A national survey of epidural use and management in elderly patients undergoing elective and emergency laparotomy

A postal questionnaire was sent to anaesthetic clinical tutors in the United Kingdom describing two hypothetical 75-year-old patients requiring abdominal surgery. Patient 1 (ASA 2) required elective anterior resection and patient 2 (ASA 3-4) required emergency laparotomy. There was a 65% response rate. For patient 1, 98.5% of respondents would insert an epidural, 93% inserting this awake and 50% placing it in the high-mid thoracic region. All respondents would use local anaesthesia (concentration varied four-fold) and 62% would use opioids. All respondents would place the epidural pre-operatively; although 36% would administer the epidural block pre-operatively and 3% postoperatively. For patient 2, 70% of respondents would insert an epidural (p < 0.0001), drug administration would be more frequently delayed until postoperatively (13%); p = 0.0005) and epidural opioid use decreased (57%); p = n/s. Epidural insertion influenced the postoperative destination in 42% of departments. Use of a critical care facility was anticipated for more than half of these patients; 60% reported difficulty accessing critical care beds.