Acute Pain Management

Patients referred for surgical or obstetric procedures have the benefit of an in-house around-the-clock acute pain management service. This service was developed as a logical extension of perioperative care. The goal of this comprehensive approach is to provide patients with the possibility of a comfortable and stress-free hospital experience.

During the anesthetic preoperative visit, post-operative analgesia discussed with the patient, taking into consideration the patient’s medical status, planned operative procedure, anesthetic technique chosen, and patient preference. Current analgesia treatments include peripheral nerve blocks, plexus blocks, epidural and intrathecal opioid administration, continuous intravenous opioid infusion, and patient-controlled analgesia.

The integration of anesthetic care and post-operative analgesia allows a smooth and comfortable transition from operating room and recovery to the patient’s hospital room through discharge to home. Post-operatively, acute pain management physicians are available 24 hours a day to ensure that the planned analgesic technique is effective.

What does Acute Pain Management Mean?

Everyone understands that having surgery can be quite painful. Unfortunately, many patients think that they "just have to suffer through it". In the past, postoperative pain medication involved giving the patient a series of intramuscular injections. This method of pain management sets the following cycle into motion:  (click here to see cycle diagram)

Obviously, with this form of pain management, the patient experiences constant "peaks and valleys of pain" and may even be more drowsy than desired. When pain is not adequately controlled, patients may not be able to perform the activities needed to get better, such as walking, eating, and doing deep breathing exercises. Thus, pain can interfere with patients' ability to get out of the hospital on a timely basis. However, adequate pain control may help avoid some problems, such as pneumonia and blood clots.

What will be used to treat my postoperative pain?

In the last several years, there have been a great number of changes occurring in the field of postoperative pain management. It is now widely accepted that patients seem to do better if their pain is under reasonable control. Methods, such as Intravenous Patient Controlled Analgesia (IV PCA), Epidural Analgesia and various Nerve Blocks and Nerve Block Catheters allow the patient to have some control over the pain, rather than having to wait for the nurse to administer an injection. If you are able to take liquids or food by mouth, oral pain medicine is frequently used in conjunction with nerve blocks, particularly after outpatient surgery. Your physician will talk to you about the options and recommend what might be best for you after your particular surgery.

What is a PCA?

This stands for Patient Controlled Analgesia. This is a mechanism recently developed to allow patients to deliver their own pain medicine. If your surgeon and anesthesiologist feel this would work well for you, you will be given a "button" connected to a small IV pump which will deliver a small dose of pain medicine when you push the button. You may actually find that overall you need less pain medicine but experience less post-operative discomfort by using a PCA. The pump is programmed by your physician so you cannot deliver an “overdose” of pain medicine. 

Will I receive an Epidural or Nerve Block Catheter for Post-Op Pain Control?  

For certain procedures an epidural or nerve block catheter can be placed to deliver medication directly to the nerves in your back, leg or arm to control post-operative pain. This type of pain control is particularly well suited to major upper and lower extremity procedures like a total shoulder, elbow, hip or knee replacement, certain abdominal or pelvic surgeries and is especially useful after chest surgery.

 

What are the types of anesthesia?

There are three main categories of anesthesia: general, regional and local. Each has many forms and uses. Your anesthesiologist, in consultation with your surgeon, will determine the best type of anesthesia for you, taking your desires into consideration whenever possible. These options will be discussed during your preoperative interview with the anesthesiologist.

  • General Anesthesia, which involves the total loss of consciousness, pain sensation and protective airway responses.
  • Local Anesthesia, which provides numbness to a small area of the body, such as a dermatologist might use to numb the skin around a mole before removing it. For some surgical procedures, a local anesthetic may be injected into the skin and tissues to numb a specific location.
  • Regional Anesthesia, which can include spinal blocks, epidural blocks or (peripheral [arm, leg or head] nerve) blocks. If you have regional anesthesia, your anesthesiologist injects medication near a cluster of nerves to numb only the area of your body that requires surgery. You may remain awake or you may be given a sedative. Spinal and epidural blocks involve interrupting sensation from the legs or abdomen by injecting local anesthetic medication in or near the spinal canal. Other blocks can be performed for surgery on your extremities, or limbs, blocking sensations from the arm or leg.

How is regional anesthesia different from general anesthesia?

