The purpose of this guideline is to provide guidance about epidural analgesia at Great Ormond Street Hospital (GOSH). Epidural (also referred to as extradural) analgesia, where appropriate, can be used to manage intra-operative and post-operative pain associated with a variety of procedures. Less commonly it may also be used to control non-surgical or chronic pain.
The epidural space is situated between the dura mater (the outer layer of the meninges) and the vertebral canal. It extends from the cranium to the sacrum and contains loose connective tissue, fat, lymph vessels, blood vessels and nerves.
Analgesics can be administered into the epidural space. They exert an effect on the nerve roots as they emerge from the spinal cord, and diffuse across the dura and the subarachnoid space binding to receptors located in the substantia gelatinosa in the dorsal horn of the spinal cord. They are also absorbed systemically from the epidural blood vessels and may be distributed throughout the subarachnoid space in the cerebrospinal fluid (CSF).
Epidurally administered analgesics are usually given as close as possible to the dermatomes involved in the surgical procedure/painful area in order to maximise their effect. A fine plastic epidural catheter can be placed in the epidural space so that drugs can be continuously infused for the duration of treatment. The catheter is inserted while the child or young person is anaesthetised.
In babies under six months or weighing less than 5kg the epidural catheter is sometimes inserted via the sacral hiatus (caudal) and threaded up the epidural space until the appropriate level has been reached because this is technically easier than direct placement at higher levels in very small infants.
Local anaesthetics may be administered with or without an opioid or other suitable analgesics; these may be given either as a single dose (one shot) or as an infusion. Patients who receive an epidural or caudal
infusion should have observations as detailed in this document.
Post-operative epidural analgesia is provided by a continuous infusion using a specially configured and clearly labelled syringe pump. The standard solution at GOSH is 0.125% levobupivacaine and 0.001% preservative free morphine. In neonates, and patients with sensitivity to morphine or an increased risk of respiratory or renal complications, a 0.125% levobupivacaine only infusion may be used.
All personnel involved in the care of patients with an epidural must be trained and competent to do so.
Epidural infusion rates and syringes must only be changed by a member of the Pain Control Service or other staff who have been assessed as competent.
Please note: In November 2009, the NPSA recommended that equipment should be developed that will enable NHS institutions to perform all epidural, intrathecal and regional infusions and boluses with devices that will not connect with intravenous Luer connectors or intravenous infusion spikes. The Pain Control Service is aware of this project and is considering options prior to the 2013 mandate for change.
For any technical or pain related problems please contact the Pain Control Service on bleep 0577 or visit the
pain control service pages here on the website.
Throughout this document the term "advanced practitioner" is used to identify any health professional who has attended the relevant in-house training and been assessed as competent.
Abbreviations used in this document:
- mcg=micrograms; mg=milligrams; ml=millilitres; kg=kilograms
- CNS=Clinical Nurse Specialist
- advanced practitioner=a nurse who has attended the GOSH Advanced Practice in Pain Management Training and been assessed as competent in adjusting epidural programming, changing syringes and troubleshooting technical problems
- Pain Control Service=Pain team CNSs, or those deputising for them, anaesthetists
- PCA=patient controlled analgesia; NCA =nurse controlled analgesia
Preparation
Patient assessment
Initial assessment
Prior to surgery/insertion of the epidural the anaesthetist will consider:
- The benefits and risks of an epidural for each individual patient (Rationale 1).
- The effectiveness of epidural analgesia for the type of surgery/pain.
The anaesthetist may choose to avoid the use of an epidural if any of the following contra-indications are present:
General
All parents should be given a copy of the leaflet entitled
pain relief after surgery using an epidural (
Rationale 6).
An anaesthetist will discuss the epidural with the child or young person and family prior to theatre and obtain verbal consent for the procedure (
Rationale 7).
The child or young person and family should be prepared for the epidural:
- The nursing staff and/or play specialist should explain the epidural to the child or young person & family at pre-admission clinic whenever possible (Rationale 8).
- They should be made aware that if the epidural is unsuccessful the child or young person will be given alternative analgesia (Rationale 9).
- If the family have any questions that staff feel unable to answer they should contact the Pain Control Service on: beep 0577.
Nursing staff should also ensure that:
- Before the child or young person goes to theatre, a baseline pain assessment should be carried out, using a validated pain assessment tool, suitable for the child or young person’s age and level of cognitive development (Rationale 10).
- The following baseline physiological observations should also be recorded (Rationale 11):
- temperature (Rationale 12)
- heart rate
- respiratory rate
- blood pressure
- oxygen saturations
- These should be documented on the Patient Assessment Form (WWG872) and the appropriate Observation Chart (WWG864/65/67/68).
- A pain history should be documented in the Family Form Part 2 (WWG869).
- Any abnormal sensation/limb weakness should be reported to the anaesthetist and recorded in the child or young person’s health care records (Rationale 13).
Equipment required: suitable drugs
Drugs given via the epidural route must always be preservative-free to prevent neurological complications.
All epidural syringes should be prepared by CIVAS.
Drugs must not be added to epidural syringes by any staff on hospital wards.
| Drug | Action |
Levobupivacaine hydrocloride
Available in strengths of:
- 0.125% for continuous infusion supplied by CIVAS
- 0.25% for initial dose only
- 0.5% is available but is not usually given via the epidural route in child or young person and young people
|
A local anaesthetic with a half-life of between 1.5 and 5.5 hours.
Works by blocking the sodium channels on the nerve axon.
It must not be given intravenously.
|
Preservative-free morphine
Available as: 1mg/ml
| Hydrophilic opioid that binds to opioid receptors in CNS. When administered via the epidural route morphine diffuses slowly into the subarachnoid space and circulates freely in the CSF. The duration of action of epidural morphine is prolonged.
|
Naloxone must be prescribed and available for all children or young people receiving epidural opioids.
| To allow for swift treatment of opiate-induced respiratory depression.
|
Intravenous naloxone
Available in ampoules of 20mcg/ml or 400mcg/ml.
Can also be given by intra-muscular route.
Has a half-life of 30 minutes.
| Reserves the (desirable and undesirable) effects of morphine.
Can provide instant reversal of opioid-induced respiratory slowing/arrest.
Dose may need to be repeated.
Also suitable for intramuscular use.
|
Table showing epidural anaesthetic drugs and their actions.
Inserting the epidural
Equipment required
Gather the following equipment (
Rationale 14):
- An anaesthetic pack containing a sterile field, sponge holding forceps, sponges and galley pots.
