SummaryWe performed a retrospective case note review to identify the major complications of epidural analgesia occurring after surgery at our hospital. By cross-referencing the radiology, microbiology and patient information management system databases, we identified patients who had undergone either spinal magnetic resonance imaging or a lumbar puncture within 60 days of surgery in the period from January 2000 to December 2005. Review of these case notes identified six cases of epidural abscess, three of meningitis and three of epidural haematoma. Symptoms of epidural abscess or meningitis developed a median of 5 days after epidural catheter removal. Methicillinresistant Staphylococcus aureus was the predominant pathogen. Epidural haematoma symptoms developed while the epidural catheter was in place. These symptoms were initially attributed to the epidural infusion. Diagnostic delays contributed to adverse neurological outcome in three patients. This study suggests that leg weakness is a critical monitor of spinal cord health. A national database is needed to establish a more accurate estimate of the incidence of major complications and to identify relevant risk factors. Epidural analgesia can provide excellent pain relief and may decrease patient morbidity after major surgery [1][2][3]. However, this technique has significant risks including epidural abscess, meningitis and epidural haematoma. The reported incidence of these complications may be an underestimate, as it is based on case reports [4][5][6][7][8][9][10][11]. In January 2000, we started a survey to determine the incidence of these complications in patients receiving epidural analgesia after surgery in our hospital. MethodsThe survey took place from January 2000 to December 2005 and had Local Research Ethics Committee approval. At the end of each year we gathered data retrospectively from four sources: 1 The acute pain service: to identify all patients receiving epidural analgesia after surgery. 2 Microbiology department: to identify all cerebrospinal fluid (CSF) samples, epidural site swabs or epidural catheter tip specimens.3 Patient information management system (PiMS): to identify all patients undergoing surgery. 4 Radiology department: to identify all spinal magnetic resonance imaging (MRI) scans. Each source was asked to provide the patient's surname, forename, hospital number and date of birth, and where relevant the date of the procedure or specimen. The patient information management system also provided details of the operation performed and the surgical speciality.The data were imported into a database (ACCESS, Microsoft, Seattle, WA). As the acute pain service dataset did not include the hospital number or date of birth, we were unable to identify all patients undergoing investigation within 60 days of epidural analgesia. However, by cross-referencing the PiMS, microbiology and radiology data, we identified those patients who had undergone either a spinal MRI or relevant microbiological investigation within 60 days of surgery. The hospit...

Objective-To offer clear guidance on the anaesthetic management of Colles' fractures in the accident and emergency (A&E) department in the light of the conflict between existing reports and current trends, and to address the issue of alkalinisation of haematoma blocks. Methods-This was a two centre, prospective, randomised clinical trial with consecutive recruitment ofadult patients with Colles' fractures requiring manipulation to receive either Bier's block or haematoma block. There was subsequent blinded randomisation to alkalinised or non-alkalinised haematoma block. Results-72 patients were recruited into the Bier's block group, and 70 into the haematoma block group. Bier's block was less painfil to give than the haematoma block (median pain score 2.8 v 5.3; P << 0.001), and fracture manipulation was also less painfiu in the Bier's block group (median pain score 1.5 v 3.0; P < 0.01). There was no significant difference in overall A&E transit time between the two groups. There was better initial radiological outcome in terms of dorsal angulation in the Bier's block group (-3.60 v 2.10; P = 0.003). More remanipulations were required in the haematoma block group (17/70 v 4172; P = 0.003). There was a trend towards decreased pain on administration of the alkalinised haematoma block when compared with non-alkalinised haematoma block, but this did not reach significance. There was no difference in pain score on fracture manipulation. There were no complications in either group. Conclusions-Bier's block is superior to haematoma block in terms of efficacy, radiological result, and remanipulation rate; transit times are equal, both procedures are practical in the A&E environment, and there were no complications. Bier's block is the anaesthetic management of choice for Colles' fractures requiring manipulation within the A&E department. (Accid Emerg Med 1997;14:352-356) Keywords: Colles' fracture; Bier's block; haematoma block; alkalinisation Colles' fractures are manipulated using a variety of anaesthetic techniques within the accident and emergency (A&E) department. A survey of the larger A&E departments in 19941 showed that haematoma block had increased dramatically in popularity over the preceding five years, largely at the expense of the general anaesthetic, accounting for 33% of all reductions; a further 33% were performed under Bier's block, a proportion which had remained unchanged over the preceding five years.2 This move away from the use of a general anaesthetic may have been driven by the cost and resource implications of not having to admit patients and prepare them for a formal theatre procedure.It is less clear why the haematoma block, rather than Bier's block, has filled the space left by the general anaesthetic when one reviews the available reports. Case3 retrospectively compared haematoma block, Bier's block, and general anaesthetic in 136 patients and found that there was no difference in the remanipulation rates between the three methods of anaesthesia. No other outcome measures were mea...

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Colles' fractures are manipulated under a variety of anaesthetic techniques. An increasing awareness of cost and time within the National Health Service contributes to a marked change in the anaesthetic management of Colles' fractures. This paper presents the results of a survey of the anaesthetic techniques used in the larger accident and emergency (A&E) departments of the UK, and demonstrates the increasing popularity of the haematoma block compared with 5 years ago (7% in 1989 vs. 33% in 1994), at the expense of the general anaesthetic (44% in 1989 vs. 24% in 1994). The popularity of the Bier's block has remained unchanged (33% in 1989 and 1994). Local and regional anaesthetic techniques can be safely performed by A&E doctors, with appropriate monitoring, and this has beneficial resource implications for the anaesthetic department and the hospital.

Topical AC should be considered the local anaesthetic of first choice for suturing appropriate children's lacerations.