Resource Manual for Anesthesiology Pain Service

Purpose:
To help streamline care for the patients admitted for pain management including
postoperative, post-traumatic, chronic and cancer pain. You should be aware that there is
also a Palliative Care Pain Service available in the hospital.
A resource for easy reference for the on-call team to effectively manage patients on the
pain service. These guidelines will be revised as necessary to improve its utilization.
Therefore, any comments and suggestions for improvement are welcome.
The Pain Faculty

Please direct comments to:

Stephen M. Breneman, MD, PhD
or
Rajbala Thakur,MD
Director,Pain Division
Box 604 or ext. 50464

TABLE OF CONTENTS

Postoperative Pain Management...3

Pre-operatively..4
Intra-operatively5
Post-operatively.6-7
Commonly Used Solutions for Epidural Infusions...8
General Practice.9
Special Situations..10
Most Common Epidural Floor Calls11
Other Pain Consults for Epidural Placements/Anticoagulation issues12
Intravenous Patient-controlled Analgesia(PCA)..13
Equianalgesic Opioid Conversion Guidelines..14-15
Appendix I. APS Consensus Recommendation: 9/30/9916
Appendix II.ASRA Consensus Statement on Anticoagulation
and Neuraxial Blockade 2002.. ..17-25
Appendix III: Pediatric Epidural Calculations Reference 25-28
Appendix IV: Sample Acute Pain Service Post-Op Admission Note 29
Appendix V: Notes on Notes30-31

Postoperative Pain Management:

Common procedures for which we should recommend Epidural Catheters include:
Total Knee Arthroplasty (incl revisions)
Total Hip Arthroplasty (incl revisions)
Extensive orthopedic procedures involving the lower body
Extensive urological procedures in both adults and pediatric patients
Gyn procedures esp.TAH, Radical hys.
Thoracotomies, esophagectomies
Living related liver donors
Other major abdominal procedures (Whipples, gastrectomies, A-P resections,
nephrectomies, open radical prostatectomies)
Peripheral Neural plexus blockade:
Single shot Brachial plexus blocks for ASC/SDA shoulder and A-V fistula surgeries
Single shot Brachial Plexus/Axillary blocks for more extensive hand surgeries
(tendon repair, wrist fusion)
Single shot Femoral nerve blocks for knee and hip surgeries
Single shot Sciatic/Popliteal blocks for extensive lower leg/foot surgeries, BKAs
We are commonly asked by plastics/ortho service to start brachial plexus catheters for
mostly traumatic re-implantations or other extensive surgical procedures. The
purpose is to provide analgesia and also a sympathectomy to optimize vascular
flow to the limb.
Continuous femoral sheath catheters for Total Knee Arthroplasty

Pre-operatively: (Generally placed by Regional Rotation Resident)

Optimal post-op pain management starts preoperatively with site-specific catheter
placement. For epidurals, these are spine interspaces which will cover the dermatomes
and referred patterns of pain associated with the incision and affected organs. For
continuous plexus blocks, this is placing the catheter high enough on the plexus to safely
cover the affected surgical area.
Documenting the length of catheter in the epidural space and at the skin helps in
adjusting the catheter postoperatively, especially in case of an uneven block.
Test dosing and documenting a sensory level before the start of surgery. This
documentation is important because it becomes very difficult and time consuming
postoperatively to assess the patient in the PACU especially when a combined epidural
and general anesthesia technique is used. It can delay starting the epidural infusions
postoperatively. If we are sure that the catheter is working we can confidently start the
infusion even in relatively sedated patients.

Intra-operatively: (OR resident,CRNA)

Whenever possible you should use the epidural catheter intraoperatively, using either
local anesthetics alone or in combination with opioids. You can always use epidural
opioids intraoperatively even in cases with big volume shifts instead of using i.v. opiods.
Preferably use lipophilic opioids (with few exceptions that will be mentioned later). At
our institution we mostly use Fentanyl at a dose of 50-100 mcg that can be repeated
every 4 hrs. Please consider diluting Fentanyl to a volume of 4-5 cc with either local
anesthetic or PF saline to increase the spread of effected dermatomes (esp. lumbar
epidural catheters).
With the use of relatively short acting opioids (as opposed to morphine) intraop you keep
your options open for choosing an appropriate epidural infusion postoperatively.
Whenever possible, use a continuous infusion of local anesthetic or dose the catheter at
the appropriate time so that patient is comfortable on emergence/arrival to PACU.
Few case scenarios where preservative- free morphine (Astromorph, Duramorph) is a
good choice:
If you are going to discontinue the catheter you can give a bolus of PF morphine before
pulling the catheter out.
If you do not have a site-specific catheter (e.g., a lumbar or a low caudal catheter for a
higher-level incision), you can give a bolus intraoperatively and a continuous morphine
infusion can be started postoperatively.
If patient is to remain intubated post-operatively or there is a significant EBL or the
patient is too sedated to use a fentanyl PCEA then a continuous PF morphine infusion
may be better

Post-operatively: (APS resident or fellow)

Assess the patient; A brief history including pre-op opioid use, intraop course especially
the blood loss, intravenous fluids, hemodynamic status. A brief exam including mental
status, vital signs, pain score, sensory levels whenever appropriate and a brief motor
exam. Formulate and implement your plan. You will need to enter orders electronically.
If patient is in pain you can use a variety of medications depending on your assessment.
You should always exclude other causes that could cause pain not related to your catheter
coverage and consider the addition of a IV PCA with continuous epidural. (Only one
button per patient.)
Situation 1:
Patient has an adequate sensory level covering the needed dermatomes yet still
experiencing pain.
You can use adjuvants.
Ketoralac IV 30mg. x1 and then 15 mg q6 hrs (not in allergic, gastritis, renal issues)
Tylenol PR 650mg q6 hrs (no liver failure; max daily dose 3 grams)
Bolus with 100mcg of fentanyl after aspirating the catheter. Assess in 5-10 minutes.
If good response, consider increasing concentration of fentanyl from 2 to 4mcg/ml or
switching to Dilaudid (12mcg/ml) in the epidural solution.
If no improvement in pain control, and catheter was used with local anesthestic
intraop then the catheter may have become dislodged in transferring patient.
Situation 2:
Patient has an inadequate sensory level.
Hemodynamic status can tolerate sympathectomy
Bolus with either 3-5ml of 1.5% lidocaine with epinephrine or 0.25% bupivacaine. Wait
for approximately 10 min. and reassess.
If patient is comfortable, you can start the infusion.
If not, try to establish that the catheter is functioning by an additional bolus with local
anesthetic to achieve an adequate sensory level, and go from there.
If level but limited after second bolus, consider more opiates for infusion.
If catheter is not functioning, you can present two options to the patient. You can
either replace the catheter or discontinue it and start the patient on IV PCA.
Situation 3:
Patient has a unilateral or an uneven block.
Compare the catheter depth with the procedure note.
If the catheter is at least 3 cms in the space, pull out the catheter by 1 cm if possible.
May need to bolus again to establish an adequate sensory level.

