'Putting the TEA back into teaching': are trainees being taught optimal epidural techniques?

The question as to whether patients undergoing major upper abdominal or thoracic surgery bene fi t from thoracic epidural analgesia (TEA) remains controversial despite admirable attempts to answer the question. Early studies showing remarkable reduc-tionsinmortalityusingTEA 1 werenotrepeatable,andtwosubse-quent major studies - the Australasian MASTER trial and the US Veteran ′ s Administration trial - failed to show differences in outcome even in selected high-risk patients. 2 3 Interestingly, the use of epidural analgesia for patients undergoing major surgery in hospitals in Australasia in theyears after publication of the MASTER trial decreased signi fi cantly 4 as clinicians, unconvinced by clinical bene fi ts but concerned by potential serious complications, stopped putting epidural catheters into their patients. There are certainly uncommon but well-described neurological complications of thoracic epidural analgesia including direct spinal cord trauma, 5 epidural abscess, 6 and vertebral canal haematoma. 7 The third Royal College of Anaesthetists national audit project (NAP3) reported that the overall risk of per-manent neurological damage from thoracic epidural placement was between 1 and 6 per 100 000 patients. 8 It would be interesting to repeat that audit project today, some 6 yr on, to see whether the prevalence of thoracic epidural analgesia in