Audit of motor weakness and premature catheter dislodgement after epidural analgesia in major abdominal surgery

Abstract

SummaryIn a quality improvement audit on epidural analgesia in 300 patients after major abdominal surgery, we identified postoperative lower leg weakness and premature catheter dislodgement as the most frequent causes of premature discontinuation of postoperative epidural infusion. Lower limb motor weakness occurred in more than half of the patients with lumbar epidural analgesia. In a second period monitoring 177 patients, lumbar catheter insertion was abandoned in favour of exclusive thoracic placement for epidural catheters. Additionally, to prevent outward movement, the catheters were inserted deeper into the epidural space (mean (SD) 5.2 (1.5) cm in Period Two vs 4.6 (1.3) cm in Period One). Lower leg motor weakness declined from 14.7% to 5.1% (odds ratio 0.35; 95% confidence interval 0.16-0.74) between the two periods. Similarly, the frequency of premature catheter dislodgement was reduced from 14.5% to 5.7% (odds ratio 0.35; 95% confidence interval 0.17-0.72). With a stepwise logistic regression model we demonstrated that the odds of premature catheter dislodgement was reduced by 43% for each centimetre of additional catheter advancement in Period Two. We conclude that careful audit of specific complications can usefully guide changes in practice that improve success of epidural analgesia regimens.

Pain Management After Thoracic Surgery

“…The major cause of epidural failure was dislodgement of the epidural catheter out of the epidural space [180]. Four centimetre of catheter is probably insufficient for thoracic epidurals that are to remain in situ for a few days, 5-6 cm may be more appropriate [181]. Migration of the catheter out of the epidural space can be reduced by appropriate fixation with adhesive dressings, tunnelling or suturing.…”

Falling after epidural analgesia: lessons from obstetric anesthesia

“…This is supported by Königsrainer et al in a prospective audit of over 300 patients undergoing thoracoabdominal, upper abdominal, or colorectal surgeries. 13 The authors showed that a mid-thoracic (T8-T11) epidural catheter insertion site was associated with a lower incidence of lower limb motor block compared with a catheter insertion site that depended on the surgical incision level (almost 20% of these cases were lumbar epidurals). Moreover, the mid-thoracic epidural provided a similar quality of postoperative analgesia.…”

“…sur plus de 300 patients ayant subissant une intervention chirurgicale thoraco-abdominale, abdominale haute ou colorectale. 13 Les auteurs ont montré qu'un site d'insertion médio-thoracique (D8-D11) du cathéter péridural était associé à une moindre incidence des blocs moteurs des membres inférieurs, comparativement à un site d'insertion du cathéter au niveau de l'incision chirurgicale (près de 20 % de ces cas étaient des péridurales lombaires). En outre, une péridurale médio-thoracique produisait une qualité d'analgésique postopératoire similaire.…”

Greater Cephalad Extent of Thoracic Epidural Sensory Anesthesia After Lidocaine and Epinephrine Test Dose Correlates With Analgesic Consumption and Pain Burden After Uterine Fibroid Artery Embolization

“…Lumbar epidural analgesia has been reported to be inadequate to control pain after UFAE, 3 and motor block secondary to lumbar epidural analgesia may delay recovery or prolong discharge. 4 Thoracic epidural analgesia is an effective method after UFAE. 5 Compared with lumbar epidural analgesia, the thoracic approach may be superior, with the potential advantage of more congruent dermatomal anesthetic administration for procedures such as UFAE.…”