In this section
Definition of terms
Dermatome distribution (Dermi Boy RCH)
Assessing sensory block
Assessing motor block
anaesthesia (RA) or neuraxial analgesia is the administration of local
anaesthetic (LA) into the epidural space through an indwelling catheter.
Epidural analgesia has shown to provide better pain relief than parenteral
opioids. Children can experience moderate to severe pain post-operatively and
is likely to be worse in the first 24-72 hours.
pain can cause stress responses that are detrimental to recovery. RA provides
excellent analgesia and reduces surgical stress response while decreasing the
need for opioids. RA (epidural) is used for moderate to severe pain.
insertion of the epidural catheter will be determined by the type and site of
surgery. This will enable the LA effect to block the nerve impulses associated
with the area of spinal nerves innervating the surgical site and giving the
best post-operative analgesia.
It is important to
communicate with families and children about the expectation and sensations of
the epidural and why it is important to assess and monitor observations.
It is important to
understand and identify epidural complications to ensure the safety of the patient
and provide effective analgesia.
and young people who have an epidural analgesia require suitably trained nursing
staff to care for them to minimise side effects, complications and ensure
analgesia is optimal.
Epidurals are used for major surgery to provide the best analgesia with
minimal side effects
Children who have a physical impairment who may be sensitive to opioids
Children who have poor respiratory drive who would be more sensitive to
Children who have cerebral palsy and experience high muscle tone and
undergoing orthopaedic surgery
Local anaesthetic (LA)
The initial assessment of a
child with an epidural is in the Post Anaesthetic Care Unit (PACU) to ensure a
base line is documented and the epidural is effective. This will include the
prescription and pump setting, the position of the epidural catheter, the sensory block (dermatome spread) and the
motor block (Bromage).
A pain assessment should
also be documented at this time.
The sensory block and motor
block should be documented in the Flowsheets in EMR, noting the motor block may
be dense due to the possible higher concentration of LA given intra operatively.
All general post-operative
observations, fluids and medications should be checked and documented at this
Any issues with sensory or motor block identified by the PACU nurse
should be escalated to the treating anaesthetist and or the In-charge
anaesthetist. These issues should be communicated to the CPMS team prior to
patient transfer from PACU.
The sensory block should be
assessed 4 hourly and on the following times
The motor block should be
assessed 4 hourly and at the following times
The catheter insertion site
should be checked 8 hourly for any redness, tenderness or leaking. If visible
the catheter markings should be checked to make sure there has been no movement
of the epidural catheter. The dressing should also be checked and reinforced if
any tape is lifting
The epidural would be expected to last for 3- 4 days unless there are
The decreased sensation and
movement cased by the epidural analgesia may cause nerve compression and
Pressure care should be strictly
observing susceptible areas such as heels, lateral malleoli and sacrum.
Pressure mattresses, and pressure
supports should be used and documented.
Often children who require
epidural anaesthesia are a high risk for pressure acquired injury.
However, all children who
have an epidural need to be assessed for an individual prevention plan based on
the Glamorgan Pressure Injury Risk Assessment Tool.
Clinical observations are to
continue until the epidural has ceased including hourly sedation, heart rate,
respiratory rate, pain score (while awake).
Blood pressure and temperature
are to be assessed 4 hourly until the epidural has ceased.
Any adverse events or concerns
about the epidural or patient should be reported to the Children’s Pain
Management Service (CPMS) urgently
Any clinical observations outside
the parameters for age should be reported to CPMS. A fever 38.5 degrees and
above must be reported to CPMS urgently Pge 5773
Any changes or increase in pain should
be reported to CPMS urgently
Any changes in the sensory block becoming
high above T3. No block or inadequate to relieve pain should be reported to CPMS
Neonates rarely have epidural
analgesia but the main difference is a lower concentration of LA and/or a lower
hourly rate and the expected duration is 36 hours
Epidurals for children and Neonates
Neonatal opioid and epidural competency
and Epidural competency
at Learning Hero
assessing the sensory block
If the patient is able to
understand and report
Patients may report the ice feels
warm, the same or colder.
NB: If the patient is unable to
understand or report due to age or cognition, an assessment should still be
performed and documented.
While assessing the epidural
block, observe for any change in facial expression as the ice is applied,
muscle flinching or pushing away.
Gentle palpation over the surgical
site can also give an impression of comfort if the epidural is effective or
pain if the epidural is not effective.
Motor nerves as well as sensory
nerves may be affected by LA
It is important to assess motor
There may be a difference between
Assess if the patient is able to
move their feet or knees prior to the epidural e.g. some children with
neuromuscular impairment may not be able to voluntary move and poor pro-perception
can also make it difficult
Report to CPMS Pge 5773 urgently
The three groups of problems
associated with epidurals
(post dural puncture headache) If the epidural
needle has inadvertently penetrated the dura and there is a CSF leak the
patient may experience a low- pressure headache. This may not be evident until
the patient mobilises. This is a very low incidence and most cases improve
treatment is rest, fluids, analgesia and rarely a blood patch (autologous blood
inserted into the epidural space). (Anaesthetic procedure)
pain This is
usually at the insertion site, it is common and transient. Moderate to
severe back pain must be reported to CPMS urgently for investigationEpidural
abscess - this is very rare. Epidural haematoma
- this is very rare and will require urgent investigation.
Both abscess and haematoma will
present with moderate to severe back pain and sensory and motor deficits
Children and young people who
have lower limb surgery will have a lumber epidural and as this area innervates
the urinary bladder it is important for the child/young person to have an
indwelling urinary catheter inserted while in theatre. This will need to stay
in until the epidural infusion has ceased.
At the same time the epidural
infusion has ceased it is important to give other prescribed analgesia to
ensure pain management is optimised as the LA wears off over the next 4-6 hours.
Removal of the epidural catheter is
performed using standard
After the removal of epidural
analgesia IV or/and oral analgesia will be needed as regular and PRN to ensure
the patient is able to continue recovery.
All families are given an epidural
information card from CPMS outlining any issues to be concerned about once they
have gone home
A contact telephone number for
RCH and CPMS is provided for the family if they have any ongoing concerns.
You can view the evidence table for this nursing guideline here.
Please remember to read the disclaimer.
The development of this nursing guideline was coordinated by Sueann Penrose, Registered Nurse, Anaesthesia & Pain Management, and approved by the Nursing Clinical Effectiveness Committee. First published June 2020.