The Problems of a PCA Pump: Patient Controlled Analgesia Pump
Having steeled myself to have a non-emotional objective perspective on my pain, I took paracetamol regularly and had been able to manage the pain effectively so far. Perhaps on that first morning, I got too complacent in thinking that if this was as bad as it gets, I would be able to cope without too much trouble. While I sat chatting with Rachel, nurses continued to flit in and out, taking my measurements, draining urine from my catheter and asking me about the level of pain I was in.
Pain that first morning
While the pain had been very uncomfortable but manageable it started to worsen significantly around 3 pm that afternoon. The pain was still located in my upper abdomen or lower chest and behind both shoulders. It was uncomfortable to take a deep breath and impossible to cough. The pain I was feeling behind both shoulders left me feeling uncomfortable, uneasy and restless. I thought that moving them could help but it didn’t. As for the pain in my upper abdomen, it was constant and unrelenting.
As I was uncomfortable the nurses helped back into bed. The hospital bed with the head and shoulders raised and the knees bent provided the most comfortable position for me to rest in. The change in position from the seat to the bed seemed to help the abdominal pain. But around an hour or so later, the pain was back and was severe this time. To help the pain, I turned slightly to the left and then to the right, whilst supported by my towel bolster. At that moment, the bolster helped the pain for a short while before re-collecting on one side or the other, once again becoming severe.
The lumbar nerve block with local anaesthetic
I had worked out that it was now some 24 hours after surgery and that the anaesthetist had injected some long lasting local anaesthetic into the spinal nerves which supplied my abdomen. Now 24 hours later the local anaesthetic was wearing off. This resulted in my the increasing pain I experienced on that first afternoon.
I tried using more of the Patient Controlled Anaesthetic Pump (PCA Pump) loaded with morphine. The pump allowed a single 1mg shot of morphine once every 5 minutes. This eased the discomfort for a short period i.e. around 30 minutes. So I kept pressing the dose button more frequently. Around evening time, I noticed that the feeling on the right side of my abdomen was returning to normal. However, my groin and scrotum remained numb. I wondered if one of the injections of local anaesthetic had been directly into the nerve rather than around it. If so this can damage the nerve permanently so the sensation never returns to normal. As this involved the nerve supplying sensation to my groin, I wondered if my sexual function would be affected by this and whether the damaged nerve would prevent me from having an erection.
The pain was now troubling me so Rachel decided to leave in the late afternoon as I slumbered in my bed under the influence of increasing amounts of morphine. after taking the regular dose of morphine.
Even deep breathing became a problem
Overnight, the pain continued unabated. Overall, I felt pretty uncomfortable and rigid and was afraid to make any movements. The degree of pain resulted in an emotional stress response that made me anxious, fractious and unable to sleep. In fact, even deep breathing became a problem. So, I had to succumb to taking more morphine. I relented using the PCA pump and taking the 1 mg bolus as it would then not allow me another dose for the next 5 minutes. So I waited keenly, watching the pump until the red light went out and signalled that I could take another dose. It would take perhaps 30 minutes to self administer a 4-5mg dose and before I would become more comfortable and settled.
However, I dozed off, only to be woken up 45 minutes later. I was, once again in pain as the short-acting morphine was wearing off and the pain was coming back. To ease some of the pain, I tried alternately tilting myself to the left then the right, adjusting the bed to lift my head and chest up higher. A few hours later I lowered it again to be more comfortable.
The problems with a PCA morphine pump
The problem was that the PCA pump only provided for a small ineffective 1mg bolus of short-acting morphine once every 5 minutes. Given that my body weight was greater than 85 Kg, this was ineffective. A dose of at least 5-10mg was required to control the pain even in the short term. To control pain in the medium term this does needs to be repeated every 1-2 hours. The PCA pumps I have used some years earlier worked in a different way. The pump provided a continuous background dose of perhaps 5mg every hour. Patients could then self-administer additional boluses in a controlled way, every 5-10 minutes. This way, there was a background of morphine analgesia on top of additional small doses that could be added sequentially.
Even when the pump was used in this particular way with a background dose, I still discouraged my patients from doing so. The reason for that was that it hindered their recovery. Patients complained of being in pain overnight due to the see-saw effect of waking up in pain and requiring additional boluses. In the morning after considerable self administered morphine overnight, they woke up with drowsiness, were nauseous and consequently, reluctant to move. This was bad for their recovery, especially when they didn’t mobilise on the first postoperative day. Considering that and other associated with consequences and complications, I preferred using a skin patch of fentanyl as background opiate analgesia. This fentanyl patch is placed on the skin during recovery or once the patient has returned to the ward. This option is an even more viable the worry was of overdosing the patients with morphine and causing respiratory depression with the PCA pump might go unrecognised in the ward.
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