Epidural and intrathecal opioids for postoperative pain management in Europe--a 17-nation questionnaire study of selected hospitals. Euro Pain Study Group on Acute Pain

Essential Elements of Multimodal Analgesia in Enhanced Recovery After Surgery (ERAS) Guidelines

Perioperative multimodal analgesia uses combinations of analgesic medications that act on different sites and pathways in an additive or synergistic manner to achieve pain relief with minimal or no opiate consumption. Although all medications have side effects, opiates have particularly concerning, multisystemic, long-term, and short-term side effects, which increase morbidity and prolong admissions. Enhanced recovery is a systematic process addressing each aspect affecting recovery. This article outlines the evidence base forming the current multimodal analgesia recommendations made by the Enhanced Recovery After Surgery Society (ERAS). We describe current evidence and important future directions for effective perioperative multimodal analgesia in enhanced recovery pathways.

Neuraxial opioids as analgesia in labour, caesarean section and hysterectomy: A questionnaire survey in Sweden

Background: Neuraxial opioids improve labour analgesia and analgesia after caesarean section (CS) and hysterectomy. Undesirable side effects and difficulties in arranging postoperative monitoring might influence the use of these opioids. The aim of the present survey was to assess the use of intrathecal and epidural morphine in gynaecology and obstetrics in Sweden. Methods: A questionnaire was sent to all anaesthetic obstetric units in Sweden concerning the use and postoperative monitoring of morphine, sufentanil and fentanyl in spinal/epidural anaesthesia. Results: A total of 32 of 47 (68%) units responded representing 83% of annual CS in Sweden. In CS spinal anaesthesia, 20/32 units use intrathecal morphine, the most common dose of which was 100 μg (17/21). Intrathecal fentanyl (10-20 μg) was used by 21 units and sufentanil (2.5 -10 μg) by 9/32 of the responding units. In CS epidural anaesthesia, epidural fentanyl (50-100 μg) or sufentanil (5-25 μg) were commonly used (25/32), and 12/32 clinics used epidural morphine, the majority of units used a 2 mg dose. Intrathecal morphine for hysterectomy was used by 20/30 units, with 200 μg as the most common dose (9/32). Postoperative monitoring was organized in adherence to the National Guidelines; the patient is monitored postoperative care or an obstetrical ward over 2-6 hours and up-to 12 hours in an ordinary surgical ward. Risk of respiratory depression/difficult to monitor was a reason for not using intrathecal opioids. Conclusions: Neuraxial morphine is used widely in Sweden in CS and hysterectomy, but is still restricted in some units because of the concern for respiratory depression and difficulties in monitoring.

Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice

Background

The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme.

Methods

Studies were selected with particular attention being paid to meta‐analyses, randomized controlled trials and large prospective cohort studies. For each item of the perioperative treatment pathway, available English‐language literature was examined and reviewed. The group reached a consensus recommendation after critical appraisal of the literature.

Results

This consensus statement demonstrates that anaesthesiologists control several preoperative, intraoperative and postoperative ERAS elements. Further research is needed to verify the strength of these recommendations.

Conclusions

Based on the evidence available for each element of perioperative care pathways, the Enhanced Recovery After Surgery (ERAS ^®) Society presents a comprehensive consensus review, clinical considerations and recommendations for anaesthesia care in patients undergoing gastrointestinal surgery within an ERAS programme. This unified protocol facilitates involvement of anaesthesiologists in the implementation of the ERAS programmes and allows for comparison between centres and it eventually might facilitate the design of multi‐institutional prospective and adequately powered randomized trials.

A clinical approach to neuraxial morphine for the treatment of postoperative pain

Opioids are considered a “gold standard” in clinical practice for the treatment of postoperative pain. The spinal administration of an opioid drug does not guarantee selective action and segmental analgesia in the spine. Evidence from experimental studies in animals indicates that bioavailability in the spinal cord biophase is negatively correlated with liposolubility, and is higher for hydrophilic opioids, such as morphine, than lipophilic opioids, such as fentanyl, sufentanil and alfentanil. Epidural morphine sulphate has proven analgesic efficacy and superiority over systemically administered morphine for improving postoperative pain. However, pain relief after a single epidural injection of morphine could last less than 24 hours. Techniques used to administered and prolong opioid epidural analgesia, can be costly and inconvenient. Moreover, complications can arise from indwelling epidural catheterization, particularly in patients receiving anticoagulants. Clinical trials have shown that epidural morphine in the form of extended-release liposome injections (EREM) gives good analgesia for a period of 48 hours, with no need for epidural catheterisation. Intrathecal morphine produces intense analgesia for up to 24 hours with a single shot, and clinical recommendation is to choose the minimum effective dose and do not exceed 300 μg to prevent the delay respiratory depression.