Situation 4:
Patient has no sensory level.
Compare the catheter depth with the procedure note.
Test dose the catheter. Ideally try to establish a level, assess the response and then start
the infusion.
Situation 5:
Patient gets a level or is comfortable after every bolus but 2-3 hrs later either looses the
level or starts hurting again.
You run into this problem few hours into the postop period. Dermatomal spread not wide
enough. Another possible explanation is that the tip of the catheter is barely or partially
in the epidural space.
Options:
Increase the volume of continuous and prn
Increase the volume and prn but decrease concentration if b.p. issues.
Replace fentanyl (2 mcg/cc) with Dilaudid (12mcg/cc) to get greater coverage of
dermatomes
Bolus the existing catheter with PF morphine (2ml) q12hrs.
Replace the catheter.
Discontinue the catheter and change to alternative analgesic regimen

Commonly Used Solutions for Epidural Infusions:

Most commonly we use a combination of local anesthetics and opioids. Pain division has
come up with these concentrations and combinations after years of experimenting with a
variety of infusions. We are always open to new suggestions and changes.
Different solutions are:
Local Anesthetics:
0.0625% bupivacaine --- mostly used in pediatric age group < 15 kg and
hemodynamically unstable adults.
0.1%bupivacaine
0.125% bupivacaine
0.25% bupivacaine--- Rarely used.
Opioids:
Fentanyl 2 mcg/mlin combination with local anesthetics
Fentanyl 20 mcg/ml for Fentanyl PCEA alone
Dilaudid 12 mcg/ml with or without local anesthetics
Morphine sulfate 0.1 mg/ml mostly used as a continuous infusion alone.
The pharmacy will make solutions with different concentrations eg. Local anesthetic(any
concentration) with 5mcg/ml or 10mcg/ml of Fentanyl in special circumstances.

General Practice
For a site-specific catheter (a catheter corresponding to the incision site):
If the patient can tolerate a sympathectomy, choose either 0.1% Bupivacaine or 0.125%
Bupivacaine with 2 mcg/ml of fentanyl in a PCEA mode @ 4-8 ml/hr continuous
infusion and 2-3 ml q 15 min prn. We usually avoid 0.125% or stronger concentration of
bupivacaine for patients with lumbar catheters and non-orthopedic procedures who will
be ambulating in the immediate postoperative period because of concern of a motor
block.
If the patient cannot tolerate a sympathectomy or has marginal volume status, you can
use fentanyl PCEA 20 mcg/ml @ 1.5 ml/hr. and 1.5 ml q 20 min prn bolus.
For a nonsite-specific catheter (low lumbar catheter for a thoracotomy or upper
abdominal surgery):
With local anesthetics, it is often difficult to get adequate coverage without causing a
significant motor weakness as well as strong sympathectomy. The best option then is to
use a hydrophilic agent e.g.
Loading Dose PF Morphine 2 to 5mg (verify not given in OR)
PF morphine (0.1mg/ml) as a continuous infusion @ 0.3-0.5 mg/hr or
PF morphine PCEA (0.1mg/ml) @ 0.3 mg/hr and 0.5mg q30 min. prn.
Loading Dose Dilaudid 0.5mg (verify not given in OR)
Dilaudid (12mcg/ml) 1 to 2mcg/kg/hr (average young adult)
Dilaudid PCEA (12mcg/ml) @ 8ml/hr with 4ml q20min prn
In both scenarios you can add a dilute local anesthetic ce.g. 0.0625% bupivacaine to the
PF morphine or Dilaudid infusion.
If not already ordered
Order adjuvants
ketorolac 30mg IV load with 15mg q6hr
Tylenol 975 PR q6hr or PO if appropriate for medical conditions
Celebrex 200mg BID PO x 3 days
Order antiemetic
Odansetron 4mg IV q8 hr prn
phenergan 6.25mg q6hr prn
Order breakthrough opiates
Dilaudid 0.5mg IV q20min max 2mg; call APS after 1mg given
morphine 2mg IV q20min max 10mg; call APS after 6mg given
Order stool softner
Order anti-puritic
Nubain 2.5mg IV Q6hr prn
Benadryl 12.5mg IV q6hr prn
Narcan 0.1mg IV q4hr prn

Special Situations:
Living, Related Liver Donors:
You can use 0.125% bupivacaine + fentanyl 2mcg/ml at 6-8 ml/hr+ 3cc q 15 min
(dosage & concentrations can be titrated depending on the patients condition) or IV
morphine or Dilaudid PCA (only PRN dosage)on the first day. A continuous infusion
can be added the 2nd postoperative day depending upon the patients requirements.
If the epidural catheter is providing only partial relief you can use continuous infusion of
plain local anesthetics through the epidural catheter with an IV opioid PCA.

Pediatric Patients:
In Pediatric patients we usually do either a one shot caudal (esp. for outpatient surgeries)
or place an indwelling catheter. Most anesthesiologists try to thread the catheter up so
that its tip is approximately at the incision site. It is recommended that you confirm the
tip site with contrast agent intra-operatively especially with a thoracic or high abdominal
incision. Same principles apply for the choice of infusion. The dosage calculation is as
follows:
Bupivacaine: See Appendix Peds epidural calculations.
Fentanyl - 1mcg/kg/hr.
PF morphine - bolus 50mcg/kg: infusion 10mcg/kg/hr max.( Max. dose 200 mcg/hr.)
Dilaudid - 1-4mcg/kg/hr.
Some Tips:
--Commonly we start with 2/3rd of the max dosage. If inadequate analgesia, bolus
with 2/3rd of the infusion rate/hr and then increase the infusion rate.
--Always write for rescue IV opioids: morphine IV 0.05-0.1mg/kg q1 hr prn.
--A PCEA mode can be used in children>6 yrs.
--Attached is a document for pediatric dose calculations.
Whenever in doubt, please check with the on-call pain attending!!

