A comparison of thoracic and lumbar epidural techniques for postthoracoabdominal esophagectomy analgesiaPurpose: To compare thoracic epidural analgesia (TEA) using a bupivacaine/[entanyl mixture and lumbar epidural analgesia (LEA) with morphine, in respect to the time to extubation and the quality of post-operative analgesia, in patients having thoracoabdominal esophagectomy. Methods: Twenty two patients scheduled for elective thoracoal:x:lominal esophagectomy were randomized to TEA or LEA. Postoperatively, the TEA group received Patient Controlled Epidural Analgesia (PCEA) with bupivacaine 0.12596 and 5/./g'ml Bt fentanyl, and the LEA group received PCEA with 0.2/ag'ml Bl morphine. A blinded observer assessed criteria for tracheal extubation and the time of tracheal extubation was recorded. Early extubation was defined as tracheal extubation within four hours postoperatively. Visual analogue pain scores at rest (Static Visual Analogue Pain Scores, SVAPS) and with movement (Dynamic Visual Analogue Pain Scores, DVAPS) were recorded at I , 6, 12, 18 and 24 hr post-extubation. Failure of the epidural protocol (FEP) was defined as a request for additional analgesia. Results: Tracheal extubation was achieved in 70% of the LEA and 100~ of the TEA at four hours postoperatively (P=NS). However, the TEA group achieved earlier extubation times when assessed with log rank testing (P = 0.01 ). By six hours postextubation FEP had occurred in 50% of the LEA group but in none of the TEA group (P = 0.0 I). Mean SVAPS and DVAPS were lower in the TEA than in the LEA group at all measured times (P < 0.01).Conclusion: This study has demonstrated superior pain control in patients undergoing thoraco-abdominal esophagectomy treated with TEA than with LEA, particularly for pain with movement. Tracheal extubation occurred earlier in the TEA group, but this difference was not significant at four hours postoperatively.

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Larry Kahn BSC (med), MB Crib Neuropathies masquerading as an epidural complicationPurpose: The purpose of this report is to emphasise the role of the Acute Pain Service in managing local anaesthetic epidural infusions for postoperative pain management, the importance of vigilant monitoring, and to offer some guidelines to using local anaesthetic epidural infusions.Clinical features: A 34-yr-old man with long-standing insulin dependent diabetes mellitus underwent a total proctocolectomy for inflammatory bowel disease. A "1"9-I 0 epidural catheter was placed prior to induction of general anaesthesia, Postoperatively, a continuous epidural infusion of fentanyt/bupivacaine was used for postoperative pain management. Total lithotomy time was four hours, On day four he was noted to have complete nght sided femoral and left sided lateral femoral cutaneous nerve of thigah neuropathies, A computerisecl tomography scan and a magnetic resonance imaging excluded a central lesion. Electromyelography confirmed peripheral nerve injunes.Conclusion: This patient's neurological deficits were not due to the epidural analgesia. However, epidural infusion of local anaesthetic caused a delay in recognising a potential neurological complication, When using local anaesthetic epidural infusions, it is important to exclude other causes of motor block before attributing it to the local anaesthetic.

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tions, leads one to ask if relatively high concentrations of local anaesthetic should ever be used for postoperative analgesia. Opioids and local anaesthetics have been shown to be synergistic in animal models and at least additive in several human postoperative analgesia trials. 2-4 However, recent reports have shown that an additive analgesic interaction can be attained with relatively low concentrations of bupivacaine (0.1-0.3 mg-m1-1) infused at a rate of 1-5 mg.hr-aJ s-s) It may also be necessary to titrate the local anaesthetic and opioid separately to obtain the greatest degree of analgesic synergy. Fixed mixtures of opioids and local anaesthetics make it difficult to optimize the benefits of each analgesic and reduce side effects, s-s This may be best accomplished by utilizing a patient controlled analgesia delivery system for the opioid component.Kahn's report points out the potential for high concentrations of bupivacaine to produce confusion in the evaluation of postoperative neurological deficits. Concentrations of bupivacaine > 0.06% do not appear to add much in analgesic benefit and contribute to a greater incidence of motor block and hypotension. 3-s I would suggest that any patient developing motor deficit in the postoperative period should have the local anaesthetic discontinued from the epidural analgesic solution. The patient should be reevaluated within two hours to examine for regression of the nerve block. Furthermore, concentrations of bupivacalne > 0.06% are not warranted and should be abandoned in the delivery postoperative epidural analgesia.