This pain management guideline was written by the staff of the Children's Pain Management Service for the Royal Children's Hospital, Melbourne.

This guideline may NOT be suitable for use in other institutions.

• Nurse competencies
• Indications
• Prescription of epidural infusions 
• Epidural infusion solutions
• Epidural infusion set up
  • Epidural lines and giving sets
  • Securing epidural catheters
  • Epidural catheters
• Epidural infusion delivery
  • Changing the infusion rate
  • Epidural boluses
  • Duration of infusion
• Observations
• Assessing sensory and motor block
  • Dermatomes
  • Motor block
• Catheter position and insertion site
• Pressure area care
• Nerve compression
• Intravenous access
• Concurrent drugs
  • Anti-coagulant medication
• Precautions
• Patient review
• Minor problems & management
  • Inadequate analgesia
  • Leaking epidural
  • Occlusion
  • Disconnection
  • Urinary retention
• Complications
  • High block
  • Back pain
  • Dense motor block
  • Sedation/Respiratory depression
  • Fever
  • Hypotension
  • Local anaesthetic toxicity
• Ceasing the epidural infusion
• Removing the epidural catheter

Nurse competencies

• All Registered Nurses caring for patients receiving epidural infusions should complete and pass their epidural competency annually. See Learning Hero

Indications

• Epidural infusions are for the management of moderate to severe pain.

Prescription of epidural infusions

• Epidural infusion is a specialised analgesia technique and is managed by CPMS.
• ONLY CPMS and Anaesthesia staff may prescribe epidural infusions.
• The epidural infusion is prescribed according to the guidelines on the Regional anaesthetic infusion presription. 
• The level of insertion of the epidural catheter, the catheter position at skin and the skin to space distance are recorded on the Regional anaesthetic infusion prescription.
• The local anaesthetic solution to be used and additives (if any) are prescribed on the Regional anaesthetic infusion prescription with the infusion rate  prescribed in mL/hr.
• For rapid relief of breakthrough pain, a bolus dose will be prescribed +/- an alteration to the infusion rate. In some situations only CPMS staff may administer the epidural bolus. The reason for this will be documented.
• A Naloxone order will be prescribed for patients who have an opioid in the local anaesthetic solution.
• The pump settings are documented within the prescription.

Epidural infusion solutions

• Ropivacaine 0.2% is the usual epidural local anaesthetic solution prescribed. More dilute concentrations may be prescribed if less sensorimotor blockade is desired.

The following analgesics may be separately added to the local anaesthetic solution to improve analgesia:

• Flasks of Ropivacaine (100 mL and 200 mL) are kept on ward pharmacy imprest and are available from the RCH pharmacy department. The pharmacy department prepares other solutions (ie different concentrations or those with additives). It is important to ensure that sufficient solution is ordered for nights, weekends and public holidays. CPMS should be contacted if there is a problem with availability of epidural solutions out of hours.

• If the epidural solution contains fentanyl or hydromorphone, it must be stored in the Drugs of Addiction (DA) safe.

Epidural infusion set up

Lines and giving sets:

• The epidural infusion must be prepared in accordance with RCH medication policy and labelled clearly. Specific yellow epidural infusion labels are to be used.
• Only REM-EPISET^TM is to be used for delivery of epidural infusions.
  The REM-EPISET^TM tubing has a T-configuration. The clear tubing with the bag spike connects to the flask of local anaesthetic solution. The short yellow tubing is connected to the syringe, allowing the syringe to be refilled. The long yellow tubing with the yellow luer lock connects to the epidural filter. There are two one-way valves in the REM-EPISET^TM tubing to prevent the risk of gravity free-flow. Only REM-EPISET^TM is to be used for delivery of epidural infusions.  
• A yellow Alaris PCAM  pump must be used for all epidural and regional infusions. Check the pump settings each shift.
• CPMS recommend the infusion pump be clearly labelled with the yellow epidural/neural labels as an added safety feature.
The two authorised persons who put up each flask must sign the record of infusion on the Regional anaesthetic infusion prescription
• The epidural lines are to be maintained as a closed system. Changing of flasks must be done using aseptic technique.
• To refill the syringe from the flask the infusion should be paused and the syringe removed from the pump before being refilled from the flask. Ensure the spiked end of the flask is pointing downwards to avoid air being drawn into the tubing.
• Use the key in the side of the pump to open the cover.