10

Most Common Epidural Floor Calls:

Mechanical problems with the infusion system
e.g. catheter disconnect, air alarms, pump alarms for occlusion or high-pressure etc.
Tips
Examine tubing from insertion site to pump for kinks or air.
Attempt to flush the catheter with normal saline and restart.
**Always make sure that the sterility of the system is maintained.
If these simple measures dont work, you may need to have the nurse get a new pump or
infusion cassette.
Inadequate Analgesia:
Whenever you are called for inadequate analgesia by the floor staff, our priority is to
make the patient comfortable in a safe way as quickly as possible.
Tips
Assess the patient and go through APS Epidural Scenarios 1-5
Either increase or change the running infusion appropriately.
Make sure the patient is comfortable after your intervention.
Write a dated and timed short note documenting your intervention and its effect.
Make Nursing aware of what you did and leave instructions to monitor the patient
appropriately. Most commonly it is monitoring vitals q 15 min. x 4.
If for some reason you cannot go up immediately, make sure to give some verbal orders
to the nurse for systemic analgesics as a temporizing measure. Ask the nurse what she/he
feels comfortable giving the patient until you can arrive. Call your colleagues or
attending if you anticipate a delay of greater than 30 min.
Side-Effects:
Most common side effects are uncomfortable sensory motor symptoms, hypotension,
pruritus, nausea, sedation, urinary retention and ileus.
Hypotension/Sensory Motor Symptoms:
Rule out any cause other than the epidural local anesthetics.
Evaluate fluid status (Is,Os, urine color, oral dryness).
Can change to an opioid infusion or reduce the dose of local anesthetics.
Make sure to follow-up until the problem resolves.
Pruritus, Nausea, and Sedation:
Not uncommon because of opioids
Decrease the dose if possible
If severe take the opioid out of the infusion; change to plain local anesthetics.
Symptomatic treatment with Benadryl, Nubain or low-dose narcan gtt.

11

Other Pain Consults for Epidural Placements:

For post-trauma patients: thoracic epidural for multiple rib fractures.
Evaluate the patient. Beside the usual contraindications, look for a c-spine evaluation.
If it is unilateral rib fractures and an epidural is relatively contraindicated alternatives
include an intrapleural catheter or IV PCA.
For vascular patients and cancer pain patient
Evaluate the patient. Beside the usual contraindications, be aware of inadequate
coags, platelet agents and any systemic infection not covered by antibiotics.
An outpatient pain patient with a continuous epidural coming to the ED.
Same type of evaluative and treatment protocol as above. Tunneled catheters that
are not functioning properly can initially be replaced with regular epidural
catheters. Any questions call the pain call fellow/attending after assessing the
patient.
Anticoagulation Issues:
**Do not insert or remove a catheter if there is any concern about the coagulation status
of a patient. Contact pain attending.
In General:
--Patient should be off low molecular weight heparin for at least 12-24 hrs. So you
ask the surgical service to hold the nighttime and the subsequent morning dose for
a procedure the following morning.
--if a patient is on Heparin drip, it should be held for at least 4 hours. (5 half lives)
--hold off on inserting or removing a catheter if a patients INR is >1.5
--heparin or LMWH can be restarted 2 hours after the procedure.
-- Be cautious in living, related liver donors, as these patients commonly develop
temporary coagulopathies in the post-operative period.
--if patient is on antiplatelet agents/herbal medicines, review the ASRA Consensus
Guidelines.
--subcutaneous heparin is not an issue unless it has affected the platelets (H.I.T.)
##See attached ASRA Consensus Statement.
Discontinuing an Epidural:
Whenever we discontinue an epidural, we should make sure an adequate alternative
analgesic regimen is ordered (e.g, IV PCA or oral opioids (percocet 1-2 tabs PO q4-6
hrs) and/or NSAIDs.

12

INTRAVENOUS PATIENT CONTROLLED ANALGESIA

DOSING GUIDELINES
Dosing guidelines must be adjusted to clinical response
* indicates need for bedside monitoring by physician/NP for loading dose administration
Fentanyl PCA infusions may be used in ICU and with terminal pts.
Morphine
Concentration
& Availability

Dosing
Guidelines
Adults &
children
>50kg

Dosing
Guideline

Pediatrics
& Adults
<50kg

Side Effects
Suggested
Adult
Antidotes

Hydromorphone

5mg/ml conc.
30cc bag prepared by pharm.
Loading dose:*
0.1mg-0.2mg/kg in 5 divided
doses Q5min apart.
Maintenance dosing:
1mg Q5-15min PCA, with or
without infusion of 1-2mg/hr
Dose adjustments usually made in
0.5-1mg increments

1mg/ml conc.
Bag prepared by pharm.
Loading dose:*
0.02-0.04mg/kg in 5
divided doses Q5mg
apart.
Maintenance dosing:
0.2mg Q5-15min PCA,
with or without basal
infusion of 0.20.4mg/hr.
Dose adjustments
usually made in 0.10.2mg increments
Loading dose:*
Loading dose:*
0.05-0.1mg/kg in 5 divided doses 0.01-0.02mg/kg in 5
Q5min apart.
divided doses Q5min
Maintenance dosing:
apart.
0.02mg/kg/hr basal with
Maintenance dosing:
0.008mg/kg intermittent dose at
0.004mg/kg/hr basal
Q5-15min at 1hr lockout
with 0.0015mg/kg
PCA only:
intermittent dose at Q50.01mg/kg Q5-15min with
15min. at 1 hr lockout.
PCA only:
1 hour lockout of
0.002mg/kg Q5-15min
0.05-0.12mg/kg depending on
dosage
with 1 hr lockout of
0.01-0.024mg/kg
depending on dosage
Respiratory depression, sedation, nausea/vomiting urinary
retention, constipation, sweating, itching, miosis
-Respiratory depression & oversedation:
naloxone 0.1-0.2mg IVP PRN
-Nausea & vomiting:
antiemetics eg prochlorperazine 10mg PO/IV Q6hr
PRN
-Constipation:
stimulant laxatives with or without stool softener
-Itching: diphenhydramine 25mg PO/IVP Q4hr PRN
-Muscle rigidity: naloxone 0.1-0.2 IVP PRN

13

Fentanyl
20mcg/ml
Bag prepared by pharm.
Loading dose:*
1-2mcg/kg in 5 divided
doses Q5 min apart.
Maintenance dosing:
10mcg Q5-15 min PCA
with or without basal
infusion of 1020mcg/hr. Dosage
adjustments are usually
made in 10-20mcg
increments.
Loading dose:
0.5-1mcg/kg in 5
divided doses Q5min
apart.
Maintenance dosing:
0.2mcg/kg/hr basal with
0.1mcg/kg intermittent
dose Q5-15min;
1mcg/kg at 1hr lockout.
PCA only:
0.1mcg/kg Q5-15ming
with 1 hr lockout of 11.2mcg/kg

Equianalgesic Dose Ratios for Opioids

IV mg
morphine

10

ORAL mg
ratios
< 1:3 >

ratio 1:5
hydromorphone

30
ratio 1:7.5

< 1:2 > #

(20)
different ratio
due to difference
in bioavailability
vs. just potency
with IV

(3)

methadone

oxycodone

20

fentanyl (patch)

(PR mg)

(chronic)

50-100mcg/hr*

NOTES:

When changing from one opioid to another or changing the route of administration
consider reducing the dosage by 30-40% to account for differences in opioid receptor
cross reactivity

* FENTANYL PATCH: For conversion may need to calculate oral per day equivalent
i.e. 200 mg/day (or 8.3 mg/hr)of morphine = 50-100 mcg/hr of Fentanyl Patch; 1mcg/hr
fentanyl = 2mg/day morphine
o

Allow for 6-8 hours of rescue medication when starting a transdermal fentanyl patch.

