delivery is available, and monitoring capability includes continuous ECG, SpO2 and blood pressure measurement. 4.5 Patients receiving epidural analgesia will be cared for on units with continuous monitoring and the nurse: patient ratio does not exceed 1:4 for the nurse caring for the patient with an epidural infusion. 4.6 Initial competency in the care of pediatric and adult epidural patients will be achieved by attending the UNMH four-hour Epidural Analgesia Class. Nurses caring for neonates will complete an abbreviated epidural analgesia class. Subsequent competency will be maintained with annual unit competencies. The online annual competency regarding epidural analgesia is intended to supplement annual unit competencies. The unit director or designee for each nursing unit will be responsible for maintaining a current list of nurses who are competent to care for a patient receiving epidural analgesia by verifying completion of the appropriate epidural analgesia class. Competency will be verified by referring to this list before Licensed Nursing Personnel (LNP) are assigned to care for a patient receiving epidural analgesia. 4.7 The registered nurse providing care for patients receiving epidural catheter or infusion device analgesia for acute or chronic pain relief must be able to: 4.7.1 Maintain the infusion to prevent interruption of medication delivery. This includes: 4.7.1.1 Troubleshooting the infusion device and correcting cause for alarms (i.e. ______Title: Epidural Analgesia Owner: Acute Pain Service Effective Date: 1/2017 Page 3 of 13 Air in line, up occlusion/down occlusion, low volume remaining, end of infusion, low battery or ac power cord missing/not in use, system malfunction) 4.7.1.2 Anticipating the need and securing a replacement medication bag prior to completion of the current infusion medication bag/cassette/syringe. 4.7.2 Provide documentation reflecting successful demonstration of competence related to the management of catheters and pain management infusion devices. A periodic educational/credentialing mechanism is required for each nurse providing this care. 4.7.3 Possess an understanding of the legal ramifications of providing this care. 4.7.4 Identify patient/family educational needs and limitations. Provide patient-focused information/education related to epidural analgesia, using appropriate teaching methods. Pertinent points to include: 4.7.4.1 Concept of epidural analgesia and PCEA (if applicable) 4.7.4.2 Concept of reporting inadequate pain management in order to improve outcomes 4.7.4.3 Potential side effects of medications in infusion solution 4.7.4.4 signs and symptoms to report: 4.7.4.4.1 Pain level at rest of ‘moderate’ to ‘severe’ as translated by the ‘Pain Instrument Crosswalk’ tool 4.7.4.4.2 Increasing level of numbness (decreased sensation) and/or decreasing motor function 4.7.4.4.3 Signs of local anesthetic toxicity (circumoral numbness, tinnitus, blurred vision, metallic taste, muscle twitches, slurred speech, feeling ‘differently’ than usual) 4.7.4.4.4 Increasing level of sedation 4.7.4.5 Vital sign monitoring and expectations 4.7.4.6 Not to attempt to get out of bed without staff assistance

5. Maintenance 5.1 For the duration of epidural analgesia, it is desirable to maintain the following: 5.1.1 an indwelling urinary drain 5.1.1.1 When the epidural catheter has been removed, or the epidural infusion has been stopped in anticipation of epidural catheter removal, the urinary drain may be removed if the patient’s primary team is in agreement. This should occur no sooner than 2 hours after the removal of the epidural catheter or the time the infusion has been stopped in anticipation of the epidural catheter removal. Beginning 24-48 hours post-op, the primary team may opt to discontinue an epidural patient’s urinary drain prior to the removal of the epidural catheter. It is advisable to assess each patient on an individual basis for this, taking into consideration the patient’s surgical procedure, interspace level of epidural catheter, concentration of local agent infusing via the epidural catheter, history of pelvic/urologic/prostate issues, other risk factors for POUR (post-op urinary retention), and length of time the urinary drain has been in place. (* For the care of the epidural patient in Labor and Delivery, please refer to ‘Care of the Obstetric Epidural Analgesia Patient’ addendum.) 5.1.1.2 If the patient does not have a urinary drain in place, frequent monitoring of voiding/bladder status must occur as urinary retention is a potential side effect of both epidural opioids and local anesthetic agents.

