Disclaimer:
Every day we encounter patients who have questions about the anesthesia services we provide. The answers to these frequently asked questions below is intended to provide some insight into what may be expected with your anesthetic experience.

This section is not intended to provide specific medical advice for your particular procedure and please do not use it for that purpose. Such advice is not provided here, and we urge you to consult with your surgeon or anesthesiologist during pre-assessment for answers to your personal questions.


General
- What is anesthesia?
- Who provides anesthesia?
- What's the purpose of a preoperative assessment?
- Should I stop smoking a month before my surgery?
- I just got several piercings at the mall yesterday - do I have to remove them before surgery?
- My daughter is scheduled to have her tonsils out next week, but has come down with a bad cold. Should we postpone it?
- I had a heart attack 4 months ago, should I have my hip replacement next month?
- I have bad emphysema (a lung disease) and need oxygen all the time at home. Should I have my prostate surgery?
- Why is drinking, eating, and even chewing gum, prohibited before surgery? Why was my surgery cancelled? What are NPO guidelines?
- Should medications still be taken before surgery?
- What about my diet pills?
- When should I stop my blood thinners (coumadin, plavix, ticlid, aspirin, herbs)?
- Can patients drive themselves to and from surgery?
- Why is there a separate bill for anesthesia?
- Why isn't your anesthesiologist on your anesthesia bill?

Surgical Anesthesia
- How do you know which anesthetic is best for me?
- What about local with sedation?
- I had a terrible reaction at the dentist, felt panicky, very light headed and my heart was racing. Was it the local?
- Are there any complications from a regional anesthetic?
- What medications are used for general anesthesia?
- Do I have to have a tube put in my throat?
- What are the risks of general anesthesia?
- How long does anesthesia last?
- Do patients wake up during surgery under general anesthesia?
- I was sick after my previous anesthetics - will this happen again?
- I had a really sore throat last time, why is that?
- My friend had a major allergy to an anesthetic and nearly died. How common is this?
- My great uncle died under a general anesthetic. Should I worry about that?
- Could I end up in intensive care after my operation?
- How painful will it be afterwards?
- Will pain medication be provided after surgery and discharge? I am having orthopaedic surgery-do I need a nerve block to control the pain?
- When can food and drink be consumed after surgery with general anesthesia?

Obstetric Anesthesia
- What is an epidural?
- What is a spinal?
- Are laboring patients required to have epidurals?
- What are the risks of spinal and epidural placement?
- Why is it important to stay still during epidural and spinal placement?
- Do patients have to be alert during epidural placement?
- How long will the epidural or spinal last?
- Can patients lay on their back with an epidural?
- Can I walk with my epidural in place?
- Why do patients in labor still have sensation after an epidural is placed?
- Are epidurals or spinals used for elective cesarean sections and elective postpartum tubal ligations?
- Can food and drink be consumed before elective c-sections and elective postpartum tubal ligations?
- I just had a baby and now I have a horrible headache. Is it because of my epidural? Do I need a blood patch?

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G E N E R A L


What is anesthesia?
Who provides anesthesia?

Anesthesia can be provided by licensed physicians called anesthesiologists who have graduated medical school and have successfully gone through an ACGME accredited anesthesiology training program. Sometimes anesthesia is administered with the help of CRNA's (nurse anesthetists) or AA's (anesthesiology assistants) under the supervision of an anesthesiologist. In academic institutions, anesthesia residents, or physicians in training, will often provide anesthesia with an ABA diplomate as well.

In NHA's practice, anesthesiologists are involved in every anesthetic administered, whether it's surgical or obstetric, and CRNA's and AA's offer their services in some of these cases. NHA is not associated with an academic institution that trains resident physicians at this time. [TOP OF PAGE]

What's the purpose of a preoperative assessment?
At this time, patients are given instructions on how to prepare for surgery. It is important that patients be evaluated prior to any procedure requiring anesthesia so that known medical conditions can be addressed and optimized prior to surgery. In addition, conditions not known to the patient can be discovered incidentally and subsequently treated so that anesthesia may be provided in the safest manner possible.