In general anesthesia, you are unconscious and have no awareness or other sensations. In regional anesthesia, your anesthesiologist makes an injection near a cluster of nerves to numb the area of your body that requires surgery.

If I choose regional anesthesia, does that mean I am awake during the surgery?

You may remain awake, or you may be given a sedative. You do not see or feel the actual surgery take place. Your anesthesiologist, after reviewing your individual situation, will discuss the appropriate amount of sedation for you. Although this sedation analgesia was once referred to as “twilight sleep”, the term “conscious sedation” has become more popular to describe a semi-conscious state that allows patients to be comfortable during certain surgical procedures.

During minimal sedation, you will feel relaxed, and you may be awake. You can understand and answer questions and will be able to follow your physician’s instructions. When receiving moderate sedation, you will feel drowsy and may even sleep through much of the procedure, but will be easily awakened when spoken to. You may or may not remember being in the operating room. During deep sedation, you will sleep through the procedure with little or no memory of the procedure room. Your breathing can slow, and you might be sleeping until the medications wear off.

While you receive sedation during surgery, your vital signs, including heart rate, blood pressure and oxygen level, will be watched closely in order to avoid sudden changes or complications. You may also receive supplemental oxygen during the surgery.

What are the different types of blocks performed for regional anesthesia?

In regional anesthesia, your anesthesiologist makes an injection near a cluster of nerves to numb the area of your body that requires surgery. There are several kinds of regional anesthesia. Two of the most frequently used are spinal anesthesia and epidural anesthesia, which are produced by injections made with great exactness in the appropriate areas of the back. They are frequently preferred for childbirth and prostate surgery. Another common type of regional anesthesia is a peripheral nerve block, which is produced by injections made with great exactness near a cluster of nerves to numb the appropriate area of your body extremity (arm, leg, head) that requires surgery. Two of the most frequently used are femoral nerve block, which is produced by injection in the leg region, and brachial plexus block, which is produced by injection in the arm and shoulder region. These blocks are frequently performed for surgery in the knee, shoulder, or arm.

May I request what type of anesthesia I will receive?

Yes, in certain situations. Some operations can be performed using different anesthetic procedures. Your anesthesiologist, after reviewing your individual situation, will discuss any available options with you. If there is more than one type of anesthetic procedure available, your preference should be discussed with your anesthesiologist in order for the most appropriate anesthetic plan to be made.

What types of surgical procedures would be amenable for regional anesthesia?

If there are no medical contraindications, anesthesiologists are able to perform regional anesthesia techniques (with either sedation or general anesthesia) for a wide variety of surgical procedures. Some examples of surgeries utilizing regional techniques are:

  • Gastrointestinal (stomach)/hepatic (liver): epidural, spinal or paravertebral nerve blocks and catheters may provide effective anesthesia and analgesia for colon resections and surgeries of the stomach, intestines, or liver.
  • Gynecology (female reproductive organ): epidural, spinal or paravertebral nerve blocks and catheters may provide effective anesthesia and analgesia for hysterectomy, pelvic procedures, Cesarean sections, and other gynecologic procedures.
  • Ophthalmology (eye): injection of local anesthetics may provide anesthesia and analgesia for many types of eye procedures.
  • Orthopedics (bone and joint): epidural, spinal, and many types of peripheral nerve blocks and catheters may be used depending on the limb/joint being operated upon.
  • Thoracic surgery (chest): epidural, paravertebral or intercostal nerve blocks and catheters may be especially useful in controlling pain following procedures of the chest or esophagus.
  • Urology (kidney, prostate, and bladder): epidural, spinal or paravertebral nerve blocks and catheters may provide effective anesthesia and analgesia for radical prostatectomy, nephrectomy, and other procedures involving the kidneys, prostate, or bladder.
  • Vascular surgery (blood vessel): cervical (neck) blocks may be used for incisional pain for carotid surgeries; epidural or paravertebral nerve blocks may be used for abdominal aortic endovascular procedures or lower extremity graft bypass procedures.

As with any other medical procedure, each type of regional/local block carries with it its own risks and benefits, which should be carefully considered and discussed with your anesthesiologist each time an anesthetic plan is chosen for a particular procedure.

How is the epidural or spinal block performed?

An epidural or spinal block is given in the back. You will either be sitting up or lying on your side. Before the block is performed, your skin will be cleansed with an antiseptic solution. The anesthesiologist will use local anesthesia to numb an area of your back.

