Pain during surgery

So I went through the club initiation rites yesterday and got my membership card.  Biotronik dual-lead PM up and running.  Had read about the procedure and got a brief explantion from the doctor but was totally unprepared for how painful it was.  They said I'd have a light sedative and local anesthesia, but I thought I'd be more out of it and feel only tugging and pressure.  Felt the injection of the anesthesia obviously, then I don't think I felt the incision, but shortly after that the dr said "This is going to hurt some" and did it ever.  I let out a groan and my whole body tensed up.  My wrists were restrained but I was able to grasp the edges of the table for some relief.  Dr ordered more of the sedative and fentanyl, nurse told me it would kick in in two minutes.  I could tell the sedative helped me relax some but I was continued to feel the dr digging into my shoulder with occasional very sharp pain.  Maybe by the end of the procedure the fentanyl kicked in while I was being stitched up but I was uncomfortable through the whole process.  I've never had surgery before so the only thing I could compare it to is a root canal on steroids.  Because the doctor said it was going to hurt I just gritted my way through it, but I don't understand why I wasn't given higher levels of sedative and fentanyl from the start.  I kept thinking of western movies where the cowboy gets shot and has to bite on a bullet or just tough it out to endure the pain.  The doctor didn't talk to me afterward, only my wife, but she said he told her that my vein was not where they expected it to be and that took longer than usual.  Maybe that complication required some deeper probing that wasn't fully anesthetized.  

The rest of the day my shoulder felt like I had been stabbed and I kept asking the nurses about it, but they said it was normal.  I was released to go home and started a regimen of ice and alternating tylenol and ibuprofen, which seems to have helped some.  I was given an arm sling at the hospital which I have used religiously as it hurts to move my shoulder.  I can tell it's getting better today so not concerned enough to follow up with the doctor, but feel like I wasn't fully prepared for what this surgery would involve.

I saw a couple of posts about similar pain during surgery but most of the other posts I've seen focus on pain after surgery, not during.  Is my experience an anomaly due to vein anatomy or insufficient anesthesia/sedative/fentanyl or both?

At any rate, glad to get it behind me and appreciative of the support I've found here.


23 Comments

Awww. Hugs

by Lavender - 2022-08-17 14:48:54

I'm so sorry to hear of your painful experience. I personally was not aware of my surgery at all. I awoke when they were almost done but no pain. No pain in the hospital that night either nor the next morning so I must've been given a long acting anesthetic. I was also given IV antibiotics as a preventative before leaving the hospital the morning after surgery. I believe I was given a propofol/fentanyl  blend for surgery. 
 

A word of caution not to use that sling during the day. It can cause frozen shoulder. Just keep your elbow below shoulder level. I only used the sling a night or two because the arm needs to move or it can get stiff and that is difficult to deal with long term. Use the arm. 
 

Honestly they should be more open about possible levels of pain. I have six years life left on my device and you can be sure that I will be asking to be unconscious when they trade it out. 

Not Typical !

by IAN MC - 2022-08-17 15:08:39

I share Lavender's sadness at your experience , but if anyone who has read this is nervously awaiting their first PM implant, I.M.H.O. your experience is not typical.

I believe that EP's vary enormously in their implantation skills and it seems to me that you were simply given an inadequate dosage  of local anaesthetic  to handle  your pain tolerance.

Hope your recovery progresses well

Ian

 

Some pain

by TLee - 2022-08-17 16:48:28

I did have more pain than I bargained for (woud have liked none!), but it was bearable. I thought it woud be more like when I had cardioversion. For that, all I remember is being in the bed wondering when they were going to start the procedure & they told me it was all done! I believe I was awake for the whole pacemaker procedure, although I guess there are chunks of time that I can't recall. There was definitely a bad couple of minutes, when the doc was making the pocket (?) and it felt like my shoulder was being pulled to pieces! I also made some sounds of distress, and they said they were "almost done", which I guess meant I could tough it out. It would be nice if the whole thing could be completely painless (including recovery, and yes, that was also more painful than I'd anticipated), because the whole experience made me wonder at first if I should have done it at all. BUT everything worked out, and I'm not even mad at my doctor any more! I'm sorry if stories like this make people nervous going in, but fore-warned is fore-armed--I'd go in saying that I've heard it can be a bit painful, and I would like a little extra anaesthetic, please!

