Pain partially responsive to opioids can lead to rapid escalating dosages due to tolerance development. In this report the case of a 58-year-old female with neuropathic pain using increasing transdermal (TTS) fentanyl dosages to a maximum dose of 3400 microg/h resulting in fentanyl plasma levels of 173 ng/ml is described. For pain relief an epidural infusion at the level T1-2 with bupivacaine was started. Immediate pain relief was accompanied by short lasting respiratory depression and drowsiness.

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Background: Epidural analgesia (EA) has been suggested to be a key element within the enhanced recovery after surgery guidelines for elective colonic surgery (ERAS). However, divergent descriptions exist concerning the optimal duration of epidural analgesia in ERAS. Our study objective was to investigate associations between epidural analgesia duration, length of stay and complication rate, focusing on the value of a third or fourth day of use. Methods: In retrospective analysis, 243 patients who underwent elective colonic surgery according to ERAS and received EA as postoperative analgesic regimen between 2009 and 2012 were studied. Data were pooled according to the duration of EA, groups 1 to 4: ≤ 24 h , >24 to ≤48 h, >48 to ≤72 h and >72 h, respectively. Length of stay (LOS) in days, complication rate, patient controlled intravenous analgesia (PCIA) opioid consumption, reason for termination of EA and other characteristics were documented. Results: Overall median LOS was 7.9 days, interquartile range (IQR) 7. LOS differed among the 4 groups (p<0.001) and was significantly higher in group 4 (19.3, IQR 21) compared to all other groups (1 to 3 respectively: 9.0, IQR 8, p=0.036; 6.8, IQR 6, p<0.001; 7.0, IQR 6, p<0.001). Median LOS in group 2 was also significantly lower compared to group 1 (p=0.033). No differences were found comparing group 3 to groups 1 and 2 (p=0.129; p=0.224). Overall median complication rate was 0, IQR 1, and differed among the 4 groups (p=0.001). It was significantly higher in group 4 (1, IQR 2) compared to all other groups (1 to 3 respectively: 1, IQR 2, p=0.040; 0, IQR 1, p=0.005; 1, IQR 2, p<0.001). Opioid consumption through PCIA after termination of EA differed significantly between group 1 and group 2 while its duration did not (87.8±35.2 mg vs. 62.4±39.3 mg, p=0.025; 54.8±19.2 hrs vs. 45.1±21.2 hrs, p=0.094). Conclusions: Maintaining epidural analgesia (EA) beyond 48 hours postoperatively is not associated with prolonged LOS or an increased complication rate. The third 24 hour period decreases change-over to PCIA. However, prolongation of EA beyond 72 hours is associated with increased LOS and complication rate within the conglomerate of factors in the ERAS clinical pathway in this exploratory study.