Question 15 from the second paper of 2002 asked to compare PCA and thoracic epidural in the setting of rib fractures. Question 20 from the second paper of 2005 asked more broadly about the role of regional anaesthesia in the critically ill.

The college comments, "Many candidates provided long lists of regional techniques, but did address the issues of when to use and when not to use a technique. Consider asking “why don’t we perform more epidurals in our patients?”"

Advantages and Disadvantages of Regional Anaesthesia in the ICU

Epidural

Peripheral nerve block

Advantages

  • Analgesia is better than with PCA
  • Better MIP (maximum inspiratory pressure) than with PCA
  • Overall improved respiratory function
  • More rapid weaning from ventilator
  • Avoidance of sedation
  • Less delirium
  • Less  risk of respiratory depression
  • If local anaesthetic used alone, possible to avoid opiate side effects
  • Lower incidence of DVT
  • Good pain control when the injury is localised
  • Avoids systemic effects of opiates
  • Avoids sympatholytic effects of epidural
  • Usually safe

Disadvantages

  • Requires skill for placement
  • Not   always   effective   (can   get patchy block)
  • Hypotension       may      require excessive fluid administration or pressor support
  • May   mask   other   associated injuries,  e.g.  ruptured  spleen  in this case
  • Risk of epidural haematoma
  • If opiate used in epidural infusion, opiate side effects such as itch, nausea, still a problem.
  • Redundant in the sedated patient
  • Requires a skilled operator to insert
  • Risk of intravascular injection
  • Difficult to cover multiple sites of pain
  • Redundant in the sedated patient
  • Risk of infection from infusion catheter
  • Risk of dislodgement with confused patients

References

Karmakar, Manoj K., and Anthony M-H. Ho. "Acute pain management of patients with multiple fractured ribs." Journal of Trauma-Injury, Infection, and Critical Care 54.3 (2003): 615-625.

Janossy, K. M., et al. "The effect of pilot balloon design on estimation of safe tracheal tube cuff pressure." Anaesthesia 65.8 (2010): 785-791.

Hoffman, Robert J., Vivek Parwani, and In-Hei Hahn. "Experienced emergency medicine physicians cannot safely inflate or estimate endotracheal tube cuff pressure using standard techniques." The American journal of emergency medicine 24.2 (2006): 139-143.

Parwani, Vivek, et al. "Practicing paramedics cannot generate or estimate safe endotracheal tube cuff pressure using standard techniques." Prehospital Emergency Care 11.3 (2007): 307-311.