- An epidural pack containing a microfilter, 10ml loss of resistance (LOR) syringe and a choice of the following needles and catheters:
- 18G short needle and 21G multiport side hole catheter (Rationale 15) OR
- 18G long needle and 21G multiport side hole catheter (Rationale 16)
- Sterile gown and gloves.
- An alcohol-based skin preparation according to current infection control guidelines (Rationale 2).
- Lancet or 19 gauge needle (Rationale 17)
- 0.9% sodium chloride for injection (Rationale 18).
- Sterile, occlusive, hypoallergenic, transparent dressing eg Opsite™ (Rationale 19).
- Adhesive dressing, eg Mefix™ (Rationale 19).
Insertion technique
An epidural catheter must only be inserted by an anaesthetist who has experience of the technique or by a trainee under supervision.
The epidural should be inserted as follows:
- A mask, gloves and gown plus full aseptic preparation should be used throughout (Rationale 16).
- Position the anaesthetised patient curled on their side (Rationale 20).
- Locate the appropriate space and clean the area with an alcohol based skin preparation; current 2010 guidelines recommend the use of 0.5% Chlorhexidine (Rationale 16).
- Make a small incision in the skin with a lancet or 19G needle (Rationale 21).
- Fill the LOR syringe with 0.9% sodium chloride for injection, attach to the epidural needle and advance the needle between the vertebral spines maintaining a constant pressure on the syringe (Rationale 22).
- Maintain continuous pressure on the syringe whilst advancing the needle until loss of resistance is felt (Rationale 23).
- Whilst advancing the needle to the use of 0.9% sodium chloride is strongly recommended although in some circumstances the LOR syringe may be filled with air (Rationales 24 and 25).
The approximate distance between the skin and the extradural space is:
- 0.5cm in neonates
- 0.75cm in infants
- 1-2cm by the age of 5-7 years
The catheter is threaded to the appropriate spinal dermatomal level, leaving 4cm in the epidural space (
Rationale 26).
The (yellow plastic) epidural catheter connector should be attached in accordance with manufacturer’s instructions.
The epidural microfilter should then be attached (
Rationale 16).
Once in situ the catheter should be secured as follows (
Rationale 27):
- A clear dressing, eg Opsite™ over the entry site (Rationale 28).
- Tape, eg Mefix™ covering the rest of the catheter up to the child or young person’s shoulder (Rationale 29).
A record of the procedure must be made on both the anaesthetic and Pain Management charts as appropriate.
Drug administration: peri-operative
A single dose may be given of:
- 0.5-0.75 ml/kg of levobupivacaine (Rationales 30 and 31).
- 0.25% Levobupivacaine is suitable for intraoperative surgical analgesia.
- 0.125% Levobupivacaine is suitable for postoperative pain.
This may be given either through the epidural needle or once the catheter is in position.
Additional doses may be given by the anaesthetist in theatre.
Postoperatively an infusion is commenced of either (
Rationale 31):
- Levobupivacaine 0.125% or
- Levobupivacaine 0.125% (1.25mg/ml) and preservative-free morphine 0.001% (10mcg/ml)
All epidural drug administration must be recorded on the anaesthetic record and on the Pain Management chart as appropriate.
Continuous epidural infusion: equipment required
Equipment for infusion includes:
- Pre-prepared epidural infusion in luer lock syringe (see below for order details from CIVAS). All syringes must be labelled ‘for epidural use only’.
- A YELLOW rigid 150cm extension sets labelled “FOR EPIDURAL USE ONLY”, eg Graesby® Flow-Safer Epidural Syringe Extension Set with Anti-siphon valve (Ref 0128-0261) (Rationale 32).
- A YELLOW Alaris P5000 syringe pump adapted for epidural programming and labelled “FOR EPIDURAL USE ONLY” (Rationale 32). The orange Biomedical engineering service label on the pump indicates when next the pump must be serviced and pump serial number must be written on the patients’ pain management chart.
Drug administration: ordering
All epidural infusions will be prepared by CIVAS as this provides additional antimicrobial and drug safety protection (
Rationale 32).
Ordering of epidural (for anaesthesia and theatre staff)
- Monday-Friday, 9am to 4pm (except Bank Holidays): ODP/Anaesthetist contact pharmacist on bleep 2008.
- Out of hours: liaise with CNS Pain Control team and resident pharmacist (bleep 0714).
- Levobupivacaine 0.125% and preservative-free morphine 0.001% epidural:
- use stock from VCB recovery - all necessary details in CD register as per usual
- VCB recovery nurse to ensure stock replenished by ordering in CD order book via CIVAS
- Levobupivacaine 0.125% epidural:
- use stock from VCB Recovery/Ocean Recovery
- VCB recovery nurse to ensure stock replenished by ordering in stock request book via dispensary
- Check expiry date on syringe before use.
Ordering of epidural (for ward staff)
- There will be no stock kept on any ward.
- Epidural levobupivacaine 0.125%:
- Contact ward pharmacist - ensure you request:
- quantity of 100ml syringes required (for the next 24 hours)
- Out-of-hours and as a last option, contact resident pharmacist (bleep 0714). There will be no stock kept on any ward - all requests must be made via ward pharmacist.
- Epidural levobupivacaine 0.125% and preservative-free morphine 0.001%:
- Order in CD book - ensure:
- patient's name, hospital number, consultant name entered
- quantity of 100ml syringes required (for the next 24 hours)
- Monday-Friday: contact ward/pain pharmacist.
- Saturday and Sunday: contact CIVAS pharmacist (ext 8363).
- Pharmacist will check prescription against CD book (on ward) and order from CIVAS.
- Syringes must be changed every 48 hours or earlier (if shorter expiry date). Check expiry date on syringe before use.
- Out-of-hours: liaise with CNS Pain Control Team and resident pharmacist (bleep 0714).
- Remember ordering cut-off times are:
- Monday-Friday: 10.30am for 12pm syringes, 4pm for all other syringes.
- Saturday-Sunday: 10.30am for all syringes.
The epidural prescription chart must stay with the child or young person at all times. Bleep the ward pharmacist to check the prescription against the order book or send a photocopy to pharmacy (
Rationale 34).
Epidural syringes must be stored in a separate locked cupboard from those holding intravenous and other types of infusions (
Rationale 35). Epidurals syringes, received from pharmacy, containing morphine must be recorded in the Controlled Drug record.
Setting up an epidural infusion
Initial programming of pumps may only be undertaken by anaesthetic or Pain Control service staff.
Staff must be familiar with the equipment used and, in addition to training, must have read pages 9-17 of the Alaris
PCAM Pump User Manual.
