epidural catheters

[CRNI-ICU20]

Hi Kids,

I recently encountered yet ANOTHER incident whereby big Pharma/Medical Device Companies are re-writing hospital policy and procedure and even going against nurse practice acts, in order to sell more wares.

Case in Point:

New epidural pump being introduced within hosp. by two RN's representing a well known medical device/medical supply company. This new pump has a BOLUS feature. These RN's were teaching all participants to use the pump, including the bolus feature, which, was taught as INITIAL BOLUS......I questioned this right away. I was ALWAYS taught that ANY epidural infusion was to be bolused only by a DR.....esp. INITIAL BOLUSES, because RN's are not trained to know epidural placement, etc.....it isn't like getting a blood return on an IV and knowing that you are "in the vein"....not to mention all the very very bad things that can go wrong...ie, dura rupture, cath migration, resp. arrest, too high of anesthetic action, paralysis of extremities, cardiac arrest, etc....

SOOO, when I asked, "Isn't this supposed to be done by a DR?, the two RN's said, "well, in some places, it is true, but we teach this feature anyway." When asking what the nurse practice act states for our state, neither of these RN's could tell me what the position was by the BON on this issue.....when asked further, "what does hosp. policy and proced. say?", they were equally unsure.

After some investigation, the dusty policy does not even ADDRESS INITIAL BOLUSING....it only vaguely speaks of increasing the continuous dosing "per doctor's orders."

What are your thoughts on this, and what does your institution say about vendors who come in and teach through inservices something that is counter to acceptable practice or written policy?

thanks, crni

[EmmaG, RN]

I don't like it.

Our hospital allowed the nurse (with an RN witnessing) to adjust the epidural rate on orders from the anesthesiologist, but never to bolus. And after two incidents on the surgical floor where epidural pumps were programmed as secondary 'antibiotics' by mistake (infusing the entire bag in a period of less than an hour), our unit was designated as the only one outside of SICU allowed to care for patients with epidural caths. We received special training for this.

As far as inservices that go against stated policy, I'm not aware that we ever had that happen. I would HOPE that a manager would step in and stop it.

[jmgrn65, RN]

we bolus epidurals and titrate all the time and have for all of my career which is about 15 years. We also recently started pulling epidurals. So really there is nothing wrong with it.

[jmgrn65, RN]

our epidural pump is different than our IV pumps.

[CRNI-ICU20]

jmgrn: I would be curious to know what training you received before you began dc'ing epidurals and also what training you received to bolus patients.....and for clarification: this was INITIAL bolusing....not giving an increase to a continuous already established infusion....

do you do the initial?

Here's what I see "wrong with it"....

First, of all the devices that are most often involved in a lawsuit, it is an epidural catheter/ or it's monitoring.

They are easily migratory....and only an anesthesiologist is trained to check for proper placement of an epidural catheter. Therefore, if you are initiating the first bolus dose, how do YOU, and RN, know that the catheter is in proper position? What signs/symptoms are you trained to watch for when caring and maintaining epidural caths? Do you know what to do when one goes awry and you have a problem? Do you check Ptt before pulling? How about heparinization post op patients for thromolytic prophylaxis vs. pulling an epidural cath, and why?

Did you lear dermatome study/ and do you understand uni vs. bilateral anesthesia control?

There are LOTS of issues with epidurals...not to mention a dural tear...which is MAJOR....and would you know the signs of that in your patient?

[Jolie, BSN]

we bolus epidurals and titrate all the time and have for all of my career which is about 15 years. We also recently started pulling epidurals. So really there is nothing wrong with it.

Maybe, maybe not. The functions you describe are considered "Category II" procedures in some states, meaning that RNs can perform them ONLY after completing a BON approved education program, and by demonstrating continuing competence, which requires formal demonstrations and check-offs. If your state considers these functions as Category II, and you are not properly trained, you are practicing medicine without a license. I would carefully check your state Nurse Practice Act to see if your practice and your hospital's policies and procedures are all in agreement. Oftentimes, this is not the case.

[EmmaG, RN]

Our hospital used regular IV pumps for epidurals; and the drip was mixed by pharmacy in regular IV bags. In many cases, the epidural IV pumps were placed on the same pole as the IV-IV pumps. It was only a matter of time before a grave error was made...

