Which conditions are contraindications to epidural blocks Select all that apply
This pain management guideline was written by the staff of the Children's Pain Management Service for the Royal Children's Hospital, Melbourne. Show
This guideline may NOT be suitable for use in other institutions.
Indications
Prescription of epidural infusions
Epidural infusion solutions
Epidural infusion set upLines and giving sets:
Securing the epidural catheter:
Epidural catheters:Two epidural kits are used at RCH the Portex 18G and 20G and Braun Perifx® Paed series 18G and 20G
Epidural infusion delivery
Changing the infusion rate:
Epidural boluses:
Duration of infusion:
ObservationsThe following observations should be recorded on the Clinical Observation ChartRespiratory rate, sedation score, heart rate & blood pressure: 1 hourly for the first four hours of the epidural infusion.Respiratory rate & heart rate: 1 hourly AND blood pressure & temperature: 4 hourly - until epidural ceased. [The need for less frequent observations for patients receiving long-term epidural infusions should be discussed with CPMS.] Pain score: 1 hourly while awake (using developmentally appropriate scale eg Wong-Baker Faces scale, Numeric scale, FLACC scale or PAT score for neonates)Vomiting score: 1 hourly for the first 12hrs, then 4 hourly as indicated Pulse oximetry: if indicatedIndications for pulse oximetryPulse oximetry MUST BE implemented and used continuously in high-risk patients with:
or patients receiving:
Clinical indicators for 'spot' pulse oximetry are:
Observations following a bolus of epidural infusion:
Observations following a rate increase:
CPMS should be called if pain relief is inadequate after 2 boluses within a six hour period. Any observations outside reportable limits (as identified on VICTOR) or outside normal values for age should be reported to CPMS +/- the primary treating team. Assessing sensory and motor blockSensory BlockDermatome assessment should be done 4 hourly and at the following times:
Contact CPMS if:
Motor Block:Motor block assessment should be done 4 hourly and at the following times:
Contact CPMS if:
Catheter position and insertion site
Pressure area care
Nerve compression
Intravenous access
Concurrent drugsOpioids
Anti-coagulant medication:
Sedatives
Patient review
Minor problems and managementInadequate analgesia:If the patient complains of pain or appears to be in pain:
Leaking epidural:
Occlusion:The catheters used are very fine. They can easily occlude, thus the infusions may need to be run at higher pressure than is usual for IV infusions. If the infusion pump occludes or is not delivering the programmed rate:
Disconnection:
ComplicationsIF RESPIRATORY DEPRESSION OR OVERSEDATION IS SUSPECTED:
Call CPMS URGENTLY if any of the following occur:
High block (dermatomes >T3)A sensory block above T3 may be result in respiratory distress, decreased SaO2, difficulty breathing, bradycardia, numbness or tingling in fingers or arms, loss of hand function and Horners sign. Back painMild back pain is common and caused by minor trauma related to epidural insertion. However, because of the serious consequences of epidural abscess and epidural haematoma, all back pain after epidural insertion must be reported to, then thoroughly assessed by CPMS staff. Dense motor block (Bromage score 2-3)Moderate motor block is common immediately following surgery due to the higher doses of local anaesthetic used during surgery. Mild motor block is common following this initial period. However, because of the serious consequences of epidural abscess and epidural haematoma, all dense motor block after epidural insertion must be reported to, then thoroughly assessed by CPMS staff. Sedation / Respiratory depressionRespiratory depression or decreased oxygen saturation unresponsive to oxygen therapy may be caused by the addition of opioids to the epidural solution. Clonidine may also contribute to sedation. If there are no opioids or clonidine in the solution but sedation is present a high block or local anaesthetic toxicity must be urgently excluded. FeverIf the patient has a temperature >38.5oC, or is suspected of having sepsis with potential for bacteraemia, the epidural catheter may need to be removed. HypotensionSympathetic blockade may cause hypotension (this is rare in children less than 8 years of age). The addition of clonidine to the epidural solution may increase the likelihood of hypotension. Local anaesthetic toxicitySigns of local anaesthetic toxicity include: dizziness, blurred vision, decreased hearing, restlessness, tremor, hypotension, bradycardia, arrythmias, numbness of tongue, seizures, sudden loss of consciousness. Ceasing the epidural infusion
Removing the epidural catheterAn accredited Registered Nurse can remove the epidural catheter after instruction by CPMS or an anaesthetist. NB If the patient is receiving anti-coagulant medication, refer to concurrent drug section before removing epidural. If there is any difficulty encountered removing the epidural catheter or if any abnormality is detected, CPMS must be called immediately. To remove the epidural catheter:
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