POSTOPERATIVE EPIDURAL INFUSION OF MORPHINE AND BUPIVACAINE IS SAFE ON SURGICAL WARDS - ORGANIZATION OF THE TREATMENT, EFFECTS AND SIDE-EFFECTS IN 2000 CONSECUTIVE PATIENTS

Background: There was an obvious need to improve the quality and safet y of our postoperative pain treatment and to introduce an improved rou tine service on surgical wards. Methods: It was decided to use postope rative epidural infusion of morphine 0.04 mg/ml and bupivacaine 2.5 mg /ml (0.25%): 4-8 ml/h as pain relief after major surgery. An education programme was run emphasising the benefits, side-effects and the impo rtance of regular monitoring of pain intensity, vital functions (respi ratory rate, blood pressure, heart rate), motor function of the legs a nd the need for additional drugs in order to detect side-effects as we ll as lack of adequate analgesic effect, A detailed observation sheet was used collecting information every 2 h throughout the epidural trea tment period in order to secure monitoring and adjustment of the treat ment, Close contact was maintained with the wards. Results: We present a detailed analysis of our first 2000 postoperative patients, mainly after orthopaedic (46.1%), gastrointestinal (32.0%), urologic (8.7%) a nd vascular (8.5%) surgery. Duration of the treatment was less than 24 h in 41.4% and more than 48 h in 29.7%. Pain relief was adequate in m ost patients, best after vascular surgery in the lower extremities (me an VAS 0.15/10.0 (95% confidence interval 0.09-0.23)) and less after g astrointestinal (mean VAS 0.49/10 (0.43-0.54)) and thoracic surgery (m ean VAS 0.59/10 (0.38-0.81)). The infusion was stopped due to respirat ory depression in 3 patients (0.15%). Four (0.2%) had systolic blood p ressure <80 mmHg and had to be treated with vasopressors. A total of 5 6 (2.8%) patients were considered to be problem patients due to excess ive sedation (0.4%), hypotension (0.7%), respiratory depression (1.6%) or lower extremity paralysis (0.05%). All patients had urinary cathet er until 6 h after termination of the epidural treatment. One patient had the epidural catheter accidentally placed subarachnoidally and exp erienced severe respiratory depression, No permanent sequelae were rec orded in the postoperative patients, but 2 traumatised patients develo ped epidural abscesses after 3 weeks of treatment, which resulted in l ower extremity paralysis. Late response to the warning signs might hav e contributed to the irreversible paraplegia. Conclusion: Our experien ce with this postoperative epidural analgesia regime is favourable. It has been easy to administer and monitor. pain relief was excellent, s ide-effects were few and picked up by the established routines followe d by the ward staff except in the 2 trauma patients who developed epid ural abscesses. The staff on the surgical wards were motivated for thi s kind of work. Education and strict surveillance routines are mandato ry in order to secure prompt action when warning signs develops (e,g, lower limb paralysis).