What are the potential side effects of an epidural. How can low blood pressure affect patients receiving an epidural. What measures are taken to manage bladder control issues after an epidural. How do healthcare providers address itching and nausea associated with epidurals. What are the risks of nerve damage from epidural procedures. How common are severe complications like permanent nerve damage or infection from epidurals.

Common Side Effects of Epidural Anesthesia

Epidural anesthesia is a widely used pain management technique, particularly during childbirth and certain surgical procedures. While generally considered safe, it’s crucial to understand the potential side effects that may occur. Let’s explore some of the most common side effects patients might experience after receiving an epidural.

Low Blood Pressure

One of the most frequent side effects of epidural anesthesia is a drop in blood pressure. This occurs because the medication affects the nerves that control blood vessel dilation. How does this impact the patient? It can sometimes lead to feelings of dizziness or nausea. To mitigate this risk, healthcare providers closely monitor blood pressure throughout the procedure and recovery period. If necessary, they may administer fluids or medications through an IV to maintain normal blood pressure levels.

Temporary Loss of Bladder Control

The epidural medication can affect the nerves controlling bladder function, leading to temporary loss of bladder control. This side effect is usually managed by inserting a catheter to drain urine until the epidural wears off. Normal bladder function typically returns once the anesthesia’s effects subside.

Itchy Skin

Some patients experience itching as a side effect of the pain relief medications used in epidurals. This can be uncomfortable but is generally not serious. Healthcare providers can often address this issue by adjusting the medication or providing anti-itch treatments.

Nausea and Vomiting

While less common than with other pain relief methods, some patients may experience nausea after receiving an epidural. This can often be managed with anti-nausea medications or by addressing any associated drop in blood pressure.

Potential Complications of Epidural Anesthesia

While most patients experience only minor side effects, it’s important to be aware of potential complications that can arise from epidural anesthesia. These are generally rare but can be more serious.

Inadequate Pain Relief

In some cases, the epidural may not provide complete pain relief. This can occur due to various factors, including the positioning of the catheter or individual variations in anatomy. When this happens, healthcare providers may offer additional or alternative pain management options.

Post-Dural Puncture Headache

A severe headache can occur if the dura mater (the protective membrane surrounding the spinal cord) is accidentally punctured during the epidural procedure. This type of headache, known as a post-dural puncture headache, can be quite severe and may require specific treatment. In some cases, a procedure called a blood patch may be used to seal the puncture and alleviate the headache.

Respiratory Effects and Monitoring

While rare, epidural medications can sometimes affect respiratory function. This underscores the importance of continuous monitoring during and after the procedure.

Slow Breathing

Some medications used in epidurals can cause slow breathing or drowsiness in certain patients. Healthcare providers closely monitor patients for any signs of respiratory depression and can quickly intervene if necessary. This side effect is usually easily treatable and rarely leads to serious complications.

Neurological Complications: Understanding the Risks

Neurological complications from epidurals are rare but can be concerning. It’s important to understand these potential risks and how they’re managed.

Temporary Nerve Damage

In uncommon cases, the epidural needle or catheter can cause temporary nerve damage. This may result in numbness or weakness in parts of the lower body. Most often, these symptoms resolve within days or weeks, though in some cases, it may take several months for full recovery.

Permanent Nerve Damage

While extremely rare, permanent nerve damage can occur as a result of an epidural. This could lead to long-term loss of feeling or movement in affected areas. What are the potential causes of such damage? They include direct injury to the spinal cord, infection, bleeding in the epidural space, or accidental injection of incorrect medications. It’s important to note that these severe complications are exceptionally uncommon, and anesthesiologists undergo extensive training to minimize these risks.

Infection Risks Associated with Epidurals

Like any medical procedure that involves breaking the skin barrier, epidurals carry a small risk of infection.

Local Infection

In some cases, an infection can develop at the site where the epidural catheter is inserted. This is typically a superficial skin infection that can be treated with antibiotics. How is this risk minimized? Healthcare providers use sterile techniques when placing the epidural to reduce the chance of introducing bacteria.

Deep Infection

While very rare, there is a possibility of a deeper infection developing in the epidural space. This is a more serious complication that may require intravenous antibiotics or, in extreme cases, surgical intervention. Prompt recognition and treatment of any signs of infection are crucial to prevent more severe complications.

