Epidural Analgesia In Patients Research Articles

Outcome and complications of epidural analgesia in patients with chronic cancer pain

BACKGROUND Some cancer patients require invasive techniques for control of chronic cancer pain. Many patients have benefited from local administration of opioids and anesthetics through an epidural catheter. However, epidural abscess and meningitis are side effects of epidural catheters that have serious morbidity and mortality. METHODS In a retrospective study, the charts of all patients who received an epidural catheter for the management of chronic cancer pain in a 3-year period (1993-1996) were reviewed. Patients with nervous system infections were identified and pertinent clinical, radiologic (magnetic resonance imaging), and bacteriologic data were analyzed. RESULTS Ninety-one patients received 137 epidural catheters for a total of 4326 catheter days. All but four patients had died at the time of the final analysis. The median survival after placement of the first epidural catheter was 38 days (range, 1 day-> 1000 days). Seventy-two patients received a percutaneous port whereas 19 patients were treated with an implanted subcutaneous port. Adequate pain relief was obtained in 76% of the 58 patients with nociceptive pain and in 73% of 33 patients with neuropathic pain. All neuropathic pain was associated with active tumor and could be classified as nociceptive nerve pain. Technical complications and superficial infections occurred in as many as 43% of patients. Deep infections occurred in 12 patients, 11 of whom had a spinal epidural abscess. CONCLUSIONS Deep infection is a frequent complication of epidural analgesia and is associated with a high morbidity and mortality. Only cancer patients with a short life expectancy (≤3 months) should be treated with epidural analgesia. Cancer 1998;83:2015-2022. © 1998 American Cancer Society.

Outcome and complications of epidural analgesia in patients with chronic cancer pain

Some cancer patients require invasive techniques for control of chronic cancer pain. Many patients have benefited from local administration of opioids and anesthetics through an epidural catheter. However, epidural abscess and meningitis are side effects of epidural catheters that have serious morbidity and mortality. In a retrospective study, the charts of all patients who received an epidural catheter for the management of chronic cancer pain in a 3-year period (1993-1996) were reviewed. Patients with nervous system infections were identified and pertinent clinical, radiologic (magnetic resonance imaging), and bacteriologic data were analyzed. Ninety-one patients received 137 epidural catheters for a total of 4326 catheter days. All but four patients had died at the time of the final analysis. The median survival after placement of the first epidural catheter was 38 days (range, 1 day--> 1000 days). Seventy-two patients received a percutaneous port whereas 19 patients were treated with an implanted subcutaneous port. Adequate pain relief was obtained in 76% of the 58 patients with nociceptive pain and in 73% of 33 patients with neuropathic pain. All neuropathic pain was associated with active tumor and could be classified as nociceptive nerve pain. Technical complications and superficial infections occurred in as many as 43% of patients. Deep infections occurred in 12 patients, 11 of whom had a spinal epidural abscess. Deep infection is a frequent complication of epidural analgesia and is associated with a high morbidity and mortality. Only cancer patients with a short life expectancy (< or =3 months) should be treated with epidural analgesia.

Clinical and bacteriologic survey of epidural analgesia in patients in the intensive care unit.

The risk of bacterial contamination related to epidural analgesia in patients cared for in the intensive care unit has not been assessed. Thus the authors studied patients who received care in the intensive care unit who were given epidural analgesia for more than 48 h to determine the rates of local, epidural catheter, and spinal space infection and to identify risk factors. Each patient receiving epidural analgesia for longer than 48 h was examined daily for local and general signs of infection. A swab sample for culture was taken if there was local discharge; all epidural catheters were cultured on withdrawal. All patients underwent weekly neurologic monitoring for 1 month; those with positive epidural catheter cultures had one spinal magnetic resonance image scan. The 75 patients cared for in the intensive care unit who were studied had been receiving epidural analgesia for a median of 4 days (interquartile range, 3.5 to 5 days). Twenty-seven patients had signs of local inflammation (erythema or local discharge), and nine of these had infections. All the patients who had both local signs also had infection. All nine infections were local (12%), but four patients also had epidural catheter infections (5.3%). No patient with erythema alone or without local signs had a positive epidural catheter culture. No spinal space infection was diagnosed. Staphylococcus epidermidis was the most frequently cultured microorganism. Local infection was treated by removing the epidural catheter without any antibiotics. Concomitant infection at other sites (21 of 75 patients, or 28%), antibiotic therapy (64 of 75 patients, or 85%), the duration of epidural analgesia, and the insertion site level of the epidural catheter were not identified as risk factors for epidural analgesia-related infections. The risk of epidural analgesia-related infection in patients in the intensive care unit seems to be low. The presence of two local signs of inflammation is a strong predictor of local and epidural catheter infection.

Epidural Analgesia in Patients with Congenital Lumbosacral Spinal Anomalies

Epidural Analgesia in Patients with Congenital Lumbosacral Spinal Anomalies

VENTILATORY FUNCTION DURING EPIDURAL ANALGESIA

Certain aspects of ventilatory function were studied before and after induction of high epidural analgesia in patients with normal and diseased respiratory systems. The changes in tidal volume, minute volume and vital capacity in both groups were small. Somewhat greater reductions in peak expiratory flow rate were observed but it is unlikely that the ability to cough is much impaired during epidural block. It is concluded that no important degree of respiratory paralysis is present during epidural block. The value of epidural analgesia for patients with poor pulmonary function and in the relief of postoperative pain is discussed.

VENTILATORY FUNCTION DURING EPIDURAL ANALGESIA

Certain aspects of ventilatory function were studied before and after induction of high epidural analgesia in patients with normal and diseased respiratory systems. The changes in tidal volume, minute volume and vital capacity in both groups were small. Somewhat greater reductions in peak expiratory flow rate were observed but it is unlikely that the ability to cough is much impaired during epidural block. It is concluded that no important degree of respiratory paralysis is present during epidural block. The value of epidural analgesia for patients with poor pulmonary function and in the relief of postoperative pain is discussed.