For the epidural block, a special needle is placed in the epidural space just outside the spinal sac. A tiny flexible tube called an epidural catheter is inserted through this needle. Occasionally, the catheter will touch a nerve, causing a brief tingling sensation down one leg. Once the catheter is positioned properly, the needle is removed and the catheter is taped in place. Additional medications are given as needed through the epidural catheter without another needle being inserted. The medication bathes the nerves and blocks out the pain. This produces epidural anesthesia and analgesia.

For the spinal block, a small needle is placed in spinal sac. Occasionally, the needle will touch a nerve, causing a brief tingling sensation down one leg. Once the needle is positioned properly, medication is administered. The medication bathes the nerves and blocks out the pain. This produces spinal anesthesia and analgesia.

How is a peripheral nerve block performed?

Depending on the location of surgery, a peripheral nerve block can be given in the shoulder-arm, back or leg regions. Typically, you will either be lying flat on your back (supine) or lying on your side (lateral) but occasionally may even be on your stomach (prone). The block is administered at an appropriate location to provide anesthesia for the surgery. Before the block is performed, your skin will be cleansed with an antiseptic solution. The anesthesiologist will use local anesthesia to numb an area of where the peripheral nerve block will be administered.

For peripheral nerve blocks, a special needle or catheter is placed near the cluster of nerves that need to be numbed for surgery. Occasionally, the needle will touch a nerve, causing a brief tingling sensation down the extremity where the regional block is being performed. The needle may also be used to temporarily obtain muscle twitches in the extremity where surgery will occur.

Specific Nerve Blocks  

This section will provide you with more detail on specific nerve blocks that can be used for anesthesia and analgesia.

  • Spinal and Epidural Anesthesia 
    Spinal and epidural blocks are forms of anesthesia that temporarily interrupt sensation from the trunk (chest and abdomen) and legs by injection of local anesthetic medication in the vertebral canal, which contains the spinal cord and spinal nerves.  The spinal cord and spinal nerves are contained within a fluid-filled sac. The fluid-filled sac is called the dural sac and the fluid is known as cerebrospinal or spinal fluid

    Prior to performing a spinal or epidural block, your anesthesiologist may place monitors to watch your vitals signs. You will be placed either on your side with your knees and chin pulled as close to your chest as possible or sit with your arms and head resting on a small table. At this time, your anesthesiologist may choose to inject a small amount of relaxing medicine into your intravenous line if you require sedation. The anesthesiologist will feel your back, clean your skin with an antiseptic (bacteria-killing) solution, and place a sterile drape around the area. Your anesthesiologist may first inject some local anesthesia into the skin and then into the deeper tissues of the lower back – this may cause a slight burning or pressure sensation.  Your anesthesiologist will then carefully insert the needle and advance it into the space between your vertebrae (backbones).  Occasionally, you may feel a brief tingling sensation (paresthesia) during the procedure.

    For spinal anesthesia, the anesthesiologist advances the needle until he or she is able to inject some local anesthesia into the spinal fluid.  Since a spinal block typically involves a one-time injection, the duration of your spinal anesthesia will depend on the type and amount of local anesthetic medication administered by your anesthesiologist.

    For epidural anesthesia, the anesthesiologist advances the needle into the epidural space which is located just outside of the dural sac containing the spinal fluid. Your anesthesiologist may insert a small flexible catheter to allow for continuous injections or infusions of local anesthesia.  The needle is removed and only the catheter remains at the end of the procedure.  Epidural analgesia is most commonly used to provide pain relief during childbirth or after painful surgical procedures of the chest, abdomen, and lower extremities.

    After your anesthesiologist has performed the spinal or epidural block, you will generally feel numbness and may notice that your legs will become weak to the point where you may not be able to move them. This is normal. The surgery will be allowed to start only when your anesthesiologist is certain that the site of surgery is completely numb. During the surgery, you will have the option of being awake or sedated. If you choose to be sedated, the anesthesiologist will administer sedatives through your intravenous line to help you sleep lightly during the operation.

    After surgery, you will be taken to the recovery room and monitored closely by recovery room nurse until your spinal or epidural block wears off. Typically, a spinal block lasts 2-6 hours depending the type and amount of local anesthetic given by the anesthesiologist. If you received an epidural catheter, it can be left in place for several days after surgery to allow a continuous infusion of pain relieving medications.  Your epidural catheter is generally removed once you are able to keep down oral pain-relieving medications.