Medical problems that interfere with safe anesthesia which are not addressed before surgery could cause a delay or even result in cancellation of elective surgical procedures. [TOP OF PAGE]

Should I stop smoking a month before my surgery?
Try to cut down a bit if you can, but don't give up unless it is 6 weeks or more until your operation. The frequency of smoking related complications is actually increased in people who gave up less than 4-6 weeks preoperatively; they had more breathing difficulties under anesthesia, and postoperative chest infections than those who continued to smoke! Since you aren't usually given 7 weeks notice, give up smoking now before you need any surgery to best minimize these complications. There are plenty of options for giving up - programs, patches, gum, etc. [TOP OF PAGE]

I just got several piercings at the mall yesterday - do I have to remove them before surgery?
Yes. Otherwise, there is risk of the piercings becoming dislodged, causing injury to yourself, or going into the surgical field, being swallowed, lost, etc. Please let your anesthesiologist know of any such jewelry before your procedure. [TOP OF PAGE]

My daughter is scheduled to have her tonsils out next week, but has come down with a bad cold. Should we postpone it?
Possibly, though it may depend on how sick she is, and how often she gets a cold. Some kids have a cold almost continuously until they get their tonsils removed. For other procedures you have to weigh the pros and cons, it may be best to put it off for a week or two. If you feel unwell with it, or notice a fever or a bad cough producing a lot more phlegm than usual then it may be best to tell your surgeon/anesthesiologist about these symptoms as soon as possible so a decision can be made to proceed or postpone the procedure. [TOP OF PAGE]

I had a heart attack 4 months ago, should I have my hip replacement next month?
Patients with coronary artery disease have a risk of heart attack with any procedure, and possibly a further increase within the first few months following an MI. Your risk will depend on how severe the heart attack was, and your condition now - do you have any heart failure for instance? Your surgeon should discuss this sort of thing with your anesthesiologist first, and then with you of course - and then decide if it is prudent to proceed with your surgery. [TOP OF PAGE]

I have bad emphysema (a lung disease) and need oxygen all the time at home. Should I have my prostate surgery?

Another case of the benefits vs. the risks, which would be discussed fully with you beforehand. Depending on the severity of your lung disease (and the prostate), your surgery could be postponed to optimize your lung condition, or it may well be quite acceptable to go ahead, using a spinal or general anesthetic. Best advice here is DON'T SMOKE!! (ever - or give up now). [TOP OF PAGE]

Why is drinking, eating, and even chewing gum, prohibited before surgery? Why was my surgery cancelled? What are NPO guidelines?
This helps to reduce the risk of aspiration pneumonitis (lung injury) that could develop if gastric contents are regurgitated into the lungs. This condition is usually managed with several days of mechanical ventilation in the ICU at a minimum. It is therefore important to reduce stomach contents and acidity as much as possible before surgery to avoid this complication.

Each individual digests food and drink at different rates, but in general, elective surgery is usually allowed 8 hours after a heavy meal, 6 hours after a light meal, and 4 hours after clear liquids. In children less than 1 year old, these times are liberalized to avoid dehydration -- milk and solids are allowed up to 4-6 hours before surgery whereas clear liquids are allowed 2-3 hours before a procedure. These rules comprise the "NPO guidelines." If these guidelines are not adhered to, surgery will be delayed or even cancelled until criteria to proceed with surgery is met. This also pertains to chewing gum and tobacco because this can stimulate gastric secretions. If a patient is "NPO," it still does not mean aspiration pneumonitis will not develop because the risk does not become 0%, as there is always some degree of gastric volume. However, it does mean the risk is probably reduced as much as possible. Only in an emergency will NPO guidelines not be followed. Medications are sometimes given to reduce acidity and increase gastric motility in emergencies and also to people with medical conditions that predispose for pulmonary aspiration such as hiatal hernia, scleroderma or pregnancy. [TOP OF PAGE]

