Further information about anaesthetics

Transcription

1 top Further information about anaesthetics Contents: Anaesthetics Types of anaesthesia General anaesthetic Sedation Local anaesthetic Regional anaesthesia Brachial plexus Finger or wrist block Femoral nerve block Ankle block TAP block Spinal anaesthesia Epidural anaesthesia How safe is my anaesthetic? Anaesthetics Anaesthesia means "loss of sensation". Medications that cause anaesthesia are called anaesthetics. Anaesthetics are used for pain relief during tests or surgical operations so that you do not feel any pain. Anaesthetists are specialists who are trained in anaesthesia, doctors can also called an anaesthesiologist. Before your procedure, they will discuss with you what anaesthetic methods are appropriate, along with any risks or side effects. If you have any queries about your anaesthetic it is important that you raise them with your Anaesthetist. Nothing will happen to you until you understand and agree with what has been planned for you. You have the right to refuse if you do not want the treatment suggested Your anaesthetist will make sure that you are safe throughout the surgery or investigation, and that you wake up comfortably after the procedure. They may also help with any pain relief that you might need after the procedure. Types of anaesthesia

2 There are several different types of anaesthesia. Most types do not make you unconscious, but they stop you feeling pain in a particular area of your body. General anaesthetic is used for operations where you need or want to be unconscious. The anaesthetic stops your brain recognising any signals from your nerves, so you cannot feel anything. Sedation is for painful or unpleasant procedures that are otherwise minor. Sedation makes you feel sleepy and relaxes you both physically and mentally. Local anaesthetic is used for minor procedures and tests to numb the nerves in the area where the procedure is taking place. You will be conscious during the procedure but you do not feel any pain. Regional anaesthetic is used for larger or deeper operations where the nerves are harder to reach. Local anaesthetic is injected near the nerves in order to numb a larger area, but you remain conscious. Spinal anaesthesia is a regional anaesthetic that is used to numb your spinal nerves so that surgery can be carried out the lower part of your body. Epidural anaesthetic is a regional anaesthetic used to numb the lower half of your body, which is for example often used for childbirth or for post operative pain relief. General anaesthesia If you are having a general anaesthetic, it will be given to you by an anaesthetist, either as a liquid that is injected into your veins through a cannula (a thin, plastic tube that feeds into a vein, usually on the back of your hand) or gas that you breathe in through a mask. Your anaesthetist will stay with you throughout the procedure. They will make sure that you continue to receive the anaesthetic and that you stay asleep, in a controlled state of unconsciousness. After the procedure, the anaesthetist will reverse the anaesthetic and you will gradually wake up. General anaesthetic is essential for some surgical procedures where it may be safer or more comfortable for you to be unconscious. If you need any form of anaesthetic, you will meet your anaesthetist and plan your anaesthetic together before surgery. Your anaesthetist will look at your medical history and will ask you whether anyone in your family has had problems with anaesthesia. They will also ask you

3 about your general health and lifestyle, including whether you: have any allergies, smoke or drink alcohol or are taking any medication. Your anaesthetist will also be able to answer any questions you have. Let them know if you're unsure about any part of the procedure or if you have any worries or concerns. You should be given clear instructions to follow before the operation, including whether you can eat anything in the hours leading up to it. Side effects General anaesthetic has some common side effects. Your anaesthetist should discuss these with you before your surgery. Most side effects occur immediately after your operation and do not last long. Possible side effects include: Feeling sick or vomiting after surgery about 33% of people feel sick after an operation. This usually occurs immediately after, although some people may continue to feel sick for up to a day Shivering and feeling cold about 25% of people experience this. Shivering may last for 20 to 30 minutes after your operation. Confusion and memory loss this is more common in elderly people and is usually temporary Chest infection this can sometimes occur in people who have abdominal surgery and who smoke. It will make you feel feverish (hot and cold) and cause breathing difficulties Bladder problems men may have difficulty passing urine and women may leak urine. This is more common after a spinal or epidural anaesthetic. Minor, temporary nerve damage this affects around 1% of people and causes numbness, tingling or pain. It may get better in a few days or it may take several weeks to improve. Dizziness this can occur after your operation. You will be given fluids to treat it. Bruising and soreness this can develop in the area where you were injected or had a drip fitted. It usually heals without treatment. Damage to teeth and mouth- During your operation, you will need to have a tube inserted down your throat to help you breathe. Afterwards, this causes a sore throat in about 40% of people. Around 5% of people may have small cuts to their lips or tongue from the tube. Around 1 in 4,500 people may have damage to their teeth. Complications and risks Some more serious complications are associated with general anaesthetics, but they are very rare (occurring in less than one case for every 10,000 anaesthetics given). Possible complications include: Permanent nerve damage, causing paralysis or numbness A serious allergic reaction to the anaesthetic or other drugs (anaphylaxis)

