Epidurals: to Dose, or Not to Dose?

  1. Hello to All,

    Am in a bit of a tiff at work concerning the dosing of continuous epidural infusions. Is this practice widely accepted, is it within an RN's scope of practice, what are your facility policy? I will refrain, at this time, from giving any particulars as not to "sway the jury". Any and all comments would be appreciated.

    Thank you in advance
    God bless your hands at work

    4Blessings
    •  
  2. 44 Comments

  3. by   JaneyW
    This has been an issue at my facility as well. We are not allowed per protocol to 'dose' if what you are talking about is a bolus. We can, however, change the bags out. It became an issue after the MDs set the pumps wrong--too much VTBI--and the bags would run dry. Air isn't much of an issue in the epidural space, but I wasn't too comfortable priming the tubing and reattching it until I was walked through it. Now it isn't so much of a worry for me. You need education on it. I don't know if it is within scope and practice for RNs in CA to actually dose or bolus because that is actually giving meds through the epidural catheter. No one seems to be able to answer me, and the regulation book is as clear as mud.
  4. by   USA987
    We are not even allowed to program the pump. We can change the bag and decrease the continous rate (after a verbal order from anesthesia). We cannot bolus the patient. Our patients have the ability to self-bolus a pre-programmed amount every 20 mins.
  5. by   Spidey's mom
    We don't have continuous epidurals. The CRNA places the epidural and gives the first dose, after that it is the physician who may bolus or the CRNA if he is available.

    steph
    Last edit by Spidey's mom on Jan 3, '05
  6. by   begalli
    Here's what we can do with epidurals (this is in CA):

    Any RN may:

    Opiates (eg: dilaudid)
    Hang the infusion (includes priming tubing and connecting to epidural)
    Monitor infusion and adjust the rate (per MD order)

    Anesthetics (eg: bupivacaine)
    Hang the infusion
    Monitor infusion and adjust rate (per MD order)

    *Epidural Certified RN, in addition to the above, may:

    Opiates
    Bolus using pump
    Bolus using syringe into epidural catheter (most commonly used method for
    breakthrough pain)

    Anesthetics
    RN may bolus using pump only
    MD gives all syringe boluses

    *All of our critical care RNs are epidural certified. Certification consists of about a 20-30 minute inservice followed by a written test and return demonstration showing how to check epidural for placement and how to bolus. This cert is renewed every year with the same test and demonstration (minus the inservice).

    More times than not the patient has a PCEA included with the continuous infusion.

    With intrathecal infusions any RN may hang, monitor and adjust the rate of the infusion with opiates and anesthetics. A certified RN may bolus opiates using the pump only and may not give any anesthetic boluses either by pump or syringe.

    We have standard orders for epidurals with prn orders for breakthrough pain, puritis, nausea. We do not customarily titrate epidurals on our own, but if an order reads for example, 0.2-0.5 mg dilaudid gtt for pain, we may titrate for the desired effect, but usually we have an order that reads 2ml/hr of a specific concentration instead of a dose such as 0.2-0.5 mg (does that make sense?). Our pain service is in charge of all epidurals and is usually very good at responding to nurse concerns.
    Last edit by begalli on Jan 3, '05
  7. by   palesarah
    we can prime the tubing, hang the initial infusion and change the bag out, program the pump and increase/decrease the infusion rate. The patient can self-bolus with a button. If the epidural needs to be dosed up by syringe the MDA needs to come back and do that.
  8. by   RNLaborNurse4U
    The anesthesiologist sets up the pump, delivers all boluses (even re-boluses/re-doses), primes the tubing. The only thing we can do is change the bag (and also change the pump setting to read a new bag was hung with the new volume amount). We can also change the ml/hr setting with a verbal order from the MD.
  9. by   renerian
    I have worked with alot of these types of pumps but never did boluses. If the doses need changed a doc did that.