Securing the epidural catheter:

• A sterile sponge or gauze may be applied at the epidural insertion site to soak up any leaking epidural solution.

• An occlusive clear dressing (eg Tegaderm or Opsite) is placed over the catheter and sponge.

• A 'window' is made around the clear dressing with tape to reinforce the clear dressing and to allow viewing of the insertion site and catheter markings. Hypoallergenic and firmly adhering tape (eg Hyperfix or Mefix) is preferred.The remainder of the catheter is taped up the child's back and over one shoulder where it connects with the filter.

• The filter is securely taped to the child's upper chest wall (in a place where it is comfortable) to avoid dislodgement of the catheter.

• Any loose catheter tubing should be carefully coiled and taped securely to the chest wall or shoulder to prevent kinking and/or disconnection.

• Routine dressing changes are not indicated and are only to be done by a member of CPMS if required.

Epidural catheters:

Two epidural kits are used at RCH the Portex 18G and 20G and Braun Perifx® Paed series 18G and 20G

•  Portex 18G  Portex 19G epidural kits can be distinguished by the colour of the locking hub on the filter and the size and markings of the epidural catheter.
• The catheter in the 18G Portex epidural kit has a single bold mark at 5 cm, then a mark every 1cm up to the two bold lines indicating 10 cm. The 1 cm markings continue until three bold lines together, which indicate 15 cm. There are no further markings until four bold lines together, which indicate 20 cm.
  The catheter has a coloured closed tip and three lateral holes.
  The locking hub at the filter is blue.
• The catheter in the 19G Portex epidural kit has a mark every cm from 2 cm with a bold mark indicating 5 cm. There are two bold lines together indicating 10 cm. Markings continue every 1 cm up to three bold lines together, which indicate 15 cm.
  The catheter has a single end hole with a coloured tip.
  The locking hub at the filter is white.
• Braun Perifx® Paed series. The epidural kits can be distinguished by the size and bold markings on the catheters.
  18G Braun epidural kit has a solid mark at 9cm and a clear tip (children)
  20G Braun epidural kit has a solid line at 12cm and a clear tip (infants)
• The Braun Perifx® filter is yellow and attached to a PinPad on the shoulder before taping

Epidural infusion delivery

• The epidural infusion is commenced in recovery.

• The usual epidural infusion rate range is 0.1 mL/kg/hr - 0.3 mL/kg/hr 0.2% Ropivacaine

• In NEONATES the for the maximum infusion rate refer to Neonatal guideline

Changing the infusion rate:

• The infusion rate may need to be changed to alter the extent of the block.
  
  
• The rate may be changed according to the prescription or by an order from CPMS or an anaesthetist. Changes in the infusion rate must be done by CPMS or an anaesthetist and recorded on the Regional anaesthetic infusion prescription. The reason for the change should also be documented.
  
  
• In the case of a life-threatening emergency or high thoracic blockade the epidural infusion should be ceased immediately, then CPMS contacted to make an urgent patient assessment.

Epidural boluses:

• It is important to optimise the analgesic effect of the epidural. A bolus of epidural solution may be required if the patient is in pain or the block is inadequate to cover the required area. This should be the first choice within the prescribed epidural prescription and guideline if the patient is in pain.
  
