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Pain Relief After Surgery
After your operation the healthcare team wants you to be as comfortable as possible. This document gives you information about the various forms of pain relief that you may be offered. Although none of them can be guaranteed to make you absolutely pain-free, they should help you not to be in a lot of pain after your operation.
Before your operation your nurse or anaesthetist (doctor trained in anaesthesia) will be able to tell you which forms of pain relief are recommended for you. However, it is your decision on the forms of pain relief to use. This document will give you information about the benefits and risks to help you make an informed decision. If you have any questions that this document does not answer, you should ask your anaesthetist or any member of the healthcare team.
Why do I need pain relief?
Operations cause pain. People who have good pain control after their operations are less likely to suffer from heart attacks, chest infections and blood clots. They also get up and about more quickly and may get home sooner. So being brave and putting up with a lot of pain may cause more harm than good. If you are in a lot of pain, ask for some pain relief.
1 Simple Painkillers
You can use these drugs on their own or combined with other painkillers. After your operation you should use simple painkillers regularly such as Paracetamol, anti-inflammatory drugs (for example, Ibuprofen and Diclofenac) and codeine or similar drugs (for example, Dihydrocodeine, Oxycodone and Tramadol). Although these drugs may not completely treat your pain, if you take them regularly they reduce the amount of other painkillers you might need.
Some people cannot take simple painkillers for various reasons. It is important that you let your anaesthetist know before your operation if you have had any problems with these types of drugs before, or if you have a history of stomach ulcers, kidney damage, bleeding or asthma.
What complications can happen?
The risks with simple painkilling drugs are small.
• Paracetamol is exceptionally safe in normal doses.
• Anti-inflammatory drugs can sometimes cause stomach irritation. This can be more severe with ulcers or stomach bleeding (risk: 1 in 200 if taken for one month).
• Anti-inflammatory drugs can make asthma worse, but most people with asthma are not affected.
• Codeine or similar drugs can make you feel sick or light-headed. They can make you itch and almost always cause some degree of constipation.
2 Morphine and Similar Drugs
For more severe pain you may be prescribed morphine or similar drugs such as Pethidine, Diamorphine or Oxycodone.
Intravenous delivery (using a drip)
The most common intravenous delivery is a technique known as patient-controlled analgesia or PCA. This involves connecting a special pump, containing the drugs, to a drip (small tube) in one of your veins. The pump has a button that you will be given to hold and when you press the button a small dose of drugs will be given. The pump has several safety features so that you cannot overdose by accident. The drugs tend to make you sleepy, so if you do have more than you need, you are likely to fall asleep and not press the button for a while.
It is important that you are the only person allowed to press the button. A nurse will, if possible, show you the pump before you have your operation so that you can be confident in how to use it. If you think you may not be able to press the button (for example, if you have arthritis), let the nurses know as they may be able to provide a button that is easier to use.
Using PCA is simple. If you are in pain, or you think you might be in pain soon, press the button. If you are comfortable, do not press the button.
Other ways of giving morphine and similar drugs
The drugs can be given by injection either under the skin (subcutaneous or ‘sc’) or into the muscle (intramuscular or ‘im’). If it is given by injection under the skin, a small plastic tube (similar to a drip) is sometimes left under the skin to avoid repeatedly inserting a needle. The drugs can also be given by mouth once you are eating and drinking normally.
Is patient-controlled analgesia better than injections?
Most people prefer PCA to injections. At busy times the nurses may not be able to respond to your request for pain relief straightaway. However, there is nothing to show that pain relief is better with one technique or another. PCAmay not be suitable for some people, such as the very young or the elderly. Your anaesthetist will discuss this with you.
What complications can happen?
Although they are effective painkillers, morphine and similar drugs do have side effects.
• Itching is common but not usually severe. It can often be treated if it is a major problem.
• Constipation is common but responds well to normal laxatives or increased diet of fruit and vegetables.
• Sickness or feeling sick is more common after certain operations than others. It can usually be treated. There is no benefit in stopping taking the drugs that are giving you pain relief as pain itself can make you feel sick. It is usually better to take anti-sickness medication along with the drugs for pain relief.
• Respiratory depression, where your breathing slows down too much. Serious complications are rare. Nurses will closely monitor your oxygen levels and will give you oxygen if you need it.
• Confusion is quite common after operations and morphine may contribute to this. This is more likely in elderly people. Any confusion will not be permanent.