______Title: Epidural Analgesia Owner: Acute Pain Service Effective Date: 1/2017 Page 4 of 13 5.1.2 IV access 5.1.2.1 If the patient has received an epidural bolus dose of a lipophilic opioid (i.e. fentanyl) IV access must be maintained for 4 hours after last bolus. 5.1.2.2 If the patient has received an epidural bolus dose of a hydrophilic opioid (e.g. morphine) IV access must be maintained for 24 hours after the last bolus

6. Activity (for patients whose baseline activity level is ambulatory) 6.1 The patient with epidural analgesia may be out of bed if the following criteria are met: 6.1.1 Presence of an LIP order from the primary service for the patient to be out of bed 6.1.2 Orthostatic VS are stable enough for the patient to progress to a standing position, i.e. HR does not increase to more than 20% above supine baseline and/or systolic BP does not decrease by 20% or more below supine baseline 6.1.3 The patient has adequate motor and sensory functions 6.1.4 A staff member should accompany the patient while ambulating. Prior to and following physical/occupational therapy working with an epidural patient, communication should occur between PT/OT personnel and the RN responsible for the patient. The appropriateness of therapy and adequacy of pain management should be included in the discussion. The PT/OT personnel assume responsibility for assessing orthostatic VS and adequacy of lower extremity motor/sensory functions prior to and during the activity session, reporting any issues to the RN.

7. Goals / Desired Outcomes 7.1 Satisfactory pain management 7.2 Early recognition and treatment of side effects and complications 7.3 Ambulation (as appropriate for individual patients’ status/condition) 7.4 Hemodynamic stability 7.5 Progressive bowel function

8. Medications 8.1 Verification/documentation of correct medication components(s), concentration(s), and pump settings (rate, prescription) will be performed with the following: 8.1.1 Change of nursing caregiver 8.1.2 Change of medication infusion bag/cassette/syringe 8.1.3 Change of prescription settings/infusion rate 8.2 Licensed Nursing Personnel (LNP) with verified competency may increase, decrease, or stop infusion rate or make changes to PCEA settings as ordered by an anesthesia care provider. (* For care of the epidural patient in Labor and Delivery, please refer to ‘Care of the Obstetric Epidural Analgesia Patient’ addendum.) Clinician bolusing via the epidural route is only to be done by an anesthesia care provider or an APS RN. 8.3 No additional opioids or sedatives are to be given to a patient receiving opioids via the epidural route without consulting the appropriate APS. 8.4 Anticoagulation medications are to be used cautiously in patients with an indwelling epidural catheter due to the potential of epidural hematoma formation. Please refer to the hospital’s policy/procedure regarding inpatient anticoagulation management for specific information as to medications and dosing in the patient who has an epidural catheter.

9. Assessment/Reassessment 9.1 every 2 hours and PRN:

______Title: Epidural Analgesia Owner: Acute Pain Service Effective Date: 1/2017 Page 5 of 13 9.1.1 Entire medication delivery system for patency, kinks, leaks, security of connections, or inadvertent occlusion, except in Pediatrics (see Age or Developmental Variations box) 9.1.2 To include: pain, level of sedation, respiratory status to include quality and depth of respirations, vital signs (to include HR, RR, SpO2, and BP), motor and sensory functions, infusion rate to include PCEA settings if applicable, and monitoring for potential side effects related to the epidural catheter and/or medications. Pump settings/program review are also to be verified at this time. These elements include: patient ID, drug protocol selection (to include solution components and concentrations), infusion rate, and PCEA settings (if applicable). (See exceptions in section 9.5 below) 9.2 Every 12 hrs and PRN 9.2.1 Catheter insertion site for swelling, erythema, drainage, or tenderness. 9.2.2 Clear shift totals 9.2.3 Clear occlusive dressing for coverage of insertion site; reinforce only (Do not attempt to change dressing as this may result in inadvertent catheter dislodgement.) The clear, occlusive dressing is to be removed or changed only by a member of the APS or other anesthesia care provider. 9.2.4 Epidural catheter removal will be done by an anesthesia care provider/APS member only. (* For care of the epidural patient in Labor and Delivery, please refer to ‘Care of the Obstetric Epidural Analgesia Patient’ addendum.) Observe the site for 24 hours after the catheter is removed for possible skin reaction to tape or adhesive or signs of infection. 9.3 Refer to chart below for minimum frequency of assessment of patients receiving neuraxial opioids: hydrophilic (e.g. morphine, lipophilic (e.g. fentanyl) hydromorphone) not extended- or sustained- release Single 1) continual (q 3 min) for 1st 20 min, 1) q 1 hr during 1st 12 hrs post injection, injection then then 2) q 1 hr until 2 hrs post injection 2) q 2 hrs for 12 to 24 hrs post injection 3) After 2 hrs, frequency to be dictated by patient’s overall clinical condition and concurrent medications