• Nurses who have completed the epidural competency may administer a bolus of Ropivacaine+/- additive as prescribed. Two authorised persons must check and sign for the bolus on the Regional anaesthetic infusion prescription. The reason for the bolus should also be documented. 
• An anaesthetist must administer an epidural bolus if the local anaesthetic concentration exceeds  0.2%. This anaesthetist must remain in the ward/unit for 20 minutes following the bolus. 
•  Bolus doses of the epidural infusion (as prescribed on 'Regional anaesthetic infusion prescription') should be administered using the yellow handset. The bolus amount in mLs and the bolus interval is programmed  by the recovery, anaesthesia or CPMS staff. For added safety the handset is covered by a yellow plastic cover easily accessed for Nurse delivered boluses 

Duration of infusion:

• Epidural infusions are usually run for 2-3 days and rarely for longer than 5 days. 
• In NEONATES the duration of infusion is limited to 36 hours to reduce the risk of local anaesthetic toxicity. Weaker solutions of local anaesthetic may be used to enable greater spread of the block or to allow a longer duration of infusion.  

Observations

The following observations should be recorded on the Clinical Observation Chart

Respiratory rate, sedation score, heart rate & blood pressure: 1 hourly for the first four hours of the epidural infusion.

• Respiratory rate & heart rate: 1 hourly AND blood pressure & temperature: 4 hourly - until epidural ceased. [The need for less frequent observations for patients receiving long-term epidural infusions should be discussed with CPMS.]
   
• Pain score: 1 hourly while awake (using developmentally appropriate scale eg Wong-Baker Faces scale, Numeric scale, FLACC scale or PAT score for neonates)
• Vomiting score: 1 hourly for the first 12hrs, then 4 hourly as indicated
     
• Pulse oximetry: if indicated  

• Sensory and motor assessment:    4 hourly
• The effectiveness of the analgesia should be recorded in the Nursing Progress note and pain assessment documented in the flow sheet

Observations following a bolus of epidural infusion:

• Heart rate, respiratory rate & blood pressure every 5 minutes for 20 minutes. If the observations remain unchanged, return to routine epidural observations.
  Pain assessment

Observations following a rate increase:

• Heart rate, respiratory rate & blood pressure 1 hourly for 4 hours. If the observations remain unchanged return to routine epidural observations.
  Pain assessment

CPMS should be called if pain relief is inadequate after 2 boluses within a six hour period.

Any observations outside reportable limits (as identified on VICTOR) or outside normal values for age should be reported to CPMS +/- the primary treating team.

Assessing sensory and motor block

Sensory Block

Dermatome assessment should be done 4 hourly and at the following times:

• In the recovery room on waking from anaesthetic
• On return to the ward/unit from the operating suite
• At commencement of each nursing shift
• If the patient complains of pain
• 1 hour after a bolus or increase in the infusion rate
  Document in flowsheet (PCA/Epidural)
  
  

Contact CPMS if:

• Epidural block higher than T3
• No evidence of block
• Block insufficient to relieve pain
• No improvement 15 minutes aftr a bolus

Motor Block:

• In the recovery room on waking from anaesthetic
• On return to the ward/unit from the operating suite
• Prior to ambulation
• 1 hour after a bolus or increase in the infusion rate
  Document in flowsheet (PCA/Epidural)
  

Contact CPMS if:

• major changes in motor function (particularly any sudden change)
• almost complete or complete motor block in legs (Bromage score 2-3)
• changes in neurovascular observations in lower limbs with plasters
• reduced hand or finger motor function with thoracic epidural

Catheter position and insertion site

• At least once each nursing shift the epidural site should be checked for redness, local tenderness, leaking and dressing integrity. Document in flowsheet
• The epidural catheter markings at the point of skin insertion should be checked against those documented on the epidural infusion prescription or flowsheet (LDA).
• Any change or abnormality must be reported to CPMS urgently.

Pressure area care

• It is important that pressure area care is meticulous for all patients receiving epidural infusions. The decreased sensation produced by epidural analgesia removes the usual warning signs that prompt patients to move. Significant motor block may limit patient movement. Both of these factors may contribute to the development of pressure areas. Most commonly the heels, medial and lateral malleoli and sacrum are involved but ALL pressure points are at risk.

