Seek knowledge from cradle to the grave. Prophet Muhammad (Peace be upon him)
Idea Transcript
Tuckey, Bath
Management of leg weakness with epidural analgesia All patients receiving epidural analgesia must have leg strength assessed regularly using the 'leg strength score'(see below) that appear on the epidural observation form. Thoracic epidural analgesia should not cause profound leg weakness. Increasing leg weakness usually means the infusion rate is too high. However it may mean that the patient is developing an epidural haematoma or epidural abscess. If not diagnosed and treated promptly, this will lead to paraplegia. Use this algorithm to help differentiate. YES Increasing leg weakness? Leg strength score 3 or 4?
NO
Switch off epidural infusion. Contact the Acute Pain Team and inform them of the situation
YES
Discuss if catheter is to be removed?
Reassess leg strength every 30 minutes
Leg strength improving?
Increasing leg weakness? Leg strength score 3 or 4? Painful, Swollen or Pus at site ?
Recommence epidural infusion and routine observations
YES
Send Catheter tip, site swab and blood cultures to microbiology.If pus is present send urgent sample to lab. Apply dry dressing to site . Inform microbiologist (Bleep 7599). Start recommended Antibiotic cover.
Patient comfortable?
NO
NO
More than 4 hours since stopping epidural infusion? YES Suspect an epidural haematoma. Procede as follows
NO
Contact the Acute Pain Team to reassess the patient's analgesia
During weekday office hours contact a member of the Acute Pain Team ( bleep 7113 or7222 ) who will arrange an urgent spinal MRI scan through the radiology department and contact the spinal surgical team . After hours and weekends contact the Anaesthetist on call (bleep 7113) who will arrange an urgent spinal MRI scan through the on call radiologist and neurosurgical teams. An epidural haematoma or abscess has to be evacuated within 8 hours of the onset of symptoms for your patient to have the best chance of recovery of neurological function. Do not delay
score score score score
1 2 3 4
Reassess leg strength every 30 minutes
YES
Leg strength improving? NO More than 4 hours since stopping epidural infusion? YES Suspect an epidural abscess. Procede as follows
Grade Criteria Degree of Block (Bromage Scale) Free movement of legs and feet Nil (0%) Just able to flex knees with free movement of feet Partial (33%) Unable to flex knees, but with free movement of feet Almost Complete (66%) Unable to move legs or feet Complete (100%)