A survey of postoperative epidural and intravenous analgesia in Greece

BACKGROUND AND OBJECTIVE

Epidural and intravenous analgesia are widely used for postoperative pain management. Efficacy and safety is enhanced with the establishment of acute pain services. We studied the terms of application of these techniques in Greek hospitals and compared practices between anaesthetic departments with or without acute pain services.

METHODS

We performed a postal survey regarding departmental policy on the application of epidural and intravenous analgesia, patient monitoring, audit and educational activities, acute pain service teams and proposals for improvement. Pain services were classified according to predetermined quality criteria. Hospitals with or without acute pain services were compared.

RESULTS

Response rate was 46.3% (51 of 110 departments). Epidural analgesia was used in 49 departments, equally applied as intermittent boluses or continuous infusion. Twenty-two of the 39 departments that were using continuous infusion, used exclusively a lumbar approach. Intravenous analgesia was used by 42 (82%) departments; 13 used exclusively continuous infusion. All eight departments that had an established acute pain service fulfilled the predefined quality criteria compared with only ten of the remaining 43 (P < 0.001).

CONCLUSION

Our study discloses important issues regarding the use of intravenous and epidural analgesia and postoperative patient monitoring in Greek hospitals. Implementation of acute pain services that are satisfying the quality criteria may help to improve patient care.

The role of intrathecal drugs in the treatment of acute pain

Intrathecal opioids are widely used as useful adjuncts in the treatment of acute and chronic pain, and a number of non-opioid drugs show promise as analgesic drugs with spinal selectivity. In this review we examine the historical development and current use of intrathecal opioids and other drugs that show promise for treating pain in the perioperative period. The pharmacology and clinical use of intrathecal morphine and other opioids is reviewed in detail, including dosing guidelines for specific surgical procedures and the incidence and treatment of side effects associated with these drugs. Available data on the use of non-opioid drugs that have been tested intrathecally for use as analgesics are also reviewed. Evidence-based guidelines for dosing of intrathecal drugs for specific surgical procedures and for the treatment of the most common side effects associated with these drugs are presented.

Tolerability of acute postoperative pain management: nausea, vomiting, sedation, pruritis, and urinary retention. Evidence from published data

This review examines the evidence from published data concerning the tolerability (indicated by the incidence of nausea, vomiting, sedation, pruritus, and urinary retention), of three analgesic techniques after major surgery; intramuscular analgesia (i.m.), patient-controlled analgesia (PCA), and epidural analgesia. A MEDLINE search of publications concerned with the management of postoperative pain and these indicators identified over 800 original papers and reviews. Of these, data were extracted from 183 studies relating to postoperative nausea and vomiting, 89 relating to sedation, 166 relating to pruritus, and 94 relating to urinary retention, giving pooled data which represent a total of more than 100,000 patients. The overall mean (95% CI) incidence of nausea was 25.2 (19.3-32.1)% and of emesis was 20.2 (17.5-23.2)% for all three analgesic techniques. PCA was associated with the highest incidence of nausea but the emesis was unaffected by analgesic technique. There was considerable variability in the criteria used for defining sedation. The overall mean for mild sedation was 23.9 (23-24.8)% and for excessive sedation was 2.6 (2.3-2.8)% for all three analgesic techniques (significantly lower with epidural analgesia). The overall mean incidence of pruritus was 14.7 (11.9-18.1)% for all three analgesic techniques (lowest with i.m. analgesia). Urinary retention occurred in 23.0 (17.3-29.9)% of patients (highest with epidural analgesia). The incidence of nausea and excessive sedation decreased over the period 1980-99, but the incidence of vomiting, pruritus, and urinary retention did not. From these published data it is possible to set standards of care after major surgery for nausea 25%, vomiting 20%, minor sedation 24%, excessive sedation 2.6%, pruritus 14.7%, and urinary retention requiring catheterization 23%. Acute Pain Services should aim for incidences less than this standard of care.

