Ether– Resources for Anesthesia Research and Education

Epidural Guidelines - Quick Start Guide

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Epidurals placed before 5 PM

*OR Direct to ICU - Before 5 PM*

  1. Bypass PACU resident.
  2. Always call report to pain fellow (#46836) or on-call pain resident (pg 2-PAIN).
  3. Pain Service will place orders and try to be at bedside for evaluation and initiation of epidural.
  4. Pain Service will communicate with ICU team before starting local or opioid infusion.
    (Spectral phone numbers for ICU Services: CVICU #42829, MICU #48820 SICU #53234)

*OR to PACU/Floor - Before 5 PM*

  1. Call PACU resident for report and orders.
  2. PACU resident evaluates epidurals before sending patient to floor.
  3. PACU resident gives report/signoff to Pain Service at 5 PM.

Epidurals placed after 5 PM

*OR Direct to ICU - After 5 PM*

  1. Bypass PACU resident
  2. Always call report to on-call pain resident (2-PAIN).
  3. OR team will evaluate epidural and place orders for Dilaudid/fentanyl, if no local (Use order set # 616: IP PAI EPIDURAL ANALGESIA POSTOP).
  4. OR team will evaluate epidural and place orders for bupivicaine as well if infusion has been initiated in OR and hemodynamics are stable. (Use order set # 616: IP PAI EPIDURAL ANALGESIA POSTOP).
  5. Pain resident or fellow will come to ICU and evaluate epidural and write orders if OR team unable to evaluate patient at hand-off (intubated or hemodynamically unstable then becomes stable later).
  6. Consider withholding bupivicaine after 11 PM if patient at risk for hypotension.
  7. Pain Service will communicate with ICU team before starting infusions.
    (Spectral phone numbers for ICU Services: CVICU #42829, MICU #48820 SICU #53234)

*OR to PACU/Floor - After 5 PM*

  1. Try to call PACU resident before 5 PM for report and orders.
  2. If PACU resident gone, OR team will place orders and contact on-call Pain resident for report (2-PAIN).
  3. OR team evaluates epidural before sending patient to floor.
  4. If OR team unable to evaluate epidural, on-call Pain resident will evaluate epidural before starting medications on floor.  As OR call resident is in-house overnight, this should be rare.

*OR to ASC PACU - After 5 PM*

  1. OR team will attempt to write orders and evaluate epidural. Always call acute pain service for report (2-PAIN).
  2. Acute pain service will write orders and evaluate epidural if OR team not available.

*General Comments Regarding Epidural Management in PACU:*

  • Write orders early so medications are available when patient arrives in PACU/ICU.
  • Give report to PACU resident (before 5 PM) or Pain Service (after 5 PM) to ensure patient is seen on rounds. COMMUNICATE IMPORTANT INFORMATION.
  • Although we work closely with PACU resident during the day, patients in the PACU remain under the care and supervision of the primary OR attending. The Pain Service does not assume care until the patient arrives to the ICU or floor.
  • We do not evaluate, write orders, or take calls on non-Stanford epidurals (ie. PAMF), unless specifically consulted by a physician.
  • Communicate directly with on-call surgery team if there is problem, such as hypotension when local anesthetic already turned off. Provide direct physician-to-physician communication, especially when problems or unanticipated events occur.

 

Link to on-call acute pain team:

https://med.stanford.edu/ether/secure/call_schedule.html

PACU Main Desk: 3.6661

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