Epidural Infusion vs IV Patient Control Analgesia. Ms Josephine PY Chen, RN. Acute Pain Service Data PWH 1/2003 – 12/2003. n=1793 PCA=1478, 80.5% CEI=261, 14.3% Others=54, 5.2%. Service Data Cont ’ d. Pain Score at termination (on exertion): PCA : 0=3.5% CEI: 0=20.9%.
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Epidural Infusion vs IV Patient Control Analgesia Ms Josephine PY Chen, RN
Acute Pain Service Data PWH1/2003 – 12/2003 n=1793 PCA=1478, 80.5% CEI=261, 14.3% Others=54, 5.2%
Service Data Cont’d Pain Score at termination (on exertion): PCA: • 0=3.5% CEI: • 0=20.9%
Service Data Cont’d Pain Score at termination (on exertion): PCA • 8-10=3.2% CEI: • 8-10=3.5%
Service Data Cont’d Satisfaction Score at termination: • PCA=49.2%> 8-10 • CEI=68.1% > 8-10
Service Data Cont’d Premature Termination • CEI=11% • Because of :ineffective; haemodynamic unstable; catheter dislodged; signs of infection, etc.
Epidural It works →comfortable PCA Re-educate Especially in elderly & children Compliance
Education for PCA • Handset control • Timing • Rehab. activities involvement • Intervention for side effects: reassurance, medications, program, close monitoring
Education for CEI • Beware of the epidural catheter • Allow mobilization • Beware of motor weakness / sensory deficit
Which modalities require more nursing attention? • Epidural or PCA?
Nursing attention • Both modalities • Crucial in first 24 hours
Rare Same RR < 10/min If SpO2 < 95% on room air, O2 supplement Specific observationsRespiratory depressionEpidural PCA
Rare Hallucination Rare Drowsy Dose related SedationEpidural PCA
Hypotension Epidural Rule out : surgical complications; hypovolaemic; on antihypertensive; in subarachnoid PCA Rare
Adjust infusion rate / rescue bolus Drug concentration Epidural catheter Adjust PCA program / bolus Education IV access Handset dislodge Side effects Pain ControlEpidural PCA
Monitor BP/P Extension of motor & sensory blockade Routine No drastic side effects After rescue bolus Epidural PCA
Signs of: infection local / systemic persistent / swing T↑38°C redness @ catheter site IV access Side effects Subsequent observationEpidural PCA
Pre-placement Coagulation Epidural Exclude coagulopathy Stop anticoagulants PCA Nil Cautions
Heparin Standard Heparin 5,000u • Avoid placement within 4-6 hours after a dose • Subsequent dose 2 hr later
Low molecular weight heparin • Avoid placement within 12 hours after a dose • Subsequent dose 2 hours later
Warfarin • Contraindicated
No other opioids or sedatives Preferably no anticoagulants Rescue drug Ephedrine Same Not a concern Naloxane While receivingEpidural PCA
Optimization • Maintain stable analgesic level • Low analgesic level takes time to titrate
Co-analgesics Check clotting Stop anticoagulants SH: 6 hrs prior LMWH: 12 hrs Same Not a concern Before cessationEpidural PCA
Tip intact Skin integrity Signs of infection Heparin/LMWH resume 2 hrs later Less concern CessationEpidural PCA
Epidural site Motor / sensory function Unless indicated Subsequent FUEpidural PCA
General Principles of Nursing Care • Analgesics ≠nursing care • Change position • Handle injured or swollen parts / tissues • Maintain body alignment • Prevent over taxing patient→↓pain threshold