Should medications still be taken before surgery?
There are some medications that ideally should be continued as usual on the day of surgery and taken with a sip of water only. These often include most blood pressure medication, thyroid pills, steroids, seizure prophylaxis and antiarrhythmic heart medication. Most other pills are not necessary. During pre-assessment, patients will be told which pills to take and not take. If this information is not provided, PLEASE ASK. [TOP OF PAGE]

What about my diet pills?
For most, it is preferred that diet pills be stopped 7 to 14 days before surgery because they can have adverse effects on blood pressure. There is no definitive guideline regarding this, but sometimes surgeries will be cancelled because diet pills are being used. You will be evaluated personally by your physician to determine what course should be taken. [TOP OF PAGE]

When should I stop my blood thinners (coumadin, plavix, ticlid, aspirin, herbs)?
There are specific guidelines regarding when blood thinners (Coumadin/warfarin, low molecular weight heparin/lovenox, plavix, ticlid, aspirin, garlic, ginko,ginseng, etc.) should be stopped before surgery. Please make sure you reveal the use of these medications during pre-assessment so that the proper measures can be taken. If not, your procedure may be postponed until enough time passes so that the blood resumes normal clotting function. [TOP OF PAGE]

Patients taking coumadin, heparin, or LMWH (Lovenox) will need to do lab work (PT/INR, PTT, platelets) to confirm that the blood's ability to clot has returned effectively. Holding these anticoagulants for the recommended times may decrease bleeding complications that could occur.

Regional anesthetic (epidural/spinal) requirements are more stringent in some cases; such techniques will probably be avoided if a bleeding tendency is suspected.

For more information go to: http://www.asra.com/consensus-statements/2.html

[TOP OF PAGE]

Can patients drive themselves to and from surgery?
No. Driving should be avoided for about 24 hours. Really, any major decision-making process should be delayed during this time as well. [TOP OF PAGE]

Why is there a separate bill for anesthesia?
Surgical and anesthetic services are separate because, although they often occur at the same time, different medical specialists are working in collaboration with one another to a) perform the procedure and b) provide anesthesia. In fact, if for some reason any other type of physician (like a cardiologist or neurologist) is consulted during your hospitalization, a bill from that specialist will appear as well. [TOP OF PAGE]

Why isn't your anesthesiologist on your anesthesia bill?
All of the anesthesiologists work together, and in essence it doesn't matter which anesthesiologist's name appears on your statement. Rest assured, though, that your care was continuous and uninterrupted. Often, anesthesiologists will help each other during cases, but only one name is used for billing purposes; sometimes this may or may not be the same physician that you spoke with before your surgery. [TOP OF PAGE]

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S U R G I C A L
A N E S T H E S I A

How do you know which anesthetic is best for me?
Depending on the operation/procedure and your physical fitness, we will suggest the most viable options for suitable for you. We will proceed with the chosen anesthetic only after full discussion and your understanding and consent. You always have the right to choose whether or not to proceed with the options you are given. [TOP OF PAGE]

What about local with sedation?
This is suitable for some smaller procedures. Sedation is usually provided before the local goes in to decrease sensation at the operative site. After that, you may become less "sleepy" but the procedure should not cause too much discomfort since the op site is numb. If it is not, or you feel anxious, let us know so that more local and sedation can be given to make you more comfortable.

A regional technique is often supplemented with some degree of sedation too, although it is not necessary if you don't desire it. A "light" general anesthetic may be combined with a regional sometimes, especially if you don't want to remember anything or you have incomplete analgesia which sometimes happens too. [TOP OF PAGE]

I had a terrible reaction at the dentist, felt panicky, very light headed and my heart was racing. Was it the local?
Probably not the actual local itself, but rather epinephrine which is usually added to the local anesthetic. This is to constrict the blood vessels, which reduces bleeding and prolongs the duration of the anesthesia. If even a small amount of epinephrine enters the bloodstream it may give you these symptoms. [TOP OF PAGE]

Are there any complications from a regional anesthetic?