4 Death this is very rare (there is approximately one death for every 100,000 general anaesthetics given) Whether you are at any risk of these complications will depend on: your medical history whether you have any other illness personal factors whether you smoke or are overweight, for example the type of surgery needed whether it is planned or carried out in an emergency, or whether it is a major or minor procedure the type of anaesthetic needed. General anaesthetics can have more side effects and complications than local anaesthetics. Your anaesthetist will discuss the risks with you before your operation. You may be advised to stop smoking or lose weight, if doing so could reduce your risk of developing complications. In most cases, the benefits of being pain-free during an operation outweigh the risks. Sedation Intravenous sedation is the most common form of sedation and is the use of drugs through a cannula in a vein (a drip) to make you feel less anxious and it will often make you drowsy or sleepy. The drugs may actually make you sleep and the drugs can make you forget what has happened. Other ways of giving sedation is by inhaling as gas and air or by swallowing a tablet or a liquid. It is a suitable way of keeping you safe and comfortable during your procedure. Sedation is used when you are undergoing a possible uncomfortable investigation or having surgery in combination with a local or regional anaesthetic. The aim of the sedation is to allow you to relax and not feel anxious or nervous during your operation. The benefits Without sedation the operation or procedure would possibly cause you anxiety, distress or pain. Recovery is quick after sedation. For day surgery it normally means that you can go home earlier.

5 A general anaesthetic can often be avoided by having sedation. In addition sedation enables the surgeon to perform your operation with greater ease and safety. You can even listen to your own music device during your procedure. General reasons for having sedation: When you feel very anxious or worried about a procedure or investigation. Where the procedure is short or involves only a small area of the body, this can be in combination with a local anaesthetic. Where the procedure is not very painful. When you are too unwell to safely receive a general or alternative anaesthetic, some procedures can still be performed under sedation in combination with a local anaesthetic. Risk Side effects include: Headache, feeling sick or vomiting and having difficulty in remembering what happened during the treatment Allergic reactions can occur whenever medication is given Deep sedation can sometimes affect your breathing and can lower your blood pressure. During a procedure under sedation you will be monitored by an anaesthetist or health professional who will be able to treat these side effects as early as possible in order to minimise the risk. Local anaesthetic A local anaesthetic is a type of painkilling medication that is used to numb areas of the body during some surgical procedures. You stay awake when you have a local anaesthetic but in some cases the local anaesthetic can be combined with sedation. How does local anaesthetic work? Local anaesthetic causes loss of feeling to a specific area of your body without making you lose consciousness. It works by blocking the nerves from the affected part of your body so that pain signals cannot reach your brain. You will not be able to feel any pain during the procedure but you may still feel some pressure or movement. It only takes a few minutes to lose feeling in the area where local anaesthetic is given. The doctor will make sure that the area is fully numb before starting the procedure. It can take a few hours for local anaesthetic to wear off and for full feeling to return. You should be careful not to damage the area during this time. When is local anaesthetic used?

