Anaesthetists Handbook - MEDICAL EDUCATION at University ...

Epidural anaesthesia and analgesiaInfusions containing fentanyl are legally controlled drugs whateverthe dilution and therefore must be stored in controlled drugscupboards.Clinical directors are responsible for putting adequate mechanisms inplace to ensure that all staff involved in epidural therapy havereceived adequate training, and have the necessary workcompetencies to undertake their duties safely.Treatment of local anaesthetic overdoseEpidural injections and infusions create serious risks for patients ifgiven inadvertently through the intrathecal or intravenous routes. Allepidural administrations must be given by doctors, nurses ormidwives and in areas where there is immediate availability of anemergency team able to treat subsequent problems.All local anaesthetic overdoses must be reported on clinical adverseevent forms.Intrathecal and subdural administrationAn unrecognised ‘dural tap’ or a catheter that migrates subsequent toinsertion may result in a high block leading to difficulty with breathingparticularly if the block reaches cervical level and causesdiaphragmatic impairment.The clinician’s first concern should be to send for help and then toprotect and secure the airway and prevent respiratory failure. Highblock can provoke great anxiety in the patient, which must not beconfused with respiratory failure. Establish whether diaphragmaticweakness exists. If the diaphragm is not weak, then the patient willprobably not need intubation. Advise them to take a breath in andout, and if they can do this counsel the patient that they are able tobreathe.In the event that intubation is needed, an appropriately trainedclinician should intubate and ventilate the patient until the block hasworn off, usually about two hours. Although muscle relaxation is notessential it is humane to provide amnesia and a routine rapidsequence induction of anaesthesia is the safest method of attaining124 Anaesthetists Handbook January 2010