3 Epidural Anaesthetic
Some people may be offered epidural pain relief after their operation. Epidural pain relief involves inserting a fine catheter (small tube) into an area called the epidural space in your back. All your nerves pass through this space. Local anaesthetics and other painkilling drugs are injected down the catheter into the epidural space to numb your nerves. Your anaesthetic will be given to you by an anaesthetist (doctor trained in anaesthesia). The anaesthetist is usually assisted by a specially-trained healthcare practitioner (either a nurse or an operating department practitioner).
An epidural has three main effects.
• Pain relief – The epidural numbs the sensory nerves responsible for pain and touch. This provides pain relief but can also make the area feel numb or heavy. Sensory nerves are more easily affected than movement nerves, so sometimes you can be numb but still able to move your legs.
• Weakness – The nerves supplying muscles may also be affected. This can make it difficult for you to move your legs. It may also make it difficult for you to pass urine properly.
• Low blood pressure – The nerves that help to control blood pressure are the most easily affected. You may not be aware of this happening, but the anaesthetist will be monitoring you closely for any problems with low blood pressure.
Epidurals provide good pain relief but, like other forms of pain relief, cannot guarantee that you will be pain-free. Sometimes the drugs are injected continuously (called an infusion) and, if needed, the dose varied by the nurses. As well as continuous infusion you can sometimes have a button that allows you to `top up’ the epidural by giving a small, safe dose when you need it. This system is designed to prevent too much being given.
What complications can happen?
Your anaesthetist will try to make your anaesthesia as safe as possible. However, complications can happen. A serious complication happens in about 1 in every 3,600 epidurals. The possible complications of an epidural anaesthetic are listed below. Any numbers which relate to risk are from studies of people who have had an epidural anaesthetic. Your anaesthetist may be able to tell you if the risk of a complication is higher or lower for you.
• Low blood pressure (risk: 1 in 30). This is easily treated.
• Headache, if the bag of fluid around the spinal cord is punctured (risk: 1 in 100). This can be treated if needed.
• Respiratory depression, where your breathing slows down too much (risk: 1 in 400). Nurses will closely monitor your oxygen levels and will give you oxygen if you need it.
• Infection around the spine (risk: 1 in 3,000).
• Cardiac arrest (where the heart stops working), due to the local anaesthetic (risk: 1 in 10,000).
• Seizures, caused by the local anaesthetics (risk: 1 in 10,000). These are usually temporary.
• Unexpected high block, if the local anaesthetic spreads beyond the intended area (risk: 1 in 18,000). This can make breathing difficult, cause low blood pressure and rarely cause unconsciousness. You may be transferred to the high-dependency unit or the intensive care unit so you can be monitored closely.
• Short-term nerve injury, which recovers fully (risk: 1 in 5,000).
• Blood clot around the spine (risk: 1 in 10,000).
• Damage to nerves supplying the bladder and bowel (risk: 1 in 30,000).
• Paralysis (risk: 1 in 100,000). This can be caused by infection, bleeding near the spinal cord or injury to the spinal cord. Epidural anaesthetic and associated complications are explained more fully in the information document called ‘Epidural Anaesthetic’.
Pain after an operation is a common problem but there is no need for you to be in a lot of pain. Pain relief after surgery is usually safe and effective. However, complications can happen. You need to know about them to help you make an informed decision about surgery and pain relief. Knowing about them will also help to detect and treat any problems early.
• NHS smoking helpline on 0800 169 0 169 and at www.gosmokefree.co.uk
• www.eatwell.gov.uk – for advice on maintaining a healthy weight
• www.eidoactive.co.uk – for information on how exercise can help you
• www.aboutmyhealth.org – for support and information you can trust
• Association of Anaesthetists of Great Britain and Ireland at www.aagbi.org
• Royal College of Anaesthetists at www. rcoa.ac.uk
• Royal College of Anaesthetists and Association of Anaesthetists of Great Britain and Ireland at www.youranaesthetic.info
• NHS Direct on 0845 46 47 (0845 606 46 47 – textphone)
You can get information locally by contacting the your own hospital or treatment centre. This document is intended for information purposes only and should not replace advice that your relevant health professional would give you.
Disclaimer: The views expressed in this article are not necessarily those of Orthopaedic Opinion Online or the author. The information is provided for general background reading only and should not be relied upon for treatment. Advice should always be taken from a registered medical practitioner for individual circumstances and for treatment of any patient in any circumstances. No liability is accepted by Orthopaedic Opinion Online, or the author in respect to the information provided in respect of the content or omission or for any reason or as a result of treatment in individual circumstances. This information is not for use in the USA.