Epidural analgesia for postoperative pain management Dr Michal Kluger MD, FRCA, FANZCA Department of Anaesthesiology & Pain Management North Shore Hospital

Overview Introduction Anatomy & Physiology of central neuraxial blocks Procedure Drugs Compications Problem solving Review of learning objectives

Learning objectives By the end of this seminar you should have an understanding of the following topics; The Anatomy & Physiology of central neuraxial blocks How an epidural is performed The drugs used for epidural anagesia Complications An approach to problem solving in the postoperative period.

Introduction What is the difference between spinal and epidural analgesia Name 3 physiological consequences of epidural analgesia on the ward List 3 important complications of epidural analgesia Name 3 drugs that can be put into the epidural space

A philosophical perspective

The Goals “..to provide a safe, effective pain management strategy that benefits patients AND which can be managed within our existing environment.. “

Why is it important for nursing staff? The therapies are medically initiated Analgesic modalities are high complex Some of these pain relieving options take up considerable nursing numbers So………………………….

Because…. “..the success of all postoperative pain management options are ENTIRELY related to the input of the nursing staff..”

Why? INTERFACE REACTIVE PROACTIVE TROUBLESHOOT MOTIVATION MANAGE

The 5th Vital sign

Drugs Local anaesthetics lignocaine bupivacaine ropivacaine levobupivacaine Others opioids morphine fentanyl 2 agonist clonidine anticholinesterase neostigmine Benzodiazepine midazolam

Securing catheters Tape standard specialised Sutured Tunnelled

Understanding the physiology of the block: why do patients get hypotensive

The Patient has a pain score of 8/10

The Patient’s blood pressure has dropped to 80/35 mmHg

Mr K who has had an epidural for 2/7 cannot move his legs at all

Mrs B who had a revision hip 3 days ago is complaining of severe back pain

Intrathecal / subarachnoid analgesia

Epidural analgesia: Historical perspectives Technical advances Germ theory of infection New drugs Koller 1880 Cocaine  eyes Halstead  brachial plexus block Bier 1899  spinal cocaine Einhorn 1904  procaine spinal Barker 1907  baricity changes Tetracaine 1931 Epidural 1940s Obstetrics 1960s Bupivacaine, Ropivacaine, LevoBupivacaine

Overview: learning objectives By the end of this seminar you should be able to: understand the physiological consequences of central neuraxial blockade understand the difference between epidural and subarachnoid analgesia understand the important complications understand and be able to respond to issues related to epidural analgesia Understand the importance in optimising analgesia in the perioperative period