A prescription must be completed for the drug chosen. The rate of infusion and the maximum volume to be administered in four hours must be prescribed. In addition, an appropriate naloxone dose must be prescribed for any infusion containing morphine (
download prescription documentation).
The epidural solution is infused at between (
Rationale 36):
- 0.1 - 0.3 ml/kg/hr for neonates and infants <5kg.
- 0.1 - 0.4 ml/kg/hr for all other patients; up to a maximum of 15mls/hr.
The maximum volume of which may be administered in a four hourly period is:
- 1.5ml/Kg for neonates and infants <5kg.
- 2ml/Kg for all other patients to a maximum of 75ml.
Infusion rates must only be changed by the Pain Control Service or advanced practitioner (
Rationale 37).
Nursing or medical staff, who are not advanced practitioners, who believe the rate needs to be changed, should contact the Pain Control Service on bleep 0577 (
Rationale 36).
All children or young people with an epidural infusion must have a Pain Management Chart completed by the prescribing anaesthetist including details of insertion technique. Initial programming must be recorded and signed on this record.
All practitioners commencing an epidural infusion should ensure the patient has patent
intravenous access.
All children and young people receiving opioids should have naloxone and anti-emetics prescribed in line with hospital policy.
Care of patient: immediate post-operative period
When delivering the child or young person to Recovery staff, and when collecting the patient from theatre, a verbal report should be obtained (
Rationale 38). This should include:
- Details of intra-operative analgesia and other drugs given.
- Details of epidural solution and rate.
- The level of sensory nerve block (range and both sides).
- Any pain or epidural related complications that have been experienced peri-operatively.
- Whether the pharmacist has reviewed the child or young person’s prescription.
Before leaving theatre,
and at any subsequent handover, the nurse should check that:
- The drug being administered corresponds with what has been prescribed (Rationale 39 and 40).
- The patient’s pain is being managed effectively.
- The patient is not excessively sedated.
- The level of sensory nerve block is not above T3.
- Bromage score is less than 3 (lumbar epidural) or absence of upper limb motor nerve block (thoracic epidural).
- The Pain Management Chart has been completed correctly. This provides details of insertion position of the epidural, intra-operative analgesia, loading dose, and current infusion rate (Rationale 41).
- The Epidural Prescription Chart has been completed correctly. The epidural solution, infusion range, and drugs to prevent side effects are prescribed here (Rationale 40 and 41).
- If the epidural solution includes morphine check that NALOXONE has been prescribed correctly (Rationale 42).
All patients should be transferred to the ward on a theatre trolley equipped with an appropriately sized re-breath set, oxygen and suction.
Care of the child or young person while receiving epidural infusions: general considerations
All children and young people receiving epidural infusions must be supervised by a registered nurse, doctor, or ODP who has undergone specific training in the care of a child or young person receiving an epidural. All children and young people with an epidural infusion
must have intravenous access, so that side effects and complications can be treated expediently.
In adults, frequent complications include: hypotension; respiratory depression (opioid use); motor block; urinary retention; inadequate analgesia; pruritus (opioid use).
Infrequent but well recognised complications include: cardiovascular collapse; respiratory arrest; unexpected development of high block, eg catheter migration, intrathecal injection; local anaesthetic toxicity; post dural puncture headache syndrome (including sub-dural haematoma); drug administration errors (especially wrong route); pressure sores; superficial infection around catheter; epidural haematoma or abscess; meningitis; spinal cord ischaemia; permanent harm, eg paraplegia, nerve injury (
RCOA 2010).
National audit of safety of epidural use in children and young people suggests an incidence of long term injury in 1 in 10,000 patients (
Llwellyn & Moriarity 2007).
The patient will be reviewed at least once a day (
Rationale 36):
- by the nurses on the Pain Control Service (weekdays and Saturdays)
- by the Duty Anaesthetist (Sundays and bank holidays)
For any queries contact the Pain Control Service, 24 hours a day on: bleep 0577.
Most children and young people receiving epidural medication will have undergone surgery and will require appropriate, regular, nursing observations as part of their post operative care; however the presence of an epidural will require specific observation to assess efficacy and to ensure any complications are detected and treated expediently.
This will include assessment and recording of:
- pain score as an indication of efficacy
- level of sedation
- respiratory function
- nausea
- pruritis blood pressure
- urinary output
- temperature
Epidural specific observations include (frequency as outlined below):
- sensory block (Dermatome assessment)
- motor block (Bromage score)
- pressure area recording
- epidural site inspection
- hourly observation of epidural pump infusion rate
- indications of local anaesthetic toxicity
Download nursing documentation for recording of epidural observations.
Prevention, detection and treatment of side effects
1. Ensuring effectiveness
Supplementary analgesia, eg paracetamol and either diclofenac or ibuprofen where appropriate, should be given regularly if the oral or intravenous or rectal route is available. Opioid drugs may be prescribed in addition if the epidural contains 0.125% levobupivicaine only (
Rationale 43).
Determine the effectiveness of the analgesia by:
- Recording pain scores hourly using a validated pain assessment tool suitable for the child or young persons’ age and cognitive ability. Document score on the patients’ on the pain assessment chart.
- When using a 0-10 pain assessment tool, as a rough guide:
- Use self-report wherever possible or a validated behavioural pain assessment tool if self-report is not possible (RCN 2009).
- Identify the type and location of pain whenever possible.
- Reassess level of pain at an appropriate interval after any interventions.
Download pain assessment documentation.
If patient is in pain:
- Administer prescribed simple analgesics, eg Paracetamol and either diclofenac or ibuprofen as appropriate (Rationale 43).
- Review the level of epidural sensory block by using ice to assess the level of sensory block (see below) to ascertain if the epidural is effective in the appropriate area.
- It may help to reposition the patient (Rationale 44).
- Administer prescribed co-analgesics as appropriate, eg anti-spasmodic drugs (Rationale 43).
- Involve family and play specialist if the pain could be anxiety related (Rationale 45).
- If pain score is 5 or above, for more than an hour, contact an advanced practitioner who may adjust rate, or the Pain Control Service on bleep 0577 who may adjust rate and/or administer bolus medication (Rationale 46).
- Consider seeking surgical review if there is potential that a surgical complication may be exacerbating pain experienced.
2. Sedation level
The administration of morphine can cause undue sedation which may precede respiratory suppression.
The scores and appropriate actions are:
0 Awake/alert
1 Sleepy/responds appropriately
2 Somnolent/rousable (light stimuli)
3 Deep sleep/rousable (deeper physical stimuli) INTERVENE
4 Unrousable to stimuli – STOP INFUSION/bleep 0577
If the patient has a sedation score greater than 2:
- Stop the infusion (Rationale 47).
