Dimensions of pain and analgesic administration associated with coronary artery bypass grafting in an Australian intensive care unit

Ultrasound-guided Modified Parasternal Intercostal Nerve Block: Role of Preemptive Analgesic Adjunct for Mitigating Poststernotomy Pain

Background and Aim

To assess the quality and effectiveness of postoperative pain relief after fast-tracking tracheal extubation in cardiac surgery intensive care unit, effected by a single-shot modified parasternal intercostal nerve block compared with routine in-hospital analgesic protocol, when administered before sternotomy.

Design

A prospective, randomized, double-blinded interventional study.

Setting

Single-center tertiary teaching hospital.

Participants

Ninety adult patients undergoing elective coronary artery bypass grafting surgery under cardiopulmonary bypass.

Materials and Methods

Patients were randomized into two groups. Patients in the parasternal intercostal block group (PIB) (n = 45) received ultrasound-guided modified parasternal intercostal nerve block with 0.5% levobupivacaine after anesthesia induction at 2^nd-6^th intercostal space along postinduction using standardized anesthesia drugs with routine postoperative hospital analgesic protocol with intravenous morphine. Patients in the group following routine hospital analgesia protocol (HAP) (n = 45) served as controls, with standardized anesthesia drugs and routine hospital postoperative analgesic protocol with intravenous morphine. The primary study outcome aimed to evaluate pain at rest and when doing deep breathing exercises with spirometry, coughing expectorations using a 11-point numerical rating scale.

Results

The postoperative pain score at rest and during breathing exercises was compared between the two groups at different time durations (15 min after extubation and every 4^th hourly for 24 h). Patients in the PIB group had significantly lower pain scores and better quality of analgesia during the entire study period at rest and during breathing exercise (P < 0.0001). Furthermore, the side effect profile and need of rescue analgesics were better in the PIB group than the HAP group at different time intervals.

Conclusion

PIB is safe for presternotomy administration and provided significant quality of pain relief postoperatively, as seen after tracheal extubation for a period of 24 h, on rest as well as with deep breathing, coughing, and chest physiotherapy exercises when compared to intravenous morphine alone after sternotomy. This study further emphasizes the role of preemptive analgesia in mitigating postoperative sternotomy pain and it's role as a plausible safe analgesic adjunct facilitating fast tracking with sternotomies on systemic heparinization.

Physiotherapy mobility and walking management of uncomplicated coronary artery bypass graft (CABG) surgery patients: a survey of clinicians' perspectives in Australia and New Zealand

Background: This study aimed to determine current mobility and walking management by physiotherapists of patients undergoing coronary artery bypass graft (CABG) surgery, the clinical milestones expected and physiotherapists' perception of the severity of pain experienced by patients after surgery. Design: Cross sectional study using a questionnaire. Methods: All hospitals in Australia and New Zealand that perform cardiac surgery (n = 54) were invited to complete a questionnaire. Findings: Forty-one questionnaires were returned and analysed (response rate 76%). Walking distance was a clinical milestone after CABG surgery. Walking and transferring patients from bed to chair required the most time of physiotherapists during one treatment session. Physiotherapists perceived that patients experienced most pain on day one after surgery [mean (SD)] visual analogue scale (VAS) 41 (16) mm and this reduced by day four to VAS 15 (10) mm. Patients' pain was perceived to be significantly higher after physiotherapy sessions compared with before (p < 0.01). Thirty-seven respondents (90%) believed that patients' pain was well managed for physiotherapy treatments. A majority of the respondents (68%) believed that pain was not a limiting factor in the distance patients walked in a physiotherapy session and most (90%) believed that general fatigue limited walk distance. Conclusion: This research provides current mobility and walking management by physiotherapists of patients undergoing CABG surgery in Australia and New Zealand.

Introducing the Cardibra: A Randomised Pilot Study of a Purpose Designed Support Bra for Women Having Cardiac Surgery

Background: Cardiac nurses instruct women to wear a brassiere (bra) after a sternotomy for cardiac surgery to reduce lateral tension on the wound. However this practice is rarely implemented because regular bras impede nursing care in the immediate postoperative period. The Cardibra was developed to address the inadequacies of the regular bra and provide an alternate method of breast support.

