Patient Controlled Epidural Analgesia

  • Reference Number: HEY-384/2018
  • Departments: Pain Medicine

Introduction

This leaflet has been produced to give you general 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 may 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 medication.

Most of your questions should have been answered by this leaflet.  It is not intended to replace the discussion between you, and your doctor, but may act as a starting point for discussion. If after reading this leaflet you require further explanation or advice on your pain relief options, please do not hesitate to ask the nurse, doctor or anaesthetist.

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 medication.

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.  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 medication

If you are taking certain types of blood thinning medication such as warfarin or clopidrogel, you will be advised at your pre-assessment when you should stop taking them. You should not restart this medication 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 (medication is given to make you feel sleepy and relaxed) or during an anaesthetic. These choices can be discussed further with your anaesthetist.

  • 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 awake you will be asked to sit up or lie on your side, bending forward to curve your back.
  • Local anaesthetic is injected into a small area of the skin in your back.
  • 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 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 the 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 anaesthetist 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 anaesthetised.

How do I use the pump?

  • With an epidural there is a dose of the medication being constantly given.
  • 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 medication. 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 are able to move your legs.

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

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 medication.   The amount of pain relieving medication being given by the epidural 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 medication, such as warfarin or clopidogrel
  • You have a blood clotting abnormality
  • You have an allergy to local anaesthetics 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 to 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 medication into your vein when you press a button (Intravenous Patient Controlled Analgesia (IV-PCA).

There are other ways in which local anaesthetics can be given or you can have pain relieving medication by mouth if you are able to eat and drink.  Every effort will always 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 are usually easy to treat.  Serious complications 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 (tube) may have to be inserted to drain it.  This is often necessary anyway after major surgery to check kidney function.  With an epidural, it 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 medication can be put into your drip to treat this.  Low blood pressure is common after surgery, even without an epidural.

Itching

This can occur as a side effect of morphine-like medication used in combination with local anaesthetic.  It is easily treated with anti-allergy medication.

Feeling sick and vomiting

These can be treated with anti-sickness medication. These problems are less frequent 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 surgical area, or the catheter can fall out.  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 (a 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.

Uncommon complications

Slow breathing

Some medication used in the epidural can cause slow breathing and/or drowsiness requiring treatment.

Catheter infection

The epidural catheter can become infected and may have to be removed.  Antibiotics may be necessary.  It is very rare for the infection to spread any further than the insertion site in the skin.

Rare of very rare complications

Other complications, such as convulsions (fits), breathing difficulty 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.  For major surgery, the risk of permanent nerve damage is about the same, with or without an epidural.

These risks can be discussed further with your anaesthetist and more detailed information is available.

Should you require further advice on the issues contained in this leaflet, please do not hesitate to contact the Pain Management Nurse Team via the hospital switchboard Tel no: (01482) 875875 (Monday-Friday).  If they are not available contact the Anaesthetic Department, Hull Royal Infirmary Tel no: (01482) 674542

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.

Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You.

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