Thankfully, our CNS was quite the obsessive. We put our epidurals and IV on separate poles, on opposite sides of the bed (the epidural on the side farthest from the door) and marked the HELL out the epidural with bright, fluorescent orange warning stickers on the bag, pump and every few inches down the line to the patient.

[CRNI-ICU20]

MY POINT EXACTLY! Too many facilities are lacking in the potential for harm to the patient, simply because they desire to save a little money and use the same pumps and tubing, or they don't adequately train their personnel...or they allow vendors to come in and "train" people in a one hour inservice, that does not encompass hospital policy or procedure, or the Nurse Practice act....this is really scarey....what's next??? A little alcohol swab to the port???ugh.

[jmgrn65, RN]

Maybe, maybe not. The functions you describe are considered "Category II" procedures in some states, meaning that RNs can perform them ONLY after completing a BON approved education program, and by demonstrating continuing competence, which requires formal demonstrations and check-offs. If your state considers these functions as Category II, and you are not properly trained, you are practicing medicine without a license. I would carefully check your state Nurse Practice Act to see if your practice and your hospital's policies and procedures are all in agreement. Oftentimes, this is not the case.

Well I didn't just fall off the turnip wagon. Yes we have competencies. BON says that as long as we are properly educated then we can do it. Obviously our states are very different.

[EmmaG, RN]

MY POINT EXACTLY! Too many facilities are lacking in the potential for harm to the patient, simply because they desire to save a little money and use the same pumps and tubing, or they don't adequately train their personnel...or they allow vendors to come in and "train" people in a one hour inservice, that does not encompass hospital policy or procedure, or the Nurse Practice act....this is really scarey....what's next??? A little alcohol swab to the port???ugh.

We used tubing without ports for our epidurals, but not from the beginning. The incidents I described were when the nurses hung the piggyback to the regular IV, then programmed the epidural pumps that were attached to the pole over (or under) the regular IV pumps. The entire epidural bag was then infused at the rate the piggyback should have been going at. (We switched to port-less tubing when a patient received a piggy-back antibiotic via epidural)

[jmgrn65, RN]

jmgrn: i would be curious to know what training you received before you began dc'ing epidurals and also what training you received to bolus patients.....and for clarification: this was initial bolusing....not giving an increase to a continuous already established infusion....

do you do the initial?

here's what i see "wrong with it"....

first, of all the devices that are most often involved in a lawsuit, it is an epidural catheter/ or it's monitoring.

they are easily migratory....and only an anesthesiologist is trained to check for proper placement of an epidural catheter. therefore, if you are initiating the first bolus dose, how do you, and rn, know that the catheter is in proper position? what signs/symptoms are you trained to watch for when caring and maintaining epidural caths? do you know what to do when one goes awry and you have a problem? do you check ptt before pulling? how about heparinization post op patients for thromolytic prophylaxis vs. pulling an epidural cath, and why?

did you lear dermatome study/ and do you understand uni vs. bilateral anesthesia control? no i don't know what this is, or what it has to do with pulling epidurals.

there are lots of issues with epidurals...not to mention a dural tear...which is major....and would you know the signs of that in your patient?

training was given by an anesthesiologist, we took a test, a competency and demonstrated pulling the epidural. we do check inr if patient is on anticoags. we are well educated. and why do you seem to be attacking me? for our hospital policy. there isn't much we don't pull or d/c. we have had proper training. we are a teaching hospital, and a magnet hospital (well i know that doesn't mean anything) but we are good hospital.

as far as intial bolus all of our patients come with them already in place. i don't know if they do intial bolus in l&d or pacu. but i wouldn't be surprised if we do.

[Spidey's mom, ADN, BSN, RN]

We don't infuse continous medication into an epidural. It is capped and the CRNA or the doc can bolus if necessary.

I've always removed the epidural catheter, with an order to do so. It was part of my orientation as an OB nurse.

I do not like vendors coming in and giving presentations w/o knowing our facility's p&p's or the state regs.

Sounds like an accident waiting to happen.

steph