6 Local anaesthetic is often used by dentists, surgeons and GPs when carrying out minor operations on small areas of the body. For example, local anaesthetic is often used during: The removal of a tooth or a filling Minor skin surgery, such as the removal of moles, lipoma s, warts and verrucas Some types of eye surgery, such as the removal of cataracts (cloudy areas in the lens of the eye) Some types of biopsies, such as a needle biopsy, where a tissue sample is removed for examination under a microscope. For surgery the local anaesthetic is often injected into the skin around the operation area to make it numb and pain free to be able to perform the operation. We always test the effectiveness before we go any further. Other forms of anaesthesia, for example a general anaesthetic, is often supplemented with a local anaesthetic to the wound area at the end of the procedure to help with post operative pain relief after surgery. Regional anaesthesia Local anaesthetic or regional anaesthesia does not put you to sleep but works by blocking the signals that pass along your nerves to your brain. We can block the nerves at different levels to numb a certain area, for example we can block just a finger or a whole region like an arm, a leg or we can numb both legs with a spinal or epidural anaesthesia so it only numbs a part of your body. There are many types of nerve blocks, such as: Brachial Plexus Finger or Wrist block Spinal Femoral nerve block Ankle block Epidural TAP block. Brachial plexus Brachial plexus is the name given to the bundle of nerves that supply your shoulder, arm and hand with feeling and power. These nerves start in the neck and travel via the armpit, eventually reaching the hand. Brachial plexus blocks may be used for surgery to the shoulder, arm or hand. The feeling and power of the shoulder, arm or hand can be blocked by placing an injection of local anaesthetic near to the nerves of the brachial plexus.

7 Your anaesthetist will discuss the benefits and risks of the procedure with you. Together, you can decide whether a brachial plexus block is best for you. The benefits are: To avoid the risks of a general anaesthetic For pain relief after your operation To help the physiotherapists to start moving the arm, which aids recovery To increase blood flow to the area How is a brachial plexus block performed? The brachial plexus block can be performed with you awake or anaesthetised but is mostly performed under sedation. Firstly, the site of the injection is cleaned and an injection of local anaesthetic is used to numb the skin. Then, a needle is used to inject local anaesthetic around the nerves. Initially your arm will feel warm and tingly. Within 40 minutes, it will become numb and heavy. Your anaesthetist may also use a small electric current, which runs through the needle to help find the nerves accurately. This will make your arm twitch. This is a strange feeling but should not be painful. Alternatively, he or she may use an ultrasound machine to place the needle correctly. Occasionally your anaesthetist may suggest placing a catheter (a very thin tube) through the needle at the same time. This remains in place next to the nerves after the needle has been removed, allowing more local anaesthetic to be given later - perhaps for up to a few days after your operation. Recovery The effects of the local anaesthetic will last between four and 24 hours on average about hours. Your arm will be held in a sling until the strength has returned. Please ensure that the strength and feeling has fully returned to your arm before trying to use it normally. Are there any risks to having a brachial plexus block? Brachial plexus blocks are not always completely effective. Sometimes the local anaesthetic does not spread to all the nerves. The operation you are having and your general body shape also affect the success rate. Your anaesthetist will be able to tell you how likely the block is to work fully. If the block does not work sufficiently for your operation, your anaesthetist will use another form of anaesthetic and/or pain relief. If the injection is placed in the side of your neck, side effects include a hoarse voice, a droopy upper eyelid and feeling faint, especially on sitting up. Rarely, you may find breathing a bit more of an effort than normal. All these are temporary and should get better when the block wears off. If the injection is placed around the collarbone, there is a small risk of damage to the lung (one in 1000 patients). This can usually be managed to keep you safe

8 and serious permanent harm is very rare. Your anaesthetist can tell you more about this. For all injection sites, there is a small risk of bleeding due to damage to a blood vessel. This can be treated by direct compression and/or extra fluids given into a vein. Nerve damage can occur because of direct injection into the nerve or because of bleeding or infection. The risk of permanent nerve damage is rare. It is the same for all injection sites. An exact measure of the risk is not available, but the best studies we have suggest that it is between one in and one in patients having a brachial plexus block. Patients commonly notice areas of tingling and/or numbness in the arm, shoulder or hand. This occurs in around one in 20 patients and usually resolves within three weeks, or occasionally up to three months. There are other causes of nerve damage that are not caused by the brachial plexus block. You can find more information in the leaflet Nerve damage associated with peripheral nerve blockade from the RCOA If you have any questions please ask your anaesthetist, your surgeon or your nurses on the ward. They may be able to arrange for you to talk to another patient on the ward who has had a brachial plexus block. What to expect after a brachial plexus block You have had an injection of local anaesthetic around the nerves that supply movement and sensation to your arm. You can expect your arm and/or shoulder to: Be heavy and floppy Have pins and needles or numbness Feel warm. These effects may last from a few hours to a day. Precautions In order to maximise your pain relief, please take regular pain killers, as prescribed, BEFORE your block wears off. (i.e. while your arm is still numb) The signs or symptoms that tell you this type of anaesthetic is wearing off may include: Tingling Increased sensation and movement to the affected part Discomfort or pain