When converting from/to METHADONE: Confirm dose calculations with your

attending

An effective prn dose should be at least 10-20% of the daily dosage; made available on a
q3-4hr dosage depending on the opioid used.

When writing an IV PCA, a continuous infusion rate should be no more than 20-30% of
the total hourly amount made available to the patient

Consider increasing the dose of opioid medications by increments of 20-30%.

#### This conversion chart & notes are guidelines. Treatment needs to be
individualized in different situations. Controversy exists with many conversions. It
is prudent to start with a conservative conversion and titrate.

14

References:
Pereira, J et al. Equanalgesic Dose Ratios for Opioids. J. Pain & Symptom
Management. 22: August 2001. pg. 672-687
# Vallner, JJ et al. Pharmacokinetics & Bioavailability of Hydromorphone

Following IV & Oral Administration to Human Subjects. J Clin Pharmacol. 21:

1981. 152-156
# Parab PV et al. Pharmacokinetics of Hydromorphone after IV, Oral & Rectal

Admin. to Human Subjects. Biopharmaceutics & Drug Disposition. 9: 1988.187199

15

APPENDIX I

APS Consensus Recommendation

9/30/99
Adult Surgical Patients Designated for Postoperative Admission to APS
Epidural Needle Insertion and Catheter Placement:
Location:
Goal: closest to site of incision,1,2 i.e.:
lower extremity lumbar
low abdominal low thoracic, T10-12
high abdominal/thoracic high thoracic, T5-7
Facilitates flexibility in choice of therapy between local versus opioids; should
optimize analgesic efficacy, and minimize undesired side effects.
balancing ease of placement
no evidence of increased incidence of complications;3
(APS available for placement assistance*)
Distance:
threaded preferably 3, no more than 4 cm4,5

B. Mankikian, Improvement of Diaphragmatic Function by a Thoracic Extradural Block After Upper

Abdominal Surgery, Anes. 68:379-386, 1988
2
S. S. Liu, Effects of Perioperative Analgesic Technique on Rate of Recovery after Colon Surgery, Anes.
83:757-765, 1995
3
K. Tanaka, Extensive Application of Epidural Anesthesia and Analgesia in a University Hospital:
Incidence of Complications Related to Technique, Regional Anes. 18:34-38, 1993
4
D. Gozal, Removal of Knotted Epidural Catheters: Case Reports, Regional Anes. 21(1)71-73, 1996
5
D. G. Halpenny, Transforaminal escape of a lumbar epidural catheter, Can J Anaesth:39(6)594-5

16

APPENDIX II
CONSENSUS STATEMENTS
Second Consensus Conference on Neuraxial Anesthesia and Anticoagulation
April 25-28, 2002
Regional Anesthesia in the Anticoagulated Patient: Defining the Risks - TOP
Introduction
Numerous studies have documented the safety of neuraxial anesthesia and analgesia in the
anticoagulated patient. Patient management is based on appropriate timing of needle
placement and catheter removal relative to the timing of anticoagulant drug administration.
Familiarity with the pharmacology of hemostasis-altering drugs, the clinical studies involving
patients undergoing neuraxial blockade while receiving these medications, as well as the case
reports of spinal hematoma will guide the clinician in management decisions.
New challenges in the management of the anticoagulated patient undergoing neuraxial
blockade have arisen as medical standards for the prevention of perioperative venous
thromboembolism were established. Likewise, as more efficacious anticoagulants and
antiplatelet agents have been introduced, patient management has become more complex. In
response to these patient safety issues, the American Society of Regional Anesthesia and Pain
Medicine convened its Second Consensus Conference on Neuraxial Anesthesia and
Anticoagulation. It is important to note that although the consensus statements are based on
a thorough evaluation of the available information, in some cases, data are sparse. Variances
from recommendations contained in this document may be acceptable based on the judgment
of the responsible anesthesiologist. The consensus statements are designed to encourage safe
and quality patient care, but cannot guarantee a specific outcome. They are also subject to
timely revision as justified by evolution of information and practice. Finally, the current
information focuses on neuraxial blocks and anticoagulants; the risk following plexus and
peripheral techniques remains undefined. Conservatively, the Consensus Statements on
Neuraxial Anesthesia and Anticoagulation may be applied to plexus and peripheral techniques.
However, this may be more restrictive than necessary.
The original manuscript developed from the Consensus Conference held during the Annual
Spring Meeting on Regional Anesthesia, April 25-28, 2002 in Chicago, Illinois is published in
the May 2003 issue of Regional Anesthesia and Pain Medicine (Reg Anesth Pain Med
2003;28:172-97) . The full-length document, used in conjunction with these abridged
consensus statements, provides the necessary background to a more complete understanding
of the clinical issues discussed at the Consensus Conference.

Regional Anesthesia in the Anticoagulated Patient - TOP

Anesthetic Management of the Patient Receiving Thrombolytic Therapy
Patients receiving fibrinolytic/thrombolytic medications are at risk of serious hemorrhagic
events, particularly those who have undergone an invasive procedure. Consensus statements
are based on the profound effect on hemostasis, the use of concomitant heparin and/or
antiplatelet agents (which further increase the risk of bleeding), and the potential for
spontaneous neuraxial bleeding with these medications.

17

1.
Advances in fibrinolytic/ thrombolytic therapy have been associated with an increased
use of these drugs, which will require further increases in vigilance. Ideally, the patient
should be queried prior to the thrombolytic therapy for a recent history of lumbar
puncture, spinal or epidural anesthesia, or epidural steroid injection to allow
appropriate monitoring. Guidelines detailing original contraindications for thrombolytic
drugs suggest avoidance of these drugs for 10 days following puncture of
noncompressible vessels.
2.

Preoperative evaluation should determine whether fibrinolytic or thrombolytic drugs

have been used preoperatively, or have the likelihood of being used intraoperatively or
postoperatively. Patients receiving fibrinolytic and thrombolytic drugs should be
cautioned against receiving spinal or epidural anesthetics except in highly unusual
circumstances. Data are not available to clearly outline the length of time neuraxial
puncture should be avoided after discontinuation of these drugs.

3.

