Introduction
Normally, the epidural infusions are initiated before the surgical procedure ends to obtain pain relief after the operation. Epidural infusions can be a harmless and successful technique for the provision of perioperative analgesia. The infusion lessens the patient’s general opioid needs while giving more steady pain management. In this paper, the intricacies of epidural infusion—with regards to the case of Mr. Keith Johnson who was diagnosed with primary lung adenocarcinoma two weeks ago—are going to be duly analyzed. In essence, the paper purports the viewpoint that Mr. Johnston can use an Epidural infusion for his pain relief in postoperative care.
This is principally based on the fact that he is experiencing pain and authoritative studies from various scholarly quarters indicate that epidural infusion has, over time, been used as an effective method of controlling such signs and symptoms. For instance, the nurses can monitor how he is reacting to the medicine thus making epidural infusion the best way of giving his pain medications. Additionally, his breathing and heart rates can also be monitored for side effects in the due process of treatment (Farrante; 2004). A more explicative and expansive analysis of the suitability and the inherent facets of epidural infusion—with regards to the case treatment of Mr. Johnston—is given in the sections below.
The rationale behind the use of an epidural infusion for pain relief in the post-operative care of Mr. Johnston
Over time, Epidural Analgesia is an extremely effective way of controlling sharp pain after the surgical operation (Purdie, 2009; Sia, 2009b). This is majorly based on its uniquely vital ability to provide terrific pain relief, fewer side-effects, and high patient gratification compared to other techniques of analgesia (Missant, 2008; & Sia, 2009b). However, on the downside, epidural analgesia can bring about severe, potentially fatal complications (Tan, 2007).
In addition, different clients respond differently to this treatment. For this reason, epidural infusions ought to be modified according to the needs of the patient to avoid any unwanted reactions. Even more importantly, the success of epidural infusion greatly depends on the monitoring of the patient by the relevant medical practitioners. Any slight lapse of medical judgment or lack of cautious monitoring of the patient with regards to issues such as side effects of the treatment, breathing rate, or even heart rate can lead to dire ramifications. Consequently, in the due cause of treating Mr. Johnston through this method, all these elements should be considered.
As per the diagnosis, Mr. Johnston’s epidural block is at T4 bilaterally. Medically, this means that his case is not utterly complicated and can therefore be managed—even though he should be duly monitored from time to time. According to Cole (2010), safe and effective management entails a harmonized multi-disciplinary approach. Furthermore, despite its complications, epidural analgesia is commonly used in medical centers based on its success rates. Some of the reasons behind its usage and its relevance in Mr. Johnston’s case, other than those that were aforementioned in the introduction, are given below.
To begin with, epidural analgesia is used for incessant use of LA agents only or with the administration of narcotic agents into the epidural space. This is pegged on its ability to lessen or eradicate the perioperative stress reactions to the surgical procedure (Ferrante, 2011). It also lessens the occurrence of post-operative surgical difficulties bring about better results (Ferrante, 2007). The pain experienced by Mr. Johnston, for instance, can be reduced through therapy made successful and safe through the provision of particular attention to the patient’s medical evaluation in terms of controlling pain and complications. Mr. Johnston does not have a high block that can sometimes be a major complication. All practitioners ought to be aware of the medical complications linked with the utilization of epidural analgesia (Paech, 2007a).
However, as was earlier stated, the epidural infusion has its fair share of complications. Some of these complications can be deadly or bring about permanent damage. Common complications include (but are not limited to); insufficient analgesia, motor block, breathing difficulties, and hypotension (Boutros, 2007). The best epidural analgesic method for a major surgical procedure can provide effectual pain relief with fewer side effects and patient gratification (Gambling, 2008a).
Moreover, epidural analgesia can provide excellent relief of pain after surgical procedures, but this advantage ought to be judged against the probability of unpleasant effects and complications (Lurie, 2010). After the surgical procedure, good pain relief is imperative to a patient’s recuperation process (Ferrante, 2008). Epidurals are pain medications given through a tiny tube known as a catheter into the spinal canal.
