Unique Plan Description: Anes Epidural/Spinal Acute Post Op Pain EKM
Plan Selection Display: Anes Epidural/Spinal Acute Post Op Pain
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-03-15 09:38:34
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2025-03-25 08:22:30
Available at all facilities: No

Anes Epidural/Spinal Acute Post Op Pain EKM
IV Solutions
	Narcan 0.8 mg/NS 250 mL
		250 mL, IV, 25 ml/hr
			Comment: as needed for severe itching.
		0.8 mg, EVERY BAG
		<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY margin:0; P margin:0 </STYLE><META name=GENERATOR content="MSHTML 10.00.9200.17566(NOTE)*
	naloxone 0.8mg/LR 1000mL
		1,000 mL, IV, Routine, 100 ml/hr
			Comment: To run as mainline infusion for Pruritis, call pharmacy if/when needed
		0.8 mg, EVERY BAG
	fentaNYL  5 mcg/mL-bupivacaine 1/32% NS 250mL
		Rate(ml/hr) = 12, Pt. Contolled Dose (mL)= 3, Lockout Interval (min) = 15, Bag Volume = 250 mL, Epidural, EPIDURAL
	fentanyl-bupivacaine 2 mcg/mL-0.125% Epidural 100mL (FH/JE)
		Rate(ml/hr) = 10, Bag Volume = 100 mL, Epidural
			Comment: Nurse may increase infusion by 1mL/hr X2 PRN persistent pain.  Nurse may decrease infusion by 1mL/hr X2 for persistant somnolence
	Ropivacaine 0.1%/NS 250mL
		Rate(ml/hr) = 8, Pt. Contolled Dose (mL)= 0, Lockout Interval (min) = 0, Bag Volume = 250 mL, Epidural, T;N, EPIDURAL
			Comment: Ropivacaine 0.1%/NS 250mL
		50 mL
	Ropivacaine 0.2%/NS 250mL
		Rate(ml/hr) = 8, Pt. Contolled Dose (mL)= 0, Lockout Interval (min) = 0, Bag Volume = 250 mL, Epidural, T;N, EPIDURAL
			Comment: Ropivacaine 0.2%/NS 250mL
		100 mL
	phenylephrine 20 mg/NS 250 mL
		250 mL, IV, Routine, Start: T;N, Maintain Parameter Goal: MAP> 65, Increment Increase: 5 mcg/min, Increment Decrease: 5 mcg/min, Increment Freq: 5 min(s), Max Dose: 25 mcg/min
			Comment: **NEO-SYNEPHRINE**, Concentration: 80mcg/mL.  Discontinue drip when at 5mcg/min and patient has sustained MAP>65 continuously for at least 60 minutes without any dose titration. If a dose 25mcg/min or less requires to be increased due to hypotension at any point, allow at least 60 minutes before weaning dose down again.If hypotension persists despite max dose of 25mcg/min, notify MD, ICU Core, and follow RRT policy/protocol based on critical vital signs.  Discontinue drip If SBP > 150mmHg.
		20 mg, EVERY BAG, 25 mcg/min
Medications
	Narcan
		0.1 mg, Injection, IV PUSH, Q5MIN, PRN, severe respiratory depression (RR<8), 2 Dose(s)/Time(s)
			Comment: Until desired response; follow with 10 mL sodium chloride flush.
