For postoperative pain, epidural analgesia may be the most effective medicine.

But there are a few

things nurses need to know about managing the patient, including the early warning signs of
complications and what to doand what not to doif they occur

Nurses have always faced the challenge of

managing pain in postoperative patients
while keeping adverse effects to a
minimum. Comfort measures, psychological
support, and pharmaceutical agents are all
part of the arsenal, but perhaps one of the
best tools is continuous epiduralanalgesia.
As with all pain management strategies,
however, careful assessment and a quick
response to trouble are imperative.
Continuous epidural analgesia is used to manage pain after major thoracic, abdominal, and orthopedic surgery.
It works by blocking transmission of pain at the spinal cord and has been shown to blunt the surgical stress
response, improve postop pulmonary function, decrease the incidence of postop thrombosis, and provide better
analgesia during walking, coughing, or other activity.1
Epidural opioids and local anesthetics also decrease postop complications and shorten the hospital stay, which
decreases costs.2
But most of all, the patient on continuous epidural analgesia receives stable, consistent pain relief instead of
experiencing the peaks and valleys associated with most other pain control methods. When patients aren't in
pain they are more willing to participate in and comply with postoperative care plans, and they're more likely to
be satisfied with their care.
For all its advantages, though, epidural analgesia isn't perfect. It can't control the pain of some surgical
procedurescraniotomies, for instancebecause of the location of the stimulus; there is a risk of epidural
hematoma among patients on anticoagulant therapies; and there is a higher level of expertise required of the
physician and nurse.
At most hospitals, only anesthesiologists and certified registered nurse anesthetists (CRNAs) are allowed to
insert and manage epidural catheters. The rationale is that their specialized expertise provides the best clinical
resource for patients. The anesthesia provider obtains informed consent; your role is to provide appropriate
forms, witness the patient's signature, and ease communication between the patient and the anesthesia
provider.

Minimize complications with proper positioning

Before the epidural catheter is inserted, you will position the patient either on his side in the fetal position
(lateral decubitus), or seated on the edge of the bed, slightly bent forward, with his feet dangling. These
positions open the spaces between the vertebrae and ease insertion of the catheter into the epidural space, the
area within the spinal canal outside the dura mater, which contains fat, blood vessels, and spinal nerves.3 The
choice of positioning is determined by the patient's condition or the anesthesia provider's preference.1
Strict aseptic technique is important during insertion to prevent infection or abscess, a rare but serious
complication.
After the patient is prepped and draped, local anesthetics are administered into the skin at the insertion site,
and a small-bore spinal needle, usually 20 gauge, is inserted into the epidural space by the CRNA or
anesthesiologist. Your job during catheter insertion is to ensure patient safety during the positioning, monitor
vital signs, including SaO2, and provide reassurance and comfort measures.
After the catheter has been threaded into the epidural space, the anesthesia provider injects a test dose of
local anesthetic to ensure proper placement. Expected effects of the test dose include changes in heart rate
and blood pressure, plus a change in sensation below the level of insertion. Other effects may include
palpitations, headache, respiratory depression, and dizziness.4
Once the catheter has been placed, a transparent stabilizing dressing is applied. This lets the nursing staff
assess the insertion site for signs of infection, leakage, or dislodgment.