• Patients with lumbar epidurals must be turned 2-3 hourly, have extra pressure control devices (such as gel pads and pressure mattresses or air mattresses), and their skin should be regularly checked for signs of pressure.

Nerve compression

• It is vital that during regular pressure area care, special attention is made to avoid nerve compression.

• Superficial nerves (eg common peroneal nerve) are vulnerable to damage from unrecognised pressure due to decreased sensation.

Intravenous access

• All patients with an epidural infusion must have intravenous access at all times with a minimum infusion rate of 5 mL/hr.

• In some situations (eg longer-term epidurals), intermittent flushing of an IV bung may be appropriate but this must be discussed with CPMS.

• After the epidural infusion is ceased the IV cannula must remain in situ until the epidural catheter is removed.

Concurrent drugs

Opioids

• If an opioid is added to the epidural solution, NO ORAL / RECTAL / INTRAVENOUS OR INTRAMUSCULAR opioids or sedatives agents should be administered without prior discussion with an anaesthetist or CPMS.

• Epidural infusions (without an opioid added) may be supplemented by IV or oral opioids to improve analgesia.

Anti-coagulant medication:

• If a patient is prescribed anti-coagulant medication and will be having epidural analgesia, the first dose must not be administered until after the epidural catheter is inserted.

• If a patient is on subcutaneous anti-coagulant medication the epidural catheter must not be removed until 12 hours after the last subcutaneous dose is administered.

• If the anti-coagulant medication is being administered by infusion, the time between ceasing the anti-coagulant infusion and removing the epidural must be discussed with CPMS.

Sedatives

• If a patient is receiving epidural opioids with other medications that may cause sedation (for example, antihistamines, benzodiazepines or anticonvulsants), they may be at increased risk of sedation and respiratory depression.

• If clonidine is added to the epidural solution hypotension and sedation may result.

Patient review

• CPMS reviews patients twice daily on week days and once daily on weekends and public holidays.

• If the patient is experiencing pain or undesirable side-effects CPMS must be called to review the patient.

• CPMS can be contacted at all times on pager 5773.

Minor problems and management

Inadequate analgesia:

If the patient complains of pain or appears to be in pain:

• Assess severity and location of pain
• Assess dermatomes on both sides
• Check catheter at insertion site for leaking/dislodgement
• Check epidural catheter position at the skin insertion site
• Check at connection of catheter and filter for disconnection/leaking
• Consider surgical review if risk of surgical complications, e.g. compartment syndrome, infection or haemorrhage.
• Call CPMS if a bolus fails to improve the pain

Leaking epidural:

• If the patient is comfortable (suggesting the epidural is providing adequate analgesia), the dressing should be reinforced and the amount of leakage monitored.
• If the patient is in pain or the epidural dressing needs changing, CPMS should be contacted.

Occlusion:

The catheters used are very fine. They can easily occlude, thus the infusions may need to be run at higher pressure than is usual for IV infusions.

If the infusion pump occludes or is not delivering the programmed rate:

• Check the epidural infusion line is not occluded or kinked
• Check that taping has not resulted in any kinks in the catheter
• Check the infusion pump pressure
• If the cause for occlusion is not found call CPMS urgently

Disconnection:

• If the epidural becomes disconnected call CPMS immediately
• DO NOT reconnect
• Wrap the two ends in a sterile towel or gauze
• Turn off the infusion pump

Urinary retention:

• Patients with lumbar or caudal epidural infusions are at increased risk of urinary retention. The risk is increased in patients receiving epidural opioids
• The patient may need to have a urinary catheter in situ

Complications

IF RESPIRATORY DEPRESSION OR OVERSEDATION IS SUSPECTED:

• CEASE the epidural infusion
• CEASE all other infusions that could be contributing to sedation
• Attempt to rouse the patient
• Call 22 22 [MET team] if appropriate
• If apnoeic: administer bag and mask ventilation with 100% oxygen
• If breathing: maintain airway, monitor oxygen saturations and administer oxygen
  via face mask at 8 L/min
• Check circulation. If pulseless: commence chest compressions
• Administer naloxone per instructions on the attachment chart if opioid toxicity is suspected
• Call CPMS for urgent review

