Epidural and caudal pain relief after surgery

What is an epidural?

An epidural is an extremely effective method of giving pain relief after surgery. A very fine tube called a catheter is placed into an area called the epidural space which sits within the spine and surrounds spinal cord. A local anaesthetic numbing type drug called Levobupivacaine is then given through the catheter.

How does an epidural work?

The epidural space contains nerves, which send messages to your child’s brain telling them that about an injury. The local anaesthetic blocks these nerves, stopping the pain messages getting through, and stop or reduces the pain. The epidural catheter is placed at different levels of the spine for different types of surgery, so the local anaesthetic works where it is needed.

Why have an epidural?

Epidurals are used mainly for children having surgery to the chest, abdomen or legs, due to the high level of pain relief that it provides. If the anaesthetist thinks an epidural would help your child, they will explain the benefits and risks to you before the operation takes place.

What is a caudal epidural?

A caudal epidural is a type of epidural where the local anaesthetic is injected into the same space that we might place an epidural catheter, but quite low down. This works very well in younger babies and children. It can be a one-off injection or an infusion. A one-off injection means the pain relief will be shorter lasting but covers the most sore period. Caudal epidurals work well for lower abdominal, groin and leg operations in younger children.

Can any child have an epidural?

It may be difficult to place an epidural in some children, for example where they have had previous spinal surgery. The risk of a serious problem is increased with certain medical problems, for example an infection or clotting problem. In this case an alternative may be more suitable.

Are there alternatives to an epidural?

The main alternative is an intravenous infusion of a strong painkiller like morphine, which may be given as a patient-controlled system for older children. Morphine is a very good painkiller, but may not be as effective as an epidural for some types of surgery. It may also cause sedation, meaning that your child may be more sleepy after the operation than they would be with an epidural. Ask the nurse or anaesthetist for further information.

Who sets the epidural up?

The anaesthetist looking after your child in theatre will put the epidural catheter in place in your child’s back while he or she is asleep, so your child will not be aware of the procedure or suffer any discomfort. The anaesthetist will cover the catheter with a clear plaster so that the nurses can check it on the ward.

How is the local anaesthetic given?

The local anaesthetic is given continuously by an epidural pump connected to the epidural catheter. This machine pumps a pre-programmed amount of local anaesthetic fluid through the catheter into your child’s back, keeping them comfortable after their surgery.

Who will look after my child?

The nurses on the ward will check your child at regular intervals, usually every hour. They will check the heart rate, breathing and blood pressure and will also check that the epidural is working within the area that it is supposed to. In addition, your child will usually be seen daily by a pain nurse or an anaesthetist who will alter the machine and doses to suit your child’s needs.

How long will my child need an epidural for?

Most children have their epidural for 2 days, but it is possible to have an epidural for longer if the benefits outweigh any risks. Before the epidural is stopped, we will give your child other pain relief medicines to keep them comfortable.

Does it hurt to remove the epidural?

Removing the catheter is not painful. Sometimes removing the sticky dressings is uncomfortable. There are things we may be able to do to make this easier, such as wetting the dressings.

What if my child still has pain while their epidural is running?

Most children can have other simple painkilling medicines, like paracetamol and ibuprofen while the epidural is running.

Sometimes a child may have an intravenous (IV) infusion of another painkiller too. The medicines all work together to improve the level of pain relief. If the epidural is more effective on one side of the body than the other, the anaesthetist or pain nurse may be able to adjust the epidural catheter to improve the pain relief. Occasionally epidurals do not work well at all and we may have to consider other options such as morphine.

Are there any more common side effects?

Epidurals can occasionally cause sickness or itching, and other drugs will be given to help with these problems if they occur.

Epidurals can also cause difficulty in passing urine so a urinary catheter is usually passed while your child is in theatre.

Sometimes the epidural can cause your child’s legs to feel numb or heavy.

Your child will also need to have a drip while the epidural is running.

All side effects will wear off after the epidural has been stopped.

Sometimes the local anaesthetic can leak around the dressing requiring a new dressing.

The catheter can also be accidentally pulled out.

Is there anything else we need to know about epidurals?

Very rarely an infection can develop where the epidural catheter was inserted.

It is important that you seek urgent medical attention if your child develops any symptoms or signs of infection in the early days and weeks following discharge. These include:

• swelling
• redness
• pain at the insertion site
• discharge at the insertion site
• a high temperature
• headache
• lethargy
• numbness
• weakness
• difficulty passing urine

The doctors looking after your child will need to know that your child had a recent epidural so they can organise the right tests and treatment.

Serious problems with epidurals are rare or very rare, which means if all the people in a town were to have an epidural, only 1 would have a serious problem.

Injury to the nerves is the most significant risk and is rare or very rare. This usually happens due to nerve injury when the catheter is put in, or due to nerve compression by a blood clot or infection at the site.

Nerve injury may lead to a range of symptoms from altered feeling to a small area of skin to leg weakness affecting mobility, and it would be very rare for this injury to be permanent. Additionally with infection or bleeding, we may need to investigate and treat the underlying issue.

Another very rare problem is related to high local anaesthetic levels in the blood, which we prevent by keeping doses to safe levels. We would be looking out for symptoms such as agitation, altered behaviour or speech. Older children may report visual disturbance, a metallic taste or tinnitus.

The pain team

Here at the Sheffield Children’s NHS Foundation Trust we have an acute pain team consisting of consultant anaesthetists, on-call anaesthetists in training and pain management nurses, who work very closely with the staff on the wards. They use a variety of treatment approaches to make sure each child is as pain-free as possible.

Should you have any questions regarding pain control, please ask a member of the nursing staff. If they are unable to answer your questions they will contact a member of the pain team.