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COMMENTARIES
Summary
Key words
Analgesic techniques, extradural. Pain, postoperative. Surgery,
postoperative period.
EQUIPMENT
SOLUTIONS
NURSING OBSERVATIONS
Results
PATIENT DATA
553
554
Table 1 Patient data (mean (SD or range))
No. of patients
Age(yr)
Weight (kg)
Duration of treatment (h)
Dose of opioid mg/24 h (1989)
Dose of opioid mg/24 h (1990-93)
1989-90
1990-91
1991-92
1992-93
0-3 (mild)
46 (moderate)
7-10 (severe)
75*
18*
7*
91
9
0
93
6
1
83
13
4
Male
Female
433
65(14-92)
70(13)
70 (1-240)
9.7
7.23
337
61(17-99)
63(13)
64(1-576)
9.7
6.8
Absent
Mild
Discomforting
Distressing
Excruciating
1989-90
1990-91
1991-92
1992-93
21
38
29
10
2
25
41
19
11
4
26
25
32
14
3
1990-91
1991-92
1992-93
0-3 (mild)
4-6 (moderate)
7-10 (severe)
57
36
14
61
23
16
47
32
21
Females
Males
1989-90
1990-91
1991-92
1992-93
26
13
23
2
19
11
24
16
MINOR COMPLICATIONS
Rest
Movement
1991-92
1989-90
1990-91
2.2*
0.85 (0-6)
1.02(0-9)
3.23 (0-10) 3.14(0-10)
1992-93
1990-93
Table 6
VAS score
I?
2
2
Table 7 Serious complications with extradural infusion analgesia 1989-1993. *Patients 3, 6 and 7 died while receiving extradural analgesia
Patient
No.
Age Sex Past history
Operation
79
82
73
75
76
81
70
Problem
Hours Ventilatory
Infusion rate
postop. freq. (b.p.m.) (ml h"1)
Obstructive
jaundice, atrial
fibrillation
Hypertension
Laparotomy for
Unrousable, sedation
51
carcinoma of pancreas score = 3, previous
scores = 1
Rt. hemicolectomy Ca. 8 h postop. sedation score 21
of colon, transverse
= 2, infusion rate I
incision
from 6 to 2 ml h"1.
Patient remained
drowsy, sedation score
= 3 at 21 h
Reasonably healthy Laparotomy abandoned Drowsy postop.
7
because of inoperable Remained drowsy
gastric carcinoma
despite decreases in
infusion rate. 7 h
postop. sedation score
- 2. AP = 90/60 mm Hg
30 h postop. sedation
30
Parkinson's disease, Laparotomy. Long
obesity
midlinc incision,
score = 3, AP =
apendicetomy
80/50 mm Hg. Previous
scores = 1
Reasonably healthy Laparotomy abandoned 16 h postop. AP =
16
because of inoperable 75/45 mm Hg, slurred
gastric carcinoma
speech, level = T3
Inferior MI 18 yr
previously, atrial
fibrillation
Cholecystectomy
resection
10 h postop. hypotensive
AP = 90/60 mm Hg
10
12 h postop. hypotensive
AP = 85/45 mm Hg
12
Treatment
Outcome
Remarks
10
20
20
14
Infusion
Good response to
discontinued, treatment but patient
i.v. fluids,
developed CCF and
pul. oedema 2 h later.
ephedrine
Treated successfully
Inadequately
Infusion
discontinued, resuscitated. Cardiac
i.v. fluids
arrest 2 h later.
PMLarge intraabdominal
haemorrhage
Inadequately
Infusion
discontinued, resuscitated. Cardiac
i.v. fluids
arrest 4 h later.
PMLarge intraabdominal
haemorrhage
Overscdated pt who
became hypoxaemic
due to fluid overload.
Aspiration occurring
as part of terminal
event
Resp. depression can
occur at any time
9
I3
556
/. Respirations
If ventilatory frequency is less than 10 b.p.m.
inform maternity anaesthetist
If ventilatory frequency is less than 8 b.p.m.
STOP PUMP
bleep maternity anaesthetist
2. Pain score
Score 0 = No pain at rest
No pain on movement (see below)
Score 1 = No pain at rest
Slight pain on movement
Score 2 = Intermittent pain at rest
Moderate pain on movement
Score 3 = Continuous pain at rest
Severe pain on movement
Movement = patient attempts to touch opposite side of bed.
