Which condition would the nurse recognize as a contraindication to subarachnoid and epidural blocks

Introduction

Definition of terms

Aim

Indications

Initial assessment

Ongoing assessment

Special considerations

Dermatome distribution (Dermi Boy RCH)

Assessing sensory block

Assessing motor block

Managing complications/troubleshooting

Removal

Documentation

Education

Companion documents

Links

Evidence Table

Introduction

Regional anaesthesia (RA) or neuraxial analgesia is the administration of local anaesthetic (LA) into the epidural space through an indwelling catheter. Epidural analgesia has shown to provide better pain relief than parenteral opioids. Children can experience moderate to severe pain post-operatively and is likely to be worse in the first 24-72 hours.

Uncontrolled pain can cause stress responses that are detrimental to recovery. RA provides excellent analgesia and reduces surgical stress response while decreasing the need for opioids. RA (epidural) is used for moderate to severe pain.

The insertion of the epidural catheter will be determined by the type and site of surgery. This will enable the LA effect to block the nerve impulses associated with the area of spinal nerves innervating the surgical site and giving the best post-operative analgesia.

It is important to communicate with families and children about the expectation and sensations of the epidural and why it is important to assess and monitor observations.

It is important to understand and identify epidural complications to ensure the safety of the patient and provide effective analgesia.

Children and young people who have an epidural analgesia require suitably trained nursing staff to care for them to minimise side effects, complications and ensure analgesia is optimal.

Aim

To provide nursing staff with a standardized guideline to enable safe and appropriate care of children and young people with an epidural
To provide excellent analgesia to a discrete area of the body by blocking the sensory nerves
To minimize the opioid requirement for pain management in the post-operative period
To optimise rest and mobility
To recognise problems and minimise complications
To prioritise the epidural as the first line analgesia

Indications

Epidurals are used for major surgery to provide the best analgesia with minimal side effects

Children who have a physical impairment who may be sensitive to opioids

Children who have poor respiratory drive who would be more sensitive to opioids alone

Children who have cerebral palsy and experience high muscle tone and undergoing orthopaedic surgery

Definition of Terms

Central block

Central neuraxial block (spinal, epidural and caudal)

Epidural

Epidural space is the Between ligamentum flavum and the dura mater
Contains fat, blood and connective tissue
Epidural space extends from the foramen magnum to the coccyx
Spinal cord ends at L1-2.

Dermatome

At each vertebra a nerve root exits from the spinal cord. A dermatome is an area of skin innervated by a single spinal nerve.
The nerve roots exit bilaterally from each vertebra

Sensory nerve

Sensory nerves respond to pain, temperature, touch and pressure. Pain and temperature nerve fibres are affected by LA.

Local anaesthetic (LA)

A drug that reversibly blocks the transmission of pain along nerve fibres
LA can block transmission in autonomic, sensory and motor fibres

Initial Assessment

The initial assessment of a child with an epidural is in the Post Anaesthetic Care Unit (PACU) to ensure a base line is documented and the epidural is effective. This will include the prescription and pump setting, the position of the epidural catheter, the sensory block (dermatome spread) and the motor block (Bromage).

A pain assessment should also be documented at this time.

The sensory block and motor block should be documented in the Flowsheets in EMR, noting the motor block may be dense due to the possible higher concentration of LA given intra operatively.

All general post-operative observations, fluids and medications should be checked and documented at this time

Any issues with sensory or motor block identified by the PACU nurse should be escalated to the treating anaesthetist and or the In-charge anaesthetist. These issues should be communicated to the CPMS team prior to patient transfer from PACU.

Management and Physical Assessment

The sensory block should be assessed 4 hourly and on the following times

In PACU after rousing from the anaesthetic, and immediately after patient initial bolus dose
On return to the ward
If the patient complains of pain
One hour after a bolus or rate change

The motor block should be assessed 4 hourly and at the following times

In PACU after waking from the anaesthetic
On return to the ward
Prior to ambulation if required
One hour after a bolus or rate change

The catheter insertion site should be checked 8 hourly for any redness, tenderness or leaking. If visible the catheter markings should be checked to make sure there has been no movement of the epidural catheter. The dressing should also be checked and reinforced if any tape is lifting

The epidural would be expected to last for 3- 4 days unless there are adverse events

Pressure care

https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pressure_injury_prevention_and_management/

The decreased sensation and movement cased by the epidural analgesia may cause nerve compression and pressure areas.

Pressure care should be strictly observing susceptible areas such as heels, lateral malleoli and sacrum.

Pressure mattresses, and pressure supports should be used and documented.

Often children who require epidural anaesthesia are a high risk for pressure acquired injury.

However, all children who have an epidural need to be assessed for an individual prevention plan based on the Glamorgan Pressure Injury Risk Assessment Tool.

Clinical observations

Clinical observations are to continue until the epidural has ceased including hourly sedation, heart rate, respiratory rate, pain score (while awake).

Blood pressure and temperature are to be assessed 4 hourly until the epidural has ceased.

