PATIENT CONTROLLED

EPIDURAL ANALGESIA

DEPARTMENT PROTOCOL

FARAH JAFRI

Topics

Review of literature

Department protocol

Our experience

ESRA GUIDELINES FOR PCEA -

This technique produces high patient

satisfaction.

Reduced dose requirements compared with CI.

Sophisticated pumps are required and accurate

catheter position is important for optimal efficacy.

Knowledge is Reassuring....

ESRA - Guidelines

“There are many possible variations in local anaesthetic/opioid concentration yielding good results, the example given here should be taken as a guideline; higher concentrations than the ones mentioned here are sometimes required but cannot be recommended as a routine for postoperative pain relief.”

ESRA- Guidelines for PCEA

Dosage for patient controlled infusion

(lumbar or thoracic):

Background 4-6 ml/h infusion

Bolus dose 2 ml (2-4 ml)

Lockout interval 10-30 min, We have kept 30 min.

Recommended max hourly dose

(bolus + Background) 12 ml/hr

Other opinions......

Bonica- Management of Pain- Ballentyne, Fishman, Rathmell

“ PCEA allows individualization of patients pain therapy.”

“Less consumption of drug” .

“ Data of over a 1000 patients shows that 90% of patients with PCEA receive adequate analgesia.”

COMPARING PCEA & CI

CONT. EPIDURAL INFUSION

PCEA

PRURITIS 1.8- 16.7% 10-22%

NAUSEA 3.8-14.8% 2-22%

SEDATION 13.2% 7.4%

HYPOTENSION 4.3% 0.7-6.6%

MOTOR BLOCK 0.1-2% 3%

RESP DEPRESSION 0.25% 0.1-1.6%

OTHER OPINIONS.......

National Guideline Clearinghouse

A public resource for evidence-based clinical practice

guidelines from the US Dept of Health

Patient Controlled Epidural Analgesia (PCEA)

is safe to use in selected older adults.

(Acute pain management in older adults. 2006)

National Guideline Clearinghouse

“Studies have demonstrated effective pain relief, decreased opioid use, and increased patient satisfaction with pain relief with PCEA (opioid and local anesthetics).”

(APS, 2003; Gopinathan et al., 2000; Lebovits et al., 2001; Mann et al., 2000; Mann, Pouzeratte, & Eledjam, 2003;

Silvasti & Pitkanen, 2001).

Evidence Grade = B

OTHER OPINIONS....

Randomized, double-blind comparison of patient-controlled epidural infusion vs nurse-administered epidural infusion for postoperative analgesia in patients undergoing colonic resection

J. J. Nightingale et al. BJA. 2007 98(3):380-384;

CONCLUSIONS: PCEA provides greater analgesic efficacy than CEI for post-op analgesia after major intra-abdominal surgery, and a decreased requirement for physician or nurse intervention.

ASA guidelines for PCEA in obs.

• Solution 0.0625% bupiv + opioid

• Continuous infusion 08-15 ml/h (most use12)

• Bolus 10-12 ml (most use12)

• Lockout 12 min (it takes the

pump almost 8 min

to get the dose in).

• Air sensitivity OFF

• 1 hour maximum 3-4 boluses.

ASA GUIDELINES-- CONTD

• Instruct patient to request physician evaluation and bolus if no relief after 2 self-administered boluses within 40 min.

• Rescue Meds: Supplement with bolus of bupivacaine ± opioid (e.g. 7 to 10 ml of 0.125% bupivacaine 10 ml, or 7 to 10 ml of 0.25% bupivacaine) and increase infusion rate and hourly maximum if necessary.

DEPARTMENT PROTOCOL

Prerequisite

Preoperative orientation of patient

Safety

PCA initiation

Pump programming

Drug regimes

Monitoring

PRE-REQUISITES

Patent IV line, I/V Fluid

Available O2,

Knowledge of Basic Life Support,

Professional Accountability,

Staff trained to use equipment and drugs,

Adequate ward staffing levels.

Pre-op orientation for PCEA

All patients must have—

Explanation pre-operatively about technique

How to press the button, with help of prop,

pictures or actual pump.

And should be told to hear the soft beep which

would indicate the have received a dose.

They should know that the dose is within safe

limit but they must not press when there is no

pain.

Safety

Epidural infusion lines should be clearly

identified.