    renerian
  10. by   BETSRN
    We change syringes on the pumps and may turn an infusion down and can always turn it off, but that's it. As far as dosing , that is the sole responsibility of anesthesia, NOt the nurses.
  11. by   stevierae
    I used to teach various infusion pumps and PCA/epidural pumps for B Braun. The little Curlin pump is one of the best, if not the best, out there, and it is very, very easy to program and very user friendly. In fact, you can program it like any other PCA, and let the PATIENT dose herself according to whatever the lockout intervals are--patient controlled epidural anesthesia is a great hospital marketing device to ensure patients that they will have some control over their labor. You can turn off the pump after delivery and leave the epidural catheter & tubing in place, just putting a stopcock cover over the end of the tubing that you have disconnected, if you want to use it later (say, the next day) for a post-partum tubal ligation.

    Making a mistake in programming the Curlin is difficult to do, because there are all kinds of "bells & whistles" and visual prompts that, in essence, warn you that you are about to make a mistake--essentially it asks, several times, if you are SURE you want to do what you are attempting to do.

    I taught both anesthesia and the OB RNs in many facilities nationwide to program and dose them. Some OB RNs felt it was anesthesia's job and that they weren't being paid enough to take on that responsibility, even if there was no clear cut policy prohibiting them from doing it. I can't say I blame them--I feel the same way about doing conscious sedation in the O.R.--why should I take on that responsibility on an R.N.'s pay just so that an extra room can be opened to rush cases along? Let them wait for anesthesia! In fact, isn't anesthesia required to be in house at all times in hospitals that have OB units--or does that vary? I did teach in a very rural hospital where they had to send a policeman out to roust a CRNA out of bed at his home---he claimed he never heard his phone or his beeper-- and the laboring OB patient never did get her epidural--by the time he got there, it was way too late to put it in--so the little pump that I had taught both him and the nurses to use went unused, and the patient and her husband were justifiably upset.
    Last edit by stevierae on Jan 3, '05
  12. by   scooterRN52
    Quote from 4Blessings
    Hello to All,

    Am in a bit of a tiff at work concerning the dosing of continuous epidural infusions. Is this practice widely accepted, is it within an RN's scope of practice, what are your facility policy? I will refrain, at this time, from giving any particulars as not to "sway the jury". Any and all comments would be appreciated.

    Thank you in advance
    God bless your hands at work

    4Blessings
    At our hospital, the doctors wright the orders as: 2 to 6mg. basal rate and 1mg.q 15 minutes, titrate as needed. The RN's here are used to it,if there is respiratory depression, we stop infusion, leave it off for a while until pt responds sometimes narcan is needed, but this is seldom. this dose I wrote is
    an example only. RN's should assess and titrate or stop as needed. THe doctor is notified of any changes.
  13. by   palesarah
    Quote from stevierae
    In fact, isn't anesthesia required to be in house at all times in hospitals that have OB units--or does that vary?
    Anesthesia is not required to be in house at all times in our hospital. When they are not in house they are required to be available within 30 mins for emergencies and epidurals and most of them are closer. It's not ideal at all, and in fact not having 24-hour in house anesthesia is the reason our hospital can no longer "offer" VBACs. But that's another issue altogether.
  14. by   palesarah
    Quote from scooterRN52
    At our hospital, the doctors wright the orders as: 2 to 6mg. basal rate and 1mg.q 15 minutes, titrate as needed. The RN's here are used to it,if there is respiratory depression, we stop infusion, leave it off for a while until pt responds sometimes narcan is needed, but this is seldom. this dose I wrote is
    an example only. RN's should assess and titrate or stop as needed. THe doctor is notified of any changes.
    We have standard pre-written orders for epidurals that the MDA signs off on; we start the pump at 10mL/hr and adjust up to the max limit within the written parameters, or down as needed. The patient can also self bolus every 20 minutes (with a lockout on max amount/hour that includes basal & bolus)

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