9 and movement have returned before you attempt to use your arm normally again. umb. You should make slow cautious movements avoiding awkward positions and over extension of your joints. your arm away from constant pressure, radiators/fires/hot water/extremes of cold. Support If you are experiencing pins and needles, numbness, weakness or difficulty breathing after one week, either inform your surgeon (if your follow-up clinic is within one week of your operation) or phone the Queen Elizabeth Hospital switchboard ( ) and ask for the on-call anaesthetist. Should you require further information please refer to Finger or wrist blocks Finger or wrist blocks are local anaesthetic injections to the nerves that go to your finger or your hand in the case of a wrist block. It makes operations to these areas possible without the need for a general anaesthetic or will help with post operative pain relief as these techniques are often used in combination with a general anaesthetic and reduce the need for strong pain medications, thus minimising risk of side effects. A single injection finger or wrist block may last six to 12 hours. While most injuries of the hand can be managed with at the surgical site or a finger block if an individual finger is involved, there are several circumstances where anaesthesia of the entire hand may be beneficial. For example: Extensive injuries of the hand - the inside of your hand may be quite difficult and painful to anaesthetise and may not last as long as a wrist block Multiple finger injuries where performing four to five individual finger blocks is required Burns and bites. Side effects Common side effects from finger and wrist blocks are pain on injection, tingling of finger, hand or arm, sickness and dizziness. Every time we puncture the skin, whether that is with a knife or a needle there is a low risk of infection but swelling or bruising around the injection site is more common.

10 Other risks from these nerve blocks include the rare possibility of nerve injury, which in most cases is temporary and resolves over several days or weeks. Permanent nerve damage is very rare. Femoral nerve block for thigh, hip or knee surgery A femoral nerve block is an injection of local anaesthetic to the nerve that runs in your groin area to your leg. The femoral nerve supplies the feeling and power to the front of the thigh, inner side of your leg and the knee and can be blocked by placing an injection of local anaesthetic near to the femoral nerve. This is one of many types of nerve block. This particular nerve block is usually used as part of an anaesthetic for an operation on the upper leg, knee or hip. The nerve block may be used with a general anaesthetic, in which case you will usually be asleep for the nerve block. This means that the anaesthetist does not need to give as much anaesthetic or strong painkillers which can make you feel sick and drowsy. Good pain relief this way means a faster recovery and less sickness after the operation. It can also help you to co-operate better with the physiotherapists to start moving the leg earlier, which aids recovery. The block usually lasts for several hours. The leg will be numb and feel heavy during this time. One advantage of the block is that it can reduce the amount or need of other strong painkillers, such as morphine, needed during and after the operation. The aim is that you will not feel any pain during the operation. The block will provide pain relief during the operation and for several hours afterwards. Your anaesthetist will talk to you before doing the block and explain whether you will be awake, asleep or sedated during the operation. There are a number of benefits to this procedure. You may have other serious medical conditions, such as heart or lung disease. In this case a general anaesthetic may have slightly more risk than normal. Doing the block, instead of using a general anaesthetic alone, will cause less stress to your medical condition and be safer. A femoral nerve block also increases the blood flow to the area. In certain situations, this may be improve healing and speed up your recovery. You should not have a femoral nerve block if you: Are on medication that prevents your blood from clotting, such as Warfarin and Clopidogrel; this would lead to more bleeding than normal unless your medication is stopped in time