Rare but Serious Complications

While the vast majority of epidural procedures are performed without incident, it’s important to be aware of the potential for rare but serious complications.

Convulsions

In extremely rare cases, epidural anesthesia can lead to seizures or convulsions. This is typically associated with the accidental injection of anesthetic into a blood vessel or the use of excessive amounts of local anesthetic. Anesthesiologists are trained to recognize and manage this complication quickly.

Severe Breathing Difficulties

If the epidural anesthetic affects the nerves controlling the diaphragm and intercostal muscles, it can lead to severe breathing difficulties. This is an extremely rare complication that requires immediate medical intervention.

Cardiovascular Complications

In very rare instances, epidural anesthesia can lead to severe cardiovascular complications. These may include significant drops in blood pressure or heart rate that don’t respond to standard treatments. While exceptionally uncommon, these situations require immediate and intensive medical management.

Making Informed Decisions About Epidural Anesthesia

Understanding the potential risks and benefits of epidural anesthesia is crucial for patients considering this pain management option. How can patients make informed decisions about epidurals?

Discussing Risks with Healthcare Providers

Before deciding to have an epidural, patients should have a thorough discussion with their anesthesiologist or healthcare provider. This conversation should cover the potential risks, benefits, and alternatives to epidural anesthesia. Patients should feel empowered to ask questions and express any concerns they may have.

Considering Individual Risk Factors

Each patient’s individual health status and medical history can influence their risk of complications from an epidural. Factors such as pre-existing medical conditions, allergies, and previous reactions to anesthesia should be carefully considered and discussed with healthcare providers.

Weighing Benefits Against Risks

While the potential risks of epidural anesthesia may seem daunting, it’s important to consider them in context. For many patients, the benefits of effective pain relief during childbirth or surgery outweigh the small risks of complications. Healthcare providers can help patients understand how these risks and benefits apply to their specific situation.

Monitoring and Managing Epidural Side Effects

Healthcare providers employ various strategies to monitor patients and manage potential side effects of epidural anesthesia.

Continuous Monitoring

During and after the administration of an epidural, patients are closely monitored for any signs of complications. This typically includes regular checks of vital signs, sensation, and motor function. How does this monitoring help? It allows for the early detection and prompt management of any potential issues.

Adjusting Medication

If a patient experiences side effects from the epidural medication, healthcare providers can often adjust the type or dosage of medication used. This flexibility allows for personalized pain management while minimizing unwanted effects.

Providing Supportive Care

Many side effects of epidurals can be managed with supportive care. This may include providing fluids for low blood pressure, anti-nausea medications for feelings of sickness, or comfort measures for itching. The goal is to ensure the patient remains as comfortable as possible while benefiting from the pain relief provided by the epidural.

Understanding the potential side effects and complications of epidural anesthesia is an important part of making informed healthcare decisions. While serious complications are rare, being aware of the possible risks allows patients to have meaningful discussions with their healthcare providers and make choices that best suit their individual needs and circumstances. As with any medical procedure, the key is to balance the potential benefits with the possible risks, always keeping the patient’s overall health and well-being at the forefront of decision-making.

Side effects of an epidural

Epidurals are usually safe, but as with all medical treatments, side effects and complications can sometimes happen.

For more on side effects of epidurals in labour, read about pain relief in labour. 

Low blood pressure

It’s normal for your blood pressure to fall a little when you have an epidural. Sometimes this can make you feel sick.

Your blood pressure will be closely monitored. If necessary, fluids and medicine can be given through a drip to keep your blood pressure normal.

Loss of bladder control

After having an epidural, you may not be able to feel when your bladder is full because the epidural affects the surrounding nerves.

A catheter may be inserted into your bladder to allow urine to drain away. Your bladder control will return to normal when the epidural wears off.

Itchy skin

This can be a side effect of the pain relief medicines that may be used in your epidural.

Medicine can be given to help the itching, or the medicine in the epidural can be changed.

Feeling sick

Feeling sick (nausea) is less common with epidural medicines than with other pain relief medicines such as morphine and other opiates.

It can be treated with anti-sickness medicines, or by raising your blood pressure if it’s low.

Inadequate pain relief

The epidural may not block all your pain. You may be offered an extra, or alternative, pain relief method.

