In 1988, questionnaires were sent to 1225 departments of anesthesiology to evaluate the practice of postoperative epidural analgesia (EA) in the Federal Republic of Germany. The following problems were investigated. To what extent are anesthesiologist concerned with postoperative pain therapy? Does EA play a major role in this, in particular outside the intensive care setting? Who is allowed to administer epidural injections: anesthesiologists, other physicans or nurses? What kind of monitoring is used? What agents are used for epidural injections and what problems and complications have arisen? In all, 461 (38%) evaluable forms were returned. Most anesthesiologists said they were responsible for postoperative pain control. In 75.3% of the responding departments EA was used as a method of postoperative pain therapy, while in 24.7% the catheter was removed immediately after the operation, in most cases for fear of complications resulting from insufficient monitoring. In clinical practice, however, EA was the only major alternative to routine intermittent injections of opioids as needed. Some departments reported that they restricted postoperative EA to patients in the intensive care unit or in the recovery room because adequate monitoring was not feasible on the ordinary wards. EA was administered in 62.4% on ordinary wards. But in only 25.7% were trained nurses allowed to give epidural injections. Most responding departments (77%) preferred epidural use of opioids during intensive care, in most cases morphine or buprenorphine in combination with low-dose local anesthetics, and 66.7% also favored epidural opioids on ordinary wards. As monotherapy, opioids were used by only 17.3% and local anesthetics by 21.8% of anesthesiologists on routine surgical wards. The preferred opioid was morphine in intensive care units, whereas buprenorphine was more often used on other wards. Hemodynamic complications are the major side effects seen with the epidural application of local anesthetics. Some cases of inadvertent subarachnoidal or intravascular injection were reported. Cases of severe respiratory depression following epidural opioids were reported from 100 departments (25%). The incidence of this complication was not influenced by the choice of the opiate and seemed higher than in earlier studies. Urinary retention and cerebral dysfunction were further problems associated with EA. Other neurologic disturbance, e.g. motor pareses, were a rare problem. In conclusion, EA has become one of the major techniques for postoperative pain therapy in Germany, especially following aortic-vascular surgery, upper abdominal surgery and thoracotomy. However, this survey revealed some problems with the supervision of EA. Most anesthesiologists are responsible for postoperative administration of EA as well as for anesthesia in the operating room. Only 7.3% have an acute pain service for such patients. Many practical problems in inadequate postoperative pain therapy arise from this deficiency. Admission of all patients to ICU for pain therapy alone is not practicable, for economic and medical reasons. Experience suggests that nurses' education, standards of prescribing and records including notes on withdrawal trials, and daily neurological examination and medical supervision by experienced anesthesiologists are the most important factors in making EA a safe method of postoperative pain relief. On these premises most hemodynamic complications, such as hypotension, are predictable or can be identified in time to avoid severe sequelae, even on ordinary wards. But in contrast to the rapid onset of these complications, respiratory depression following epidural opioids may have a delayed onset. Therefore, the use of eqidural opioids is not recommended for postoperative pain therapy outside intensive care units.
