• Reference Number: HEY-384/2022
• Departments: Pain Medicine
• Last Updated: 1 March 2022

Introduction

This leaflet has been produced to give you information about a method of pain relief known as Patient Controlled Epidural Analgesia (PCEA), which is used after major surgery. It describes what happens when you have an epidural, together with any side effects and complications that can occur.

Whilst you have a PCEA your care will be reviewed daily by a member of the acute pain team (Not on a weekend), this is to ensure you are getting the best results from your pain relief.

What is patient controlled epidural analgesia (PCEA)?

The nerves from your spine which supply your lower body pass through an area in your back close to your spinal cord, called the “epidural space”. An epidural involves injecting local anaesthetic through a fine plastic tube, called an epidural catheter, into the epidural space. This causes the nerve messages to be blocked.

The epidural pump allows local anaesthetic to be given continuously and/or as an extra dose by pressing a button, this will depend on how the pump is programmed. Whilst you have a PCEA, you can still take other pain relieving drugs.

What are the benefits?

After an operation, it is important that you are able to move around and return to normal activities as soon as possible.

PCEA provides better pain relief than most other methods, particularly when you need to move around and return to normal activities as soon as possible.

PCEA provides better pain relief than most other methods, particularly when you move. PCEA reduces the risk of complications after major surgery such as nausea/vomiting, blood clots in the leg and lung, chest infection and delayed bowel function.

You should experience a quicker return to eating, drinking and full movement, possibly with a shorter stay in hospital compared to other methods of pain relief.

Blood thinning drugs

If you are taking certain types of blood thinning drugs such as warfarin or clopidrogel, you will be advised at your pre-assessment when you should stop taking them. You should not restart these drugs until after your epidural has been removed. You may need some small blood thinning injections before and after your operation.

What will happen?

Epidurals can be put in when you are awake, when you are sedated (drugs are given to make you feel sleepy and relaxed) or during an anaesthetic. These choices can be discussed further with your anesthetist.

• A needle will be used to put a short, thin plastic tube (a cannula) into a vein in your hand or arm for giving fluids (a drip).
• If you are conscious you will be asked to sit up or lie on your side, bending forwards to curve your back.
• Local anaesthetic is injected into a small area of the skin in your bag.
• A special epidural needle is pushed through this numb area, and a long thin plastic tube (catheter) is passed through the needle into your epidural space. The needle is then removed, leaving only the catheter in your back.

What will I feel?

The local anaesthetic stings briefly when it is injected into your skin, it is common to feel slight discomfort in your back as the catheter is inserted, as well as some pressure and pushing.

• Occasionally an electric shock like sensation or pain occurs during needle or catheter insertion. If this happens you must tell your anesthetist immediately.
• A sensation of warmth and numbness gradually develops like the sensation after a dental anaesthetic injection. You may still be able to feel touch, pressure, and movement.
• Your legs may feel heavy and become increasingly difficult to move.
• You may only notice these effects for the first time when you recover consciousness after your operation, particularly if the epidural was put in when you were anaesthetized.

How do I use the pump?

• With an epidural there is a dose of the medication being constantly given initially.
• You can have extra doses, by pressing the button on the handset (when the green light is on the button).
• The green light will flash while you are being given a dose.
• The pump will then lock you out, this is so you do not have too much of the drug.
• If your pain is still not controlled, then please speak to your nurse.

What happens afterwards?

At regular intervals the nurses will ask you about your pain and how you are feeling.  They will observe your breathing, pulse, blood pressure and check that you’re able to move your legs.

• They may adjust the epidural pump and treat any side effects.
• They will check that the pump is functioning correctly. They will encourage you to move, eat and drink (according to your surgeon’s instructions).
• The Acute pain Nurses will visit you daily (except on weekends); to ensure you are getting the most from your pain relief.

When will the epidural be stopped?

The epidural will be stopped when you no longer need it for pain relief. This is usually after you have started to take oral pain relief. The amount of pain relieving drug being given by the pump may be slowly reduced. The epidural may be removed after 2-4 days.