  • Brachial Plexus Block
    The brachial plexus is the major nerve bundle going to the shoulder and arm.  Depending on the level of surgery, your anesthesiologist will decide at what level he wants to block the brachial plexus. For example if you have surgery at the shoulder, your anesthesiologist may choose a nerve block (interscalene or cervical paravertebral block) performed at a location above the clavicle. For surgeries below the shoulder joint or clavicle, an infraclavicular or axillary technique may be used. Your anesthesiologist may use ultrasound, a nerve stimulator or other techniques to help identify the appropriate location along the brachial plexus to inject the local anesthetic. If a nerve stimulator is used, you may feel the muscles in your shoulder or arm twitch. This is normal. If you experience any sharp pain or any type of paresthesia (“shock-like” sensation similar to if you were to hit your “funny-bone” in your elbow) shortly before or during the injection you should notify your anesthesiologist immediately. You should also notify your anesthesiologist before performing any brachial plexus block if you have any type of pain below the elbow, preexisting pain, or preexisting nerve injury. If you have serious respiratory (lung, breathing) problems you should notify your anesthesiologist before proceeding with the block. Your anesthesiologist will then decide whether a brachial plexus block is safe for you and will provide adequate analgesia for the surgery.

  • Paravertebral Block
    Paravertebral blocks can be utilized to numb a specific area in one part of the body depending on where the block is performed. For example, paravertebral blocks at the level of the neck can be used for thyroid gland or carotid artery surgery. Paravertebral blocks at the level of the chest and abdomen can be used for many types of breast, thoracic, and abdominal surgery. Paravertebral blocks at the level of the hip can be used for surgeries involving the hip, knee, and the front of the thigh.

    In general, all paravertebral blocks are performed with a similar technique. Your anesthesiologist will feel your back, clean your skin with an antiseptic (bacteria-killing) solution, and may inject some local anesthesia into the skin and then into the deeper tissues of the back – this may cause a slight burning or pressure sensation. Your anesthesiologist will then carefully insert and advance a needle and inject local anesthesia to numb the nerves. If a nerve stimulator is used to help locate the nerves, you may feel the muscles in your chest, abdomen, or legs twitch. This is normal. If paravertebral blocks are utilized for thoracic and abdominal surgery, more than one injection may be needed to provide achieve adequate anesthesia. Your anesthesiologist may insert a small flexible catheter to allow for continuous injections or infusions of local anesthesia. The needle is removed and only the catheter remains at the end of the procedure if this is the case. As with other blocks, always let your anesthesiologist know if you experience any sharp or radiating pain during the procedure or injecting of the local anesthetic. Always notify your anesthesiologist if you experience sudden numbness, bilateral numbness or warmness with the injection of your local anesthetic

  • Femoral Nerve Block
    The femoral nerve provides sensation and motor function to the front of the thigh and knee. This block is commonly used for procedures that cover this area (such as surgery of the knee). If you receive a femoral nerve block, you generally will be positioned on lying on your back. Your anesthesiologist will feel your back, clean your groin area with an antiseptic (bacteria-killing) solution, and may inject some local anesthesia into the skin – this may cause a slight burning or pressure sensation. Your anesthesiologist will then carefully insert and advance a needle and inject local anesthesia to numb the nerves. A nerve stimulator is generally used to help your anesthesiologist determine the appropriate location to inject the local anesthetic. You may feel the muscles in your leg twitch – this is normal. Your anesthesiologist may insert a small flexible catheter to allow for continuous injections or infusions of local anesthesia. The needle is removed and only the catheter remains at the end of the procedure if this is the case. As with other blocks, always let your anesthesiologist know if you experience any sharp or radiating pain during the procedure or injecting of the local anesthetic. You may have difficulty with weight bearing on the blocked leg and you should have help in attempting to get up and care should be taken not to prevent falls. 
  • Sciatic and Popliteal Nerve Block
    This sciatic nerve provides sensation and motor function to the back of the thigh and most of the leg below the knee. This block is commonly used for surgery on the knee, calf, Achilles tendon, ankle, and foot. If you receive a sciatic nerve block, you generally will be place on your belly or side but occasionally you may be lying on your back. Your anesthesiologist will clean your skin with an antiseptic (bacteria-killing) solution, and may inject some local anesthesia into the skin and then into the deeper tissues – this may cause a slight burning or pressure sensation. Your anesthesiologist will then carefully insert and advance a needle and inject local anesthesia to numb the nerves. A nerve stimulator is often used to help your anesthesiologist determine the appropriate location to inject the local anesthetic. You may feel the muscles in your leg twitch – this is normal. Your anesthesiologist may insert a small flexible catheter to allow for continuous injections or infusions of local anesthesia. The needle is removed and only the catheter remains at the end of the procedure if this is the case. As with other blocks, always let your anesthesiologist know if you experience any sharp or radiating pain during the procedure or injecting of the local anesthetic. As with other blocks, always let your anesthesiologist know if you experience any sharp or radiating pain during the procedure or injecting of the local anesthetic. You may have difficulty with weight bearing on the blocked leg and you should have help in attempting to get up and care should be taken not to prevent falls.

