Anesthesia mechanism

Hello Everyone,

It’s time for my monthly medical question. INYANAD and I am not asking for specific medical advice, rather I’m looking for answers how something works using my own experience as an example.

A few weeks ago I underwent relatively minor surgery. Apparently my Gall Bladder and Steak & Shake were conspiring to kill me and the gall baldder had to come out. The surgery was successful and I have made a complete recovery with almost no side effects from the removal of the organ.

After the surgery I woke up in EXTREAME pain. The dilaudid (however you spell it) did absolutely nothing for me. I now know how it feels to be stabbed and it ain’t pretty. The reason for this was my high tolerance to opiods as I take morphine everyday for chronic pain. In conversation with the surgeon during a follow up appointment he told me that the attending nurses were visibly shaken when dealing with me because I was screaming with pain and no matter how much of the pain drugs they gave me I didn’t seem to improve. They thought that they might kill me with the amount of drugs they were shoving into my body.

I’ll get to that question in a minute, but what really interested me was the conversation the surgeon had with me concerning putting me under. He told me that the anesthesiologist was “sweating bullets” the entire time I was on the table and at one point wanted to stop the surgery for fear of killing me with the amount of sleepy juice I required. Apparently I am tolerant to that as well. So, the first question is, why would my tolerance of narcotic pain meds make me tolerant to the sleepy juice used to sedate someone? Do they work on the same receptors in the brain? I really am fascinated by how things like pain meds and such work on the body and brain.

I guess that this shouldn’t have surprised me. I had trouble at the dentist, he was unable to numb me for a routine cavity. He shot me so many times in the jaw with novicain I am surprised there was any jaw left without a hole in it from a needle. Nitrous Oxide also did not work on me even though the dentist said he had it turned up to 11.

The next question I have goes back to the earlier statement about the surgeon being unable to control my pain after surgery. I understand that my tolerance is going to make pain control very difficult, but what happens if I really get hurt? If they are already maxing me on pain meds without effect how will they manage to control pain in me for something really major like a car accident or such? Can I be kept “out” until such time as the pain can be brought under control?

I can’t tell you how weird it is knowing that if you get seriously injured you might face hours or days of pure agony. It scares the crap out of me, but such is life I guess. Anyways, I would be very interested to know how anesthesia works and how it relates to narcotic pain medication in effect and in application. Thanks

How much of the post-surgical Dilaudid did they end up giving you, and how did it compare to your daily morphine dose?

I didn’t get the amount from the doctor, I forgot to ask. However, he did say that the post op staff were “afraid” to give a drop more. He also said that the staff made sure to have the means handy to breathe for me SS they were afraid if stop breathing. When it came to the sleepy juice the surgeon demonstrated by holding up a pen cap and said “a normal man your size gets this much”, he then grabbed two one gallon milk jugs and said, “this is what it took to get you down”. Of course he wasn’t being literal, but the point was well made.

He did say that the amount of dilaudid they gave me made every single medical professional present very uncomfortable and that I was in a very dangerous zone. Like I don’t have enough to worry about already. He then told my wife that if I ever am in an emergency room situation that it was imperative that she act swiftly as my Advocate. He said that without being informed, the ER staff would assume I was a junkie. Great, just what I need.

Didn’t the anesthetist check with you how much morphine you had in your system at the time ? (eg how much you took in the last few days ? )
Dilaudid , hydromorphinone is very similar to morphine, and acts in a similar way.

If he gave you something to reverse the Dilaudid he gave you, then he reversed your background morphine TOO. So then you woke up in extreme pain…

The actual question is why did he use dilaudid at all even though he know you had a “tolerance” of it. (… the receptor, triggered by morphine already, could achieve no stronger effect.)

The wikipedia entry lists the following for pain killing in the mix used for during general anesthetic.

(there will be something else to put you out, and to stop your skeletal muscles from working…but they don’t stop the pain.)
Did he use something else ? If not, why not ? If he did, why didn’t it work ?
Maybe the worry is that there are interactions ?
From http://en.wikipedia.org/wiki/Anesthetic

Short acting - to relieve the extreme pain of surgery procedures.

Alfentanil
Fentanyl
Remifentanil
Sufentanil (Not available in the UK)

The following agents have longer onset and duration of action and are frequently used for post-operative pain relief:

Buprenorphine
Butorphanol
diacetyl morphine, (Diamorphine, also known as heroin, not available in U.S.)
Levorphanol
Meperidine, also called pethidine in the UK, New Zealand, Australia and other countries
Methadone
Morphine
Nalbuphine
Oxycodone, (not available intravenously in U.S.)
Oxymorphone
Pentazocine

Yeah, unfortunately, your high opioid tolerance means that if you are ever in a serious accident or have surgery or something and require painkillers, it’s going to basically be up to you and your wife (hopefully she will be there) to explain that you’re going to require a very high dose to feel any effect. Individual doctors and nurses will have widely different reactions to this, so hopefully you will get someone who understands.

