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Child Health Guideline Identifier

Pain - epidural and caudal management

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Introduction

Epidural catheters are inserted into the epidural space at or near to the level at which analgesia is required. This level can range from the mid thoracic to low lumbar regions, making epidural infusions a versatile method of providing analgesia.

Epidurals work predominantly on the anatomical dermatomes around the level at which the tip of the catheter sits. A dermatome is the area of skin supplied by a single dorsal spinal nerve root.

Epidurals are placed in the area that pain relief is required in relation to the most appropriate dermatome.

Information for families

Where possible, epidural analgesia should be explained to the patient and parent(s) / carer pre-operatively. The anaesthetist will identify suitable children and explain the procedure to the child and family.

Indications for use

Epidural analgesia is not appropriate for all children. Epidurals can be used to provide analgesia for patients following surgery, trauma, or pre-operatively.

Advantages Disadvantages
• Effective analgesia
• Earlier return of GI function
• Reduces opiate side effects
• Better compliance with cares & mobilising
• Improved wound perfusion 
• Potential risk of infection
• Technical difficulties with placement
• Side effects (eg. urinary retention)
• Motor weakness
• Itching

Children who are to undergo surgery that is likely to result in pain that would require opiates can be considered for an epidural.

Factors that should be considered when deciding whether to use an epidural include:

  • The child (illness, previous experience, etc.)
  • Type of surgery
  • Site of surgery
  • Severity of pain expected
  • Appropriate postoperative environment
  • Good alternative to PCA (if child unsuitable for PCA)

Absolute & Relative Contraindications

Absolute Relative
• Bleeding disorders
• Unstable cardiovascular system
• Local infection (near site of epidural)
• Systemic infection
• Unstable spinal fracture
• Allergy to medications that may be used
• Raised intracranial pressure 
• Neurological disease
• Obesity
• Systemic infection
• Arthritic spine
• Anatomical anomaly
• Patient, surgeon, parent(s)/carer, anaesthetist preference.

Medications

The "standard" epidural mix is supplied by pharmacy in premixed 100 ml bags. These are stored in the controlled drug cupboard.

The "standard" solution is Bupivacaine 0.125% with Fentanyl 2 mcg/ml.

Other solutions may be used, which is at the discretion of the anaesthetist involved in the case.

The usual infusion rate is:

  • <3 months 0.1 - 0.2ml/kg/hr
  • >3 months 0.1 - 0.3 ml/kg/hr up to a maximum of 12ml/hr

Epidural Infusion Management

Prescription

Epidurals are charted on the paediatric epidural/regional infusion form (CR3652).

A patient name label must be attached to the Epidural medication bag with the time, date and initials of two registered nurses completing the check.

Ensure drug and patient checking procedures are completed as per medication administration policy.

Equipment

  • CADD solis pump (sourced from equipment pool)
  • CADD solis lockbox key (kept with the controlled drug keys)
  • CADD® Yellow Striped Administration Set (21-7024-24)

Programming

A registered nurse, who has attended the pain study day and had their epidural infusion pump competency signed off, can set up and programme the pump. This must be done with a second registered nurse both of whom must sign the Epidural infusion prescription (CR3652).

It is uncommon that a ward nurse will be required to set up an epidural pump as the majority of epidural infusions are set up by nursing staff in PACU.

On receiving the patient, ensure the pump is programmed as per the prescription (CR3652):

  • Paediatric epidural
  • Continuous rate is correct
  • Correct reservoir volume

The program should be rechecked when taking over a new patient or after a bag change. These program checks can be done by a single registered nurse. Any rate changes should be checked by two registered nurses and be within the prescribed limits. A code (supplied to all registered nurses) will be required to make any changes to the program.

Changing medication bag and lines

Epidural bags should be changed when empty or after 96 hours if it is a premixed infusion bag. If the epidural bag has been made up in recovery with an additive it should be changed every 24hrs.

Line changes are not necessary as Epidurals are removed after 3 - 5 days. In unique situations where epidurals may remain past this point please contact the pain service for advice on line change.

Documentation

Commencement and cessation of the Epidural should be documented on the back of the paediatric epidural/regional infusion (CR3652) form.

