Title: Pre-reading about Epidural Analgesia for Children
1Pre-reading about Epidural Analgesia for Children
- Royal Childrens Hospital
- Melbourne Australia
2What is epidural analgesia?
- Epidural analgesia is a regional analgesic
technique where locally administered agents such
as local anaesthetics (often in conjunction with
opioids or clonidine) are used to block pain
pathways in the spinal cord or spinal nerve roots
3 Why use an epidural?
- Advantages
- excellent analgesia is possible
- improved post-operative mobility
- improved respiratory function
- reduced use of opioids
- improved peripheral circulation
- decreased endocrine and metabolic response to
stress
- Disadvantages
- degree of practice skill required
- extra supervision needed
- possibility of complications
- analgesia not always totally effective
4Indications for epidural analgesia
- Major surgery
- Prevention of specific complications
- eg muscle spasm following orthopaedic surgery
- Improvement of surgical outcomes
- eg improved blood supply following skin flap
grafts - To minimise the use of opioids
5Contraindications to epidurals
- (Some are relative contraindications only)
- Allergy or hypersensitivity to amide anaesthetics
- Bleeding disorders or use of anti-coagulants
- Infection - locally or systemically
- Spinal abnormality or previous spinal surgery
- Patients at risk of compartment syndrome
- Patients at risk of neurological complications
- Inadequate staffing on ward
6What to tell children/parents
- Sensations to expect
- eg numb and heavy legs, tingling, or no sensation
- Pain relief
- eg often complete, but may be partial
- Monitoring required
- regular BP, HR, RR, Temp, SpO2
- Urinary catheter may be required
- usually only if lumbar epidural
7How local anaesthetics work
- Local anaesthetics block nerve impulses in
sensory, motor and autonomic nerve fibres - The sensory nerve fibres respond to pain,
temperature, touch and pressure
8Drugs used in epidurals
- Short-acting local anaesthetics Lignocaine
- Medium/Long-acting local anaesthetics Levobupiva
caine - Ropivacaine
- Other drugs Adrenaline
- Clonidine
- Opioids
9Adding opioids to epidurals
- Opioids are added to local anaesthetic to enhance
analgesia - Lipid soluble drugs have a more rapid onset, act
more locally and are shorter lasting - Lipid solubility
- fentanyl gt hydromorphonegtmorphine
10Spinal vs Epidural vs Caudal
- Different techniques are used depending on the
type of surgery and the need for postoperative
analgesia
11Spinal
- Drugs are administered into the intrathecal space
- Usually a single shot prior to surgery, but
the catheter can be left in situ - Local anaesthetic /- opioid may be used
- Duration of single dose of opioid is variable
(eg morphine 4-24 hours), thus risk of delayed
respiratory depression
12Anatomy of the spinal space
- Intrathecal space situated between the pia and
arachnoid mater (also called spinal or
subarachnoid space) - Contains CSF, the spinal cord, spinal nerves and
blood vessels - Subarachnoid space ends at the second sacral
vertebra - The spinal cord ends at L1/2 (adults) or L3/4
(neonates)
13As appears in McCaffrey M, Pasero C Pain
Clinical Manual, p218, 1999, Mosby, Inc.
14Epidural
- Drugs are administered into the epidural space
- Drug infuses thru to CSF/spinal nerves
- Local anaesthetic /- opioid or clonidine may be
used - The epidural catheter is usually left in situ
and an infusion or boluses of analgesic solution
are given
15Anatomy of the epidural space
- Epidural space is between ligamentum flavum and
the dura mater - Contains fat, blood vessels and connective tissue
(the spinal nerves pass through epidural space) - Epidural space extends from the foramen magnum to
the coccyx
16As appears in McCaffrey M, Pasero C Pain
Clinical Manual, p216, 1999, Mosby, Inc.