Aim: To develop a purpose designed support bra (the Cardibra) and evaluate its effectiveness on sternal wound healing and the reduction of pain for women who had a sternotomy for cardiac surgery.

Methods: The study consisted of two stages. Stage 1 described the development of the Cardibra. Stage 2 was a pilot study of a clinical trial, prospective, randomised two-group design. The treatment group consisted of 10 women using the Cardibra immediately following surgery and the control group of 10 who wore a regular bra 3 days post surgery. Repeated measures at six time points assessed pain levels and wound healing.

Results: This study indicated that the Cardibra might have beneficial therapeutic effects on pain levels and wound healing up to day 14 after cardiac surgery.

Conclusion: This innovative device may offer therapeutic benefits to women following cardiac surgery.

Pain management in neurocritical care

The core challenge of pain management in neurocritical care is to keep the patient comfortable without masking or overlooking any neurological deterioration. Clearly in patients with a neurological problem there is a conflict of clinical judgement and adequate pain relief. Here we review the presentation, assessment, and development of pain in the clinical spectrum of patients with associated neurological problems seen in a general intensive care setting. Many conditions predispose to the development of chronic pain. There is evidence that swift and targeted pain management may improve the outcome. Importantly pain management is multidisciplinary. The available non-invasive, pharmacological, and invasive treatment strategies are discussed.

Treinamento e avaliação sistematizada da dor: impacto no controle da dor do pós-operatório de cirurgia cardíaca

Neste estudo analisou-se o efeito do Treinamento e uso de Ficha de Avaliação Sistematizada para controle da dor após cirurgia cardíaca, sobre a intensidade da dor e o consumo de morfina suplementar. Três grupos de pacientes foram submetidos a um ensaio clínico não randomizado com prescrição analgésica padronizada. No Grupo I, a equipe de enfermagem não recebeu treinamento sobre avaliação e manejo da dor e cuidou dos doentes conforme a rotina da instituição. Nos grupos II e III, toda a equipe foi treinada. A equipe de enfermagem do grupo II utilizou a Ficha Sistematizada sobre Dor, e a do grupo III não a utilizou. O grupo II apresentou dor menos intensa e maior uso de morfina suplementar. O treinamento associado à Ficha de Avaliação aumentou a chance de identificar a dor e influenciou o processo de decisão do enfermeiro na administração de morfina, favorecendo o alívio da dor dos pacientes.

Facial expression and pain in the critically ill non-communicative patient: state of science review

The aim of this review is to analyse the evidence related to the relationship between facial expression and pain assessment tools in the critically ill non-communicative patients. Pain assessment is a significant challenge in critically ill adults, especially those who are unable to communicate their pain level. During critical illness, many factors alter verbal communication with patients including tracheal intubation, reduced level of consciousness and administration of sedation and analgesia. The first step in providing adequate pain relief is using a systematic, consistent assessment and documentation of pain. However, no single tool is universally accepted for use in these patients. A common component of behavioural pain tools is evaluation of facial behaviours. Although use of facial expression is an important behavioural measure of pain intensity, there are inconsistencies in defining descriptors of facial behaviour. Therefore, it is important to understand facial expression in non-communicative critically ill patients experiencing pain to assist in the development of concise descriptors to enhance pain evaluation and management. This paper will provide a comprehensive review of the current state of science in the study of facial expression and its application in pain assessment tools.

Sedation in the mechanically ventilated patient

OBJECTIVE

To discuss the approach to sedation of the mechanically ventilated patient.

DATA SYNTHESIS

Mechanically ventilated patients in the intensive care unit frequently require sedation and analgesia for anxiety and pain experienced during the time they are intubated. Multiple drugs are available for this purpose. Strategies that optimize comfort while minimizing the predilection for sedative and analgesic drug accumulation with prolongation of effect have been shown to improve outcomes. In particular, such strategies may decrease mechanical ventilation duration, intensive care unit length of stay, and complications associated with critical illness.

