Pain Management – Rebuild

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The Limb Reconstruction Charity at KCH
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Recovery from the surgery fitting the frame is painful, and you will need pain relief immediately after the operation and for several weeks more, at least – possibly longer.

You will, however, be supported by the expert pain team within the limb reconstruction unit, who will advise you on all available methods of pain relief and the most effective way for you to minimise your discomfort.
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Pain relief
You should discuss post-operative pain relief with your anaethesist before the surgery. You may have a PCA (Patient-Controlled Analgesia) device. This allows you to receive strong painkiller directly into the circulation via a pump whenever you require it, simply by pressing a button. You cannot receive too much because the device will be limited by the anaesthetist to a dose which is safe for you. Your surgeon will also put some long-acting local anaesthetic into the wound if this is appropriate. Local anaesthetic catheters (fine tubes) can be useful for reducing the pain from smaller operative sites and you should discuss this with your surgeon. These can be left in for a day or two

What type of drugs are used?
Some procedures are relatively painless and will require only simple analgesia such as Codydramol or Cocodramol (paracetamol and a weak opiate such as morphine type drugs).

We can add in anti-inflammatories such as Ibuprofen (Brufen or Nurofen) or Diclofenac Sodium (Voltarol), but we are keen to avoid these in limb reconstruction since they delay bone healing.

In more major procedures, we will use stronger drugs such as OxyContin, Tramadol, Morphine or Diamorphine. These can have the disadvantage of making some patients feel off their food or nauseous, delirious or sleepy. They can also cause constipation and breathing problems. So we do try to tail these off as soon as possible.

Spinal anaesthetics (epidural) are injections info the spine to make you numb from the waist down. They normally last for two hours. If your operation will take less time, it may be appropriate for the operation period, but it is not usually used for post-operative relief.

An epidural catheter (fine tube) can be inserted around the nerves leaving the spine and left in for a few days, in a similar procedure to the spinal anaesthetic. We try to avoid these in limb reconstruction, because there is a risk that the signs of compartment syndrome could be covered up by the total numbness that results from epidurals. Compartment syndrome is a rare build up of pressure in the leg or forearm that needs to be released immediately. It is only detectable by rising levels of pain.

Further help
While you are in hospital you will have regular visits from the pain teams who will monitor your pain and advise on the particular combination of drugs to manage your pain levels. You will also be sent home with a prescription of your combination of pain relief. Make sure you have the contact details of who you should call if you find are not able to manage your pain when you get home. In an emergency go to your nearest accident and emergency department.
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Will I have pain after my operation?
Yes, unfortunately limb reconstruction surgery is accompanied by pain post-operatively, but there are many available methods of pain relief which you can discuss with your anaesthetist and the pain team.

How can the pain be relieved immediately after my operation?
Post-operative pain relief is tailored to individual patient needs. This can be a combination of different methods that include a PCA, local anaesthetic infiltration or regular opiate-based analgesia orally.

Are there any alternatives to morphine?
Yes, there are other equally strong pain killers such as oxycodone or fentanyl. There are given either into a vein (intravenous) or under the skin (subcutaneous).

Are there any dangers associated with morphine?
Morphine can cause you to become drowsy and your breathing to slow down and become more shallow if you have too much of it. The nurse will check this at regular intervals.

Can I overdose myself with a PCA?
No. If you are using a PCA machine and you become drowsy you will not press the button on the machine. The machine is set to deliver small doses at 10 minute intervals, so you will not overdose yourself. This is called the ‘lock-out’ period. It is most important that you and only you press the button to activate the PCA.

Can I become addicted to morphine?
You should use morphine for as short a time as possible. You will not become addicted to it in a few days. If you need it for longer than 2 weeks you can become tolerant (need more and more to have the same effects) or dependent (withdrawal symptoms such as shivering, shaking and nausea when it is stopped). The pain team nurses and doctors will come and advise you about other pain relieving drugs if your pain is persistent.

