We do the sorting. You do the medicine.
OSCE: actor and procedure stations · Core14 / 22

Failed epidural and an angry patient after laparotomyActor: a 58-year-old man, day 1 after open bowel resection; his thoracic epidural is not working

Actor: angry patient with failed analgesia, then opioid over-sedation

From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.

Know this first

  • Epidural review: breathing rate, sedation, sensory level, motor function, haematoma signs.
  • Best catheter test: block level and density that match the drug given.
  • Back pain or persistent motor block: think epidural haematoma.
  • Naloxone: 40 mcg IV every 2 min, up to 200 mcg.
  • Paracetamol: 1 g IV every 6 h, maximum 4 g a day.

The patient

Actor: a 58-year-old man, day 1 after open bowel resection; his thoracic epidural is not working. Pain 9/10 and he is angry. The ward gave extra IV morphine an hour ago. Vitals: BP 150/90, HR 104, RR 22, SpO2 95% on 2 L. Task: assess and manage his pain.

The examiner asks

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  1. Open

    How do you start?

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    • I'm reviewing a man in severe pain the day after bowel surgery, whose epidural isn't working. Patient
    • I'm from the pain team. You're clearly hurting badly; I'll treat it while I assess you. Communication
    • Where is it worst, and does any part of your belly feel numb?

  2. Explain

    Tell him what you are checking and what you will do.

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    • I'll test with ice where it feels cold, to see how high and even the numbness is. (Communication)
    • I'm checking the catheter site and its skin mark, in case it has slipped out.
    • I'll test your leg strength and ask about back pain; either needs urgent action.
    • If the block is patchy, I'll top it up and recheck the level.
    • If it has failed, I'll remove it and start a morphine pump you control.
    • Regular paracetamol and other non-opioid drugs will cut how much morphine you need.

  3. Respond

    He says: 'I was promised this would work!'

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    • You were told it would control your pain, and it hasn't. I'm sorry. (Communication)
    • You've every right to be angry. Let's sort it out now.
    • I'm giving paracetamol 1 g through your drip now, while I check the epidural.

  4. Respond

    Twenty minutes later the nurse calls: he is very sleepy. RR 8, SpO2 88% on 2 L. What now?

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    • Likely opioid; I check BP and block height to exclude a high block, and stop the epidural. (Communication)
    • I stop all opioids and rouse him.
    • Oxygen by face mask, sit him up, support his breathing if needed.
    • Naloxone 40 mcg IV, repeated each 2 minutes to a 200 mcg maximum, until breathing recovers.
    • Then hourly sedation and breathing checks; more naloxone may be needed later.

  5. Close

    How do you close?

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    • I'm sorry this has been so hard. We'll be back to review you this evening. Communication
    • The nurses will call us if the pain returns or you become drowsy.
    • I document the block findings, drugs given, the sedation episode and the new plan. After surgery

Fatal mistakes

  • Leaving him in pain.
  • Stacking opioids without monitoring.
  • Ignoring the catheter site and leg signs.

Checked against: Miller 10e · Barash 9e · Stoelting 8e

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