Falling after epidural analgesia: lessons from obstetric anesthesia

Excerpt

Most upper abdominal and thoracic surgeries produce significant postoperative pain, and patients expect anesthesiologists to provide efficacious postoperative pain relief. Modern epidural analgesia provides significant advantages over opioid-based analgesia, including better pain control at rest as well as during mobilization and coughing; improved cardiovascular, respiratory, and gastrointestinal morbidity endpoints; reduced postoperative mortality; less sedation; and less nausea and vomiting.1,2 Concerns remain, however, that epidurals may cause lower limb motor weakness and affect proprioception of the legs, which, together with sympathetic blockade-induced postural hypotension, may increase the risk of inpatient postoperative falls. In this month’s issue of the Journal, Elsharydah et al. 3 use the Nationwide Inpatient Sample (NIS) datasets to explore the relationship between epidural analgesia in patients undergoing various thoracic or upper abdominal surgeries and the rate of inpatient accidents and falls (IAF). The authors found that, although the rate of inpatient falls increased over a five-year period, postoperative epidural analgesia (thoracic or lumbar) was not associated with the incidence of IAFs. These results are pertinent because they can provide clinicians with further reassurance about the safety of postoperative epidural analgesia in this setting. Nevertheless, the NIS datasets reviewed by the investigators did not provide details about the type, loading dose, and rate of administration of the local anesthetics and opioids used. Furthermore, they did not provide information about the duration of postoperative epidural drug administration and especially any temporal relationship between cessation of the epidural analgesic regimen and the documented fall. The question then arises regarding which epidural regimen can provide pain-free postoperative analgesia for patients while allowing them to walk safely without any increased risk of falling. …