A reply

We thank Dr Chincholkar for his interest in our survey. We agree with his assessment of Rodgers' meta-analysis [1], in light of improvements in postoperative care. However, the risk/benefit ratio of epidural use are influenced by multiple factors, many outside the immediate control of anaesthetists (for example the provision of ward nursing expertise and acute pain team staffing). This alters the risk/benefit ratio such that it may be appropriate that similar cases be treated differently where local provision varies. The document ‘Good practice in the management of continuous epidural analgesia in the hospital setting’[2] offers a template on which best practice can be judged. This may allow clinicians to move the risk/benefit equation towards benefit. When considering patient harm it is easy to attribute harm to interventions that lead to complications. An obvious example is an epidural abscess after epidural analgesia. What is less easy to determine and less obvious to observers but equally important is harm caused by omission, for example poor postoperative pain control causing respiratory failure. This form of harm is easy to forget and probably unmeasureable, making quantitative analysis of risk and benefit virtually impossible. Dr Chincholkar suggests anaesthetists should be willing to ‘justify’ epidural use; we argue it is equally appropriate for anaesthetists to justify not using an epidural. In each case the decision should be one taken with the patient, after an appropriate discussion of the available evidence. Finally, the Royal College of Anaesthetists is attempting to quantify the ‘risk’ we expose patients to when undertaking epidural anaesthesia. The Third National Anaesthesia Audit will collect data on both the number of central neuraxial anaesthetic procedures performed (national snapshot audit for two weeks) and on major complications of these procedures (national prospective data collection for one year). This ambitious project will start in mid-September 2006, and by now all anaesthetic departments should have a ‘local reporter’ who will supervise the audit in their hospital. This project offers a genuine opportunity to quantify risks, to the benefit of patient and anaesthetist. Further information will be advertised and is available by emailing Tim Cook at tcook@rcoa.ac.uk.