British Journal of Anaesthesia 1994; 73: 552-558

COMMENTARIES

Extradural infusion analgesia for postoperative pain relief

S. LEITH, R. G. WHEATLEY, I. J. B. JACKSON, T. H. MADEJ AND D. HUNTER

Summary

Key words
Analgesic techniques, extradural. Pain, postoperative. Surgery,
postoperative period.

The publication in 1990 of the Joint College Report

on Post Operative Pain [1] highlighted the inadequacy of postoperative analgesia in hospitals in
the UK. In particular, it advocated the establishment
in all major hospitals of an acute pain team (APT)
with responsibility for the safe introduction and
evaluation of newer methods of pain relief.
An APT was set up in York District Hospital in
April 1989 and continues to work within its original
framework [2]. The results of the first year's
experience with the use of extradural infusion
analgesia for postoperative pain control were encouraging. The majority of patients (75 %) reported
mild pain during the first 24 h, with only 7 %
experiencing severe pain. This contrasted favourably
with previously reported studies on the incidence of
postoperative pain in patients receiving i.m. analgesia [3, 4].

Patients and methods

The members of the APT monitor all patients
recovering from surgery and other patients with
acutely painful conditions who are receiving extradural infusion analgesia or patient-controlled analgesia (PCA). The decision to use extradural
analgesia instead of PCA rested solely with the
patient's anaesthetist, after discussion with the
patient before operation. Accepted contraindications
to the placement of an extradural catheter were
observed.
Extradural catheters were sited, where possible, at
the dermatomal midpoint of the proposed incision
either before or after induction of anaesthesia. No
procedure was specified for perioperative management apart from the avoidance of long-acting i.v.
opioids. Analgesia was provided during operation by
increments of 0.25-0.5 % bupivacaine 5-20 ml with
diamorphine 2.5-5.0 mg. The extradural infusion
was started after operation by the nursing staff in the
recovery room using a standardized procedure (see
below).

EQUIPMENT

The infusion system used to maintain extradural

infusion analgesia was updated during the study
period. Initially, in 1989, PCA pumps in background
infusion mode were used to provide analgesia. These
pumps used 50-ml syringes and required refilling
twice a day. A potential existed for confusion

S. LEITH, FRCA, R. G. WHEATLEY, FRCA, I. J. B. JACKSON, FRCA,

T. H. MADEJ, FRCA, D. HUNTER, RGN, Department of Anaes-

thetics, York District Hospital, Wiggington Road, York YO3

7HE. Accepted for publication: April 13, 1994.
Correspondence to R. G.W.

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We describe 4-yr experience providing extradural

infusion analgesia in a district hospital for treatment
of postoperative pain. A total of 770 patients
recovering from major surgery were treated on
general surgical wards between April 1989 and
March 1993. The results of a retrospective audit
showed that pain control, assessed with both a
visual analogue scale (VAS score (0-10 cm)) and a
verbal rating scale (VRS), was good. At rest, more
than 80% of patients scored pain as absent or mild
(VAS score 0-3) during the first 24 h, with only 4%
experiencing severe pain (VAS score 7-10). On
movement, 50% of patients had good pain control
(VAS score 0-3) while 20% of patients experienced
severe pain (VAS score 7-10). Minor complications
such as emetic sequelae and pruritis were common;
these conditions were mild and rarely required
treatment. Hypotension ( < 1 0 0 m m Hg) occurred
in 34% of patients in the first 24 h. Ventilatory
frequencies of 8 b.p.m. or less occurred in 2.6% of
patients. Four patients (0.52%) developed severe
respiratory depression. These patients demonstrated
increased sedation but only one had a low
ventilatory frequency. Three patients died while
receiving extradural infusion analgesia. (Br. J.
Anaesth. 1994; 73: 552-558)

The fear of life-threatening complications, such as

respiratory depression and hypotension associated
with extradural infusion analgesia, brought suggestions that extradural analgesia should be used only in
high dependency units (HDU) [5]. This strategy
would deny the majority of patients this improved
method of analgesia.
The aim of the audit was to ascertain the efficacy
and safety of administering extradural infusion
analgesia to patients on general wards under the
guidance of the APT, without the availability of high
dependency nursing and monitoring.

