Management of Epidurals, Bolus dosing?

Nurses General Nursing

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Specializes in Med Surge, Tele, Oncology, Wound Care.

Hello

My questions revolve around bolus dosing.

Our policy only goes over the CAD Prism pump itself, and also goes over how to monitor the patient. The policy does not clarify bolus dosing.

So with that said, I have gone to management with my concerns about bolus dosing. I was told that since our merge with a larger hospital group we will "soon be taking on their policies and procedures."

Questions I have:

What size of syringe do you use?

- We use 5ml syringes per the old "we have always done it this way."

How long will it take for the drug to take effect?

- Since we have parameters to bolus from 25-100mcg of Fentanyl, I want to know when I should bolus more to relieve discomfort.

Is feeling "cool" down the back normal?

- One nurse told me that this is a sign that we are pushing the drug to fast. An Anesthesiologist told me that this is normal and due to temperature differences.

How fast do you push the drug?

- Anesthisiology told me "you can't mess it up, just push it."

Do you withdrawal before you bolus to make sure there is no blood in the line?

- Again another "we have always done it this way" theory.

I think that if a patient requires more analgesia then Anesthesiology needs to come and administer the drug to determine if the patient is on the right combo of drug and if the rate needs to be increased. I feel like this is a large responsibility on my shoulder especially when we dont have a policy on bolus dosing.

I have been taking in another nurse with me when I give a bolus because I don't feel comfortable doing it alone.

I might be a bit dramatic in my views about this, but...

I did do some research and so far it takes me to the practice by the Anesthesiologist and not nursing administration.

Any help is greatly appreciated!

Specializes in ER.

I'm a new grad with only 6mo experience on a med-surg floor, and I've taken care of a few patients on epidurals. My reply will be based off just my limited experience...

We have orders written for epidurals by the Anesthesiologist, and anything relating to the epidural, we call the Anesthesiologist in regards. I've never started an epidural, since they typically come up to the floor with one all set up. Orders are written with typically a dosage range the MD wants it running. Our policy requires us to take vital signs every 2 hours for the first 24 hours of having an epidural, then every 4. We assess if there is any numbness or tingling in the lower extremities and if they can fully move/flex their legs.

I've never given a bolus before, so I don't really know how that works. We typically are given an order for morphine for break through pain. I've had it where a patient was in alot of pain, so I called to increase the dose. But then his legs went numb, so we had to back off to the original setting. I've also had where my pt's BP kept dropping so we'd shut off the epidural for a bit, then start it back on (I did get an order to D/C the epidural for that case, but her surgery left her in considerable amounts of pain so we kept using it.)

I really hope that helped some. Also, our policy is, nothing can be done without two RNs present. LVNS can't change any settings, but can monitor a patient on one.

Specializes in Surgical, quality,management.

We used to be able to bolus but our new dept of anaesthesia head does not want us to. Which is fine 8-5 when we have our fantastic Acute Pain Service but as always issues pop up out of hours and during the night when we have only the anaesthist on call, as a trauma centre we often have major surgery overnight so they are not always able to come out at the time we need them.

When I have assisted with bolusing it has been sterile technique with a 5ml syringe and the anaesthist pushes 1ml and waits for 5min for effect and VS, and repeats as required.

Talk to your dept of anaesthesia docs, ICU liasion nurse and PACU nurses. You are right your hospital needs a policy.

Take care

Our epidural pumps are awesome. You can program the bolus into it, so there's no syringes/speed/whatever worries with it. It's also programmed with hard and soft limits for patient weight, so there's less worry about dosage errors.

Quite honestly, I can't imagine our anesthesia or pain team members wanting us to be hooking up a syringe to the epidural tubing. In fact, our tubing is made so that you can't do so. Infection risk, risk of hooking up the wrong drug, all that good stuff. The only time the line is open is on the rare occasion when we have to change the bag (which is really rare on my floor as little as we use them.)

But I guess it depends on the equipment you have. Hoping with your new policies that things will be a bit clearer so y'all can be more comfortable. I'm actually kind of bummed we don't have epidurals more often, as our pumps are really that cool, they're really just so easy to use that it makes our IV PCA pumps look medieval.

Specializes in PACU, OR.

The argument about "hospital policies" should not apply to prescribed treatments. Whatever systems the new organization has in place should only affect staffing issues, job descriptions, brands used, ordering policies etc. They should not interfere with patient care carried out by the nurse. As long as it is within your scope of practice, is prescribed by the doctor and does not constitute a medico-legal risk to you or your hospital, top management has nothing to do with it.

I'd suggest you and your co-workers get together and work out a protocol for bolus administration, ensuring that all risks and side effects, and the correct procedure to be followed in the case of adverse reactions, are listed as part of it.

Specializes in Non-Oncology Infusion currently.

I am assuming you are on a general care floor......is this correct??

In our institution when administering epidural bolus doses, we ONLY use the pump, and I work with the Acute Pain Service AND, when administering a bolus dose even with a pump, 2 nurses must be present to double check order and drug/dose etc. In fact, I think scope of practice might be an issue with an RN injecting anything into an epidural catheter, if he or she is not a CRNA. We are not authorized to even flush an epidural with preservative free normal saline where I am employed.

