Introduction
Definition of terms
Aim
Indications
Initial assessment
Ongoing assessment
Special considerations
Dermatome distribution (Dermi Boy RCH)
Assessing sensory block
Assessing motor block
Managing complications/troubleshooting
Removal
Documentation
Education
Companion documents
Links
Evidence Table
Introduction
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
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 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.
Children
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.
Aim
- To
provide nursing staff with a standardized guideline to enable safe and
appropriate care of children and young people with an epidural
- To
provide excellent analgesia to a discrete area of the body by blocking the
sensory nerves
- To
minimize the opioid requirement for pain management in the post-operative period
- To
optimise rest and mobility
- To
recognise problems and minimise complications
- To prioritise
the epidural as the first line analgesia
Indications
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
opioids alone
Children who have cerebral palsy and experience high muscle tone and
undergoing orthopaedic surgery
Definition of Terms
Central block
- Central neuraxial block (spinal, epidural and
caudal)
Epidural
- Epidural space is the Between
ligamentum flavum and the dura mater
- Contains
fat, blood and connective tissue
- Epidural
space extends from the foramen magnum to the coccyx
- Spinal
cord ends at L1-2.
Dermatome
- At each vertebra a nerve root exits from the
spinal cord. A dermatome is an area of skin innervated by a single spinal
nerve.
- The nerve roots exit bilaterally from each
vertebra
Sensory nerve
- Sensory nerves respond to pain, temperature,
touch and pressure. Pain and temperature nerve fibres are affected by LA.
Local anaesthetic (LA)
- A
drug that reversibly blocks the transmission of pain along nerve fibres
- LA
can block transmission in autonomic, sensory and motor fibres
Initial Assessment
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
time
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.
Management
and Physical Assessment
The sensory block should be
assessed 4 hourly and on the following times
- In PACU after rousing from the anaesthetic, and immediately after
patient initial bolus dose
- On return to the ward
- If the patient complains of pain
- One hour after a bolus or rate change
The motor block should be
assessed 4 hourly and at the following times
- In PACU after waking from the anaesthetic
- On return to the ward
- Prior to ambulation if required
- One hour after a bolus or rate change
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
adverse events
Pressure care
https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pressure_injury_prevention_and_management/
The decreased sensation and
movement cased by the epidural analgesia may cause nerve compression and
pressure areas.
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
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.
Ongoing
assessment
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
Pge 5773
Special considerations
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
information
https://www.rch.org.au/anaes/pain_management/Epidural_Infusion/
and
Neonatal opioid and epidural competency
and Epidural competency
at Learning Hero
www.rch.org.au/orgdev/HERO/
Dermatome distribution (Dermi Boy RCH)

Assessing
Sensory Block
Procedure for
assessing the sensory block
If the patient is able to
understand and report
- Explain the procedure to the patient and family
- Wrap an ice cube in tissue or paper towel leaving an area exposed
- Place the ice on an area well away from the dermatomes and ask how
cold does this feel
- Apply the ice to an area expected to be numb and ask if it feels
the same cold as your face or different?
- Apply the ice above and below this area until you determine the
upper and lower dermatomes blocked
- Assess one side then the other to see if the block is unilateral
or bilateral
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.
Assessing
Motor Block

Motor nerves as well as sensory
nerves may be affected by LA
It is important to assess motor
block:
- To prevent pressure areas
- To assess safety for standing/walking if allowed
- To detect complications e.g. epidural haematoma, or abscess
Procedure
when assessing motor block
- Explain procedure to patient and family
- Ask the patient to flex their ankles and knees
- Document the score in the clinical observation chart
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
Management complications/troubleshooting
Report to CPMS Pge 5773 urgently
if
- Any major change in motor
function
- Almost complete or complete motor
block in legs
- Reduced motor function in hands
or fingers (with a thoracic epidural)
- All patients who have an epidural
in situ must have a working intravenous (IV) to allow access for any adverse
events.
- CPMS must be notified if the patients’
vascular access IV has dislodged.
The three groups of problems
associated with epidurals
1. Complications
related to epidural catheter insertion
Headache
(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
spontaneously. Conservative
treatment is rest, fluids, analgesia and rarely a blood patch (autologous blood
inserted into the epidural space). (Anaesthetic procedure)
Back
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 investigation
Epidural
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
2. Complications related to epidural drugs
- Overdose/toxicity
- Signs of LA
toxicity are dizziness, blurred vision, decreased hearing, restlessness, tremor,
hypotension, bradycardia, arrhythmia, seizures, and sudden loss of
consciousness.
- Cease the RA
infusion
- Resuscitation
and management of cardiac, neurological and respiratory side effects
3. Complications
related to pain
- Pain escalation
- Check dermatomes,
if there has been a reseeding block an epidural bolus may be required and the
rate may need to be increased
- The first
line analgesia is an epidural bolus before other analgesia.
- Has the
epidural catheter become disconnected?
- Has the
epidural catheter dislodged?
- Is the
epidural leaking?
Lumber epidurals
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.
Removal
of the epidural
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
aseptic technique
- Explain the removal technique to the patient and carer with age
appropriate language
- Have the patient sitting up and bending gently forward or lying on
their side supported and comfortable
- After turning the epidural infusion off, remove tape in the normal
way, holding the epidural catheter at the site of insertion at the skin
gently pull with a steady pressure. If there is any difficulty in removing
the catheter stop and call CPMS Pge 5773
Documentation
- The site needs to be assessed and
findings documented
- The epidural catheter needs to be
assessed and the cm at the skin needs to be documented.
- The tip of the catheter needs to
be observed to be intact.
- The exit site does not require a
dressing, however the site needs to be checked in the next 12-24 hours for any
abnormality such as infection or haematoma.
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.
Education needs
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.
Companion
Documents
- parent information (Kids Health Info)
- procedures (comfort Kids)
- assessment tools (Pain assessment)
- staff training and learning packages
(learning Hero)
Links
- Guidelines
- RCH Nursing Guidelines
- RCH P&P
- RCH Anaesthesia & Pain Management
Evidence Table
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.