What are the choices for pain relief after surgery? There are several choices for pain relief after surgery:

  • Intravenous “I.V.” or Intramuscular “I.M.” Medications: Pain-relieving medications that are injected into a vein or muscle will help to dull your pain but may not eliminate it completely. These medications are usually prescribed by your surgeon.
  • Local Anesthesia: Other pain-relieving medications may be injected into the surgical incision by your surgeon. These medications are local anesthetics. They provide numbness or loss of sensation in a small area.
  • Regional Blocks: Regional blocks can reduce the pain after surgery and can provide either analgesia or anesthesia. Local anesthetics and other drugs are used for these procedures to reduce or “block” pain and other sensation over a wider region of the body.

It is possible to combine regional and general anesthesia and in what situations would this combination be desirable?

Often, both general anesthesia and regional anesthesia are combined during the procedure, especially if the one of the intentions of the regional technique is to help control pain after surgery. If you have regional anesthesia in addition to general anesthesia, this may possibly allows your anesthesiologist to use less general anesthesia which might allow you to recovery faster after the surgery is finished. The types of regional anesthesia techniques that are commonly used in combination with general anesthesia are single-shot (one time) injections of nerve blocks and continuous catheters.

If you receive a single-shot nerve block, you can expect up to 4-24 hours of pain relief after surgery; however, the exact duration of analgesia depending on many factors. For adults, single-shot nerve blocks are a onetime injection of local anesthesia given typically under sedation but before general anesthesia is started. A single-shot nerve block may also be given to children to help with pain control after surgery but in most cases, your anesthesiologist will perform the block while your child is already asleep (after general anesthesia has started). Single-shot nerve blocks are often used for pain control after orthopedic (bone and joint) surgery.

What if I need pain control for more than 24 hours after surgery?

If you require pain control for more than 24 hours after surgery, for many types of surgery then your anesthesiologist can place a continuous catheter to allow the continuous deliver of pain relieving medications. If you receive a continuous catheter, you can generally expect analgesia for as long you have the catheter. Insertion of a continuous catheter for postoperative pain is typically done under sedation but before general anesthesia is started in adults and generally placed after general anesthesia is started in children. 

What are some of the possible side effects from the medications used for pain relief after surgery? 

The two commonly used types of medications are opioids (narcotics) and local anesthetics. In normal doses, narcotics may cause some itching, nausea, retching, or drowsiness. Local anesthetics may cause some numbness or, heaviness. There will be some difficulty with weight-bearing on the blocked leg afterwards, and patients should take care not to fall; however, the pain control lasts longer than the motor effects.

Can the regional block used for my surgery also help with pain relief after surgery? 

The regional block used for the surgery may last for some time after the end of surgery and may help with pain relief during this time. Occasionally, a catheter may be placed during the nerve block to extend the duration of pain relief after surgery.

What will I feel after the block takes effect? 

No matter what regional anesthesia technique you receive, whether it be a single-shot or a continuous catheter technique, you might some degree of temporary numbness, heaviness or weakness in your legs at the end of surgery. You might also not have the full muscle control of the affected part of your body. Please be sure to always check with your physician or nurse before you start to use any affected extremities for standing up or try to do other motor tasks. Also make sure that you don’t put pressure on any extremity which feels numb from your regional analgesic technique.

