Pediatrics : Epidural or Intrathecal

        • Epidural or Intrathecal
          • Involves catheter placed into epidural, caudal, or intrathecal space for continuous infusion or single or intermittent administration of opioid with or without a long-acting local anesthetic (e.g., bupivacaine, ropivacaine)
          • Analgesia primarily from drug’s direct effect on opioid receptors in spinal cord
          • Respiratory depression rare but may have slow and delayed onset; can be prevented by checking level of sedation and respiratory rate and depth hourly for initial 24 hours and decreasing dose when excessive sedation is detected
          • Nausea, itching, and urinary retention common dose-related side effects from the epidural opioid
          • Mild hypotension, urinary retention, and temporary motor or sensory deficits common unwanted effects of epidural local anesthetic
          • Catheter for urinary retention inserted during surgery to decrease trauma to child; if inserted when child is awake, anesthetize urethra with lidocaine
        • Patient-Controlled Analgesia
          • Patient controls the amount and frequency of the analgesic, which is typically delivered through a special infusion device. 
          • Children who are physically able to “push a button” (i.e., 5 to 6 years of age) and who can understand the concept of pushing a button to obtain pain relief can use PCA
          • PCA infusion devices typically allow for three methods or modes of drug administration to be used alone or in combination:
            • Patient-administered boluses that can be infused only according to the preset amount and lockout interval (time between doses).
              • More frequent attempts at self-administration may mean the patient needs the dose and time adjusted for better pain control.
            • Nurse-administered boluses that are typically used to give an initial loading dose to increase blood levels rapidly and to relieve breakthrough pain (pain not relieved with the usual programmed dose).
            • Continuous basal rate infusion that delivers a constant amount of analgesic and prevents pain from returning during those times, such as sleep, when the patient cannot control the infusion.
        • Epidural Analgesia
          • Although an epidural catheter can be inserted at any vertebral level, it is usually placed into the epidural space of the spinal column at the lumbar or caudal level
          • The thoracic level is usually reserved for older children or adolescents who have had an upper abdominal or thoracic procedure, such as a lung transplant. 
          • An opioid (usually fentanyl, hydromorphone, or preservative-free morphine, which is often combined with a long-acting local anesthetic, such as bupivacaine or ropivacaine) is instilled via single or intermittent bolus, continuous infusion, or patient-controlled epidural analgesia. 
          • Analgesia results from the drug’s effect on opiate receptors in the dorsal horn of the spinal cord, rather than the brain. 
          • As a result, respiratory depression is rare, but if it occurs, it develops slowly, typically 6 to 8 hours after administration.
          • Careful monitoring of sedation level and respiratory status is critical to prevent opioid-induced respiratory depression.
          • Assessment of pain and the skin condition around the catheter site are important aspects of nursing care.
        • Transmucosal and Transdermal Analgesia
          • Oral transmucosal fentanyl (Oralet) and intranasal fentanyl provides nontraumatic preoperative and preprocedural analgesia and sedation. 
          • Fentanyl is also available as a transdermal patch (Duragesic). 
          • Duragesic is contraindicated for acute pain management, but it may be used for older children and adolescents who have cancer pain or sickle cell pain or for patients who are opioid tolerant.
          • One of the most significant improvements in the ability to provide atraumatic care to children undergoing procedures is the anesthetic cream

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