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St. Joseph's Health Centre Toronto

Pain Management and Anesthesia

Welcome to the department of anesthesia. Here our patients can learn about who we are and what we do in our roles to take care of you and in managing your pain before, during, and after your operation. Please click the tabs to move between the different sections of information for you and your family.

Your anesthesia care team

Members of the anesthesia care team work in collaboration to provide patients with safe and effective anesthesia during their surgical procedure. The team members will also provide pain management after the procedure during the patient’s stay in hospital, when consulted by the surgeon.

Members of the team are:

Anesthesiologists are physician specialists who are responsible for your safety both during your surgery and during your stay in the recovery room. They provide you with an anesthetic, whether that be general anesthesia, a regional anesthetic like a spinal anesthetic or a nerve block or intravenous sedation to keep you from feeling pain during your surgery.

Anesthesiology residents:
These are physicians that have completed medical school and are currently undergoing a further five year specialty training program in anesthesiology.

Anesthesia assistants:
The anesthesia assistants at St. Joe’s are healthcare professionals who participate in the care of surgical patients during general or regional anesthesia or procedural sedation under the supervision of the anesthesiologist. They provide clinical and technical assistance as members of the anesthesia care team in a wide array of cases including all major and emergency cases.

Nurse practitioner:
The nurse practioner (NP) is a member of the acute pain service. The NP works in collaboration with the anesthesiologist and the patient and family to develop a pain management plan of care for the patient while they recover from surgery in hospital.

Prior to your operation you will be seen by a member of the anesthesia care team. They will obtain a medical history, examine you and then discuss the anesthesia options for your surgery.

Some patients will meet an anesthesiologist only on the day of surgery while other patients will be scheduled for an anesthesiology consultation in our pre-admission clinic in advance of the day of surgery.

What if your operation is delayed or postponed?
We often request that you stop certain medications for several days before an operation, particularly blood thinners. If your surgery is delayed or postponed, it is important to get directions to guide you with respect to your medications.

Every patient’s situation is different, so an anesthesiologist will have to review your particular situation and instruct you on the medications that will need to be restarted. Please call the pre-admission clinic at 416-530-6000 ext. 4144 and we will assist you.

Please see below for important information about other medical issues that can impact your upcoming anesthetic and surgery.

History of Difficult Intubation

If you have been through a previous general anesthetic and have been told that you are a difficult intubation, you must inform the anesthesiologists you speak with preoperatively, both in the pre-admission clinic and the anesthesiologist you meet on the day of your surgery. A difficult intubation means that the usual methods anesthesiologists use to insert endotracheal tubes (the breathing tube that goes in between your vocal cords for most general anesthetics) were difficult or unsuccessful. Ideally, you should have a copy of the anesthesia record from the operation where you were found to be a difficult intubation. Otherwise, we can request for the anesthetic record to be sent to us to review and then a plan made on the best way to proceed with your upcoming anesthetic. This is best done well in advance of your upcoming surgery.

Obstructive Sleep Apnea

If you are known to have obstructive sleep apnea (OSA) and have a CPAP machine, it is very important that you bring your machine with you on the day of surgery. If your machine is broken or you have not acquired a CPAP machine yet, but have known sleep apnea, we can set you up with one in hospital. It is important to know the settings of your machine at home (how many centimeters of water the pressure is set at, and the amount of oxygen that you are on, if any).

If you are suspected of having a high risk of sleep apnea (history of very loud snoring, gasping and choking causing awakenings at night), you might require overnight admission to hospital, for what would otherwise be day surgery.

Antibiotic Allergies

Antibiotics are given in a number of surgeries to prevent wound infections after your operation. Typically, the most frequently ordered drug to prevent wound infections is called Cefazolin or Ancef. This drug is part of the cephalosporin class of antibiotics. If you have been diagnosed with anaphylaxis to penicillins, there is approximately a five per cent chance of having anaphylaxis to the cephalosporin antibiotics. The alternative antibiotics to penicillin, such as clindamycin, are not as efficacious in preventing wound infections and have a higher incidence of potential complications like C. difficile colitis. If there is adequate time before your surgery, it is worthwhile to have a referral to an allergist and get testing to see if you have a true penicillin allergy or not.

Local Anesthetic Allergies

Local anesthetics are ‘freezing’ medications that numb or freeze your skin or nerves so that you do not feel pain from your incisions. There are two types of local anesthetics which differ in their chemical structure, amides and esters. Most people who develop allergies to local anesthetics are allergic to the ester class, and in this case, it is safe to use the amide class of local anesthetics. In the vast majority of cases, physicians in hospital will use an amide-based local anesthetic such as lidocaine or bupivacaine. Often these local anesthetics have a small concentration of adrenaline/epinephrine mixed in to help prolong the local anesthetic effects. Adrenaline, when absorbed into your blood can cause your heart rate and blood pressure to go up, and make you feel anxious or nervous. This is a normal reaction to adrenaline.