Ongoing assessment

Any adverse events or concerns about the epidural or patient should be reported to the Children’s Pain Management Service (CPMS) urgently

Any clinical observations outside the parameters for age should be reported to CPMS. A fever 38.5 degrees and above must be reported to CPMS urgently Pge 5773

Any changes or increase in pain should be reported to CPMS urgently

Any changes in the sensory block becoming high above T3. No block or inadequate to relieve pain should be reported to CPMS Pge 5773

Special considerations

Neonates rarely have epidural analgesia but the main difference is a lower concentration of LA and/or a lower hourly rate and the expected duration is 36 hours

Epidurals for children and Neonates information

https://www.rch.org.au/anaes/pain_management/Epidural_Infusion/

and

Neonatal opioid and epidural competency and Epidural competency

at Learning Hero

www.rch.org.au/orgdev/HERO/

Dermatome distribution (Dermi Boy RCH)

Assessing Sensory Block

Procedure for assessing the sensory block

If the patient is able to understand and report

Explain the procedure to the patient and family
Wrap an ice cube in tissue or paper towel leaving an area exposed
Place the ice on an area well away from the dermatomes and ask how cold does this feel
Apply the ice to an area expected to be numb and ask if it feels the same cold as your face or different?
Apply the ice above and below this area until you determine the upper and lower dermatomes blocked
Assess one side then the other to see if the block is unilateral or bilateral

Patients may report the ice feels warm, the same or colder.

NB: If the patient is unable to understand or report due to age or cognition, an assessment should still be performed and documented.

While assessing the epidural block, observe for any change in facial expression as the ice is applied, muscle flinching or pushing away.

Gentle palpation over the surgical site can also give an impression of comfort if the epidural is effective or pain if the epidural is not effective.

Assessing Motor Block

Motor nerves as well as sensory nerves may be affected by LA

It is important to assess motor block:

To prevent pressure areas
To assess safety for standing/walking if allowed
To detect complications e.g. epidural haematoma, or abscess

Procedure when assessing motor block

Explain procedure to patient and family
Ask the patient to flex their ankles and knees
Document the score in the clinical observation chart

There may be a difference between legs

Assess if the patient is able to move their feet or knees prior to the epidural e.g. some children with neuromuscular impairment may not be able to voluntary move and poor pro-perception can also make it difficult

Management complications/troubleshooting

Report to CPMS Pge 5773 urgently if

Any major change in motor function
Almost complete or complete motor block in legs
Reduced motor function in hands or fingers (with a thoracic epidural)
All patients who have an epidural in situ must have a working intravenous (IV) to allow access for any adverse events.
CPMS must be notified if the patients’ vascular access IV has dislodged.

The three groups of problems associated with epidurals

Headache (post dural puncture headache) If the epidural needle has inadvertently penetrated the dura and there is a CSF leak the patient may experience a low- pressure headache. This may not be evident until the patient mobilises. This is a very low incidence and most cases improve spontaneously. Conservative treatment is rest, fluids, analgesia and rarely a blood patch (autologous blood inserted into the epidural space). (Anaesthetic procedure)

Back pain This is usually at the insertion site, it is common and transient. Moderate to severe back pain must be reported to CPMS urgently for investigation
Epidural abscess - this is very rare.
Epidural haematoma - this is very rare and will require urgent investigation.
Both abscess and haematoma will present with moderate to severe back pain and sensory and motor deficits

Overdose/toxicity
Signs of LA toxicity are dizziness, blurred vision, decreased hearing, restlessness, tremor, hypotension, bradycardia, arrhythmia, seizures, and sudden loss of consciousness.
Cease the RA infusion
Resuscitation and management of cardiac, neurological and respiratory side effects

Pain escalation
Check dermatomes, if there has been a reseeding block an epidural bolus may be required and the rate may need to be increased
The first line analgesia is an epidural bolus before other analgesia.
Has the epidural catheter become disconnected?
Has the epidural catheter dislodged?
Is the epidural leaking?

Lumber epidurals

Children and young people who have lower limb surgery will have a lumber epidural and as this area innervates the urinary bladder it is important for the child/young person to have an indwelling urinary catheter inserted while in theatre. This will need to stay in until the epidural infusion has ceased.

Removal of the epidural

At the same time the epidural infusion has ceased it is important to give other prescribed analgesia to ensure pain management is optimised as the LA wears off over the next 4-6 hours.

Removal of the epidural catheter is performed using standard aseptic technique

Explain the removal technique to the patient and carer with age appropriate language
Have the patient sitting up and bending gently forward or lying on their side supported and comfortable
After turning the epidural infusion off, remove tape in the normal way, holding the epidural catheter at the site of insertion at the skin gently pull with a steady pressure. If there is any difficulty in removing the catheter stop and call CPMS Pge 5773

Documentation

The site needs to be assessed and findings documented
The epidural catheter needs to be assessed and the cm at the skin needs to be documented.
The tip of the catheter needs to be observed to be intact.
The exit site does not require a dressing, however the site needs to be checked in the next 12-24 hours for any abnormality such as infection or haematoma.

After the removal of epidural analgesia IV or/and oral analgesia will be needed as regular and PRN to ensure the patient is able to continue recovery.

Education needs

All families are given an epidural information card from CPMS outlining any issues to be concerned about once they have gone home

A contact telephone number for RCH and CPMS is provided for the family if they have any ongoing concerns.

Companion Documents

parent information (Kids Health Info)
procedures (comfort Kids)
assessment tools (Pain assessment)
staff training and learning packages (learning Hero)

Evidence Table

You can view the evidence table for this nursing guideline here.

Please remember to read the disclaimer.

The development of this nursing guideline was coordinated by Sueann Penrose, Registered Nurse, Anaesthesia & Pain Management, and approved by the Nursing Clinical Effectiveness Committee. First published June 2020.