Extradural analgesia for postoperative pain

between patients receiving PCA and extradural

analgesia. To minimize this risk and the time
involved in refilling the syringes, a new system was
introduced. The updated system used an ambulatory
PCA device (Bard Ltd, Crawley, W. Sussex, UK)
which included a 250-ml infusion bag. This system
was again updated in 1992 and now extradural
infusion analgesia is maintained using ambulatory
Abbott Pancretec Provider pumps (Abbott Laboratories Ltd) which use a 500-ml infusion bag prepared
by our pharmacy. This system differs physically
from the PCA system, avoiding confusion, and
provides analgesia for up to 5 days without refilling.

SOLUTIONS

NURSING OBSERVATIONS

While patients were in the recovery room, nursing

observations (ventilatory frequencies, pain score
(0-3) [2], dermatomal level, arterial pressure and
sedation score (0-3)) were assessed at 15-min
intervals. In the ward, similar observations were
made by the nursing staff, hourly for the first 4 h and
then 4-hourly for the duration of the infusion. Each
set of observations was signed for by the recording
nurse. The extradural forms were assessed daily on
die APT ward round for occurrence of complications
and completeness of recording. The compliance of
die nursing staff in recording the data was extremely
high (approaching 100%). In the first year,
1989-1990, sedation was not assessed but a simple
sedation score was included subsequently in the
postoperative observations. Each extradural chart
contained guidelines for the management of
complications. Guidelines were available also on the
wards and the nursing staff attended in-house
training on the management of extradurals (See
appendix). A member of the APT was available on a
24-h basis (including weekends) to give advice and
treatment if required. Bolus doses and changes in the
infusion rate could be given only by a member of the
pain team.

the morning and afternoon ward rounds for the

duration of treatment. The acute pain service (APS),
which has been in operation since 1989 [2], is based
on the existing obstetric anaesthetic service and is
provided by three consultant anaesthetists, an acute
pain sister, and die on-call obstetric trainee anaesthetist. An audit of the entire workload of the
APS for the year 1989-1990 showed that approximately 30 % of each consultant session was spent on
the ward rounds and work related to the provision of
the service (both extradural analgesia and PCA). The
trainee anaesthetists spent 26% of their working
time on acute pain work. A substantial part of the
time spent by the trainee anaesthetist in the year
19891990 was refilling and attending to problems
with the PCA pumps which were also being used for
extradural analgesia during this year. This proportion of work has decreased over the past 3 yr widi
the increasing involvement of die nursing staff.
However, the increase in die number of patients
referred to the service (660 in 1989-1990, 1362 in
1992-1993) has kept the workload of the trainee
anaesthetist constant. The assessment at 24 h included: (1) VAS score (0-10) for pain at rest; (2)
VAS score (0-10) for pain on movement; (3) VRS
for satisfaction (poor, fair, adequate, good, excellent); and (4) VRS for pain (absent, mild, discomforting, distressing, excruciating). Both (2) and
(4) were introduced in 1990 after the first year's
experience with die service. The inclusion of a
movement component improved the measurement of
efficacy without significantly increasing die workload
of the APT. In addition, the incidences of emetic
sequelae and pruritus were recorded.

Results
PATIENT DATA

In die 4-yr period, April 1989 to March 1993, 770

patients received extradural infusion analgesia on
general wards in York District Hospital (table 1).
The number of patients receiving extradural infusion
analgesia increased from 150 in 1989-1990 to 226
in 1992-1993. The mean duration of treatment
increased from 55 to 80 h over die same period.
The majority of patients (65-82%) were referred
to the service after general abdominal surgery. Nonsurgical referrals included pancreatitis and chest
trauma.
ASA status ranged from ASA I to IV with the
majority of patients (73%) of ASA II-IV status.
There was an annual decrease in the percentage of
ASA I patients receiving extradural infusion analgesia (40% in 1989-1990, 16% in 1992-1993).
Patients satisfaction with the method of analgesia
was high, widi more dian 88 % of patients regarding
it as adequate, good or excellent.
PAIN ASSESSMENT (VAS SCORE 0 - 1 0 )