Call CPMS URGENTLY if any of the following occur:

• high block >T3
• back pain
• dense motor block
• sedation / respiratory depression
• fever >38.5^oC
• hypotension
• signs of local anaesthetic toxicity

High block (dermatomes >T3)

A sensory block above T3 may be result in respiratory distress, decreased SaO2, difficulty breathing, bradycardia, numbness or tingling in fingers or arms, loss of hand function and Horners sign.
[Horners sign = miosis (small pupil), ptosis (drooping upper eyelid), dry/warm skin on the face. This may be unilateral or less commonly bilateral.]

Back pain

Mild back pain is common and caused by minor trauma related to epidural insertion. However, because of the serious consequences of epidural abscess and epidural haematoma, all back pain after epidural insertion must be reported to, then thoroughly assessed by CPMS staff.

Dense motor block (Bromage score 2-3)

Moderate motor block is common immediately following surgery due to the higher doses of local anaesthetic used during surgery. Mild motor block is common following this initial period. However, because of the serious consequences of epidural abscess and epidural haematoma, all dense motor block after epidural insertion must be reported to, then thoroughly assessed by CPMS staff.

Sedation / Respiratory depression

Respiratory depression or decreased oxygen saturation unresponsive to oxygen therapy may be caused by the addition of opioids to the epidural solution. Clonidine may also contribute to sedation. If there are no opioids or clonidine in the solution but sedation is present a high block or local anaesthetic toxicity must be urgently excluded.

Fever

If the patient has a temperature >38.5^oC, or is suspected of having sepsis with potential for bacteraemia, the epidural catheter may need to be removed.

Hypotension

Sympathetic blockade may cause hypotension (this is rare in children less than 8 years of age). The addition of clonidine to the epidural solution may increase the likelihood of hypotension.

Local anaesthetic toxicity

Signs of local anaesthetic toxicity include: dizziness, blurred vision, decreased hearing, restlessness, tremor, hypotension, bradycardia, arrythmias, numbness of tongue, seizures, sudden loss of consciousness.

Ceasing the epidural infusion

• Ceasing the epidural infusion should only be done in consultation with CPMS or an anaesthetist.

• When it is decided that epidural analgesia is no longer required, the infusion is ceased and alternative analgesia administered. There is no logic in 'weaning' epidural infusions.

• It is important to warn the child and parents about the possibility of experiencing some discomfort as the local anaesthetic wears off and normal sensation returns (usually in about 2 - 4 hours).

• If significant pain occurs after ceasing the epidural infusion despite alternative analgesia, CPMS should be contacted.

Removing the epidural catheter

An accredited Registered Nurse can remove the epidural catheter after instruction by CPMS or an anaesthetist.

NB If the patient is receiving anti-coagulant medication, refer to concurrent drug section before removing epidural.

If there is any difficulty encountered removing the epidural catheter or if any abnormality is detected, CPMS must be called immediately.

To remove the epidural catheter:

• Explain the procedure to child and parent.

• Position the patient either on their side or sitting, bending forward. This spreads the laminae of the vertebra apart, making removal easier.
• Remove the tape from the patient's shoulder and then back, terminating at the epidural insertion site.
• Put on non-sterile gloves.
• Withdraw the catheter slowly and steadily. If any resistance to catheter withdrawal is felt, STOP and call CPMS urgently. DO NOT forcefully withdraw the catheter.
• Check the epidural catheter tip is intact and the epidural site for redness, pus or any abnormality.
• If clinically indicated or requested by CPMS, the epidural catheter tip should be sent to pathology along with a skin swab, full-blood examination (FBE) and blood cultures. CPMS must be notified if this is done.
• Place a bandaid over the insertion site. This can be removed the following day.
• Complete the details about the epidural removal and sign on the Regional anaesthetic infusion prescription and flowsheet.
   

First version written June 1998, Updated July 2023