CASE STUDY 1

Patient A is 64 years of age and was scheduled to undergo a thoracotomy for the resection of a lung nodule. On the morning of surgery, Patient A was transferred to the preoperative holding area where an arterial line, peripheral IVs, and an epidural catheter were inserted. A 16F Foley catheter was also inserted to monitor urine output and prevent urinary retention associated with epidural analgesia.

For epidural catheter placement, the patient was positioned in the left lateral decubitus position with his hips and neck fully flexed. The selected site for the catheter, the T10–T11 interspace, was draped and prepped with antiseptic. The thoracic epidural catheter was then inserted using the loss of resistance technique. To verify placement, the catheter was aspirated with no returns of CSF or bloody fluid. A filter was attached to the slide-lock adapter, and the catheter port was cleansed with antiseptic prior to dosing the catheter. Patient A received an initial bolus of 5 mg morphine and 75 mcg fentanyl, followed by a continuous infusion of 0.3 mg morphine per hour. A sterile occlusive dressing was placed at the insertion site, and the catheter was taped securely along the patient's back, with the end of the catheter positioned over his shoulder. The administration set was clearly labeled "epidural catheter."

After he was transferred to the operating room, the patient was intubated and anesthetized. A left thoracotomy incision was made, and the procedure ensued. At the end of the procedure, one chest tube was placed in the left pleural space. After the operation was completed, the patient was extubated and placed on a 50% oxygen mask and transferred to the cardiothoracic ICU.

In the ICU, patient assessment included frequent monitoring of vital signs, especially respiratory rate and tidal volume. After the patient awoke from anesthesia, nursing assessment also focused on his level of pain, neurologic status, and observation for narcotic-related side effects and catheter-related complications. On initial assessment, Patient A's respiratory rate was 20 breaths per minute with an oxygen saturation of 100%. The electrocardiogram monitor showed sinus rhythm with a rate of 98 beats per minute and a few isolated unifocal premature ventricular contractions. Arterial blood pressure was 104/72 mm Hg. When he recovered from anesthesia, he was awake, alert and oriented, with a sedation rating of 2. Patient A rated his pain as a "3" on a 0–10 VAS and stated his pain primarily occurred with pulmonary toilet (coughing and deep breathing) and turning due to his bilateral chest tubes. The Pain Service continued orders for a 0.3 mg continuous infusion of morphine for pain management. Assessment of the epidural catheter revealed that the dressing was dry and intact. The site was slightly erythematous, with some bruising noted. However, the site was free of signs and symptoms of infection, abscess, or hematoma development. Later that evening, Patient A began complaining of pruritus. The itching was present in his face and neck but was especially intense in his truncal region. A slightly raised erythematous rash soon became apparent. Patient A was medicated with 25 mg IV diphenhydramine, which was repeated in six hours due to his continued complaints of intense itching.

On the morning of the first postoperative day, Patient A's respirations became shallow and his respiratory rate dropped to eight breaths per minute. Although he was still arousable with a sedation rating of 3, the physician ordered a set of arterial blood gases. The PCO₂ level had climbed to 63 from his baseline in the lower 50s. These assessment findings suggested delayed-onset respiratory depression. As a result, the continuous infusion of morphine was turned off and the patient received 0.2 mg of naloxone slow IV push. The naloxone dose was repeated in 30 minutes with an additional 0.1 mg IV. Patient A continued to rate his pain a "3" on a 0–10 VAS. Thus, the respiratory depressant effects were reversed without negating the beneficial analgesic effects of the morphine infusion. Patient A remained on a 50% face mask, which was supplemented with 7 L per nasal cannula.

Eight hours later, the patient's level of consciousness was at baseline and respirations were greater than 12 breaths per minute with a good tidal volume. The morphine infusion was restarted at 0.3 mg per hour. With good pain relief, Patient A was able to be assisted to the chair for activity. On the second postoperative day with continued good pain relief, the patient was up to the chair and ambulated twice for 150–250 feet with assistance from physical therapy.

After three days, the epidural catheter was removed by the anesthesiologist. Again, Patient A was placed in the lateral decubitus position with his hips and neck flexed and the occlusive dressing was removed. The epidural catheter was then slowly and carefully removed and the tip of the catheter was inspected. The black colored marking was present on the tip of the catheter, indicating it was fully intact upon removal. In assessing the catheter site, only a small degree of erythema was noted. After discontinuation of epidural analgesia, the patient's Foley catheter was removed and he obtained good pain relief with oxycodone/acetaminophen and nonsteroidal anti-inflammatory agents, including ibuprofen and ketorolac. Effective pain control helped Patient A meet his postoperative recovery goals, including pulmonary toilet, maintaining adequate nutrition for wound healing and general strength, and gradual activity progression. After the air leak sealed, the right mediastinal tube was discontinued.