The epidural catheter tubing must be correctly labeled and have no injection ports. This prevents inadvertent
administration of solutions or medications into the epidural space. At my hospital we use yellow striped tubing
and big yellow tabs labeled "EPIDURAL CATHETER." At most institutions, only anesthesia providers are
allowed to inject solutions into the epidural catheter.
The nursing staff is responsible for maintaining the system and administering prescribed medications, but only
via an infusion pump. You'll monitor and maintain the continuous epidural infusion according to the inserting
practitioner's orders. Most hospitals allow only the pharmacy and the anesthesia provider to mix solutions to be
given through the epidural catheter because it lessens the risk of paralysis-causing injury from solutions that
contain preservatives.
Medications used for epidural analgesia can be grouped into two categories: opioids and local anesthetics.
These can be given individually, but they're usually used together.
Epidural medications relieve pain by diffusing into the cerebrospinal fluid in the subarachnoid space, which is
between the dural space and the spinal cord. The medications act on the spinal cord and nerve roots to block
conduction of pain stimuli to the brain.1
The areas of the body in which pain stimuli are blocked or altered depend on the spinal level at which the
medication is administered, the specific medication used, and its strength.5This is why epidural analgesia is
sometimes called "painting the fence," or segmental blockade. It can be achieved for a particular dermatome
range while sparing the dermatome levels below the range.
For example, pain can be relieved in the abdomen, but the legs and feet will be unaffected by the medication,
allowing the patient to walk. This is in stark contrast to spinal or subarachnoid medication, which provides
sensory and motor block from the injected dermatome down. You can accurately predict the effect of the
medication by referring to the specific dermatome on a chart.
Dermatome charts show the spinal levels and the affected regions of the body. For example, the T10
dermatome affects sensation at the level of the umbilicus, L2 at the thigh, and L3 at the knee. The use of this
standard reference makes communication between practitioners easier.

The effects of opioids and what can go wrong

Opioids produce a segmental analgesic effect of the dermatomes near the catheter tip. The ones most
commonly used for epidural analgesia are morphine sulfate (Duramorph), fentanyl citrate (Sublimaze), and
sufentanil citrate (Sufenta). (See the table for more details on these drugs.)
Although they offer effective pain relief, opioids can produce several complications:
Respiratory depression is characterized by a respiratory rate of fewer than eight breaths per minute, oxygen
saturation of less than 90%, and a decreased level of consciousness. If respiratory depression occurs, stop or
slow the rate of the epidural infusion, administer an IV push of 0.4 mg of naloxone HCl (Narcan)provided you
have a standing order to do soand notify the anesthesia provider.
Ventilate with an ambu bag if the patient isn't breathing. In an extreme emergency, call for intubation.
Respiratory depression can occur up to 20 hours after morphine is stopped, so careful monitoring is essential.6
Urinary retention is characterized by a higher intake of fluids than output. The patient may complain that he
feels as though he needs to urinate, but can't. If he has not urinated in six to eight hours, you should assess the
situation by palpating the bladder. Be sure to notify the surgeon or anesthesia provider. The patient may need
to be catheterized and you'll need to keep careful track of fluid I&O.
Itching is most often treated with 25 mg of diphenhydramine HCl (Benadryl) every four hours, administered
intravenously.
Local anesthetics administered into the epidural space provide excellent analgesia but produce sympathetic
blockade, which causes vasodilation, hypotension, and motor blockade, hampering the patient's ability to
move. The drugs that are used most often are lidocaine HCl (Xylocaine), bupivacaine HCl (Marcaine,
Sensorcaine), and ropivacaine HCl (Naropin). (The table gives details on onset and duration of effect.)

The dose and effects vary according to the concentration of the medicationlidocaine comes in solutions of
0.5%, 1%, and 2%, for exampleand whether the solution contains epinephrine, which increases the duration
of blockade.
Using opioids and local anesthetics in combination maximizes the benefits of both classes of drugs and
reduces the adverse effects.