Yes there are, but thankfully they are rare and almost always transient, especially with recent advancements in regional techniques. For instance, special blunted needles now reduce the risk of nerve injuries which cause numbness, tingling or weakness. If they do occur, these complications usually resolve within days or weeks. Prolonged pressure on a nerve (such as from a hematoma) may result in more serious complications, but again this is rare. Other risks with certain regional blocks include: local anesthetic toxicity, infection, or a collapsed lung. Your anesthesiologist should discuss major complications of the block with you as part of informed consent before beginning any procedure. [TOP OF PAGE]

What medications are used for general anesthesia?

A variety of medications are used to provide amnesia, unconsciousness, pain relief and muscle relaxation during surgery. Benzodiazepines are often used preoperatively to reduce anxiety. Several types of narcotics are available to help with pain control throughout the perioperative period. They usually differ in their time of onset and length of action and are chosen based on the requirements of the case. Both benzodiazepines and narcotics can be used for sedation during the procedure itself. Sedation can be further enhanced with intravenous drugs such as propofol, etomidate and ketamine. These drugs may also be employed to provide an immediate state of unconsciousness so that general anesthesia can be undertaken. General anesthesia is then maintained by allowing the patient to breathe anesthetic gases such as nitrous oxide and isoflurane through a breathing tube or face mask. If the surgery requires muscle relaxation, medication that allows for transient paralysis will be given and is reversed with medications (an anticholinesterase agent in combination with an anticholinergic) at the end of surgery.

Local anesthetics can also be used to provide regional, spinal or epidural anesthesia. Novocaine is the most notable, but there are several kinds of local anesthetics with different lengths of action that can be used. Of course, cardiac drugs and medications used to treat underlying medical problems will be used as needed throughout the operation. All of the drugs mentioned here do have side effects and may cause allergic reactions. It is important to distinguish between side effects and allergies so that unnecessary restrictions in the medications available for a particular case can be avoided. For instance, itching and nausea are typical reactions most people get with narcotics, but shortness of breath and hives are not. Nevertheless, please inform your anesthesiologist if you or anyone in your family has had a true allergic reaction to any anesthetic administered in the past and in particular with any anesthetic gases or the paralytic drug succinylcholine. [TOP OF PAGE]

Do I have to have a tube put in my throat?

In most cases general anesthesia is performed with a "secured airway" that protects the lungs from gastric secretions and allows for controlled ventilation of the lungs. Placement of an endotracheal tube through the trachea or a laryngeal mask airway in the oropharynx allows your anesthesiologist to be able to "secure" your airway and ventilate your lungs while you are asleep. Both of these airway devices are placed and removed while you are still asleep or sedated so you probably will not remember this ever occurring. Your anesthesiologist will determine which is right for you. Both are safe and usually required for surgery to take place. There is a small risk that must be assumed when these devices are used, involving damage to teeth or adjacent tissue in the mouth. As a result, it is important to notify your anesthesiologist of any loose or chipped teeth, piercing, dentures, bridges, loose fillings, caps, etc. before surgery. [TOP OF PAGE]

What are the risks of general anesthesia?
The risks of anesthesia vary with each individual patient. The younger patient who has few medical problems and has had anesthesia in the past without complication will probably incur less risk than an older, sicker patient. The type of surgery also influences risk; major cases will involve more risk than minor ones because the stress of surgery can exacerbate many medical conditions such as heart disease, asthma, diabetes and so forth. It is ideal that all medical problems be stabilized as best as possible before surgery so that these complications can be minimized. With that said, advances in technology and medical training have minimized anesthetic risks for even the healthiest of patients. It is safer now than it is has ever been to undergo anesthesia. However, some complications may occur despite adequate monitoring and the best of efforts. Some of these problems include (but are not limited to): dental trauma, allergic reactions including malignant hyperthermia, peripheral nerve injury, postoperative nausea, postoperative pain, hypoxic events, blood loss requiring blood transfusion, corneal abrasion, and of course, the ever popular, awareness under anesthesia. These are all rare events with modern anesthesia, and accordingly the most risk will actually derive from the patient's own comorbidities and health problems as noted above. [TOP OF PAGE]

