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EXPLANATION
✔ Correct answer:
Respiratory depression. The most serious complication of epidural analgesia is respiratory depression, which can occur if the anesthetic or opioid used in the epidural spreads too high in the spinal cord, affecting the phrenic nerve (C3-C5) and respiratory centers in the brainstem. This can lead to bradypnea, hypoxia, and potentially respiratory failure, requiring immediate intervention.
Epidural analgesia involves the administration of local anesthetics (e.g., bupivacaine, ropivacaine) and/or opioids (e.g., fentanyl, morphine) into the epidural space to block pain signals. However, excessive drug spread above the thoracic or cervical level can impair respiratory muscles and central respiratory drive, causing severe complications.
Opioids and local anesthetics can depress respiratory function through two mechanisms:
- Direct central nervous system depression (opioids) → decreases the brainstem’s respiratory drive.
- Motor blockade of intercostal muscles and diaphragm (local anesthetics) → weakens breathing effort.
Signs of Respiratory Depression to Monitor:
- Respiratory rate <12 breaths per minute.
- Shallow respirations or apnea.
- Decreased oxygen saturation (<90%) and cyanosis.
- Drowsiness progressing to unresponsiveness.
Imagine a dimmer switch controlling a room’s lighting. If you turn it down too much, the room gets too dark. Similarly, if an epidural’s effects spread too far, it can "dim" the body's ability to breathe properly.
Nurse Martinez should take immediate nursing actions to ensure patient safety and collaborate with the healthcare team if the situation worsens.
- Monitor respiratory rate, depth, and oxygen saturation frequently (at least every hour or more often if needed).
- Assess level of sedation using a standardized sedation scale (e.g., Pasero Opioid-Induced Sedation Scale).
- Ensure the epidural infusion settings are correct and verify that the prescribed medication and dose match the provider’s order.
- Encourage deep breathing exercises and reposition the patient to promote optimal lung expansion.
- Notify the physician or anesthesia provider immediately if respiratory rate decreases significantly, sedation deepens, or oxygen saturation drops persistently.
- Administer oxygen therapy as prescribed and prepare for emergency interventions if necessary.
- Have emergency airway equipment (e.g., bag-valve mask, suction) readily available in case of worsening respiratory status.
✘ Incorrect answer options:
Heightened alertness. Heightened alertness is not a typical complication of epidural analgesia. In fact, opioids used in epidurals often cause sedation, not increased alertness. This symptom would not indicate a serious problem requiring immediate intervention.
Increased heart rate. While an increased heart rate may indicate pain or mild hypotension from epidural-induced vasodilation, it is not the most serious complication. Hypotension from an epidural is common but usually manageable with fluids and vasopressors (which are prescribed and administered per provider orders).
Numbness and tingling of the extremities. Some numbness and tingling in the lower extremities are expected side effects of an epidural due to local anesthetic action. However, if the numbness extends to the upper body, it could signal excessive spread of the anesthetic, requiring monitoring, but it is not as immediately life-threatening as respiratory depression.
References
- Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
- Pasero, C., & McCaffery, M. (2011). Pain Assessment and Pharmacologic Management. Elsevier.