Non-OB Epidural Infusions

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Important Points

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• EVERY patient who has an epidural catheter placed (thoracic or lumbar) MUST GO TO THE ICU following the recovery room. So please ask PACU for an ICU bed as soon as you know the patient will have an epidural. 

• There are 2 epidural pumps are located in the Anesthesia Supply Room, they belong to us so it is your responsibility to get one for the patient, sign it out (there is an epidural pump binder) and return it to the supply room when finished.

• Epidural keys are located in the PICUS, please return after use.  There are also extra keys on OB.

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Epidural Placement, Documentation, & Orders (While in the OR)

 

1. Place your epidural, make sure to document “block start” and “block end” on the EPIC intraop record.  This is important for billing.

2. Create a Neuraxial Procedure Note using the "Procedures" tab in the intraoperative anesthesia record.  

3. It is essential that when filling out the Procedure note, for “Provider Requested Procedure” you write in“Thoracic (or Lumbar) Epidural per surgeon’s request”

4. For “Indication” you must click “postoperative analgesia”

5. Fill out the rest of the procedure note and sign it.

6. On Orders, search for "Anesthesia Neuraxial Adult."  Double click on it.

7. It should now be checked.  (To add "Anesthesia Neuraxial Adult" order set to your favorites, just right-click on it, then select "Add to Favorites")

8. Click "Open Order Sets" to open the "Anesthesia Neuraxial Adult" order set

9. With the order set now open, look under "Nursing" and click on the small blue text that says "Discontinue all neuraxial orders after epidural removal: Yes" underneath Neuraxial Management.  It should underline when you run your mouse over it. Click on it and type in the answers to the thee Prompt questions at the bottom with these answers in bold:

   1. Discontinue all neuraxial orders after epidural removal:  Yes

   2. Allowable anticoagulants (this is while epidural is in place) Subcutaneous Heparin 5000u q12

   3. Allowable opioids, sedatives, or hypnotics: Fill this in with your preferences

10. On "comments (F6)", click to add text.  Add with free text "For any epidural issues, call Dr. (Your Name) at (your phone number)."  This is important so the nurses know who to call for problems.

11. Chose your epidural mixture. As on OB, there are pre-mixed bupivacaine and ropivacaine bags that are easy and fast to obtain from pharmacy.  Creating your own mixture on the Custom Builder can cause delays in obtaining your infusion bag since the pharmacy has to make it, not only the first time you hang it, but when you re-order it to change the bag in the future. You are free to do what you like, however because of the infrequency that pharmacy mixes epidural bags, there may be delays/issues with custom bags. 

12. Sometimes a 500mL volume bag may be required (for higher epidural infusion rates) so that the bag is able to run for 24hrs.  This requires using the Custom Builder.  Make sure to type in "500" in the bag volume section.  DO NOT type in the notes "make a 500mL bag" as the pharmacist may not see this.

13. After choosing/creating your mixture, click on the small blue text underneath to complete the three questions:

    1. Enter the rate (ml/hr): Insert rate here  

    2. For Patient-controlled Bolus Dose (mL): 0 (please DO NOT allow for PC boluses as this creates problems with nursing/pharmacy)

    3. Lockout Interval (min):  0 (please DO NOT allow for PC boluses as this creates problems with nursing/pharmacy)

14. For the remainder of the order set, select your Hypnotics or Pain medications (IV or PO).   Please tell your surgical team not to order pain medications and that YOU are responsible for all IV and/or PO pain/hypnotic medication orders while the epidural infusion is running, 

15. Sign your orders.

 

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Epidural Placement, Documentation (Outside of the OR) 

 

For pain consults and ad-hoc pain procedures on the floor, such as epidurals, create a NEW ad-hoc anesthesia record for the procedure.

 

1. Go to Patient Station

2. Find your patient by MRN and double click on their name

3. You will get a pop-up to select an encounter and also have the option to create an ad-hoc encounter

4. Select the appropriate procedure from the drop-down list

5. Once you have created an anesthesia record for epidural placement outside the OR, follow above steps 1-12 on "Epidural Placement, Documentation, & Orders (While in the OR)" 

  

 

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Setting up the Epidural Infusion (initial)

 

1. Once you have placed the orders for the epidural infusion, ask the OR pharmacist for a premixed bag, or remove one from the OMNIcell under the patient’s name.  If you made a custom bag with the epidural builder, either the OR pharmacy or the main inpatient pharmacy will need to be contacted and they will make the bag for you.  They will bring the custom bag to you when it is ready.  If you are initially setting up the infusion outside of the OR, you will always need to call the main pharmacy to have them bring you the bag.

2. Get an epidural pump from the anesthesia workroom.  We currently have only 2 pumps, however we are ordering more.  Make sure you have the clear yellow lockbox case, the pump, the AC cord, and the lockbox key.  There is a patient control button for each pump, however please leave in the black container in the workroom and DO NOT attach to the pump.  Having a patient control button on a pump where you are not allowing patient-controlled boluses will create confusion, and vice versa.  Until nursing education has occurred, the buttons create too many problems so please do not use them.

3. After you obtain the bag, set up the infusion and run at the rate you ordered.

4. Make sure the clear yellow lockbox case is locked with the epidural key.  HOLD ONTO THE EPIDURAL KEY BY ATTACHING IT TO YOUR OWN KEYCHAIN, OR RETURN TO THE ANESTHESIA WORKROOM.  

