Having an epidural for pain relief after an operation
What is an epidural?
An epidural is an injection of a local anaesthetic between the bones in your back to temporarily numb the nerves to the lower body. Epidurals are used to relieve pain during and after surgery on the abdomen (tummy) and legs. The epidural injection places a very small plastic tube called an epidural catheter into the back. A pump can then be used to deliver a numbing drug (local anaesthetic) continuously, both during and after an operation. The epidural can be continued for between 1 and 4 days. This keeps you comfortable and also enables you to move, take deep breaths and cough after your surgery, which are important functions to aid your recovery.
Epidurals can also be used in pregnant women to relieve labour pains and sometimes for other painful conditions. Epidurals are often combined with a general anaesthetic for major operations.
What does it involve?
Your anaesthetist will tell you what he/she is going to do:
- First a needle is used to insert a small plastic tube (a drip) into your hand or arm.
- The epidural is usually inserted when you are awake, or when you are under sedation (a drug to make you drowsy and relaxed, but still conscious). It can also be inserted during a general anaesthetic.
- You will be helped into the correct position for the epidural injection; either sitting, or lying on your side, curled up with knees tucked up towards your chest.
What will I feel?
- Your anaesthetist will clean your back with an antiseptic cleaning solution that feels very cold. Then local anaesthetic is injected into the skin. This may sting but afterwards you should just feel pushing or mild discomfort when the epidural injection is performed. Your anaesthetist will ask you to keep still during the procedure. You may feel ‘pins and needles’ or sharp tingles in your back or legs during the injection. Let your anaesthetist know about it, but this should not last long and does not mean anything is wrong. The needle is removed leaving only the fine tube (catheter) in your back.
- A sensation of warmth and numbness gradually develops and your legs may become heavy, this can take about 20 minutes. You may still be able to feel touch, pressure and movement. You may only notice these effects for the first time when you wake up after the operation.
What are the benefits to me of an epidural anaesthetic?
- Better pain relief than other methods.
- It may reduce some of the complications of major surgery such as blood clots in the legs and lungs (deep vein thrombosis), chest infections and blood transfusions. It also causes less nausea and vomiting.
- Compared to strong painkillers such as morphine, epidurals cause less confusion in older people.
- Quicker return to eating, drinking and full movement, possibly with a shorter stay in hospital compared to other methods of pain relief.
Are there any risks to me?
As with all anaesthetic techniques there is a possibility of unwanted side effects and complications, your anaesthetist will be happy to discuss these with you and answer your questions: -
Very Common and common side effects:
- Low blood pressure. A small drop in blood pressure is common and can also occur after surgery without an epidural. Fluids or drugs are put into your arm ‘drip’ to treat this.
- Difficulty passing water (urinary retention). You will normally need a urinary catheter to drain the bladder. The bladder catheter is often put in place while you are asleep for your operation. Difficulty passing urine can also occur after operations without an epidural.
- Itching. Itchy skin can occur as a side effect of the painkiller drugs often given together with the local anaesthetic drugs. It can be treated.
- Headache. Headaches are quite common after surgery, particularly if you normally have frequent headaches or if your normal caffeine consumption is high. There is also a risk (about 1 in 100) of headache due to the epidural needle inadvertently puncturing the fluid filled space inside the epidural space (a ‘dural tap’). This can settle with bed rest and ensuring you have plenty of fluids. Occasionally an ‘epidural blood patch’ is used to treat this type of headache which your anaesthetist will discuss if necessary.
- Back ache. Back pain is common after operations (particularly long operations), and is very rarely due to the epidural injection.
- Inadequate pain relief. It is sometimes difficult for the anaesthetist to put the epidural needle in a satisfactory position or the numbness produced does not cover the whole surgical area. It is also possible for the epidural tube to move or fall out of position. The incidence of problems with incomplete pain relief is up to 1 in 5 (20%). Your acute pain nurse or anaesthetist may be able to adjust your epidural pump rate to improve your pain relief. Sometimes it is necessary to change to another form of pain relief.
