Epidural Management Guidelines
BACKGROUND
- Placement and management of epidural catheters with infusions of local anaesthesia requires meticulous attention to detail to avoid potentially serious complications.
- The guidelines below are targeted to anaesthesia and nursing staff who will be managing epidural catheters in the ICU or HDU setting.
Epidural vs Spinal
| Epidural | Spinal | |
|---|---|---|
| Level | Any level of the vertebral column | Usually L3/4, 4/5. Must be below where spinal cord ends (L1 adults) |
| Anatomy | Potential space between ligamentum flavum and dura | Subarachnoid space, puncture through dura mater |
| ID of space | Loss of resistance technique | “Pop” (dura mater) a free-flowing CSF through needle |
| Onset | Slow (15-20 min) | Rapid (2-5 min) |
| Duration | Up to 5 days with catheter in place | 1-3 hours, depending on local used; single-shot, cannot redose |
| Density of block | Less dense (analgesia) | Very dense (surgical-level anesthesia) |
| Sympathectomy | Slow | Rapid |
GENERAL CARE
- Placement of epidural catheters will be done by anaesthesia providers only.
- Anaesthesia providers should leave a procedure note on HMIS indicating: level at which catheter was placed, depth (cm) at which loss of resistance occurred, marker (cm) at which catheter was secured, bolus/infusion preparation and dosage, connection confirmed by anaesthesia team, additional precautions (i.e., management of hypotension or anticoagulation).
- Anaesthesia providers are responsible for making and refilling the preparations for boluses/infusions and must leave clear instructions on the preparations of the same.
- Syringes intended for epidural boluses/infusions should be clearly labelled indicating drug concentrations, infusion rates, and designated ‘Epidural Only.’
- Anaesthesia providers are solely responsible for connecting and disconnecting any infusion to the epidural catheter. Once the infusion tubing is connected to the epidural catheter, the anaesthesia team will secure the connection with strapping to prevent disconnection.
- Any patient receiving infusions via their epidural catheter should be reviewed daily by an anaesthesia provider (see ‘Precautions’ below for review checklist) with progress notes documented in HMIS.
- Any dose/infusion rate changes should be recommended by an anaesthesia provider however, the attending nurse may adjust them based on given instructions. The usual dose range for adults is 4 to 10ml/hr.
- Removal of epidural catheter should be done by an anaesthesia provider only (following anticoagulation guidelines). Documentation in HMIS confirming check for anticoagulation, catheter tip intact, and recommended analgesia plan should be placed.
PRECAUTIONS FOR CRITICAL CARE TEAM & ANAESTHESIA TEAM
Always verify the following when checking the epidural catheter:
- Properly secured catheter at the back with dressing intact. The depth of the catheter will be indicated in the patient’s notes.
- Epidural catheter has been labelled with a sticker written ‘EPIDURAL.’
- Absence of inflammation on the skin surrounding the catheter (redness, swelling, warmth. etc). Notify the anaesthesia team if these signs are present.
- Absence neurological changes, e.g., change in sensation/power in the lower limbs, altered mental status. Notify the anaesthesia team if these signs are present.
- Vital signs including SpO2, heart rate, and blood pressure are monitored at least every 30 minutes while epidural catheter is in place. Any blood pressure value below normal (SBP < 90mmHg, MAP < 65mmHg) should be discussed with the anaesthetist or anaesthesia consultant on call.
- Prophylactic enoxaparin (QD) should be held for at least 12 hours before removal of the catheter.
- Prophylactic enoxaparin (QD) should not be started until 4 hours post removal of the catheter.
- Any other anticoagulant usage should be discussed with the anesthesia team prior to starting while an epidural catheter is in place.
- Ensure that the epidural infusion is NOT connected to any intravenous access.
- Ensure all other medications/infusions are NOT connected to the epidural catheter.
LOCAL ANAESTHETIC SYSTEMIC TOXICITY (LAST)
Features include:
- Tinnitus
- Perioral numbness/ tingling
- Metallic taste
- Seizures
- Arrhythmias
- Altered mental status
- Cardiac arrest
Immediate management of LAST:
- Call for help and notify the on-call anesthetist.
- Give O2 and support ventilation, as needed.
- Stop bupivacaine infusion immediately.
- Request for 20% Intralipid solution from pharmacy:
- Give 1.5ml/kg IV bolus over 1 min (100mL in adult).
- Continue infusion at 0.25-0.5ml/kg/min; after hemodynamic stability is restored, continue infusion for at least 10 min.
- Avoid Propofol, Vasopressin and calcium channel blockers.
- Anti-seizure medication: Midazolam.
- Treat hypotension: Epinephrine 1 mcg/kg IV/IO.
- Check ABGs.
- If in cardiac arrest, follow ACLS protocols of management; administration of Intralipid is key.
USE OF OTHER MEDICATIONS VIA EPIDURAL CATHETER
- Injection of other medications into the epidural catheter MUST BE AVOIDED, as this could lead to other harmful effects, particularly nerve damage or nerve toxicity.
- Always check for proper connection of medications and fluids to ensure this is prevented.