A guide to epidural management.

Epidural analgesia is a key component in the management of inpatient pain relief, particularly in surgical and trauma patients, and those with comorbidities. When used appropriately epidurals can decrease a patient's opiate consumption, as well as reducing the risk of adverse cardiorespiratory outcomes. To non-anaesthetists, or those not versed in their usage, epidurals can appear complex and intimidating, and the potential complications, although rare, can be catastrophic if not picked up on in a timely fashion. This article demystifies the epidural for hospital clinicians, looking at the anatomy and pharmacology, helping to identify patients who may benefit from epidural analgesia, highlighting some common pitfalls and questions posed by nursing staff, and providing a framework via which junior clinicians can detect, manage and appropriately escalate epidural-related problems and complications. Epidural analgesia is an invasive and high-risk intervention; as such it should always be managed by a multidisciplinary team, including anaesthesia and acute pain services.

A Project to Increase Nurses' Comfort in Offering Bedpans to Women Laboring With Epidural Analgesia.

OBJECTIVE: To improve nurses' comfort in helping laboring woman void on a bedpan after initiation of epidural analgesia, to increase the frequency of bedpan use in the labor and birth unit, and to decrease the use of continuous indwelling Foley catheters during the intrapartum period. DESIGN: Quality improvement project. SETTING: A single large, midwestern U.S. hospital (>3,000 births annually), where bedpans are infrequently used after epidural placement. PARTICIPANTS: Registered nurses on a labor and birth unit. INTERVENTION/MEASUREMENTS: A 20-minute educational presentation that included current urinary catheter evidence-based practice, preferential use of bedpans, and methods to help women void successfully was taught to all registered nurses in the author's labor unit. Nurses rated on a scale of 0 (not comfortable at all) to 10 (extremely comfortable) their comfort level at helping a woman with a bedpan. Primary data were collected through a convenience sample of anonymous surveys (n = 52) completed by registered nurses regarding their experience with bedpan and catheter use during labor and their comfort level helping women be successful with voiding. This was followed by a retrospective chart audit for women with term, singleton pregnancies who labored with epidural analgesia. RESULTS: Nurses' comfort levels increased from an average of 5.7 to 7.2 (p = .067). Postepidural bedpan use increased from 5.5% (n = 12) to 19% overall (n = 20; p < .001), with five women using bedpans exclusively. When assisted with bedpan use, 38% (n = 12) of women were able to void 34 of the 53 times it was offered (64%). Use of continuous indwelling Foley catheters decreased from 61.7% (n = 137) to 54.7% (n = 58), and use of intermittent catheterization increased from 30.6% (n = 68) to 37.7% (n = 40). CONCLUSION: When assisted by nurses educated in and comfortable with different voiding techniques, women may be able to avoid medically unnecessary use of urinary catheters during labor.

Removing epidural catheters: A guide for nurses.

Short-term epidural analgesia is effective for postoperative pain, procedural pain, trauma pain, and labor pain. This article describes the skills, procedures, and nursing care required for removing a short-term, temporary epidural catheter.

Development and Evaluation of an Epidural Analgesia Workshop for Senior Nursing Students.

BACKGROUND: Most prelicensure nursing students receive little to no training in providing care for patients who receive epidural analgesia, despite exposure in clinical settings and the potential for devastating adverse effects. To develop and pilot an epidural workshop for senior nursing students using standardized patients (SPs), and to evaluate feasibility and learner outcomes. METHOD: A 4-hour epidural workshop consisted of a large group lecture and demonstration, small-group practice scenarios, and individual learner evaluation with SPs. Learning outcomes were evaluated using a performance checklist and critical thinking rubric, and pre- and posttests. RESULTS: Participants scored well on the performance-based evaluation (mean score of 86% items performed correctly) and rated the workshop highly. However, learners and instructors made several recommendations for improving the learning module for future sessions. CONCLUSION: This pilot project demonstrated that an epidural analgesia workshop using SPs is feasible and results in positive learning outcomes and high satisfaction with senior nursing students. [J Nurs Educ. 2018;57(6):359-365.].

Using Simulation to Enhance Education Regarding Epidural Analgesia for Registered Nurses.