In those patients who have received neuraxial blocks at or near the time of fibrinolytic
and thrombolytic therapy, neurological monitoring should be continued for an
appropriate interval. It may be that the interval of monitoring should not be more than
two hours between neurologic checks. Furthermore, if neuraxial blocks have been
combined with fibrinolytic and thrombolytic therapy and ongoing epidural catheter
infusion, the infusion should be limited to drugs minimizing sensory and motor block to
facilitate assessment of neurologic function.

4.

There is no definitive recommendation for removal of neuraxial catheters in patients

who unexpectedly receive fibrinolytic and thrombolytic therapy during a neuraxial
catheter infusion. The measurement of fibrinogen level (one of the last clotting factors
to recover) may be helpful in making a decision about catheter removal or
maintenance.

Regional Anesthesia in the Anticoagulated Patient - TOP

Anesthetic Management of the Patient Receiving Unfractionated Heparin
Anesthetic management of the heparinized patient was established over two decades ago.
Initial recommendations have been supported by in-depth reviews of case series, case reports
of spinal hematoma and the ASA Closed Claims Project.
1.

During subcutaneous (mini-dose) prophylaxis there is no contraindication to the use of

neuraxial techniques. The risk of neuraxial bleeding may be reduced by delay of the
heparin injection until after the block, and may be increased in debilitated patients
after prolonged therapy. Since heparin-induced thrombocytopenia may occur during
heparin administration, patients receiving heparin for greater than four days should
have a platelet count assessed prior to neuraxial block and catheter removal.

2.

Combining neuraxial techniques with intraoperative anticoagulation with heparin

during vascular surgery seems acceptable with the following cautions:
a.

Avoid the technique in patients with other coagulopathies.

18

b.

Heparin administration should be delayed for 1 hour after needle placement.

c.

Indwelling neuraxial catheters should be removed 2-4 hours after the last
heparin dose and the patient's coagulation status is evaluated; reheparinization should occur one hour after catheter removal.

3.

d.

Monitor the patient postoperatively to provide early detection of motor

blockade and consider use of minimal concentration of local anesthetics to
enhance the early detection of a spinal hematoma.

e.

Although the occurrence of a bloody or difficult neuraxial needle placement

may increase risk, there are no data to support mandatory cancellation of a
case. Direct communication with the surgeon and a specific risk-benefit
decision about proceeding in each case is warranted.

Currently, insufficient data and experience are available to determine if the risk of
neuraxial hematoma is increased when combining neuraxial techniques with the full
anticoagulation of cardiac surgery. Postoperative monitoring of neurologic function and
selection of neuraxial solutions that minimize sensory and motor block is
recommended to facilitate detection of new/progressive neurodeficits.

4.

The concurrent use of medications that affect other components of the clotting
mechanisms may increase the risk of bleeding complications for patients receiving
standard heparin. These medications include antiplatelet medications, LMWH and oral
anticoagulants.

Regional Anesthesia in the Anticoagulated Patient - TOP

Anesthetic Management of the Patient Receiving Low Molecular Weight Heparin
(LMWH)
Anesthesiologists in North America can draw on the extensive European experience to develop
practice guidelines for the management of patients undergoing spinal and epidural blocks
while receiving perioperative LMWH. All consensus statements contained herein respect the
labeled dosing regimens of LMWH as established by the FDA. Although it is impossible to
devise recommendations that will completely eliminate the risk of spinal hematoma, previous
consensus recommendations have appeared to improve outcome. Concern remains for higher
dose applications, where sustained therapeutic levels of anticoagulation are present.
1.

Monitoring of the anti-Xa level is not recommended. The anti-Xa level is not predictive
of the risk of bleeding and is, therefore, not helpful in the management of patients
undergoing neuraxial blocks.

2.

Antiplatelet or oral anticoagulant medications administered in combination with LMWH

may increase the risk of spinal hematoma. Concomitant administration of medications
affecting hemostasis, such as antiplatelet drugs, standard heparin, or dextran
represents an additional risk of hemorrhagic complications perioperatively, including
spinal hematoma. Education of the entire patient care team is necessary to avoid
potentiation of the anticoagulant effects.

19

3.

The presence of blood during needle and catheter placement does not necessitate
postponement of surgery. However, initiation of LMWH therapy in this setting should
be delayed for 24 hours postoperatively. Traumatic needle or catheter placement may
signify an increased risk of spinal hematoma, and it is recommended that this
consideration be discussed with the surgeon.

4.

Preoperative LMWH
a.

Patients on preoperative LMWH thromboprophylaxis can be assumed to have

altered coagulation. In these patients needle placement should occur at least
10-12 hours after the LMWH dose.

b.

Patients receiving higher (treatment) doses of LMWH, such as enoxaparin 1

mg/kg every 12 hours, enoxaparin 1.5 mg/kg daily, dalteparin 120 U/kg every
12 hours, dalteparin 200 U/kg daily, or tinzaparin 175 U/kg daily will require
delays of at least 24 hours to assure normal hemostasis at the time of needle
insertion.

c.

5.

Neuraxial techniques should be avoided in patients administered a dose of

LMWH two hours preoperatively (general surgery patients), because needle
placement would occur during peak anticoagulant activity.

Postoperative LMWH
Patients with postoperative initiation of LMWH thromboprophylaxis may safely undergo
single-injection and continuous catheter techniques. Management is based on total
daily dose, timing of the first postoperative dose and dosing schedule.
Twice daily dosing. This dosage regimen may be associated with an increased risk of
spinal hematoma. The first dose of LMWH should be administered no earlier than 24
hours postoperatively, regardless of anesthetic technique, and only in the presence of
adequate (surgical) hemostasis. Indwelling catheters should be removed prior to
initiation of LMWH thromboprophylaxis. If a continuous technique is selected, the
epidural catheter may be left indwelling overnight and removed the following day, with
the first dose of LMWH administered at least two hours after catheter removal.
a.

Single daily dosing. This dosing regimen approximates the European

application. The first postoperative LMWH dose should be administered 6-8
hours postoperatively. The second postoperative dose should occur no sooner
than 24 hours after the first dose. Indwelling neuraxial catheters may be
safely maintained. However, the catheter should be removed a minimum of
10-12 hours after the last dose of LMWH. Subsequent LMWH dosing should
occur a minimum of 2 hours after catheter removal.

Regional Anesthesia in the Anticoagulated Patient - TOP

Regional Anesthetic Management of the Patient on Oral Anticoagulants
The management of patients receiving warfarin perioperatively remains controversial.
Consensus statements are based on warfarin pharmacology, the clinical relevance of vitamin K

20

coagulation factor levels/deficiencies, and the case reports of spinal hematoma among these
patients.
1.