- Slow breathing. Some of the drugs used in the epidural can cause excessive drowsiness, or slow breathing requiring treatment.
- Catheter infection. The skin where the epidural tube (catheter) goes into the back can be come infected. The catheter will need to be removed and antibiotics may be required. It is rare (less than 1 in 3,000) for the infection to spread deeper (epidural abscess or meningitis) and affect the nerves.
Rare or very rare Complications
- Convulsions (fits). This can occur due to too much of the local anaesthetic drugs. This is usually short lived and can be treated.
- Nerve damage. This is a rare complication of epidural anaesthesia. It can be caused by an epidural abscess or blood clot (haematoma). Temporary loss of sensation, pins and needles and sometimes muscle weakness may last for a few days or even weeks but almost all of these make a full recovery with time. Permanent nerve damage is very rare. (Incidences; temporary problems: about 1 in 5,000, long term problems: less frequently than 1 in 25,000, permanent nerve damage (eg. resulting in loss of the use of legs) less frequently than 1 in 100,000).
What should I expect after my operation and epidural anaesthetic?
- Your tummy and legs will be numb but you should still be able to move your legs and feet. You should be able to move about in bed and be helped to sit out and possibly walk, depending on your operation.
- The epidural may be used for up to 4 days after your operation to help keep you pain-free. The epidural tube is attached to a pump so the numbing drugs (local anaesthetic) are given continuously. You may be given a ‘patient control’ button so that you can control top up doses of the local anaesthetic. Your nurse will regularly check your pain score and skin sensation. An acute pain nurse will visit you regularly to help ensure your pain control is good.
- When the epidural is stopped, you may get some ‘pins and needles’ or tingling as sensation returns to normal. You will have been started on other painkillers (usually tablets) so that these are working when the effect of the epidural wears off. It does not normally hurt when the thin epidural tube is removed from your back.
- Once your epidural has been stopped, if you develop any new numbness or heaviness of your legs, it is important to let your nurse or doctor know.
Frequently asked Questions
Are there any reasons I may not have an epidural anaesthetic?
Yes, sometimes an epidural anaesthetic can be dangerous or undesirable, this could include in patients who need to remain on ‘blood thinning’ drugs such as warfarin and heparin during surgery. Some people with severe back problems or an infection of the skin over the back will be advised not to have an epidural.
If you are overweight it can be more difficult to perform the epidural injection, but the benefits may mean this is still the best choice of painkiller for you.
Can I choose not to have an epidural anaesthetic?
Your anaesthetist will carefully consider what they think is the best procedure for you and explain and discuss this with you. You will never be forced to have any anaesthetic procedure that you don’t want.
How can I get more information?
Your anaesthetist will be able to answer any questions you have. You should have been given a copy of our general leaflet ‘Information About Your Anaesthetic’. The Royal College of Anaesthetists and The Association of Anaesthetists have produced a number of useful information leaflets about anaesthesia, which can be accessed via the Internet at www.youranaesthetic.info
Consent – What does this mean?
Before any doctor, nurse or therapist examines or treats you they must have your consent or permission. Consent ranges from allowing a doctor to take your blood pressure, (rolling up your sleeve and presenting your arm is implied consent), to signing a form saying you agree to the treatment or operation.
It is important before giving permission that you understand what you are agreeing to. If you do not understand – ask. More detailed information is available on request.
Information about you- The Data Protection Act 1998
Confidential records are kept about your health and the care you receive. These records are important, helping to make sure you receive the best possible care from us. The information may also be used to plan services and assist in the teaching and training of health professionals. To make sure that patient confidentiality is maintained a policy has been written informing all staff of their responsibilities.
How to comment on your treatment
We aim to provide the best possible service and staff will be happy to answer any questions that you have. However, if you have any concerns you can also contact firstname.lastname@example.org who will be happy to help.
Authors: Portsmouth Anaesthetic Department Governance Group February 2009
Review date: Feb 2011
References: Some of the text used in this leaflet has been extracted from the patient information leaflet; ‘Epidurals for pain relief after surgery’, produced by the Royal College of Anaesthetists and The Association of Anaesthetists.