Nevertheless, this pain relief technique can slow the opening of blood thinners, which stops fatal blood clot patterns in the veins, since there is also the danger of hemorrhage at the epidural injection area if blood thinners are utilized at the same period (Lurie, 2010). Epidural analgesia patient selection is supposed to be founded on cautious benefit/risk psychoanalysis for every patient. Common risk factors are; coagulation impairment, infectivity, compromising immunity, epidural catheterization’ period, cardiovascular constancy, and insufficient post-operative monitoring ability, among many others (Missant, 2008).
Seven Priorities in nursing care that you would need to consider with a patient, such as Mr. Johnston, who has an epidural infusion insitu
Firstly, constant epidural analgesia is an important process with definite and possible severe complications; thus, well-versed patient approval ought to be obtained. Therefore, in administering treatment to a patient like Mr. Johnston, there ought to be a discussion concerning the dangers and the possible benefits of epidural analgesia as well as information on complications that may arise after the patient is released from the hospital (Paech, 2007b). This will greatly help in preparing the patient for any eventualities in case things do not go as planned—as they sometimes do.
Secondly, patients obtaining epidural analgesia ought to be located close to their practitioners’ station to ensure close management. This helps the nurses to establish how the medication is working in the patient. For instance, sedation and pain scores, aid in identifying insufficient or extreme administration of the epidural drug. In this regard, monitoring the procedures should give comprehensible guidance on procedures needed if analgesia is insufficient. Nurses should know that increased pain can signify surgical complications including the raise of compartment syndrome (Paech 2007a).
Thirdly, exceptional care ought to be taken when interpreting symptoms in patients who could have suffered neurological damage. Pain is also experienced after a surgical procedure is serious; pain therapy should thus include a routine, if possible consisting of epidural opioids and local anesthetics agents together with NSAIDs or COX-2 inhibitors considering the risk factors. If the epidural routine is not obtainable, then analogous analgesia may be attained with an incessant thoracic paravertebral block, with the possibility of lesser occurrence of urine retention and post-operative queasiness and nausea.
Even though comparable, the incessant para-vertebral method can be practically complex. If no regional analgesic method is obtainable, then the substandard NSAIDs regimen and systemic opioids can be utilized. Cryoanalgesia is not proposed because it is less effective. Acetaminophen is proposed as a fundamental analgesic for multi-modal analgesia.
Thirdly, Pain after a surgical procedure with sternotomy is less serious, and therefore systemic opioids together with NSAIDs are proposed. There are pain complications that arise if appropriate regimens are not available (Cole, 2008). A common mistaken belief is that pain, despite how harsh and serious, can at all times be successfully alleviated by opioid analgesics. It has repetitively been established, nonetheless, that in a high percentage of post-operative patients, pain is ineffectually treated.
This incongruity between what is achievable and what is takes place can be credited to a range of causes, which to some extent can be improved by better teaching efforts (Vandermeulen, 2009). The latest evidence also points out that opioid therapy over-reliance may be intrinsically limiting because of the expansion of opioid-provoked hyperalgesia and acute tolerance.
Fourthly, the potential of opioids in high dosages or with continuous administration to possibly induce pain demonstrates the significance of utilizing multi-modal analgesic regimens that aims at numerous analgesic passageways. Moreover, post-operative pain is composed of an assemblage of horrible sensory, poignant, and psychological experiences linked with autonomic, mental, and behavioral reactions precipitated by the damage of surgical procedures (Taylor, 2007).
For this reason, priority should be given to pain management in patients such as Johnston. Notably, management of pain has received escalating attention, and numerous government bureaus and health specialty associations have now come up with guiding principles for postoperative pain treatment and management. For example, in 2000, JCAHO (The Joint Commission on Accreditation of Healthcare Organizations) initiated pain management standards, alleging that post-operative patients have the right to acquire proper assessment, treatment, and management of the complications they experience during treatment (Tan, 2007).
