Control of postoperative pain

CONTROL OF POSTOPERATIVE APPLICATION

OF COLD TO THE OPERATIVE

PAIN

EARL

G. KRIEG,

Senior Attending

M.D.

Surgeon, Woman’s

DETROIT,

SITE

Hospital

MICHIGAN

T

HE empirica control of pain by thermal methods is as oId as time. During the last few years the experiences of F. M. Allen, Brooks and Duncan, N. K. Neuman and others have shown that by means of low temperatures pain can be controlIed even at surgica1 Ievels. These authors have further shown that with the proper technic there is no interference with the heaIing or preservation of tissues by these Iow temperatures for relatively long periods of time. For some time I have been interested in the controI of postoperative pain by means of the appIication of ice caps to the operative area. The aim of this procedure has been the substitution of coId for narcotic drugs either in whole or in part. Our initial experience invoIved a patient who required appendectomy and who was vioIentIy alIergic to a11 opium derivatives. Her postoperative pain was entireIy controlIed by the application of ice caps. Since then further interesting observations have been made. The temperatures induced by the appIication of bare ice caps is approximately 6”~. There has been no evidence of any interference with wound heaIing in any of our cases. The efficacy of the ice cap is attested to by the reduction in the amount and the type of narcotic actuaIIy required. After preIiminary experience it was found that codeine suIfate in I gr. dosage was sufficient to controI the residua1 pain in a11 except the occasiona individua1. In this series 20 per cent of the adults and 70 per cent of the chiIdren required no narcotic. In the Iast sixty-seven consecutive cases the average number of hypodermic injections of I gr.

of codeine suIfate given postoperativeIy has been Iess than two and in no instance has the hypodermic been given oftener than every ten hours. Coincident with the reduction in the amounts of narcotic administered there has been an apparentIy abrupt faI1 in the comphcations attributed to anesthesia and/ or operation. This is not at a11 surprising when one reviews the pharmacology of the opium derivatives with the postoperative picture in mind. We hope to report upon this aspect of postoperative care when our series is suffIcientIy Iarge. The method is simple and its two component parts have been used by others in various ways. The dressing consists of a doubIe thickness of ceIIophane sealed to the skin by wide strips of adhesive tape thus providing a water-proof dressing of Miss E. Anderson, good conductivity. operating-room supervisor at Woman’s HospitaI, has found after considerable experimentation that the ceIlophane shouId be of the thickness of that commonIy used for oxygen tents and that handhng is best accompIished by wrapping in cloth as a fiat package which is steriIized in the autoclave. The second part consists of one or more ice caps without the usual ffanne1 jacket. The bare cap is pIaced directly upon the ceIIophane immediately after operation. In order to be effective the coId must be applied for at Ieast one-half hour. The contents of the ice cap must be renewed as frequentIy as the ice disappears because ice water alone is not effective. In this series hypodermic administrations of codeine were most frequentIy administered just after an operation performed under I’4

Krieg-Postoperative

New SERIES VOL. LXII. No. I

Pain

cases onIy; morphine suIfate in $4 gr. dosage was used onIy twice in the last one hundred odd cases. Spinal analgesia was

spina analgesia which had subsided before the ice became effective and during the night when the nurse did not fill the ice

TABLE (ADULTS)

KIND

AND

AMOUNT

-

I i 2 ( Cases

Operation

OF NARCOTIC

cotic

(her

12345

Totals.

3414?

.

13 8

I

. . I

i 1 3 2

I I

4I

3

. . I. . 1

I

I I

. I

2

1 4 5

_-I

6 Over

6

I

-. I

I

I

1

2914

I2

I

2

I

I

I..

I

I

1.

I I....

I . .

7

--

I

.

I

5

1

I

I

I..

I

I

I .

I

I

I

I

I

2

2365:

I

2

I ;1

__-----36

.,.,......

4

4

_4

7 4I -

AND

UNDER)

I

21

2

..

of disturbing the patient. The replaced from one to three average case the ice cap may after the second day.

_.

Codeine Gr. I

I 1 I

Operation

Totals..

Gr. 36

I

I I

: 3 3

L

2..

-

Appendix................. H ernia.................... Intussusception.. Pyloric stenosis.

I --

I

I . . . .. t . . I . .

. . .

33

TABLE II CHILDHEN (FOURTEEN YEARS

PERIOD

-

I

185

caps for fear ice must be hours. In the be discarded

Morphme

POST-OPERATIVE

1

4

30

THE

- _ --

._

23

75

DURING

----

------Appendix. Gallbladder Gastrointestinal resections. Hysterectomy (abd.). Hysterectomy (vag.). . Colostomy. .I Breast (radical). Breast (simple). Thyroid. Salp-ooph. Suspension, etc. ! Append. (25). Finger (incision and drainage)............. .I Bilateral varicocele.. Hernia...................

I

GIVEN

Morphine Gr. J,$

No Nar_

“5

Journnlof Surgery

American

__-

-

2

3 4

--

-

5 51

1 2

I

2

I

3 15

6

1

-.

_ 8 i 7 4 3 2 - - 1

-

-1: 2

4 -

-_ 6 ; -

3

most frequently used in the operations requiring average operative time; the operations of Ionger duration or of minor severity were performed under nitrous oxide combined with IocaI and spIanchnic block when necessary. Suture materia1 of choice in the clean cases was fine silk, in the infected case, fine catgut. TabIe II is simiIar to TabIe I and represents chiIdren under fourteen years. Babies and the younger children received the sedation in the form of suppositories. Open drop ether anesthesia was used in all except those having pyIoric stenosis. SUMMARY

--

-

3 2

I

Table I pIots the operation and the kind and number of doses of narcotic used in the adult cases. Morphine sulfate in g gr. dosage was used in the first twenty-eight

The substitution of a therma method for the administration of narcotics in the controI of pain is of genera1 surgica1 interest and especiaIIy when operations are performed upon the aged, the aIIergic and-the badIy injured in civi1 and miIitary practice. I am particularly indebted to the nursing staffs of the various hospitals in which these

116

Amerrcan

Journalof Surgery

Krieg-Postoperative

patients were treated and to Dr. W. S. Lovas and Dr. M. D. MacCauIey now in the miIitary service for their assistance in this work. REFERENCES ALLEN, F. M. Experiments

on peIvic and abdominal refrigeration with especia1 reference to traumatic and miIitary surgery. Am. J. Surg., 55: 451, rgq.1.

Pain

Ocmem, ,943

ALLEN, F. M. Experiments concerning ligation and refrigeration in relation to local intoxications and infections. Surg., Gynec. Ed Obst., 68: 1047, 1939. BROOKS, B. and DUNCAN, G. W. Effects of temperature 130, on surviva1 of anemic tissue. Ann. Surg., 112: .

I O&O. BRC&, B. and DUNCAN, G. W. InfIuence of temperature on wounds. Ann. Surg., I 14: 1069, ,941. NEWMAY, MAX K. Personal communications.

FIBROMA of the ovary is a relativeIy common growth, but not nearly so common as the cysts. It occurs usually in women less than 25 years of age, frequently at the age of 18 or 19, and is often bilateral. From “Essentials of Gynecology” by WiIIard R. Cooke (J. B. Lippincott Company).