CONCLUSIONS

Sedation and analgesia are important in the management of patients who require mechanical ventilation. An evidence-based approach to administering sedatives and analgesics is necessary to optimize short- and long-term outcomes in mechanically ventilated patients.

Validation of the Critical-Care Pain Observation Tool in Adult Patients

• Background Little research has been conducted to validate pain assessment tools in critical care, especially for patients who cannot communicate verbally.

• Objective To validate the Critical-Care Pain Observation Tool.

• Methods A total of 105 cardiac surgery patients in the intensive care unit, recruited in a cardiology health center in Quebec, Canada, participated in the study. Following surgery, 33 of the 105 were evaluated while unconscious and intubated and 99 while conscious and intubated; all 105 were evaluated after extubation. For each of the 3 testing periods, patients were evaluated by using the Critical-Care Pain Observation Tool at rest, during a nociceptive procedure (positioning), and 20 minutes after the procedure, for a total of 9 assessments. Each patient’s self-report of pain was obtained while the patient was conscious and intubated and after extubation.

• Results The reliability and validity of the Critical-Care Pain Observation Tool were acceptable. Interrater reliability was supported by moderate to high weighted κ coefficients. For criterion validity, significant associations were found between the patients’ self-reports of pain and the scores on the Critical-Care Pain Observation Tool. Discriminant validity was supported by higher scores during positioning (a nociceptive procedure) versus at rest.

• Conclusions The Critical-Care Pain Observation Tool showed that no matter their level of consciousness, critically ill adult patients react to a noxious stimulus by expressing different behaviors that may be associated with pain. Therefore, the tool could be used to assess the effect of various measures for the management of pain.

New approaches and old controversies to postoperative pain control following cardiac surgery

OBJECTIVE

To evaluate the effect of postoperative pain control in cardiac surgical patients on morbidity, mortality and other outcome measures.

BACKGROUND

New approaches in pain control have been introduced over the past decade. The impact of these interventions, either alone or in combination, on perioperative outcome was evaluated in cardiac surgical patients.

METHODS

We searched Medline for the period of 1980 to the present using the key terms analgesics, opioid, non-steroidal anti-inflammatory drugs, cardiac surgery, regional analgesia, spinal, epidural, fast-track cardiac anaesthesia, fast-track cardiac surgery, myocardial ischaemia, myocardial infarction, postoperative care, accelerated care programmes, postoperative complications, and we examined and discussed the articles that were identified to be included in this review.

RESULTS

Pain management in cardiac surgery is becoming more important with the establishment of minimally invasive direct coronary artery bypass surgery and fast-track management of conventional cardiac surgery patients. Advances have been made in this area and encompass specific techniques, such as central neuraxial blockade or selective nerve blocks, and drugs (opioids, sedative-hypnotics and non-steroidal anti-inflammatory drugs). Ideally, these therapies provide not only patient comfort but also mitigate untoward cardiovascular responses, pulmonary responses, and other inflammatory and secondary sympathetic responses. The introduction of these newer approaches to perioperative care has reduced morbidity, but not mortality, in cardiac surgical patients.

CONCLUSIONS

Understanding perioperative pathophysiology and implementation of care regimes to reduce the stress of cardiac surgery, will continue to accelerate rehabilitation associated with decreased hospitalization and increased satisfaction and safety after discharge. Reorganization of the perioperative team (anaesthesiologists, surgeons, nurses and physical therapists) will be essential to achieve successful fast-track cardiac surgical programmes. Developments and improvements of multimodal interventions within the context of 'fast-track' cardiac surgery programmes represents the major challenge for the medical professionals working to achieve a 'pain and risk free' perioperative course.

