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Protocol L&D/OB-GYN - Unit Practice Manual John Dempsey Hospital ­ Department of Nursing The University of Connecticut Health Center PROTOCOL FOR:

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Epidural Anesthesia: Care of the Patient with a Second Trimester Termination of Pregnancy 1. Following a patient assessment by the physician, the anesthesiologist will be notified of the request for epidural anesthesia. 2. A consent for anesthesia services and time out procedure and safety checklist will be completed prior to anesthesia administration. 3. Patients will have IV access at all times when epidural infusions are being administered. 4. Only a pharmacist or an anesthesiologist may prepare epidural infusions (both basal infusions and patient controlled epidural anesthesia (PCEA) infusions). 5. A narcotic reversal kit (naloxone [Narcan]), needle and syringe from the pharmacy will be kept in the medication room when a patient is receiving an epidural narcotic infusion. 6. A resuscitation bag and mask must be readily available on the nursing unit. Oxygen and suction must be available in the patient's room. Pulse oximetry must be available on the nursing unit. 7. The anesthesia care provider will be consulted before any anticoagulant (IV heparin, enoxaparin, etc.) or any systemic CVS depressant other than those specifically excluded by the Department of Anesthesiology policy (see below) is given. diphenhydramine (Benadryl®) diphenhydramine (Benadryl®) diphenhydramine (Benadryl®) diphenhydramine (Benadryl®) lorazepam (Ativan®) lorazepam (Ativan®) zolpidem (Ambien®) 25mg p.o. q 6h prn for anxiety/itching 50mg p.o. q 6h prn for anxiety/itching 12.5mg i.v. q 6h prn for anxiety/itching 25mg i.v. q 6h prn for anxiety/itching 0.5mg p.o. q 6h prn for anxiety/itching 1.0mg p.o. q 6h prn for anxiety/itching 5mg p.o. qhs prn for insomnia

POLICY:

8. Patients will be instructed of the use of PCEA. If the patient is unable to be instructed/understand proper use of PCEA, the patient should be evaluated by an anesthesia care provider. 9. An of is be RN must remain with the patient at all times during the placement the epidural. After the epidural has been placed and the patient stable, the RN may leave the room. However, both side rails must up and the call bell within reach if the patient is left alone.

10. Bladder assessment must be made at least every hour and prn (i.e., following fluid bolus). Straight cath as needed or place Foley catheter as ordered. 11. Postpartum patients who have received epidural anesthesia for termination of pregnancy and have delivered will be considered at least a low risk level of the falls risk assessment for the period from delivery until the anesthesia effects are absent.

Protocol L&D/OB-GYN - Unit Practice Manual John Dempsey Hospital ­ Department of Nursing The University of Connecticut Health Center PROTOCOL FOR:

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Epidural Anesthesia: Care of the Patient with a Second Trimester Termination of Pregnancy 12. A pain level of 5/10 or greater or any level that is unacceptable to the patient requires further assessment and review. 13. Under no circumstances shall the amount of time between full assessments exceed 2 hours during the first 24 hours.

SUPPORTIVE DATA:

The epidural catheter size is 20 gauge and is threaded through a specialized 18 ga epidural needle. The needle is inserted between the lumbar vertebrae so that the tip lies within the epidural space. The catheter tip can be advanced into the epidural compartment to any degree but most commonly it will be threaded at least 2-3 cm to a maximum of 10 cm. 1. The patient will demonstrate or report adequate pain relief as evidenced by a pain score that is acceptable to her. 2. The patient will experience minimal or no complications or side effects as a result of receiving an epidural infusion. 3. The patient will demonstrate knowledge of the effects and side effects of the infusion and its expected resolution.

DESIRED PATIENT OUTCOME:

CLINICAL ASSESSMENT AND CARE:

1. Obtain the patient's medical history for possible contraindications, such as: a. Neurological abnormalities (i.e., multiple sclerosis) b. Coagulation abnormalities (i.e., abnormal bleeding time; platelets <100K, abnormal PT/PTT) c. Skin infection at the site of insertion d. History of back injuries/problems e. Hyporolemia, bleeding 2. Initiate maternal pulse oximeter monitoring. may order ECG or Doppler monitoring. The anesthesiologist

3. Confirm patient's understanding of the 0 to 10, face pain scale, or alternative pain scale and instruct as necessary. 4. Bolus the patient with at least 500cc of Lactated Ringers Solution prior to the procedure and maintain the IV rate of 125cc to 150cc/hr during epidural placement unless contraindicated. 5. Position the patient either side-lying or sitting as ordered by the anesthesiologist. 6. Place patient on automatic blood pressure machine and initiate BPs every 3 minutes during epidural placement. After initiation of the