How long does anesthesia last?
General and epidural anesthesia lasts as long as needed to complete your procedure. However, one-shot spinal anesthetics are time limited by the type of local anesthetic used; for adequate surgical anesthesia, they can last between 1 and 2 hours. [TOP OF PAGE]

Do patients wake up during surgery under general anesthesia?
The general incidence of awareness under anesthesia is about 0.2% to 1.5%, and even then occurs mostly in emergency situations (emergent c-sections and traumas) where there is hemodynamic instability (hypotension and major blood loss), and in procedures involving cardiopulmonary bypass. For comparison, the risk of dying randomly in a motor vehicle crash is about 1.41%. So at worst the risk of awareness is the same as the risk of dying while driving your car today. Nevertheless, anesthesiologists have been very cognizant of this complication even before today's media attention regarding this subject. Every precaution is taken to prevent this occurrence. However, there is no monitoring equipment that is standard of care for preventing awareness under anesthesia. In fact, out of the two studies that have shown that the BIS monitor may help with awareness, only one was done in a way to eliminate bias (B-AWARE). Additionally, this monitor is often used a reference by which to prevent anesthesia overmedication for faster recovery times which one would tend to think would lead to more cases of awareness. In the end, the best monitor to prevent awareness is the anesthesiologist him or herself. Awareness is truly a rare event that occurs most often in patients who don't tolerate anesthesia, and every anesthesiologist will always do his or her best to provide adequate anesthesia for surgery as long as it does not compromise the bodily functions of the patient. [TOP OF PAGE]

I was sick after my previous anesthetics - will this happen again?
We cannot guarantee that it won't, but newer, better anesthetics are associated with less post-operative nausea and vomiting. We also use extensive prophylaxis with 2 or even 3 different "anti-emetic" drugs, which counter-act and treat nausea. Using these, we can do much better than in the past, but if you still get sick we can try a couple of other ones that usually succeed. Unfortunately, the strongest pain killers like morphine or demerol (narcotics) are associated with nausea as a side-effect, so you may prefer some mild discomfort as a trade-off for no nausea. A regional anesthetic continued afterwards may be a good idea, to reduce the need for narcotics, and hence nausea or vomiting. [TOP OF PAGE]

I had a really sore throat last time, why is that?
Usually because you were "intubated", or had a plastic breathing tube inserted through your larynx , into your trachea or windpipe. Alternatively you may have had another type of breathing tube called a laryngeal mask airway, which sits above the larynx. Unfortunately, there is an incidence of sore throat after these devices are used but it does not usually last more than a few days. You may be in the 1 - 2 % of people who are a "difficult intubation" in which case your anesthesiologist would usually tell you for future reference. [TOP OF PAGE]

My friend had a major allergy to an anesthetic and nearly died. How common is this?
Not common, 1 in 10,000 perhaps. The most severe form is called anaphylaxis, sometimes due to an anesthetic drug or an antibiotic. 99% of the time we can treat anaphylaxis successfully because we have all the best treatments at our disposal - epinephrine, oxygen, etc. Please tell us all your allergies when we ask, no matter how trivial they may seem. Simple allergies like pollens, dust or cats causing hay fever are not usually any problem, neither is an antibiotic causing diarrhea. Remember, some "allergies" are really side effects (e.g. nausea with narcotics). [TOP OF PAGE]

My great uncle died under a general anesthetic. Should I worry about that?
Possibly, yes - depending on the cause of death. There are some inherited /genetic disorders which run in families, the worst of which is called malignant hyperthermia. This is extremely rare, and involves disordered muscle metabolism precipitated by certain anesthetic drugs This causes you to heat up to a dangerous level, but we do have medications to treat this. If we suspect the possibility, we will avoid using the triggering drugs and closely monitor your metabolic response, including your temperature. We may decide to test you for it, but it is an invasive test that involves cutting out a small piece of muscle (biopsy). There are other familial/genetic conditions that increase risk (e.g., scoline apnoea, muscular dystrophy and porphyria). [TOP OF PAGE]