Can anyone have an epidural?

An epidural may not always be possible if the risk of complications is too high.

The anaesthetist will ask you if:

• You are taking blood thinning drugs, such as warfarin or clopidogrel.
• You have a blood clotting abnormality.
• You have an allergy to local anaesthetic, such as Lignocaine or Bupivacaine.
• You have severe arthritis or deformity of the spine.
• You have an infection in your back.

What if I decide not to have an epidural?

It is your choice; you do not have an epidural. There are several alternative methods of pain relief that work well, such as a pump which gives you a dose of strong pain relieving drug into your vein when you press a button (IV-PCA).

There are other ways in which local anaesthetic can be given or you can have pain relieving drugs by mouth if you are able to eat and drink.

Every effort will be made to ensure your comfort.

Side effects and complications

All the side effects and complications described can occur without an epidural. Common side effects are often minor and usually easy to treat. Serious side effects are fortunately rare. The risk of complications should be balanced against the benefits and compared with alternative methods of pain relief. Your anaesthetist can help you do this.

Inability to Pass Urine

The epidural affects the nerves that supply the bladder, so a catheter may have to be put in to drain it. This is often done routinely after major surgery to keep a check on kidney function.

With an epidural, this is a painless procedure. Bladder function returns to normal when the epidural wears off.

Low Blood Pressure

The local anaesthetic affects the nerves going to your blood vessels, so blood pressure always drops a little.  Fluids and or drugs can be put into your drip to treat this. Low blood pressure is common after surgery, even without an epidural.

Itching (Pruritis)

This can occur as a side effect of Morphine like drugs used in combination with local anaesthetic. It can be easily treated with anti-allergy drugs.

Feeling Sick and Vomiting

These can be treated with an anti-sickness drug.

This is less of a problem with an epidural than with most other methods of pain relief.

Backache

This is common after surgery, with or without an epidural and is often caused by lying on a firm flat operating table.

Inadequate Pain Relief

It may be impossible to place the epidural catheter, the local anaesthetic may not spread adequately to cover the whole operation site.

Overall epidurals usually provide better pain relief than other techniques. Other methods of pain relief are available if the epidural fails.

Weak or Numb Legs

The local anaesthetic can affect the nerves going to your muscles making them weak. This means that you will not be able to walk or move around easily. The nurse will adjust the epidural so that the numbness or weakness will go away, and you will be able to move around. The nurse will check the movement in your legs regularly by asking you to bend your knees.

Headaches

Minor headaches are common after surgery with or without an epidural. Occasionally a severe headache occurs after an epidural because the lining of the fluid filled space surrounding the spinal cord has been inadvertently punctured (dural tap). The fluid leaks out and causes low pressure in the brain, particularly when you sit up. Occasionally it may be necessary to inject a small amount of your own blood into your epidural space; this is called an “epidural blood patch”. The blood clots and plugs the hole in the epidural lining. It is almost always immediately effective. The procedure is otherwise the same as for a normal epidural.

If your epidural is not working properly, the epidural catheter will be removed, and an alternative method of pain relief will be commenced.

Uncommon complications

• Slow breathing – some drugs used in the epidural can cause slow breathing and/or drowsiness needing treatment.
• Catheter Infection –the epidural catheter can become infected, and may need to be removed. Antibiotics may be needed.  It is very rare for the infection to spread any further than the insertion site in the skin.

Rare or very rare complications

Other complications, such as convulsions (fits), difficulty in breathing and temporary nerve damage are rare, whilst permanent nerve damage, epidural abscess, epidural haematoma (blood clot), and cardiac arrest (stopping of the heart) is very rare indeed.

This leaflet was produced by the Department, Hull University Teaching Hospitals NHS Trust and will be reviewed in 2024.

General Advice and Consent

Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.

Consent to treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.

The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

• you must be able to give your consent
• you must be given enough information to enable you to make a decision
• you must be acting under your own free will and not under the strong influence of another person

Information about you

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We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.

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