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Division of Trauma Anesthesiology, R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
To the Editor:
Drs. Rosenquist and Birnbach provide an excellent discussion of the risks and benefits associated with placement of lumbar epidural catheters in anesthetized adults (1) but may have failed to consider issues that we see commonly in our practice at a specialty trauma center. The potential benefits of intraoperative epidural anesthesia and postoperative analgesia to patients undergoing major pelvic or lower extremity orthopedic procedures have been well documented and include reduced intraoperative blood loss, reduced incidence of deep venous thrombosis, earlier postoperative mobilization, and decreased requirement for narcotic analgesia (2). Few would disagree that this technique is appropriate for patients undergoing acetabular fixation or open femoral reconstruction and even more beneficial in patients with open wounds or fasciotomy sites who will be undergoing repeated surgical debridement. While placement of an epidural catheter may be safer with the patient awake, as detailed by Rosenquist and Birnbach, this practice may in fact reduce the number of patients who can benefit. Many of our patients come to the operating room already intubated and sedated. Others cannot be positioned awake for epidural placement because of painful and unstable fractures. Some patients will refuse awake epidural catheter placement due to anxiety regarding pain and needle sticks but welcome the procedure if performed following the induction of general anesthesia, even when informed regarding the possibly increased potential for nerve damage.
While not able to report on an experience like that of Dr. Horlocker (3), our own records indicate that we have placed at least 1000 lumbar epidurals over the past 15 years in anesthetized patients, with no subsequent nerve deficits attributable to this technique. While we cannot quantify the absence of venous thrombosis, the units of blood not transfused, and the improvement in postoperative pain management this approach has brought to our patients, we can at least suggest that the benefits have outweighed the risks for those in whom placement under anesthesia was the only acceptable approach.
References
University of Iowa College of Medicine, Iowa City, IA University of Miami School of Medicine, Miami, FL
In Response:
We would like to thank Dr. Dutton and his colleagues for their comments regarding our editorial (1). We are pleased that they believe that we provided an excellent discussion of the risks and benefits associated with placement of lumbar epidural catheters in anesthetized patients. The purpose of our editorial was not to dissuade anesthesiologists from this technique in all patients or to ignore the trauma patient, but rather to reiterate that the risks and benefits of neuraxial blockade in the anesthetized adult should be considered and discussed with the patient prior to initiation of the block.
While Dutton and colleagues make a cogent argument for the use of neuraxial anesthesia for lower extremity surgery, especially in practices such as theirs, they do not convince us that epidural anesthesia should be performed routinely in healthy anesthetized patients. For example, while we agree that an intubated and sedated patient might otherwise be denied a beneficial regional anesthetic and thus justify the risks involved, we do not believe that the risk is equally acceptable because the patient has "anxiety regarding pain and needle sticks."
The data presented by Dutton complement those presented by Horlocker et al. (2) and are somewhat reassuring. However, the fact that no complications have "been seen" by Dutton and his colleagues in over 15 years of practice does not mean that there is no risk to this technique. How were the patients examined and interviewed postoperatively? Were they all seen? While interesting, there are just too many unanswered questions regarding their experience, and therefore we suggest that Dr. Dutton and colleagues consider writing up their results and submitting them to peer review before they are accepted as fact.
As discussed in our editorial, we believe that this is an exciting topic that needs further evaluation via prospective randomized trials. For the time being, however, we still think that there is not nearly enough data to support the routine initiation of epidural blocks in anesthetized patients without additional compelling circumstances.
References
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