11 Have an illness that prevents your blood from clotting, such as haemophilia; this would lead to more bleeding around the nerves in the leg. Have an infection of the skin over the site where the needle needs to be put in; this could lead to further infection in the deeper tissues and possibly blood poisoning. This could also cause infection around the nerves Previous injury or disease affecting your femoral nerve; perhaps you have had a previous injury to your upper leg, or groin. This could make it unsafe to do this type of block. Nerve damage Nerve damage can occur because of direct injection into the nerve or because of bleeding or infection. The risk of permanent nerve damage is rare. It is the same for all injection sites. An exact measure of the risk is not available, but the best studies we have suggest that it is between one in and one in patients having a femoral nerve block. There are other causes of nerve damage that are not caused by the femoral nerve block. Your anaesthetist will discuss the benefits and risks of the procedure with you. Together, you can decide whether a femoral nerve block is best for you. Ankle or foot block Ankle blocks are local anaesthetic injections to the nerves that go to your foot. It makes operations on your foot possible but is in our hospital often used in combination with a general anaesthetic or even a spinal anaesthetic. Ankle blocks will help with post operative pain relief as it reduces the need for strong pain medications, thus minimising risk of side effects. A single injection ankle block may last six to 12 hours. While most injuries of the foot can be managed with either local anaesthetic where you are having surgery or a toe block if an individual toe is involved, there are several circumstances where anaesthesia of the entire foot or a large portion of it may prove beneficial: Extensive injuries of the foot, especially on the heel and sole, may be quite difficult and painful to anaesthetise and may not last as long as an ankle block Multiple toe injuries where performing four to five individual toe blocks is required Burns, bites. Common side effects from ankle blocks are pain on injection, tingling of toes, foot or leg, sickness and dizziness.

12 Every time we puncture the skin, is that with a knife or a needle there is a low risk of infection but swelling or bruising around the injection site is more common. Other risks from these nerve blocks include the rare possibility of nerve injury, which in most cases is temporary and resolves over several days or weeks. Permanent nerve damage is very rare. TAP block A TAP block (or Transversus Abdominis Plane) is a local injection between a layer of muscles often on both sides of your abdomen. We do this while you are having a general anaesthetic, so you are asleep. If successful, this relatively new way of anaesthetising nerves, will numb your tummy or abdomen after surgery in this area and so help to improve comfort after surgery. Operations where TAP blocks are used include removing your appendix, inguinal hernia repair, gall bladder removal, etc. Studies have shown that TAP blocks provide highly effective post operative pain relief in the first hours. This way it can reduce the need of other pain killers like morphine by more than 70%. Therefore there is a lower risk of side effects from pain medication and post-operative nausea and vomiting was reduced by more than half by patients that had a TAP block. Generally, TAP blocks have so far shown to be very safe. Possible side effects are: Sickness and dizziness Every time we puncture the skin, (is that with a knife or a needle) there is a low risk of infection but swelling or bruising around the injection site is more common There is a rare possibility of nerve injury, which in most cases is temporary and resolves over several days or weeks. Permanent nerve damage is very rare TAP blocks can potentially numb your leg if local anaesthetic spreads to nerves that go to your leg, this is only temporary. There are few complications mentioned in the current literature involving TAP blocks but are rare, these are: liver damage, and bruising or bleeding from the bowel after a needle puncture. If it is beneficial for you to have TAP blocks for your operation your anaesthetists will discuss this with you before your operation. Spinal anaesthesia For many operations, patients receive a general anaesthetic which produces a state of controlled unconsciousness during the operation. A spinal anaesthetic

