Continuous Epidural Infusions - Patient Controlled

Bwick · May 12, 2005

Sorry, I got an extra letter in the email address

begalli · May 14, 2005

Hi,

We see a lot of epidural analgesia/anesthetic in the ICU usually following a large belly surgery (AAA's, Whipples, etc.). We have pre-printed orders in which the docs (anesthesia/pain service) check off what they want and the RN manages the line and the meds.

A patient will come from the OR with the epidural in place. It will be capped. As the patient wakes up from OR anesthesia, the RN prepares to start the continuous epidural drips and hook up the PCEA.

Our standing orders include:

Continuous epidural opiate infusion - always Dilaudid .05 concentration that runs at ~2 ml/hr.

Continuous epidural anesthetic infusion - always Bupivicaine either 1/8% or 1/4% concentration that runs at 2-4 ml/hr.

Epidural PCA opiate - almost always Fentanyl 50mcg/ml syringe. The dose is usually 15-25mcg (or more) q 10 - 15 minutes bolus with no basal rate/no loading dose. We also use Dilaudid and Morphine, but Fentanyl seems to be our ICU's drug of choice.

Breakthrough pain management - always Fentanyl via epidural bolus administered by the RN.

Adjuvants - Toradol IV if needed.

For side effect management our orders include:

Respiratory depression or excessive somnolence/sedation - Narcan 0.1 - 0.2 mg IV which may be repeated to a total of .6mg.

Nausea/vomiting - Reglan 10mg IV q 4-6 hrs; Nubain 2.5 - 5 mg IV q 4 hr

Pruritus - Nubain 2.5 - 5.0 mg IV q 2-4 hrs; Benadryl 10 - 25 mg q 4 hr

Insomnia - Benadryl 10 - 25 mg IV or PO q 4 - 6 hr

Nursing:

For opiates - T,P,BP q 4hr, RR q 2hr, then q 8hr if stable; Continuous O2 sats x 24hrs, then d/c if O2 sats >90% on room air.

For anesthetics - BP & P q 2 hr, then q 4 hr if stable; Orthostatic BP before ambulation x 24hr.

Of course the patient is in the ICU and documentation of vitals occurs hourly. These nursing orders are more for the patient on the surgical step-down or surgical floor. However, rarely does a patient transfer from the ICU with the epidural still running or even in place. By the time they transfer out of ICU, the patient will be changed over to a regular IV PCA and the epidural d/c'd.

Most of the RN's in the ICU are epidural certified (an initial class/inservice is provided with yearly competencies). Before we start a drip or bolus an opiate through the epidural, we check placement according to written policy and procedure.

I've had to give Narcan, I've titrated drips within the orders to achieve an acceptable level of comfort, and it seems that I almost always end up blousing opiates for breakthrough pain when a drip is first started and sometimes with activity. I've also had to stop drips because of severe numbness or tingling or one-sided only relief. The good thing about these orders is that the RN completely manages the patient and the orders are thorough enough to do so. Pain service/anesthesia is on call/on site 24/7 for any problems.

pricklypear · May 14, 2005

We use epidurals for some of our abdominal patients, too. We only use Fent/bupivicaine, though. We have orders like Begalli's, but we don't have standing titration orders. Our anesthesia is not on site 24h, and they don't like to come in, so we have had some problems with dislodged caths in the middle of the night.

Bwick · May 16, 2005

Begalli, would you be willing to share a copy of your order set?

Thanks for all the great information!

[email protected]

Sue

begalli · May 19, 2005

Bwick- give me a day or so to get a copy of the orders and then scan them into my computer. I'll send you an email attachment asap.

Bwick · May 20, 2005

Bwick- give me a day or so to get a copy of the orders and then scan them into my computer. I'll send you an email attachment asap.

Would appreciate it very much! :)

emmanuil · Apr 23, 2011

I had a pt with fentanyl epidural and was found lethargic with shallow breathing rate of

six per min. Do you give narcon thru the epidural?