Patient-controlled epidural analgesia as a sedation-sparing strategy for repeated postoperative wound care following anorectal surgery: A case report

Repeated dressing changes following anorectal surgery may result in severe procedural pain that is inadequately controlled with conventional systemic analgesia. Procedural sedation is often used when pain remains refractory but may be associated with adverse effects and increased resource utilization. We describe the use of patient-controlled epidural analgesia (PCEA) as an alternative strategy for managing severe procedural pain and avoiding repeated procedural sedation. We report the case of a 34-year-old male undergoing surgery for recurrent perianal fistula after three previous procedures. Postoperatively, he experienced severe pain, particularly during dressing changes, with Numerical Rating Scale (NRS) scores of 9–10 despite a multimodal non-opioid analgesic regimen consisting of intravenous paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) administered intravenously and rectally. Repeated procedural sedation was required for wound care but was complicated by respiratory adverse effects, nausea, vomiting, and dizziness. After discussion of available options, the patient consented to PCEA. Following initiation of PCEA, pain during dressing changes decreased from NRS 9–10 to 3–4, no further procedural sedation was required, no clinically apparent motor impairment or urinary retention was observed, and the patient reported high satisfaction with pain management. Epidural analgesia has well-established benefits in postoperative pain control and is associated with additional perioperative benefits. In this case, the principal benefit of PCEA extended beyond analgesia to facilitation of repeated wound care without recurrent exposure to procedural sedation. This case suggests that PCEA may be a feasible sedation-sparing option in selected patients with severe recurrent procedural pain when conventional systemic analgesia is inadequate and repeated procedural sedation is poorly tolerated.