Painful procedure

by Dixie Chick 65 - 2022-08-17 16:49:40

As the others have said, I'm sorry you went through this.
I was given Versed and fentanyl ( I saw this later in my patient portal ) but I felt nothing. I remember hearing the " time out" and they threw a blue sterile sheet over me...Head and all. I tried to say " hey, y'all covered up my head !" But couldn't say it. Next thing I knew it was over and they were giving me 7Up with a straw.

That said, I think some people probably require a higher dose than normal.

Maybe you just didn't get enough. I'd definitely tell your doctor though.

Hope you're on the mend soon !

Other thoughts

by Lavender - 2022-08-17 17:43:25

Honestly, I was working on my bushes today and couldn't stop thinking of your post today. Two things:

ANGER- why would anyone have to endure the type of pain you describe?  No reason at all!!😫

I have had three babies. The second birth was an unexpected unplanned natural delivery because the anesthesia didn't work. When I said I wanted more-they said it's too late because by the time it would kick in, they would be done with delivery and stitching up. So I felt every thing-it made me angry that more wasn't done. Now it's fine if I had chosen natural birth-but I asked for the epidural in advance.
 

Having unexpected pain adds to the trauma.  You did not expect this level of pain. No one should have to grab on and put up with it. The dr told you it was going to hurt-during the surgery! 😖I'd like to let him lie there and carve a pocket in him with inadequate pain relief so he's enlightened for future surgeries! 😡

Also-why did they not know where your vein was? Wouldn't preop tests show that? 
 

Ugh-it's over. Thanks be to God. May your recovery be as easy as this surgery was hard. You deserve a break, madhatter, and a cup of tea with the white rabbit-without the Queen of hearts. 
 

hugs and double hugs and remember what I said about that sling!

Trauma

by Persephone - 2022-08-17 17:55:30

I'm so sorry you had such a traumatic experience, mad. I hope you seek any mental health counseling that you feel you may need in addition to pursuing this with the surgery team as others have recommended. You don't need to tough it out alone.

Thanks everyone

by Mad Hatter - 2022-08-17 19:28:46

Feeling quite a bit better this afternoon and able to move my arm some without the sling.  The more I think about it, several things don't make sense.  The EP talked to me for 10 minutes when I was diagnosed and 5 minutes prior to the surgery to get informed consent, then only spoke to my wife afterwards.  Of course, he answered any questions that I asked, but most of what I learned about the procedure I read online, including here.  The nurse I spoke to from his office focused on pre-op preparation.  I received no written materials before the surgery.  I didn't even know what kind of pacemaker I was getting until the company rep showed up in pre-op.  I was told to let them know if I felt pain, which my groan apparently did, but it occurs to me also that the sedative (it was Versed) also made my brain cloudy so I'm not sure I was thinking clearly or could have verbalized what I felt. My wife remembers the nurse remarking afterward that it had been painful as she wheeled me to post-op, but I don't recall that.  Medical records aren't uploaded to the portal yet, but will be interested to read them.  

Anyway, venting on here helps and it sounds like my experience is atypical for any Nervous Neds like me, but I think it shows the importance of advocating for yourself.  I had lots of questions about the diagnosis, but didn't really ask much about the procedure itself.  You can bet I'll be very vocal when it comes time to change the batteries!

Similar bad experience

by MaxWax - 2022-08-17 20:19:02

Hello Mad Hatter

Your PM experience sounds horrendous. I had a dual chamber PM fitted in 2016 and was also unpleasantly surprised by how painful it was. When I told the operating theatre staff how much pain I felt I was given more meds, however they didn't work for very long. Eventually I stopped mentioning it to them as it wasn't easing the pain.

I was sent home with advice to take Paracetamol for the pain ... but the next day I had to call my GP and was prescribed Codeine. The pain l was feeling post op was an acute, disabling nerve and muscle spasm. I honestly believe that a nerve had become inflamed or irritated during the procedure.

Like you I dread needing a new battery. I am in the UK by the way, not sure about yourself.

Batteries not replaced

by Lavender - 2022-08-17 20:30:43

They don't replace the batteries. When your device needs replacing, they take it out and put a new one in-using the same leads. 
 

Be sure to discuss your pain with your EP at the followup. Maybe he will be wiser to it for a future patient. I think the anesthesiologist determines the amount given so he can watch over that better.  
 

My EP came into my room the morning after the procedure to ask me if I had questions and remove the larger dressing.  His team members also visited with me before and after surgery. 

ditto not typical

by skigrl3 - 2022-08-17 21:37:45

Sorry you had such a bad experience. My procedure was not painful, I have a dual lead biotronik as well. The recovery was a bit of work and took a little time but Frankly, the loop recorder I had prior to my pm - that insertion procedure was a little more painful. 

