HHC Health & Home Care Clinical Policy And

HHC HEALTH & HOME CARE Section: 9-26
Infusion Therapy: Epidural Catheter, Site Care and Dressing Change __RN
PURPOSE:
To provide for the administration of uniform and effective pain
management via the epidural/intraspinal route.
CONSIDERATIONS:
1. This procedure is to be used as a guide; follow specific
physician orders that may vary depending upon type of
epidural or intrathecal access device.
2. Epidural or intraspinal administration of medication, i.e.,
Morphine Sulfate, has a longer duration of action, requires
lower doses of medication and results in lower incidence of
side effects. A bolus of epidural morphine sulfate analgesia
may last for more than 20 hours.
3. Epidural or intraspinal access can be achieved using one of
several different devices. Examples are: Implanted ports
with attached catheters, tunneled catheters similar to central
venous catheters, implanted continuous infusion systems,
e.g. Infusaid pump, and intrathecal (spinal) infusion lines.
4. Implanted epidural ports are similar to central venous ports,
i.e., Mediport, Port-a-Cath, and require placing of the noncoring
needle (Huber) securely against the backplate when
accessed. Implanted reservoirs may not have a steel
backplate, and care should be taken not to penetrate it upon
access.
5. Epidural or intrathecal catheters are for both temporary and
long-term use. Temporary catheters are directly placed in
the epidural space and are most often used in the hospital
until a long-term catheter can be placed. Temporary
catheters should be monitored closely for stability and intact,
staying sutures. Long-term catheters are placed in the
epidural space and tunneled through the subcutaneous
tissue to an exit site usually on the anterior aspect of the
patient. Epidural port catheter is placed in the epidural
space and the port body is placed against a bony
prominence on the anterior or side of the patient.
6. A neurosurgeon or anesthesiologist performs placement of
epidural or intrathecal access devices.
7. Complications of this therapy include but are not limited to:
paraesthesia, pruritus, nausea, vomiting, urinary retention,
respiratory depression, hypotension, respiratory arrest, and
catheter complications such as infection, dislodgement and
leaking. Complications shall be documented and reported to
the physician immediately.
8. Initial doses of intraspinal pain medication should be given
in the hospital or physician's office. The patient should be
stable on the same medication regimen for 24 hours in a
controlled setting prior to acceptance for home therapy.
9. Narcan may be ordered by the physician to reduce possible
overdose symptoms.
10. Any pain medication given intraspinally MUST BE IN A
STERILE, PRESERVATIVE - FREE SALINE SOLUTION.
Medications not preservative-free will permanently scar
nerve endings when given via the epidural space.
11. ALCOHOL IS CONTRAINDICATED for site preparation or
when accessing the catheter because of the potential for
migration of alcohol into the epidural space and possible
nerve damage.
12. All procedures involving the use or access of an epidural
line are to be done using strict aseptic technique.
13. Continuous intraspinal infusions shall be administered via
an electronic infusion device (pump).
14. Continuous infusions will only be considered when there is
assurance of continued proper catheter positioning (e.g.,
sutures, tunneled catheter, or port). Do not administer any
medication if there is any concern or doubt regarding
catheter placement. The nurse can measure the external
portion of the catheter with each visit to verify catheter
placement.
15. For continuous infusions, the tubing will be changed:
a. When replacing the medication cassette.
b. Whenever the integrity of the dosed system is violated.
c. Weekly if the system remains closed and cassette does
not require changing sooner.
16. All medications to be administered through epidural or
intrathecal catheters should be labeled for use via those
routes. Ex: “Epidural/Intrathecal – No IV Access”.
(Intrathecal narcotic doses are 10 times less than
epidural doses.)
17. A 0.2 micron filter without surfactant should be utilized for
medication administration.
18. The routine aspiration of an intraspinal catheter is not
recommended.
19. The RN should check line placement by gentle aspiration
with a sterile syringe.
a. Before administering a bolus dose of medication.
b. When patient is experiencing inadequate pain control or
over sedation. If epidural catheter is properly positioned,
no fluid will be aspirated.
20. Aspiration of clear fluid may indicate that the epidural
catheter has migrated into the intrathecal space. Bloody
aspirate may indicate displacement into the vascular
system. In either case, do not administer the bolus epidural
medication, discontinue the infusion and notify the
physician.
21. Epidural or intrathecal catheters do not require routine
flushing. After intermittent drug delivery and if the catheter
will not inject, flush gently with 1-3cc preservative-free
saline. A physician's order is required to flush the catheter.
22. The nurse caring for the infusion, teaching and
administering therapy is expected to be knowledgeable of
the medication, expected therapeutic effects, recommended
dosage range, side effects, toxic symptoms, and the
particular equipment used to deliver medication.
23. An education program for self-administration will be initiated,
where appropriate and as ordered by the physician.
24. Patient/caregiver education should include:
a. Information related to the medication being given.
b. Purpose of therapy and procedures.
c. Administration of therapy.
d. Care of the medication, solution and pump.
e. Initiating and maintaining the infusion.
f. Recognition of signs and symptoms of complications.
g. Emergency phone numbers.
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