PCA/Epidural

Question 1

Which patients are selected to receive PCA?

Answer 1

Post op, trauma, labour and delivery, cancer, end of life pain. Chronic pain not managed with oral analgesia.

Question 2

Which patients are not good candidates for PCA?

Answer 2

Patients with asthma, obesity, sleep apnea, or use of concurrent drugs that potentiate opioids.

Question 3

Define “total injections” in relation to PCA.

Answer 3

The number of times the patient received the medication since the pump was last cleared.

Question 4

Define “demands” in relation to PCA.

Answer 4

Demands is how many times the patient has pressed the button, whether they received medication each time or not.

Question 5

Define “total dose” in relation to PCA.

Answer 5

Total dose is the amount of medication they received (mg).

Question 6

Define “loading dose/bolus dose” in relation to PCA.

Answer 6

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.

Question 7

Define “basal infusion rate” in relation to PCA.

Answer 7

A small amount of medication running in the background.

Question 8

Why is a basal infusion rate uncommon?

Answer 8

Patients tend to have a higher rate of respiratory depression when using a basal infusion rate and PCA together.

Question 9

What are the advantages of PCA?

Answer 9

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

Question 10

What do you need to assess about PCA?

Answer 10

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

Question 11

What are some complications related to PCA?

Answer 11

Drug related - eg. overdose
Client related - eg. lack of understanding
Pump related - eg. battery dies
Operator errors - eg. RN programs it wrong

Question 12

What should be done if the PCA analgesia is ineffective?

Answer 12

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.

Question 13

Where is the epidural catheter inserted?

Answer 13

At L2-3 or L3-4 into the epidural space.

Question 14

Why doesn’t the epidural catheter need flushing?

Answer 14

It does not involve the bloodstream, so it won’t clot.

Question 15

What is the first type of nerve function to be affected by local anesthetics? (And what happens as a result)

Answer 15

Sympathetic response (this causes dilation of skin and blood vessels).

Question 16

What is the second nerve function to be affected by local anesthetics?

Answer 16

Pain/temperature recognition.

Question 17

What is the third nerve function to be affected by local anesthetics?

Answer 17

Touch/pressure

Question 18

What is the second last nerve function to be affected by local anesthetics?

Answer 18

Proprioception

Question 19

What is the last nerve function to be affected by local anesthetics?

Answer 19

Motor function

Question 20

What are the contraindications for an epidural?

Answer 20

Bleeding disorders or on an anticoagulant.
Site issues.
Sepsis.
Utero-placental insufficiency in antepartum patient.
Patient refusal.
Uncorrected Hypovolemia

Question 21

What are four precautions related to epidural catheters?

Answer 21

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.

Question 22

What are the important assessment points in a patient with epidural analgesia?

Answer 22

Vital signs

Analgesia scale

Sedation scale

Respiratory rate and quality

O2 sats

Sensory level (dermatomes if local anesthetic)

Motor power (if local anesthetic used)

Question 23

What are some ways to manage ineffective analgesia?

Answer 23

Assess dermatomes
Breakthrough analgesia
Reposition patient
Check catheter and insertion site
Increase infusion rate
Optimize multimodal medications
Notify APS or anesthesia

Question 24

What are some potential complications of epidural therapy?

Answer 24

Post dural puncture headache
Infection
Epidural hematoma
Local anesthetic toxicity
Catheter occlusion or dislodgement
Accidental disconnection

Question 25

What are some complications related to epidural medications?

Answer 25

Nausea/vomiting
Loss of motor control
Loss of sensation
Postural hypotension
Respiratory depression
Urinary retention

Question 26

What are the possible epidural anelgesia effects on mobilization/?

Answer 26

Change in sensation in legs
Possibility of motor block in the legs
Postural hypotension due to sympathetic block
Possibility of block of proprioception

Question 27

What are the things we should notify APS or anesthesia about in the epidural patient?

Answer 27

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

Question 28

When should an epidural be discontinued?

Answer 28

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