- Contact the Pain Control Service on bleep 0577.
- The infusion may be recommenced once the sedation score returns to 2 or on instruction from the Pain Control Service. Alternatively the team may elect to change the epidural rate of infusion or the drug administered to 0.125% levobupivicane only.
These actions must be recorded in the child or young person’s health care records (
Rationale 41).
All patients should be nursed in close proximity to oxygen and suction.
The following patients should be monitored using continuous pulse oximetry (
Rationale 48):
- Patients whose sedation score is repeatedly greater than 2.
- Patients with respiratory complications or obstructed airway.
- Infants under one year of age.
All other patients should have regular pulse oximetry checks during routine observations.
3. Respiratory depression
The administration of opioids may cause respiratory suppression.
The patient’s respiratory rate should be monitored and recorded hourly while the epidural infusion is in progress and for twelve hours after it has been discontinued (
Rationale 48). The frequency should be increased if the patient is excessively sedated or their condition deteriorates.
The patient’s minimum satisfactory respiratory rate is written on the epidural prescription chart. This is for guidance only and health professionals should also take into account (
Rationale 49):
- depth of respiration
- respiratory effort
- level of sedation
- oxygen saturation
If respiratory depression occurs:
- Stop the infusion.
- Administer intravenous naloxone as prescribed (Rationale 50).
- Contact the pain control service on Bleep 0577 (Rationale 46).
These actions must be recorded in the child or young person’s health care records (
Rationale 41).
If respiratory arrest occurs:
- Stop the infusion.
- Administer basic life support.
- Contact the clinical emergency team on ext 2222.
- Administer intravenous naloxone as prescribed.
- Contact the Pain Control Service (Rationale 46).
- Record incident according to the hospital policy.
4. Nausea and vomiting
The patient should be assessed for nausea and/or vomiting at least four hourly and one- to two-hourly if they feel nauseated or have vomited. All children and young people receiving opioid drugs should have anti-emetics prescribed in line with hospital policy (
Rationale 51).
If the patient complains of nausea or has been vomiting:
- Administer an anti-emetic as prescribed.
- Aspirate nasogastric or gastrostomy tube if appropriate.
- Consider the use of an alternative anti-emetic if nausea/vomiting is not reduced.
- Consider a reduction on the rate of epidural infusion (if it contains morphine) if pain control is acceptable.
5. Pruritus (itching)
Administration of opioids, particularly by the epidural root may predispose to pruritis.
The patient should be assessed for pruritus (itching) at least four hourly and one- to two-hourly if itching is troublesome (
Rationale 52).
Pruritis should be treated by administering intravenous naloxone (0.5mcg/Kg) as prescribed. A maximum of four doses may be administered at 10 minute intervals. This may be repeated after one hour if not effective (
Rationale 50).
If naloxone is not effective, an anti-histamine, eg chlorphenamine, may be prescribed, however anti-histamines have sedative properties and may exacerbate sedation caused by epidural opioids. The patient’s sedation status should be assessed prior to administering such therapy.
These actions must be recorded in the child or young person’s health care records (
Rationale 41).
If pruritus continues contact the Pain Control Service who may reduce the epidural rate or remove the opiate.
6. Low blood pressure
Local anaesthetic affects the nerves supplying blood vessels, so blood pressure drops slightly when an epidural is used.
Regular blood pressure monitoring is essential as peripheral vasodilatation may mask the visual signs of hypovolaemia. For this reason all children and young people with an epidural infusion must have intravenous access maintained and intravenous fluids prescribed. Fluids should be administered to treat hypotension as directed on intravenous fluid infusion prescriptions or according to standard hospital guidelines (as outlined in CEWS documentation).
Children and young people do not need to lie flat during the epidural infusion. They should be advised to sit or stand up slowly while the epidural is in progress as postural auto-regulation of blood pressure may be slightly delayed. It must be explained to the family that children and young people should not attempt to stand or walk unaccompanied during the epidural infusion.
7. Urinary retention
The pain control service advises that all patients with an epidural have a urinary catheter in situ.
The epidural affects the nerves that supply the bladder, so a urinary catheter (tube) will usually be inserted in theatre. The catheter will normally be left in until after removal of the epidural. Bladder function returns to normal after the epidural wears off.
Nursing care of the patients includes:
- Record the patient’s urine output (Rationale 53).
- Check fluid intake if the patient has not passed urine twelve hours after surgery (Rationale 54).
If the patient (without a urinary catheter) has a palpable bladder or bladder discomfort, an ultrasound assessment, if available, of the bladder may be helpful in diagnosing urine retention.
If indicated:
- Administer intravenous naloxone as prescribed (0.5mcg/kg) if opioid induced retention is suspected (Rationale 50).
- Four doses may be given at 10-minute intervals.
- Repeat the four doses of naloxone if the patient has not passed urine after one hour.
- Contact the Pain Control Service to reduce the infusion rate if the patient is pain free (Rationale 55).
- If no diuresis occurs after the repeated doses of naloxone, contact the medical team to determine if the patient needs to be catheterised (Rationale 56).
These actions must be recorded in the child or young person’s health care records (
Rationale 41).
If the patient is catheterised: the amount drained should be recorded (
Rationale 41).
If the patient has a urinary catheter this should NOT be removed until the epidural has been discontinued (
Rationale 57).
8. Sensory block assessment
(adapted from
Royal Children’s Hospital Melbourne guidelines)
Local anaesthetics work by blocking nerve impulses on sensory, motor and autonomic nerve fibres. The smallest diameter fibres are most sensitive to the effects of local anaesthetics: autonomic fibres will be blocked first then sensory fibres then motor fibres.
Pain and temperature nerve fibres are similarly affected by local anaesthetic drugs, so changes in temperature perception indicate the area where the epidural is working. The area of sensory block should be assessed using cold sensation (eg ice) to establish which dermatome levels are covered. Both left and right sides need to be assessed.
- The degree of motor nerve block is indicated by loss of movement.
- Observe for motor nerve block on both legs.
- Document the degree of motor nerve block in clinical records.
The pain control service/duty anaesthetist must be contacted if the Bromage score is 2 or more, and if block does not recede within an hour of reducing infusion rate.
To assess motor nerve block in the upper limbs:
- Explain procedure to the child or young person.
- Ask the patient to grip your hand, then to raise their arms.
- Assess for any paraesthesia (loss of sensation/numbness in the hands or arms).
- An unduly high motor block is indicated by loss of power, voluntary movement or sensation.