Could I end up in intensive care after my operation?
This might be planned anyway, say after heart surgery or some other major operation, or because of your poor state of health beforehand. In these situations it would be discussed preoperatively, unless you were already unconscious (e.g. following major trauma, or a stroke). Sometimes something unexpected may occur during the anesthetic or procedure - an anaphylactic reaction, significant aspiration, major unexpected bleeding or an unplanned, but life-saving bigger operation. In this case, your doctors may think it safer to keep a closer eye on you in the ICU, perhaps even kept on the ventilator overnight, or even longer. You would normally be sedated to a comfortable level if this were the case, and the situation explained to you as soon as you were awake enough. Your family would be fully informed at all times as well. [TOP OF PAGE]

How painful will it be afterwards?
Most procedures have some pain afterwards. Pain should be minimal with purely diagnostic procedures like colonoscopy, and most severe after major chest or upper abdominal surgery. We try to pre-empt this before you wake up, with analgesic (pain killing) and anti-inflammatory drugs, and local or regional anesthetic in the operative area. Minimal or no pain may be difficult to guarantee, but most of the time you should eventually become comfortable via the pain relieving options available to you in the hospital. The most common, a "pain pump" or patient controlled analgesia (PCA) device, works well through your IV, and you can decide how much narcotic you need to remain comfortable. The nurses will explain how to use it; it is not difficult and quite safe, and you will not become addicted to anything in just a few days! Another technique uses a continuous infusion of local anesthetic, most commonly via an epidural catheter placed in your back. Most people like it because, aside from great pain relief, it does not have the irritating side effects that narcotics have such as nausea, itching, and sedation. This is usually placed preoperatively before you go back to the operating room for use after surgery. The pros and cons will be discussed, if this is an option for you. If you are interested in an epidural please mention it during your pre-assessment so we can optimize any condition that would prevent you from having one on the day of your procedure. [TOP OF PAGE]

Will pain medication be provided after surgery and discharge? I am having orthopaedic surgery-do I need a nerve block to control the pain?
See the answer to the above question. If you are having outpatient surgery, usually your surgeon will provide a prescription for pain medication to take home with you. Alternatively, there are cases, particularly orthopaedic procedures, where your anesthesiologist can perform a peripheral nerve block to essentially numb up the operative site for several hours to treat postop pain. Patients benefit from nerve blocks by not having to endure the side effects of narcotics, and when the pain actually develops, it is often not as intense as it would normally be. Nerve blocks are actually preferred for shoulder surgery and repair of fractures involving the arm or leg. Your anesthesiologist will go over the pros and cons of this procedure with you and determine if you are a candidate for it or not. You do not have to have a nerve block if you don't desire it. For patients who are going to be admitted, IV narcotics and oral pain pills can be provided as noted in the preceding question. Of course, if there are not contraindications, epidurals, spinal shots and peripheral nerve blocks are all available for postoperative pain control in patients who are hospitalized after surgery. [TOP OF PAGE]

When can food and drink be consumed after surgery with general anesthesia?
Usually, during the first hour of recovery, alert patients are given ice chips to start off with if they do not have nausea and demonstrate good muscle strength and control. If tolerated, clear liquids can even be allowed before discharge from the recovery room. After that point, food and drink can be consumed at the patient's discretion. This does not apply to patients undergoing major abdominal surgery or surgery where there is a risk of decreased bowel function; in these cases your surgeon will probably not allow anything by mouth until evidence of bowel function returns. [TOP OF PAGE]

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O B S T E T R I C
A N E S T H E S I A



