2.  Purpose
 Responsibilities
 Proper Verification and Set-Up
 Assessment and Documentation
 Warnings and Contraindications
 Patient Teaching
 Signs and Symptoms of Local Anesthetic
Toxicity
 Emergency measures
 Conditions requiring notification of
anesthesia provider within 30 minutes.

3.  To establish guidelines for the
safe, standardized care for patients receiving
analgesic medications via epidural, and
continuous peripheral nerve block routes at
Craig Joint Theater Hospital
 It is specifically aimed at all registered nurses
and 4N0s on the ward or Intensive Care and
Intermediate Care units.

4.  The RN is responsible to ensure:
◦ There are current orders in patients chart
◦ CJTH Anesthesia has evaluated all epidurals and
nerve blocks placed prior to arrival (PTA)
◦ Two RN’s will initiate any continuous epidural or
peripheral nerve block infusions and set up the
initial infusion and pump
◦ Label tubing IV or epidural

5.  The RN is responsible to ensure:
◦ Confirm concentration of solution and setting of
PCEA or continuous infusion pump as ordered.
◦ Check epidural site, tubing connection site is
tight, ensure dressing is secure, note drainage;
Qshift
 Some drainage is expected- should be minimal
◦ Document on the Epidural/Peripheral Nerve
Catheter (PNC) infusion flow sheet Q4 hours
◦ Change the infusion bag

6.  A sign will be placed at the head of the bed
and on the wall or door outside of the room
at the entrance to the room reading
 "EPIDURAL PRECAUTIONS” or “peripheral
NERVE CATHETER”
◦ (with anatomic location—i.e. Right supraclavicular /
Left
 An oxygen flow meter with ambu
bag, appropriate size mask, and suction unit
with Yankuer tip will be available for
immediate use.

7.  Two RN’s will verify:
◦ MD orders (both RN’s will note/sign orders)
◦ medication type and dosing with MD orders
◦ programming the Ambit PCA pump
◦ tubing is labeled in two places and pump with
respective labels: “Epidural” or “Nerve Block”
◦ The PCA is hooked up to the proper site
 Epidural site, Nerve Block site, or a PIV
 Ex: Pt’s may have a Dilaudid or Morphine PCA (PIV), as
well as a Ropivocaine Epidural or Nerve Block.

8.  RN will assesses and Document:
◦ sedation level, pain level, dermatomal level, side effects,
tubing labeled, signs posted, emergency equip at
bedside
 The RN will re-document this information on this
form every four hours.
 Catheter Site will be assessed and documented
Qshift
 The initial dermatome level and motor function
will be established and documented by
anesthesia.
 Accepting RN will verify analgesia level and motor
function on acceptance.

9.  DO NOT give anticoagulant medications until
at least 2 hours after Epidural/PNC have been
removed by anesthesia.
 If the epidural dressing becomes
soiled, anesthesia will change the dressing as
needed.
 If epidural or PNC analgesia is deemed to be
ineffective, anesthesia should be notified.

10.  Proper teaching will be completed with the
patient on how to properly use the Ambit PCA
pump.
 Teaching related to epidural and
patient/family response.
 Instruction should be given to the
patient/family to notify staff regarding:
◦ Decreased level of alertness
◦ Slow or difficult breathing
◦ Change in level of pain control
◦ Signs and symptoms of infection

11.  tremors
 seizures
 coma
 respiratory arrest
 hypotension
 dysrhythmias
 cardiac arrest

12.  Early signs: circumoral numbness (earliest)
 Tongue paresthesia
 Dizziness
 Excitatory signs such as restlessness and
agitation often precede CNS Depression
◦ slurred speech, drowsiness, unconsciousness
 Muscle twitching heralds the onset of tonic
clonic seizures
 Respiratory arrest often follows

13.  Local anesthetics depress hypoxic drive
 Apnea can result from phrenic and intercostal
nerve paralysis
 Tx : respiratory support as indicated

14.  Nursing Care Issue:
◦ Q1Hr respiratory checks with pulse oximetry
monitoring
Treatment and prevention
◦ Limit number and dose of additional opioids or
sedatives given
◦ Consider NSAIDS if not contraindicated
◦ Oxygen, call for help/assistance, mask ventilate, call
code if needed, give IV narcan

15.  In general, LA s depress myocardial
automaticity and reduce the refractory period.
◦ This direct myocardial depression causes
bradycardia.
 Heart block (varying degrees), and
hypotension which may lead to cardiac arrest
 Ropivacaine is 70% less likely to cause severe
cardiac arrhythmias than bupivacaine

16. ◦ Turn off the epidural infusion
◦ Stimulate the patient to breathe
◦ Place oxygen on at 10-15L or maximum per minute
by mask.
◦ RN will remain with the patient and have another
staff member bring the crash cart to the bedside.
◦ Notify anesthesia provider immediately.
◦ Support respirations via ambu bag with 100%
oxygen as needed.
◦ If these measures are not effective, follow ACLS
procedures.

17.  Catheter dislodgment. Stop infusion;
◦ save catheter if it becomes completely dislodged for
the anesthesia provider to verify catheter is intact.
(wrap end in sterile 4 X 4)
 Drainage from the catheter site.
◦ NOTE: a small amount of serous/serosanguinous
drainage is normal.
 Pain at the catheter site.
 Vital sign changes.
 Inadequate analgesia.

18.  Signs and symptoms of local or systemic
infection
◦ fever, nuchal rigidity, increased WBC, catheter site
inflammation
 Inability to maintain IV access.
 Intractable pruritis, nausea, vomiting, headache
◦ which is not responsive to treatment already ordered.
 Early manifestations of local anesthetic toxicity:
◦ circumoral numbness or tingling, metallic taste, ringing in
the ears, vertigo, blurred vision.

19.  RN and 4NO Responsibilities
 Proper Verification and Set-Up
 Assessment and Documentation
 Warnings and Contraindications
 Patient Teaching
 Signs and Symptoms of Local Anesthetic
Toxicity
 Emergency measures
 Conditions requiring notification of
anesthesia provider within 30 minutes.

20. ???