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VOL: 98, ISSUE: 49, PAGE NO: 29

- Epidural analgesia is the administration of certain drugs into the epidural space to achieve effective relief of acute pain. By acting locally, it can provide more effective pain relief than other methods of opioid administration, often removing all pain sensation, with lower levels of respiratory depression and sedation and increased motility in the gastrointestinal system.

- At each vertebral level a pair of nerves cross the epidural space en route to a specific area of the body. An epidural catheter or needle is inserted into this space and drugs can be injected as a once-only dose, as a continued infusion or via a patient-controlled epidural pump.

- The injection of epidural drugs at the appropriate level and in sufficient quantities requires frequent assessment. The level of epidural analgesia can be measured by testing sensory responses in the areas of the skin supplied by specific nerve roots. These areas are known as dermatomes, and are labelled according to the vertebral level at which their nerves leave the spinal column (cervical (C), thoracic (T), lumbar (L), sacral (S) and coccygeal (CX) - see above left and centre).

- Sensory, motor and autonomic nerves are all affected by epidural analgesia. If the epidural sensory block level is above T4, for example, respiratory function may be affected. Regular observation of the patient and infusion device must be carried out; this is often documented on a dedicated epidural infusion chart that includes the drug prescription.

- When the patient returns to a ward area observations should be carried out every hour for four hours, two-hourly for the next 24 hours then four-hourly or as determined by the patient's condition.

- The epidural can affect sensory, motor and autonomic nerves, and observations should therefore include: date and time of observation; respiratory rate; oxygen saturations; pulse; urine output; itching; pain; sedation and nausea score; sensory level; motor block; blood pressure.

- Cumulative dose rate, infusion rate, total request and boluses rate (in patient-controlled analgesia epidurals) should also be recorded.

- The epidural site should be checked daily for signs of infection, leakage or tenderness.

- If not in a high dependency unit, the patient should be monitored in a high-observation area and not in a side room.

- The patient should receive at least 2l/min of oxygen via a nasal cannula (or via a face mask if the flow rate is higher) for 48 hours, and overnight on subsequent nights. Continual oxygen may be needed if opioid administration continues.

- Given the loss of sensation resulting from epidural analgesia, pressure area care must be rigorous, and micturation should be encouraged.

- Exercise caution when mobilising patients at risk from motor block.

- No other opioids should be given in any form while the epidural is in progress.

- Drugs to treat adverse reactions should be readily available.

- Intravenous access must be maintained until 24 hours after the epidural has been removed.

- Management of epidurals should be overseen and directed by an anaesthetist and, where available, an acute pain service.

- All staff using epidurals should receive training and updates.

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