Latex Allergies

If you have a latex allergy/sensitivity, be sure to inform your anesthesiologist, surgeon, and nursing staff. Most medical equipment used in the operating room is latex-free but some equipment still contains latex. We simply will avoid any products that contain latex for your operation. Some people with a known kiwi or banana allergy can also have a latex allergy. If you have any allergies at all, please let your doctor know.

Patients with Chronic Pain

If you have chronic pain and are on chronic pain medications, you might be wondering what to do with your pain medication before an operation. It is very important to follow the directions given to you by the anesthesiologist that speaks to you in the pre-admission clinic regarding your usual medications. If you are not attending the clinic, it is usually recommended that you take your usual morning pain medications on the morning of the operation with a sip of water. If you are staying in hospital after your operation, the acute pain service will likely be involved in your care and pain management in order to keep you as comfortable as possible. The pain service is available seven days a week to assist with your pain management.

Patient with a History of Post-Operative Nausea and Vomiting

Post-operative nausea and vomiting (PONV) is a common side-effect of general anesthesia and certain types of surgery. If you have previously had PONV then you are at higher risk of having it again. There are several medications we can give to prevent nausea and vomiting during your operation. We can also employ different anesthetic techniques that have a lower incidence of nausea and vomiting such as performing a spinal anesthetic (which has a very low incidence of nausea and vomiting) instead of a general anesthetic. Let your anesthesiologist know about your nausea history so that they can help prevent it for your upcoming operation.

Family History of Significant Anesthesia Reactions

Malignant hyperthermia (MH) is a relatively rare but potentially fatal, inherited disorder usually associated with the administration of certain general anesthetics and/or the drug succinylcholine. MH is caused by an acceleration of metabolism in skeletal muscle. If diagnosed during an operation, immediate treatment with the drug dantrolene can usually reverse this process. Without immediate treatment, MH is often fatal.

If you are known to have MH or have any family members that have MH it is critical that you inform your anesthesiologist before your surgery. Special precautions can be taken to avoid the drugs that trigger malignant hyperthermia. For more information visit

Pseudocholinesterase Deficiency

Pseudocholinesterase deficiency is an inherited enzyme abnormality that results in a prolonged metabolic breakdown of certain drugs that are often given during an anesthetic such as succinylcholine. If there is a deficiency in the activity of the enzyme pseudocholinesterase, there may be prolonged muscle paralysis which would result in the need for prolonged mechanical ventilation. If anyone in your family has had this problem, because the disorder is inherited, there is a chance that you may have it as well. In such cases, to avoid this issue, we would avoid giving you the drugs that are broken down by this enzyme. Several alternatives are available.

A member of the anesthesia care team will be with you throughout your entire surgery, monitoring your vital signs (heart rate, blood pressure, oxygen levels, temperature etc.) and administering medications including pain medications and anti-nausea medications. Here we discuss the common options for your anesthetic. The type of anesthesia offered depends on the surgery that you are having.

Intravenous Sedation

More minor operations are often done under light sedation. For these operations surgeons often inject local freezing medications in the area they are working, and then your anesthesia care team will make you relaxed and comfortable with intravenous medications. These medications can allow you to sleep during the procedure. The sleep is not as deep as a general anesthetic, as you will be breathing on your own and won’t require the insertion of a breathing device.

Intravenous sedation is often combined with spinal anesthesia or regional anesthesia so that a part of you might be very frozen. You may still able to go to sleep and not be aware of anything going on during your operation.

General Anesthesia

Most operations are done under general anesthetics. A general anesthetic is a drug-induced, reversible coma. You will be completely unaware while under a general anesthetic. Typically, a breathing device is inserted into your mouth while you are asleep and a ventilator assists with your breathing. Anesthetic agents are continuously given in order to keep you asleep. Once these medications are turned off you wake up in a matter of minutes. Pain medications and anti-nauseants are given while under general anesthesia so that you wake up without significant discomfort or nausea. More medications for pain or nausea can be given in the recovery room after you awaken from your operation.

Epidural Anesthesia

An epidural is a very small catheter/tube that is introduced by the anesthesiologist near the nerves in the spine. Medication is continuously infused through the tube to block pain signals and keep you comfortable from your surgical incision. Epidurals allow you to breathe better and move better after your operation and are important in helping to prevent serious postoperative complications like pneumonia and serious blood clots. Epidurals may also provide better pain relief than can be achieved with conventional pain medications. Epidurals are usually only recommended for certain types of surgeries with incisions in the upper abdomen or in the chest.

Epidurals are placed in the operating room before you go off to sleep for your surgery. The epidural catheter is usually left in place for a few days after your operation. After the epidural is removed, we keep you comfortable with pain medications that can be given by mouth or through an IV.