Continuous 1) continual (q 3 min) for 1st 20 min, 1) q 1 hr during 1st 12 hrs of infusion, infusion then then st (with or 2) q 1 hr during the remainder of the 1 2) q 2 hrs for remainder of infusion without 12 hrs after initiation of infusion PCEA) 3) q 2 hrs for remainder of infusion

9.4 For epidural analgesia solutions not containing opioids, routine assessment should also occur every 2 hours. 9.5 If the patient is sleeping at the time a routine assessment is due, it is not necessary to wake the patient for a comprehensive assessment if VS are stable and the respiratory status is satisfactory. Respiratory status should be assessed by direct observation of the patient’s quality and depth of respirations for a full minute. The rationale for the abbreviated

______Title: Epidural Analgesia Owner: Acute Pain Service Effective Date: 1/2017 Page 6 of 13 assessment is to be documented. (The ‘Epidural Comments’ section may be used for this purpose.) 9.6 After initial placement of an epidural catheter and initial medication infusion, the patient will have continuous cardiac monitoring to include SpO2 monitoring. Continuous cardiac monitoring is an expectation of units providing care of SAC status or higher. (* For care of the epidural patient in Labor and Delivery, please refer to ‘Care of the Obstetric Epidural Analgesia Patient’ addendum.) 9.7 Following a pump bolus, an assessment by an RN (to include documentation of VS) is to occur within 30 minutes. It is the responsibility of an anesthesia care provider/APS team member to notify the primary RN or charge nurse when a pump bolus has been delivered. 9.8 Following a clinician-delivered bolus, HR and B/P must be obtained and documented q 5 min x 4. It is the responsibility of the APS to stay with the patient following the bolus until he/she is hemodynamically stable or communicate with the primary RN if it is not possible to remain at the patient’s bedside. (* For care of the epidural patient in Labor and Delivery, please refer to ‘Care of the Obstetric Epidural Analgesia Patient’ addendum.)

10. Notification /Communication to the APS Notify APS for all acute pain related epidural management issues including: 10.1 Pain relief is less than desired 10.2 Pain level at rest is ‘moderate’ to ‘severe’ as translated by the ‘Pain Instrument Crosswalk’ tool, decreased BP, decreased HR, decreased RR, decrease in level of consciousness, inability or difficulty to arouse, and sustained oxygen saturation <90%. 10.3 Uncontrolled nausea, pruritus, back pain, lower extremity weakness, or decreased sensation 10.4 Catheter removal or accidental disconnect 10.5 Rash or blister development at/near insertion site following catheter removal 10.6 Signs of infection, i.e., elevated temp, increased WBC count, increased HR, purulent drainage at insertion site, etc. 10.7 Any change in condition that is not anticipated 10.8 Patient is to undergo an MRI 10.9 Hemodynamic instability following a bolus via the epidural catheter

11. Turn off the epidural infusion for any of the following; institute emergency measures, and notify the APS ASAP: 11.1 Respiratory quality/rate indicating respiratory depression 11.2 Difficulty or inability arousing the patient 11.3 Disorientation/mental confusion/seizures 11.4 BP outside of ordered parameters 11.5 Accidental catheter disconnection or removal 11.6 Sustained SpO2 less than 90% 11.7 Sudden decrease in sensory level, plus sudden onset of motor or function changes 11.8 Signs of local anesthetic toxicity, i.e., hypotension, metallic taste in mouth, circumoral tingling, tinnitus, slurred speech 11.9 Complaints of sudden severe pain to back or lower extremities 11.10 Decreasing bowel/bladder function, foot drop, or loss of tendon reflexes in LE’s

12. Trouble-shooting 12.1. If patient begins to complain of inadequate pain relief, examine insertion site, tubing and pump for problems. 12.1.1 For upstream occlusion/air in line alarm, verify presence of medication solution in the bag, look for kinks/clamps in/on the pump tubing, and inspect system for presence of