13 ( a spinal ) may be used instead for some operations below the level of the waist. Depending on the type of operation and your own medical condition, a spinal anaesthetic may sometimes be safer for you and suit you better than a general anaesthetic. You can normally choose: to remain fully conscious or to have some sedation during your operation. This makes you relaxed and drowsy although you remain conscious, or occasionally a spinal anaesthetic may be combined with a general anaesthetic. Almost any operation performed below the waistline is suitable for a spinal and there are benefits to both you and your surgeon when a spinal is used. What is a spinal? A local anaesthetic drug is injected through a needle into the small of your back to numb the nerves from the waist down to the toes for two to three hours. How is the spinal performed? Your anaesthetist will discuss the procedure with you beforehand. A needle will be used to insert a thin plastic tube (a cannula ) into a vein in your hand or arm and then the staff looking after you will help you into the correct position for the spinal. You will either sit on the side of the bed with your feet on a low stool or lie on your side, curled up with your knees tucked up towards your chest. In either case, the staff will support and reassure you during the injection. The Anaesthetist will explain what is happening throughout the process so that you are aware of what is taking place "behind your back". Your anaesthetist will give you the spinal injection and stay with you throughout the operation. As the spinal begins to take effect, your anaesthetist will measure its progress and test its effectiveness. What will I feel? Usually, a spinal should not cause you any unpleasant feelings and should take only a few minutes to perform. As the injection is made you may feel pins and

14 needles or a sharp tingle in one of your legs if you do, try to remain still, and tell your anaesthetist about it (see side effects and complications). When the injection is finished you normally lie flat as the spinal works quickly and is usually effective within five to ten minutes. To start with the skin feels numb to touch and the leg muscles are weak. When the injection is working fully you will be unable to move your legs or feel any pain below the waist. During the operation you may be given oxygen to breathe via a lightweight, clear plastic mask to improve oxygen levels in your blood. Only when both you and the anaesthetist are completely happy that the anaesthetic has taken effect will you be prepared for the operation. Why have a spinal? The advantages of having a spinal are that there may be: Less risk of chest infections after surgery Less effect on the heart and lungs Excellent pain relief immediately after surgery Less need for strong pain-relieving drugs Less sickness and vomiting Earlier return to drinking and eating after surgery Less confusion after the operation in older people. With a spinal, you can communicate with the anaesthetist and surgeon before, during and after surgery. If an operating camera is being used, you may even be able to watch the operation on television if you wish! Alternatively, you may decide that you wish to have sedation while the operation is in progress. Operations a spinal is often used for: Orthopaedic surgery any major operation on the leg bones or joints General surgery hernia repair, varicose veins, piles (haemorrhoids) Vascular surgery repairs to the blood vessels of the leg Gynaecology vaginal repair or operations on the bladder outlet Urology prostate removal, bladder operations and genital surgery. However you may still need a general anaesthetic if: Your anaesthetist cannot perform the spinal satisfactorily The spinal does not work satisfactorily The surgery is more complicated than expected. Risk and complications

15 Low blood pressure As the spinal takes effect, it can lower your blood pressure and make you feel faint or sick. This can be controlled with the fluids given by the drip and by giving you drugs to raise your blood pressure. Itching This can occur as a side effect of using morphine-like drugs in combination with local anaesthetic drugs in spinal anaesthesia. If you experience itching it can be treated, as long as you tell the staff when it occurs. Difficulty passing water (urinary retention) You may find it difficult to empty your bladder normally for as long as the spinal lasts. Your bladder function returns to normal after the spinal wears off. You may require a catheter to be placed in your bladder temporarily, either while the spinal wears off or as part of the surgical procedure. Pain during the injection As previously mentioned, you should immediately tell your anaesthetist if you feel any pain or pins and needles in your legs or bottom as this may indicate irritation or damage to a nerve and the needle will need to be repositioned. Headache There are many causes of headache, including the anaesthetic, the operation, dehydration and anxiety. Most headaches get better within a few hours and can be treated with pain relieving medicines. Severe headache can occur after a spinal anaesthetic. If this happens to you, your nurses should ask the anaesthetist to come and see you. You may need special treatment to settle the headache. Rare complications Nerve damage This is a rare complication of spinal anaesthesia. 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 in time. Permanent nerve damage is even more rare and has about the same chance of occurring as major complications of general anaesthesia. More information can be found on After your spinal Your nurses will make sure that the numb area is protected from pressure and injury until sensation returns. It takes between one and a half to four hours for feeling (sensation) to return to the area of your body that is numb. You should tell the ward staff about any concerns or worries you may have. As sensation returns you may experience some tingling in the skin as the spinal wears off. At this point you may become aware of some pain from the operation site and you should ask for more pain relief before the pain becomes too obvious.

