Medications
What is the difference between Analgesia and Anesthesia
Analgesia is the relief of pain without the loss of consciousness or sensation using analgesics (e.g., Ibuprofen, Tylenol, etc.).
Anesthesia is the loss of physical sensation with or without loss of consciousness using anesthetics (e.g., Ketamine, Propofol, Isoflurane, etc.).
If pt has symptoms of frontal/occipital headache, photophobia, visual disturbances, nausea/vomiting, and/or neck or back stiffness, what has happened and how do we treat?
Spinal Headache: 1-2% of epidural blocks. Typically present 24-48 hrs post puncture.
Caused by leak of CSF if dura is punctured
Tx: Analgesics (T3), caffeine, fluids and position for comfort. Blood patch (inject blood into epidural space to form patch to stop the leak
How can you promote the spread of solution if patient is experiencing unilateral block?
The catheter may have lodged on one side of the epidural space:
Encourage Pt to lie on the unblocked side
Anesthetist may be able to readjust
Can you stop an epidural infusion for 3 hours and then restart it?
Yes
Epidural space is potential space. Do not flush unless ordered to by anaesthetist.
When would an epidural be an effective form of pain management?
Surgery on lower extremities, abdomen
Post operative or post tramatic analgesia
Obstetrical anaesthesia/analgesia (labour & CS)
If pt unable to tolerate general anesthesia (pre-existing pulmonary or cardiac conditions)
Which drug takes longer to diffuse, Fentanyl or Morphine? Why?
Morphine: (hydrophilic) Not attracted to fatty CNS. It lingers in CSF therefore opioid receptors can be affected for 18-24 hrs. Watch resps and sedation closely
Fentanyl: Lipophilic, diffuses quickly and attaches to opioid receptors in spinal cord (spinal tissue is lipid rich)
The sensory block is above T4 when performing an "ice check" on your pt with an epidural. What are your actions
If it was a spinal it would be more significant. But due to low concentrations of local anesthetic in epidurals it can be common, especially in thoracic placements. Ensure ability to deep breath or cough, no muscle weakness, no bradycardia or hypotension.
The epidural pump is alarming "air in line". You notice a small air bubble. What do you do?
Air bubbles are not considered dangerous as the epidural space is a potential space. If it will not effect the amount of medication given there is no need to be concerned about small amounts of air in the line
How long post epidural infusion must you maintain IV access?
4 hrs after infusion with Fentanyal
24 hrs after infusion with hydromorphone or epimorph
What are some contraindications for epidural/spinal anesthesia
Untrained staff
sensitivity to local anesthetic
Concurrent or recent anticoagulation
uncorrected hypovolemia
pt refusal
infection at site of insertion
To prevent neurotoxicity medication delivered via spinal or epidural routes must be _______
Preservative free
Fentanyl is preservative free
Epimorph is preservative free Morphine
2 complications of epidural therapy that requires STAT recognition and intervention.
Infection (rare): risks: immunocompromised, diabetes, malignancy, steriod use, difficult insertion and prolonged catheterization. Symptoms: similar to hematoma with s&s of infection.
Epidural Hematoma (rare): Risks: multiple attempts, anticoagulants, meds that alter coagulation, liver & kidney impairment, insertion or removal (greatest risk). Symptoms: back pain/tenderness (cardinal sign) poor pain relief, weakness, bowel or bladder dysfunction, numbness or paralysis.
The pump alarms that the epidural catheter is blocked. what can you do to troubleshoot?
Inspect for integrity and kinks
Try to reposition patient
if not resolved suspect catheter occlusion or subcutaneous kinking and inform Dr.
In what order does an pt with an epidural loose nerve function (due to the local anesthetic agent)
sympathetic: dilation of skin and arteries
Temp and pain
Touch and pressure
Proprioception (spatial awareness of body)
Motor function
Return in reverse order as meds wear off
Your post-op Pt is experiencing pain despite administering post-op analgesia as ordered. Do you call the anesthetist or the surgeon for further orders?
Anesthetist while epidural infusing.
Anesthetist for 24 hours post single dose epidural or spinal (epimorph)
Only the anesthetist shall order all narcotics, analgesics, NSAIDS, CNS depressants and provide consultation for inadequate analgesia or other problems related to analgesia.
When is it safe to remove an epidural catheter if your patient is taking a Low Molecular Wt Heparin Med? (time frame)
12 hours after the last dose.
Do not administer for 4 hrs post removal
Can receive LMWH while on epidural infusion
Needle placement: 12 hrs after last dose of daily LMWH
Local anaesthetic toxicity!
What can cause it?
What are the signs and symptoms?
Cause: Absorbed & circulated systemically (high infusion rates and concentrations), Catheter migrate to epidural vein, admin into IV line, older adults have decreased ability to clear.
S&S: Early: Perioral numbness /tingling/ tinnitus/ dizziness/ metallic taste in mouth
Late: blurred vision/ shaking/ excitement confusion/ sedation/ hypotension/ bradycardia/ heart block/ convulsions/ Loss of consciousness
Lower head of bed, O2 if necessary
IV bolus (if ordered)
Stop epidural if necessary and contact anesthetist
Ephedrine (vasoconstriction): Full Monitoring (ECG) Though for perinatal use only: Advanced Monitoring & Perinatal Monitoring
(cardiac monitoring not required in NH for patients with epidurals)
RN can administer direct IV for hypotension
When do you perform a neurological check post catheter removal?
4-6 hrs post removal
When to use: in pain, going to ambulate...
How to use it: push button, ONLY pt
Can not overdose:
Why are Opioids and Local Anesthetics both used in Epidurals and Spinals
They work synergistically to provide better analgesia with fewer side effects
Why is migration of an epidural infusion into the subarachnoid space a life threatening event? What may it look like?
Meds given via epidural route are 10x more potent than those given intrathecal (into spinal fluid).
Opioids: decreased ventilation and LOC, sedation
Anesthetic agents: rapidly increase sensory and motor block, bradycardia, hypotension, unconscious, cardiac arrest.
Stop infusion, call anaesthesia, monitor, code blue!
Treatment of hematoma is surgical evacuation. Permanent damage can occur within what time frame?
6-8 hours
Will need to be identified and flown out *Life or Limb* to receive surgery
What factors influence the level of analgesia (5)
Site of catheter insertion (middle of the dermatome segment)
Volume and rate of infusion determines the spread (higher rate = larger spread)
Age: older need smaller amount due to size and compliance of epidural space
Height: shorter ppl need less
Concentration of the anesthetic agent
What are some adverse effects of unrelieved pain?
Cardio: unstable angina, MI, DVT, PE
Resp: Atelectasis, Pneumonia, Hypoxemia
GI/GU: Constipation, Anorexia, Ileus
Metabolic: High sugars, wt loss, slow wound healing, decreased immune function
Skeletal: Immobility, weakness, Fatigue, muscle wasting
Psyc: increased pain, poor sleep, suffering
CNS: chronic pain