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Epidural and Intrathecal (Neuraxial) Analgesia (6.1.15)

Epidural and Intrathecal (Neuraxial) Analgesia (6.1.15) - Policies, Clinical, UW Health Clinical, Medications and Pharmacy


Policy Title: Epidural and External or Non-Implanted Intrathecal (Neuraxial) Analgesia
Policy Number: 6.1.15
Category: UW Health
Type: Inpatient
Effective Date: October 20, 2017


The purpose of this policy is to allow for the safe administration of epidural and intrathecal medications and
to ensure that ordering and management of epidural and external or non-implanted intrathecal catheters are
standardized across all units.


Pain Service: The Pain Service consists of the following providers: (1) Department of Anesthesia Physicians
(i.e. faculty, fellow, resident); (2) Anesthesia Advanced Practice Providers (APP); (3) Interventional Pain
Service (IPS) Physicians.


Only the Pain Service may initiate, modify, or discontinue epidural or intrathecal analgesia orders. Primary
service physicians should request changes in neuraxial therapy by communicating directly (verbally) with the
Pain Service or via a written clinical progress note in the clinical record detailing the request. The request
should not be written as an order. Any emergent order made by the primary service to modify the neuraxial
infusion must be communicated to the Pain Service immediately.

The use of epidural and intrathecal medications precludes the use of any other opioids, or central nervous
system depressants except as ordered by the Pain Service. Epidural and intrathecal analgesia therapy
orders supersede previously ordered (postoperative) analgesia. Orders should be provided by the Pain
Service when applicable, to clarify (discontinue or maintain) previous opioids and other central nervous
system depressants.

Only nurses completing the competency training for epidural and intrathecal catheters through the Education
and Development for Nursing and Patient Care Services Department may care for patients with external
epidural or intrathecal catheter.

Refer to Appendix 1 for the list of units that provide care for patients with epidural or intrathecal catheters.

A. Initiation of epidural/intrathecal therapy
B. Preparation and dispensing of epidural/intrathecal products
C. Insertion of the catheter
D. Administration of epidural/intrathecal therapy
E. Maintenance of epidural/intrathecal therapy
F. Patient monitoring and documentation in Health Link of epidural/intrathecal analgesia
G. Suspected pump malfunction/adverse patient event
H. “Hold” on epidural/intrathecal therapy
I. Discontinuation of the epidural/intrathecal therapy and catheter
J. Patient education
K. Training and education
A. Initiation of Epidural/Intrathecal Therapy
i. The Pain Service completes a standardized Epidural or Intrathecal Analgesia Physician Order
Form (order set) ensuring that all care providers have the necessary information to assure safe and
efficient order entry.

Policy Title: Epidural and External or Non-Implanted Intrathecal (Neuraxial) Analgesia
Policy Number: 6.1.15