Incidence and Characteristics of Naloxone Use in Postoperative Pain Management: A Critical Examination of Naloxone Use as a Potential Quality Measure

The administration of naloxone may be an important monitor of the quality and safety of postoperative pain management. However, studies that support the use of naloxone as a quality measure are absent. The purposes of this study are to determine the incidence and factors associated with naloxone administration in the postoperative setting and to critically examine naloxone as a potential quality measure. Participants included all postoperative adult inpatients at an academic hospital who received naloxone and an equal number of matched control patients who did not receive naloxone during the calendar year 2003. Medical record audits were performed to examine patient demographics, relevant medical history, postoperatively administered analgesics and central nervous system depressants, documented sedation and respiratory assessments, reason provided for naloxone administration, and patient outcome. Naloxone was administered to .53% (56/10,511) of all adult inpatient postoperative patients. Patients who received naloxone were significantly older and received more central nervous system depressants than cohorts. No significant differences were found in comorbidities, route of opioid administration, or amount of opioids taken by the two groups. Reversal of excessive opioid-induced sedation was the primary reason provided for naloxone administration. However, 25% of the patients were later determined to have a new diagnosis that contributed to sedation. Examination of naloxone administration proved useful in uncovering deficits in structures and processes of care. However, caution is warranted when using naloxone as a quality measure to avoid the implication that higher use indicates opioid analgesic over-treatment or error.

Spinal anesthesia for emergency abdominal surgery in uncontrolled hyperthyroidism

Patients with uncontrolled hyperthyroidism presenting as an emergency are at considerable risk. The anesthetic management of a thyrotoxic patient undergoing incidental emergency surgery is discussed. We focus on the intraoperative problems and, above all, postoperative pain management with regional anesthesia.

Respiratory and haemodynamic effects of acute postoperative pain management: evidence from published data

BACKGROUND

This study examines the evidence from published data concerning the adverse respiratory and haemodynamic effects of three analgesic techniques after major surgery; i.m. analgesia, patient-controlled analgesia (PCA), and epidural analgesia.

METHODS

A MEDLINE search of the literature was conducted for publications concerned with the management of postoperative pain. Information relating to variables indicative of respiratory depression and of hypotension was extracted from these studies. Over 800 original papers and reviews were identified. Of these papers, 212 fulfilled the inclusion criteria but only 165 provided usable data on adverse effects. Pooled data obtained from these studies, which represent the experience of a total of nearly 20,000 patients, form the basis of this study.

RESULTS

There was considerable variability between studies in the criteria used for defining respiratory depression and hypotension. The overall mean (95% CI) incidence of respiratory depression of the three analgesic techniques was: 0.3 (0.1-1.3)% using requirement for naloxone as an indicator; 1.1 (0.7-1.7)% using hypoventilation as an indicator; 3.3 (1.4-7.6)% using hypercarbia as an indicator; and 17.0 (10.2-26.9)% using oxygen desaturation as an indicator. For i.m. analgesia, the mean (95% CI) reported incidence of respiratory depression varied between 0.8 (0.2-2.5) and 37.0 (22.6-45.9)% using hypoventilation and oxygen desaturation, respectively, as indicators. For PCA, the mean (95% CI) reported incidence of respiratory depression varied between 1.2 (0.7-1.9) and 11.5 (5.6-22.0)%, using hypoventilation and oxygen desaturation, respectively, as indicators. For epidural analgesia, the mean (95% CI) reported incidence of respiratory depression varied between 1.1 (0.6-1.9) and 15.1 (5.6-34.8)%, using hypoventilation and oxygen desaturation, respectively, as indicators. The mean (95% CI) reported incidence of hypotension for i.m. analgesia was 3.8 (1.9-7.5)%, for PCA 0.4 (0.1-1.9)%, and for epidural analgesia 5.6 (3.0-10.2)%. Whereas the incidence of respiratory depression decreased over the period 1980-99, the incidence of hypotension did not.

CONCLUSIONS

Assuming a mixture of analgesic techniques, Acute Pain Services should expect an incidence of respiratory depression, as defined by a low ventilatory frequency, of less than 1%, and an incidence of hypotension related to analgesic technique of less than 5%.

Definitions of "respiratory depression" with intrathecal morphine postoperative analgesia: a review of the literature

PURPOSE

To review the postoperative intrathecal morphine (ITM) analgesia literature for their definitions of "respiratory depression" (RD).

