Epidurals: to Dose, or Not to Dose?

[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

[palesarah]

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)

[4Blessings]

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.

Thank you for your reply, but I am intrerested in what makes one "certified" in epidural infusions? That is the key question. I am from the wonderful, but often slow, state of Arkansas. Our states policy states that no RN may give medications throuth an epidural cath unless "certified" beyond licensure. I have contacted the state office and am still having difficulty obtaining clarification. In my mind, an inservice would not meet the needs of "certification". Would you agree?

[4Blessings]

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)

How do you check placement of cath?

[4Blessings]

Thank you for your response. It sounds as though our facilities are similar. Do you know if your state endorses such practices for RN's?

[4Blessings]

Thank you for your response, but I am curious. How do you check placement and patency to ensure safe administration of medication?

[4Blessings]

I like your way of doing things. I wish it were that simple were I must practice. Thank you for your response. If I may, is this your states policy or your facility standing?

[4Blessings]

Thank you for your response. Your practices seem much more risky than ours though. If I may, how do you check placement and patency of your catheter and do you check level of sensation?

[4Blessings]

So sorry about all the misplaced replies. I am grateful for the responses. It appears that I am not alone in this issue. QUESTION?....For those who dose, adjust infusion rates, etc. ....How do you check placement? This is my hold up. My clients with epidurals, often still move around in bed which could displace the catheter. How do I know the medication will go were it was meant to go? Your further input would be appriciated.

[begalli]

4Blessings? Are your questions in regard to my post?

[4Blessings]

Well, I got my defining ansewer today. I got a response from my state board that sealed the deal. Must be a CRNA to dose an epidural. We are being asked to do something that is out of our scope of practice. My advise is to check with your own state boards and find out their stance. Now I'm in for an up hill battle to change policy in my institution.

[4Blessings]

4Blessings? Are your questions in regard to my post?

Not so much to your posting, although I would like your input. I got the word today that the practice is outside of my scope as an RN. Must be a CRNA. What is your states policy, and do you know wether AWON endorses such practices?

[begalli]

How do you check placement of cath?

Each time before an epidural bolus is given or a new drip ius started, we gently draw back on the catheter to see if there is any return. I have never had a return, but if you draw back a clear fluid, the catheter could be misplaced into the intrathecal space. Presence of blood may indicate vascular placement. The amount drawn back would be less than 0.5 ml.

Like I said, this has never happened to me or anyone else I know. If it ever did happen of course I would d/c what I was doing and notify the doc.