Will my pain last for a long time?
This is very variable but, because of the pins and frame, there tends to be pain and discomfort for several weeks.

What can be done to help persistent pain and discomfort?
Less strong pain relieving drugs are used, such as codeine and Tramadol. If these are not strong enough for you a slow acting morphine table taken twice a day by mouth can be used, or a drug called buprenorphine can be given as a skin patch. Paracetamol is safe and this is continued for as long as you need it.
Other drugs, such as Gabapentin and Amitriptyline, are often used for nerve pain.

Can anti-inflammatory drugs such as Ibuprofen (Brufen, Nurofen) and Diclofenac (Voltarol) be used?
No. This group of pain killers is not recommended as there is evidence as they can delay bone healing.

What are the side effects of painkillers?

Nausea, occasionally vomiting (being sick)
Drowsiness
Constipation (you may need laxatives)
Itching all over the body (without a rash)
Difficulty in passing urine (especially if you have a prostrate problem)
Dizziness
Mood changes
Sweating
Headache (Tramadol)

These side effects may pass or you may need to try a different pain killer.
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Drugs like morphine are call opioids. All these drugs lower the hormones in your body after months of use, especially testosterone in men and oestrogens in women. This could have an adverse effect on your bone density which will affect healing, so these drugs should be used for as short a time as possible. Hormone levels should be checked if you are on morphine or similar for several months.

Codeine
Codeine is changed in your liver to morphine, so if you take it in large doses, for example co-codamol 30.500, which contains 30mg codeine and 500mg paracetamol per tablet, it has the same short and long term side effects as morphine, and is very constipating.

Tramadol
Tramadol is classified as a strong opioid analgesic. It has a dual effect, which means that it works partly in the same way as morphine, but also through other chemicals in the nervous system. It can be addictive in some people.
It is best to take all your pain killers in the lowest dose possible and for as short a time as possible, but you should not be afraid to take them as needed immediately after surgery.

Other drugs
Trauma, surgery and the application of limb frames may stretch or damage fine nerves and give rise to nerve pain, called neuropathic pain. This is associated with a burning, stinging feeling on the skin, or sharp stabbing pains which come at any time. There may be numbness, pins and needles or increased sensitivity of the skin to touch, to hot or to cold. This is a normal part of the healing process, but does take weeks or months to settle. The pain team doctors will advise you about drugs, such as Gabapentin, Pregabalin and/or Amitrypyline, which are used for treating nerve pain. Local anaesthetic skin patches, called Versatis, can sometimes be used on areas of sensitive skin or around the pins.
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Physiotherapy can help in reducing your pain after your operation and during the treatment period. Exercise and movement within your pain-controlled limits and as recommended by your Physiotherapist or Consultant are important to help prevent problems from occurring.

The common problems that physiotherapy can help with are:

Muscle contractures and tightness
Joint stiffness
Muscle weakness
Swelling
Poor mobility and walking pattern

If you are taking painkillers make sure you give them enough time to take effect before doing your exercises.

You will be able to move more easily if you pain is well-controlled.

Can I relieve pain without drugs?
Keeping occupied, moving as much as possible, socialising and being with family and friends all help you to cope with the pain. Acupuncture may be helpful but is not recommended until healing of the skin has taken place.
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Depression increases pain, so if you feel you are becoming depressed it’s important to talk about your feelings. As a result of research through the King’s College Hospital IMPARTS (Integrated Mental and Physical Healthcare Research Training and Services) programme, the Limb Reconstruction Unit at KCH has had its long held view confirmed: patients undergoing limb reconstruction surgery have a real need for access to psychological counselling. Rebuild has therefore paid for the development of a patient psychological support service with the assistance of the Consultant Psychiatrist, Matthew Hotopft of the Maudsley Hospital.

Alternatively, if you prefer, a referral can be made by your consultant to your GP.
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