ACUTE PAIN TEAM WARD ROUND

After referral to the APT, each patient receiving

extradural infusion analgesia was seen twice daily on

In the first year of the service, 75% of patients

receiving extradural analgesia scored pain as mild,
with only 7% experiencing severe pain (table 2).
After the introduction in 1990 of separate VAS

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Initially the extradural infusate consisted of a

solution of 0.15% bupivacaine with diamorphine
5 mg in 50 ml (0.01 %). The dose of diamorphine
was reduced to 2.5 mg in 50 ml (0.005 %) in patients
more than 65 yr of age. In 1990, after the introduction
of the larger infusion bags, the dose of diamorphine
added to 0.15% bupivacaine was reduced and all
patients, irrespective of age, received diamorphine at
the lower concentration of 0.005 % (25 mg in
500 ml). This change was designed to reduce the
daily dose of diamorphine administered. The first
year's experience with the service demonstrated that
the lower concentration was effective in the majority
of patients. Infusion rates varied from 4 to 10 ml h"1.

553

British Journal of Anaesthesia

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)

Table 2 Twenty-four-hour pain assessment (VAS 0-10) at rest

(% patients). M989-1990 single VAS at 24 h
VAS score

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

Table 5 Patient assessment of pain severity (VRS)

(% patients)

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

Table 3 Twenty-four-hour pain assessment (VAS 010) on

movement (% patients)
1989-90

1990-91

1991-92

1992-93

0-3 (mild)
4-6 (moderate)
7-10 (severe)

57
36
14

61
23
16

47
32
21

Incidence of vomiting in the first 24 h (% patients)

Females
Males

scores (0-10) for assessing pain at rest and on

movement, the results showed that more than 80 %
of patients scored their pain as mild at rest (table 2),
but this declined to 50% on movement, with
16-21 % experiencing severe pain (table 3). Mean
pain scores varied from 0.85 to 1.3 at rest and from
3.14 to 3.84 on movement (table 4). On assessing the
severity of pain experienced by patients using the
VRS, 50% experienced no pain or mild pain and
less than 4 % described dieir pain as excruciating
(table 5).

1989-90

1990-91

1991-92

1992-93

26
13

23
2

19
11

24
16

[2]. Both patients had lumbar extradural catheters

sited for pain relief after abdominal hysterectomy.
While formal assessment of motor block was not
made, it was noted frequently on the APT ward
round that after hysterectomy, patients with extradural infusion analgesia had difficulty mobilizing
because of motor block. It has since become
departmental policy to use PGA for pain control
after this type of surgery, avoiding the use of lumbar
extradural catheters.
Urinary retention was not studied as most patients
receiving extradural infusion analgesia were
catheterized before operation.

MINOR COMPLICATIONS

Hypotension secondary to relative hypovolaemia was

a frequent finding; 34% of patients had a systolic
arterial pressure of less than 100 mm Hg at some
time in the first 24 h (see discussion).
Mean ventilatory frequency varied between 14 and
15 b.p.m., with 2.6 % of patients with frequencies of
8 b.p.m. or less.
Emetic sequelae. The incidence of vomiting in
females was (19-26 %) compared with males (2-16 %)
(table 6).
Pruritis. The incidence of pruritus varied between
12 and 22%, but treatment was rarely required.
Prolonged block. Two patients in the first year of
the study developed prolonged unilateral motor
block lasting 410 days which delayed mobilization
Table 4

MAJOR COMPLICATIONS (TABLE 7)

In the 4-yr period 1989-1993, four patients (0.52 %)

developed severe respiratory depression associated

with excessive sedation, airway obstruction and

hypoxaemia. One patient subsequently died (patient
No. 3).
High block. One patient with a thoracic extradural
catheter in situ for analgesia after laparotomy developed hypotension associated with slurred speech
because of block to the third thoracic dermatome
(patient No. 5).
Two patients (Nos 6, 7) with major postoperative
intra-abdominal

haemorrhage were managed in-

adequately as hypotension was attributed incorrectly

Twenty-four-hour VAS 0-10 (mean (range)). M989-1990 single 24 h VAS 0-10

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

1.3 (0-10) 1.05(0-10)

