Part of the ICU Emergencies Hub — browse every related guide in one place.
| Parameter | What to Check | Abnormal — Act |
|---|---|---|
| Pain level | Patient-reported scale; is analgesia adequate? | Uncontrolled pain despite infusion — notify anesthesia |
| Sensory level | Ice or alcohol wipe test moving upward from abdomen — where does patient stop feeling cold? | Sensory block above T4 (nipple line) — high spinal risk; notify immediately |
| Motor block (Bromage scale) | 0=no block; 1=cannot raise leg; 2=cannot flex knee; 3=cannot flex ankle | Bromage 3 (complete block) or asymmetric block — notify anesthesia; ambulation contraindicated |
| Blood pressure | Baseline and Q1H (more frequently if unstable) | SBP drop >20% from baseline or <90 mmHg — epidural hypotension; fluid bolus + position change + notify provider |
| Respiratory rate + SpO2 | Q1–2H and with any opioid epidural | RR <8–10 or SpO2 <92% — opioid-induced respiratory depression; stop infusion, administer naloxone, call for help |
| Catheter site | Dressing intact, no leakage, no redness or swelling at insertion site | Leakage (catheter displaced), erythema/swelling (infection), hematoma (back pain + new neurological deficit = emergency) |
| Urinary output | Epidural opioids cause urinary retention | No void after 4–6 hours — bladder scan; catheterize per order |
Hypotension is the most common epidural complication — caused by sympathetic blockade from local anesthetics, which dilates blood vessels below the level of the block. Most common in labor epidurals and immediately after bolus doses or rate increases.
Nursing management: Position left lateral decubitus (labor patients) or supine with legs elevated. IV fluid bolus (250–500 mL NS or LR) per order — preloading before epidural insertion is standard in obstetric anesthesia. Ephedrine or phenylephrine (vasopressors) per anesthesia order for persistent hypotension. Stop or reduce epidural infusion rate. Notify anesthesia provider. In obstetric patients, apply fetal monitoring continuously and notify OB team of maternal hypotension.
If local anesthetic spreads too high (cervical level), it blocks respiratory muscles and the cardiac accelerator nerves — causing respiratory arrest and bradycardia/cardiac arrest. Signs: rapid ascending sensory block above T4; difficulty breathing; hypotension + bradycardia; upper extremity weakness; patient reporting inability to breathe; loss of consciousness.
Epidural hematoma is rare but catastrophic — blood accumulates in the epidural space, compressing the spinal cord. Risk is highest with anticoagulated patients, difficult epidural placement, and catheter removal in anticoagulated patients. Signs: new or worsening back pain after epidural placement or removal; new motor weakness or sensory deficit; bowel or bladder dysfunction (new incontinence or retention). Time-sensitive: spinal cord compression must be surgically decompressed within 6–8 hours to prevent permanent paralysis.
Any new neurological symptom after epidural placement or removal — especially back pain with new weakness — requires immediate provider notification and urgent MRI. Do not assume symptoms are from residual anesthetic effect.
If the epidural needle accidentally punctures the dura (wet tap), CSF leaks out — causing a characteristic positional headache: severe when upright, relieved within minutes of lying flat. Onset typically 24–48 hours after the procedure. The "postural" character is the diagnostic hallmark.
Conservative treatment: flat rest, aggressive oral/IV hydration, caffeine (caffeine causes cerebral vasoconstriction and reduces headache). Definitive treatment: epidural blood patch (anesthesia injects 15–20 mL of the patient's own blood into the epidural space to seal the leak) — approximately 85% effective with the first patch.
Never inject anything into an epidural catheter without an explicit order from the anesthesia provider — only anesthesia administers epidural medications. Never use an epidural catheter for IV medications (wrong-route error; IV medications given epidurally can cause seizures, cardiac arrest). The catheter and tubing should be distinctly labeled "EPIDURAL — NOT FOR IV USE." Never remove an epidural catheter without verifying coagulation status and anesthesia approval — premature removal in an anticoagulated patient increases hematoma risk.
Related guides: PCA pump | Pain assessment | Post-op complications
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