Still, on the issue of pain, Post-operative pain can cause permanent damage to a patient and severe complications; these pains can also be life-threatening. Severe pain mostly indicates that the patient is going through greater complications; after a surgical procedure, the patient should be given close attention and both his heart and breathing rate should be monitored to detect side effects. Post-operative pain relief has two realistic objectives.
The first entails provisions of individual comfort/relief which is enviable for humanitarian and charitable reasons. The second aim involves reticence of trauma-provoked nociceptive reaction to direct somatic and autonomic impulse reactions to pain and to develop consequent re-establishment of function by letting the patient take breaths, cough, and move without difficulty. Since these effects lessen complications of pain, they can bring out enhanced postoperative results (Sia 2009).
Fifthly, ultimate accountability for the epidural infusion should be restricted to the medical doctor who instituted it while proper communication procedures are intermittently put in place to ensure adequate treatment of the patient and free flow of relevant information. Nonetheless, the patient’s direct supervision may be transferred to the Acute Pain Service and competently trained ward personnel.
A concurred kind of communication ought to be utilized to enable this reassigning of supervision. Before the patient goes back to his/her ward, the answerable anesthetist must be convinced that the ward is adequately staffed to make sure there is secure management and treatment of epidural. A communication system should also exist to notify the theatre personnel or anesthetist of any problem. There should also be sufficient hand-over info between staff on duty concerning patients being given epidural analgesia. Ideally, an updated list of continuing epidurals must be maintained and readily accessible (Sumikura, 2008).
Again, about the issue of communication and supervision, nurses who have explicit skills and training regarding supervision and management of epidural analgesia and its complications ought to be present during all shifts and on the ward. Staffing levels and knowledge ought to be adequate to facility sufficient monitoring and care are given to all patients being administered epidural infusion. These members of staff are supposed to be present to respond to unpleasant events (Gambling, 2007). Oxygen and full resuscitation apparatus should also be available; epidural catheter’s tip should be situated at a spinal, ready for the surgical procedure. A catheter situated in a low position can be linked-with inadequate analgesia and the need for large quantities of infusion in adults.
Like in the case of Mr. Johnston, the catheter must be secured to decrease movement in or out of the epidural space. The dressing is supposed to allow painless and effortless visibility of the infusion area and catheter. Preferably, apparatus for epidural infusion and insertion ought to be standardized all through the medical center so that it can be familiar with practitioners administering and managing epidural analgesia. Members of staff should be trained on how to use this equipment; pumps of infusion should be arranged exclusively for Epidural analgesia with stipulated limits for highest infusion rate and volume of bolus; lock-out period should also be consistent if utilized for PCEA (Ferrante, 2011). Infusion pumps should be designed for epidural analgesia only and must be marked as such.
Sixthly, there should also be a recognized maintenance program; the epidural system of infusion between the patient and the pump should be considered as closed and without ports of injection. An anti-bacterial sieve should be put at the intersection of the infusion line and epidural catheter (Ferrante, 2007). Effectual epidural analgesia management can require bolus injection administration of solution into the system. This may be carried out using the syringe in the pump, hence not breaking the system. If a separate syringe is being used, the injection is supposed to be carried out using a severe aseptic method (Ferrante, 2011). Injections of Bolus should be carried out by members of staff with proper training and proficiency and more exhaustive monitoring of the patient is needed soon after the injection (Viscomi, 2010).
Seventhly and lastly, epidural infusions must be marked to avoid mix-up and epidural infusions must be kept in separate areas from other equipment and other kinds of infusions to lessen the danger of mistaken route administration. Resuscitation tools, oxygen, and proper medications ought to be readily obtainable wherever there is the usage of epidural infusions. Patients should be examined closely all through the phase of epidural analgesia (Missant, 2008). It should be carried out by trained personnel who are aware of its importance and the procedures needed in response to irregular values. Monitoring is supposed to include; blood pressure, heart, and breathing rate, pain and sedation score, temperature, and extent of sensory and motor block.