- Observe for motor nerve block on both arms.
- Document the degree of motor nerve block in clinical records ( use the comments section on the epidural record)
- If there are any signs of paraesthesia (sensation of tingling, pricking, or numbness) or loss of motor function, stop the infusion and contact the pain team.
Bromage score should be ascertained every four hours and:
- in recovery
- on return to the ward/unit
- at commencement of each nursing shift
- if the patient complains of pain or paraesthesia
- one hour after a bolus or increase in infusion rate
- before the child or young person attempts to stand
Pressure area care and mobility
Reduction in motor function and sensation predisposes patients to problems with pressure area perfusion.
The patient may be encouraged to mobilise if their condition allows (
Rationale 58):
- Bromage score should be 0 before mobilisation is attempted.
- Patients should be accompanied at all times while mobilising (Rationale 59).
- Older children and young people should be warned that initially they may experience some dizziness when mobilising (Rationale 60).
- Patients may sit out in a chair or walk to the toilet as directed by the surgeon.
If on bed rest or reluctant to mobilise regular pressure area care should be given and the patient repositioned regularly (
Rationale 61).
10. Epidural site care
The epidural catheter entry site should be observed when turning the patient and at least four-hourly (
Rationale 63).
Contact the Pain Control Service if:
- The entry site becomes red or swollen.
- The child or young person complains of tenderness at the site of insertion.
- The catheter has become displaced.
- The dressing has fallen off.
- There is excessive leaking of fluid around the entry site.
- The patient has a pyrexia of unknown origin.
These observations must be recorded in the child or young person’s health care records along with any actions taken (
Rationale 41).
Leaking of the epidural solution from the entry site is common, particularly in younger children.
If leaking occurs:
- Observe the entry site more frequently - one- to two-hourly if possible (Rationale 62).
- If the dressing starts to peel off place a new one over the top (Rationale 27).
- Do not remove the dressing – contact the pain control service for assistance.
If the dressing falls off:
- Put a new sterile transparent occlusive hypoallergenic dressing on immediately (Rationale 27).
- Contact the Pain Control Service.
The Pain Control Service practitioner will review the position of the catheter and compare the external markings on the catheter with the known initial positioning. The practitioner may:
Care of patient: observations
Suspected epidural site infection
Infection of the epidural space is extremely rare with an estimated occurrence in 1 in 100,000 patients; however localised infection at the skin site is more common. If epidural infection is suspected (see indications above) the Pain Control service will remove the catheter (see Discontinuing Epidural).
The nurse caring for the patient should:
- Swab the epidural site and any epidural exudate and send the specimen to the laboratory for Microscopy, Culture and Sensitivity.
- Monitor temperature - if hyper-pyrexia occurs, or sepsis is suspected, consider taking blood cultures.
- Ensure the child or young person is examined by a competent practitioner to determine any neurological impairment.
- If necessary, contact the microbiologist for advice relating to prophylactic antibiotic therapy while awaiting swab results.
- If there is evidence of localised infection, an urgent MRI should be performed to eliminate an epidural abscess as the cause: this can arranged by the neurology team on call.
- The Pain Control Service will complete an Epidural Information Form (pink form) for audit and ongoing observation.
- The Pain Control Service will review the results of investigations and contact the appropriate medical team if the child or young person requires antibiotic therapy while in hospital or young person’s family at home if the child or young person has been discharged.
- If the patient is still awaiting microbiology results at time of discharge:
- Ensure the family are advised of the necessary epidural care required at home.
- If necessary arrange for the epidural site to be reviewed by the child or young person’s Community Nurse or GP.
- Inform the Pain Control Service of the patient's discharge.
Epidural infusion rate
The volume of epidural solution administered should be in accordance with the rate requested on the pain management chart.
The pump volume infused reading should be checked and documented hourly on the epidural observation chart. This should be compared to the syringe reading to ensure that the amount of drug infused is accurate (
Rationale 64) (
download a copy of the epidural observation chart).
Charting should include:
- amount infused (hourly and running totals)
- syringe readings at least every four hours
Midnight totals should be recorded on the Pain Management Chart by the pain control service (
Rationale 68).
Local anaesthetic (levobupivacaine) toxicity
Although levobupivacaine toxicity is rare, it is most likely to occur in the following situations:
- if the drug is accidentally administered intravenously (Rationale 65)
- in neonates and babies if high rates are infused for long periods (Rationale 66)
- patients with renal failure (Rationale 67)
Toxicity may be indicated by:
- confusion, increased anxiety, irritability, loss of consciousness
- tingling mouth and lips.
- excessive sedation
- hypotension, cardiovascular collapse including bradycardia , arrhythmias, asystole
If the patient is experiencing any of these symptoms:
- Stop the epidural infusion.
- Initiate Basic Life Support if required and contact clinical emergency team on extension 2222.
- Contact the Pain Control Service on: bleep 0577 and the resident pharmacist (bleep 0714 out of hours)(Rationale 68).
- Record the symptoms observed and the action taken in the child or young person’s health care records (Rationale 41).
Guidance for managing severe local anaesthetic toxicity is provided by The Association of Anaesthetists of Great Britain & Ireland 2010.
Cardiac arrest associated with LA injection may be refractory to conventional treatment and require treatment with lipid emulsion or cardiopulmonary bypass .
Intralipid
® 20% is kept in pharmacy.
Other
The following complications are rare; however they may occur while the epidural is in situ or after it has been removed. Contact the Pain Control Service if any of the following are observed (
Rationales 69 and 70):
- headache – may be indicative of a dural tap during insertion of the epidural
- signs of neurological damage/deterioration such as:
- loss of motor function
- paresthesia – loss of sensation
- "foot drop"
Record symptoms in the child or young person’s health care record (
Rationale 41).
Technical issues
Drug administration: syringe changes
The syringe and administration set should be changed at least every 48 hours (
Rationale 39).
Syringes must only be changed by a member of the Pain Control Service or an advanced practitioner (
Rationale 39 and 47).
Ward staff should check that syringes of epidural solution are available on the ward (
Rationale 45).
Staff should also check whether there is an advanced practitioner available to change the epidural syringe or contact the Pain Control Service on bleep 0577 when a syringe is nearing empty, ideally giving at least an hour’s notice. If there is a delay, families should be reassured that a short break (less than one hour) in administration is unlikely to be of clinical significance and the pump should be set on ‘call back’ to silence the alarm temporarily.
To change an epidural syringe
- Ensure the preparation area is socially clean; cleanse surfaces with soap and water if necessary, and ensure surface is dry.
- Put on an apron.
- Perform a clinical hand wash.