16 As the spinal anaesthetic wears off, please ask for help when you first get out of bed. You can normally drink fluids within an hour of the operation and may also be able to eat a light diet. Frequently asked questions Can I eat and drink before my spinal? You will need to have an empty stomach before your operation and you must follow the same rules as if you were going to have a general anaesthetic. (See link 14 to fasting guide lines)this is because it is occasionally necessary to change from a spinal anaesthetic to a general anaesthetic. The hospital should give you clear instructions about fasting. Must I stay fully conscious? Before the operation you and your anaesthetist can decide together whether you remain fully awake during the operation or would prefer to be sedated so that you are not so aware of the whole process. The amount of sedation can be adjusted so that you are aware but not anxious. It is also possible to combine a spinal with a light general anaesthetic. Will I see what is happening to me? Sometimes you can choose. Normally a screen is placed across your upper chest so that you see nothing when surgery starts. Some operations use video cameras and telescopes for keyhole surgery and many patients like to see what is happening to them on the video screen. You will be aware of the hustle and bustle of the operating theatre when you come in. Once surgery starts noise levels drop. You will be able to relax, with your nurse and your anaesthetist looking after you. Some patients like to wear personal stereo headphones to listen to their own choice of music during the operation. The options available to you will vary, depending on a number of factors to do with your operation. You will be able to discuss all these possibilities with your anaesthetist at the preoperative visit. Do I have a choice of anaesthetic? Yes. Your Anaesthetist will assess your overall preferences and needs for the surgery and discuss them with you. If you have anxieties regarding the spinal then these should be answered during your discussions, as it is usually possible to accommodate individual patients wishes and still use a spinal anaesthetic. Can I refuse to have the spinal? Yes. If, following discussion with your anaesthetist, you are still unhappy about having a spinal anaesthetic you can always say no. You will never be forced to have any anaesthetic procedure that you don t want. Will I feel anything during the operation?

17 Your anaesthetist will not permit surgery to begin until you are both convinced that the spinal is working properly. You will be tested several times to make sure of this. You should not feel any pain during the operation but you may well be aware of other sensations such as movement or pressure as the surgical team carry out their work. Should I tell the anaesthetist anything during the operation? Yes, your Anaesthetist will want to know about any sensations or other feelings you experience during the operation. They will make adjustments to your care throughout the operation and be able to explain things to you. Is a spinal the same as an epidural? No, although they both involve an injection of local anaesthetic between the bones of the spine in the small of your back, the injections work in a slightly different way. Epidural anaesthesia For information about epidurals in labour, please visit the maternity section of our website. What is an epidural? The nerves from your spine to your lower body pass through an area in your back close to your spine, called the "epidural space". To establish an epidural an anaesthetist injects local anaesthetic through a fine plastic tube (an epidural catheter) into the epidural space. As a result, the nerve messages are blocked. This causes numbness, which varies in extent according to the amount of local anaesthetic injected. An epidural pump allows local anaesthetic to be given continuously through the epidural catheter. Other pain relieving drugs can also be added in small quantities. The amounts of drugs given are carefully controlled. You may be able to press a button to give a small extra dose from the pump. Your anaesthetist will set the pump to limit the dose which you can give, so overdose is extremely rare. When the epidural is stopped, full feeling will return. Epidurals may be used during and/or after surgery for pain relief. How is an epidural done?

18 Epidurals can be put in when you are conscious or when you are under sedation (when you have been given a drug which will make you drowsy and relaxed, but still conscious) or during a general anaesthetic. These choices can be discussed further with your anaesthetist. A needle will be used to put a 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. It is important to keep still while the epidural is put in. Local anaesthetic is injected into a small area of the skin of your back. A special epidural needle is pushed through this numb area and a thin plastic 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, but usually allows an almost painless procedure. It is common to feel slight discomfort in your back as the catheter is inserted. 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 feel heavy and become increasingly difficult to move. You may only notice these effects for the first time when you recover consciousness after the operation, particularly if your epidural was put in when you were anaesthetised. Overall, most people do not find these sensations to be unpleasant, just a bit strange.