The following should also be documented on this form:

  • Rate changes
  • Bag changes (and bag volume discards)
  • Checks when taking over patient care
  • Top ups should be documented on the front of the form by the anaesthetist administering the top up

Observations required should be documented on the paediatric early warning signs (PEWS) chart where sections allow for it. All other details should be documented in the patient's clinical notes.

Additional Analgesia

The child who has a combined epidural of local anaesthetic and an opiate must not be given opiates via any other route, unless discussed with the anaesthetist/ pain service.

Non-opiate analgesics, i.e. Paracetamol and NSAIDS (if not contraindicated), should be administered to a child with an Epidural. By adding a non-opiate analgesic, the combined analgesic effect can be significantly increased.

The child who has an epidural infusion of local anaesthetic alone may have opiate (e.g. Morphine, tramadol) and non-opiate analgesia (e.g. Paracetamol and NSAIDS)

Observations

Observations required can be found on the paediatric epidural/regional infusion form (CR3652). They are as follows:

Hourly  4 hourly  Observe and document each shift
HR, RR, Sp02
BP (1st 4 hours)
Level of consciousness
Pain Assessment 
BP - unless paediatric early warning
Score (PEWS) > 3
Sensory block (dermatome level)
Motor block (bromage score)
Pressure area cares (Glamorgan)
Nausea/Vomiting 
Agitation/toxicity
Urinary retention
Catheter and site
Itching
• Continuing oximetry for patients 'at risk' or requiring oxygen
• If asleep and PEWS are stable for over 6 hrs: document Level of Consciousness and Pain Assessment 4 hourly
• Continue observations for 4 hrs after stopping Epidural/Regional Infusion

Top ups - monitor HR, RR, BP and Sp02 every 5 minutes for 15 minutes, then every 15 minutes for 1 hour.

Essential Requirements

  • Maintain IV access
  • No prescription changes except by Pain Service
  • No other opioids except by order of Pain Service if Fentanyl in infusion
  • No 'top-ups' except by Pain Service
Record Rationale
Blood Pressure Local anaesthetics block the autonomic nervous system leading to vasodilatation and reduced blood pressure
Pulse - Bupivacaine can cause bradycardia.
- May get tachycardia due to hypotension
Respiratory Rate - Fentanyl can cause central respiratory depression.
- A high motor block can interfere with respiration
Oxygen Saturation Early detection of respiratory problems
Pain Assessment To identify:
 - Failed or patchy blocks and
 - The need for further analgesia or
 - A regime change
Level of Block To monitor the spread and the level of the sensory block and to ascertain;
 - Failed or patchy block,
 - Respiratory difficulties if block too high
Motor Block The local anaesthetic affects the motor nerves as well as the sensory nerves it is therefore not unusual for the child to experience altered limb function. Observe for;
 - Motor deficit
 - Return to normal function
Pressure Areas Reduced sensation can allow areas of pressure to go unnoticed increasing the possibility of tissue breakdown.
Epidural Catheter & Epidural Site To observe for any problems;
 - Leak
 - Catheter migration
 - Occlusion
 - Infection
Pruritis Fentanyl can cause itching
Urine Retention Both bupivacaine and fentanyl administered epidurally can cause urine retention
Agitation & Fitting High serum levels of bupivacaine can cause agitation and convulsions.

Untoward Occurrences & Action Needed

Occurrences Action
Hypotension - Review by primary team to determine cause of hypotension
- Contact Pain Service
- Stop epidural if cause not clear
Change in Pulse Rate Contact Medical Staff & Pain Service
Decreased Respiratory Rate - Check oxygen saturation
- Consider giving oxygen
- Contact Pain Service
Increased Pain Score - Check level of block
- Check epidural catheter site
- Check pump is functioning correctly
- Consider giving additional analgesia
- Consider surgical or medical review
- Contact the Pain Service
Unrousable - Stimulate patient
- Stop epidural infusion
- Assess ABC
- Give 100% oxygen
- Contact medical staff urgently (Code Pink 777)
- Call Code Blue and commence PALS (Paediatric Advance Life Support) if required
- Inform the Pain Service
Problems with the Epidural Catheter  Contact the Pain Team
Nausea & Vomiting - Give anti emetic
- Contact Medical Staff
Urine Retention - Determine if bladder is full
- Consider catheterisation
Cannula Tissues Contact Medical Staff to resite the cannula 
Pruritis  - Consider phenergan, loratidine or low dose naloxone
- Contact the Pain Service
Deterioration in Skin Integrity Alleviate pressure areas 
Level of Block too high  - Nurse child in an upright position
- Reduce infusion rate or stop if concerned
- Contact the Pain Service 
Dense Motor Block  - Monitor pressure areas
- Inform Pain Service 
Epidural Catheter Leakage - A small amount of leakage is acceptable as long as analgesia is maintained and the dressing is intact
- Observe and inform Pain Service if concerned
Epidural catheter disconnection  - Stop infusion
- Wrap each end in a sterile dressing towel and inform Pain Service as soon as possible
Patchy block - If possible, move patient so they are lying on the side of the poor block.
- Inform the Pain Service 
Local Anaesthetic Toxicity (see below) - Stop infusion
- Contact the Pain Service 

