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Anaesthesia for surgery to the hand, wrist and elbow - control of postoperative pain

Many of the operations carried out on the hand and fingers, wrist and elbow take place within 1 – 2 cm of the skin surface.   In these circumstances, there is little disruption to the underlying tissues so the body’s inflammatory response is typically minimal, and any pain is likely to be similarly mild and short-lived.   Thus, most of these operations are suitable to be carried out on a day-case basis and many procedures can be carried out by injecting local anaesthetic (LA) in and around the area of surgery. Fortunately, pain is the easiest sensation to block with local anaesthetic but when the territory of the operation involves the bone itself or the joints, then additional anaesthetic steps, such as general anaesthesia and/or regional anaesthesia (nerve blocks) are required in order to achieve complete anaesthesia.   Using these methods will promote good control of postoperative pain and permit many of these bigger operations to be carried out on a day stay basis.  

The local anaesthetic that we normally use is a long-lasting variety (up to 20 hours) so it is possible that, after the smallest of operations, no pain of any significance may be felt when the LA wears off. Nonetheless we always recommend that you have something suitable available in case of discomfort. The kind of pain killer that you are familiar with and probably already have at home is perfectly appropriate following the smaller operations.   Even though you may have no pain to begin with, it makes sense to take some tablets before the local anaesthetic wears off.   That way it is simple to ‘top-up’ the pain-killing effect rather than starting from scratch.   Obviously the precise situation will vary from one individual to another but please ask for advice if you do not keep any pain killers at home or are not sure what to do.

However the presence of a pre-existing pain problem makes the situation more complicated.   When pain has been present on a daily basis for 3 months or more, it is called chronic pain, (this expression does not in fact refer to the severity but simply means that the pain is persistent).   Chronic pain is often difficult to control because ordinary pain killers can lose their effect over time, and as a separate problem surgical interventions may not completely abolish the pain.

Analgesic Drugs (pain killers)

Simple analgesic drugs are available without a prescription from pharmacies and some supermarkets.   Most people are familiar with one or other of the commonly used favourites.

Ibuprofen (also known as neurofen or advil) is one of the non-steroidal anti-inflammatory drugs (NSAIDS).   It has an excellent record of safety and the maximum daily dose is 3 x 800mg or 4 x 600mg = 2400mg, but usually smaller amounts are adequate for routine postoperative pain relief.   Larger doses can cause irritation of the stomach, as can prolonged use.   About 3% of asthmatics are sensitive to NSAIDS and aspirin; so most asthmatics may be able to safely take NSAIDS on the recommendation of the anaesthetist.   The new generation of NSAIDS are called COX2 inhibitors and can be a useful alternative in some patients but are not recommended for prolonged use.

Paracetamol (Panadol) is free of the common side effects of the NSAIDS.   It also available combined with other mild pain killers.   We find Cocodamol (the addition of a small amount of codeine) useful for many patients.   There is also a strong form of Cocodamol (cocodamol forte) which is only available on prescription.  The adult dose of paracetamol is 1g (2 tablets) x 4 per day. The adult dose of cocodamol is also 2 tablets x 4 per day.   To avoid taking more than this maximum dose, paracetamol and cocodamol must NOT be used together, but either of them can be used in combination with ibuprofen or other NSAIDS.

Codeine phosphate is only available on prescription.   It may be necessary to use this strong pain killer for a few days.   The constipation produced by codeine is best countered with an appropriate laxative.   Tramadol is another strong pain killer that is only available on prescription.   Morphine is used in hospital and is given by nurses as an injection or, when appropriate, controlled by the patient and delivered from a reservoir pump.   Morphine elixir can also be given by mouth if sickness is not a problem.

Chronic Pain is discussed separately.