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9. The use of continuous background epidural infusion combined with PCEA results in
improved maternal analgesia and reduced unscheduled clinician interventions (N)
(Level I).
10. Thoracic epidural analgesia reduces need for ventilation in patients with multiple rib
fractures (S) (Level I) and reduces incidence of pneumonia (U) (Level II).
11. The combination of thoracic epidural analgesia with local anaesthetics and nutritional
support leads to preservation of total body protein after upper abdominal surgery (U)
(Level II).
12. The risk of permanent neurological damage in association with epidural analgesia is very
low; the incidence is higher where there have been delays in diagnosing an epidural
haematoma or abscess (S) (Level IV).
13. Immediate decompression (within 8 hours of the onset of neurological signs) increases SUMMARY
the likelihood of partial or good neurological recovery (U) (Level IV).
The provision of epidural analgesia by continuous infusion or patient‐controlled
administration of local anaesthetic‐opioid mixtures is safe on general hospital wards, as
long as supervised by an anaesthesia‐based pain service with 24‐hour medical staff cover
and monitored by well‐trained nursing staff (U).
Magnetic resonance imaging investigation may be warranted if patients who have had an
epidural catheter inserted develop a fever and infection at the catheter insertion site;
urgent investigation is especially indicated if other signs are present that could indicate
an abscess, such as back pain or neurological change (N).
Intrathecal analgesia
1. Intrathecal morphine offers improved analgesia and opioid‐sparing for up to 24 hours
especially following abdominal surgery (S) (Level I).
2. Intrathecal morphine doses of 300 mcg or more increase the risk of respiratory
depression (N) (Level I).
3. After major surgery, the incidence of respiratory depression and pruritus is higher with
intrathecal morphine compared with IV PCA opioids, but there is no difference in the
incidence of nausea and vomiting (N) (Level I).
Clinical experience with morphine, fentanyl and sufentanil has shown no neurotoxicity or
behavioural changes at normal clinical intrathecal doses (U).
The absence of consistent dose‐responsiveness to the efficacy of intrathecal opioids or
the adverse event rate, suggests that the lowest effective dose should be used in all
circumstances (N).
Regional analgesia and concurrent anticoagulant medications
1. Anticoagulation is the most important risk factor for the development of epidural
haematoma after neuraxial blockade (U) (Level IV).
Consensus statements of experts guide the timing and choice of regional anaesthesia and
analgesia in the context of anticoagulation, but do not represent a standard of care and
will not substitute the risk/benefit assessment of the individual patient by the individual
anaesthetist (U).
Acute pain management: scientific evidence xxxi