Note: When a child is receiving an epidural infusion there is a risk of urine retention and most children require urinary catheterisation, this will be done prior to leaving theatre if needed. Patients having a thoracic epidural for a thoracotomy may be managed without a urinary catheter.

Local Anaesthetic Toxicity

The signs and symptoms of local anaesthetic toxicity include:

  • Tingling around the mouth and tongue
  • Light headedness and visual disturbances
  • Twitching of mouth and fingers
  • Convulsions
  • Unconsciousness
  • Respiratory and cardiovascular depression

In children who are unable to report these initial symptoms a first indication could be unusual twitching/ jerking of limbs. This can easily be confused for pain.

Local anaesthetic toxicity

Epidural Catheter Securing

The epidural catheter is secured in place with a circular plastic looking dressing. This is then covered with a transparent occlusive dressing. This is to be replaced by the anaesthetist/pain service if necessary.

Nursing staff may reinforce the dressing if required.

Assessment of block levels

Pain and temperature nerve fibres are similarly affected by local anesthetic medications. Therefore, changes in temperature perception indicate the area where the epidural is working effectively.

For this reason block levels are measured using ice in a glove or ethyl chloride spray. The mechanism used is dependent on the patient and what the nurse feels is appropriate. The epidural dermatome levels reference guide can be found on the front of the pediatric early warning score (PEWS) chart and the level is documented on the front of this chart.

The epidural block height may be difficult to determine in the preverbal child/ or those children who cannot co-operate with sensory checks. In these instances assessment may be based on analgesia, sensation and function of the upper torso and extremities, alongside assessment of other vital signs.

Assessment of Motor Block - Bromage Score

A patient's motor function can be assessed by asking the patient to flex their knee and ankles or in the younger child by eliciting movement by tickling toes. Both the right and left side should be assessed and documented in the patients clinical notes. With the thoracic epidural upper limb motor function should be assessed by testing bilateral hand and finger extension and flexion.

Bromage

Transitioning the Patient off

  • Most children will have the epidural catheter in place for 2 - 3 days and no more than 5 days.
  • The epidural should be stopped as directed by the Pain Service.
  • The epidural infusion rate does not need to be reduced prior to being discontinued.
  • Additional analgesia should be administered pre-emptively to minimise discomfort as the effects of the epidural wear off.
  • Intravenous access should be maintained for 4 hours following discontinuation of the epidural infusion

Removal of Catheter

The catheter should be removed approximately 4 hours after discontinuation of the epidural infusion. This can be done by a registered nurse by initially washing their hands and then positioning the child with their spine flexed if able. Once the tape is removed the catheter should be removed slowly without force. If resistance is felt on removal - stop and call the pain service. DO NOT PULL.

Observe site for any CSF or blood leakage. Apply a band aid to the area. Check the epidural catheter is intact.

Monitor the epidural site for 24hrs post removal.

For patients receiving:

  • Low molecular weight heparin (Enoxaparin)
  • An intravenous heparin infusion
  • Warfarin

Refer to Pain Management Epidurals & Anticoagulation - RBP - Adult

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Document Control

  • Date last published: 24 January 2017
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Pain Service
  • Author(s): Paediatric Pain Service
  • Owner: Paediatric Pain Service
  • Editor: Greg Williams
  • Review frequency: 2 years

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