Spinal Anesthesia

Spinal anesthesia is similar to epidural anesthesia. It involves a needle in the back that freezes some of your abdomen and legs.  It is one of the anesthetic options for certain types of surgery. The key differences between an epidural and a spinal are:

  1. A spinal anesthesia uses a much smaller needle.
  2. No tube is left in place with a spinal anesthetic.
  3. The spinal lasts for a period of time and then wears off.

Please click on the link below to view our information hand-out on spinal anesthesia.

Regional Anesthesia (Nerve Blocks)

Regional anesthesia involves injecting local anesthesia (freezing) medicine very close to major nerves, producing a sense of numbness for a specific area of the body where you will have surgery. Many people also refer to regional anesthesia as nerve blocks. Nerve blocks usually last anywhere from 12 to 24 hours.

A nerve block is often performed using an ultrasound machine. Ultrasound machines allow us to “see” deep body structures such as muscles, blood vessels and nerves. Some nerve blocks are also performed with the help of a nerve stimulator, a special device that produces a small electrical impulse that may cause your arm or leg to jerk. These techniques allow the anesthesiologist to produce a more effective and safer nerve block.

Many different nerve blocks are available. The most commonly performed ones are described below. If a particular type of nerve block is thought to be of benefit, your anesthesiologist will discuss it with you before surgery.

Adductor Canal Block

An adductor canal nerve block is a nerve block performed at the inner thigh, which freezes nerves that go down the thigh, knee, and part of the lower leg. An ultrasound machine is used to guide the needle. There may be some temporary weakness in the leg, but this is not common with this block.

Femoral Nerve Block

A femoral nerve block is similar to the adductor canal nerve block but is performed a little higher up the leg, just beneath the groin. A nerve stimulator is usually used to guide the needle; sometimes an ultrasound machine is also used for this nerve block. The femoral nerve block usually results in temporary weakness in the leg.

Interscalene Block

An interscalene block is a nerve block injected at the side of the neck which freezes nerves that go down the shoulder, arm, and even the hand. A nerve stimulator is usually used to guide the needle; sometimes an ultrasound machine is also used for the nerve block. You should expect pain relief as well as temporary weakness in the shoulder, arm and hand for approximately 16-24 hours until the freezing medication wears off.

After your operation is done you are taken to the recovery room. If you are going home on the day of your surgery, you will go to surgical daycare (SDC) from the recovery room and then be discharged home. If you are staying in hospital you will go from the recovery room up to your hospital bed. If staying in hospital, you might be looked after by the acute pain service to assist with your post-operative pain management.

Acute Pain Service (APS)

For more painful procedures, patients with chronic pain and any patients requiring a pain pump or those who have an epidural, the anesthesia care team will be involved with your pain management after your operation.

What we do:
The APS is made up of a team of anesthetists and a nurse practitioner that are available for inpatient consultation, as requested by the surgical or medical team, 24 hours a day, seven days a week.

The APS is able to provide acute pain management to post-operative patients by a variety of methods including patient-controlled analgesia, epidural analgesia and by peripheral nerve block. The APS also manages acute pain in non-surgical patients on request. Each patient consulted to the APS will be assessed daily or as appropriate by a member of the APS.

During the regular work week, we perform dedicated rounds on all inpatients under our care. On evenings and weekends, coverage is provided by the on-call anesthesia staff and residents.

The APS works with surgeons, pharmacists, nurses, allied health and other healthcare professionals, to ensure the best patient care. We see patients when requested by the primary medical or surgical team.

Members of our team include:

  • Nurse practitioners
  • Anesthesiologists
  • Anesthesia residents

Types of pain management available to post-operative patients:

Patient-Controlled Analgesia (PCA)

PCA involves the use of a special pump that is attached using an IV. The device is usually set up in the recovery room. The pump delivers a small dose of an intravenous pain medication, usually hydromorphone, when you press a button. There are many features built into the pump to prevent overdosing. While using a PCA pump, you will be under the care of the acute pain service and will be visited on a daily basis to ensure that you remain comfortable after your surgery.


An epidural is a very small catheter/tube that is introduced by the anesthesiologist near the nerves in the spine. Medication is continuously infused through the tube to block pain signals and keep you comfortable from your surgical incision. Epidurals allow you to breathe better and move better after your operation and are important in helping to prevent serious postoperative complications like pneumonia and serious blood clots. Epidurals may also provide better pain relief than can be achieved with conventional pain medications. Epidurals are usually only recommended for certain types of surgeries with incisions in the upper abdomen or in the chest.

Epidurals are placed in the operating room before you go off to sleep for your surgery. The epidural catheter is usually left in place for a few days after your operation. After the epidural is removed, we keep you comfortable with pain medications that can be given by mouth or through an IV.

