SummaryEpidural abscess is a well-recognised but rare complication of epidural catheter placement. We have found only five previous reports of epidural abscess from noncatheter-related administration of steroids and/or local anaesthetic. We describe a further case which led to critical illness and emphasise the association between diabetes mellitus and epidural infection.Keywords Anaesthetic techniques, regional; epidural, caudal. Complications; epidural abscess, paraplegia, diabetes. ...................................................................................... Correspondence to: Dr M. G. A. Palazzo Accepted: 21 January 1997 Case historyA 53-year-old man, with noninsulin-dependent diabetes mellitus, was referred for specialist opinion by his general practitioner because of right buttock pain radiating into the posterolateral thigh and calf.Examination revealed straight leg raising limited to 75Њ on the left and 55Њ on the right. Knee reflexes were present and equal but ankle reflexes were absent. The plantar responses were equivocal and power was normal in both legs. A clinical diagnosis was made of lumbosacral nerve root compression due to intervertebral disc pathology and a caudal epidural injection was performed.A mixture of procaine hydrochloride and triamcinolone acetonide (unlicensed for epidural use) was drawn up from new sterile vials, the tops of which had been swabbed with 0.5% chlorhexidine in 70% spirit and allowed to dry. The skin was cleaned with 0.5% chlorhexidine in 70% spirit and allowed to dry. A new sterile 2'' 21G needle was introduced through the sacral hiatus using a no-touch technique (without the use of gloves, gown or mask). A total of 22 ml of 0.5% procaine hydrochloride with 80 mg of triamcinolone acetonide was slowly injected into the epidural space. After an initial administration of 10 ml, continued injection produced bilateral leg pain. However, within minutes of completing the procedure re-examination revealed that straight leg raising was full and painfree at 85Њ. On review 3 weeks later the patient reported significant coccygeal pain which had made sitting difficult. In addition he had experienced 4 days of bilateral leg pain, radiating into the posterior thighs and calves which had necessitated bed rest. Examination revealed pain-free spinal movements and straight leg raising was pain-free at 80Њ. His neurological status was unremarkable except for absent ankle reflexes. A further caudal injection was performed in an identical way to the first, including drug volume and dosage. However, bilateral leg pain was provoked after 5 ml had been injected.The following day he felt feverish and had a headache. He developed rigors and was admitted to hospital 3 days after the second epidural injection. On examination he was afebrile, had a stiff neck but no focal neurological signs. His bladder was distended. Haematological investigation showed a white blood cell count of 24.6 × 10 9 .l ᮊ 1997 Blackwell Science LtdAn L 4/5 and L 5 /S 1 bilateral foraminal and nerve root...

SummaryAcute Physiology and Chronic Health Evaluation (APACHE) II scoring is widely used as an index of illness severity, for outcome prediction, in research protocols and to assess intensive care unit performance and quality of care. Despite its widespread use, little is known about the reliability and validity of APACHE II scores generated in everyday clinical practice. We retrospectively re-assessed APACHE II scores from the charts of 186 randomly selected patients admitted to our medical and surgical intensive care units. These`new' scores were compared with the original scores calculated by the attending physician. We found that most scores calculated retrospectively were lower than the original scores; 51% of our patients would have received a lower score, 26% a higher score and only 23% would have remained unchanged. Overall, the original scores changed by an average of 6.4 points. We identified various sources of error and concluded that wide variability exists in APACHE II scoring in everyday clinical practice, with the score being generally overestimated. Accurate use of the APACHE II scoring system requires adherence to strict guidelines and regular training of medical staff using the system. [4] are used widely in most intensive care units (ICUs). They are used not only as an index of illness severity and outcome prediction, but also to assess clinical performance and quality of care [5, 6]. The APACHE II score is the most frequently used scoring system and has become an important tool in efforts to improve effective use of intensive care [7±11]. In addition, it is often used in research protocols to ascertain that different treatment groups are comparable.Despite its widespread use in ICUs, little is known about the reliability and validity of the APACHE II scoring system in everyday medical practice. We reported that there was wide interobserver variation in the application of the APACHE II score when a group of doctors (residents and intensivists) assessed the same patient [12]. Chen et al.[13] studied interobserver variability and variability in data collection in a number of community and teaching hospitals; they reported that revised mortality predictions were similar to the original [13]. However, their study did not discuss in detail the specific sources of error and problems in APACHE II scoring.This study was designed to: (i) assess the accuracy of APACHE II scoring in a medical and surgical ICU; (ii) assess the influence of the method of data collection, manual or via a patient data management system (PDMS), on accuracy and overall variability in scoring; (iii) specifically identify and discuss sources of error and q 2001 Blackwell Science Ltd 47 confusion; and (iv) provide suggestions on how to decrease variability. MethodsThe charts of 64 patients admitted to the medical ICU and 122 patients admitted to the surgical ICU over a 6-month period were randomly selected. APACHE II scores are assessed routinely in all patients admitted to the ICU within 2 days of admission. In the medical ICU...

An understanding of the factors which contribute to postoperative fatigue may benefit the rehabilitation of patients after surgery. Subjective feelings of fatigue and fatigue measured objectively in the adductor pollicis muscle after ulnar nerve stimulation have been studied in relation to changes in cardiorespiratory function and muscular efficiency both at rest and when walking on a treadmill at a work rate of 20 and 56 kpm min-1. Twelve patients admitted for elective abdominal surgery were studied before operation and again on the third postoperative day. The postoperative period was characterized by an increased feeling of fatigue. Surgery had no effect upon fatigue in the adductor pollicis muscle suggesting that the genesis of postoperative fatigue is partly central in origin. Muscular efficiency (s.d.) fell from 34(6) per cent before operation to 22(3) per cent (P less than 0.05) on the third postoperative day and was accompanied by a 19 per cent rise in the net energy (s.d.) expenditure (7.3(0.8) to 8.6(0.3) kJ min-1; P less than 0.03) required to perform a given workload. The increased cardiorespiratory effort and reduced muscular efficiency associated with the performance of low-intensity exercise may limit mobilization after surgery and contribute to a greater feeling of fatigue.

A randomised, double-blind study comparing a variety i$ different concentrations of jentanyl with and without 1:200000 adrenaline is described. It was shown that the quality and duration of analgesia with epidurul fentanyl was concentration-dependent betow 10 ,ug/ml, hut that the addition of adrenaline aholi,sked this phenomenon. The rate of .failure to achieve any analgesia was very high with the more dilute solutions. but adrenaline reversed this problem. In general the incidences of side effects were related to the concentrations of,fentanyl used and apart from itching, the incidences of these side efiects were reduced by the addition Qf adrenaline.

A double-blind study comparing a totally patient-controlled on-demand intravenous regime delivering fentanyl and a simple, regular, 4-hourly intramuscular regime delivering morphine is described. It was demonstrated that mean pain scores in the two groups were almost identical whilst sedation scores were no1 Jignifcantly different. Nausea scores were significantly lower in the regulur morphine group. Postoperative respiratory function tests were not significantly different in the two groups.