PCA/Epidural Flashcards
Which patients are selected to receive PCA?
Post op, trauma, labour and delivery, cancer, end of life pain. Chronic pain not managed with oral analgesia.
Which patients are not good candidates for PCA?
Patients with asthma, obesity, sleep apnea, or use of concurrent drugs that potentiate opioids.
Define “total injections” in relation to PCA.
The number of times the patient received the medication since the pump was last cleared.
Define “demands” in relation to PCA.
Demands is how many times the patient has pressed the button, whether they received medication each time or not.
Define “total dose” in relation to PCA.
Total dose is the amount of medication they received (mg).
Define “loading dose/bolus dose” in relation to PCA.
Loading dose/bolus dose is in the nurse’s control. This is an immediate dose, sometimes higher than the PCA dose. It can help when there is delay in getting PCA set up.
Define “basal infusion rate” in relation to PCA.
A small amount of medication running in the background.
Why is a basal infusion rate uncommon?
Patients tend to have a higher rate of respiratory depression when using a basal infusion rate and PCA together.
What are the advantages of PCA?
Patient directed Prompt/on demand Independent of nurse Individualized Reduces analgesic peaks and valleys Decreases amount of opioid consumption when compared with intermittent dosing Fewer side effects Increases client control, decreases client anxiety Fewer post-op complications Better pain control
What do you need to assess about PCA?
PCA settings Total dose delivered Number of times pump activated Sedation level Level of cognition Analgesia level Respiratory assessment Vital signs IV site and pump Effectiveness Side effects
What are some complications related to PCA?
Drug related - eg. overdose
Client related - eg. lack of understanding
Pump related - eg. battery dies
Operator errors - eg. RN programs it wrong
What should be done if the PCA analgesia is ineffective?
Assess the pump usage.
Increase the PCA dose as prescribed and reassess.
Additional multi-modal medications.
Notify Acute Pain Services.
Assess for possible surgical complications.
Where is the epidural catheter inserted?
At L2-3 or L3-4 into the epidural space.
Why doesn’t the epidural catheter need flushing?
It does not involve the bloodstream, so it won’t clot.
What is the first type of nerve function to be affected by local anesthetics? (And what happens as a result)
Sympathetic response (this causes dilation of skin and blood vessels).
What is the second nerve function to be affected by local anesthetics?
Pain/temperature recognition.
What is the third nerve function to be affected by local anesthetics?
Touch/pressure
What is the second last nerve function to be affected by local anesthetics?
Proprioception
What is the last nerve function to be affected by local anesthetics?
Motor function
What are the contraindications for an epidural?
Bleeding disorders or on an anticoagulant.
Site issues.
Sepsis.
Utero-placental insufficiency in antepartum patient.
Patient refusal.
Uncorrected Hypovolemia
What are four precautions related to epidural catheters?
Do not disconnect the epidural port from the epidural catheter.
Do not inject any solution into the epidural catheter.
Do not remove the dressing over the insertion site on the lower back.
Do not flush epidural catheter.
What are the important assessment points in a patient with epidural analgesia?
Vital signs
Analgesia scale
Sedation scale
Respiratory rate and quality
O2 sats
Sensory level (dermatomes if local anesthetic)
Motor power (if local anesthetic used)
What are some ways to manage ineffective analgesia?
Assess dermatomes Breakthrough analgesia Reposition patient Check catheter and insertion site Increase infusion rate Optimize multimodal medications Notify APS or anesthesia
What are some potential complications of epidural therapy?
Post dural puncture headache Infection Epidural hematoma Local anesthetic toxicity Catheter occlusion or dislodgement Accidental disconnection
What are some complications related to epidural medications?
Nausea/vomiting Loss of motor control Loss of sensation Postural hypotension Respiratory depression Urinary retention
What are the possible epidural anelgesia effects on mobilization/?
Change in sensation in legs
Possibility of motor block in the legs
Postural hypotension due to sympathetic block
Possibility of block of proprioception
What are the things we should notify APS or anesthesia about in the epidural patient?
Low BP and/or decrease in pulse
Postural BP
Inability to bend knees
Ascending sensory block above T4
Sudden onset of moderate to severe back pain
Inadequate analgesia or persistent side effects
Dressing moist or wet
When should an epidural be discontinued?
It can be discontinued when weaned down and pain control is adequate.
INR equal to or below 1.2 and PTT less than 40
Remove 2 hours prior to next dose of BID heparin or 4 hours prior to next dose of once a day heparin/dalteparin