SOURCE

Medline (1966 - June Week 5 2001) and reference lists were searched for original studies involving bolus-dose ITM for postoperative analgesia, which used "respiratory depression" or similar terms.

PRINCIPLE FINDINGS

The search identified 209 studies. These were included if ITM use was appropriate (bolus dose, postoperative analgesia) and the term "respiratory depression" was used, which left 96 studies remaining. Forty-four (46%) did not define "RD" despite using this term. A further 24 (25%) defined RD with respiratory rate (RR) alone. Only 28 (29%) defined RD with more than RR alone. There was no statistically significant association between the presence of a definition for RD with study design, study size or publication period. Also, no significant association existed between rigorousness of RD definitions and the above factors.

CONCLUSION

The term "respiratory depression" has no clear definition from a review of the literature on ITM use for postoperative analgesia. While defining RD with bradypnea is superior to having no definition, this is still inadequate. In future research, the consistent use of terms with specific meanings will facilitate understanding the true incidence of ITM's respiratory effects. If "respiratory depression" is used, then an explicit definition of its meaning should be provided. Future research must also address what is clinically significant respiratory impairment from intrathecal opioids, and how to optimally monitor for this. Further delineating their risks vs benefits will allow for more optimal dosing.

Use of intrathecal morphine for postoperative pain relief after elective laparoscopic colorectal surgery

Laparoscopic surgery has become popular in recent years, but few studies have addressed analgesia for this type of surgery. We conducted a prospective double-blind randomised trial on 36 cases of laparoscopic colorectal surgery to determine the influence of intrathecal morphine on postoperative pain relief. All patients received a subarachnoid block with local anaesthetic in addition to general anaesthesia. One group also received intrathecal morphine. A patient-controlled analgesic (PCA) device was prescribed for pain control postoperatively and the visual analogue score (VAS) was used for pain assessment. The group who received intrathecal morphine used significantly less morphine. There were no adverse cardiovascular effects of the combined anaesthetic technique. Nausea and vomiting remained the main side-effect of intrathecal morphine but this was easily treated with anti-emetics.

The use of epidural and intrathecal analgesia in palliative care

Oral analgesics and adjunctive medicines will be used to meet the needs of most palliative care patients in terms of pain relief. However, for a small number of patients, this will not be adequate for satisfactory relief from pain, resulting in a lower quality of life. For such patients, using some of the more 'technical approaches' to pain relief, e.g. epidural or intrathecal analgesia, can prove beneficial. Taking the anatomy of the spinal space into consideration, this article will present the indications and contraindications for spinal analgesia, as well as drugs used and the most appropriate methods of drug administration.

Long-term outcome after neurosurgically treated spinal epidural abscess following epidural analgesia

BACKGROUND

A recent investigation demonstrated a high incidence of epidural abscess secondary to epidural catheterization and a 50% frequency of neurologic deficits. We studied short- and long-term neurologic outcome in patients operated for spinal epidural abscess after epidural analgesia.

METHODS

Nineteen patients who had undergone neurosurgical decompression and drainage of a spinal epidural abscess during a 5-year period at three neurosurgical departments in East Denmark were identified by manual review of operating lists.

RESULTS

Median epidural catheterization time was 8 days (range 3-44). Preoperatively 12 patients suffered from inferior paraparesis, one had irradiating pain from the back, and 6 patients had no neurologic deficits. Postoperatively 2 patients had recovered, but 3 other patients had deteriorated; therefore, 13 patients were discharged with paresis/plegia. Seven patients died during a median follow-up time for all patients of 41.6 months. One patient recovered completely, and one suffered from minor deficits. The remaining patients suffered from paraparesis/plegia or bladder/bowel dysfunction.

CONCLUSION

Overall recovery rate for patients with paresis/plegia after epidural abscess was 20%. No patients with paresis/plegia following a thoracic abscess recovered in contrast to a 50% recovery rate for patients with lumbar epidural abscess. The majority of long-term survivors had severe neurologic deficits. Abscess formation contributed to one death.

