Königsrainer I, Bredanger S, Drewel-Frohnmeyer R, Vonthein R, Krueger W A, Königsrainer A, Unertl K E, Schroeder T H
Department of General-, Visceral- and Transplantation Surgery, University Hospital Tübingen, Tübingen, Germany.
Anaesthesia. 2009 Jan;64(1):27-31. doi: 10.1111/j.1365-2044.2008.05655.x. Epub 2008 Jul 29.
In a quality improvement audit on epidural analgesia in 300 patients after major abdominal surgery, we identified postoperative lower leg weakness and premature catheter dislodgement as the most frequent causes of premature discontinuation of postoperative epidural infusion. Lower limb motor weakness occurred in more than half of the patients with lumbar epidural analgesia. In a second period monitoring 177 patients, lumbar catheter insertion was abandoned in favour of exclusive thoracic placement for epidural catheters. Additionally, to prevent outward movement, the catheters were inserted deeper into the epidural space (mean (SD) 5.2 (1.5) cm in Period Two vs 4.6 (1.3) cm in Period One). Lower leg motor weakness declined from 14.7% to 5.1% (odds ratio 0.35; 95% confidence interval 0.16-0.74) between the two periods. Similarly, the frequency of premature catheter dislodgement was reduced from 14.5% to 5.7% (odds ratio 0.35; 95% confidence interval 0.17-0.72). With a stepwise logistic regression model we demonstrated that the odds of premature catheter dislodgement was reduced by 43% for each centimetre of additional catheter advancement in Period Two. We conclude that careful audit of specific complications can usefully guide changes in practice that improve success of epidural analgesia regimens.
在一项针对300例腹部大手术后患者硬膜外镇痛的质量改进审计中，我们确定术后小腿无力和导管过早移位是术后硬膜外输注过早停止的最常见原因。超过一半接受腰段硬膜外镇痛的患者出现下肢运动无力。在第二个阶段对177例患者进行监测时，放弃了腰段导管置入，改为仅进行胸段硬膜外置管。此外，为防止导管向外移动，导管在硬膜外腔的置入深度增加（第二阶段平均（标准差）为5.2（1.5）cm，第一阶段为4.6（1.3）cm）。两个阶段之间，小腿运动无力从14.7%降至5.1%（比值比0.35；95%置信区间0.16 - 0.74）。同样，导管过早移位的发生率从14.5%降至5.7%（比值比0.35；95%置信区间0.17 - 0.72）。通过逐步逻辑回归模型，我们证明在第二阶段，导管每多推进1厘米，导管过早移位的几率降低43%。我们得出结论，对特定并发症进行仔细审计可有效指导实践中的改变，从而提高硬膜外镇痛方案的成功率。