17Caudal
- Drugs are administered into the caudal epidural
space - Local anaesthetic /- adrenaline /- opioid /-
clonidine may be used - Adrenaline or clonidine may be added to the local
anaesthetic for a longer lasting block - In neonates epidurals may be inserted at caudal
level and threaded up to thoracic level
18Anatomy of the caudal space
- Caudal space is well below the termination of the
spinal cord - Caudal space lies within the sacral bone (which
is not fully ossified in children) - It is accessed via the sacrococcygeal membrane at
level of sacral hiatus (S5-coccyx)
19Epidural set
- The 18G and 19G PortexTM epidural kits can be
distinguished by the colour of the hub on the
filter and the size of the epidural catheter - 18G kit has blue hub
- 19G kit has white hub
20Securing epidural catheters
- Accidental or deliberate removal of the epidural
catheter by children can be a problem - The use of non-allergenic tape to secure the
epidural catheter to the skin and covering all
vulnerable points of disconnection from
childrens fingers will decrease the likelihood
of premature dislodgement
21Epidural insertion site
- A sterile sponge is often applied at the
insertion site to soak up any leaking epidural
solution - An occlusive clear dressing is placed over the
sponge
22Taping the epidural catheter
- The epidural catheter must be securely taped to
the skin - A window is made with the tape to allow viewing
of the insertion site and catheter markings
23Prevention of disconnection
- The filter hub must be firmly screwed on to the
epidural catheter to prevent accidental
disconnection - If the hub is screwed on too tightly the catheter
may be occluded
24Securing the epidural filter
- The epidural filter must be securely taped to the
upper chest wall in a comfortable position
25Securing the epidural filter
- Any loose catheter should be coiled and taped
securely to prevent kinking and disconnection
26Where will the epidural be inserted?
- The level of insertion is determined by the site
of surgery and the desired number of dermatomes
to be blocked - Ideally the catheter tip should lie level with
the middle dermatome (when local anaesthetics are
being infused)
27Thoracic epidurals
- Thoracic epidurals are used for surgical
procedures of the upper abdomen or chest wall - They may be combined with IV opioids (nurse
controlled infusion or PCA) to provide optimal
analgesia
28Lumbar epidurals
- Lumbar epidurals are used for orthopaedic,
urological, general surgical procedures below the
umbilicus - They may be combined with IV opioids to provide
optimal analgesia
29Caudal epidurals
- Caudals are used for surgical procedures below
umbilicus (generally sacral, perineal, lower limb
and lower abdominal surgery) - Caudals are the most frequently used block in
children - Most commonly given as a single shot
30Post-operative epidural management
- Observation of vital signs
- Assessment of analgesia
- Detection of side effects
- Early detection of major complications
- Pressure area care
31Assessing sensory block
- Dermatomes
- Dermatomes are areas of skin that are primarily
innervated by a single spinal nerve - Pain and temperature nerve fibres are similarly
affected by local anaesthetic drugs, thus changes
in temperature perception indicate the area where
the epidural is working
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33Why check dermatomes?
- To ensure the epidural/caudal is covering the
patients pain - To ensure the block is not too extensive, which
may increase the risk of complications
34Pressure areas
- If the epidural block is very dense the patient
will not be able to move, will have no sensation
of pressure or pain and may develop pressure
areas - Meticulous pressure area care is vital
35Nerve compression
- Superficial nerves (eg common peroneal nerve) are
vulnerable to damage from unrecognised pressure
due to decreased sensation - It is vital that during regular pressure area
care special attention is made to ensure nerve
compression is avoided
36Assessing motor block
- Motor nerves (as well as sensory nerves) may be
affected by local anaesthetics - Assessing the motor function of legs and feet can
give an indication of the degree of motor nerve
blockade
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38Why check for motor block?
- To detect the onset of complications eg epidural
haematoma or abscess - To ensure the patient can move their legs to
prevent pressure areas - To ensure the patient is safe to ambulate
39Causes of breakthrough pain
- Epidural catheter kinked or dislodged
- Epidural catheter disconnected at filter
- Epidural block is unilateral on the wrong side
- Insufficient epidural infusion rate to cover
desired dermatomes - The epidural catheter tip is situated too high or
too low in the epidural space
40Causes of breakthrough pain cont.
- Surgical complications
- eg compartment syndrome, haemorrhage, sepsis,
peritonitis - Tight plaster /- swelling
- Full bladder /- urinary retention
- Urinary catheter or drains obstructed or occluded
41Causes of breakthrough pain cont.
-
- ALWAYS be concerned if the pain is remote to the
surgical site - get an URGENT review!
42Managing breakthrough pain
- If the patient complains of pain or appears to be
in pain - Check catheter at insertion site for leaking
- Is the epidural still in situ?
- Check at connection of catheter and filter for
disconnection/leaking - Check the epidural catheter position is the same
as stated on prescription - Give an epidural bolus as charted
43Managing breakthrough pain cont.
- Assess dermatomes on both sides
- Assess severity and location of pain
- Consider surgical review if risk of surgical
complications - Call Childrens Pain Management Service for
review
44Children's Pain Management Service
- The Children's Pain Management Service supervises
all patients with epidural analgesia at the Royal
Children's Hospital - CPMS can be contacted at all times on pager 5773
45Finally
- Optimal pain management is the right of all
patients and the responsibility of all health
professionals