- Clean the preparation area with an alcohol impregnated wipe.
- Apply alcohol-based gel to hands and put on gloves.
- Avoid contact of the epidural catheter or syringe with alcohol wipes (Rationale 71)
- Epidural syringes containing morphine must be signed for in the Controlled Drugs record.
- Check the syringe against the prescription chart and the patient, ensuring that the syringe is labelled “FOR EPIDURAL USE ONLY” (Rationale 46).
- Record the time and date on they syringe.
Then:
- Attach a yellow epidural administration (Rationale 32) set with anti-siphon valve to the syringe and “prime the line”. The administration set must be changed every 48 hours.
- Take to patient and check their details according to the hospital’s Drug Policy.
- Stop the old infusion.
- Disconnect the old administration set/syringe.
- Purge the system to take up mechanical slack BEFORE attaching to the patient, in line with the IVAC PCAM syringe pump directions for use.
- Attach new syringe and administration set (if changed) to the epidural filter.
- Recommence infusion.
- Dispose of used equipment according to the hospital’s Waste Policy (GOSH 2009).
- Wash hands.
- Record procedure in child or young person’s health care records.
Drug administration: changing rates
Changes must only be made by an advanced practitioner or the Pain Control Service. All changes to epidural rates must be documented on the pain management chart and notified to the Pain Control Service.
Decreasing infusion rates
The Pain Control Service or other advanced practitioner will usually reduce the rate by approximately 0.1ml/kg/hr every 24 hours if the patient is comfortable. Where possible, this change should be made in the morning.
The Pain Control Service may also consider reducing the epidural infusion if the patient is experiencing side effects (
Rationale 37), or if assessment of sensory block indicates that there is scope to make a reduction safely.
To change the rate:
- check the prescribed running rate on the prescription chart
- decrease rate by 0.1ml/kg/hr unless otherwise indicated (eg side-effects)
- document the change on the Pain Management Chart
- inform clinical bleep 0577
All changes should be agreed with a second checker and be within prescribed limits.
Increasing infusion rates
The Pain Control Service or other advanced practitioner may increase the epidural rate if the patient is in pain.
Only increase the epidural rate if:
- the patient’s pain score is greater than 4 using a 0-10 scale (ie moderate pain)
- the epidural block is below dermatome level T3
- other analgesic measures have been ineffective
- pain is related to the surgical procedure.
If the pain could be indicative of surgical complications or some other cause, contact the surgeons or the Pain Control Service for advice.
To change the rate:
- check the range prescribed on the prescription chart
- increase the epidural rate by no more than 0.1ml/kg/hr
- ensure any increase is within prescribed limits and does not exceed 15mls/hr
- document change on Pain Management Chart
- inform clinical bleep 0577
Drug administration: additional bolus doses
If pain is severe, the Pain Control Service may administer additional doses of epidural solution, via the “clinician override” facility (
Rationale 73).
Only administer an additional epidural bolus dose if:
- the patient’s pain score is greater than 4 using a 0-10 scale
- epidural block is less than dermatome level T3
- other analgesic measures have been ineffective
- pain is related to the surgical procedure
Any additional bolus dose must comply with the prescribed “Maximum Dose in 4 hours” as indicated on the yellow prescription chart and PCAM pump settings. This is based upon the maximum dose range of 2.5mg/kg (2mg/kg in neonate) in a four-hour period (
Anaesthesia UK)(
Rationale 74).
When using a solution of 0.125% levobupivacaine (1.25mg/ml), this equates to maximum four-hourly allowance of:
- neonates: 1.6mls/kg of levobupivicaine 0.125% in any four-hour period
- all other patients: 2mls/kg of levobupivicaine 0.125% in any four-hour period
Additional boluses should be based on a dose of:
0.1ml/kg - not exceeding 5mls.
To administer an additional bolus:
- check the prescription chart
- access “Clinician Override” facility on PCAM
- programme and initiate additional bolus dose
- document additional bolus dose on prescription chart and Pain Management Chart
- closely monitor patient and reassess pain score and sensory nerve block after 20 minutes
All changes should be agreed with a second checker and be within prescribed limits.
Particular care must be taken in the early post-op period (ie initial four hours) to assess, and make allowance for, the dose of 0.25% levobupivacaine (2.5mg/ml) solution administered in theatre (this being
twice as concentrated as the 0.125% infusion solution).
For example: if a 10kg patient, aged one year, received:
- 5ml 0.25% levobupivacaine in theatre at 2pm (containing the same quantity of levobupivacaine as 10ml of 0.125% solution) and
- 0.125% solution running at 3ml/hr for three hours, between 3pm and 6pm (9ml total)
He will have received the equivalent of 19ml of 0.125% levobupivacaine in the last four hours.
With a maximum four hourly limit of 2ml/kg (20ml) of 0.125% solution, he could receive one additional bolus of 0.1ml/kg (1ml) if required.
Drug administration: pump occlusion
If the pump occludes:
- Stop the infusion.
- Check that the catheter is not kinked or trapped.
- It may help to reposition the patient.
- Ensure that the correct administration set is being used.
- Check the pump - the administration set may be clamped. Squeeze finger grips on plunger holder to relieve any pressure in the syringe or administration set (SQUEEZE FINGER GRIPS ON PLUNGER HOLDER TO RELIEVE ANY PRESSURE IN THE SYRINGE OR ADMINISTRATION SET BEFORE UNCLAMPING)
- Check whether the pump is faulty - if so it will need to be replaced and returned to biomedical engineering with a label describing the fault (Rationale 75)
- Restart the infusion.
- If the pump continues to occlude contact the Pain Control Service on bleep 0577.
The following interventions must only be attempted by the Pain Control Service or advanced practitioner:
- Check the filter to ensure the connection is not too tight.
- To open the Portex Epifuse™ catheter connector (Smiths Medical 2010):
- Firmly insert a Luer slip tip (eg a non luer lock syringe) into the hole on the back of the connector.
- The locking mechanism will disengage.
- Open connector and then examine the catheter for kinking or stretching.
- Ensure the catheter is inserted as far as it can go into the connector as the clamping mechanism may obstruct catheters not fully inserted.
- Attempt to flush the catheter from the filter with 2mls of 0.9% sodium chloride for injection in a 10ml syringe.
- Observe the epidural catheter entry site and re-dress if necessary (Rationale 76)
- If the catheter is kinked under the skin it may be possible for the Pain Control Service to correct this by pulling back the catheter a few millimetres, provided the catheter is known to be threaded at least 2cm in the epidural space (Rationale 77).
