patient control epidural analgesia al razi hospital kuwait
DESCRIPTION
This is the Patient Controlled Epidural Analgesia protocol at Al Razi Hospital. This presentation was done before initiating the PCEA as a pain control modality in the hospital.TRANSCRIPT
PATIENT CONTROLLED
EPIDURAL ANALGESIA
DEPARTMENT PROTOCOL
FARAH JAFRI
Topics
Review of literature
Department protocol
Our experience
ESRA GUIDELINES FOR PCEA -
This technique produces high patient
satisfaction.
Reduced dose requirements compared with CI.
Sophisticated pumps are required and accurate
catheter position is important for optimal efficacy.
Knowledge is Reassuring....
ESRA - Guidelines
“There are many possible variations in local anaesthetic/opioid concentration yielding good results, the example given here should be taken as a guideline; higher concentrations than the ones mentioned here are sometimes required but cannot be recommended as a routine for postoperative pain relief.”
ESRA- Guidelines for PCEA
Dosage for patient controlled infusion
(lumbar or thoracic):
Background 4-6 ml/h infusion
Bolus dose 2 ml (2-4 ml)
Lockout interval 10-30 min, We have kept 30 min.
Recommended max hourly dose
(bolus + Background) 12 ml/hr
Other opinions......
Bonica- Management of Pain- Ballentyne, Fishman, Rathmell
“ PCEA allows individualization of patients pain therapy.”
“Less consumption of drug” .
“ Data of over a 1000 patients shows that 90% of patients with PCEA receive adequate analgesia.”
COMPARING PCEA & CI
CONT. EPIDURAL INFUSION
PCEA
PRURITIS 1.8- 16.7% 10-22%
NAUSEA 3.8-14.8% 2-22%
SEDATION 13.2% 7.4%
HYPOTENSION 4.3% 0.7-6.6%
MOTOR BLOCK 0.1-2% 3%
RESP DEPRESSION 0.25% 0.1-1.6%
OTHER OPINIONS.......
National Guideline Clearinghouse
A public resource for evidence-based clinical practice
guidelines from the US Dept of Health
Patient Controlled Epidural Analgesia (PCEA)
is safe to use in selected older adults.
(Acute pain management in older adults. 2006)
National Guideline Clearinghouse
“Studies have demonstrated effective pain relief, decreased opioid use, and increased patient satisfaction with pain relief with PCEA (opioid and local anesthetics).”
(APS, 2003; Gopinathan et al., 2000; Lebovits et al., 2001; Mann et al., 2000; Mann, Pouzeratte, & Eledjam, 2003;
Silvasti & Pitkanen, 2001).
Evidence Grade = B
OTHER OPINIONS....
Randomized, double-blind comparison of patient-controlled epidural infusion vs nurse-administered epidural infusion for postoperative analgesia in patients undergoing colonic resection
J. J. Nightingale et al. BJA. 2007 98(3):380-384;
CONCLUSIONS: PCEA provides greater analgesic efficacy than CEI for post-op analgesia after major intra-abdominal surgery, and a decreased requirement for physician or nurse intervention.
ASA guidelines for PCEA in obs.
• Solution 0.0625% bupiv + opioid
• Continuous infusion 08-15 ml/h (most use12)
• Bolus 10-12 ml (most use12)
• Lockout 12 min (it takes the
pump almost 8 min
to get the dose in).
• Air sensitivity OFF
• 1 hour maximum 3-4 boluses.
ASA GUIDELINES-- CONTD
• Instruct patient to request physician evaluation and bolus if no relief after 2 self-administered boluses within 40 min.
• Rescue Meds: Supplement with bolus of bupivacaine ± opioid (e.g. 7 to 10 ml of 0.125% bupivacaine 10 ml, or 7 to 10 ml of 0.25% bupivacaine) and increase infusion rate and hourly maximum if necessary.
DEPARTMENT PROTOCOL
Prerequisite
Preoperative orientation of patient
Safety
PCA initiation
Pump programming
Drug regimes
Monitoring
PRE-REQUISITES
Patent IV line, I/V Fluid
Available O2,
Knowledge of Basic Life Support,
Professional Accountability,
Staff trained to use equipment and drugs,
Adequate ward staffing levels.
Pre-op orientation for PCEA
All patients must have—
Explanation pre-operatively about technique
How to press the button, with help of prop,
pictures or actual pump.
And should be told to hear the soft beep which
would indicate the have received a dose.