What is an epidural?
The epidural space is a layer of tissue, blood vessels and nerves that lie outside the fluid filled sac containing the spinal cord. To provide epidural anesthesia, the skin on the back is made numb, and a needle is used to guide a catheter or small tube into the epidural space. Once the tube is in place, medication, usually local anesthetic, can be given continuously to infiltrate the nerves in the epidural space and prevent the transmission of pain sensation in the lower half of the body. It usually takes 15-20 minutes for this to take place once the medication is given. In obstetrics, an epidural is usually placed to help reduce the pain of labor. The intensity of the epidural can be increased such that it could be used to provide surgical anesthesia for a c-section if it became necessary. It is also used as a first option in certain patients with high-risk pregnancies undergoing elective c-section, instead of a spinal. [TOP OF PAGE]

What is a spinal?
The goal of the spinal is to introduce medication (again, primarily local anesthetic) into the fluid that surrounds the spinal cord to eliminate sensory and motor function for surgery (c-section). Sometimes anesthesiologists can give smaller doses of the medication in a spinal for labor pain; these smaller doses have less effect on sensory and motor function, but work well to ease the pain of labor transiently until delivery or an epidural is placed. A spinal is actually similar to an epidural in terms of its placement (as noted in the above question). The main difference is that the needle is advanced a few millimeters further to go past the epidural space and into the spinal fluid. The other differences are that the spinal works almost immediately, is usually just one shot and will eventually wear off because there is no tube in place to keep giving medication. However, a tube or catheter will be placed into the spinal fluid in certain circumstances for continuous labor analgesia. [TOP OF PAGE]

Are laboring patients required to have epidurals?

No. Although routine today, successful deliveries have occurred in the past without an epidural and in fact still do. However, most women do prefer an epidural these days as they are safe and provide excellent pain relief. They also can be used immediately to provide surgical anesthesia for a c-section if needed without going to sleep or having to place a spinal at the last second. Whether you want an epidural or not, it is important to make this decision ahead of time. That is, if you decide to get an epidural towards the end of your labor, there is no guarantee that there will be enough time for it to be placed and be effective. If you know for sure you do not want an epidural, you can receive IV pain medication (narcotics) or nothing at all - it's your choice. [TOP OF PAGE]

What are the risks of spinal and epidural placement?
Your anesthesiologist will go over the pros and cons of the procedure before beginning. If there is any contraindication (such as fever, infections, or bleeding disorders), the epidural or spinal will not be placed. Complications are rare but do include: nausea, headaches, back pain, unsuccessful placement, bleeding, infections, and local anesthetic toxicity. More details will be provided during pre-assessment, but remember, that the more serious the problem, the more rare it is to happen. Again, spinals and epidurals are relatively safe and are performed thousands of times a day throughout the country for obstetric anesthesia, and we always do our best to take all precautions to avoid any side effects. [TOP OF PAGE]

Why is it important to stay still during epidural and spinal placement?

Any sudden movements on the patient's part can cause inadvertent trauma by the needle. Your nurse will be at your side to help position you and keep you still during your contractions. [TOP OF PAGE]

Do patients have to be alert during epidural placement?
Yes. First of all, only an alert patient can consent to this procedure. More importantly, patient cooperation is required to safely and correctly place an epidural. This often entails patients repositioning themselves or remaining still during the procedure, and only an alert patient can do this. Additionally, the patient will be asked specific questions to determine whether the epidural is in the right position; sedated patients may not respond appropriately if there is an adverse reaction to epidural use. Therefore, it is ideal that patients not receive IV pain medication before beginning the procedure unless it is really early in labor and the patient has not progressed sufficiently to warrant an epidural. If it is found that the patient is too disoriented, epidural placement could be delayed until the pain medication has worn off and the patient is more alert (which sometimes can take an hour or two). If you know you want an epidural and you're at the right stage of labor, it is probably best to try and wait for it to be placed before receiving pain medication through the IV-- if possible (because sometimes we know you can't wait). [TOP OF PAGE]

How long will the epidural or spinal last?
The epidural can provide continuous analgesia via an infusion of local anesthetic and narcotic that runs through the epidural tube or catheter. Epidurals will stop when we stop providing medication through the tube. Spinals are not continuous (unless a catheter is placed). For labor pain, spinals can last 30 minutes to an hour and for c-sections, they can last 1 to 2 hours. [TOP OF PAGE]

