Pre-reading about Epidural Analgesia for Children

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Pre-reading about Epidural Analgesia for Children

• Royal Childrens Hospital
• Melbourne Australia

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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

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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

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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

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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

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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, SpO2
• Urinary catheter may be required
• usually only if lumbar epidural

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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 

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Drugs used in epidurals

• Short-acting local anaesthetics Lignocaine
• Medium/Long-acting local anaesthetics Levobupiva
  caine
• Ropivacaine
• Other drugs Adrenaline
• Clonidine
• Opioids

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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 gt hydromorphonegtmorphine

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Spinal vs Epidural vs Caudal

• Different techniques are used depending on the
  type of surgery and the need for postoperative
  analgesia

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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

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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 L1/2 (adults) or L3/4
  (neonates)

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As appears in McCaffrey M, Pasero C Pain
Clinical Manual, p218, 1999, Mosby, Inc.
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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

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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 

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As appears in McCaffrey M, Pasero C Pain
Clinical Manual, p216, 1999, Mosby, Inc.
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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

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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 (S5-coccyx)

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Epidural 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

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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
  childrens fingers will decrease the likelihood
  of premature dislodgement

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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

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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

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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

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Securing the epidural filter

• The epidural filter must be securely taped to the
  upper chest wall in a comfortable position

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Securing the epidural filter

• Any loose catheter should be coiled and taped
  securely to prevent kinking and disconnection

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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)

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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 

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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 

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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

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Post-operative epidural management

• Observation of vital signs
• Assessment of analgesia
• Detection of side effects
• Early detection of major complications
• Pressure area care

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Assessing 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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Why 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 

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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

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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

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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

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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

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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

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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

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Causes of breakthrough pain cont.

• ALWAYS be concerned if the pain is remote to the
  surgical site
• get an URGENT review!

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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

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Managing 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

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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

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Finally

• Optimal pain management is the right of all
  patients and the responsibility of all health
  professionals