Pain Management Options for Labour and Delivery

Anesthesiologists play an important role in pain management during labour and delivery. At St Joseph’s Health Centre, an anesthesiologist is always available to help you make an informed decision on the best options for you, to help monitor the adequacy of the chosen method and to treat side effects from medications. Your doctor or midwife can also refer you for an obstetrical anesthesia assessment prior to labour if needed.

There are both non-medical pain management options for labour such as massage, breathing exercises and hydromassage as well as medical pain management options such as nitrous oxide (laughing gas), nurse administered pain medications, patient-controlled analgesia (PCA) or epidural anesthesia.

The anesthesia department is usually not involved in your labour unless you require PCA or epidural anesthesia.

Options for Pain Management

Pharmacologic or medication-based pain management options during labour and delivery can either be given systemically or regionally. Systemic medications are given by mouth or intravenous and reach the entire body. These medications also can cross the placenta and affect your baby. Regional options such as an epidural, spinal injection or combined spinal-epidural injection temporarily numb part of the body to reduce or eliminate pain. These regional techniques are very effective at reducing pain during labour and delivery and limit the transfer of pain medications to your baby. General anesthesia is typically used only for emergency C-section deliveries where there is no time to perform a spinal or epidural.

Systemic Pain Medication for Labour and Delivery:

Intermittent Nurse-Administered Pain Medication

These medications, such as morphine or fentanyl, are usually ordered by your obstetrical doctor or midwife. The medications will eventually enter the bloodstream and can cross the placenta to the baby. They are considered safe for both mom and baby at certain doses and at a certain time of labour but may cause side effects such as drowsiness in both mom and baby. Patients receiving these medications will be monitored for side effects.

Patient-Controlled Analgesia (PCA)

Intravenous medication (such as fentanyl) is given through a pre-programmed pump under the direction of an anesthesiologist and supervision of a registered nurse. The patient in labour can self-administer small doses of medication. Potential side effects can include drowsiness and nausea. PCA is typically the best option for pain management in labouring patients who cannot receive an epidural during labour. Breastfeeding is generally safe in patients who have received PCA but your baby should be monitored for potential breathing problems.

Nitrous Oxide (Entonox)

Nitrous oxide (commonly referred to as “laughing gas”) has recently been made available at St Joe’s. It is an inhaled gas that provides temporary pain relief with contractions and may provide some anxiety relief. Nitrous oxide can be ordered and administered by your midwife or nurse. It is delivered by a mouthpiece or mask with each contraction and is eliminated from the body within minutes of delivery. Nitrous oxide is safe for mom and baby.

Regional Anesthesia Options for Labour and Delivery:

Labour Epidurals

A labour epidural may be requested at any time (i.e. before beginning of labour to full dilation and imminent delivery). An anesthesiologist will assess if the procedure can safely be performed and discuss risks and benefits with you prior to proceeding. You must be able to sit/lie still during the procedure in order for it to be performed safely.

At St. Joseph’s Health Centre once you have received an epidural during labour, you will not be permitted to walk (though the type of epidural you may receive may be the equivalent of what is known as a ‘walking epidural’). All patients with an epidural will also have an intravenous for safety reasons. Once you are comfortable after the epidural, you may have a bladder catheter inserted by your nurse.

You may have one support person with you during the insertion of the epidural. They will need to wear a surgical mask to help prevent infection. The procedure is usually done while sitting up. Many people are worried about pain during epidural insertion. Your anesthesiologist will freeze the skin at the insertion site before starting the procedure.

An epidural takes several minutes to insert and you will likely have contractions during the procedure. It is very important to stay still for your safety. Do not worry, most patients do exceptionally well.

Once the procedure is over, we will check your blood pressure and baby’s heart rate frequently for medication-induced side effects, which are usually very short-lasting. In addition to the risks and side effects described in ‘epidural section’, an epidural may infrequently cause a drop in your baby’s heart rate. This is monitored closely and treated immediately.

Medications such as local anesthetic and pain medications will be infused through the epidural catheter/tube by a pump during your labor. Some patients may have the option to give themselves more epidural medication as their labour progresses, if needed. The epidural will be removed by your nurses after labour and delivery. Epidurals can also be used for assisted delivery (such as forceps) and for C-sections in some cases.

General Anesthesia

General anesthesia is usually reserved for emergency C-sections or in rare cases when patients cannot have a spinal or epidural for delivery. General anesthesia is not the preferred option for delivery for several reasons. There are risks such as aspiration (stomach contents entering the lungs and causing a life-threatening pneumonia), blood pressure fluctuations affecting baby and mother, medication side effects for the baby and impairment of the uterus’ ability to properly contract after delivery. Breastfeeding is considered safe after a general anesthetic but your doctor may recommend that you “pump and dump” (discard some breastmilk) for a short period of time after surgery.

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