BACKGROUND: Registered nurses (RNs) receive didactic training regarding caring for patients receiving epidural analgesia. Although RNs are tested on their knowledge after this training, their ability to critically think through adverse events has not been assessed at our institution. AIM: The aim of this study was to examine the feasibility and effectiveness of simulation education for RNs regarding the assessment and management of patients receiving epidural analgesia. METHOD: The study included an education intervention, which consisted of a 4-hour workshop. After obtaining informed consent, RNs completed a preworkshop evaluation of skill performance where they completed an Objective Structured Clinical Examination (OSCE) in which they demonstrated an epidural assessment of a standardized patient. RNs then completed a demographic and knowledge questionnaire followed by a lecture regarding care, management, and assessment of patients who are receiving epidural analgesia. After the lecture, RNs practiced epidural assessments within small groups. A postworkshop OSCE, questionnaire, and debriefing were completed before the end of the workshop. RESULTS: Thirty-seven RNs completed the workshop. The mean age of participants was 43 years. For the pre- and postworkshop knowledge questionnaire, there was significant improvement in answers related to epidural pharmacology and assessment of blockade questions. For the pre- and postworkshop OSCE, there was a significant increase in the number of correct procedures performed in all categories, with the exception of assessment of equipment. There was also a significant change in the proportion of RNs who stated that they felt confident in their assessment of a patient receiving epidural analgesia.

Análisis etnográfico del intervencionismo en la atención perinatal / Ethnographic analysis of the perinatal care interventionism

Objetivo principal: analizar los factores culturales que determinan el intervencionismo de la atención perinatal en un área de salud de la Región de Murcia. Metodología: se desarrolló una investigación cualitativa con enfoque etnográfico. Se realizaron dos grupos de discusión a profesionales, dieciocho entrevistas etnográficas en profundidad a puérperas y observación participante en atención primaria y hospital de referencia del área de estudio. Resultados principales: los resultados se circunscribieron a las representaciones ideológicas del dolor en la gestante, la incertidumbre del riesgo del proceso perinatal, y el hospital como espacio de seguridad y eje del intervencionismo. Conclusión: la alta demanda de la analgesia epidural por las embarazadas y la oferta sistemática por los profesionales, la incertidumbre del riesgo durante el embarazo, la representación del hospital como espacio de seguridad y control durante el parto, y la endoculturación de la mujer en el circuito asistencial serán factores determinantes en el intervencionismo de la atención perinatal

Objective: To analyse the cultural facts that determine the perinatal interventionism in a Health Area of Murcia Region. Methods: A qualitative research with ethnographic approach was carried out in this research by using both focus group to professionals and eighteen in depth interviews to women who were in postpartum period. These methods were complemented by carrying out a participant observation in both primary health care and hospital. Results: Three central themes emerged from narratives: pregnant women's ideologic representations about pain, the uncertainty of the risk of the perinatal process, the hospital: security environment and axis of the interventionism. Conclusions: the determinant facts about the interventionism of the perinatal care are related to the high demand for epidural analgesia from pregnant women and its systematic offer provided by professionals, the uncertainty of the risk during the pregnancy, the hospital representation as a safe place during childbirth, and the pregnancy women's enculturation that takes place through circuit of care

Effects of a 30-mL Epidural Normal Saline Bolus on Time to Full Motor Recovery in Parturients Who Received Patient-Controlled Epidural Analgesia With 0.125% Bupivacaine With 2 µg/mL of Fentanyl.

Previous research suggests that an epidural bolus of 30 mL of normal saline after vaginal delivery may decrease the time for recovery from motor block. A double-blind, randomized controlled study was conducted in 46 parturients to determine if a 30-mL normal saline bolus or sham administered via epidural approach after delivery reduces the time to full motor recovery and the time to 2-dermatome regression. No significant difference was found in time to full motor recovery (saline group 83.18 ± 54 minutes vs control group 100.23 ± 48 minutes, P = .27) or time to 2-dermatome sensory regression (saline group 29.32 ± 16.35 minutes vs control group 36.14 ± 14.39 minutes, P = .15). Results suggest no advantage to the administration of a saline bolus after delivery to hasten the motor recovery in parturients. A post hoc power analysis suggested a sample size of 204 subjects would have been needed to show a difference for this dilute local anesthetic regimen. There were no complications to the technique, which suggests that it is safe to perform, but the difference in recovery (approximately 17 minutes) from a dilute local anesthetic dose may not be clinically significant.

The epidural trip: why are so many women taking dangerous drugs during labor?

Two million American women will take an epidural trip this year during childbirth. In most cases, they'll be ill­informed as to possible side effects or alternate methods of pain relief. In many ways, epidurals are the drug trip of the current generation. Similar to street drug pushers, most anesthesiologists in the delivery rooms maintain a low profile, avoid making eye contact and threaten to walk out if they don't get total cooperation. Women get epidurals for one of the main reasons so many women smoked pot in the 1970s­their friends are doing it. This article examines why so many women in the Western world are compelled to take powerful drugs during their labor and exposes the risks epidurals pose to both mother and baby.

Abordaje del dolor en emergencias. SEM-061 y bomberos / Medical approach of pain in prehospitalary system

En los equipos médicos de emergencias extrahospitalarias, la analgesia constituye uno de los tratamientos principales después de descartar cualquier otro tipo de riesgo vital para el paciente. En este artículo describimos los tipos de dolor según presentación y sus respectivos tratamientos en el ámbito de la medicina extrahospitalaria(AU)

In emergency medical system (EMS), the analgesia is one of the principal treatment after rule at risk of death for the patient. This article describes some types of pain according to presentation and their treatment in the prehospitalary ambit(AU)

Parent-assisted or nurse-assisted epidural analgesia: is this feasible in pediatric patients?