- If these interventions are unsuccessful the epidural may need to be removed and alternative analgesia prescribed (Rationale 46).
Staff must ensure that faulty pumps are reported and returned to biomedical engineering (
Rationale 75).
Drug administration: catheter disconnection
The Pain Control Service will consider reconnection a maximum of three times, if appropriate.
If the catheter becomes disconnected:
- Wrap the connector and catheter in a dry, sterile, non-adhesive dressing or paper towel (Rationale 2 and 71).
- Do not clamp the epidural catheter.
- Stop the infusion.
- Contact the Pain Control Service on bleep 0577.
The Pain Control Service or an advanced practitioner will reconnect the epidural catheter if:
- The disconnection occurred less than two hours earlier.
- The fluid level within the catheter does not drop when held at patient level.
- The fluid level within the catheter is not more than 5cm from the end of the catheter.
- The catheter does not appear to be contaminated (Rationale 2).
An aseptic technique must be used to reconnect the catheter. The Pain Control Service or advanced practitioner will:
- Perform a clinical hand wash (Rationale 2).
- Put on an apron and gloves.
- Clean the catheter with an alcohol-impregnated swab, eg Clinell® wipe and allow to dry fully (Rationale 78).
- Cut the end off the catheter with sterile scissors.
- Reconnect it to the catheter connector.
- Dispose of used equipment according to the hospital’s Waste Policy.
- Record action on the child or young person’s Pain Management Chart (Rationale 41).
The Pain Control Service or an advanced practitioner will remove the epidural catheter if:
- It has been disconnected for longer than two hours (Rationale 2).
- The catheter has been contaminated.
- If there have been more than two previous disconnections and this has been discussed with a consultant anaesthetist.
If the epidural catheter has to be removed alternative analgesia will be prescribed (
Rationale 46).
Drug administration: inadvertent catheter removal
If the epidural catheter is pulled out inadvertently:
- Reassure the patient.
- Put a spot plaster over the entry site.
- Ensure the whole catheter has been removed (check blue tip). If in doubt, keep the catheter for the Pain Control Service to review.
- Stop the infusion pump.
- Contact the Pain Control Service on bleep 0577 to instigate an appropriate pain management plan (Rationale 46).
- Record the incident in the child or young person’s health care records (Rationale 41).
Discontinuing epidural
The epidural infusion must normally only be discontinued after discussion with a member of the Pain Control Service or advanced practitioner however the infusion may be stopped by the nurse in the following situations (
Rationale 79):
- over sedation
- respiratory depression or respiratory arrest
- pump malfunction
- concern about potential levobupivicaine toxicity
The pump should be suspended on ‘call back’ settings in the case of:
- displacement of the epidural catheter
- disconnection of the catheter from the filter
- pump occlusions
In all of the above situations, the Pain Control Service should be contacted immediately to allow for patient review.
Discontinuation of the epidural must be recorded in the child or young person’s health care records (
Rationale 41) and the Pain Control Service must be informed.
An epidural catheter is left in situ for a maximum of 96 hours (72 hours in a neonate) (
Rationale 2). If simple analgesia and oral opioids are not sufficient or are contra indicated after this period a PCA/NCA will be prescribed and provided.
The epidural catheter must only be removed by a member of the Pain Control Service or an advanced practitioner.
Special considerations apply if the child or young person has a coagulopathy or is receiving anticoagulation therapy so contact the Pain Control Service for discussion if this applies before attempting removal.
Prepare the patient involving the play specialist and family as appropriate prior to the elective removal of the epidural catheter (
Rationale 8).
To remove the epidural catheter the Pain Team or anaesthetist will:
- Gather equipment:
- plastic apron and non-sterile gloves
- spot plaster
- plaster remover eg Zoff®/Apeal spray
- charcoal swab
- Put on plastic apron and perform a clinical hand wash (Rationale 2).
- Position child or young person comfortably either on their side or sitting upright (Rationale 80).
- Remove the dressing using plaster remover.
- Put on gloves.
- Gently pull the catheter out.
- Check that the catheter is intact.
- Swab the entry site if red or swollen (Rationale 81).
- Place a small plaster over the site.
- Dispose of used equipment according to the hospital’s Waste Policy (Rationale 134) (GOSH 2009).
- The plaster should remain in situ for at least 24 hours, after which time the entry site should have healed (Rationale 2).
- Record the removal of the catheter in child or young person’s heath care records (Rationale 41).
Any pain, swelling or redness that is present at time of removal or develops after the catheter has been removed should be reported to the Pain Control Service immediately (
Rationale 81).
If the entry site is swabbed the Pain Control Service will notify the child or young person’s doctor, check microbiology results & review the patient’s progress (
Rationale 81).
Long-term management of epidural complications
The following complications are rare, but should be investigated thoroughly:
- Patients with a persistent motor or sensory block should be referred to a neurologist. Nerve damage following epidural is rare (one in every 10,000 patients), but can result in permanent injury.
- In the presence of persistent neurological deficit beyond the time frame attributable to the local anaesthetic an early EMG study is indicated.
Any child or young person with residual problems thought to be related to the presence of an epidural must be reported to the Pain Control Service to ensure appropriate follow up is undertaken.
Rationale 1: To ensure potential risks are balanced against the benefits.
Rationale 2: To minimise the risk of infection.
Rationale 3: To minimise the risk of haemorrhage.
Rationale 4: To minimise the risk of exacerbating condition.
Rationale 5: To ensure ease of catheter threading.
Rationale 6: To facilitate informed consent.
Rationale 7: To ensure informed consent is obtained.
Rationale 8: To meet information needs and reduce anxiety.
Rationale 9: To reduce anxiety.
Rationale 10: To ensure the child or young person understands and can use the tool prior to the painful experience.
Rationale 11: To establish normal parameters with which to compare future observations.
Rationale 12: Pyrexia may be suggestive of infection, in which case an epidural may be contra-indicated.
Rationale 13: To prevent problems that are already present being attributed to the epidural.
Rationale 14: To ensure the necessary equipment for inserting and securing the epidural is prepared before starting the procedure.
Rationale 15: For neonates.
Rationale 16: To allow for the greater depth required by older child or young person).
Rationale 17: To pierce the skin (an epidural needle is blunt).
Rationale 18: To check position of needle during advancement.
Rationale 19: To secure catheter to skin.
Rationale 20: To allow for ease of insertion.
Rationale 21: To allow blunt epidural catheter to be inserted.
Rationale 22: The epidural space is reached when loss of resistance is felt.
Rationale 23: To ensure loss of resistance to injection is detected as soon as the needle passes through the ligamentum flavum.
