Management of

Epidural Injection

By: Mariepaz Olvin

For postoperative pain, epidural

analgesia may be the most
effective medicine. But there are
a few things nurses need to
know about managing the
patient, including the early
warning signs of complications
and what to doand what not to
doif they occur.

Nurses have always faced the

challenge of managing pain in
postoperative patients while keeping
adverse effects to a minimum.
Comfort measures, psychological
support, and pharmaceutical agents
are all part of the arsenal,
butperhaps one of the best tools is
continuous epidura lanalgesia.

Epidural Analgesia
is used to manage pain after major
thoracic, abdominal, and orthopedic
surgery. It works by blocking
transmission of pain at the spinal
cord and has been shown to blunt
the surgical stress response, improve
post-op pulmonary function,
decrease the incidence of post-op
thrombosis, and provide better
analgesia during walking, coughing,

Management of Epidural
Injection
1. Minimize complications with
proper positioning.

Management of Epidural
Injection
2. Awareness regarding the
effects of opioids and what can
go wrong.
Opioids produce a segmental
analgesic effect of the dermatomes
near the catheter tip. The ones most
commonly used for epidural
analgesia are morphine sulfate
(Duramorph), fentanyl citrate
(Sublimaze), and sufentanil citrate

Although Opioids offer effective pain

relief, opioids can produce several
complications:
Respiratory depressionis characterized
by a respiratory rate of fewer than eight
breaths per minute, oxygen saturation of
less than 90%, and a decreased level of
consciousness.
Urinary retentionis characterized by a
higher intake of fluids than output. The
patient may complain that he feels as
though he needs to urinate, but can't.
Itchingis most often treated with 25 mg of
diphenhydramine HCl (Benadryl) every four
hours, administered intravenously.

Local anesthetics administered into the

epidural space provide excellent analgesia
but produce sympathetic blockade, which
causes vasodilation, hypotension, and
motor blockade, hampering the patient's
ability to move. The drugs that are used
most often are lidocaine HCl (Xylocaine),
bupivacaine HCl (Marcaine, Sensorcaine),
and ropivacaine HCl (Naropin
Using opioids and local anesthetics in
combination maximizes the benefits of
both classes of drugs and reduces the
adverse effects.

Management of Epidural
Injection
3. Nurses are the front line of
patient management.
Nursing care of the patient with a
continuous epidural infusion includes
educating the patient and family and
assessing the levels of pain relief
and sensory/motor blockade. But the
most important part of your duties is
to keep a close watch for a number
of complications.

EPIDURAL INJECTION COMPLICATIONS:

Abscessis rare, but serious. Symptoms begin
one to three days after surgery and include
back pain, fever, flaccid paralysis followed by
spastic paralysis, an elevated white blood
count, sensory and motor changes, and a
positive Brudzinski's SIGN.
Epidural hematomamanifests with severe
back pain, lower extremity paresthesia, and a
change in sensory or motor function without
definable cause.
Cauda equina syndromeis a rare
complication that causes back pain, motor
weakness in the lower extremities, sensory

Catheter migrationcauses nausea, a

decrease in blood pressure, and a loss of
motor function without a definable cause. It's
important to call the anesthesia provider
immediately.
Sympathetic blockadeis characterized by
decreased blood pressure and, less commonly,
a decreased heart rate.
Toxicitycaused by the local anesthetic will
manifest differently according to the drug, but
general symptoms include lightheadedness,
numbness of lips and tongue, visual and
auditory disturbances, muscle twitches,
unconsciousness, seizures, coma, respiratory

Dural punctureduring insertion of the

epidural catheter is an inherent risk
because of the close proximity of the
epidural and spinal spaces. If the needle or
catheter punctures the dura, cerebrospinal
fluid will be aspirated and the anesthesia
provider will often reinsert the catheter at
a different spinal level.
Breakthrough painmay also occur. The
patient may exhibit signs of restlessness,
increased respiratory and heart rates, and
elevated blood pressure, and he may
complain of pain.

Allergic reactionis another serious

complication, characterized by hives,
respiratory distress, and anaphylaxis.
Limited mobilityin areas not affected by
the sensory/motor blockade and orthostatic
hypotension are common reactions. Don't
let the patient get out of bed without
assistance, and then only if the surgeon
has approved it. Elevate the head of the
bed 30 - 40 degrees.

Managed properly, continuous

epidural infusion provides excellent
pain relief without limiting the
patient's involvement in postop
activities. It decreases postop
complications caused by pain and
immobility. Your diligence in care will
reward the patient and the
healthcare team by decreasing
postop complications, increasing
customer satisfaction, and
decreasing hospital costs.