How does the epidural work?
Nerves send messages including pain messages through the spinal cord to your child’s brain. The medicine given into the epidural space is a local anaesthetic called levobupivacaine, which temporarily blocks these nerves, stopping pain messages getting through to the brain. The local anaesthetic is often mixed with a small amount of morphine, which will also help to relieve pain. The pump is programmed to give the medicines continuously to ensure your child has good pain relief and is comfortable.
When is an epidural used?
Epidurals are generally used after operations that are expected to be quite painful. They are also used if a child cannot take medicines by mouth for a few days. If your child is likely to have an epidural, the anaesthetist will discuss this with you and your child before the operation. They will discuss the benefits, possible side-effects and complications to ensure you are happy to proceed. The anaesthetist can discuss alternatives if you have any concerns.
Most children have an epidural for 3-4 days. The Paediatric Site Practitioner (PSP) will visit your child every morning and will, assess how comfortable they have been, and gradually reduce the amount of medicine infused each day. Before the epidural is stopped, the PSP and ward nurses will make sure that your child is able to have other pain relief medicines to keep them comfortable.
How long will my child need the epidural?
When they no longer need the epidural, the tube will be removed. This is not painful and the nurse will use a wipe or spray to make the sticky dressing easier and more comfortable to remove.
Can any child have an epidural?
An epidural is not suitable for every child as certain medical conditions may mean that some children are at a higher risk of problems. If your child has any of the following, an epidural may not be suitable:
If an epidural is not suitable for your child, the anaesthetist and PSP will use a different method to keep your child comfortable.
Are there any side effects and problems from an epidural?
While your child has an epidural in place, the ward nurses, PSP and doctors will monitor them closely for any problems or side effects. The anaesthetist will be informed of any issues that arise.
The most common complication are headaches caused by small puncture in the membrane surrounding the spinal cord. The headache can be severe and is worse when the child sits or stands up. If this happens, pain relieving medication can be given.
Epidurals can sometimes make your child feel sick or itchy. This is usually due to the morphine in the medicine mixture. Other medicines can be prescribed to stop these side effects e.g. antiemetics (anti-sickness).
Some children also find it difficult to pass urine (wee) when they have an epidural. A catheter will be inserted into the bladder to drain off urine while the epidural is being used and will stay in place until the epidural catheter is removed.
While the epidural is delivering medicine to the epidural space, your child’s legs may feel heavy and possibly difficult to move, although most children can still move around in bed. Some children say that their legs feel numb or like cotton wool but this is the normal pain relieving effect of the local anaesthetic. If possible, the anaesthetist or the PSP will reduce the amount of medicine to a minimum to reduce this feeling, whist ensuring that your child is comfortable.
The medicine may leak a little from the catheter in the epidural space. This is not usually a problem as long as your child is still receiving enough pain medicine to be comfortable. If the sticky dressing holding the catheter in place becomes too wet, it may need to be changed.
Occasionally, the epidural may not give enough pain relief to keep your child comfortable. If this happens, the anaesthetist and PSP will discuss another form of pain relief for your child.
Infection may occur on the skin at the site of the catheter insertion. This may appear as redness or oozing or your child developing a high temperature. This infection is very unlikely to spread further from the skin, but if it develops, the epidural catheter will be removed and a course of antibiotics may be started.
Sometimes the morphine in the pain relief mixture can cause your child to become sleepy and it can also slow the rate of their breathing. The nurses will monitor your child closely for these signs and all children having epidural morphine are prescribed another medicine that can reverse this effect very quickly.
A rare but potentially serious complication of an epidural is called ‘local anaesthetic toxicity’. This can occur due to excessively high levels of the local anaesthetic medicine in the blood. Symptoms can include confusion, light-headedness, dizziness, ringing in the ears, and a metallic taste in the mouth, tingling around the lips, drowsiness or very rarely seizures (fits). These problems are avoided by carefully calculating your child’s dose according to their weight. However, if your child shows any of these symptoms, please inform a member of nursing staff immediately.
An even rarer but potentially serious complication is nerve damage either by injury to the nerve when an epidural is inserted or by a blood clot (haematoma) forming in the area. To prevent this, all anaesthetists inserting epidurals are highly trained in techniques designed to avoid this complication. The estimated frequency of nerve damage from an epidural is 1 in every 10,000 patients, compared with the frequency of being involved in a road traffic accident of 1 in every 200 people.
Infection in the epidural space is another very rare but potentially serious complication, occurring around 1 in 100,000 patients. An infection can develop close to the spinal cord, which may cause an abscess (collection of pus) to develop. If such an infection were to occur, it would need treatment with antibiotics to prevent nerve damage. To avoid this, all epidurals are inserted in sterile conditions. The site is kept clean under a dressing and the ward nurses will review your child’s back frequently.
It is important to tell the nurse if your child:
Any questions
If you have any questions about your child’s pain, please ask our nurses on the ward, your child’s Anaesthetist, Pharmacist, RMO or the PSP – Ext 10838/10840/10843
Please also contact – Nasra Ahmed, Complex Surgical/Pain Lead Nurse: Tel Tel: 020 7580 4400 (ext 10838)
References:
Pain Control Service in collaboration with the Child and Family information group, Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London WC1N 3JH
Published 2021