Protocol L&D/OB-GYN - Unit Practice Manual John Dempsey Hospital ­ Department of Nursing The University of Connecticut Health Center PROTOCOL FOR:

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Epidural Anesthesia: Care of the Patient with a Second Trimester Termination of Pregnancy block and with each successive dose, blood pressures must be taken at least every 5 minutes for 20 minutes and then every 15 minutes for 1 hour, then every hour. 7. Patients with a continuous epidural infusion should be turned every hour to prevent the block from disappearing from the patient's elevated side. Assess for headache or neck pain which may indicate that the continuous epidural infusion rate is too high. Despite a continuous infusion, the block may descend and the patient may need to have a re-injected of the epidural medication to bring the block back to an acceptable level. 8. During or after placement, if the blood pressure falls by more than 30% of the systolic pressure or 15% of diastolic pressure from baseline values prior to epidural placement: a. Begin and IV bolus of 500cc, preferably Lactated Ringers. b. Elevate the patient's legs on several pillows. c. Administer O2 at 10L/min by mask. d. Notify anesthesiologist immediately. e. Notify obstetrician. f. Repeat BPs at least every 3 minutes until stable. 9. If the patient complains of inability to talk, facial numbness, difficulty breathing or appears confused or disoriented, frank convulsions may be imminent. Notify anesthesia and OB physician immediately and be prepared to ventilate patient with 100% oxygen and assist with manual ventilation. If the patient has a continuous epidural infusion, immediately shut off the pump. 10. For epidural infusion and PCEA: a. Pain score assessment ­ hourly or more frequently with unrelieved pain b. Epidural infusion rate assessment ­ hourly. c. Vital signs ­ hourly. Call anesthesiology if temp > 102. d. Sedation score assessment ­ hourly. e. Respiratory rate assessment ­ hourly. Respiratory rate for a full 60 seconds watching for: · shortness or shallowness of breath · use of accessory muscles

Protocol L&D/OB-GYN - Unit Practice Manual John Dempsey Hospital ­ Department of Nursing The University of Connecticut Health Center PROTOCOL FOR:

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Epidural Anesthesia: Care of the Patient with a Second Trimester Termination of Pregnancy · ineffective respirations · absence of respirations · any other parameters as noted in the anesthesiology orders Report respiratory rate 8/min or otherwise ineffective breathing or shortness of breath to Anesthesiology immediately and bring narcotic reversal kit to bedside. For the first 24 hours: assess respiratory rate and sedation level every hour. After the fourth hourly assessment is complete, if the patient is sleeping and their eyes remain closed when the nurse enters room, check respiratory rate only. If the respiratory rate is > 8 per minute, document "eyes closed" and the respiratory rate; It is not required that the patient be aroused for further assessment of sedation until the next hourly assessment. Under no circumstances shall the amount of time for respiratory and sedation assessments exceed 2 hours during the first 24 hours. f. Sedation level hourly unless patient meets criteria above regarding "eyes closed" as above. Sedation Scale Awake (4) Minimal (3) *Moderate (2) Description Awake, alert Ptosis, slight slurring of speech Spontaneous eye closure, delayed response to verbal commands, appropriate response to verbal/tactile stimulation* Responds only to repeated or painful stimulation* No response to painful stimulation*

*Deep (1) *Unresponsive (0)

*Must attempt to arouse the patient 11. Assess for pruritis: administer medication as ordered. 12. Evaluate the catheter insertion site every 8 hours for redness, bruising, swelling or leakage and document condition of site each shift. 13. If local anesthetic is added, document sensorimotor function q4h on unit flowsheet. Notify anesthesiology immediately if: a. Sensory-motor function indicates loss of temperature (ice) or pressure (needle prick) above T4; or b. Motor function indicates inability to move legs or upper extremity weakness.

Protocol L&D/OB-GYN - Unit Practice Manual John Dempsey Hospital ­ Department of Nursing The University of Connecticut Health Center PROTOCOL FOR:

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Epidural Anesthesia: Care of the Patient with a Second Trimester Termination of Pregnancy 14. Monitor I&O at least every 8 hours. 15. After first 24 hours and if no dosage increase: a. Respiratory rate and sedation scale q4h, with any further reductions on subsequent days per physician order; b. BP, HR, and T q4h. 16. If dosage increase is needed or new infusion is begun, document RR, sedation score, HR and BP q 15 minutes x 2, then initiate hourly assessments as delineated in Clinical Assessment and Care #2. 17. After discontinuation of infusion, assessment of respiratory rate and sedation level should continue per physician order.