Pain!

by AgentX86 - 2022-08-17 22:27:51

Yes, I only had a local in my groin and shoulder (ablation at the same time - one EP at each end). It was pretty uneventfull until they made the pocket. I thougth they were going to skin me (essentially, they did).  Yes, that was really painful.  I have a pretty high pain threshold/tolerance but that was something. It didn't last all that long and I was good after.

Appalled

by Lavender - 2022-08-18 10:24:14

AgentX86- did you agree to this low level of anesthesia? I'm stunned that making sure the patient is comfortable isn't top on the list before they proceed. 
 

My career was spent in dentistry. There's no way we would proceed with a tooth extraction or root canal without first ensuring that the patient was numbed up. When people compare pain to a root canal, I am always perplexed. I can see pain before you're treated by a dentist, when you have swelling and throbbing-but not during a root canal procedure. There're anesthetics to prevent pain. 
 

Brutal to read of this torture. Again, it's not the norm from my understanding.

Be sure to carry your pacemaker ID card with you at all times. Also look into wearing a medical ID to identify you as having a pacemaker. 

Pain

by AgentX86 - 2022-08-18 12:33:15

No, my doctors aren't big on anesthesia.   My neurologist demands that I be held overnight for observation if they use a general. They use the minimum possible.  I had only a local fo one ablation that turned out to be rather painful, too.  When he did the burns, it felt like a hot soldering iron on my back.

I had carotid stent surgery (that they didn't place) with only a local, too.  In that case I had to be lucent (squeeze a ball and answer questions (so they could tell if anything broke off and went to the brain.

Wow

by Lavender - 2022-08-18 19:36:26

Prior to having a pacemaker, I had general anesthesia for gallbladder surgery. I ended up in complete heart block while coming out of the anesthesia. Then, my ankle got a tendon tear. My foot surgeon wouldn't do surgery on me because of my reaction to anesthesia. 
 

My cardiologist has now approved surgery because of the pacemaker.  I'm not having it. I'm wearing an ankle brace as needed that the foot dr prescribed. I'm taking a break from surgery. They said it's my choice. At this stage, I am not risking general anesthesia. 
 

oh the joys of life🥴

madhatter! Get better! Again, I am horrified at what you endured!

Better today

by Mad Hatter - 2022-08-18 19:55:13

Thanks Lavender.  If my surgery experience was horrendous, recovery seems to be progressing as well as I could expect.  Most of the pain gone today, just lingering discomfort.  No longer wearing the sling.  Sleeping reasonably well.  I continue to take Tylenol/ibuprofen. Noticeable bulge that I'm hoping goes down.  No other side effects that I can tell. 

Whew!

by Lavender - 2022-08-18 21:55:47

Glad you're recovery is progressing nicely. Good you're not wearing the sling. Just be mindful not to raise your arm above the shoulder. 
 

My surgery site was a raised red lump with bruises around it for a while. I also noticed new veins around the pacemaker and out into my armpit. It soon went down and is now only a thin white inch and a half line that's barely noticeable. 
 

Try and not take the ibuprofen. Just take Tylenol because your stomach may get irritated from ibuprofen but not Tylenol. 

You may feel little jabs and pulls as it heals inside and out but it will get better. 
 

 

Question for Lavender

by IAN MC - 2022-08-19 06:33:27

With your dental background you can probably answer this faster than I can Google it :-

I assume that for PM implants, the local anaesthetic used is no different to that used by dentists .....lidocaine, or something similar

Why do so many cardiologists  / E.P.s seem to favour  the "' top up, when the patient experiences pain " approach . Are the safety margins of local  anaesthetic dosages so critical ???.

Why not give an adequate initial dose to cover all eventualities?

I had a replacement PM fitted 3 weeks ago and the E.P. resorted to  local anaesthetic " top-up" when I showed signs of discomfort. This would seem to be common practice.

Ian

Local anaesthetics are quite toxic

by crustyg - 2022-08-19 08:18:21

One of the techniques that used to be used for complex arm/hand surgery was to infuse lignocaine into the arm and then apply a tourniquet above systolic pressure to create a painless, bloodless field to operate in.  There was a significant risk when the tourniquet was released of a large amount of lignocaine reaching the heart in one slug - and that could cause major heart rhythm disorders (even though lignocaine is licensed for the treatment of ventricular arrhythmias), and elsewhere convulsions, & respiratory depression.  It's specifically contraindicated for SA-node disease, all grades of AV-block.  There's a new approach to this area of delicate surgery, called WALANT.  Wide Awake Local Anaesthetic No Tourniquet, which is based on the old, nearly forgotten (in human practice) use of lignocaine mixed with adrenaline.  Brilliant for complex repairs - surgeon can ask patient to wiggle <x> digit and see if the tendons are all attached correctly etc. and sliding smoothly.