______Title: Epidural Analgesia Owner: Acute Pain Service Effective Date: 1/2017 Page 7 of 13 air. If air is distal to the in-line air/particulate matter filter of the pump tubing (between the in-line filter and the patient), this can be eliminated by momentarily disconnecting the tubing from the filter (distal to the pump) and priming/purging the pump solution through the distal filter. If air is proximal to the in-line air/particulate filter (between the pump and the in-line filter), it will likely be eliminated by that filter. Caution must be exercised in order to prevent contamination of either end of the opened infusion system and to prevent air from infusing into the patient’s epidural space. 12.1.2 For downstream occlusion alarms, inspect catheter and tubing for kinks or clamps. 12.1.3 For low/dead battery alarm, verify battery is securely in charger base and connected to an AC power source. 12.1.4 If catheter has been accidentally removed, check the site for bleeding. Notify APS immediately to report the catheter removal and last dosing of anticoagulation agent, if any. Note integrity of catheter and retain for APS inspection. Cleanse insertion site and apply a small band aid. 12.1.6 If catheter becomes disconnected from pump tubing, cover the open end of the epidural catheter with sterile gauze or apply a non-injectable cap and stop infusion. Notify APS immediately for removal. (see section 3.4.7)

13. Documentation (* For care of the epidural patient in Labor and Delivery, please refer to ‘Care of the Obstetric Epidural Analgesia Patient’ addendum.) 13.1 Epidural Analgesia documentation is to be completed in the ‘epidural’ section within the ‘Interactive I & O’ portion of the Electronic Medical Record (EMR) and is to include: 13.1.1 Verification of epidural infusion/medication(s) with change of bag/cassette or change of caregiver to include correct medication protocol (i.e. medications, concentration(s), rate, and PCEA settings) 13.1.2 q 2 hour assessments to include: elements listed in section 9.1.2 as well as the rate of infusion, pump volume remaining and pump volume delivered 13.1.3 q 12 hour documentation is to include: shift total volumes to include PCEA doses (attempted and delivered), pump ACN #, location and condition of epidural catheter insertion site, and elements of epidural analgesia education as described in section 4.7.4 of this procedure. (See Pediatric Units section below for exception re: condition of site.) 13.1.4 Volume of epidural solution when new bag/cassette hung 13.1.5 Additional epidural medication administration (bolus dosing/supplemental medication) by anesthesia care provider or Acute Pain Nurse 13.1.6 Location and condition of catheter insertion site and dressing at least once/shift (See Pediatric Units section below for exception.) The ‘Epidural Comments’ section may be used for this purpose. 13.1.7 Elements of epidural analgesia education as described in section 4.7.4 of this procedure 13.1.8 Appropriate opioid waste procedures per UNMH’s Controlled Substances policy must be followed when discarding remaining epidural solutions containing opioids. 13.1.9 Results of frequent assessments following a bolus or hemodynamic instability

* All items noted with an asterisk denote the need to refer to Labor and Delivery unit-specific variations. Please refer to addendum re: Care of the Obstetric Epidural Analgesia Patient

______Title: Epidural Analgesia Owner: Acute Pain Service Effective Date: 1/2017 Page 8 of 13 AGE OR DEVELOPMENTAL VARIATIONS 1. Non-critical care pediatric units will use continuous SpO2 monitoring for the duration of epidural analgesia. Insertion site will be assessed a minimum of q2hrs and more frequently when patient has experienced loose stools. Assessment of site will be documented. The proximity to the rectum of the caudal/epidural catheter increases the risk of infection due to soiling by fecal material. 2. Patient/family education will be directed to adult family members as appropriate.

DEFINITIONS and Supplemental Information

APS/Acute Pain Service at UNM Hospitals is a consulting service and consists of an attending anesthesiologist and a physician resident who rotate through the service. There is also an Acute Pain Nurse assigned to this service. The APS can be reached 24/7 by referring to AMION. Dermatomes; specific skin surface areas innervated by a single spinal nerve or a group of nerves Epidural space: The epidural space is a potential space containing vasculature, fat, and a network of nerve extensions. The dura mater separates the epidural space from the subarachnoid (or intrathecal) space, which contains cerebrospinal fluid (CSF). Epidural analgesia may be administered in the thoracic, lumbar, or caudal regions of the spine. Local anesthetics (LA’s) disrupt the transmission of pain by blocking sodium channels resulting in slowing/stopping the propagation of the action potential of nerve impulses. Administered via the epidural route, this has the potential to cause a sympathectomy, which results in loss of vascular tone leading to hypotension, especially in hypovolemic patients. (Epidural opioids bind with opiate receptors in the dorsal horn of the spinal cord to prevent/reduce pain transmission.) NRS: Numerical Rating Scale; tool used to measure pain intensity whereas patients self-report level of pain on a 0-10 scale, with 0 being no pain and 10 being the worst imaginable pain PCA: patient controlled analgesia, usually via IV route PCEA: patient controlled epidural analgesia; combination of a basal/continuous epidural infusion with the added component of patient-controlled supplemental boluses via the epidural infusion pump

ADDENDUM: Care of the Obstetric Epidural Analgesia Patient

The pregnant woman differs both physiologically and anatomically from the nonpregnant woman, which can increase the risk for regional analgesia/anesthesia complications (in the pregnant woman). Indications for epidural analgesia may include the woman’s desire for pain relief, or for medical or obstetric reasons. The primary care provider and/or the OB anesthesia team may determine that epidural analgesia is contraindicated in certain conditions.

