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Epidural Analgesia and Surgical Complications — FRCA Final MCQ

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HardPain MedicineEpidural Analgesia and Surgical ComplicationsFRCA Final

A 65-year-old man (ASA III) has a postoperative epidural infusion of levobupivacaine 0.125% with fentanyl 2 micrograms/mL running at 10 mL/hour after open colonic surgery. On postoperative day 2, having previously reported good analgesia, he develops new, severe, deep abdominal pain rated 7/10. Cold testing demonstrates a clear, symmetrical sensory block from T4 to L1, including the dermatomes of the incision. The pump, connections and visible catheter are intact. What is the most important concern?

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Correct answer: E — An intra-abdominal surgical complication requiring urgent surgical review

Explanation lettering: D = shown as A · C = shown as B · E = shown as C · A = shown as D · B = shown as E

The correct answer is B. New severe pain breaking through a demonstrably functioning epidural — previously effective, with a symmetrical T4–L1 sensory block covering the incision and an intact delivery system — is a red flag for an intra-abdominal surgical complication such as anastomotic leak, bowel ischaemia, collection or evolving peritonitis, and mandates urgent surgical review. UK epidural best-practice guidance (FPM/Association of Anaesthetists/RCoA, 2020) requires prompt trained review of inadequate analgesia and consideration of causes beyond the epidural itself. Options A and E fail because the confirmed bilateral block covering the relevant dermatomes with intact hardware makes catheter failure or migration unlikely. Option C would increase local anaesthetic exposure and block height without addressing the cause, and could mask deterioration. Option D may later be appropriate as adjunct analgesia (with caution, as the epidural contains fentanyl), but giving opioid without investigating new pain risks concealing a surgical emergency.

Reference: Faculty of Pain Medicine, Association of Anaesthetists and Royal College of Anaesthetists. Best Practice in the Management of Epidural Analgesia in the Hospital Setting, 2020. https://www.rcoa.ac.uk/sites/default/files/documents/2020-11/Epidural-AUG-2020-FINAL.pdf