Pump & cartridge must be labeled “ for

epidural connection only”.

All patients must have a patent iv cannula

during & for 12 hr after cessation of

epidural.

Safety

Ensure that the patient is not fluid depleted

before insertion of epidurals- e.g. due to: bowel prep,

fasting/starvation

insensible per-operative loss from evaporation – up to

10ml/kg/hr)

Ensure hydration during the initial post-op

period, with iv fluids and later by good oral

intake.

PCEA- Initiation

In Recovery, program the Cadd Legacy pump,

Set an base line infusion of 5ml/hr initially.

Possibly raising up to 8 ml/hr:

if analgesia proves inadequate,

after the patient is settled and

is using the PCEA satisfactorily.

PCEA- Initiation

Bolus dose 2-3 ml.

Lockout 30 min.

Basal infusion 6-8 ml/ hr

Normal epidural care

Regular analgesic and

Side effect assessments.

ADMINISTRATION OF DRUGS

A ‘test’ dose of drug will be given by the anaesthetist prior to commencement of infusion.

The infusion will be commenced in the Theatre or Recovery and patient monitored prior to transfer to ward.

Instructions for drug doses and infusion rates will be clearly written on the patient’s drug and epidural analgesia chart.

ADMINISTRATION OF DRUGS • Regimes

• Patients admitted to ICU

• Inj Bupivacaine 0.1% and inj Sufentanil 0.16 mcg/ml

• Patients admitted to ICU

• Inj bupivacaine 0.1% and inj Fentanyl 1-2 mcg/ml

• All ward patients:

• Inj Bupivacaine 0.125%

Drug dilutions Simple formula--

actual conc x actual vol. = desired conc. x desired vol.

To make bupiv. 0.1% with suf. 0.16 ug/ml, 100 ml

For bupivacaine-

0.5 x ? = 0.1% x 100, we need 20 ml that is 1 amp

For sufent. 5 ug/ml

5 x ? = 0.16 x 100, we need 3.2 ml of the vial.

Drug dilutions So putting it all together...

For sufentanil+ L.A PCEA cartridge

20 ml marcaine + 3.2 ml of sufentanil from 10 ml vial + 76.8 ml = 100 ml cartridge.

Similarly for fentanyl + LA PCEA cartridge

20 ml marcaine + 4ml fentanyl + 76 ml saline = `100 ml cartridge

Drug dilutions

Continuing in the same way

For plain L.A solutions

0.125% x 100 = 0.5 x ?

We need 25 ml of 0.5% solution.

Just remember the formula and you can calculate if in doubt!

ADMINISTRATION OF DRUGS

The epidural catheter will be clearly

labeled and screwed tightly into the

bacterial filter.

The filter will be anchored to the

patient’s skin to avoid traction on the

giving set and unnecessary disconnection.

ADMINISTRATION OF DRUGS

Bolus doses of drugs outside of Theatre,Recovery Unit and ITU will only be administered by an anaesthetist

On discontinuation of epidural infusion, the amount of controlled drug remaining in the syringe must be checked by two nurses, or the pain tech. and doctor

The discarded amount must be recorded, i.e., in the patient’s notes, care plan and/or on the epidural observation chart.

Check & Record before starting the

epidural infusion:

Temperature

Pulse

BP

Respiratory rate

Pain score

Sedation level

Movement & Sensation

Items recorded every 6 hrs by nursing

staff

BP

Pulse

Respiration rate

Sedation level

Pain scores (on movement & deep breathing)

Nausea and vomiting

Movement and Sensation

Urine output

If not catheterized:

Check & record UOP q 4 hr,

Observe for bladder distension.

OUR EXPERIANCE

STILL IN PRELIMINARY STAGE

10 cases till date

Mostly TKRS, 1 femur, 1 tibial ilizhorov

PATIENT SATISFACTION IS GOOD

Median Pain Score of 2.5/10

OUR EXPERIANCE

Complications No of Patients

Hypotension 2

Itching 2

Nausea - Vomiting 2

Constipation 1

Breakthrough pain because of cartridge change over time

Most Patients

WAYS TO IMPROVE

Prepare 2 cartridges at same time with identical solution.

Put patient label and send to ward.

They can be used alternatively, the anesthetist attending the cartridge change can refill and keep the other for next change.

Ward teaching and awareness of complications.

Thanks