AIM: The aim of this study was to assess the feasibility of parent-assisted or nurse-assisted epidural analgesia (PNEA) for control of postoperative pain in a pediatric surgical population. METHODS: After the institutional review board (IRB) approval was obtained, an analysis of our pain treatment services database of pediatric surgical patients with epidural catheters in whom the parent and/or nurse were empowered to activate the epidural demand-dose button was evaluated. RESULTS: Over a 10 -year period between 1999 and 2008, 128 procedures in 126 patients were provided parent or nurse assistance of the epidural demand dose. Satisfactory analgesia was obtained in 86% of patients with no or minor adjustments in PNEA parameters. Fourteen percent of patients were converted to intravenous patient-controlled analgesia (PCA) for inadequate analgesia (7%) or side effects (7%). None of the patients in this cohort required treatment for respiratory depression or excessive sedation. CONCLUSIONS: Parent-assisted or nurse-assisted epidural analgesia can be safely administered to children undergoing surgery who are physically or cognitively unable or unwilling to self-activate a demand dose. Additional studies are needed to compare the efficacy of PNEA with other modalities for postoperative pain control in children.

Associação entre a analgesia epidural e o trauma perineal no parto vaginal / Association between epidural analgesia and perineal laceration in vaginal delivery / Asociación entre la analgesia epidural y el trauma perineal en el parto vaginal

O objetivo deste estudo foi analisar a associação entre a analgesia epidural e a laceração perineal em mulheres submetidas ao parto vaginal. Foi realizado um estudo descritivo e transversal, para o qual foram pesquisados 109 prontuários de mulheres assistidas durante o processo de parturição, em uma maternidade em Ribeirão Preto. Os dados foram coletados nos meses de março e abril de 2003. Para analisar a correlação entre as variáveis foi aplicado o teste qui-quadrado. Foi realizado parto normalem 91,7% (100) das parturientes e fórceps em 8,2% (9). Na análise dos dados, 74,3% da amostra receberam analgesia epidural; destas, 26,5% tiveram algum grau de laceração perineal e 9,1%, períneo íntegro, não sendo possível verificar a associação entre as variáveis mencionadas. Não foi verificada, neste estudo, significância estatística para afirmar que as condiçõesdo períneo após o parto vaginal e a utilização da analgesia epidural estão associadas (valor x²4GL= 3,1).

Registered nurses' and midwives' knowledge of epidural analgesia.

BACKGROUND: Despite epidural analgesia increasingly being utilized in hospitals, very little research-based evidence is available about registered nurses' (RNs) and midwives' knowledge of this technique. OBJECTIVE: To describe the current epidural knowledge levels of RNs and midwives in a multi-site setting. METHOD: RNs and midwives at four, regional teaching facilities completed an epidural knowledge test. The instrument included demographic items and five knowledge subscales relating to epidural analgesia: spinal cord anatomy and physiology; epidural pharmacology; complications of epidural analgesia; assessment of sensory and motor blockade and the general management of patients with epidural analgesia. RESULTS: A total of 408 (99.7% response) RNs and midwives completed the test. Respondents demonstrated good knowledge of sensory and motor blockade assessment and the general management of epidural analgesia subscales with correct responses to 75 and 77% of the questions in these subscales, respectively. Fair knowledge relating to the spinal cord anatomy and physiology subscale was demonstrated with 69% of the questions answered correctly. The knowledge subscales relating to epidural pharmacology (57% correct responses) and the complications of epidural analgesia (56% correct responses) were problematic for the sample. CONCLUSION: The research results provide generalizable information about what RNs and midwives know about epidural analgesia. These results are an important guide in the development of new and existing dedicated epidural education programs. The results also provide some direction for further research into this important topic.

The Great 'Pump'kin Fest: a creative and efficient PCA/epidural pump learning experience.

Keeping up with changing technology is a constant in the healthcare environment. This article focuses on a creative approach to teaching large numbers of staff, a new patient controlled analgesia/epidural pain pump, in a short time frame with a limited number of educators. Implementation of competency checklists was utilized to verify that the learners understood the concepts and were able to apply the new skills learned. The success of this program is attributed to the active involvement of participants in a festive environment.

Nursing peer review: developing a framework for patient safety.

Patient safety is of great concern to healthcare leaders and is a top priority in all healthcare organizations. It is essential to promote an organizational commitment that values a culture of safety through reporting of medical error and analysis of untoward events. Nursing peer review facilitates the establishment of a culture of safety, as it seeks to analyze medical errors and eliminate the reoccurrence of untoward events.