Pain Control After Surgery

You may be surprised where you experience pain after surgery. Quite often, the incision is not the only area of discomfort. You may or may not feel the following:

• Muscle pain - Pain in the neck, shoulders, back, hips, arms, legs or chest from lying on the operating table, or prolonged bed rest.
• Throat pain - Your throat may feel sore or scratchy with some hoarseness if a breathing tube was used in the operating room.
• Movement pain - Sitting up, walking, and coughing are all very important recovery steps after surgery, but they may cause increased pain at or around the surgical site. Your doctors, nurses and therapists will set safe limits on your activity.

Good communication is the most important aspect of pain management. Please tell your nurse when you are having pain. Patients should never feel as though they are being a "bother." When pain increases, this may signal a need for more medication, or a different option altogether.

You will be frequently asked by the medical staff to rate your pain. This is done on a scale of 0-10. Our scale sets "0" as no pain and "10" the worst pain you can imagine.

Reporting your pain as a number helps the doctors and nurses judge how well your treatment is working and whether to make any changes. Patients quite often have a hard time converting their pain to a number, especially in the upper range.

We tell patients at a level of "7" it becomes difficult to focus on activities other than your pain, such as watching TV or working on a computer. Our table below gives facial expressions of what various numbers may look like. The number you choose is very important, however, and our ultimate goal is to put you in the best condition to walk, cough, deep breathe and safely recover from surgery.

Based on the type of surgery and a review of your medical history, the surgeon will have a pain management plan. Before surgery, an anesthesiologist will review your medical history, perform an exam, and then discuss your anesthetic options. This will include pain management during and after surgery.

The anesthesiologist may choose to consult the Acute Pain Service (APS) to help manage your pain following surgery. Doctors and pharmacists with this service are specially trained in the types of pain control options described on the next several pages. Remember, you are the one who ultimately decides which pain control option is chosen.

After surgery, you will be continually assessed to ensure your comfort. If necessary, new options and adjustments to your pain management regimen will be made.

Patient-Controlled Analgesia (PCA) is a computerized pump that safely permits you to push a button and deliver small amounts of pain medicine into your intravenous (IV) line. No new needles are injected into your skin or muscle for this. PCA provides stable pain relief in most situations. Many patients like the sense of control they have over their pain management without having to ask a nurse for each dose.

The PCA pump is programmed to give a certain amount of medication when you press the button. It will only allow you to have so much medication, no matter how often you press the button, so there is little worry that you will give yourself too much. The amount of medicine can be adjusted at any time based on your response.

We caution patients against a family member pushing the PCA button. Sedation is a side effect of the pain medications and may signal reaching the maximum safe dosage. Additional doses at this point may be dangerous.

Many people are familiar with epidural analgesia. It is commonly used to control pain during childbirth. Postoperative epidural analgesia uses a pump to continuously deliver pain medicine into the spine through a very thin catheter taped to your back. During labor, epidural analgesia will help block the pain of incisions anywhere below the neck.

Placing the epidural catheter usually causes no more discomfort than having an IV inserted. Before placement, a sedating medication may be given through your IV to help you relax. The skin of your back is cleaned with a sterile solution and numbed with a local anesthetic.

Next, a thin needle will be carefully inserted between the vertebrae into an area called the "epidural space." The catheter is then passed through the needle into the epidural space, and the needle is then removed. During and after your surgery, pain medications can be infused through this epidural catheter with the goal of providing you excellent pain control when you awaken. If additional pain medication is required, we can increase the dosage of the epidural or supplement with IV medications.

We feel epidural analgesia is more effective in relieving surgical pain than intravenous medication. There is less sedation and the numbing effect on nerves provides greater ability to cough, deep breathe and walk. For postoperative patients, epidural analgesia may reduce the risk of serious complications such as blood clots and pneumonia.

Patients who may not be a candidate for epidural placement include:

• Those with an infection in their blood or on their back
• Those with very low blood pressure
• Patients who have thinned blood
• Patients with a history of major back surgery

Epidural analgesia is safe, but like any procedure or therapy, it is not risk free. Sometimes the epidural does not adequately control pain. In this situation, you will be given additional treatments or be offered a replacement of the epidural. Nausea, vomiting, itching, and drowsiness can occur. Occasionally, numbness and tingling or weakness of the legs can occur but this disappears after the medication is reduced or stopped. Headaches can occur, but this is rare. Severe complications, such as nerve damage and infection, are extremely rare.

You may be offered a nerve block to supplement your pain control after surgery. Whereas an epidural controls pain over a broad area of your body by blocking multiple nerves in the spine, a single nerve block is used to treat a smaller region of your body, such as an arm or leg. Usually a catheter is placed near the nerve and connected to a pump for uninterrupted delivery of pain medicine.