ii. Orders will include the epidural or intrathecal medications for infusion; rate of infusion; parameters
for monitoring the patient's respiratory function, blood pressure, heart rate, sedation level and
changes in strength or sensation of extremities; treatment of side effects; and parameters when to
notify the Pain Service.
iii. The responsible physician contact information will be specified in the orders.
B. Preparation and Dispensing of Epidural/Intrathecal Products
i. The pharmacy sterile products production area personnel will place unique colored warning labels
on epidurals (yellow) and intrathecals (purple) and place tactile feedback on all dispensed products.
ii. Only preservative-free medications/solutions should be used for the preparation of medications to
be infused into the epidural/intrathecal space.
C. Insertion of the Catheter
i. Follow UW Health Clinical Policy #4.1.8, Standard Precautions and Isolation.
ii. Prior to the neuraxial catheter insertion procedure, the Universal Protocol should be followed per
UW Health Clinical Policy #2.3.32, Operative, Invasive, and Other Procedures. The Universal
Protocol is documented on the appropriate form for the clinical area.
iii. Document baseline vital signs to enable assessment for changes.
iv. For continuous epidural or intrathecal infusions, a 0.22 micron filter is recommended (but not
mandatory) between the catheter and the medication tubing, which can be found in the Epidural
Anesthesia Tray, PACU or obtained from Central Supply. The filter may become occluded after a
few days and may be changed by the Pain Service, certified registered nurse anesthetist,
anesthesiologist assistant, or APS/IPS clinical nurse specialist.
v. Ensure that the neuraxial catheter is clearly labeled to prevent accidental administration of
solutions and/or medications not intended for epidural/intrathecal use.
vi. The physician inserting the catheter will document in the clinical record the placement of the
catheter noting the date, time, and location of the catheter, and medication bolus dose given (if
D. Administration of Epidural/Intrathecal Therapy
i. The initial (and subsequent) line connection of the epidural or neuraxial catheter to the neuraxial
pump administration tubing will be made by the Pain Service, Anesthesia Clinical Nurse Specialist,
Anesthesia Registered Nurses, or inpatient PACU nursing staff.
ii. Administer neuraxial infusions per the designated epidural/intrathecal infusion pump, using the
specific pump set tubing. This tubing is specifically designed for use with the pump and without side
ports, which prevents accidental administration of non-epidural medications.
iii. An independent double-check is required per the UWHC High Alert Medication Administration
Policy #8.33 when therapy is initiated. An infusion should not start until double check occurs.
iv. Document the date and time when initiating new infusion bag.
v. Ensure all connections are secure to prevent infection or interruption of the infusion. In particular,
the connection where the epidural catheter inserts into the micron filter should be securely
connected to prevent catheter slippage. The catheter and filter should be securely fastened up and
over the shoulder to the front of the patient.
E. Maintenance of Epidural/Intrathecal Therapy
i. A double check of neuraxial medications is performed anytime a neuraxial analgesia solution bag is
changed or the pump is reprogrammed per UWHC High Alert Medication Administration Policy
ii. NO ANTICOAGULANTS/ANTIPLATELET may be administered unless approved by the Pain
Service. Subcutaneous Unfractionated Heparin, up to 5000 units/dose, two times daily or three
times daily; NSAIDs; and Aspirin, up to 325 mg two times daily ordered by the primary care service
are approved/allowed.
iii. Do not administer other opioids, sedatives, or central nervous system depressants to patients who
are receiving epidural/intrathecal analgesia except as ordered by the Pain Service to avoid risks of
respiratory depression.
iv. Epidural and intrathecal catheters should not be flushed or heparinized.
v. Epidural tubing is not routinely changed due to the short-duration of therapy and risk of opening a
sterile closed system. Intrathecal tubing is changed in the home setting with new solution bags.
vi. Intrathecal therapy is to be by continuous infusion only. Intrathecal boluses may be administered
only by the Pain Service.
vii. Syringe bolusing of epidural catheters may only be performed by the Pain Service. An order must
be documented immediately following the administration of an epidural syringe bolus and indicate

Policy Title: Epidural and External or Non-Implanted Intrathecal (Neuraxial) Analgesia
Policy Number: 6.1.15

"Already given; Do not administer". The Pain Service will notify the nursing staff on the patient care
unit of the bolus dose administration.
viii. RNs may administer a bolus dose for epidural infusions as ordered by the Pain Service via the
epidural/intrathecal infusion pump bolus option.
ix. The responsible physician contact information will be specified in the orders.
x. Standard epidural catheters are not MRI safe. When MRI safe catheters are used, a label must be
placed near the catheter connection.
F. Patient monitoring and documentation in Health Link of epidural/intrathecal analgesia
i. The assessment and documentation in Health Link requirements are according to the orders
written by Pain Service.
ii. Document all bolus doses and rate changes in MAR. Intrathecal therapy is to be by continuous
infusion only.
iii. Document total volume of drug infused in MAR every eight hours and upon admission or transfer to
iv. Per Nursing Departmental Patient Care Policy #14.33AP, Nurse to Nurse Change of Shift Hand-
Off-Inpatient (Adult and Pediatric), nurses will conduct a face-to-face hand-off at change of shift or
with patient transfer.
v. Documentation of naloxone dose in Health Link, if given, and complete a Patient Safety Net report.
Naloxone, a short acting opioid antagonist, should be available on the unit to treat side effects such
as respiratory depression.
vi. Monitor for and notify the Pain Service if any of these symptoms or problems occur:
a. Epidural hematoma. May note pain, swelling at site, diffuse back pain, or sensory/motor
function changes.
b. Signs of infection tenderness, erythema, swelling, drainage, fever, changing neuro exam.
c. Catheter displacement. Migration of an epidural catheter into the subarachnoid space
(intrathecal) may cause sudden or slow increase in side effects such as increased
sedation, loss of sensory/motor function. The catheter may also migrate into blood
vessels, which may cause systemic side effects from the absorption of local anesthetic
such as dizziness, agitation, and seizures.
d. Displacement of dressing or presence of leakage of fluid from the site of from the catheter
itself: RNs should not change or reinforce dressings for inpatients with neuraxial catheters.
Notify the Pain Service to reinforce or change the dressing.
e. Catheter Disconnection: If the catheter becomes disconnected from the infusion tubing,
place a sterile syringe on end of catheter and immediately notify the Pain Service. (If an
intrathecal catheter is disconnected, clamp the catheter to avoid leakage of cerebrospinal
f. An increase in sedation score or decrease in respiratory rate as indicated by the
parameters ordered. Support the airway, and ventilate as necessary. Administer Naloxone
as ordered. Naloxone effectively reverses respiratory depression but is short acting.
Repeated doses may be necessary.
g. Spinal headache: classically severe when upright, reduced or eliminated when supine.
Contact the Pain Service for treatment including possible epidural blood patch.
h. Inadequate analgesia unrelieved by analgesic medication administration per orders.
i. Nausea/vomiting unrelieved by anti-emetics medication administration per orders.
j. Pruritus unrelieved by anti-pruritic medication administration per orders.
G. Suspected pump malfunction/ adverse patient event
i. In the event of a suspected pump malfunction or an adverse patient event possibly related to the
neuraxial infusion, the following steps should be followed:
a. Stop the infusion and notify the Pain Service.
b. Review patient history from the pump and document the current shift total and total dose
c. Document the contents and volume remaining in the infusion bag. The Pain Service may
send the bag to pharmacy if medication analysis is required.
d. After the Pain Service has assessed the patient, remove the pump from service and follow
the UWHC Policy, #12.40, Reporting of Device-Related Adverse Events & Other Product
Problems Policy.
H. Hold on Epidural/Intrathecal Therapy