5. On the pump there is a dry-erase marker section where you will write your name and contact number clearly (use a dry-erase marker please).

6. If you are in the OR when you start the infusion, on your intra-op record, you can find the epidural mixture on the LD tab within Medications.  Select it, then chart the infusion starting a the rate you ordered, just as you would on L&D. 

7. If you are outside the OR (PACU, ICU, PCCU) when you start the infusion, have the nurse scan the infusion bag so it can be captured on the MAR for billing purposes. (When you start the infusion in the OR and chart the infusion on your anesthestic record, this automatically captures the infusion so you do not need to scan it)

8. Make sure you give a detailed sign out about the epidural infusion to the PACU nurse.

 

Changing the Rate of Infusion

 

1. Change the actual pump rate setting yourself

2. Open patient chart in EPIC

3. Go to Orders

4. Find your previous order for the epidural infusion and modify it to reflect the new rate

5. Always notify the nurse of this change so they can update their charting

 

Changing the bag & tubing

 

Note:  Until nursing education is up to speed with operating the Curlin pumps and changing bags/tubing, we anesthesiologists will continue to change the bags on our own.  Because the bags have narcotics, we need to waste any residual fluid and have this waste documented and cosigned with the nurse.  The sign out and wastage of epidural infusion bags can be done on the yellow narcotic sheet available on every nursing unit.  The nurse will log the waste amount, sign it, and then you will cosign.  In the future, when the nurses have been trained on bag changing, this will be performed by 2 nurses (bag sign out and wasting) just as it does with PCAs. Also remind the nurse to scan the new infusion bag, just as they would a PCA syringe refill.

 

1. Contact the pharmacy staff and they will deliver the epidural bag by hand (if it contains narcotic).  Narcotics are hand delivered to the RN and signed for by the RN.

2. If you are using pre-mixed bags, you can pull one out of the OMNIcell under the patient’s name.

3. Tubing can be found in the anesthesia workroom or in L&D.

4. When the new bag arrives, remove the old bag & tubing, record the amount infused and amount wasted with the nurse on the yellow narcotic sheet, and cosign it with the nurse. 

5. The nurse will need toscan the new infusion bag to have it capture on the patient's MAR.

6. Hang the new bag and tubing, then restart infusion at the ordered rate.

7. You do not need to document anything in EPIC aside from the Daily Pain Management Note.

 

Writing a Daily Anesthesia Pain Management Note

 

1. Open patient chart

2. Go to Notes tab

3. Click on "New Note" at the top

4. For type of note, select "Anesthesiology Pain Management"

5. Make sure you fill in the correct date & time

6. Type in .CJNEPIDURALPROGRESSNOTE and select it for a note outline which includes patient data with recent vitals and pain levels.

7. Fill in the *** blanks to complete your note. Be sure to include a neuro exam detailing the upper and lower levels of analgesia from the epidural, and description of the epidural site (clean, dry, etc.). 

8. Sign your note.

 

If there is no epidural infusion, but an epidural catheter remains, there should be a note in the chart indicating existence of such catheter and what the plan is. PRN blousing by MD? Plan to remove catheter at a certain date/time? The MD should also address the timing of when the catheter is to be removed, since certain anticoagulants cannot be given prior to catheter removal (see anticoagulation guidelines).

 

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Discontinuing the Epidural

 

1. Remove catheter and dressing.

2. Record amount infused and amount wasted with nurse on the yellow narcotic sheet and cosign.

3. Bring epidural pump and key back to anesthesia workroom.  Erase your name and number from the pump.  If for some reason you are unable to, please ask Edwin to pick up the pump.  WE CANNOT AFFORD TO LOSE THESE PUMPS.

4. Open the patient's chart and go to Orders.

5. Discontinue all your epidural-related orders. 

6. Ensure that the surgical team or internist writes for pain medications now that the epidural is d/c’d and you are no longer responsible for pain management.

 

 

Important Points

 

• On the pump, write your name and contact info in the space provided so that nurses will know who to call if there is an emergency or the pump is malfunctioning.  Additionally, remember to put your contact info in the Nursing Instructions (free text instructions).

• DONOT using the patient-controlled option of the pump.  With thoracic epidurals particularly, even a small bolus can cause severe hypotension, resulting in complications.  Simply do not attach the patient bolus button and make sure you enter "0" for Patient-controlled Bolus Dose and "0" for Lockout Interval on your orders.

• You are responsible for writing all pain or hypnotic medications for your epidural patients.  Surgeons pain orders will be ignored or removed by pharmacy. This is to avoid overlapping pain medications orders.

• Epidural patients are only to go to the ICU or PCCU after recovery.  The education and staffing is inadequate on the wards to look after epidural patients immediately after epidural placement.

• Always document amount infused & amount wastedwith the nurse on the yellow narcotic sheet.

• Make sure the nurse scans any new infusion bagsbeing hung

• Write a daily progress note.  Not just for billing, but so nurses and pharmacy can stay current with the epidural

• Don't lose the epidural pump key.  Keep it somewhere safe (on your keychain), or return it to the workroom if you're good at losing things.

• Return the pump to the workroom when you're done with it.  If you're messy and irresponsible, admit this to Edwin, and then ask him to please get it for you.

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