19 The degree of numbness and weakness gradually decreases over the first day after the operation. What are the benefits? If your epidural is working properly, you will have better pain relief than other methods, particularly when you move. There may be reduced complications of major surgery, e.g. nausea/vomiting, leg/lung blood clots, chest infections, blood transfusions, delayed bowel function. There may be quicker return to eating, drinking and full movement, possibly with a shorter stay in hospital compared to other methods of pain relief. How do the nurses look after me on the ward with an epidural? At regular intervals, the nurses will take your pulse and blood pressure and ask you about your pain and how you are feeling. They may adjust the epidural pump and treat side effects. They will encourage you to move, eat and drink, according to the surgeon s instructions. The pain relief team doctors and nurses may also visit you, to check your epidural is working properly. When will the epidural be stopped? The epidural will be stopped when you no longer require it for pain relief. The amount of pain relieving drug being given by the epidural pump will be gradually reduced. A few hours after the pump is stopped, the epidural catheter will be removed, as long as you are still comfortable. The epidural catheter will be removed if it is not working properly. It may be possible to insert another epidural catheter if necessary. Can anyone have an epidural? No. 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 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. Side effects and complications All the side effects and complications described can occur without an epidural. Side effects are secondary effects of a treatment. They occur commonly and may be unavoidable. Although they may be unpleasant (for example, feeling sick),

20 they are not usually dangerous. Complications are unwanted and unexpected events that are known to occur occasionally due to a treatment. Serious complications are rare or very rare. Permanent nerve damage is a very rare serious complication of having an epidural. It can also happen if you do not have an epidural. You can read more about this in the risk articles on 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. Very common or common side effects and complications Inability to pass urine. The epidural affects the nerves that supply the bladder, so a catheter (tube) will usually be inserted to drain the urine away. A catheter is often necessary after major surgery even if you do not have an epidural, to keep a close check on the rate of urine production. If you have a working epidural, you cannot feel the catheter, which will normally be left in for a few days. Bladder function returns to normal after 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. This can occur as a side effect of pain-relieving drugs that may be mixed with the local anaesthetic in your epidural. It can be treated with anti-allergy drugs. Feeling sick and vomiting. These can be treated with anti-sickness drugs. These problems are less frequent with an epidural than with most other methods of pain relief. Backache. This is common after surgery whether you have an epidural or not. It is not related to having an epidural. It may be 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. Epidurals can provide better pain relief than other techniques. Other methods of pain relief are available if your epidural fails. Headaches. Minor headaches are common after surgery, with or without an epidural.

21 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. If this happens, 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. This will cure the headache in the majority of cases. Uncommon complications Slow breathing. Some drugs 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 or very rare complications Other complications, such as convulsions (fits), breathing difficulty and damage to nerves are rare. Permanent disabling nerve damage, epidural abscess (infection), epidural haematoma (blood clot) and cardiac arrest (stopping of the heart) are very rare indeed. In comparison, you are more likely to die from an accident on the roads or in your own home every year than suffer permanent damage from an epidural. These risks can be discussed further with your anaesthetist and more detailed information is available. 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 morphine that work well. This includes injections given by the nurses or you may be offered a machine which allows you to control your pain relief yourself (patient controlled analgesia, or PCA). There are other ways in which local anaesthetics can be given. You may be able to take pain-relieving drugs by mouth. Every effort will always be made to ensure your comfort. How do I ask further questions? Ask the nursing staff or your anaesthetist. You can ask to see a member of the pain team at any time. They may have leaflets available about pain relief. There is also more information about epidurals on the website:

22 How safe is my anaesthetic? In modern anaesthesia, serious problems are uncommon due to modern equipment, training and drugs. Many of the drugs used by anaesthetists have been successfully used for a long time. In the UK, all drugs must be tested and licensed by the committee on Safety of Medicines before they can be generally prescribed. This involves examining the risks, safety effectiveness and side effects of each drug before it is given a licence. It is the responsibility of the anaesthetist to advise you on what anaesthetic techniques will give you greatest benefit and reduce the risk as far as possible. Your anaesthetist will want to help you so that you can make the choices that are right for you.