TO PROVIDE THE VERY BEST CARE FOR EACH PATIENT ON EVERY OCCASION

If English is not your frst

language and you need help,

please contact the Ethnic Health

Team on 0161 627 8770

For general enquiries please contact the Patient

Advice and Liaison Service (PALS) on 0161 604 5897

For enquiries regarding clinic appointments, clinical care and

treatment please contact 0161 624 0420 and the Switchboard

Operator will put you through to the correct department / service

www.pat.nhs.ukWood pulp sourced from

sustainable forests

Jeżeli angielski nie jest twoim pierwszym językiem i potrzebujesz pomocy proszę skontaktować się z załogą Ethnic Health pod numerem telefonu 0161 627 8770

Epidurals for painrelief after surgeryAn information guide

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Epidurals for pain relief after surgery

IntroductionThis leaflet describes what happens when you have an epidural,together with any side effects and complications that can occur. Itaims to help you and your anaesthetist make a choice about thebest method of pain relief for you after your surgery.

What is an epidural?The nerves from your spine to your lower body pass through anarea in your back close to your spine, called the “epidural space”.To establish an epidural an anaesthetist injects local anaestheticsthrough a fine plastic tube, called an epidural catheter, into thisepidural space. As a result, the nerve messages are blocked. Thiscauses numbness, which varies in extent according to the amountof local anaesthetic injected.An epidural pump allows local anaesthetic to be givencontinuously. Other pain-relieving drugs can also be added in smallquantities. The amounts of drugs given are carefully controlled.When the epidural is stopped, feeling will return in full. Epiduralsmay be used during and/or after surgery for pain relief.

How is an epidural done?Epidurals can be put in:• when you are conscious. This is the usual and safest option• when you are under sedation (when you have been given a drugwhich will make you drowsy and relaxed, but still conscious)• during a general anaesthetic. However, the risks of nerve damageare higher if an epidural is inserted when you are asleep.

These choices can be discussed further with your anaesthetist.1. a needle will be used to put a thin plastic tube (cannula) into avein in your hand or arm for giving fluids (drip)

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2. if you are conscious, you will be asked to sit up or lie on your side,bending forwards to curve your back. It is important to keep stillwhile the epidural is put in3. local anaesthetic is injected into a small area of the skin of yourback4. a special epidural needle is pushed through this numb area and athin plastic catheter is passed through the needle into yourepidural space. The needle is then removed, leaving only thecatheter in your back.

What will I feel?The local anaesthetic stings briefly, but usually allows an almostpainless procedure.It is common to feel slight discomfort in your back as the catheter isinserted.Occasionally, an electric shock-like sensation or pain occurs duringneedle or catheter insertion. If this happens, please tell youranaesthetist immediately, because the catheter may be touching anerve.A sensation of warmth and numbness gradually develops, like thesensation after a dental anaesthetic injection. You may still be ableto feel touch, pressure and movement. Your legs feel heavy anddifficult to move.

You may only notice these effects for the first time when yourecover consciousness after the operation, particularly if your

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epidural was put in when you were asleep for your operation.Overall, most people do not find these sensations to be unpleasant,just a bit strange.The weakness of the leg muscles or numbness may persist after youleave the theatre recovery room. This will wear off once theepidural stops. If you feel that this is a problem and you don’t likethe sensation, then tell the nurses immediately and they willcontact a member of the pain team.Please don’t attempt to get out of bed on your own whilst theepidural is running – you will probably fall.

After your epidural• the nurses will take your pulse and blood pressure at regularintervals and ask you about your pain and how you are feeling• they may adjust the rate at which the epidural pump runs and willtreat any side effects which may occur• they will check that the pump is functioning correctly. They willencourage you to move, eat and drink, according to the surgeon’sinstructions• the Pain Relief team doctors and nurses may also visit you, tocheck that your epidural is working properly.

When will the epidural be stopped?• the epidural will be stopped when you no longer require painrelief• a few hours after the pump is stopped, the epidural tubing will beremoved, as long as you are still comfortable• the epidural catheter will be removed if it is not working properly.Another epidural catheter may be reinserted if necessary. Howeverthis depends upon the anaesthetist and whether you wish to havethe procedure repeated.

Can anyone have an epidural?No. An epidural may not always be possible if the risk of

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complications is too high.The anaesthetist will ask you if:• you are taking blood thinning drugs, such as warfarin• you have a blood clotting abnormality• you have an allergy to local anaesthetics• you have severe arthritis or deformity of the spine• you have an infection in your back.