Headache

A severe headache can happen if the bag of fluid that surrounds your spine is accidentally punctured. You may need specific treatment for the headache.

A procedure known as a blood patch may be used to seal the puncture. It involves taking a small sample of your blood and injecting it into the puncture.

When the blood thickens (clots), the hole will be sealed and your headache will stop.

Not all headaches from an epidural require a blood patch. Your anaesthetist will discuss your options with you.

Slow breathing

Occasionally, some medicines used in an epidural can cause slow breathing or drowsiness.

You will be monitored closely to look for this, and it can be treated easily.

Temporary nerve damage

The needle or epidural tube can damage nerves, but this is uncommon. Nerve damage can cause loss of feeling or movement in parts of your lower body.

The most common symptom is a small, numb area with normal movement and strength. This usually gets better after a few days or weeks, but can sometimes take months.

Infection

An infection can sometimes happen around the skin next to the epidural tube.

It’s rare for the infection to spread. Antibiotics may be necessary or, rarely, emergency surgery.

Permanent nerve damage

In rare cases, an epidural can lead to permanent loss of feeling or movement in, for example, 1 or both legs.

The causes are:

• direct damage to the spinal cord from the epidural needle or catheter
• infection deep in the epidural area or near the spinal cord
• bleeding in the epidural area, causing pressure on the spinal cord
• accidentally injecting the wrong medicine into the epidural catheter

These are rare events, and anaesthetists have extensive training to reduce the chances of these complications.

Nerve damage can also happen for other reasons during surgery, which are unrelated to the epidural.

Other complications

Other, very rare, complications of an epidural include:

• fits (convulsions)
• severe breathing difficulties
• death

Before deciding to have an epidural, you should discuss the procedure with your anaesthetist.

They can provide further information and advice on the risks of developing complications.

Page last reviewed: 01 February 2023
Next review due: 01 February 2026

11 Risks of Epidurals During Delivery: Itching, Fever, and More

11 Risks of Epidurals During Delivery: Itching, Fever, and More

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Medically reviewed by Karen Gill, M. D. — By The Healthline Editorial Team on February 9, 2018

What is an epidural block?

The act of delivering a baby lives up to its name. Labor is hard, and painful, work. To make the experience more comfortable, women have a few options for pain relief, including epidurals and spinal blocks. Here’s how they’re different:

• Epidural block. For women in the United States, this is the most commonly used form of pain relief during labor. It combines analgesic and anesthetic pain relievers, which are delivered through a tube in your back. The medication blocks pain signals before they can get to your brain. Once you’ve had the injection, you’ll lose some feeling below the waist, but you’ll be awake and able to push when the time comes.
• Spinal block. A spinal blockalso numbs you from the waist down, but the medication is delivered via a shot into the fluid around your spinal cord. It works quickly, but the effects only last for an hour or two.
• Combined spinal-epidural block.This option offers the advantages of both types of anesthesia. It goes to work quickly. The pain relief lasts longer than a spinal block alone.

Both epidural blocks and combined spinal-epidural blocks make labor a less laborious and painful experience, but they’re not risk-free. These drugs can have side effects, such as low blood pressure, itching, and headache. Though rare, some side effects associated with epidurals can be serious.

Being aware of these side effects ahead of time can help you decide which option to choose.

What are the common side effects?

Common side effects range from itching to difficulty urinating.

Itching

Some of the medications used in an epidural — including opioids — can make your skin itch. A change in medication can relieve this symptom. Your doctor might also give you medication to relieve the itch.

Nausea and vomiting

Opioid pain relievers can sometimes make you feel sick to your stomach.

Fever

Women who get an epidural sometimes run a fever. According to PubMed Health, about 23 percent of women who get an epidural run a fever, compared to about 7 percent of women who don’t get an epidural. The exact reason for the spike in temperature is unknown.

Soreness

After your baby is born, your back might feel sore, but the feeling should only last for a few days. Back pain is also a common side effect of pregnancy, as the weight of your belly puts extra strain on your back. Sometimes it’s hard to tell whether the cause of your soreness is the epidural, or residual strain from the added weight of pregnancy.

Low blood pressure

About 14 percent of women who get an epidural block experience a drop in blood pressure, although it’s usually not harmful. An epidural block affects nerve fibers that control muscle contractions inside the blood vessels. This causes the blood vessels to relax, lowering blood pressure.