3.84 (0-10) 3.40 (0-10)

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Table 6
VAS score

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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

M Reasonably healthy Abdominal-perineal

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

I.v. naloxone Good, no adverse

sequelae

Resp. depression can

occur at any time

I.v. naloxone Good, no adverse

sequelae

Some elderly patients

are very sensitive to
opioids

20

I.v. fluids, Good recovery

infusion
initially. At 13 h
discontinued postop. cardiac arrest
PM = Basal
congestion/aspiration

20

I.v. naloxone, Good, no adverse

i.v. fluids sequelae

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

CCF due to fluid

overload and rebound
vasoconstriction on
stopping infusion
Other causes of
hypotension should
be suspected when
there is an inadequate
response to simple
measures
As above

9
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British Journal of Anaesthesia

556

to the effects of extradural block. A surgical cause

was not considered.
Discussion
Efficacy and safety are major considerations in the
provision of pain relief. This is particularly relevant
with the use of invasive techniques such as extradural
infusion analgesia where hypotension and respiratory depression are potential complications. It is
therefore important to demonstrate a high benefit to
risk ratio.
EFFICACY

EMESIS AND PRURITUS

The incidence of emetic sequelae was higher than

that reported previously by Hobbs and Roberts [8].
The clinical impression of the APT is that nausea
and vomiting in patients receiving extradural analgesia is confined to the first few hours after surgery
and is controlled easily by a single dose of antiemetic.
Similar results have been found with the use of
extradural fentanyl [13].
The incidence of pruritus was high compared with
that found by Hobbs and Roberts (22% vs7.5%)
[8]. Few of our patients required treatment for
pruritus and on no occasion was it necessary to
discontinue the infusion. Semple and colleagues [14]
and Lee and colleagues [15] noted previously that
pruritus after extradural diamorphine is often not
severe enough to require treatment and may only be
elicited on direct questioning.
SAFETY

The incidence of respiratory depression was less

than that of Hobbs and Roberts (2.6% vs 6.3%) [8].
With the exception of the four patients described in
table 7, no other patient presented a problem or
required active treatment apart from either stopping
the infusion for a short period or reducing the hourly
infusion rate. Three of the four patients with
respiratory depression requiring treatment had
ventilatory frequencies greater than 8 b.p.m. All
four patients had sedation scores of 2 or more. Our

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The VAS score (0-10) at 24 h has been used widely

to quantify postoperative pain and has been shown to
be an acceptable indication of a patient's pain after
surgery [6]. The visual analogue and verbal descriptive score techniques have been shown to
successfully assess the sensory intensity of experimental pain [7]. These two methods of pain
assessment were used for the 3-yr period 1990-1993.
The results showed that more than 80% of our
patients were comfortable at rest (mean VAS 1.05),
with 50% (47-54%) being comfortable on movement (mean VAS 3.4). Using the VRS to assess the
quality of pain experienced by the patient, more than
50% (51-67%) described their pain as absent to
mild, with less than 20% (12-17 %) describing their
pain as distressing or excruciating. Direct comparison of our results with similar studies is difficult
because of the different methods used for pain
assessment [8, 9]. The use of a local anaesthetic with
an opioid in the extradural space results in better
pain relief than one of the agents alone [10], while
minimizing the side effects associated with the
administration of each drug alone. Administration
by infusion also produces effects in a more gradual
manner.
Extradural infusion analgesia provides improved
postoperative pain control compared with parenteral
methods. In a study using i.m. analgesia, Kuhn and
colleagues [3] found that only 13% of patients had
little or no pain while 40% described pain as very
painful. Similarly, Owen, McMillan and Rogowski
[4], using a pain rating scale, found that only 26 % of
patients described pain as mild or absent while 37 %
rated pain as unbearable or severe. Jayr and
co-workers, [11] in a recent study comparing the
effects of extradural bupivacaine and opioids with
parenteral opioids (s.c. morphine 2.5 mg h~')j found
that pain control was significantly better in the
extradural group than in the s.c. group, especially
during recovery and on the first and second postoperative days. The results of our first year's
experience with the APT [2] showed that patients
receiving extradural analgesia were more likely to
have no pain or mild pain than those receiving PCA
(chi-square, P < 0.05). The mean pain scores for the
first 24 h were lower in patients receiving extradural
analgesia (extradural analgesia 2.2, PCA 3.5). Extradural infusion analgesia offers potential benefit over
PCA in certain clinical situations, as elderly patients

