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Pain management - epidural analgesia infusion in PICU

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General Points

Epidural catheters can be caudal, lumbar (commonest) and thoracic (rarely). Infusion of a mixture of low dose local anaesthetic and an opioid provides excellent post operative analgesia for lower limbs, perineal and abdominal surgery.

Children under 6 months are nursed on the ward with an infusion must have an apnoea monitor, continuous pulse oximetry and a nurse available in the room at all times. Discussion with the ward needs to take place prior to placement to determine whether they are able to meet these requirements.

Thoracic Epidural patients with blocks above T4/ nursed on the ward may require continuous pulse oximetry. An order of IV atropine with set parameters may need to be prescribed on the medication chart.

The Acute Pain Service must be notified about all epidurals (Pain Nurse Practitioner 935070, Anaesthetic Registrar 934817)

Please ensure Epidural Prescription Chart completed before patients are sent to ward

Protocol

Infusion Marcain (Bupivicaine) 0.125% + Fentanyl 2 mcg/ml
(+/- clonidine 0.5 mcg/ml)
Usual rate Under 6 months 0.1-0.15 ml/kg/hr
Over 6 months 0.2-0.3 ml/kg/hr
Top ups To be performed only by anaesthetic/ PICU Registrar.
Bolus dose is equal to hourly rate. Repeat in 15 minutes  if inadequate.
No more than 2 boluses in 4 hours

Side Effects

Inadequate Analgesia Inspect dermatome level in relation to surgical incision.
Exclude intravascular placement.
Exclude other causes ↑ pain i.e. compartments syndrome.
Top up (as above) and small rate increase.
Itching Consider promethazine 0.5 mg/kg.
Revert to Bupivicaine 0.125% plain (no fentanyl)
Nausea/Vomiting Check not hypotensive (rare if < 8 years)
Consider metoclopramide 0.2mg/kg, cyclizine 1 mg/kg,  ondansetron 0.1 mg/kg IV
Urinary Retention May require catheterisation.
Motor blockade Rare with 0.125% Bupivicaine.
Stop infusion till motor function returns (usually 1 hr) then  restart at a lower rate.
Unexplained High Block (Above T6)
Cease infusion, check respiratory function, hypotension.
Aspirate catheter to rule out subarachnoid catheter
position.
Hypotension Fluid bolus 10 -20 ml/kg.
Ephedrine 0.1mg/kg - Consult with o/c Anaesthetic Reg  934817.
Epidural rare cause of hypotension < 8 years
Respiratory Depression 1. Stop infusion
2. Commence resuscitation including oxygen and assisted ventilation.
3. Call emergency team 777.
4. Nalaxone 5 mcg/kg IV.

Leaking about insertion site

This is a common problem. No action is necessary if the epidural is working effectively. If efficacy is reduced, then increasing the epidural infusion rate usually compensates for the leak.

Catheter disconnection from filter

Discuss with o/c Anaesthetic Reg 934817. The catheter may be contaminated and have to be removed. Usually the catheter can be cleaned externally, shortened and reconnected.

Backpain during Epidural

Severe or increasing backpain or rapidly increasing motor block may signify epidural haematoma or abscess. Discuss with Consultant Anaesthetist.

Weaning

When tolerating oral fluids, the epidural infusion may be ceased and oral analgesics continued. The catheter remains in situ for approximately 6 hrs after the epidural is turned off, if pain control is adequate, the epidural/ catheter can be removed.
Epidurals are not weaned by decreasing the infusion rate. The infusion rate that is effective is the rate required blocking the necessary dermatomes.

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Document Control

  • Date last published: 31 October 2005
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Intensive Care Unit
  • Author(s): Brian Anderson
  • Editor: John Beca
  • Review frequency: 2 years