The principal is that the adrenaline causes very small arteries (arterioles, almost the last branch before the capillaries) to constrict, which reduces bleeding AND reduces the rate at which the lignocaine wears off - win-win.

My own PM was implanted under local, plain lignocaine, and it had all worn off by the time that the anchor stitch went in, and I felt all of the skin closure.

To answer your Q, Ian: yes, quite toxic *and* infusing too much is a) painful, b) makes the tissue difficult to work with, c) doesn't last any longer.

EP-docs are nervous about injecting adrenaline.  Which is one of the reasons why premixed lignocaine+adrenaline is still not widely used in human practice.

Ian

by Lavender - 2022-08-19 09:30:47

There's a limit to how much local anesthetic can be used. In dentistry, we lay out the carpules used so we don't lose track. The technique is important too. Some dentists get it on the first try, some miss the mark and need to add up. The goal is to use as little as possible while achieving adequate pain relief. 
 

It's also important to WAIT long enough for the local to take effect. Many people leave the office and are numb for a long time, more numb than during the procedure, depending on which anesthetic was used-because it kicks in. 
 

In implanting a pacemaker, my thought is the technique of the person giving the local anesthetic injections would be crucial in correct management of pain. They could miss the mark. 
 

Crustyg's post was very insightful.

Wow........... Thanks Lavender / Crusty

by IAN MC - 2022-08-19 10:32:43

Far more info. than I would have got from Google !

I guess the important thing  is that ANY local anaesthetic given before surgery will help suppress pain levels prior to top-up so the whole thing should be tolerable.

I will in future look forward to events after those famous words " You will feel a small scratch "

Thanks again

Ian

 

Having a PM fitted under local will always hurt - how much depends on you

by crustyg - 2022-08-19 12:25:55

I discussed this with my EP-doc.  His preference is local + midazolam, which is pretty effective at preventing creation of memories, so it might hurt a bit but you probably won't recall anything.  Most of his colleagues prefer iv opioids (usually fentanyl) + midazolam so their patients are in a state of conscious sedation.

Two things will always hurt: pocket creation - the EP-doc is tearing apart two layers of issue that are normally well stuck together and there's no local infused for that.  Second: insertion of the sheaths into the sub-clavian vein.  There's no local there either and although there aren't as many nerve endings as in the pocket area, it really does hurt - the sheath is quite large and one is needed for each pacing lead.

My experience

by atiras - 2022-08-19 16:12:55

I had my pacemaker put in in 2018 (UK). It was more painful than I expected, but whenever I have complained (and I was not backwards in doing so) they topped me up. Until they got to the point when they had given me thr maximum they were allowed. Fentantyl and midozolam IIRC. Luckily there wasn't a lot left to do at that point and I toughed it out with a nurse holding my hand and making encouraging noises.

Three weeks later I was back in the same place with the same team (the pacemaker had moved into my armpit and was pressing on the nerves. I was prepared at the pre op session with the guy who was doing the work to argue my case for something better but didn't need to. He recognised me, went away to double check my notes and came back to say they would do it differently this time. Much heavier sedation and a different local mix. It went like a dream - I floated through it. And had information tucked away for battery replacement time.

Which hopefully will never happen. Three years pretty well to the day after the pm went in, it was replaced by an ICD in a different hospital. Their protocol (they assured me) was intended to ensure no pain where possible and no memory of it otherwise. And they were true to their word. So it is possible to make the experience if not pleasant at least not traumatic but making it clear beforehand if you've had pain and sedation issues in the past and sticking to your guns that you want to remember nothing is IMO essential. 

I also felt nothing when the ICD came out 8 months later (same hospital as the ICD)  but that happened under a GA. probably because I was having a heart transplant at the same time ...😆

Pacemaker replacement

by DMJ - 2022-08-24 00:44:43

I'm very sensitive to medications and always ask for no Benzos or opioids. They usually give these prior to going to surgery to relax you.  I'm allergic to them.  So I tell them, "I don't want to be aware of the surgery, feel anything, hear anything, know anything once it is go time.  I did not feel anything with my pacemaker replacement yesterday.  I did feel my catarat surgery and I didn't like it.  Got to speak up.

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