Caution should be used when performing neuraxial techniques in patients recently

discontinued from chronic warfarin therapy. The anticoagulant therapy must be
stopped, (ideally 4-5 days prior to the planned procedure) and the PT/INR measured
prior to initiation of neuraxial block. Early after discontinuation of warfarin therapy, the
PT/INR reflect predominantly factor VII levels, and in spite of acceptable factor VII
levels, factors II and X levels may not be adequate for normal hemostasis. Adequate
levels of II, VII, IX, and X may not be present until the PT/INT is within normal limits.

2.

The concurrent use of medications that affect other components of the clotting
mechanisms may increase the risk of bleeding complications for patients receiving oral
anticoagulants, and do so without influencing the PT/INR. These medications include
aspirin and other NSAIDs, ticlopidine and clopidogrel, unfractionated heparin and
LMWH.

3.

For patients receiving an initial dose of warfarin prior to surgery, the PT/INR should be
checked prior to neuraxial block if the first dose was given more than 24 hours earlier,
or a second dose of oral anticoagulant has been administered.

4.

Patients receiving low dose warfarin therapy during epidural analgesia should have
their PT/INR monitored on a daily basis, and checked before catheter removal, if initial
doses of warfarin are administered more than 36 hours preoperatively. Initial studies
evaluating the safety of epidural analgesia in association with oral anticoagulation
utilized mean daily doses of approximately 5 mg of warfarin. Higher dose warfarin may
require more intensive monitoring of the coagulation status.

5.

As thromboprophylaxis with warfarin is initiated, neuraxial catheters should be

removed when the INR is <1.5. This value was derived from studies correlating
hemostasis with clotting factor activity levels greater than 40%.

6.

Neurologic testing of sensory and motor function should be performed routinely during
epidural analgesia for patients on warfarin therapy. The type of analgesic solution
should be tailored to minimize the degree of sensory and motor blockade. These
checks should be continued after catheter removal for at least 24 hours, and longer if
the INR was greater than 1.5 at the time of catheter removal.

7.

An INR > 3 should prompt the physician to withhold or reduce the warfarin dose in
patients with indwelling neuraxial catheters. We can make no definitive
recommendation for removal of neuraxial catheters in patients with therapeutic levels
of anticoagulation during neuraxial catheter infusion.

8.

Reduced doses of warfarin should be given to patients who are likely to have an
enhanced response to the drug.

21

Regional Anesthesia in the Anticoagulated Patient - TOP

Anesthetic Management of the Patient Receiving Antiplatelet Medications
Antiplatelet medications, including NSAIDs, thienopyridine derivatives (ticlopidine and
clopidogrel) and platelet GP IIb/IIIa antagonists (abciximab, eptifibatide, tirofiban) exert
diverse effects on platelet function. The pharmacologic differences make it impossible to
extrapolate between the groups of drugs regarding the practice of neuraxial techniques.
1.

There is no wholly accepted test, including the bleeding time, which will guide
antiplatelet therapy. Careful preoperative assessment of the patient to identify
alterations of health that might contribute to bleeding is crucial. These conditions
include a history of easy bruisability/excessive bleeding, female gender, and increased
age.

2.

NSAIDs appear to represent no added significant risk for the development of spinal
hematoma in patients having epidural or spinal anesthesia. The use of NSAIDs alone
does not create a level of risk that will interfere with the performance of neuraxial
blocks.

3.

At this time, there do not seem to be specific concerns as to the timing of single-shot
or catheter techniques in relationship to the dosing of NSAIDs, postoperative
monitoring, or the timing of neuraxial catheter removal.

4.

The actual risk of spinal hematoma with ticlopidine and clopidogrel and the GP IIb/IIIa
antagonists is unknown. Consensus management is based on labeling precautions and
the surgical, interventional cardiology/radiology experience.

a.

Based on labeling and surgical reviews, the suggested time interval between
discontinuation of thienopyridine therapy and neuraxial blockade is 14 days for
ticlopidine and 7 days for clopidogrel.
b.

Platelet GP IIb/IIIa inhibitors exert a profound effect on platelet aggregation.

Following administration, the time to normal platelet aggregation is 24-48
hours for abciximab and 4-8 hours for eptifibatide and tirofiban. Neuraxial
techniques should be avoided until platelet function has recovered. GP IIb/IIIa
antagonists are contraindicated within four weeks of surgery. Should one be
administered in the postoperative period (following a neuraxial technique), the
patient should be carefully monitored neurologically.

5.

The concurrent use of other medications affecting clotting mechanisms, such as oral
anticoagulants, unfractionated heparin, and LMWH, may increase the risk of bleeding
complications. Cyclooxygenase-2 inhibitors have minimal effect on platelet function
and should be considered in patients who require anti-inflammatory therapy in the
presence of anticoagulation.

22

Regional Anesthesia in the Anticoagulated Patient - TOP

Anesthetic Management of the Patient Receiving Herbal Therapy
Herbal drugs, by themselves, appear to represent no added significant risk for the
development of spinal hematoma in patients having epidural or spinal anesthesia. This is an
important observation since it is likely that a significant number of our surgical patients utilize
alternative medications preoperatively and perhaps during their postoperative course.
1.

The use of herbal medications alone does not create a level of risk that will interfere
with the performance of neuraxial blocks. Mandatory discontinuation of these
medications, or cancellation of surgery in patients in whom these medications have
been continued, is not supported by available data.

2.

Data on the combination of herbal therapy with other forms of anticoagulation are
lacking. However, the concurrent use of other medications affecting clotting
mechanisms, such as oral anticoagulants or heparin, may increase the risk of bleeding
complications in these patients.

3.

There is no wholly accepted test to assess adequacy of hemostasis in the patient

reporting preoperative herbal medications.

4.

At this time, there do not seem to be specific concerns as to the timing of neuraxial
block in relationship to the dosing of herbal therapy, postoperative monitoring, or the
timing of neuraxial catheter removal.

Regional Anesthesia in the Anticoagulated Patient - TOP

New Anticoagulants (Direct Thrombin Inhibitors and Fondaparinux)
New antithrombotic drugs which target various steps in the hemostatic system, such as
inhibiting platelet aggregation, blocking coagulation factors, or enhancing fibrinolysis are
continually under development. The most extensively studied are antagonists of specific
platelet receptors and direct thrombin inhibitors. Many of these antithrombotic agents have
prolonged half-lives and are difficult to reverse without administration of blood components.
Thrombin Inhibitors
Recombinant hirudin derivatives, including desirudin, lepirudin, and bivalirudin inhibit both
free and clot-bound thrombin. Argatroban, an L-arginine derivative, has a similar mechanism
of action. Although there are no case reports of spinal hematoma related to neuraxial
anesthesia among patients who have received a thrombin inhibitor, spontaneous intracranial
bleeding has been reported. Due to the lack of information available, no statement regarding
risk assessment and patient management can be made. Identification of interventional cardiac
and surgical risk factors associated with bleeding following invasive procedures may be
helpful.
Fondaparinux
Fondaparinux produces its antithrombotic effect through factor Xa inhibition. The FDA released
fondaparinux with a black box warning similar to that of the LMWHs and heparinoids. The

23

actual risk of spinal hematoma with fondaparinux is unknown. Consensus statements are
based on the sustained and irreversible antithrombotic effect, early postoperative dosing, and
the spinal hematoma reported during initial clinical trials. Close monitoring of the surgical
literature for risk factors associated with surgical bleeding may be helpful in risk assessment
and patient management.
1.

