Question 6

Outline your management of thoracic epidural analgesia in a 56 year old man who has stable angina on a beta blocker who has been involved in a motor vehicle accident causing a left-sided flail chest. What are the most potential complications?

[Click here to toggle visibility of the answers]

College Answer

Important considerations include:

a) Other injuries need to be ruled accounted for that may have implications – spinal injury, intra-abdo injury (though abdo pain from intra-abdo injury not likely to be totally masked by epidural local anaesthetic)

b) Coagulopathy is a contraindication

c) Epidural Local anaesthetic/opiate combination at thoracic level likely to be associated with hypotension/bradycardia needing volume and likely inotropic support –relatively contraindicated in a middle aged male on beta blockers.

Infusion vs bolus vs PCEA

d) Other epidural analgesics – opiate alone eg fentanyl, pethidine or epidural clonidine –



a)  Hypotension, bradycardia

b)  Masking of abdominal / evolving neurological signs

c)  Inadequate analgesia due to limited / patchy block

d)  Increased pain in unblocked areas – relative phenomenon esp with bony injury eg shoulder.

e)  Short duration of blockade – catheters usually removed after 3 days.

f)      Epidural haematoma / abscess

g)  Epidural drug side effects – pruritus, nausea, respiratory depression

h)  Hypotension on mobilisation


Thoracic epidural anaesthesia is compared to a parenteral opiate PCA in Question 26 from the first paper of 2010.

Management considerations:

  • More difficult to assess the patient; abdominal block tends to obscure changes in clinical condition
  • Choice of drug needs to be considered
  • The injuries will persist longer then the catheter (max. 5 days)
  • Contraindicated in coagulopathy
  • May be contraindicated in bony vertebral injury

Complications of thoracic epidural

  • Hypotension will develop
  • Bradycardia will develop
  • Changes in sympathetic innervation of the abdominal viscera may increase abdominal visceral perfusion, thus increasing blood loss from damaged solid organs.
  • Opiates will cause pruritis
  • There may be respiratory depression and respiratory muscle paralysis with a high block
  • There is a risk of infection (epidural abscess)
  • There is a risk of epidural haematoma
  • There is a risk of dural puncture or spinal cord damage
  • The epidural may not work, or the block may be patchy


Wu, Christopher L., et al. "Thoracic epidural analgesia versus intravenous patient-controlled analgesia for the treatment of rib fracture pain after motor vehicle crash." Journal of Trauma-Injury, Infection, and Critical Care 47.3 (1999): 564-567.


MACKERSIE, ROBERT C., et al. "Prospective evaluation of epidural and intravenous administration of fentanyl for pain control and restoration of ventilatory function following multiple rib fractures." Journal of Trauma-Injury, Infection, and Critical Care 31.4 (1991): 443-451.


Kieninger, Alicia N., et al. "Epidural versus intravenous pain control in elderly patients with rib fractures." The American journal of surgery 189.3 (2005): 327-330.


Moon, M. Ryan, et al. "Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic trauma." Annals of surgery 229.5 (1999): 684.


Jarvis, Amy M., et al. "Comparison of epidural versus parenteral analgesia for traumatic rib fractures: a meta-analysis." OPUS 12 (2009): 50-57.



Scherer, R., et al. "Complications related to thoracic epidural analgesia: a prospective study in 1071 surgical patients." Acta anaesthesiologica scandinavica 37.4 (1993): 370-374.


Kapral, Stephan, et al. "The effects of thoracic epidural anesthesia on intraoperative visceral perfusion and metabolism." Anesthesia & Analgesia 88.2 (1999): 402-406.