A patient was given an epidural infusion of bupivacaine for analgesia following elective abdominoplasty. During the morning ward round, the sensory block was noted to be at T4. During the course of the day, the bupivacaine infusion was titrated according to block, based on the telephoned instructions of the ICU Consultant. At the evening nurse handover, it was noted that the patient was increasingly bradycardic. During assessment - by the only doctor on the unit- the patient became unresponsive, with an audibly obstructed airway.  They were profoundly hypotensive with flattened arterial and ECG traces. Extra nursing staff were called over and the ICU consultant was contacted. Following administration of atropine the heart rate immediately increased to 66 but the BP remained labile. The epidural infusion was stopped. At the time the sensory block was noted to be at T4. A jaw thrust was used to establish a patient airway and oxygen 15L/min administered via a waters circuit. On arrival of the consultant a noradrenaline infusion was requested.

Commentary

The Faculty of Pain medicine in conjunction with the RCoA has produced best practice guidelines for the management of epidural analgesia in the hospital setting.¹  They state that there must be designated personnel and clear protocol the responsibility for which lies with the multidisciplinary inpatient acute pain team. Patients with epidural analgesia should be cared only by nurses with specific training and skills and there must be a resuscitation team with a resident doctor with the requisite competencies immediately available. There should be 24/ 7 senior anaesthetic advice and availability.

In order to induce profound hypotension and bradycardia, an epidural block needs to extend to the upper thoracic dermatomes. However, measuring the sensory block is inherently unreliable and frequently poorly performed. When infusions are used, changes in position can produce acute changes in block height leading to haemodynamic instability as in this case.

Perhaps because of the potentially serious risks associated with epidurals, lack of evidence for superior efficacy compared with other forms of post-operative analgesia and development of alternative regional techniques, use in the postoperative setting is decreasing.² It is essential that alternative forms of analgesia are discussed with the patient pre-operatively. Even with optimum resources and staffing, when the surgery is cosmetic, less invasive, inherently safer forms of analgesia may be preferable.

1. Faculty of Pain Medicine, Association of Anaesthetists, Association of Paediatric Anaesthetists, Pain Nurse Network, RCoA. Best practice in the management of epidural analgesia in the hospital setting (3^rd Ed), 2025
2. Rawal, N. Epidural analgesia for post-operative pain: Improved outcomes or added risk? Best Pract Res Clin Anaesthesiol, 2021: 35(1); 53-65