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- 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.
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