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Perceptions of pain relief after surgery

SIR,-The study by Ms Sandra Kuhn and colleagues highlighted the misconceptions surrounding pain relief among some practising hospital staff and patients.' Although the visual analogue scale used by the authors can yield some information about pain experienced, it is difficult to draw conclusions from an analysis based on incomplete records, particularly in association with lack of uniformity and variation among patients, in number of doses, and in frequency of administration (as admitted by the authors). One of the most important reasons why postoperative pain relief was shown in the article to be inadequate is the choice of analgesic. The widely used narcotics, either by an intermittent intramuscular route (as used by the authors) or by continuous or patient controlled intravenous infusion, carry the risk of respiratory depression, particularly in patients with compromised respiratory reserve.24 In addition, they provide unsatisfactory pain control4" and tend to worsen hypoxaemia, which is most profound and persistent after upper abdominal procedures such as cholecystectomy.' Although earlier studies claimed that infusion of intravenous opiates can reduce pain effectively,67 thus decreasing the incidence of postoperative pulmonary complications,7 recent reports suggest that continuous infusion of narcotics neither improves respiratory function nor reduces the incidence of postoperative pulmonary complications,4 which are encountered by 20-80% ofpatients undergoing upper abdominal surgery.'3 The undesirable effects ofopiates on respiration, interference with alertness of patients and the resultant poor cough compliance, and nausea and vomiting occur commonly and can have serious consequences, particularly in patients with compromised respiratory function. Fear of precipitating respiratory depression can lead to opiate analgesia being withheld and result in irregular administration, widely fluctuating plasma drug concentrations, and inadequate pain relief.4 These problems can be overcome with local anaesthetics that are safer, reliable, and far more effective in controlling postoperative pain. We have developed a greatly simplified technique of continuous intercostal nerve block using bupivacaine instituted by the surgeon at operation. So far 93% of our patients have had adequate pain relief in the first four days after operation-the period when the system is in use-and required no additional analgesia. We encountered no pulmonary complications or adverse reactions to the procedure or to the bupivacaine pump infusion. Our method has not only eliminated the wide variation in the level of analgesia commonly seen with intermittent administration of opiates (as experienced by the authors themselves); it has also obviated the need for experienced staff to be on standby for regular "topping up," as required with continuous epidural analgesia. We find this method of pain control highly successful in reducing postoperative pain without interfering with patients' levels of alertness and ability to cough and comply with intensive physiotherapy.