Managing Epidural Catheters (depending on the level of placement)

Epidural infusion guidelines by level

A. Catheter placed below L2-3

1. Start Bupivacaine 0.125% (1/8) + Fentanyl 2mcg/ml
2. Loading dose( if indicated): 0.125% Bupivacaine 8-12cc
3. General Default settings: Basal rate/bolus/lockout 6-8cc per hour/2-4cc/20 min
4. Can be sent to regular nursing floor if hemodynamically stable.

B. Catheter placed between T9-10 to L1-2

1. Start Bupivacaine 0.125% (1/8) + Fentanyl 2mcg ml
2. Loading dose( if indicated): 0.125% Bupivacaine 7-9cc
3. General Default settings: Basal rate/bolus/lockout 5-6cc per hour/2-3cc/20 min
4. Needs to be transferred to a monitored floor for 24 hours and then can be transferred to
regular nursing floor if clinically stable.

C. Catheter placed above T9-10

1. Start Bupivacaine 0.125% (1/8) + Fentanyl 2mcg/ml
2. Loading dose( if indicated): 0.125% Bupivacaine 5-7cc
3. General Default settings: Basal rate/bolus/lockout 5-6cc per hour/2-3cc/20 min
4. Needs to be transferred to a monitored floor. Decision to transfer to regular nursing floor will
be made by pain attending.

RULES
Avoid opioids in epidurals if age > 65, morbid obesity, sleep apnea, unless specifically indicated for some
reason.

The epidurals can be started in the OR depending on attending anesthesiologists preference. If so, the
pain resident (at Weiler) may prepare the pump and deliver it to the OR setting.

If epidural is started at the end of the surgery or in PACU, a loading dose may be considered (unless
CSE).

ANY EPIDURALS PLACED BY ANESTHESIA TEAM IN THE OR NEEDS TO BE SIGNED OUT TO THE PAIN
RESIDENT.

NO CHANGES TO EPIDURAL INFUSIONS OR CATHETERS SHOULD BE DONE WITHOUT INFORMING THE

PAIN TEAM OR PAIN ATTENDING ON CALL.

Side Effects (from Opioids)

A. Pruritis - Nubain 5mg IV q4h prn.
If symptoms persist, remove the opioid from mix. Patients may tolerate same opioid via PCA
w/o symptoms.
B. Nausea- Zofran, Reglan, Phenergan and also remove opioid from mix +/- PCA.
 Management of Malfunctioning Epidural

A. Catheter disconnects
1. Ask RN to cover exposed ends with Tegaderm until you arrive. Reconnect sterilely wear
sterile gloves, wipe ends with alcohol, cut off several cm of exposed catheter tip prior to re-
attaching (Use different connectors and change infusion tubing).
B. One sided blocks / Pain Refractory to PCEA Boluses
1. Look at back. Assess catheter depth in epidural space and check anesthesia record to
see at what level the catheter has been placed and if there has been catheter
migration. If catheter is out then start IV PCA as needed.
2. Check for malfunctioning machinery (pump on and plugged in and settings)
3. Examine catheter tubing for disconnects and stopcock turns and any catheter kinks.
4. Assess level of pain (motor and sensory check)
5. Check sensory level of pain by temperature and/or pin prick (alcohol swab, paper clip,
tongue depressor.
6. Consider readjustment of catheter by pulling back catheter so that 3-5 cm remains in
the epidural space. Use sterile technique (gown, gloves mask). To re-dress site, clean
with benzoin, place tegaderm, and form a pound sign with tape around entry site so
that it is visible in the center square.
7. Consider bolus with 1% Lidocaine 5-7 cc only as a last resort. ASPIRATE FIRST as well as
PLACE PT ON MONITOR. Remain with patient 10-15 minutes and monitor vital signs.
Hypotension can occur if injecting >5ml at one time and should only be done if an
anesthesia resident is in attendance. Be prepared with phenylephrine and ephedrine.
8. If pain decreased then consider increasing rate or concentration as appropriate.
9. If not better consider catheter removal as it is presumed not to be in.
C. Pain Refractory to adjustments
1. Split out opioid into a PCA
2. Consider recommending adjuncts
3. Consider replacing epidural.

Rate versus Concentration Adjustments / Adjunct Analgesics

A. Narrow band with good analgesia but not covering surgical site adequately usually increase
rate (faster) or adjust catheter
B. Adequate band covering surgical area with poor analgesia increase concentration
C. Add PCA IV when patient has inadequate pain relief from epidural alone (e.g. chest tube
pain, extensive abdominal/perineal surgery) but then remove opioids from epidural
solution.
D. Add Adjunct analgesics (e.g. in the opioid tolerant) if side effects begin to exceed benefit.
(e.g. Toradol 15-30mg IV q6h which is effective for thoracic procedures such as shoulder
pain referred from chest tube)
E. Neurontin is effective for neuropathic pain but somnolence is major side effect and need to
titrate up slowly (usual start at 100 tid)
Epidural Removal

A. Check coagulation status, platelets, and medications prior to removal. If OK then shut off
the machine (See guidelines for anticoagulation requirements prior to removal).
B. Apply sterile gloves
C. Apply traction to the catheter. If resistance is felt stop the procedure, ensure pt safety and
seek assistance.
D. Pull catheter out slowly and check that the tip is intact.
E. Clean the skin with antibacterial solution.
F. Optional to apply dressing , and reposition pt to ensure that they are comfortable
G. Document in the chart the following; coagulation status; catheter removed and tip intact;
VS; motor and sensory status; and skin integrity. Use SOAP format.

Epidural Issues RESPOND IMMEDIATELY!!!

A. Hypotension
Rule out other etiologies (third spacing, bleeding) Epidural is always implicated as the
source. Do check and document epidural level. Treat likely cause (fluids/ PRBCs). Discuss
with surgeon who may be reluctant to give adequate volume but do not argue with them.
Document recommendations. Reduce epidural rate as appropriate and if shutting off
completely start IVPCA to address rebound pain.
B. Mental Status Changes
Epidural opioid can cause somnolence and confusion particularly in the elderly. Remove
opioid from epidural mix and reserve starting a PCA unless the pt proves they need one.
C. Fever
Epidural is rarely the site of infection but may be the source of seeding. If temperature >
101.5 F twice within an eight hour period, consider epidural removal (risk/benefit). Examine
epidural site and assess pt for signs and symptoms consistent with epidural abscess (back
pain, site with erythema and exudates) as well as neurological exam. Document exam.
D. Epidural Hematoma or Abscess (very rare but can happen)
If pt has the following symptoms, then epidural process should be ruled out; Motor and
sensory deficits that do not improve within 2 hours or that continue to progress after
epidural stopped; Incontinence and loss of sphincter tone; Severe back pain at level of
epidural; Purulence at epidural site. ALWAYS CONTACT COVERING APMS ATTENDING
IMMEDIATELY!!!!!! Notify primary service of concern. STAT MRI should be ordered (or CT if
pt cannot have MRI) and page neuro-radiology on call. Covering spine service (or to neuro)
consult should be done early in process. Surgical intervention as necessary.
E. Motor Block
Usually one sided and related to poorly positioned epidural catheter. Rate and
concentration may also be the source. Examine pt, assess likely cause and possibly readjust
level of catheter. If the block is bilateral, stop epidural and verify resolution of symptoms
within 2 hours. (Ensure that pt has alternate analgesia). If symptoms persist, r/o epidural
hematoma.