Rationale 24: Children’s and young people's tissues are more compliant than adults, making the loss of resistance harder to detect.
Rationale 25: Resistance to injection of 0.9% sodium is much greater, resulting in a more accurate endpoint.
Rationale 26: To provide effective analgesia and reduce the likelihood of leaking or displacement of the catheter.
Rationale 27: To reduce the risk of infection, leakage, or displacement of the catheter.
Rationale 28: To allow for observation of entry site.
Rationale 29: To prevent kinking of the catheter.
Rationale 30: To establish the initial block.
Rationale 31: To provide effective analgesia.
Rationale 32: To distinguish them from those used for intravenous and other routes (
NPSA 2007).
Rationale 33: To ensure availability of continuous epidural infusion.
Rationale 34: The naloxone prescription for respiratory depression is on this chart and it may be needed at any time.
Rationale 35: Reduce the risk of the wrong medicine being selected by storing epidural infusions in separate cupboards from those holding intravenous and other types of infusions (
NPSA 2007).
Rationale 36: To provide effective analgesia with minimal complications/side effects.
Rationale 37: To minimise the risk of complications.
Rationale 38: To provide adequate information.
Rationale 39: To adhere to the hospital’s Drug Administration Policy.
Rationale 40: To ensure that the correct drug is prescribed and administered.
Rationale 41: To maintain an accurate record.
Rationale 42: To allow for immediate treatment of opiate induced respiratory depression.
Rationale 43: To provide optimal multimodal analgesia.
Rationale 44: To relieve pressure areas/relieve tension on catheters.
Rationale 45: To manage the emotional component of pain.
Rationale 46: To ensure swift action is taken if analgesia is unsatisfactory.
Rationale 47: To prevent further sedation and an increased risk of respiratory depression.
Rationale 48: To ensure early detection and treatment of opiate induced sedation.
Rationale 49: These reflect a range of situations which might lead to respiratory depression/arrest.
Rationale 50: Naloxone is an opioid antagonist.
Rationale 51 : To ensure early detection and treatment of opioid induced nausea and vomiting.
Rationale 52: To ensure early detection and treatment of opiate induced pruritus.
Rationale 53: To ensure early detection and treatment of urinary retention.
Rationale 54: To determine whether the patient is dehydrated.
Rationale 55: To minimise the risk of the problem reoccurring.
Rationale 56: To allow for drainage of the bladder.
Rationale 57: Patients receiving epidural opiates are at risk of developing urinary retention.
Rationale 58: Early mobilisation improves circulation, increases respiratory effort and reduces the likelihood of complications.
Rationale 59: Patient may experience some transient loss of motor power in legs.
Rationale 60: Sympathetic nerve block may cause hypotension.
Rationale 61: To maintain intact healthy skin and minimise the risk of pressure sores.
Rationale 62: To ensure the dressing remains intact.
Rationale 63: To ensure early detection of infection, leakage, or displacement of the catheter.
Rationale 64: To ensure the syringe pump is infusing correctly.
Rationale 65: Levobupivacaine can be toxic if given intravenously.
Rationale 66: Accumulation can occur due to metabolic immaturity.
Rationale 67: Accumulation can occur due to reduced renal function.
Rationale 68: On call pharmacist will assist with guidance and the provision of intralipid required to treat levobupivicaine toxicity.
Rationale 69: These may potentially be due to a dural tap or nerve damage.
Rationale 70: To ensure that the cause of the problem is investigated and appropriate action taken.
Rationale 71: To prevent the introduction of alcohol in the epidural space.
Rationale 72: To maintain patient safety (
NPSA 2007).
Rationale 73: An increase in the infusion rate takes about four hours to take effect.
Rationale 74: To minimise the risk of toxicity.
Rationale 75: To prevent/identify administration errors due to faulty equipment.
Rationale 76: To correct the problem if the catheter is kinked under the dressing.
Rationale 77: To correct the problem if the catheter is kinked just under the skin.
Rationale 78: Avoid introduction of alcohol into the epidural space.
Rationale 79: To ensure patient safety.
Rationale 80: For ease of removal.
Rationale 81: To ensure early detection and treatment of infection.
Reference 1:
Association of Anaesthetists of Great Britain and Ireland (AAGBI) (2002)
Infection Control in Anaesthesia AAGBI London; UK.
Reference 2:
Association of Anaesthetists of Great Britain & Ireland (AAGBI) (2010)
Guidelines for the Management of Severe Local Anaesthetic Toxicity. Last accessed 03/06/2011.
Reference 3:
Association of Paediatric Anaethetists (2008).
Good practice in Postoperative and Procedural Pain. APAGBI London 2008.
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Complications of epidural and spinal anaesthesia in children and young people. Current Opinions in Anaesthesia 8: 420-425.
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Bromage PR (1978)
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NAB Work Programme: Epidural Infusion Standardisation Reference 7:
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Best practice in the management of epidural analgesia in the hospital setting. London, RCoA (III).
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GOSH (2009)
Operational Policy: Hospital Waste Policy (available on hospital intranet).
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McNeely JK, Trentadue NC, Rusy LM, Farber NE (1997)
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National Patient Safety Agency (2007)
Patient Safety Alert 21 - Safer practice with epidural injections and infusions. Reference 16:
Reynolds J, Parfitt K, Parsons A, Sweetman S (1996)
The Extra Pharmacopea (31st edition). England, Royal Pharmaceutical Society of Great Britain.
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Royal College of Anaesthetists 2010
Best practice in the management of epidural analgesia in the hospital setting. Last accessed 6/09/2010.
Reference 18:
Royal College of Anaesthetists 2009 NAP3
Major complications of central neuraxial block in the United Kingdom. RCOA, London
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Royal College of Nursing [RCN] (2003)
Standards for Infusion Therapy. London, UK RCN.
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Royal College of Nursing (2009)
The recognition and assessment of acute pain in children and young people – Quick reference guide and poster. London: Royal College of Nursing
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Rowney DA, Doyle E (1998)
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Schmid RL, Sandler AN, Katz J (1999)
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Smiths Medical (2010)
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Wood CE, Goresky GV, Klassen KA, Kuwahara B, Neil SG (1994)
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Document control information
Lead author(s)
Judy Peters and Liz Robinson, Clinical Nurse Specialists, Pain Control Service
Document owner
Richard Howard, Director, Pain Control Service
Approved by
Clinical Practice Committee
First introduced: 31 December 2002
Date approved: 23 January 2012
Review schedule: Two years
Next review: 23 January 2014
Document version: 2.0
Replaces version: 1.0
