Prereading about Epidural Analgesia for Children Royal Childrens

Pre-reading about Epidural Analgesia for Children Royal Children’s Hospital Melbourne Australia

What 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 Children's Pain Management Service, RCH, Melbourne

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

Indications 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 Children's Pain Management Service, RCH, Melbourne

Contraindications 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 Children's Pain Management Service, RCH, Melbourne

What 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, Sp. O 2 • Urinary catheter may be required • usually only if lumbar epidural Children's Pain Management Service, RCH, Melbourne

How 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 Children's Pain Management Service, RCH, Melbourne

Drugs used in epidurals • Short-acting local anaesthetics: Lignocaine • Medium/Long-acting local anaesthetics: Levobupivacaine Ropivacaine • Other drugs: Adrenaline Clonidine Opioids Children's Pain Management Service, RCH, Melbourne

Adding 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 > hydromorphone>morphine Children's Pain Management Service, RCH, Melbourne

Spinal vs Epidural vs Caudal • Different techniques are used depending on the type of surgery and the need for postoperative analgesia Children's Pain Management Service, RCH, Melbourne

Spinal • 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 Children's Pain Management Service, RCH, Melbourne

Anatomy 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 L 1/2 (adults) or L 3/4 (neonates) Children's Pain Management Service, RCH, Melbourne

As appears in Mc. Caffrey M, Pasero C: Pain: Clinical Manual, p 218, 1999, Mosby, Inc. Children's Pain Management Service, RCH, Melbourne

Epidural • 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 Children's Pain Management Service, RCH, Melbourne

Anatomy 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 Children's Pain Management Service, RCH, Melbourne

As appears in Mc. Caffrey M, Pasero C: Pain: Clinical Manual, p 216, 1999, Mosby, Inc. Children's Pain Management Service, RCH, Melbourne

Caudal • 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 Children's Pain Management Service, RCH, Melbourne

Anatomy 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 (S 5 coccyx) Children's Pain Management Service, RCH, Melbourne

Epidural set • The 18 G and 19 G Portex. TM epidural kits can be distinguished by the colour of the hub on the filter and the size of the epidural catheter • 18 G kit has blue hub • 19 G kit has white hub Children's Pain Management Service, RCH, Melbourne

Securing 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 children’s fingers will decrease the likelihood of premature dislodgement Children's Pain Management Service, RCH, Melbourne

Epidural 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 Children's Pain Management Service, RCH, Melbourne

Taping 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 Children's Pain Management Service, RCH, Melbourne

Prevention 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 Children's Pain Management Service, RCH, Melbourne

Securing the epidural filter • The epidural filter must be securely taped to the upper chest wall in a comfortable position Children's Pain Management Service, RCH, Melbourne

Securing the epidural filter • Any loose catheter should be coiled and taped securely to prevent kinking and disconnection Children's Pain Management Service, RCH, Melbourne

Where 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) Children's Pain Management Service, RCH, Melbourne

Thoracic 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 Children's Pain Management Service, RCH, Melbourne

Lumbar 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 Children's Pain Management Service, RCH, Melbourne

Caudal 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’ Children's Pain Management Service, RCH, Melbourne

Post-operative epidural management • • • Observation of vital signs Assessment of analgesia Detection of side effects Early detection of major complications Pressure area care Children's Pain Management Service, RCH, Melbourne

Assessing sensory block Dermatomes: • Dermatomes 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 Children's Pain Management Service, RCH, Melbourne

Children's Pain Management Service, RCH, Melbourne

Why check dermatomes? • To ensure the epidural/caudal is covering the patient’s pain • To ensure the block is not too extensive, which may increase the risk of complications Children's Pain Management Service, RCH, Melbourne

Pressure 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 Children's Pain Management Service, RCH, Melbourne

Nerve 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 Children's Pain Management Service, RCH, Melbourne

Assessing 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 Children's Pain Management Service, RCH, Melbourne

Children's Pain Management Service, RCH, Melbourne

Why 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 Children's Pain Management Service, RCH, Melbourne

Causes 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 Children's Pain Management Service, RCH, Melbourne

Causes 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 Children's Pain Management Service, RCH, Melbourne

Causes of breakthrough pain cont. ALWAYS be concerned if the pain is remote to the surgical site: • get an URGENT review! Children's Pain Management Service, RCH, Melbourne

Managing 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 Children's Pain Management Service, RCH, Melbourne

Managing breakthrough pain cont. • Assess dermatomes on both sides • Assess severity and location of pain • Consider surgical review if risk of surgical complications • Call Children’s Pain Management Service for review Children's Pain Management Service, RCH, Melbourne

Children'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 Children's Pain Management Service, RCH, Melbourne

Finally… Optimal pain management is the right of all patients and the responsibility of all health professionals Children's Pain Management Service, RCH, Melbourne