They should know that the dose is within safe
limit but they must not press when there is no
pain.
Safety
Epidural infusion lines should be clearly
identified.
Pump & cartridge must be labeled “ for
epidural connection only”.
All patients must have a patent iv cannula
during & for 12 hr after cessation of
epidural.
Safety
Ensure that the patient is not fluid depleted
before insertion of epidurals- e.g. due to: bowel prep,
fasting/starvation
insensible per-operative loss from evaporation – up to
10ml/kg/hr)
Ensure hydration during the initial post-op
period, with iv fluids and later by good oral
intake.
PCEA- Initiation
In Recovery, program the Cadd Legacy pump,
Set an base line infusion of 5ml/hr initially.
Possibly raising up to 8 ml/hr:
if analgesia proves inadequate,
after the patient is settled and
is using the PCEA satisfactorily.
PCEA- Initiation
Bolus dose 2-3 ml.
Lockout 30 min.
Basal infusion 6-8 ml/ hr
Normal epidural care
Regular analgesic and
Side effect assessments.
ADMINISTRATION OF DRUGS
A ‘test’ dose of drug will be given by the anaesthetist prior to commencement of infusion.
The infusion will be commenced in the Theatre or Recovery and patient monitored prior to transfer to ward.
Instructions for drug doses and infusion rates will be clearly written on the patient’s drug and epidural analgesia chart.
ADMINISTRATION OF DRUGS • Regimes
• Patients admitted to ICU
• Inj Bupivacaine 0.1% and inj Sufentanil 0.16 mcg/ml
• Patients admitted to ICU
• Inj bupivacaine 0.1% and inj Fentanyl 1-2 mcg/ml
• All ward patients:
• Inj Bupivacaine 0.125%
Drug dilutions Simple formula--
actual conc x actual vol. = desired conc. x desired vol.
To make bupiv. 0.1% with suf. 0.16 ug/ml, 100 ml
For bupivacaine-
0.5 x ? = 0.1% x 100, we need 20 ml that is 1 amp
For sufent. 5 ug/ml
5 x ? = 0.16 x 100, we need 3.2 ml of the vial.
Drug dilutions So putting it all together...
For sufentanil+ L.A PCEA cartridge
20 ml marcaine + 3.2 ml of sufentanil from 10 ml vial + 76.8 ml = 100 ml cartridge.
Similarly for fentanyl + LA PCEA cartridge
20 ml marcaine + 4ml fentanyl + 76 ml saline = `100 ml cartridge
Drug dilutions
Continuing in the same way
For plain L.A solutions
0.125% x 100 = 0.5 x ?
We need 25 ml of 0.5% solution.
Just remember the formula and you can calculate if in doubt!
ADMINISTRATION OF DRUGS
The epidural catheter will be clearly
labeled and screwed tightly into the
bacterial filter.
The filter will be anchored to the
patient’s skin to avoid traction on the
giving set and unnecessary disconnection.
ADMINISTRATION OF DRUGS
Bolus doses of drugs outside of Theatre,Recovery Unit and ITU will only be administered by an anaesthetist
On discontinuation of epidural infusion, the amount of controlled drug remaining in the syringe must be checked by two nurses, or the pain tech. and doctor
The discarded amount must be recorded, i.e., in the patient’s notes, care plan and/or on the epidural observation chart.
Check & Record before starting the
epidural infusion:
Temperature
Pulse
BP
Respiratory rate
Pain score
Sedation level
Movement & Sensation
Items recorded every 6 hrs by nursing
staff
BP
Pulse
Respiration rate
Sedation level
Pain scores (on movement & deep breathing)
Nausea and vomiting
Movement and Sensation
Urine output
If not catheterized:
Check & record UOP q 4 hr,
Observe for bladder distension.
OUR EXPERIANCE
STILL IN PRELIMINARY STAGE
10 cases till date
Mostly TKRS, 1 femur, 1 tibial ilizhorov
PATIENT SATISFACTION IS GOOD
Median Pain Score of 2.5/10
OUR EXPERIANCE
Complications No of Patients
Hypotension 2
Itching 2
Nausea - Vomiting 2
Constipation 1
Breakthrough pain because of cartridge change over time
Most Patients
WAYS TO IMPROVE
Prepare 2 cartridges at same time with identical solution.
Put patient label and send to ward.
They can be used alternatively, the anesthetist attending the cartridge change can refill and keep the other for next change.
Ward teaching and awareness of complications.
Thanks