Good nursing care should prevent pressure sores

EDITOR—Shah reported three cases of heel ulcers related to pressure after epidural analgesia.1 A Medline search on the occurrence of pressure sores after epidural anaesthesia shows that, together with the cases reported by Shah, so far only 10 cases of heel ulcers have been reported in the literature.2-5 There are also two reports on seven patients developing decubitus ulceration after epidural analgesia administered during labour, in whom prolonged sitting and disinfectant pooling under and irritating the perineal skin could have been contributing factors.

The reported concentration of bupivacaine in the postoperative continuous epidural infusion varied from 0.1% to 0.25%, the infusion rate from 6 ml/h to 10 ml/h. Patient controlled epidural analgesia with a background infusion of 2 ml/h and a demand dose of 2 ml of 0.11% bupivacaine together with adrenaline (epinephrine), sufentanil, and clonidine was reported in three cases.3 In the report by Shah the infusion rate of 0.15% bupivacaine is missing. The most prominent finding is the occurrence of a motor block on the first day after the operation in two patients.

So far in our hospital we have no documented cases of postoperative pressure sores related to epidural anaesthesia. In 1999, 608 patients received patient controlled epidural analgesia, mostly after orthopaedic (41%), gynaecological (20%), urological (16%), and thoracic or abdominal surgery (13%). Of 252 patients undergoing orthopaedic surgery, 69% had combined spinal epidural anaesthesia and 31% general combined with epidural anaesthesia. Patient controlled epidural analgesia with 0.0625% bupivacaine, 2 μg/ml fentanyl, and 2 μg/ml adrenaline (epinephrine) is administered as a continuous infusion of 6-8 ml/h and a demand dose of 3-4 ml (lockout time 30 minutes). The goal is to obtain sufficient analgesia without motor and profound sensory block, and any motor block should be limited to the immediate postoperative period. Patients may …