Nursing care needed to alleviate Mr. Johnston’s blood pressure and related complications
Epidural blockade can bring about high blood pressure—commonly known as hypotension. Nonetheless, when hypotension takes place after a surgical procedure, other prevalent causes are supposed to be considered for example; myocardial shortage, bleeding, dehydration, and sepsis (Purdie 2009). Pain scores and sedation scores will assist in identifying insufficient or extreme epidural administration of drugs. The monitoring procedure ought to give comprehensible guidance on actions to take if analgesia is insufficient (Collis 2009). Sedation is frequently the most responsive indication of opioid-provoked respiratory stress. Monitoring of motor and the sensory block is important for the early discovery of potentially severe complications. The Bromage scale is approved equipment for motor block measurement (Lurie 2010).
An escalating extent of motor weakness normally implies extreme epidural medication administration. Nonetheless, it can indicate extremely severe complications as well as catheter dural penetration or growth of epidural hematoma. For that reason, procedures must be in place to administer the scenario of unwarranted motor block. The motor block is supposed to be evaluated and documented properly through the use of age-appropriate evaluation. A comprehensible action plan must be in place if motor block continues or develops. Mr. Johnston has an epidural block so his case should be evaluated and treated.
The explanation for Headache and Increased Respiratory rate in Mr. Johnston and Proposed Treatment
Essentially, an epidural hematoma can also bring about serious, enduring neurological damage thus leading to side effects such as headaches and increased respiratory rates (Bush, 2009). Keen monitoring of the patient can greatly help in discovering such—just as was the case with Mr. Johnston whose case was identified by the night nurse. Once such complications are identified, viable measures should be administered as soon as possible. Such a diagnosis should be considered if extreme motor block doesn’t resolve quickly after putting a stop to the epidural infusion. A clear procedure must also be in place explaining the actions needed in this situation, together with notifying senior anesthetic personnel of the proper emerging surgical expertise.
The main complication of an epidural infusion and relevant nursing care needed to alleviate it
Essentially, there have been inconclusive medical debates regarding the major complication of an epidural infusion. To some, low blood pressure is the main complication while to others; pain (especially postoperative pain) is the key issue—with viable proofs available to support both sides of the debate. Therefore, in the section below, succinct analysis of these two issues, considered as key complications of epidural infusion, will be given with relevant methods of alleviation also detailed.
With regards to low blood pressure as the main complication of Epidural infusion; it is believed that the local anesthetic has an effect on the nerves that goes to the blood vessels, so the patient’s blood pressure goes down. This complication can be treated by drinking a lot of fluids and prescribed drugs.
Regarding pain (postoperative pain) as a major complication; it is believed that postoperative pain can lead to many other serious complications—some of which are life-threatening. For this reason, relevant medical measures must be duly taken. On a commendable note, however, in a high percentage of post-operative patients; pain is ineffectually treated using a myriad of methods such as opioid analgesics, painkillers, and other available pain-relief methods (Curry, 2007).
A common belief in most medical circles is that whether that pain is harsh or mild; it can always be successfully alleviated by opioid analgesics; something which has been severally proved otherwise. If progress is to be made in alleviating pain and its effects on the patients, such misconceptions must be utterly done away with. Once such misconceptions are resolved, objectivity will be enhanced since the focus will now be on finding a way forward in solving or treating the pain rather than debating on issues such as whether or not the pain can always be treated by opioid analgesics.
Finally, post-operative pain is usually composed of a myriad of health-related complications (Gambling, 2008b). Provisions should therefore be put in place to mitigate such complications that, in one way or another, worsen the effects of pain.
Conclusion
Despite having several risks and related complications, it can be conclusively stated that epidural infusion is indeed a vital method for relieving pain in post-operative care—as has been detailed in the discussion herein. Nonetheless, if the ultimate potential of epidural infusions is to be achieved; more provisions should be put in place to help better its efficacy while eliminating the misconceptions that surround it.
References
Boutros, A. (2007). Comparison of intermittent epidural bolus, Continuous epidural infusion, and patient controlled-epidural analgesia during labor. New York, NY: Int J Obstet Anesth.