Until further clinical experience is available, performance of neuraxial techniques

should occur under conditions utilized in clinical trials (single needle pass, atraumatic
needle placement, avoidance of indwelling neuraxial catheters). If this is not feasible,
an alternate method of prophylaxis should be considered.

Regional Anesthesia in the Anticoagulated Patient - TOP

Summary
Practice guidelines or recommendations summarize evidence-based reviews. However, the
rarity of spinal hematoma defies a prospective-randomized study, and there is no current
laboratory model. As a result, these consensus statements represent the collective experience
of recognized experts in the field of neuraxial anesthesia and anticoagulation. They are based
on case reports, clinical series, pharmacology, hematology, and risk factors for surgical
bleeding. An understanding of the complexity of this issue is essential to patient management;
a "cookbook" approach is not appropriate. Rather, the decision to perform spinal or epidural
anesthesia/analgesia and the timing of catheter removal in a patient receiving antithrombotic
therapy should be made on an individual basis, weighing the small, though definite risk of
spinal hematoma with the benefits of regional anesthesia for a specific patient. Alternative
anesthetic and analgesic techniques exist for patients considered an unacceptable risk. The
patient's coagulation status should be optimized at the time of spinal or epidural
needle/catheter placement, and the level of anticoagulation must be carefully monitored
during the period of epidural catheterization. Indwelling catheters should not be removed in
the presence of therapeutic anticoagulation, as this appears to significantly increase the risk of
spinal hematoma. It must also be remembered that identification of risk factors and
establishment of guidelines will not completely eliminate the complication of spinal hematoma.
Vigilance in monitoring is critical to allow early evaluation of neurologic dysfunction and
prompt intervention. We must focus not only on the prevention of spinal hematoma, but also
optimization of neurologic outcome.
References- TOP
Horlocker TT. Wedel DJ. Benzon H. Brown DL. Enneking FK. Heit JA. Mulroy MF. Rosenquist
RW. Rowlingson J. Tryba M. Yuan CS. Regional anesthesia in the anticoagulated patient:
defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and
Anticoagulation).Regional Anesthesia & Pain Medicine. 28(3):172-97, 2003 May-Jun.

24

APPENDIX III

Pediatric Epidural/Caudal Calculations Reference

These standards apply to all children and adults < 40 kg.
Infants < 1year of age must be approved by Acute Pain Service Attending

Morphine 0.1 mg/ml (100 mcg/ml)

Load:

50 mcg/kg

Infusion:

5-10 mcg/kg/hr

Max infusion rate 10 mcg/kg/hr (Max dose 200 mcg/hr)

Hydromorphone (Dilaudid) 12 mcg/ml

Load:
Infusion:

5-7 mcg/kg.
1-4 mcg/kg/hr (Can increase to 6 mcg/kg/hr-with permission from Acute Pain
Service or Pediatric Anesthesia)
*Note: a more dilute concentration maybe requested for infants weighing <10kg

Fentanyl 1 mcg/ml
Load:

0.5 1 mcg/kg

Infusion:

1 mcg/kg/hr (Max Dose)

Bupivacaine (various concentrations)

Age < 4 months: (0.0625 to 0.1%)
0.1 0.3 ml/kg/hr (Max dose 0.2 mg/kg/hr)
Age > 4 months: (0.0625 to 0.1%) may use 0.125% to 0.25% for >10kg
0.1 0.7 ml/kg/hr (Max dose 0.5 mg/kg/hr)
BUPIVACAINE Max Dose if < 4 months old = 0.2 mg/kg/hr
0.2 mg/kg/hr * wt(kg) = mg/hr divided by (% solution) divided by 10 = ml/hr (MAX)
*Should be no more than 2.5 ml/hr (usually 0.8-1.5 ml/hr)
BUPIVACAINE Max Dose if > 4 months old = 0.5 mg/kg/hr
0.5 mg/kg/hr * wt(kg) = mg/hr divided by (% solution) divided by 10 = ml/hr (MAX)
FENTANYL Max Dose = 1 mcg/kg/hr
1 mcg/kg/hr * wt (kg) = mcg/hr divided by 2 mcg/ml = ml/hr (MAX)
*Fentanyl may limit the rate of infusion if 0.0625% bupivicaine is used.
HYDROMORPHONE Max Dose = 4 mcg/kg/hr
4 mcg/kg/hr * wt (kg) = mcg/hr divided by 12 mcg/ml = ml/hr (MAX)
*May increase to 6 mcg/kg/hr with APS/Peds Anesthesia approval
*If opioids are mixed with bupivicaine, use max dose for bupivicaine

25

Bupivacaine 0.0625% with Fentanyl 2 mcg/ml

(Bupivacaine 0.0625% = Bupivacaine 0.625 mg/ml)
Age < 4 months:
Example:

3 kg neonate

Bupivacaine

0.1 0.2 ml/kg/hr (Max dose 0.2 mg/kg/hr)

0.2 mg/kg/hr x 3 kg = 0.6 mg/hr (Max dose)
0.6 mg/hr
0.625 mg/ml = 0.96 ml/hr (Max rate)

Fentanyl

1 mcg/kg/hr x 3 kg = 3 mcg/hr (Max dose)

3 mcg/hr
2 mcg/ml = 1.5 ml/hr (Max rate)

Note: In this example, the max infusion rate is determined by Bupivacaine (0.96 ml/hr) not Fentanyl
(1.5 ml/hr)
Age > 4 months:
Example:
Bupivacaine

10 kg child
0.1 0.5 ml/kg/hr (Max dose 0.5 mg/kg/hr)
0.5 mg/kg/hr x 20 kg = 10 mg/hr (Max dose)
10 mg/hr
0.625mg/ml = 8 ml/hr (Max rate)

Fentanyl

1 mcg/kg/hr x 10 kg = 10 mcg/hr (Max dose)

10 mcg/hr
2 mcg/ml = 5 ml/hr (Max rate)

Note: In this example, the max infusion rate is determined by Fentanyl (5ml/hr) not Bupivacaine
(8ml/hr).