Sedation in the intensive care unit with remifentanil/propofol versus midazolam/fentanyl: a randomised, open-label, pharmacoeconomic trial

Introduction

Remifentanil is an opioid with a unique pharmacokinetic profile. Its organ-independent elimination and short context-sensitive half time of 3 to 4 minutes lead to a highly predictable offset of action. We tested the hypothesis that with an analgesia-based sedation regimen with remifentanil and propofol, patients after cardiac surgery reach predefined criteria for discharge from the intensive care unit (ICU) sooner, resulting in shorter duration of time spent in the ICU, compared to a conventional regimen consisting of midazolam and fentanyl. In addition, the two regimens were compared regarding their costs.

Methods

In this prospective, open-label, randomised, single-centre study, a total of 80 patients (18 to 75 years old), who had undergone cardiac surgery, were postoperatively assigned to one of two treatment regimens for sedation in the ICU for 12 to 72 hours. Patients in the remifentanil/propofol group received remifentanil (6- max. 60 μg kg^-1 h^-1; dose exceeds recommended labelling). Propofol (0.5 to 4.0 mg kg^-1 h^-1) was supplemented only in the case of insufficient sedation at maximal remifentanil dose. Patients in the midazolam/fentanyl group received midazolam (0.02 to 0.2 mg kg^-1 h^-1) and fentanyl (1.0 to 7.0 μg kg^-1 h^-1). For treatment of pain after extubation, both groups received morphine and/or non-opioid analgesics.

Results

The time intervals (mean values ± standard deviation) from arrival at the ICU until extubation (20.7 ± 5.2 hours versus 24.2 h ± 7.0 hours) and from arrival until eligible discharge from the ICU (46.1 ± 22.0 hours versus 62.4 ± 27.2 hours) were significantly (p < 0.05) shorter in the remifentanil/propofol group. Overall costs of the ICU stay per patient were equal (approximately €1,700 on average).

Conclusion

Compared with midazolam/fentanyl, a remifentanil-based regimen for analgesia and sedation supplemented with propofol significantly reduced the time on mechanical ventilation and allowed earlier discharge from the ICU, at equal overall costs.

The problem of postoperative pain: Issues for future research

Uncontrolled postoperative pain continues despite abundant research in the area. The purposes of the paper are to review how past research influences our understanding of pain in the postsurgery context and to argue for a methodological shift towards naturalistic inquiry. Such a shift incorporates the complexities of pain assessment and management in the clinical practice environment. Decisions regarding pain are often examined outside of the contextual concerns of clinical practice. Research approaches have involved analyses of nurse and patient-related factors associated with pain. These approaches do not account for complex interactions that occur between nurses, patients and the dynamic environment in which these interactions take place. The failure of research to address the context of pain decisions has several implications. It limits our understanding of why pain continues despite ongoing research and it does not enable evaluation of clinical strategies to improve pain decision-making and pain outcomes for patients.

Management of sedation in mechanically ventilated patients

PURPOSE OF REVIEW

There are many new and exciting studies in the sedation literature. Recent studies of new scoring systems to monitor sedation, new medications, and new insights into post-intensive care unit (ICU) sequelae have brought about interesting ideas for achieving an adequate level of sedation of our patients while minimizing complications.

RECENT FINDINGS

The recent literature focuses on monitoring the level of a patient's sedation with new bedside clinical scoring systems and new technology. Outcomes studies have highlighted problems with both inadequate sedation and excessive sedation in regard to patients' post-ICU psychological health. More insight into drug withdrawal and addiction as complications of ICU care were examined. A new medication for sedation in the ICU has been approved for use, but its role is not yet defined.

SUMMARY

Many patients in the ICU receive mechanical ventilation and will require sedative medications. A frequently overlooked cause of agitation in the ventilated patient is pain, and assessing the adequacy of analgesia is an important part of the continuous assessment of a patient. The goal of sedation is to provide relief while minimizing the development of drug dependency and oversedation. Careful monitoring with bedside scoring systems, the appropriate use of medications, and a strategy of daily interruption can lead to diminished time on the ventilator and in the ICU.

