|Inadequate analgesia||Check pump, catheter site and connections for leakage. Increase infusion rate within prescribed limits.
If PCEA is being used check patient understanding of using the demand button and ask patient to press the button (perhaps more frequently)
Check level of sensory block using ice / ethyl chloride.
If uni-lateral block consider withdrawing epidural catheter
Seek advice if pain persists despite epidural analgesia infusing at maximum prescribed rate.
|Motor loss||If unilateral consider withdrawing epidural catheter when rate reduction and inclining patient away from affected side has not resolved the problem.
If gross motor weakness seek urgent senior anaesthetic review for neurological assessment and possible MRI scan. Gross motor weakness may be indicative of an epidural haematoma and in order to prevent permanent paralysis the time frame for dealing with this is about 6 hours from identification to surgical intervention – i.e. spinal cord decompression
|Respiratory rate 9/10 per minute or sedation score 2||Opioid concentration in infusing epidural solution may need decreasing.
Give oxygen 15L via a non-rebreather reservoir mask, check and record oxygen saturation and monitor closely. Record respiratory rate and sedation score every 5 minutes until respiratory rate is >12 and sedation improves.
|Respiratory rate <8 or sedation score 3||Switch off infusion, give oxygen 15L via non-breather reservoir mask, support ventilation with a pocket mask/bag valve mask where necessary, check and record oxygen saturation and respiratory rate and monitor closely. Give IV naloxone (*refer to section 4.2, re administration), until sedation score 0-1 and respiratory rate > 12. Monitor continuously.|
|Hypotension||Do not assume that epidural is causing hypotension.
Check for signs of hypovolaemia.
Increase IV infusion rate if necessary and as prescribed.
Ephedrine may be required. Ensure available. (To dilute Ephedrine: Into a 10ml syringe dilute 1ml of Ephedrine 30 mgs/ml with 9mls of Normal Saline). This would be administered by a Doctor in 3mg (1 ml) increments. To evaluate effect blood pressure should be recorded in two minute cycles.
|Nausea & Vomiting||Give anti-emetic as prescribed, according to postoperative nausea and vomiting protocol and reassess.|
|Itching||Give IV Naloxone 50mcg if epidural opiate is thought to be causal factor
This may need to be repeated as required.
|Urinary retention where patient has not routinely been catheterised||Insert urinary catheter, however if orthopaedic patient, discuss firstly with orthopaedic team as antibiotic cover will be required.|
|Inflamed epidural insertion site / pus at epidural site / back pain||Stop infusion Seek advice from anaesthetistand refer to epidural care plan. If it is necessary to remove the epidural catheter then remove according to section 2.9 / 2.10.
Send catheter tip and wound swab from epidural site to microbiology for culture and sensitivity, ensure all clinical details are documented. Inform H/O.
|Suspected epidural site infection||Seek advice from anaesthetist.
The epidural catheter will need to be removed according to section 5.9 / 5.10.
Vancomycin or Teicoplanin should be started along with either a Cephalosporin or Ciprofloxacin and reviewed when C+S results are available. The patient should be reviewed regularly by the pain service and/or anaesthetist.
|Confirmed epidural site infection||Treat with antibiotics as per microbiology advice in accordance with C+S results. The patient should be reviewed regularly by the pain service and/or anaesthetist.|
|Epidural catheter disconnected from filter||The epidural will need to be discontinued and removed and must not be reconnected. See epidural care plan.|
|Epidural dressing becomes removed/dislodged||Refer to the epidural care plan.|
|Local anaesthetic toxicity||Please refer to section 5.12 of the Pain Management Guidelines reproduced courtesy of Pain Management Service Cardiff and Vale University Health Board.|
|Severe frontal headache that is worse when sat forward||This may be indicative of a dural tear.
Lie the patient flat and initially try managing with fluids and simple analgesia i.e. paracetamol +/-an NSAID.
If this does not resolve a blood patch may be necessary.