If the blood pressure drops too low, it can affect blood flow to your baby. To reduce this risk, most women get intravenous (IV) fluids before the epidural is placed. Your blood pressure will also be checked during labor. You’ll get medication to correct it, if needed.

Difficulty urinating

After an epidural, the nerves that help you know when your bladder is full will be numb. You may have a catheter inserted to empty your bladder for you. You should regain bladder control once the epidural wears off.

What are the rare side effects?

Rare side effects associated with epidurals range from breathing problems to nerve damage.

Breathing problems

In rare cases, the anesthetic can affect the muscles in your chest that control breathing. This can lead to slowed breathing or other breathing problems.

Severe headache

If the epidural needle accidentally punctures the membrane covering the spinal cord and fluid leaks out, it can cause a severe headache. This only happens in about 1 percent of deliveries with epidurals, according to the American Society of Anesthesiologists. The headache is treated with oral pain relievers, caffeine, and plenty of fluids.

If these doesn’t relieve the headache, the doctor performs a procedure called an epidural blood patch. A small sample of your blood is injected into the hole. When the blood clots, the hole closes and the headache should stop. Most new mothers get relief within one or two hours of having this procedure.

Infection

Any time you create an opening in the skin — such as with a needle — bacteria can get inside and cause an infection. It’s rare to have an infection from an epidural. This is because the needle is sterile and your skin is cleaned before it’s inserted. However, it can happen. The infection can spread to other parts of your body, too, but this is even more rare.

Seizure

In rare cases, an epidural can trigger a seizure if the pain medication gets into your vein. A seizure is shaking or convulsions due to abnormal electrical activity in your brain.

Nerve damage

The needle used to deliver the epidural can hit a nerve, leading to temporary or permanent loss of feeling in your lower body. Bleeding around the area of the spinal cord and using the wrong medication in the epidural can also cause nerve damage.

This side effect is extremely rare. It affects only 1 in 4,000 to 1 in 200,000 people who have an epidural block, according to the American Society of Regional Anesthesia and Pain Medicine.

Let your anesthesiologist know right away if you have symptoms such as numbness or tingling after the epidural is supposed to have worn off.

Epidurals and assisted births

Having an epidural can increase the amount of time you spend in the second stage of labor. This stage starts when your cervix is fully dilated and ends when your baby is born. Women who have an epidural can spend an extra hour in this stage of labor.

When your labor progresses too slowly, your doctor is more likely to recommend help getting your baby out. Past research showed that women who got epidurals were more likely to need a cesarean delivery. More recent studies find that this may not be true, but you may be more likely to need an assisted delivery with a vacuum or forceps if you have an epidural.

In one study done in Great Britain, the instrument-assisted delivery rate was 37.9 percent in women who’d had an epidural, compared to 16.4 percent in those who didn’t.

What’s the outlook?

Most risks from epidurals are either mild or rare. If a highly trained anesthesiologist performs your epidural or spinal block, your odds of having a complication decrease.

Meet with your anesthesiologist before your due date. Ask about their experience. Work together to create a pain relief plan that works for you.

Remember that you do have other choices besides an epidural for pain relief. Some techniques involve medication, while others are natural. Labor pain relief options include:

• deep breathing techniques
• acupuncture and acupressure
• relaxation exercises
• support from a doula or labor coach
• water immersion
• inhaled pain medication, such as nitrous oxide
• opioids

Talk to your doctor about the advantages and disadvantages of each technique. Medication provides the greatest pain relief, but it can cause side effects. Natural techniques will help you avoid side effects, but they may not cut through your pain. Make the decision based on your personal preferences and ability to tolerate pain.

Last medically reviewed on February 9, 2018

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How we reviewed this article:

Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. We avoid using tertiary references. You can learn more about how we ensure our content is accurate and current by reading our editorial policy.