SAFETY:

1. In the event of suspected narcotic overdose for patients receiving patient controlled epidural analgesia (PCEA): a. Retrieve PCEA history and record immediately following patient stabilization, to include: 1) Number of attempted doses 2) Number of delivered doses 3) Total dosage delivered A witness will be used whenever possible to verify the accuracy of the data recorded. b. Remove the PCEA pump from service and send to Clinical Engineering. c. Send the remaining infusion to the Pharmacy. d. Inspect the infusion site and the tubing for irregularities; and e. Document all pertinent information in the patient's medical record.

REPLACING MEDICATION BAGS ON CONTINUOUS EPIDURALS:

1. Two RNs must check the infusion bag and confirm the rate prior to hanging a replacement bag. 2. For the Abbott Pump: a. Press run/stop b. Change bag c. Press #2 to set a "new container"

Protocol L&D/OB-GYN - Unit Practice Manual John Dempsey Hospital ­ Department of Nursing The University of Connecticut Health Center PROTOCOL FOR:

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Epidural Anesthesia: Care of the Patient with a Second Trimester Termination of Pregnancy d. Press run/stop 3. If there is a need for a change in the concentration or the infusion rate, anesthesia must be notified to do this.

DISCONTINUING THE EPIDURAL INFUSION:

1. The epidural infusion should be discontinued at the time of delivery unless an extensive repair or other complication is anticipated. 2. After discontinuation of the infusion during the immediate postpartum period, the patient should be assessed for fall risk and appropriate measures should be in place (i.e., room labeled for fall risk, patient to call for assistance, dangle legs before rising) until the effects of the anesthesia are absent. A fall risk identification bracelet is not required for this short term period of recovery, provided the patient is identified by a magnet on her door. 3. When the anesthesia effects are absent, assist patient to the bathroom on her first OOB experience after delivery. 4. After the first OOB experience when the patient has demonstrated the ability to self ambulate, she may be re-evaluated for fall risk and returned to universal status. 5. The epidural catheter after discontinuation of the infusion may remain in place during the recovery period until it is determined that no further intervention is necessary (i.e., D&C, hematoma evacuation). 6. If a D&C is required, the epidural catheter may be left in place when the patient is transferred to L&D with an order from the anesthesiologist.

REMOVAL OF EPIDURAL CATHETER:

1. Peel off the adhesive dressing and ask the patient to lean forward, which will open the intervertebral space. The catheter position is maintained only by a sterile adhesive dressing applied to the patient's skin in the lumbar area. The tissues through which the catheter passes will provide a small degree of retention. 2. Grasp the catheter with a gloved hand and attempt to withdraw the catheter smoothly. This should result in the catheter easily being withdrawn from the patient. Do not attempt to jerk or rapidly pull the catheter out. It should be virtually pain-free for the patient so there is no need to rush. If the catheter is trapped within the spine, aggressive withdrawal forces could break off the tip of the catheter. If the catheter does not easily come out, do not persist attempting to remove it but rather consult with the obstetric anesthesiologist (voice pager # 567-0159). 3. After removal, examine the catheter tip. You should see a colored mark on the end of the catheter. If you have doubts about whether

Protocol L&D/OB-GYN - Unit Practice Manual John Dempsey Hospital ­ Department of Nursing The University of Connecticut Health Center PROTOCOL FOR:

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Epidural Anesthesia: Care of the Patient with a Second Trimester Termination of Pregnancy the catheter was removed intact, please consult the anesthesiologist. 4. Clean the lumbar area with a clean cloth and apply a Band-Aid or other dressing to the puncture site as you would after an IV removal. 5. Document the time of removal and whether the tip was intact.

PATIENT EDUCATION:

1. Reinforce education about the purpose and use of the PCEA. 2. Instruct the patient/family that only the patient should be pushing the control button. 3. Instruct the patient to report the following: a. Unacceptable level of pain relief b. Itching c. Nausea/Vomiting d. Constipation e. Urinary retention 4. Inform the patient about the necessity of: a. Frequent monitoring activities b. Activity level ­ what the patient can/cannot do without assistance

APPROVAL: EFFECTIVE DATE: REVISION DATES: REVIEWED DATES: XX/XX XX/XX XX/XX

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