A randomized, double-blinded comparison of intrathecal morphine, sufentanil and their combination versus IV morphine patient-controlled analgesia for postthoracotomy pain

We compared the analgesic effect of lumbar intrathecal (IT) 0.5 mg morphine (Group M, n = 10), 50 microg sufentanil (Group S, n = 10), and their combination (Group S-M, n = 10) given before general anesthesia and patient-controlled analgesia with IV morphine (Group C, n = 19) in a randomized, double-blinded study performed in patients undergoing thoracotomy. Pain visual analog scale (VAS) and morphine consumption were assessed for 24 h. In Group S-M the number of patients initially titrated with IV morphine was less than in group C (30 vs 84%, P < 0.05). Morphine requirement was higher in Group C (71 +/- 30 mg) than in Groups S (46 +/- 34 mg, P < 0.05), M (38 +/- 31 mg, P < 0.05) and S-M (23 +/- 16 mg, P < 0.01). VAS scores were significantly decreased during the first 0-11 postoperative h at rest and during the first 0-8 postoperative h on coughing in Groups M and S-M rather than in Group C. The incidence of side effects was infrequent except for urinary retention. Preoperative IT morphine or combined sufentanil and morphine could be given as a booster to achieve rapidly effective analgesia in the immediate postoperative period.

IMPLICATIONS

As compared with IV patient-controlled analgesia, intrathecal morphine or combined sufentanil and morphine provided superior postoperative pain relief both at rest (11 h) and on coughing (8 h) than did IV patient-controlled analgesia morphine alone. IV morphine requirement was decreased during the first postoperative day after posterolateral thoracotomy.

A comparison of bupivacaine-fentanyl-morphine with bupivacaine-fentanyl-diamorphine for caesarean section under spinal anaesthesia

In a randomised double-blind trial, postoperative analgesia and side effects of intrathecal morphine 0.1 mg and intrathecal diamorphine 0.25 mg were compared. Sixty women were randomised to receive intrathecal injection of 12.5 mg hyperbaric bupivacaine and 12.5 microg fentanyl with either morphine 0.1 mg (group M), or diamorphine 0.25 mg (group D). All women received 100 mg diclofenac rectally at the end of surgery and were given intravenous morphine via a patient controlled analgesia (PCA) system. Pain, PCA morphine usage and side effects were assessed at 2, 4, 8 and 24 h after spinal anaesthesia. The two groups were comparable for quality of intraoperative analgesia. There were no significant differences between the groups in time to first PCA demand, morphine consumption or oral analgesic use in each time period. Significantly more patients in group M were nauseated at 4 h whilst at 24 h nausea was significantly worse in group D. There was no significant difference between the groups in the number of women vomiting in the 24-h period. The two groups were comparable for pruritus and drowsiness. We conclude that 0.25 mg subarachnoid diamorphine is a suitable alternative to 0.1 mg morphine for post caesarean section analgesia.

Evidence-based review of the literature on intrathecal delivery of pain medication

Evidence-based medicine depends on the existence of controlled clinical trials that establish the safety and efficacy of specific therapeutic techniques. Many interventions in clinical practice have achieved widespread acceptance despite little evidence to support them in the scientific literature; the critical appraisal of these interventions based on accumulating experience is a goal of medicine. To clarify the current state of knowledge concerning the use of various drugs for intraspinal infusion in pain management, an expert panel conducted a thorough review of the published literature. The exhaustive review included 5 different groups of compounds, with morphine and bupivacaine yielding the most citations in the literature. The need for additional large published controlled studies was highlighted by this review, especially for promising agents that have been shown to be safe and efficacious in recent clinical studies.

Efficacy and respiratory effects of low-dose spinal morphine for postoperative analgesia following knee arthroplasty

A randomized, double-blind study of 38 patients undergoing total knee replacement was undertaken to compare the efficacy and respiratory effects of low-dose spinal morphine and patient-controlled i.v. morphine against patient-controlled i.v. morphine alone. Patients received either morphine 0.3 mg or saline 0.3 ml with 0.5% heavy spinal bupivacaine 2-2.5 ml. Respiratory effects were measured continuously for 14 h postoperatively with an Edentec 3711 respiratory monitor. There was an improvement in pain relief in the intrathecal morphine group, with significantly lower median VAS pain scores on movement at 4 h (0 (median 0-1.5) vs 5 (1.25-7.75) P < 0.01), 12 h (2 (1-5) vs 6 (3-8) P < 0.01) and 24 h (3 (1-5) vs 5 (3-7) P < 0.05) postoperatively, despite using significantly less patient-controlled morphine (20 mg (10.25-26.25) vs 38.5 mg (27-51) P < 0.01) in the first 24 h. There was a small but statistically significant reduction in the median oxygen saturation (SpO2) in the intrathecal morphine group 97 (95-99)% compared with the placebo group 99 (97-99)% (P < 0.05). Although marked disturbances in respiratory pattern were observed in both groups, none of the patients in the study had severe hypoxaemia (SpO2 < 85% > 6 min h-1) and there was no significant difference in the incidence of mild (SpO2 < 94% > 12 min h-1) or moderate (SpO2 < 90% > 12 min h-1) hypoxaemia or in the incidence of episodes of apnoea or hypopnoea in the two groups.