• Anaesthetic, epidural. (n.d.).
  hse.ie/eng/health/az/A/Anaesthetic,-epidural/Risks-and-side-effects-of-an-epidural.html
• Antonkou A, et al. (2016). The effect of epidural analgesia
  on the delivery outcome of induced labour: A retrospective case series. DOI:    
  10.1155/2016/5740534
• Epidural: Side effects. (2017).
  nhs.uk/conditions/epidural/side-effects/
• Jones L, et al. (2012). Pain management for women in labour:
  An overview of systematic reviews. DOI:
  10.1002/14651858.CD009234.pub2
• Mayo Clinic Staff. (2017). Labor pain: Weigh your options
  for relief.
  mayoclinic.org/healthy-lifestyle/labor-and-delivery/in-depth/labor-pain/art-20044845
• Mayo Clinic Staff. (2015). Spinal headaches.
  mayoclinic.org/diseases-conditions/spinal-headaches/symptoms-causes/syc-20377913
• Medications for pain relief during labor and delivery.
  (2017).
  acog.org/Patients/FAQs/Medications-for-Pain-Relief-During-Labor-and-Delivery
• Potential epidural side effects and risks. (n.d.).
  asahq.org/lifeline/what%20to%20expect/potential%20epidural%20side%20effects%20and%20risks
• Pregnancy and birth: Epidurals and painkillers for labor
  pain relief. (2012).
  ncbi.nlm.nih.gov/pubmedhealth/PMH0072751/
• Risks and benefits of regional anesthesia. (n.d.).
  asra.com/page/43/risks-and-benefits-of-regional-anesthesia
• Safe prevention of the primary cesarean delivery. (2014).
  acog.org/Clinical-Guidance-and-Publications/Obstetric-Care-Consensus-Series/Safe-Prevention-of-the-Primary-Cesarean-Delivery

Our experts continually monitor the health and wellness space, and we update our articles when new information becomes available.

Current Version

Feb 9, 2018

Written By

The Healthline Editorial Team

Edited By

Nizam Khan (TechSpace)

Medically Reviewed By

Karen Richardson Gill, MD

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Medically reviewed by Karen Gill, M.D. — By The Healthline Editorial Team on February 9, 2018

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All about epidural anesthesia – Private maternity hospital Ekaterininskaya Clinics

What to do if long-term epidural anesthesia (analgesia) is contraindicated for you or you for some reason do not want to do it during childbirth?

There is, in fact, only one real alternative – childbirth can be anesthetized with narcotic analgesics (usually fentanyl or promedol).

In certain situations (regular strong contractions, good dilatation of the cervix, satisfactory condition of the child according to ultrasound and CTG), it is safe and effective.

But, firstly, the duration of the effective action of narcotic analgesics in childbirth is much shorter (from 30 minutes to 1 hour) than the duration of the effect of DEA. Secondly, the possibility of prolonging such pain relief is significantly limited, since high doses of narcotic analgesics increase the risk of respiratory depression in mother and child. This method is usually used when there are contraindications to DEA.

There are no medical procedures that do not carry potential risks and have no contraindications for the patient. Long-term epidural anesthesia (DEA) is no exception, and it would be irresponsible not to talk about them.

What are the contraindications for DEA?

• Injuries of the spine and metal structures in the lumbar region, some congenital diseases of the spine and severe forms of curvature (scoliosis).
• Severe disorders of blood coagulation in the direction of reducing the density of the blood clot (hypocoagulation).
• Allergy to local anesthetic ropivacaine (very rare).
• Severe heart disease with fixed cardiac output.
• Tattoo in the lumbar region (the paint may contain salts of heavy metals, the entry of which into the epidural space is highly undesirable).
• The categorical written refusal of the patient from DEA (with justification of the reasons for the refusal).

What is the risk of complications and side effects with DEA?

• Insufficiently effective pain relief (mosaic block).
• Unintentional puncture of the dura mater with the development of post-puncture headache syndrome.
• Sudden drop in blood pressure.
• Nausea, vomiting, chills.
• Post-puncture back pain.
• Respiratory and cardiac arrest.
• Urinary retention and dysfunction of the pelvic organs.
• Development of persistent neurological complications in the form of paresis and paralysis.

A very impressive and intimidating list, especially the second half of it.

But according to world statistics for the 1990-2000s, the risk of fatal complications of regional anesthesia (DEA is a regional method) is 25-38 cases per 10 million obstetric patients, and does not differ significantly from the risk of general anesthesia.

The risk of developing any complications of EA (not only fatal, but generally all) is higher, but it is also quite low, and, according to various estimates, is 1 case per 50,000-80,000 births. This risk is about 8-10 times less than the risk of dying in an accident (driver, passenger or pedestrian).