Onset and peak action depend on actual drug given and amount. The higher the dose, the longer the duration. Fentanyl may have a 5-15 min onset, and peak at 10-20 minutes. Dilaudid has 15-30 minute onset and peak 45-60 minutes. Morphine has 30- 60 minute onset and 90-120 minute peak.

The rate of administration is not an issue for us, as we use the pump. I would be very cautious of anyone telling you "just push it, you can't mess it up". I am sure there must be safety issues!!! Are you monitoring the pt with EKG or pulse ox?? What kind of vs checks are you doing after the bolus is given? (AND, do you check the patient's BP BEFORE the bolus, to make sure he or she is not hypotensive???)

As far as aspirating catheters, we always do it when we start an infusion or are re-starting one if it has been off at least 6 hrs. I know catheter migration is rare, but if it does happen and you are administering a dose and have NOT assessed for it, I would think there could be issues. .......and who would be liable if there was an issue???

I think you are correct in having a big concern about this. Actually, until you get more answers I would NOT be administering bolus doses via epidural catheters with syringes. Seek out the evidence and make them show you the policies you are operating under.

Good luck!!!

Specializes in Med Surge, Tele, Oncology, Wound Care.

Wow, THANK YOU all for your responses!

I feel so much better about my decisions with your support.

I am going to talk to management again (we have been switched over for 6 months now and I haven't seen a new policy as of yet).

I will also go to the Anesthesia department, because what scares me is that we do not take a new set of vitals after administration of boluses. I do CMS checks with every bolus and I thought that this was just my anal personality because the other nurses I drag in the room with me (which I may be the only one who wants a witness during bolusing) told me they re-assess for pain which is about it.

GHGoonette you are right about policies and not necessarily needing one for what is within our scope of practice. I have not recieved any education on this procedure, other than from the other nurses on the floor. I am not even sure if this is within my scope of practice without the education I need.

Do you think I should ask the board in my state? Or is this just overboard?

I am very grateful for your responses!

Specializes in Critical Care.

I also use the CAD prisms, which are hardly user friendly, but it seems like I remember being able to bolus through the pump. I don't have a lot of epidurals, we only see them on thoracotomies, so I've maybe given a bolus dose once, but it seems like that was something the prism could do although it required you to enter some sort of secret launch code while reciting the alphabet backwards (or something like that).

Specializes in pulm/cardiology pcu, surgical onc.

We cannot bolus anything through an epidural. We can titrate the hourly rate per anesthiologist's written parameters but if the pt needs more than that we would be paging the anesthiologist to come see the patient. I've honestly never heard of this being in the scope of practice.

Specializes in PACU, OR.

Op, definitely check up on your scope of practice as regards bolus doses. As most of the other posters have pointed out, they only administer them via the infusion pump. I have assisted an anaesthesiologist by administering the bolus via the syringe under his direction, while he was busy with something else, but they do normally give it themselves. Your BON must advise you regarding that.

Specializes in CRNA, Law, Peer Assistance, EMS.
Wow, THANK YOU all for your responses!

I feel so much better about my decisions with your support.

I am going to talk to management again (we have been switched over for 6 months now and I haven't seen a new policy as of yet).

I will also go to the Anesthesia department, because what scares me is that we do not take a new set of vitals after administration of boluses. I do CMS checks with every bolus and I thought that this was just my anal personality because the other nurses I drag in the room with me (which I may be the only one who wants a witness during bolusing) told me they re-assess for pain which is about it.

GHGoonette you are right about policies and not necessarily needing one for what is within our scope of practice. I have not recieved any education on this procedure, other than from the other nurses on the floor. I am not even sure if this is within my scope of practice without the education I need.

Do you think I should ask the board in my state? Or is this just overboard?

I am very grateful for your responses!

So I am not entirely clear....are we in fact talking about using the pump and not a syringe in your particular situation?

In order to develop a protocol (which I think is a MUST before proceeding) which has any authority or value it obviously has to be approved by the institutional committee which approves all clinical policies. I recommend approaching the anesthesia department, since they already have one i am sure. Your concern about checking vital signs is quite valid...it is mandatory.

One of the greatest dangers inherent to caring for epidurals in such a way that they may be 'disconnected' for syringe bolus is that mistakes where medication meant for the IV is injected into the epidural...which can have devastating effects.

Regarding your original questions:

Use the smallest syringe which will hole the medication volume. Hiving 3 cc's? Use a 3 cc syringe, 5 use 5 etc. The smaller the syringe, the easier it is to push the liquid into a tiny catheter. 20 cc syringes take a great deal of pressure.

Yes it is normal to feel cold down the back...does not mean it is too fast.

Always withdraw to check for blood. If blood returns do not inject..call anesthesia.

Push the drug as fast as you want...you will find that the diameter of the catheter will not allow you to push 'too fast'. It is VOLUME of the drug rather than speed of administration that you have to watch.

Depending on what drug you are injecting, and how much, onset varies.

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