In this section
Regional 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 it is likely to be worse in the first 24-72 hours.
Uncontrolled 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.
The 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 and educate 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.
Children and young people who have epidural analgesia require suitably trained nursing staff to care for them to minimise side effects and complications and ensure analgesia is optimal.
To provide guidance on safe care of children and young people with an epidural and consideration of potential complications.
Epidurals are used post major surgery to provide excellent analgesia to a discrete area of the body by blocking the sensory nerves with minimal side effects. Epidurals can minimise the opioid requirements and optimise rest and recovery in the post–operative period.
The epidural infusion may be prescribed for children and young people who:
Have cerebral palsy and experience high muscle tone and are undergoing orthopaedic surgery.
The initial assessment of a child with an epidural in the PACU includes:
(Information about dermatome distribution and assessment of sensory block and assessment of motor block is located at the end of this guideline)
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.
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 Children’s Pain Management Service (CPMS) team prior to
patient transfer from PACU.
All general post-operative observations, fluids and medications should be checked and documented at this time.
Checking of the epidural infusion should be incorporated into OILs check at handover times see Standardised checking procedure for infusion pump programming at the RCH.
The sensory block (dermatomes) should be assessed 4 hourly and at the following times:
The motor block (bromage) should be assessed 4 hourly and at the following times
The catheter insertion site should be checked at least 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 be checked and reinforced if any tape is lifting.
The epidural infusion would be expected to last for 3 - 4 days unless there are adverse events.
All patients who have an epidural in situ must have a working intravenous (IV) to allow access for management of any adverse events.
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 at least 4 hourly until the epidural has ceased.
Please see the
Nursing Assessment Guideline and/or the
observation and continuous monitoring guidelines for more information.
The decreased sensation and movement caused by the epidural analgesia may cause nerve compression and pressure areas.
Children/young persons who require epidural anaesthesia are at increased risk for pressure acquired injury. All children/young persons who have an epidural therefore need to be assessed for an individual prevention plan based on the Glamorgan Pressure Injury Risk Assessment Tool. For more information see the
pressure injury prevention and management nursing guideline.
Pressure care should be strictly observed at a minimum of 4 hourly, or more frequently as required, to susceptible areas such as heels, lateral malleoli and sacrum. Pressure mattresses, and pressure supports should be used to reduce risk and documented
in the primary assessment flowsheet. See the
pressure injury prevention and management guideline for more information.
The following adverse events or concerns about the epidural or patient should be urgently reported to the Children’s Pain Management Service (CPMS) urgently – page 5773
More information regarding epidural
complications can be found below.
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 of infusion is less at 36 hours.
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. The urinary
catheter will need to stay in until the epidural infusion has ceased.
Report to CPMS Pge 5773 urgently if
There are three types of complications associated with epidurals: complications related to epidural catheter insertion, complications related to epidural drugs, complications related to pain.
Headache (post dural puncture headache)
Both abscess and haematoma will present with moderate to severe back pain and sensory and motor deficits
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.
Speak to CPMS and Medical team if patient is on heparin, prior to removal of epidural.
Removal of the epidural catheter is performed using
standard aseptic technique
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.
If the patient is able to
understand and report
patient is unable to understand or report due to age or cognition, an assessment should still be performed and documented.
Patients may report the ice feels warm, the same or colder.
Motor nerves as well as sensory nerves may be affected by LA.
It is important to assess motor block:
There may be a difference between legs. 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.
You can view the
evidence table for this nursing guideline here.
Please remember to read the
The development of this nursing guideline was coordinated by Sueann Penrose, Registered Nurse, Anaesthesia & Pain Management, and approved by the Nursing Clinical Effectiveness Committee. Revised August 2023.