Epidural and spinal agents for postoperative analgesia

The discovery of opioid receptors and the subsequent development of the technique of epidural and intrathecal opioid administration are undoubtedly two of the most significant advances in pain management in recent decades. The use of spinal opioids is widespread and increasing. The technique is used widely to treat intraoperative, postoperative, traumatic, obstetric, chronic, and cancer pain. Newer developments include the increasing use of combined local anesthetics and opioids or nonopioids and also PCEA, particularly in the obstetric population. Meta-analysis of controlled trials has demonstrated improved pulmonary outcome in patients receiving epidural postoperative analgesia. Although rare, respiratory depression continues to be a major problem of the technique. None of the currently available opioids is completely safe; however, extensive international experience has shown that patients receiving spinal opioids for postoperative analgesia can be safely nursed on regular wards, provided that trained personnel and appropriate guidelines are available. The importance of a good acute pain service to provide the safe and effective use of spinal opioids cannot be overemphasized.

Postoperative epidural infusion of morphine and bupivacaine is safe on surgical wards. Organisation of the treatment, effects and side-effects in 2000 consecutive patients

BACKGROUND

There was an obvious need to improve the quality and safety of our postoperative pain treatment and to introduce an improved routine service on surgical wards.

METHODS

It was decided to use postoperative epidural infusion of morphine 0.04 mg/ml and bupivacaine 2.5 mg/ml (0.25%) 4-8 ml/h as pain relief after major surgery. An education programme was run emphasising the benefits, side-effects and the importance of regular monitoring of pain intensity, vital functions (respiratory rate, blood pressure, heart rate), motor function of the legs and the need for additional drugs in order to detect side-effects as well as lack of adequate analgesic effect. A detailed observation sheet was used collecting information every 2 h throughout the epidural treatment period in order to secure monitoring and adjustment of the treatment. Close contact was maintained with the wards.

RESULTS

We present a detailed analysis of our first 2000 postoperative patients, mainly after orthopaedic (46.1%), gastrointestinal (32.0%), urologic (8.7%) and vascular (8.5%) surgery. Duration of the treatment was less than 24 h in 41.4% and more than 48 h in 29.7%. Pain relief was adequate in most patients, best after vascular surgery in the lower extremities (mean VAS 0.15/10.0 (95% confidence interval 0.09-0.23)) and less after gastrointestinal (mean VAS 0.49/10 (0.43-0.54)) and thoracic surgery (mean VAS 0.59/10 (0.38-0.81)). The infusion was stopped due to respiratory depression in 3 patients (0.15%). Four (0.2%) had systolic blood pressure < 80 mmHg and had to be treated with vasopressors. A total of 56 (2.8%) patients were considered to be problem patients due to excessive sedation (0.4%), hypotension (0.7%), respiratory depression (1.6%) or lower extremity paralysis (0.05%). All patients had urinary catheter until 6 h after termination of the epidural treatment. One patient had the epidural catheter accidentally placed subarachnoidally and experienced severe respiratory depression. No permanent sequelae were recorded in the postoperative patients, but 2 traumatised patients developed epidural abscesses after 3 weeks of treatment, which resulted in lower extremity paralysis. Late response to the warning signs might have contributed to the irreversible paraplegia.

CONCLUSION

Our experience with this postoperative epidural analgesia regime is favourable. It has been easy to administer and monitor. Pain relief was excellent, side-effects were few and picked up by the established routines followed by the ward staff except in the 2 trauma patients who developed epidural abscesses. The staff on the surgical wards were motivated for this kind of work. Education and strict surveillance routines are mandatory in order to secure prompt action when warning signs develops (e.g. lower limb paralysis).