Policy Title: Epidural and External or Non-Implanted Intrathecal (Neuraxial) Analgesia
Policy Number: 6.1.15

i. The Pain Service may write an order to "hold" an epidural or intrathecal infusion with the intention
to either restart the infusion at a later time once side effects have resolved or to evaluate if a patient
can tolerate alternative modes of analgesia before discontinuing a neuraxial catheter.
ii. If a "hold" or "stop neuraxial infusion" has been ordered the following actions are to be taken by the
nurse caring for the patient:
a. Turn off the infusion pump.
b. Do NOT disconnect tubing.
I. Discontinuation of the Epidural/Intrathecal Therapy and Catheter.
i. Occasionally coagulation abnormalities or anticoagulant/antiplatelet medication administration may
prevent or delay neuraxial catheter removal.
ii. Only the Pain Service may order the discontinuation of therapy and remove the catheter.
iii. The Pain Service will:
a. Document complete catheter removal.
b. Specify which medications are to be continued and which are to be discontinued, making
sure alternative analgesics are ordered and available for the patient.
c. Specify when anticoagulant/antiplatelet therapy can be restarted.
iv. After removal of the neuraxial catheter, the RN will:
a. Discard remaining drug in accordance with organizational waste management plans and
Hospital Administrative Policy 8.30-Controlled Substance Control Systems in Patient Care
Areas. Remaining solution should be discarded immediately to avoid inadvertent
b. Inspect the catheter site after removal. Notify the Pain Service of any evidence of
infection, back pain, bleeding, spinal headache, or CSF leakage at the site.
c. If the patient is to be discharged soon after the catheter is discontinued, instruct the
patient to have a family member or other support person assess the catheter site as noted
above. Instruct the patient and family to notify the Pain Service physician if problems or
questions arise concerning the site.
J. Patient Education
i. Patient and family teaching should be coordinated by the Registered Nurse throughout the patient's
hospital stay.
ii. Content for both epidural and intrathecal analgesia should include:
a. Use of pain rating scale.
b. Goals of therapy.
c. Method of administration, i.e., how the analgesia will be administered and how the patient
should trigger PCEA dose.
d. Potential complications including infection, hematoma, and side effects of medications.
e. Management of side effects.
f. Activity or bathing restrictions. No submerging or showering. Must keep dressing dry and
g. Patients who have had their catheter discontinued before discharge should be reminded
of the signs of epidural infections and hematoma.
iii. Patient and family education tools may include:
a. Health Fact for You #7345- Epidural-Common Questions and Our Answers
iv. Discharge of a Patient with Epidural or Intrathecal Catheter
a. Review patient discharge instructions, which may include, but are not limited to the
1. Activity or bathing restrictions.
2. Site care or wound care if applicable following discharge:
A. Home care RN to change dressing weekly and PRN if soiled or wet.
Carefully remove old dressing so as not to dislodge catheter. Cleanse
site with chlorhexidine or povidine iodine. After product dries may
optionally apply Skin Prep (protectant) to prevent adhesive irritation to
skin. Cover with Tegaderm.
3. Emergency numbers and clinic or home care follow-up contacts.
b. If the patient is discharged home on a continuing infusion, contact Chartwell at 831-8555
at least two days prior to discharge. They will arrange for a pump if they are an in-network
provider. If Chartwell is not an in-network provider, Chartwell will provide in-network
options to the referral source who can arrange for another Home Infusion vendor and/or