What are the benefits?• better pain relief than other methods, particularly when youmove• reduced complications of major surgery. These may includenausea/vomiting, leg or lung blood clots, chest infections, bloodtransfusions and delayed bowel function• quicker return to eating, drinking and full movement, possiblywith a shorter stay in hospital compared to other methods of painrelief.

What are the side effects and complications?All the side effects and complications described can occur withoutan epidural.Side effects are common, are often minor and are usually easy totreat. Serious complications are fortunately rare.The risk of complications should be balanced against the benefitsand compared with alternative methods of pain relief. Youranaesthetist can help you do this.

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Very common or common side effects and complicationsInability to pass urine. The epidural affects the nerves that supplythe bladder, so a catheter (tube) will usually have to be inserted todrain it. This is often necessary anyway after major surgery, to checkkidney function, however with an epidural, it is a painlessprocedure. Bladder function returns to normal when the epiduralwears off.Low blood pressure. The local anaesthetic affects the nerves goingto your blood vessels, so blood pressure always drops a little. Fluidsand/or drugs can be put into your drip to treat this. If you takemedication to control your blood pressure these may be omittedwhilst your epidural is running because of this effect. Low bloodpressure is common after surgery, even without an epidural.Itching. This can occur as a side effect of morphine-like drugs usedin combination with local anaesthetic. It is easily treated with anti-allergy drugs.Feeling sick and vomiting. These can be treated with antisicknessdrugs. These problems are less frequent with an epidural than withmost other methods of pain relief.Backache. This is common after surgery, with or without anepidural and is often caused by lying on a firm, flat operating table.Inadequate pain relief. It may be impossible to place the epiduralcatheter, the local anaesthetic may not spread adequately to coverthe whole surgical area, or the catheter can fall out. However,overall epidurals usually provide better pain relief than othertechniques. Other methods of pain relief are available if theepidural fails.You will not be left in unmanageable pain.Headaches. Minor headaches are common after surgery, with orwithout an epidural.

Occasionally a severe headache occurs after an epidural. This isbecause the lining of the fluid-filled space surrounding the spinalcord has been inadvertently punctured (dural tap). The fluid leaksout and reduces the pressure of the fluid which surrounds the

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brain, particularly when you sit up. Occasionally it may be necessaryto inject a small amount of your own blood into your epiduralspace. This is called an ‘epidural blood patch’. The blood clots andthen plugs the hole in the epidural lining. It is almost alwaysimmediately effective. The procedure is otherwise the same as for anormal epidural.

Uncommon complicationsSlow breathing. Some drugs used in the epidural can cause slowbreathing and/or drowsiness requiring treatment. The nursesmonitor for this continually whilst your epidural infusion isrunning.Catheter infection. The epidural catheter can become infected andmay have to be removed. Antibiotics may be necessary. It is veryrare for the infection to spread any further than the insertion site inthe skin.

Rare or very rare complicationsComplications are exceptionally rare and these risks will bedicussed further with you. Other complications, such as convulsions(fits), breathing difficulty and temporary nerve damage are rarewhilst permanent disabling nerve damage, epidural abscess,epidural haematoma (blood clot) and cardiac arrest (stopping ofthe heart) are very rare indeed.

What if I decide not to have an epidural?It is your choice. You do not have to have an epidural.There are several alternative methods of pain relief with morphinethat work well; injections given by the nurses or by a pump into avein which you control by pressing a button (Patient ControlledAnalgesia - PCA).

There are other ways in which local anaesthetics can be given.You may be able to take pain-relieving drugs by mouth or as

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suppositories.Every effort will always be made to ensure your comfort.

How do I ask further questions?Ask the nursing staff or your anaesthetist.Future sources of information about epidural anaesthesia areavailable from the website. www.youranaesthetic.info.Our hospitals have a team of nurses and anaesthetists whospecialise in pain relief after surgery. You can ask to see a memberof the pain team at any time. They may have leaflets availableabout pain relief.

Questions you may like to ask your anaesthetist• who will give my anaesthetic?• do I have to have this type of pain relief?• have you often used this type of pain relief?• what are the risks of this type of pain relief?• do I have any special risks?• how will I feel afterwards?

Headache after an epidural or spinal anaestheticThere is a special type of headache that can occur after having anepidural or spinal anaesthetic. Many people have epidural or spinalanaesthetics for surgery. Occasionally, a headache may developfollowing the procedure.

What is special about the headache?Headaches after surgery or childbirth are common. However, afterhaving an epidural, you may develop a ‘post dural puncture’headache. The chance of this is about 1 in 200, but depends on yourage, the procedure and other circumstances.