On the plus side, it should be possible to control your pain without killing you, as long as they keep a close eye on your vitals.

Maybe you could get a letter from your regular pain management doctor to carry with you in case of an accident or surgery or whatever. It could explain the situation and help you feel better while traveling.

I have the same situation - extreme tolerance for all CNS depressants - analgesics, sedative, hypnotics.
Last time I was under, the anesthesiologist came by twice - first time was to ask the lithium question (if you drink moderate to heavy, they add lithium to the mix). I told him at that time that I was extremely tolerant. He acknowledged that he heard me, but did not question me - I suspect he was also thinking “junkie looking to score”.
After surgery, he stopped by just to tell me he had had a hell of a time keeping me down. “Told you so”.

Anyway, I keep a small supply of morphine and hydromorphone with me. I also have a xerox of the scripts in my wallet. Between the two, I hope EMT’s et al would note “opioid tolerant” and adjust dosing accordingly.

I suggest you make a habit of having a copy of your scripts on you - if you can’t talk, they will at least give notice. If you are young enough for them to think “junkie”, showing them the scripts will at least let them know you are an experienced junkie.

What???

Who told you it goes to 11? I simply cannot believe that! It sounds like something made up from a movie or something! I think somebody has been lying to you.

J/K :slight_smile: :slight_smile: :slight_smile:

So sorry. But I just could not resist!

I don’t know all the ins and outs of pain management, but I do know that some patients will end up using an intrathecal pump - kind of like an epidural, but one layer of tissue deeper - for pain relief. The good thing about this is that the dose needed for pain relief is much, much less than the oral dose, or even the IV dose, and 1/10 the epidural dose. The pump lasts for 5-7 years and does not need charging. It is implanted under the skin in the abdomen, and filled periodically by a nurse or doctor with a needle that goes into a reservoir, and the pump programed with a little remote you hold over that spot on the abdomen. Morphine is one of the approved meds for these pumps.

I only know how to program and refill the pumps, I don’t know who is a good candidate for them and/or what kinds of pain they best treat. But I know that if I was in your situation, I’d be talking to my doctor to see if it was an option for me.

That pump is perhaps the second-most scary use of programming chips - the first being a pacemaker-type device.

Somebody hacks your chip and you die.

Just give me a vial and some needles/syringes - at least I don’t need to worry about every electro-magnetic device injecting a lethal morphine dose.

If you have people that hate you so much they want to kill you, I’m thinking a kitchen knife or a car might be more convenient murder weapons.

But a knife would need to be aimed directly at me. A misdirected data stream could have been aimed at a chip on a car next door.

Relying on signal strength alone seems a bit dicey.

I’m curious if the OP takes regular OTC pain medication for anything, like a headache? Does the regular morphine keep you from feeling other pain like a pulled muscle or headache, or do you take acetaminophen or ibuprofen in those cases?

I’m asking because I would think your normal morphine dose would still be given to keep you on schedule with what you take every day, and would still help with your post-op pain, wouldn’t it? I’m also curious, because I just had gallbladder surgery in December and my only post-op medication was 1000mg of acetaminophen given in my IV every 8 hours. That was all I needed after the in-surgery fentanyl + percocet wore off.

As to the anesthetic, I don’t have any knowledge to add, but it is indeed fascinating. I’ve no idea how inhaled or injected anesthetics work in the brain compared to opioids. I would have thought they would be different mechanisms.

I apologize for the delay in my response, life got in the way for a few days. The morphine doesn’t seem to keep “new” pain from bring felt. If I were to hit my thumb with a hammer it would hurt just as much. Things like headache or a toothache seem to be completely unfazed by morphine. Acetaminophen works much better. What was curious however was the morphine did help very much with the initial pain from the gall bladder. The night I went to the ER with unexplained stomach pain it rally wasn’t that bad. It was more uncomfortable than painful, but I knew something want right. The ER doc told me that a stone blockage of the gall bladder is very painful with many suffering from it doubled over in pain. So, the morphine was certainly masking most of that pain. The surgeon also told me that most people have quite a number of indications that their gall bladder is going bad, I only had the one, so more than likely the morphine had been hiding the symptoms for quite a while.

I also got lucky with kidney stones, having passed several large ones with nothing more than being slightly uncomfortable.