Policy Title: Epidural and External or Non-Implanted Intrathecal (Neuraxial) Analgesia
Policy Number: 6.1.15

continuing home health services as appropriate to the patient/family needs and insurance
K. Training and Education
i. Nursing, pharmacy and medical staff leadership are responsible for developing and maintaining
orientation information, training materials and competency assessments for their respective staff.
These educational materials shall review elements of competence in the care of epidural/intrathecal
systems and be consistent with this policy.
Units that Provide Care for Patients with Epidural or Intrathecal Catheter


Author: Pain Management Program Director, Anesthesiology
Senior Management Sponsor: VP, Professional Services
Reviewers: Drug Policy Analysts, Nursing Practice Innovations Pain Clinical Nurse Specialist; Professor,
School of Medicine and Public Health, Department of Anesthesiology
Approval committees: Nursing Patient Care Policy and Procedure Committee; Medication Safety Committee;
Pharmacy and Therapeutics Committee; UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: September 18, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.


Peter Newcomer, MD
Chief Clinical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee


UW Health Clinical Policy #2.3.32, Operative, Invasive, and Other Procedures
UWHC Policy # 8.33, High Alert Medication Administration
UWHC Policy #8.30, Controlled Substance Control Systems in Patient Care Areas
UWHC Policy #12.40, Reporting of Device-Related Adverse Events & Other Product Problems
UW Health Clinical Policy #3.5.5, Pain Management
UW Health Clinical Policy #4.1.8, Standard Precautions & Isolation
Nursing Departmental Patient Care Policy #14.33AP, Nurse to Nurse Change of Shift Hand-Off-Inpatient
(Adult and Pediatric)
Nursing Patient Care Policy and Procedure # 1.24, Alaris System (Adult and Pediatric)
Appendix 1
UWHC Hazardous Material and Waste Management Plan
UCMF Hazardous Material and Waste-Medical Waste Management Resources
Health Fact for You #7345- Epidural-Common Questions and Our Answers
Department of Anesthesiology Medication Policy
Intranet Pain Management Resource Site
Management of Antithrombotic Therapy in Periprocedural, Regional Anesthesia and/or Pain Procedure
Settings- Adult- Inpatient/Ambulatory
Medtronic patient information booklet "Ease of Pain, Ease of Mind" (SynchroMed Pumps)
Andreae MH, Andreae DA. Regional anaesthesia to prevent chronic pain after surgery: a Cochrane
systematic review and meta-analysis. Br J Anaesth. 2013;111(5):711-720.
Guay J, Kopp S. Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery.

Policy Title: Epidural and External or Non-Implanted Intrathecal (Neuraxial) Analgesia
Policy Number: 6.1.15

Cochrane Database Syst Rev. 2016;(1):CD005059. doi:10.1002/14651858.CD005059
Pasero C. Eksterowicz N, Primeau M, Cowley C. Registered nurse management and monitoring of
analgesia by catheter techniques: position statement. Pain Manag Nurs. 2007;8(2):48-54.
Rawal N. Epidural technique for postoperative pain: gold standard no more? Reg Anesth Pain Med.
Sawhney M. Epidural analgesia: what nurses need to know. Nursing. 2012;42(8):36-41.
Shi WZ, Miao YL, Yakoob MY, et al. Recovery of gastrointestinal function with thoracic epidural vs. systemic
analgesia following gastrointestinal surgery. Acta Anaesthesiol Scand. 2014;58(8):923-932.

Version: Revision
Last Full Review: October 20, 2017
Next Revision Due: October 2020
Formerly Known as: Hospital Administrative policy #8.92