3. Sedation score
Score
Score
Score
Score
Score
results confirm the observation of Ready and coworkers that excessive sedation is a valuable clinical
sign of impending respiratory depression [16]. In
this series, extradural infusion analgesia tended to be
used in older, high-risk patients with associated
cardiorespiratory disease, undergoing extensive surgery, who were more prone to the depressive effects
of opioids. In patients receiving morphine orally or
parenterally (i.v., i.m., s.c.) the incidence of lifethreatening respiratory depression has been reported
to be 0.9% [17], which is higher than in our study.
Opioid-induced respiratory depression is not the
only hazard to the surgical patient. Myocardial
ischaemia secondary to tachycardia and hypertension
with poor analgesia may pose a greater risk to the
elderly surgical patient than the rare case of respiratory depression with extradural opioids. In highrisk patients undergoing non-cardiac surgery, early
postoperative myocardial ischaemia is an important
correlate of adverse cardiac outcome [18].
Hypotension secondary to hypovolaemia from
inadequate fluid replacement and sympathetic vasodilatation was a frequent finding: 34 % of patients
devejoped hypotension of less than 100 mm Hg at
some time during the first 24 h. While Hobbs and
Roberts [8] recorded an incidence of only 2.6% for
hypotension less than 95 mm Hg, Jayr and coworkers [11] found that 2 1 % of his patients with
extradural infusion analgesia had hypotension of less
than 80 mm Hg which responded rapidly to treatment. This is significantly greater (P < 0.05) than
the 8 % noted in his group of patients receiving s.c.
morphine. In the first year of the study, 8 % of our
patients had hypotension of less than 80 mm Hg.
The incidence has decreased as anaesthetic and
surgical staff have become aware of the problem and
paid particular attention to postoperative fluid
replacement and the use of colloid solutions with a
longer half-life. In the period 1990-1993, the
incidence of hypotension less than 80 mm Hg
decreased to 1.54.9%. This compares favourably
with Jay's s.c. morphine group.
Apart from the two patients (patients Nos 6, 7)
described in table 7, the remainder were treated
promptly and successfully by either the surgical staff
or the APT. The management procedures in place
ensured that it was readily recognized and treated
(appendix). Most of the patients in this series were
undergoing major laparotomy associated with larger
fluid shifts and losses during operation. It is common
for this group of patients to require frequent revision
of the i.v. fluid regimen after operation, irrespective
of the method of analgesia.
Three patients (patients Nos 3, 6, 7) died while
receiving extradural analgesia (table 7). In two
patients (Nos 6, 7) hypotension was attributed
incorrectly to extradural analgesia. Both patients
were suffering from major postoperative intraabdominal haemorrhage and while both responded
initially to i.v. fluids and stopping the extradural
infusion, hypotension recurred. A surgical cause was
deemed unlikely and both patients suffered cardiac
arrest after a period of hypotension with inappropriate fluid replacement. Other causes of hypotension should be suspected when there is in-
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558
4. Arterial pressure
IF BP IS LESS THAN
THEN
INCREASE I.V. INFUSION RATE
LIE PATIENT FLAT
ADMINISTER OXYGEN
BLEEP MATERNITY ANAESTHETIST
References
1. Report of a Working Party of the Commission on the
Provision of Surgical Services. Pain after Surgery. London:
Royal College of Surgeons of England and College of
Anaesthetists, 1990.
2. Wheatley RG, Madej TH, jackson IJB, Hunter D. The first
year's experience of an acute pain service. British Journal of
Anaesthesia 1991; 67: 353-359.
3. Kuhn S, Cooke K, Collins M, Jones JM, Mucklow JC.
Perceptions of pain relief after surgery. British Medical
Journal 1990; 300: 1687-1690.
4. Owen H, McMillan V, Rogowski D. Postoperative pain
therapy: a survey of patients' expectations and their
experiences. Pain 1990; 41: 303-307.
5. Morgan M. Epidural and intrathecal opioids. Anaesthesia and
Intensive Care 1987; 15: 60-67.
PROBLEMS
If there are any problems with the extradural please contact the
junior or consultant maternity anaesthetist.
N.B. Extradural analgesia is an effective method of pain relief
which relies on the administration of local anaesthetic and opioid
drugs via a catheter in the extradural space. The settings on the
pump are chosen by the anaesthetist with reference to the patient's
age, general condition and type of surgery. The settings should
only be altered by members of the acute pain team.