Wednesday, March 25, 2009

Pain relief.

We expect it to be painful when someone slices your tummy open. I remember seeing a war film once where the soldiers hit the ground when showered with machine gun bullets. After the shooting stopped the sergeant told his men to start moving out, only to be greeted by one of his men asking, "What shall I do with these?" as the camera panned down to his abdomen where he held several coils of intestine in his hand. The very thought makes many people squirm, but it is just what an abdominal operation involves.

Naturally, some form of pain relief is necessary, and the best form is an epidural which stops the messages from nerve to brain, for although it seems as though we feel the pain in our tummy, in reality it is the brain that really does the feeling. Almost all other forms of pain relief involve impairing the function of the brain, sometimes so much that we are rendered unconscious.

It is also true that most forms of pain relief have serious side effects. Morphine and other opiates induce nausea and vomiting, suppress the cough reflex, slow down the bowel causing constipation and in large doses suppress the respiratory center causing one to stop breathing. The non-steroidal anti-inflmmatories can cause mucosal ulceration and depending whether they are cox-1 or cox-2 inhibitors affect the clotting mechanisms, either by leading to bleeding (cox-1) or thrombotic (cox-2). The one drug that is pretty free of side effect is acetaminophen (paracetamol), but overdoses (greater than 15 g or 30 tablets) are fatal, causing liver damage. Standard hospital guidelines allow a safety margin and require anti-poisoning measures after 24 tablets, but strangely the maximum permitted therapeutic dose in hospital in 8 tablets.

Since normally the required dose for pain relief is 2 tablets every 4 hours, this leaves anyone who is kept awake by pain with nowhere to go in the middle of the night. This happened to me. My pain was adequately controlled by paracetamol, but at 4 in the morning I needed another dose. The nurse informed me that I was not allowed any more paracetamol for another hour, but I could have some morphine.

I didn't blame the nurse, she was only obeying her instructions, but I do blame whoever wrote the instructions. It was not a local decision it is a central NHS decision. The maximal allowable dose is just one third of the toxic dose - even when there is a built in safety margin - and did I mention that there is a perfectly adequate antidote for paracetamol?

Had I been at home I could have taken paracetamol with impunity. As it was I suffered for another hour.


Anonymous said...

I have always felt that pain was a very personal "thing".

In the US, there has been quite an emphasis of adequate pain control in recent years, to the point where the nursing staff (and , in turn, the patients) obsess about their pain levels (what # from 1 to 10 is your pain level?).

One of my frustrations as a physician has been dealing with the over use of analgesics and the complications that they cause, from hepatic dysfunction, to renal impairment, to gastrointestinal ulcerations, diarrhea, constipation, alterations of mental status, etc.

I have been given narcotic analgesics on several occasions and always found that the nausea that they induced was worse than the pain for which they were given.

My one experience with post-operative PCA was comical. I had had major surgery and when my partner came to visit me a few hours after I had been returned to my room the nausea was reaching a crescendo. I was appreciative of his visit, but morbidly fearful that I would vomit on him at any moment.

Finally I turned the pump off myself and asked the nurses to disconnect it entirely after he left to continue his rounds. My wife did not approve, but she wasn't the one with the nausea!

After that I took several doses of Toradol (a potent NSAID-analgesic) and made a point of negotiating with the nursing staff to give me the Toradol as well as a hypnotic for sleep prior to going to sleep. This managed to hold me during the two nights of post-operative hospital care.

When I was discharged , my surgeon wanted to give me a narcotic analgesic to have. I negotiated this down to a synthetic narcotic analog which I never took. The combination of acetemenophen and naproxen proved to be more than adequate.

For any lay people reading this who are interested, I would suggest "negotiating" with the health care to minimize the use of analgesics when possible and to consider combining them as appropriate to garner the desired effect with the least disturbance to other bodily functions, including sleep!

I hope that improvement continues,


Anonymous said...

Just out of curiosity, would an epidural provide good (ie both safe and effective !) pain relief for someone who has chosen to donate part of their liver, in the immediate post-donation period ? Or would the incision needed in this case mean that a block would need to be impossibly high ?

We have a family member who is considering being a "living liver" donor to another family member in the near future......

Terry Hamblin said...

Elizabeth, you would have to ask the anestnesiologist.

Anonymous said...

Oh boy, yes, I remember the pain from two C-Sections. It is intense and the Drs. will tell you not to pick up anything over 10 pounds until you heal. Well, with babies weighing in at 10.8 pounds, I found that not negotiable. Try breast feeding immediately after abdominal surgery. At least I had a new, fresh little face to look at while I hit the morphine button!
Feel better soon.

Jenny Lou

Goosey said...

I was so interested to read your comments on pain relief, I spent many years working in an acute ward as a staff nurse and was stuck with these 4 hour windows of pain control. I once, on night shift gave an elderly lady another dose of Oramorph 2.5mg,before the 3-4 hours was up. She was clearly in pain and she was settled and able to get a little sleep after the second dose, I had tried to contact the on-call Dr but they were very busy.For my troubles I was reported and had to visit my seniors.
I now work in a Hospice and pain control is so different, no-one is ever left in pain and our Consultant is happy for us to phone any time day or night if we cannot make someone comfortable.
I realise you wrote this a while ago and I don't know if you will see this but felt I wanted to comment.