1. Delineation of Roles: In accordance with the guidelines of the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), the registered nurse and anesthesia care provider have unique roles in caring for the pregnant woman receiving epidural analgesia. A qualified, credentialed, licensed anesthesia-care provider is responsible for the following (the non-anesthetist registered nurse may not perform these tasks): 1.1 Obtain informed consent from the patient for epidural analgesia. 1.2 Insert/place the epidural catheter. 1.3 Verify correct catheter placement. 1.4 Initiate/re-initiate a continuous infusion of epidural infusion or inject any substance into the epidural catheter, to include bolusing either manually or via the epidural pump. 1.5 Manipulate patient-controlled epidural analgesia (PCEA) doses or dosage intervals. 1.6 Increase or decrease the rate of the continuous infusion.

______Title: Epidural Analgesia Owner: Acute Pain Service Effective Date: 1/2017 Page 9 of 13 2. Additional Nursing expectations specific to the Obstetric Clinical setting: 2.1 Preparing for Epidural Catheter Placement 2.1.1 If the patient requests epidural analgesia for labor, a consult to the OB anesthesia care team for epidural placement should be initiated. 2.1.2 After it has been determined by the OB anesthesia care team that an epidural catheter will be placed, administer prophylactic intravenous bolus of non-glucose-containing isotonic crystalloid solution as ordered (typically 500-1000 ml). 2.1.3 Assess baseline maternal vital signs and fetal heart rate pattern. 2.1.4 Encourage the patient to void before the epidural is initiated. 2.1.5 Notify anesthesia provider of patient’s readiness for an epidural. 2.1.6 Ensure presence of epidural pump and its components in patient’s room in anticipation of epidural infusion. 2.1.7 Verify that lab results, including platelet count, are complete and available. 2.1.8 Allow no more than one visitor in the room during the epidural placement procedure. 2.1.9 Provide education to the patient (and visitors) re: epidural analgesia, in particular to emphasize that the labor epidural patient will not be allowed out of bed once epidural has been dosed. 2.2 During Epidural Placement 2.2.1 A registered nurse is to remain in the patient’s room throughout the epidural placement procedure. 2.2.2 Provide positioning assistance and emotional support to the woman during epidural placement procedure. 2.2.3 If possible, assess the fetal heart rate during the procedure. If an indeterminate or abnormal fetal heart rate is noted, initiate corrective measures as needed, and notify the primary-care provider and anesthesia personnel. 2.2.4 Assess blood pressure every 3 minutes during procedure. Continuous pulse oximetry is required throughout procedure. While continuous cardiac monitoring is not a standard requirement, it should be available and initiated as the patient’s condition dictates. Assess fetal heart rate, uterine contractions, and maternal vital signs (BP, HR, SpO2, RR) once regional analgesia or anesthesia is initiated, and every 5 minutes for the first 15 minutes after the procedure. The frequency of subsequent assessment should be based on maternal-fetal response to medication, maternal–fetal condition, stage of labor, unit protocol, and is not to occur any less frequently than every 2hrs. 2.3 Post Epidural Catheter placement 2.3.1 Assess for complications that may be associated with epidural initiation/continued infusion, in particular if the distal tip of the catheter is in the intrathecal space: 2.3.1.1 Local anesthetic toxicity: Assess for drowsiness, light-headedness, tinnitus, and circumoral paresthesia, metallic taste in mouth, slurred speech, and blurred vision. Notify anesthesia personnel immediately if any of these symptoms are present. If ACLS is initiated, anticipate need for Intralipid 20% (1.5mg/kg bolus, followed by a continuous IV infusion of 0.25mL/kg/minute). 2.3.1.2 Assess for numbness or weakness of the upper extremities, dyspnea, weak speech or inability to speak, hypotension, apnea, and/or loss of consciousness. Notify anesthesia personnel immediately if any of these symptoms are noted as any/all of these symptoms can indicate epidural placement in the intrathecal space. 2.3.1.3 Maternal hypotension: Position mother in lateral position, administer intravenous fluid bolus as ordered, and notify anesthesia personnel or primary-care provider, or both.