Nurses are the front line of patient management

Nursing care of the patient with a continuous epidural infusion includes educating the patient and family and
assessing the levels of pain relief and sensory/motor blockade. But the most important part of your duties is to
keep a close watch for a number of complications:
Abscess is rare, but serious. Symptoms begin one to three days after surgery and include back pain, fever,
flaccid paralysis followed by spastic paralysis, an elevated white blood count, sensory and motor changes, and
a positive Brudzinski's signan involuntary flexion of the patient's hips when his neck is flexed. Abscesses are
treated with surgery and antibiotics.
Epidural hematoma manifests with severe back pain, lower extremity paresthesia, and a change in sensory or
motor function without definable cause. If you notice any of these conditions, immediately call the anesthesia
provider, who likely will call for a neurosurgery consult.
The patient will need a CT scan to confirm the diagnosis, and then emergency surgery. Paralysis is usually
reversible if surgery is done within six hours of onset. The chance of epidural hematoma is increased if the
patient is getting anticoagulants.
Cauda equina syndrome is a rare complication that causes back pain, motor weakness in the lower
extremities, sensory deficits, "saddle" anesthesia, urinary retention, and bowel incontinence. It is caused by
compression of the neural elements below the end of the spinal cord, at L1 - 2, and it can lead to permanent
damage or paralysis. Report the symptoms immediately.
The patient will need a CT scan to confirm the diagnosis and immediate surgery to relieve the symptoms.
Catheter migration causes nausea, a decrease in blood pressure, and a loss of motor function without a
definable cause. It's important to call the anesthesia provider immediately.
Sympathetic blockade is characterized by decreased blood pressure and, less commonly, a decreased heart
rate. Have the patient lie flat with his legs elevated, then be sure to notify the anesthesia provider, who likely
will order an IV fluid bolus, and possibly ephedrine sulfate. You will need to monitor the patient closely.
Toxicity caused by the local anesthetic will manifest differently according to the drug, but general symptoms
include lightheadedness, numbness of lips and tongue, visual and auditory disturbances, muscle twitches,
unconsciousness, seizures, coma, respiratory arrest, prolonged PR and QRS intervals on an EKG,
bradycardia, and sinus arrest.
Allergic reaction is another serious complication, characterized by hives, respiratory distress, and
anaphylaxis. If an allergic reaction develops, stop the infusion, notify the anesthesia provider, and begin
supportive measures to treat the symptoms.
Dural puncture during insertion of the epidural catheter is an inherent risk because of the close proximity of
the epidural and spinal spaces. If the needle or catheter punctures the dura, cerebrospinal fluid will be
aspirated and the anesthesia provider will often reinsert the catheter at a different spinal level.
It's not a serious complication, but the patient has up to an 80% chance of developing a headache.5 The
headache, believed to be the result of a loss of cerebrospinal fluid through the dural tear, usually begins in the
occipital region and radiates to the frontal and orbital regions. The patient will often complain of associated
cervical muscle spasm. The pain is worse if the patient sits up or stands, and he may have nausea, vomiting,

sweating, dizziness, stiff neck, tinnitus, photophobia, double vision, trouble focusing, or see spots before the
eyes. Treatment consists of bed rest, analgesics, and liberal hydration.
Postdural headaches usually resolve in 24 - 48 hours. Patients whose headaches persist beyond 72 hours or
for whom it's the only thing keeping them hospitalized are candidates for an epidural blood patch. The patient's
own blood is injected into the epidural space, where it clots and seals the dural tear. The loss of cerebrospinal
fluid stops, and 95% of the time, the postdural headache goes away.6
Nausea is also a common reaction to epidural analgesia. It's usually treated with 10 mg of IV metoclopramide
(Reglan) every six hours.
Breakthrough pain may also occur. The patient may exhibit signs of restlessness, increased respiratory and
heart rates, and elevated blood pressure, and he may complain of pain. Do not give the patient any additional
oral or parenteral narcotics without the express order of the anesthesia provider. He or she may order 15 - 30
mg of IV ketorolac tromethamine (Toradol) or administer a manual bolus of epidural medication.
Limited mobility in areas not affected by the sensory/motor blockade and orthostatic hypotension are common
reactions. Don't let the patient get out of bed without assistance, and then only if the surgeon has approved it.
Elevate the head of the bed 30 - 40 degrees.
It's up to you to manage the epidural drip and provide prompt intervention if the patient has complications. It's
also important to monitor the patient's vital signs frequently. Check BP and pulse every hour for the first two
hours after the catheter is inserted, then every two hours. Respiration should be checked every hour for the first
day, then every two hours.
Check sedation levels every hour, and sensory and motor functions every two hours. Check the dressing every
two hours, and if it becomes wet, shut off the infusion and call the anesthesia provider.
System checks should be done with each assessment. Checking the tubing connections will provide early
recognition of breaks in sterility, which could severely compromise the patient.
Policies for management of epidural analgesia vary from hospital to hospital, so you should look up your own
institutional policy to see what your precise responsibilities are.
Managed properly, continuous epidural infusion provides excellent pain relief without limiting the patient's
involvement in postop activities. It decreases postop complications caused by pain and immobility. Your
diligence in care will reward the patient and the healthcare team by decreasing postop complications,
increasing customer satisfaction, and decreasing hospital costs.