Epidural analgesia: After hip. abdominal, or (horacic procedures, a continuous epidural technique is often used for analgesia. An infusion of bupivacaine 0.125% to 0.0625% solution containing fentanyl 4 to 5

usually provides excellent analgesia. When the epidural cathe¬ter is placed at the dermatome level where discomfort is perceived, the amount of local anesthelic and narcotic can be reduced, minimizing (he possibility of toxicity. For hip procedures, a lumbar, epidural catheler placement is used; for abdominal procedures, a low-thoracic, epidural catheter placement is used; and lor thoracotomies, a niidthoracic, epi¬dural catheter placemen! is used. Fenlanyl is lipophilic and does not spread widely in the epidural space, so the catheter must be placed close to the segmental area of Ihe lesion. The need for precise catheter placement can he circumvented by using epidural morphine, which spreads more readily in the epidural space. However, the rostral spread of morphine may result in late respiratory depression.
The most common complication is inadvertent removal of the cathe¬ter during routine nursing care. Meticulous taping of Ihe catheter and nursing education can reduce (his problem. Urinary retention second¬ary to the local anesthetic and Ihe narcotic occurs and is more prevalent in elderly men. Migration of the catheter to the subcutaneous tissues or the spinal space can also occur. The former results in a lack of pain relief; the latter can result in disastrously high spinal anesthesia. Fortu¬nately, the latter rarely occurs.
In an elderly patient, an epidural infusion must be titrated precisely, and intravascular volume must be maintained by close monitoring of fluid status. Blood loss of 300 lo 500 ml, from a hip wound drain can result in severe hypotension in an elderly palient with a sympathetic blockade if volume resuscitation is nol promptly instituted.
Posloperalive pain control in the elderly patient is best accomplished by a dedicated, functioning pain control service. Strict attention to the patient’s hemodynamic parameters and mental status along with a thor¬ough understanding of the altered effects of various medications in the elderly are essential. Cooperation between the surgical, nursing, and pain service staffs can provide safe and effective analgesia for even the most frail elderly patient.