Can patients lay on their backs with an epidural?
Yes. This is encouraged, but do not rub your back on the bed as this may dislodge the epidural. If you have to turn, lift your back off the bed and position yourself as needed. [TOP OF PAGE]

Can I walk with my epidural in place?
No. So-called "walking" epidurals do exist, but the amount of medication needed to adequately control the pain of labor usually decreases motor function enough that walking is not safe. [TOP OF PAGE]

Why do patients in labor still have sensation after an epidural is placed?
The concentration and quantity of local anesthetic given in an epidural is dosed to eliminate the sharp pain of labor contraction while maintaining enough muscle strength to help push with delivery (but not walk). This means that the epidural is not dosed to full strength and that the pressure sensation of your contraction (not the sharp pain) will remain and can actually intensify as labor progresses. Even at full strength, patients will still feel light touch when stimulated. In some cases, sharp pain may actually return after a period of pain relief; this usually means that the epidural needs to be re-dosed to get back to a good level of pain control. If you experience no significant improvement in your pain at all after the epidural is placed, it may not be in the right position, and the procedure may need to be repeated. Sometimes, patients only get "numb" on one side. There could be a number of reasons for this, but it may be due to ligaments in your back that prevent the medications from spreading to both sides. This is a problem few people have but could explain why your epidural always works only on one side. [TOP OF PAGE]

Are epidurals or spinals used for elective cesarean sections and elective postpartum tubal ligations?
Typically a spinal is used, but either can be used depending on the situation, and both will allow you to be awake to see the birth of your baby. If you did deliver vaginally with an epidural, it can be kept in place to be used for a tubal if you desire to have that done while you are hospitalized. General anesthesia is usually a last resort in these situations. It is primarily avoided because pregnant patients have a higher risk of lung aspiration than non-pregnant patients since they have less ability to empty their stomach and more acid reflux (heartburn). If you do have to go to sleep, every effort will be made to minimize this complication. [TOP OF PAGE]

Can food and drink be consumed before elective c-sections and elective postpartum tubal ligations?
No. Please see the earlier question on eating and drinking before surgery. Pregnant patients actually have a higher risk of pulmonary aspiration due to delayed gastric emptying so "NPO" guidelines will be enforced at all times before elective obstetric surgery. [TOP OF PAGE]

I just had a baby and now I have a horrible headache. Is it because of my epidural? Do I need a blood patch?

Just because you had an epidural or spinal and now have a headache, doesn't mean that it is necessarily a "spinal headache." Every other cause of headache (high blood pressure, head injury, infections, dehydration, etc.) should really be eliminated before this diagnosis is made. For instance, it is not uncommon that we see someone with a mistaken diagnosis of spinal headache who is really presenting with an exacerbation of his or her chronic migraine headaches. Patients who have a true spinal/postdural puncture headache have extreme throbbing pain in the front and sides of their heads that is worse with sitting, and even more painful when standing, and is only relieved by lying down. Some patients may even have pain at the base of their skulls, but most patients can't even walk, and no pain medication relieves it. These symptoms, along with a recent spinal/epidural and no other causative factors, make a spinal headache very suspicious. Conservative therapy is usually employed initially by providing generous fluid hydration, caffeine administration and NSAID medication. If there is no improvement, then an epidural blood patch is considered. Your anesthesiologist will go over the pros and cons of this procedure before doing it. It will not be done if there is any contraindication (such as suspected high intracranial pressure). The procedure itself simply entails attaining blood in a sterile manner from a vein and placing it into the epidural space via a needle in the back. Almost instantaneous relief is achieved in true spinal headaches. In fact, a blood patch is 90% effective on the first attempt if given during the first 48 hours of the headache, and 95% effective if a second attempt is required. However, this procedure has risks (infection, worsened headache, etc.) as does any procedure, and that is why all other causes of headache must be eliminated to reduce these risks. [TOP OF PAGE]

 


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