26

Bupivacaine 0.1% with Fentanyl 2 mcg/ml

(Bupivacaine 0.1% = Bupivacaine 1 mg/ml)
Age < 4 months:
Example:

3 kg neonate

Bupivacaine

0.1 0.2 ml/kg/hr (Max dose 0.2 mg/kg/hr)

0.2 mg/kg/hr x 3 kg = 0.6 mg/hr (Max dose)
0.6 mg/hr
1 mg/ml = 0.6 ml/hr (Max rate)

Fentanyl

1 mcg/kg/hr x 3 kg = 3 mcg/hr (Max dose)

3 mcg/hr
2 mcg/ml = 1.5 ml/hr (Max rate)

Note: In this example, the max infusion rate is determined by Bupivacaine (0.6 ml/hr) not Fentanyl
(1.5 ml/hr)
Age > 4 months:
Example:
Bupivacaine

Fentanyl

20 kg child
0.1 0.5 ml/kg/hr (Max dose 0.5 mg/kg/hr)
0.5 mg/kg/hr x 20 kg = 10 mg/hr (Max dose)
10 mg/hr
1 mg/ml = 10 ml/hr (Max rate)
1 mcg/kg/hr x 20 kg = 20 mcg/hr (Max dose)
20 mcg/hr
2 mcg/ml = 10 ml/hr (Max rate)

Note: In this example, the max infusion rate is the same for Fentanyl and Bupivacaine.

27

Bupivacaine 0.125%
(Bupivacaine 0.125% = Bupivacaine 1.25 mg/ml)

Not to be used for patients < 10 kg

0.5 mg/kg/hr (Max dose)
Example:

20 kg child
0.5 mg/kg/hr x 20 kg =10 mg/hr (Max dose)
10 mg/hr
1.25 mg/ml = 8 ml/hr (Max rate)

Bupivacaine 0.125% with Fentanyl 2 mcg/ml

(Bupivacaine 0.125% = Bupivacaine 1.25 mg/ml)
NOT to be used in patients <10kg
Example:

20 kg neonate

Bupivacaine

0.1 0.7ml/kg/hr (Max dose 0.5 mg/kg/hr)

0.5 mg/kg/hr x 20 kg = 10 mg/hr (Max dose)
10 mg/hr
1.25 mg/ml = 8 ml/hr (Max rate)

Fentanyl

1 mcg/kg/hr x 20 kg = 20 mcg/hr (Max dose)

20 mcg/hr
2 mcg/ml = 10 ml/hr (Max rate)

Note: In this example, the max infusion rate is determined by Bupivacaine (8 ml/hr) not Fentanyl
(10 ml/hr)

Bupivacaine 0.25%
(Bupivacaine 0.25% = Bupivacaine 2.5 mg/ml)
Example:

30 kg child
0.5 mg/kg/hr x 30 kg = 15 mg/hr (MAX dose)
15 mg/hr
2.5 mg/ml = 6 ml/hr (Max rate)

28

APPENDIX IV
Acute Pain Service Admission Note
Date:
Time:
Patient:
Surgeon:
Surgery:
Brief Medical history including history of chronic opioid use
Type of Anesthesia: *Epidural Level__________
(Circle)
_____cm @ skin & _____cm in space
SAB Meds________________ _@ ___________(time)
*GA
*Other:
Intra-Op:

*Total IVF:
*Total EBL:
*Total IV Opioids:
*Total Urine Output:
*Total / Last Dose of Local Anesthetic:
- (Local):___________________________
- (Total):___________________________
- (Last Bolus):_______________________
- (Infusion):_________________________
- (Opioids):__________________________
*Hemodynamically Stable:
*Notes:

PACU:

BP (
/
) , HR (
Intubated: YES / NO
Pain Score:
Sensory Level:
Motor Block:
Aspiration: Negative / Positive
Bolus Given:
Post-Bolus Pain Score:
Other:

PCEA:
PCA:
Other Meds:
Patient Seen By:

), SaO2 on __________ (

Plan:

Pain Service Beeper 7004

29

APPENDIX V
Notes on Notes
Daily Rounding Note on Epidural
-your job is to gather enough information and document it so that an appropriate plan can
be made from your note alone.
-any significant finding during interview or exam, please call your attending
IMMEDIATELY
-do not write a change in current management without checking with your attending
Please write the standard SOAP note including the following:
S: Pain scores at rest and with cough/movement. Urination. BM. Ambulation. Overnight
issues. Sleep quality. Specific complaints even if not related to epidural. (e.g. NG is
killing me). Nursing comments.
O: Vitals, pertinent labs (INR, WBC, Plt), Mental status. ve inspirometry volume
Sensory level, Motor Exam upper and lower extremity,
Epidural solution and settings with 24hr and since midnight useage. Cather site exam
Prn pain meds used as well as related meds (antiemetics, antipuritics)
A/P: summary statement including age, condition, POD epidural, pain control and eval.
e.g. 85 yo s/p gastrectomy POD#4 with PCEA whos pain is adequately controlled with
current regiment. No changes at this time.
e.g. 63 yo s/p R thoracotomy POD#6 with PCEA who no longer has a sensory level but
still has adequate pain control. Plan to hold PCEA in AM with removal later in the day.
e.g. 45 yo s/p MVS with bilateral rib fractures with PCEA placed 2 days ago who
continues to have significant pain with coughing. Sensory level below the area of rib
fracture so will increase coverage of epidural by changing the epidural solution from
fentanyl to Dilaudid with an increased rate from 6 to 8cc/hr. Discussed with attending.
e.g. 27 yo s/p VATS who had epidural catheter pulled yesterday with no evidence of
complication from epidural. Pain adequately controlled with prn pain medication. Please
call with any questions.
Non-Post-Op APS Admit Notes
-think and write as if you were back on the medicine service with an added emphasis on
pain history
Must Include
Reason or Question of Requesting Service
Chief Complaint: CC:
HPI: including location, severity, quality, duration, timing, context, modifying factors
(things that have worked and havent worked), assoc signs and symptoms (radiation)
Interventions by Current Service
Social History: smoking, EtOH, support, fam hx of pain/abuse issues
PMedHx: Cover all the major organ systems, previous pain issues and interventions,
addiction and dependency issues
PSurgHx: esp those that might interfere with a pain procedure
ROS: GI, GU, Neuro, Endocrine including psych and abuse hx
Allergies:

30

Medications: Please divide out pain medication (opioids, NSAIDS, neuromodulators)

from other medication. Also highlight any medication which might influence procedures
like coumadin, plavix, lovenox.
Physical Exam: Vitals, General Eval, Mental Status, Hrt and Lungs, Neuro, Pain area in
greater detail(skin color, texture, tenderness, extent, reaction to touch, strength, ROM)
Relevant Labs/Relevant Studies:
Assessment Statement:
PLAN (please write up a brief outline of a plan on a separate sheet of paper to present to
the attending. Run plan by attending prior to writing the plan in the consult note.)

31