______Title: Epidural Analgesia Owner: Acute Pain Service Effective Date: 1/2017 Page 10 of 13 2.3.1.4 Urinary retention: Place indwelling urinary catheter after initiation of epidural infusion. Notify physician if <30cc/hr urine output.

3. Continued Assessment/Reassessment During Epidural Analgesia: Refer to ‘section 9’ of the main body of the Epidural Analgesia Procedure above. In addition: 3.1 Monitor fetal heart rate. 3.2 Maintain competency in the operation of the epidural analgesia infusion pump used in the L & D clinical setting. 3.3 Replace empty epidural medication syringe/bag/cassette in the epidural pump containing the same medication and concentration as to avoid interruption of epidural analgesia. 3.4 When stopping the infusion for any reason, the assigned anesthesia care provider is to be notified as soon as possible. 3.5 Initiate emergency therapeutic measures according to protocol if complications arise. 3.6 Continue to evaluate and document maternal pain level/coping with ongoing patient assessments. Educate patient regarding her increased risk for falls. Patients who are maintained on bed rest should be assisted to change position every hour. 3.7 If epidural analgesia will not be continued postpartum, the epidural catheter may be removed by a qualified RN after the recovery period per order from a qualified anesthesia or physician provider. Document the condition of the distal catheter tip appropriately (intact vs not intact). The anesthesia provider should be notified immediately if the tip was not intact and the catheter should be retained for inspection by the anesthesia provider.

4. Documentation may be made in the labor flowsheet portion of the electronic medical record. Nurses with verified competence in the care of the patient receiving epidural analgesia/anesthesia may remove the epidural catheter with an anesthesia care provider order. Documentation must include notations regarding the condition of the insertion site and of catheter tip.

SUMMARY OF CHANGES Changing of verbiage to reflect changes in PCEA delivery modality and correlation with wording/terminology of BBraun pump which is used to deliver epidural analgesia to non L&D patients. Addition of urinary drain details (section 5.1.1.1) to incorporate guidelines should the patient’s primary team desire early removal Minor changes made to clarify existing procedure (opioid witnessed waste in MAR, sustained decreased SpO2, and option of L&D nursing epidural documentation to occur in electronic labor flowsheet). Addition of AWHONN references to support practice differences in L&D Addition of asterisks for referencing practice differences in L&D Addition of OT/PT staff responsibilities and communication with the patient’s primary nurse when working with an epidural patient (6.1.4) Change from assessing medication delivery system to q 2hrs to from q shift (9.1) Replaces “Epidural Analgesia”, last revision 10/2014. Addition of ‘Care of the Obstetric Epidural Analgesia Patient ADDENDUM’

______Title: Epidural Analgesia Owner: Acute Pain Service Effective Date: 1/2017 Page 11 of 13 RESOURCES/TRAINING Resource/Dep’t Contact Information Clinical Education Learning Central; Epidural Analgesia Class E-resources for BBraun BodyGuard 545 Colorvision infusion pump (video of pump inservice, Quick Reference guide, and Operator Clinical Education web page (via the UNMH intranet) Manual) can be accessed on line in the ‘Equipment Resources’ section of the Clinical Education web page

DOCUMENT APPROVAL & TRACKING Item Contact Date Approval Owner ED, Clinical Education Consultant(s) Cindy Gillespie, RN-BC, BSN, CPAN, Tony Yen, MD, Director of Acute Pain Service Clinical Operations PP&G Committee, Nurse Practice PP&G Subcommittee, Committee(s) Y Medical Executive Committee Nursing Officer Sheena Ferguson, Chief Nursing Officer Y Medical Director Tony Yen, MD, Director of Acute Pain Service, Dep’t of Anesthesia Y Official Approver Sheena Ferguson, RN, MSN, CNS, CCRNr Y Official Signature Sheena Ferguson Date: 1-24-17 Effective Date 1/2017 Origination Date 7/1997

Issue Date Clinical Operations Policy Coordinator 1-27-17

______Title: Epidural Analgesia Owner: Acute Pain Service Effective Date: 1/2017 Page 12 of 13 ATTACHMENT Epidural Catheter Sign (signage must be printed on yellow paper and laminated)

√ orthostatic VS and motor/sensory functions priorEPIDURAL to getting patient OOB

CATHETER

NOT MRI SAFE

placed at ______interspace Check orthostatic vital signs and motor/sensory functions prior to getting patient out of bed

______Title: Epidural Analgesia Owner: Acute Pain Service Effective Date: 1/2017 Page 13 of 13