Bush, D. (2009). Intravascular migration of an epidural catheter during postoperative patient-controlled epidural analgesia. New York, NY: Anesth Analg.
Collis, R. (2009). Comparison of midwife top-ups, continuous Infusion, and patient-controlled epidural analgesia for maintaining mobility after a Low-dose combined spinal-epidural. New York, NY: Br J Anaesth.
Cole, C. (2010). A comparative study of patient-controlled epidural analgesia (PCEA) and continuous infusion epidural analgesia (CIEA) during labor. New York, NY: Can J Anaesth.
Curry, P. (2007). Patient-controlled epidural analgesia in obstetric anesthetic practice. New York, NY: VDM Verlag Dr. Mueller e.K.
Ferrante, F. (2008). Segal M: 0.0625% bupivacaine with 0.0002% fentanyl via patient-controlled epidural analgesia for the pain of labor and delivery. New York, NY: Clin J Pain.
Ferrante, F. (2011). Jamison SB: Patient-controlled epidural analgesia: demand dosing. New York, NY: Anesth Analg.
Ferrante, F. (2007). The role of continuous background infusions in patient-controlled epidural analgesia for labor and delivery. New York, NY: Anesth Analg.
Fontenot, R. (2010). Double-blind evaluation of patient-controlled epidural analgesia during labor. New York, NY: Int J Obstet Anesth.
Gambling, D. (2007). Epidural infusions in labor should be abandoned in favor of patient-controlled epidural analgesia. New York, NY: Int J Obstet Anesth.
Gambling D. (2008). Comparison of patient-controlled epidural analgesia and conventional intermittent ‘top-up’ injections during labor. New York, NY: Anesth Analg.
Gambling, D. (2008). Patient-controlled epidural analgesia in labor: varying bolus dose and lockout interval. New York, NY: Can J Anaesth.
Lysak, S. (2009). Patient-controlled epidural analgesia during labor: a comparison of three solutions with a continuous infusion control. New York, NY: Anesthesiology.
Lurie, S. (2010). Patient-controlled epidural anesthesia during labor may be hazardous. New York, NY: Anesthesiology.
Missant, C. (2008). Patient-controlled epidural analgesia following combined spinal-epidural analgesia in labor: the effects of adding a continuous epidural infusion. New York, NY: Anaesth Intense Care.
Paech, M. (2007a). Patient-controlled epidural analgesia for labor. New York, NY: Anesth Analg.
Paech, M. (2007b). Clinical experience with patient-controlled and staff administered intermittent bolus epidural analgesia in labor. New York, NY: Anaesth Intensive Care.
Purdie, J. (2009). Continuous extradural analgesia: Comparison of midwife top-ups, continuous infusions, and patient-controlled administration. New York, NY: Br J Anaesth.
Sia, A. (2009a). A comparison of basal infusion with automatic mandatory boluses in parturient-controlled epidural analgesia during labor. New York, NY: Anesth Analg.
Sia, A. (2009b). Chong JL: Epidural 0.2% ropivacaine for labor analgesia: parturient controlled or continuous infusion? New York, NY: Anaesth Intensive Care.
Sumikura, H. (2008). Comparison between a disposable and electronic PCA device for labor epidural analgesia. New York, NY: J. Anesth.
Tan, S. (2007). Extradural analgesia in labor: complications of three techniques of administration. New York, NY: Br J Anaesth.
Taylor, H. (2007). Clinical experience with a continuous epidural infusion of bupivacaine at 6ml per hour in obstetrics. New York, NY: Can Anaesthet Soc J.
Van, Z. (2008). High volume spinal anesthesia with bupivacaine 0.125% for cesarean section. New York, NY: Anesthesiology.
Vandermeulen, E. (2009). Vertommen JD: Labor pain relief using bupivacaine and sufentanil: Patient-controlled epidural analgesia versus intermittent injections. New York, NY: Eur J Obstet Gynecol Reprod Biol.
Viscomi, C. (2010). Eisenach JC: Patient-controlled epidural analgesia during labor. New York, NY: Obst Gynecol.