undergoing major surgery are often unable to

comprehend the device and technique appropriately.
Despite improved postoperative pain control with
extradural analgesia, 20% of our patients still
experienced severe pain on movement during the
first 24 h. Although this is disappointing, it became
apparent early in the provision of extradural analgesia that the end-point of a "pain free" patient
was unrealistic on a general ward setting. Our aim
therefore was to provide analgesia sufficient to allow
movement and adequate cough. Our results might
have been improved by increasing the dose of both
drugs, but this would increase the incidence of
complications and would restrict the use of extradural infusion analgesia to HDU and to a small
number of patients. Laveaux and colleagues compared high concentration/low volume with low
concentration/high volume extradural bupivacaine
with sufentanil and concluded that with extradural
administration of bupivacaine and sufentanil for
postoperative analgesia the total dose is more
important than the concentration or volume of the
solution [12]. The percentage of patients experiencing severe pain (VAS 7-10) increased during
the period 1990-1993 because of a change in referral
pattern, with a decrease in the percentage of
gynaecology patients receiving extradural analgesia
(21% in 1989-1990, 1^1% in 1990-1993) and a
comparable increase in the percentage of general
surgical patients (65% in 1989, 76-82% in
1990-1993) receiving extradural analgesia for upper
abdominal and thoracic surgery.

Extradural analgesia for postoperative pain

adequate response to simple measures and it is

important that both the surgical and APT review
problem patients.
A third patient (patient No. 3) who was found to
have an inoperable gastric carcinoma at laparotomy
died in the early postoperative period. This patient
demonstrated increasing sedation scores despite
decreasing the extradural infusion rate. Seven hours
after surgery she developed hypotension. While she
responded initially to i.v. fluids and stopping the
infusion, she suffered a cardiac arrest 6 h later. The
post-mortem report showed basal consolidation with
evidence of aspiration. Persistent or increasing
sedation in any patient receiving extradural infusion
analgesia should alert to the possibility of impending
respiratory depression. In the last year of the audit
it became departmental policy to prescribe supplementary oxygen for all patients recovering from
major surgery for at least the first 48 h and the third
night after operation.
In conclusion, we believe that our experience of
managing 770 patients over a 4-yr period with
extradural infusion analgesia on general wards
demonstrates that this is an effective method of
postoperative pain control that can be used safely on
general wards if supervised by an acute pain team.
Procedures for management of the patient must be in
place and understood. The early recognition and
management of hypotension is important. Complications such as hypotension should not be attributed
solely to extradural analgesia and other possible
causes should be excluded. A multidisciplinary team
approach with clearly defined roles, ongoing staff
education and frequent audit is necessary to ensure
that extradural analgesia can be used safely' on
general wards in a district general hospital.
Appendix
NURSING CHECKS

/. 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.

INFORM MATERNITY ANAESTHETIST IF CONTINUING INADEQUATE PAIN RELIEF

3. Sedation score
Score
Score
Score
Score
Score

0 = None (patient alert)

1 = Mild (occasionally drowsy, easy to arouse)
2 = Moderate (frequently drowsy, easy to arouse)
3 <= Severe (somnolent, difficult to arouse)
S = Sleep (normal sleep, easy to arouse)

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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-

557

558
4. Arterial pressure
IF BP IS LESS THAN
THEN
INCREASE I.V. INFUSION RATE
LIE PATIENT FLAT
ADMINISTER OXYGEN
BLEEP MATERNITY ANAESTHETIST

5. Level = dermatome at which cold sensation

returns
Dermatomes: T5Xiphistemum
T10Umbilicus
T12Pubis
If level is greater than
then inform maternity anaesthetist

References
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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.

British Journal of Anaesthesia