How long will the block last? 

Depending on the type of medication used for the regional block, the block may last for several hours after the conclusion of surgery. This may help with pain relief after surgery. If a catheter was placed during the nerve block, then the duration of analgesia can be extended for as long as you need it. After the catheter is placed, medication can be administered through it as necessary. After the catheter is removed, sensations will return to normal typically within a few hours.

Can I keep my regional block catheter when I go home after surgery? 

Depending on your anesthesiologist, surgeon and hospital, continuous peripheral nerve catheters have been used for analgesia at home after surgery. These outpatient or ambulatory catheters need some special attention and preparation and not all hospitals will provide this service. First, your anesthesia provider will check with your insurance company whether they cover the costs of the home going catheter and the nursing visits required for its care. You will then receive formal instructions in the process of catheter care including a list of emergency contact phone numbers. You will also receive a special pump which will be connected to your catheter and deliver the local anesthetic. Depending on the protocol utilized at your healthcare facility, you can change the reservoir of that pump yourself or it will be changed by a visiting nurse.

For most types of orthopedic surgeries, these peripheral catheters may stay in for an average of 3-4 days. You should inspect the catheter entry site for any signs of redness, swelling or purulent discharge. Whenever you notice one of those symptoms, contact your anesthesia provider or the visiting nurse immediately. Visiting nurses will inspect your catheter site with every visit. They will also be able to adjust the flow rate of your pump if needed. If no visiting nurse service is used by your institution, you will receive the appropriate instructions for managing the pump and removal of the catheter. Always make sure the catheter is completely removed. The most common reason for peripheral nerve catheter failure to provide adequate pain control is dislocation of the catheter. In order to lessen the chances of this happening, you might want avoid any pulling or tension on the infusion line and catheter.  

What are the benefits of a regional block?

Frequently, there is less nausea from regional blocks and patients generally awaken faster after regional blocks. Regional blocks can also be used to reduce the pain after surgery. Generally, regional nerve blocks and catheter will provide better pain control than intravenous or intramuscular opioids (narcotics).

Epidural analgesia for pain control after surgery might provide you with some specific benefits:
  • Better pain control than intravenous narcotics,
  • Earlier recovery of bowel function,
  • Less need for systemic opioids (narcotics) and less nausea as a result,
  • Easier breathing resulting from better pain control,
  • Easier participation in physical therapy

What are the risks of a regional anesthesia block?

Like any other medical procedures, there are risks associate with regional anesthesia. Complications or side effects can occur, even though you are monitored carefully and your anesthesiologist takes special precautions to avoid them. To help prevent a decrease in blood pressure, fluids may be administered intravenously. Although not common, a headache may develop following the block procedure. By holding as still as possible while the needle is placed, you may help to decrease the likelihood of a headache. The area where the nerve block was administered may be sore or tender for a few days. These discomforts, if they do occur, often disappear within a few days. If they do not disappear or become severe, additional treatments are available.

There are veins in the epidural space and other areas where epidural nerve blocks are administered. There is a risk that the anesthetic medication could be injected into one of them. To help avoid unusual reactions stemming from this, it is important to notify your doctor or nurse immediately if you notice any dizziness, rapid heart beat, funny taste or numbness around your mouth.

Nerve blocks of the brachial plexus are generally well tolerated but there may be signs and symptoms that you may notice. You might experience a change of your pupil size on the affected side, this is called Horner’s syndrome. You also might experience a light drop of your eyelid (ptosis). These are normal reactions which typically go away after the nerve block is gone. You might experience a stuffy nose and may experience a certain degree of hoarseness.

You might have the feeling that you might have to make a stronger effort to take deep breaths because one of the nerves going to your diaphragm will be affected as part of the normal block. An important, although very rare, complication of the cervical paravertebral, interscalene, or infraclavicular blocks, is the development of a pneumothorax (air trapped between the lung and the rib cage). In the unlikely case you do develop a pneumothorax, you may not notice any changes immediately but you might develop respiratory symptoms like persistent coughing, chest pain, or problems breathing and shortness of breath within 24 hours after performance of the block. If any of those symptoms occur you should contact your anesthesiologist or your nearest emergency room immediately. An x-ray will confirm the diagnosis of pneumothorax and sometimes the evacuation of the air with a chest tube is necessary. Because this is a rare but serious side effect, you should be aware of those symptoms.