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It typically occurs between one day and one week after having anepidural. It is usually a severe headache (felt at the front or back ofyour head). This gets better when lying down and worse on sittingor standing. Along with the headache you may experience neckpain, sickness and a dislike of bright lights.

‘...it was like the worst hangover in the world…’

If you have a spinal anaesthetic, the headache tends to be lesssevere (it depends on the size of the needle used).Young patients and women during childbirth are especially likelyto have post dural puncture headaches.

What causes the headache?Your brain and spinal cord are contained in a bag of fluid. The bagis called the dura and the fluid is called the cerebro-spinal fluid(CSF).When an epidural is given, a needle is used to inject localanaesthetic just outside the dura. Occasionally the needle passesthrough the dura: the chances of this happening depend on theexperience of the anaesthetist and certain patient relatedcircumstances. You can discuss this with your anaesthetist.When a spinal is given, a fine needle is inserted into the duradeliberately to inject local anaesthetic into the CSF.If too much fluid leaks out through the hole in the dura, thepressure in the rest of the fluid is reduced. If you sit up, the pressurearound your brain is reduced even more. This decreased pressurecan cause the symptoms typical of a post dural puncture headache.Some patients describe it as like a very bad migraine which is madeworse when sitting or standing up.

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What can be done about the headache?The hole in the dura will usually mend itself in a number of weeksbut it can take longer.

Lying flat and taking simple pain relieving drugs (such asparacetamol and ibuprofen) may help. You should drink plenty offluid (some people find tea or coffee especially helpful) and avoidlifting and straining.A severe post dural puncture headache will often need to betreated by an ‘epidural blood patch’.Being given a blood patch is like having an epidural and takesabout half an hour. The anaesthetist will take your blood and injectit near the hole in the dura where it will clot. This will tend to plugthe hole.In 60% to 70% of people who have this kind of headache, the bloodpatch will cure the headache within 24 hours. After this, if you stillhave a headache you may be advised to have a second blood patch.It is very rare to need more than two blood patches. In some peoplethe headache goes away but then returns. A second blood patchmay then help. Your anaesthetist will discuss this with you.After a blood patch, we recommend that you lie flat in bed for 4hours and do not lift anything heavy for at least two days.You may need someone at home with you to help you with yourdaily activities.

What problems are associated with a blood patch?There is a chance that another accidental dural puncture couldoccur.A blood patch may not cure your headache. In about 60 – 70% ofpatients, a blood patch will take away the headache very quickly.In the others, although a blood patch may help initially, theheadache soon returns.

‘...when it finally worked, the blood patch was wonderful…’

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A blood patch may cause local bruising and backache which lastsfor a few days. Epidurals do not cause chronic long-term backache.

‘...I was back to normal very quickly, but my back was stiff for quitea while…’

Difficulty passing urine, severe pain or loss of sensation in your backor legs are not normal and you should contact your anaesthetist ordoctor immediately.Infection or bleeding into your back are very rare complications ofepidurals, spinals and blood patches.There are alternative treatments but none has been shown to be aseffective as an epidural blood patch. You can discuss this with youranaesthetist.Your anaesthetist will be happy to discuss this in greater detail andto answer any questions that you have.

For more information and help please contact the anaestheticdepartment in your local hospital.

Booklets produced in the same series by the Royal College ofAnaesthetists and Association of Anaesthetists are available atwww.youranaesthetic.info. They include:

• Epidurals for pain relief after surgery• Your spinal anaesthetic

ReferencesFor further information on the references used in this leafletplease visit www.pat.nhs.uk

TO PROVIDE THE VERY BEST CARE FOR EACH PATIENT ON EVERY OCCASION

If English is not your frst

language and you need help,

please contact the Ethnic Health

Team on 0161 627 8770

For general enquiries please contact the Patient

Advice and Liaison Service (PALS) on 0161 604 5897

For enquiries regarding clinic appointments, clinical care and

treatment please contact 0161 624 0420 and the Switchboard

Operator will put you through to the correct department / service

www.pat.nhs.ukWood pulp sourced from

sustainable forests

Jeżeli angielski nie jest twoim pierwszym językiem i potrzebujesz pomocy proszę skontaktować się z załogą Ethnic Health pod numerem telefonu 0161 627 8770

Date of publication: February 2006Date of review: February 2014Date of next review: February 2017Ref: PI_DS_224© The Pennine Acute Hospitals NHS Trust