Despite the impressive list of contraindications and risks, there are many undeniable advantages of using long-term epidural anesthesia (DEA).

There is practically no effect on the child – the area of ​​action of the anesthetic is limited to the nerve roots of the spinal cord of the woman in labor; neither the blood flow in the umbilical cord nor the fetal heart rate is affected by DEA performed in compliance with all safety rules.

If the situation in labor is such that there is an indication for an emergency caesarean section, an epidural catheter inserted in labor allows you to quickly inject a large dose of anesthetic (about 4 times more than for pain relief in labor), adequate for a caesarean section – and more one significant plus DEA. This is called “conversion of analgesia to anesthesia”.

In such a situation, drugs for general anesthesia are either not used at all, or are used in small doses (depending on the situation), which significantly reduces the burden on the body of the mother and child, and allows the patient to recover faster after the operation. DEA lowers blood pressure by 15-20 percent of baseline, and in patients with high blood pressure, it is a real lifesaver.

What can be said in conclusion of this large, complex and rather acute topic?
⠀
Absolutely safe medical manipulations with a degree of risk equal to zero do not exist in principle. But compliance with all the rules, safety precautions, indications and contraindications allows you to reduce the risk to an insignificant minimum. Epidural anesthesia, like any other medical manipulation, is performed when the potential benefit significantly (hundreds and thousands of times) exceeds the possible risks. And in the vast majority of cases, that is exactly what it is. One of the most important tasks of the anesthetist is to assess the risk-benefit ratio for each individual patient, and convey this information to the patient so that she understands it and can make the right decision.
⠀

articles of Oxford Medical Rivne Medical Center

Modern medical statistics show that about 7% of patients have a partial or complete allergy to local anesthesia (anesthetics). The rejection of the body is caused not by the injections themselves, but by the chemicals that make up this or that anesthesia.

Paradoxically, even the safest and most common lidocaine can cause a serious allergic reaction in a certain category of people, which can only be detected experimentally. We are talking about urticaria, various dermatological rashes, a critical deterioration in well-being and even the risk of anaphylactic shock.

The cause of an allergic reaction

Recognizing an allergic reaction to a harmless anesthetic that has been successfully used by thousands of doctors around the world is quite simple. However, first you need to deal with the nature of the problem itself, because in most people local anesthesia does not cause any negative consequences and rejection of the immune system.

Any anesthetic substance is, in fact, an irritant for the body. Most often, the body successfully fights the administered dosage, however, in some cases, sensitization occurs, due to which the immune system begins to perceive the anesthetic as a serious irritant. With subsequent “acquaintances” with the drug, the body rapidly produces antibodies, and signs of a formed allergy appear on various parts of the body: skin, nasopharynx, mucous membranes, on the surface of the bronchi and lungs.

Symptoms of drug allergy to anesthetics

Most often, allergy to anesthetic drugs manifests itself in the following reactions:

• dermatitis in various forms – redness, peeling, deterioration of skin tone;

• urticaria, in which the size, nature and total number of wheals may vary;

• allergic rhinoconjunctivitis with copious nasal and eye discharge;

• bronchospasm, the nature of which is similar to acute attacks of bronchial asthma;

• angioedema following urticaria;

• acute attack of anaphylactic shock.

The best (and sometimes the only) way to check the patient’s response to lidocaine and other local anesthetics is a test performed using a subcutaneous injection of a microdose of the substance (no more than 0. 1 ml).

First aid for anaphylactic shock

Anaphylactic shock is an allergic reaction of the body to the injected drug, which is characterized by a state of hypersensitivity of the body. This reaction is dangerous with the risk of death in the absence of immediate medical care: according to medical statistics, an acute attack of anaphylactic shock as one of the types of drug allergy has 5-10% of cases of sudden death of a patient.

Anaphylactic shock occurs in 0.03-0.05% of cases of anesthetic administration, but the risk is real and exists. There is a percentage of people in whom the test does not cause any reactions, or has a delayed effect. Therefore, unfortunately, not a single person is immune from anaphylaxis.

Oxford Medical Center doctors are theoretically and practically trained to provide emergency medical care for various conditions.

Our offices are equipped with modern equipment for diagnosing health conditions, as well as all the necessary medicines and means for emergency treatment and removing the patient from a state of shock.