There are several potential advantages of a nerve block. Its main goal is to provide a significant reduction in the amount of narcotic medication used after surgery while increasing overall mobility. This may result in fewer side effects, such as nausea, vomiting, itching, and drowsiness. All injection therapy has risk involved. Our anesthesiologists use ultrasound-visual guidance when placing postoperative nerve blocks and catheters. We feel this increases the success of the block while minimizing traumatic complications.

You, your anesthesiologist, and surgeon will decide before surgery if a nerve block is a suitable pain management option for you.

At some point during your recovery from surgery, your doctor will order pain medications to be taken by mouth (oral pain medications). These may be ordered to come at a specified time, or you may need to ask your nurse to bring them to you. Make sure you know if you need to ask for the medication! Most oral pain medications can be taken every four hours.

Important! Do not wait until your pain is severe before you ask for pain medications. Also, if the pain medication has not significantly helped within 30 minutes, notify your nurse. Extra pain medication is available for you to take. You do not have to wait four hours to receive more medication. Most patients will have a backup IV medication ordered when oral medicines are ineffective.

Narcotics IV: Medications such as morphine, fentanyl, hydromorphone

• Benefits: Strong pain relievers. Many options are available if one is causing significant side effects. 
• Risks: May cause nausea, vomiting, itching, drowsiness, and/or constipation. The risk of becoming addicted is extremely rare.

Narcotics by mouth: (Percocet®, Vicodin®, Darvocet®, Tylenol ®)

• Benefits: Effective for moderate to severe pain. Many options available.
• Risks: Nausea, vomiting, itching, drowsiness, and/or constipation. Stomach upset can be lessened if the drug is taken with food. You should not drive or operate machinery while taking these medications.

These medications often contain acetaminophen (Tylenol®). Make sure other medications you are taking do not contain acetaminophen. For adults, a daily acetaminophen dose over 3250 mg can be damaging to the liver. Always ask your medical provider or pharmacist if you have any questions or concerns. Please confirm all medication dosages for pediatric patients.

Non-narcotic Analgesics (Tylenol®, Feverall®)

• Benefits: Effective for mild to moderate pain. They have very few side effects and are safe for most patients. They often decrease the requirement for stronger medications, which may reduce the incidence of side effects. 
• Risks: Liver damage may result if more than the recommended daily dosage is used. Patients with pre-existing liver disease or those who drink significant quantities of alcohol may be at increased risk.

Nonsteroidal Anti-inflammatory Drugs (NSAIDS): ibuprofen (Advil®), naproxen sodium (Aleve®), celecoxib (Celebrex®)

• Benefits:These drugs reduce swelling and inflammation and relieve mild to moderate pain. Ibuprofen and naproxen sodium are available without a prescription, but you should ask your doctor about taking them. They may reduce the amount of opioid analgesic you need, possibly reducing side effects such as nausea, vomiting, and drowsiness. If taken alone, there are no restrictions on driving or operating machinery.
• Risks: The most common side effects of Nonsteroidal Anti-inflammatory medication (NSAIDS) are stomach upset and dizziness. You should not take these drugs without your doctor's approval if you have kidney problems, a history of stomach ulcers, heart failure or are on "blood thinner" medications such as Coumadin® (warfarin), Lovenox® injections, or Plavix®.

There are other non-medication options to relieve pain, and it is important to keep an open mind about these techniques. When used along with, or instead of medication, these techniques can dramatically reduce pain.

Relaxation tapes or guided imagery is a proven form of focused relaxation that coaches you in creating calm, peaceful images in your mind; a "mental escape." For the best results, practice using the tape or CD before your surgery, and then use it twice daily during your recovery. You can get relaxation tapes at a bookstore, or rent CDs from your library. You can bring a battery-operated listening device to the hospital to play prior to surgery and during your hospital stay.

Listening to soft music, watching television, playing video games, or reading may divert your attention from pain.

At home, heat or cold therapy may be an option that your surgeon will choose to help reduce swelling and control your pain. Specific instructions for the use of these therapies will be discussed with you by your surgical team.

If you have an abdominal or chest incision, you will want to splint the area with a pillow or blanket when you are coughing or breathing deeply to decrease motion near your incision.

Always make sure you are comfortable with your treatment plan. Talk to your doctor and nurses about your questions and concerns. This will help avoid miscommunication, stress, anxiety, and disappointment, which may make pain worse. Keep asking questions until you have satisfactory answers. You are the one who will benefit.

You may be given prescriptions for pain medication to take at home. These may or may not be the same pain medications you took in the hospital. Talk with your doctor about which pain medications will be prescribed at discharge. 

IMPORTANT Note: Make sure your doctor knows about pain medications that have been successful or caused you problems in the past. This will prevent possible delays in your discharge from the hospital.