Any time a needle or catheter is inserted under the skin and near a blood vessel, bruising, infection, or bleeding may occur. An uncommon complication of the axillary approach to the brachial plexus can be the formation of large hematomas. You should notify your anesthesiologist about any expanding hematoma in the puncture area immediately.

The specific risks of anesthesia vary with the particular procedure and the condition of the patient. You should ask your anesthesiologist about any risks that may be associated with your particular anesthesia. Your anesthesiologist carefully evaluates your condition, makes medical judgments, takes safety precautions and provides special treatment throughout the procedure. You should feel free to talk with your anesthesiologist about your options for anesthesia, pain control after surgery, their benefits and their possible side effects.

What is a spinal (postdural puncture) headache? What are the treatments for spinal headache?

A spinal or postdural puncture (PDPH) (or also sometimes called a meningeal puncture headache) may occur after spinal or epidural anesthesia when puncture of the dural sac allows for spinal fluid to leak out of the dural sac. If enough spinal fluid leaks out, a headache may occur especially when standing or sitting. A spinal headache may occurs any time after spinal or epidural anesthesia but most cases generally show themselves within 3-5 days after a spinal or epidural anesthetic. The characteristics and severity of the headache may vary. With improvements in needle design, the risk of a spinal headache after anesthesia is much less than a few decades ago. 

If you have a headache after spinal or epidural anesthesia, you need to contact your surgeon or primary care physician if you are at home or notify the health care providers caring for you if you are still in the hospital. If you are at home and do not have a physician contact person, you should be evaluated at an emergency room. There are many possible causes for headache other than spinal headache from spinal or epidural anesthesia and your physician may need to examine you and perform several tests to see what is causing your headache.  

If your headache is the result of spinal or epidural anesthesia, then there are several treatment options depending on the severity of your symptoms. If your headache is mild, treatment is conservative and includes taking oral pain-relieving medications, drinking fluids, and consuming caffeine (usually in the form of caffeinated beverages). The leaking puncture will normally repair itself in a few days-weeks and your symptoms will gradually improve. If your symptoms are severe or your symptoms do not improve, your anesthesiologist may recommend an “epidural blood patch” . This involves carefully takes a small amount of blood from one of your veins and injecting it into the epidural space in your back. The injected blood in the epidural space will form a clot and seal the puncture site. After the epidural blood patch, your spinal headache should improve within 12-24 hours. If after this time period, you still have symptoms compatible with a spinal headache, your anesthesiologist may recommend repeating the epidural blood patch one more time. Your anesthesiologist will discuss the balance between the risks and benefits of an epidural blood patch.

How common is nerve injury after a regional block?

Nerve injury after a regional block is a rare occurrence, which can occur anywhere from 1 in 4000 blocks to 1 in 200.000 blocks depending in the type of block and specific risk factors. It can be related to direct needle injury of the nerve or to secondary complications like bleeding or infection. In order to prevent nerve injury, please inform your anesthesiologist if you experience any sharp or radiating pain during needle placement or injection. If you experience any new symptoms like tingling, numbness, or motor dysfunction after a nerve block has already worn off you should seek medical attention immediately because this can be a sign of secondary damage by hematoma or infection. Because recovery of nerve function depends on timely initiation of diagnosis and treatment, do not take any unexpected changes lightly.

Can the epidural or regional block catheter become infected?

Every time a foreign body like a needle or catheter is introduced into your body, there is the risk of infection. Bacteria can enter the body through the primary puncture or along the catheter site. The risk of infection increases over time but the chance of a serious infection leading to abscess formation and requiring surgical intervention or damage to the nerve secondary to an infection is extremely rare.

Careful monitoring of the catheter insertion site is required to detect early signs of infection. Redness, swelling and purulent discharge should lead to immediate inspection of the catheter site and removal of the catheter. While most often no other treatment than removal of the catheter is required, sometimes systemic antibiotics might be administered or surgical drainage of an abscess can be necessary. Abscess formation in the epidural space is extremely rare bit it can be a very dangerous complication leading to permanent paralysis. If you experience any fevers or chills, one of the described local symptoms or any change in your neurologic status like increased numbness or loss of motor function, bladder and bowel disturbances, you need to contact you anesthesiologist or health provider immediately.