		0.4 mg, Injection, IV PUSH, Q5MIN, PRN, severe respiratory depression (RR<8)
			Comment: then call anesthesia
	Nubain (NMH/WH/FH)
		4 mg, Injection, IV PUSH, Q4H, PRN, itching
			Comment: from epidural
		2.5 mg, Injection, IV Push, Q4H, PRN, itching
			Comment: from epidural
		5 mg, Injection, IV Push, Q4H, PRN, itching
			Comment: from epidural
	Reglan
		10 mg, Injection, IV PUSH, Q8H, PRN, nausea
		10 mg, Injection, IV PUSH, Q6H, PRN, nausea
	ondansetron
		4 mg, Injection, IV PUSH, Q6H, PRN, nausea
			Comment: for nausea not responsive to metoclopramide.
	morphine  IV (MH/WH/FH)
		2 mg, Syringe, IV PUSH, Q30MIN, PRN, pain-breakthrough
			Comment: max dose 6 mg in 2 hours.
	ketorolac injectable
		15 mg, Injection, IV PUSH, Q6H, PRN, pain-moderate, 24 hr
	Benadryl
		25 mg, Injection, IV PUSH, Q6H, PRN, itching-severe
	HYDROmorphone 20 mcg/mL-bupivacaine 1/8% 250 mL
		Rate(ml/hr) = 12, Pt. Contolled Dose (mL)= 3, Lockout Interval (min) = 15, 1-hour limit (mL) 20, Bag Volume = 250 mL, Epidural, EPIDURAL
Patient Care
	IV-Maintain
		T;N
			Comment: for 24 hours after last dose of epidural / spinal / Morphine (i.e. IV drip, peripheral lock)
		T;N
			Comment: for 12 hours after last dose of epidural / spinal / Morphine (i.e. IV drip, peripheral lock)
	No Opioids
		T;N
			Comment: if respiratory rate less than 12 breaths/minute  or if patient not fully awake & without notifying Anesthesia first
	No Sedatives
		T;N
			Comment: if respiratory rate less than 12 breaths/minute  or if patient not fully awake & without notifying Anesthesia first
	No Anticoagulants/antiplatelets/thrombolytics
		T;N
			Comment: ONLY SQ Heparin doses of 5000 units q8h & q12h are allowed while epidural is in place per Methodist Hospital Guidelines. Wait >=6hr after a heparin dose to pull epidural line; wait >=1hr after pulling a line to give next heparin dose.  This rule excludes Aspirin.
	Notify Anesthesia if:
		Marked change in sedation or CMS status | Persistent pain | Persistent side effect despite treatment | Respiratory rate less than 10 | Systolic BP less than 90 mmHG
	Epidural Assessment
		Q1H, 12, Dose(s)/Time(s)
			Comment: Until epidural catheter removed.  Assessment to include vital signs, pain, RASS, Bromage Scale, resp rate, resp pattern, pulse oximetry, epidural site, ETCO2 if ordered.
		T;N+720, Q2H-Sch, 6, Dose(s)/Time(s)
			Comment: Until epidural catheter removed.  Assessment to include vital signs, pain, RASS, Bromage Scale, resp rate, resp pattern, pulse oximetry, epidural site, ETCO2 if ordered.
		Q4H-Sch
			Comment: Until epidural catheter removed.  Assessment to include vital signs, pain, RASS, Bromage Scale, resp rate, resp pattern, pulse oximetry, epidural site, ETCO2 if ordered
	Do Not
		Shower or Bathe with epidural in place
	Cardiac Telemetry Monitoring
		T;N, Telemetry Indications: Other
	Vital Signs/Hemodynamic Monitoring
		T;N, MAP goal>65mmHg, unless otherwise directed by MD, vitals Q15MIN for first hour and Q15MIN after any decrease dosage, q60MIN once MAP sustained >65mmHG after first hour, and Q15MIN for 1 hour once phenylephrine IV discontinued. If MAP drops below and
			Comment: does not sustain >65mmHg, monitor vitals q5min with increase dosage changes until MAP reaches goal, then resume q15MIN monitoring per initial step.
Therapies
	Oxygen Therapy
		Via Nasal Cannula, Titrate->Keep Sats>/= to 92
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID
Consults/Follow-up
	Consult Anesthesiologist
		Reason for Referral: thoracic epidural, intrathecal opioid, or tap block
			Comment: Single Intrathecal Dose (of preservative free morphine < or = to 0.2 mg). or Thoracic Epidural

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase