Nursing Management of Patient Controlled Epidural Analgesia Adam Cooper, RN, MSN Adult Nurse Educator PCEA- What is it?  A method for administering epidural analgesia continuously and intermittently.  Continuous infusions of analgesics and/or local anesthetics can be provided through a catheter placed in the epidural space.  PCEA Pump- medications are infused continuously through a pump into the epidural catheter. 1 PCEA Basics Spinal level of catheter insertion guides the RN in assessing what pain will be controlled and what pain will not be alleviated Most common btwn: L2-L4 (33 vertebrae) 2 PCEA- RN Responsibilities      Assessing patient pain Notifying the physician of pain assessment Planning pain management with team Monitoring the patient and the patient’s response to interventions Documenting PCEA Orders   The epidural infusion is ordered by the MD on the pre-printed order sheet Includes: – Standard Mix (Ropivicaine w/ Fentanyl) – Delivery Settings – Titration Orders – Additional Meds – Monitoring Orders 3 Delivery Settings     Continuous Rate (basal rate)- mL/hr Demand Dose (pt controlled injection)mL/inj Demand Dose Lockout (interval of how often pt can use)- min One hour limit- mL Titration Orders  Continuous (basal) rate may be: – Increased by __mL/hr every 1 hour for severe pain. 1 hour limit is max. – Decreased by __mL/hr every 1 hour for excessive sedation, arm/leg/chest numbness, or hypotension. 4 Other Important Issues  No opioids, sedatives, or anticoagulants (except Aspirin or SC Heparin)  Only MD/NPs or Adult ICU/PACU RNs may attach epidural catheters to tubing  IV & Foley Catheter must be in during the infusion and must be in place for 12 hours after d/c. RN Monitoring  Assess & Document Q 2 x 12hrs then Q4hrs: – – – – – –  RR (call if <10) O2 (call if <90%) Pain Sedation (watch for somulence) Other Vital Signs (n/v/, hypotn) Abnl absorption: numb mouth/metallic taste, tinnitus Total dose infused Q 24hrs – Clear Pump/Document: CC- 0700 AC- 0000 5 RN Monitoring  If RR < 8 or O2< 85%, unresponsive, or severe hypotension (SBP<80): – Stop infusion – Check vitals now – Give Naloxone (Narcan) – Notify Pain Svc and primary MD – Place O2 bag/mask on high – Check vitals q 1hr x 12 hours – Call rapid response or even code blue! Naloxone (Narcan)           Opioid antagonist IV acts within 2 minutes Must monitor as Narcan can wear off before opioids Expect pain, tachy, diaphoresis afterwards Comes in a 0.4mg/ml vial Dilute in NS to a total volume of 10 mL = 0.04 mg/ml 0.1 mg IV q 1 min PRN respiratory depression or unresponsiveness 0.1mg = 2.5ml Push SLOWLY. Using the 10ml syringe of diluted naloxone push 1 ml every 1-2 minutes until sedation and respiratory depression improves. IR 6 CADD Pump  Directions at bottom of screen  2 RN Check  Green light- GO!  Use arrows to adjust settings  Slow….. CADD Pump (con.) Must be unlocked to make changes 7 CADD Pump (con.) There is NO on/off button! Pump is turned on when battery is inserted Pump is turned off when battery is removed CADD Pump (con.) 8 More Info  Pain ServiceParnassus: 719-2398 Mt. Zion: 443-2676  Quick Reference Cards  Video in nursing education  Nursing P&P 9