Background and aims Oesophageal perforation is a life-threatening, rare and easily-missed surgical emergency. Its mortality of 20% worsens greatly with diagnostic delay, from sepsis and respiratory failure.
A 31-year-old male swallowed a denture, only attending hospital when peritonism supervened, a week later. At his first laparotomy, a gastric tear was repaired and a chest drain inserted for a right-sided pleural effusion. Over the next 6 days, he required multimodal, high-dose, intravenous analgesia on critical care. He developed extensive pleural effusions and consolidation. a contrast swallow unmasked a low oesophageal perforation. This was repaired by a second upper laparotomy, with multiple chest and abdominal drains inserted. He was extubated, because maintaining intubation worsened overall prognosis and ‘non-invasive ventilation’ would damage his friable oesophagus. However, his severe post-operative pain immediately limited respiratory function, despite extensive intravenous analgesia. An epidural remained contraindicated by sepsis.
Methods Therefore, we inserted bilateral PVBCs, using 16-gauge epidural kits, at T8, under Ketamine analgesia, in sitting position. Ultrasound confirmed transverse process depth. Bilateral 20 mls of 0.25% boluses and 10 mls/hr 0.1% infusions of levo-bupivacaine were delivered.
Results Within 20 minutes, cardiorespiratory dynamics, patient distress and oxygen requirement improved dramatically. PVBCs remained in situ for 7 days, enabling effective physiotherapy and mobilisation. He left critical care after 10 days, hospital after 55 days.
Conclusions Having witnessed his severe pain and ventilatory compromise, PVBCs undoubtedly prevented reintubation and materially contributed to his recovery and survival. Bilateral pneumothorax risk is published as only 1:40,000, so we concur that in certain circumstances, bilateral PVBCs can be a safe substitution for epidural analgesia.