Pain Assessment and Management in Critically Ill Intubated Patients: a Retrospective Study

• Background Little research has been done on pain assessment in critical care, especially in patients who cannot communicate verbally.

• Objectives To describe (1) pain indicators used by nurses and physicians for pain assessment, (2) pain management (pharmacological and nonpharmacological interventions) undertaken by nurses to relieve pain, and (3) pain indicators used for pain reassessment by nurses to verify the effectiveness of pain management in patients who are intubated.

• Methods Medical files from 2 specialized healthcare centers in Quebec City, Quebec, were reviewed. A data collection instrument based on Melzack’s theory was developed from existing tools. Pain-related indicators were clustered into nonobservable/subjective (patients’ self-reports of pain) and observable/objective (physiological and behavioral) categories.

• Results A total of 183 pain episodes in 52 patients who received mechanical ventilation were analyzed. Observable indicators were recorded 97% of the time. Patients’ self-reports of pain were recorded only 29% of the time, a practice contradictory to recommendations for pain assessment. Pharmacological interventions were used more often (89% of the time) than nonpharmacological interventions (&lt;25%) for managing pain. Almost 40% of the time, pain was not reassessed after an intervention. For reassessments, observable indicators were recorded 66% of the time; patients self-reports were recorded only 8% of the time.

• Conclusions Pain documentation in medical files is incomplete or inadequate. The lack of a pain assessment tool may contribute to this situation. Research is still needed in the development of tools to enhance pain assessment in critically ill intubated patients.

Pain Levels Experienced With Activities After Cardiac Surgery

• Background Acute pain is common after cardiac surgery and can keep patients from participating in activities that prevent postoperative complications. Accurate assessment and understanding of pain are vital for providing satisfactory pain control and optimizing recovery.

• Objectives To describe pain levels for 5 activities expected of patients after cardiac surgery on postoperative days 1 to 6 and changes in pain levels after chest tube removal and extubation.

• Methods Adults who underwent cardiac surgery were asked to rate the pain associated with various types of activities on postoperative days 1 to 6. Pain levels were compared by postoperative day, activity, and type of cardiac surgery. Pain scores before and after chest tube removal and extubation also were analyzed.

• Results Pain scores were higher on earlier postoperative days. The order of overall pain scores among activities (P &lt; .01) from highest to lowest was coughing, moving or turning in bed, getting up, deep breathing or using the incentive spirometer, and resting. Changes in pain reported with coughing (P=.03) and deep breathing or using the incentive spirometer (P = .005) differed significantly over time between surgery groups. After chest tubes were discontinued, patients had lower pain levels at rest (P = .01), with coughing (P=.05), and when getting up (P=.03).

• Conclusions Pain relief is an important outcome of care. A comprehensive, individualized assessment of pain that incorporates activity levels is necessary to promote satisfactory management of pain.

Patients' perceptions of pain management after cardiac surgery in an australian critical care unit

OBJECTIVE

The purpose of this study was to investigate patients' perceptions of the effectiveness of a pain management regimen, which consisted of intermittent prn bolus doses of morphine, in a critical care unit after cardiac surgery.

DESIGN

This was a escriptive and correlational study.

SETTING

This study took place at the cardiothoracic intensive care unit of a major teaching hospital in Sydney, Australia.

PATIENTS

The subjects were 102 patients who underwent cardiac surgical procedures. The mean age of the group was 61 years, and 24.5% were females and 75.5% were males.

RESULTS

Analysis revealed that patients received limited total amounts of morphine during their critical care stay (mean = 26.7 mg; SD = 13.3; range: 0-68). All activities were associated with increased pain sensation. Patients requiring an internal mammary artery graft experienced increased pain despite receiving greater amounts of morphine. Elderly patients received less morphine and were refused pain killers more often than younger patients. Females found their overall pain experience to be less acceptable than did males. Less than half the participants always communicated their experience of pain to nurses.

CONCLUSION

Overall, the majority of participants were reasonably satisfied with their pain experience. However, the following areas need improvement: the assessment and management of pain in relation to gender and age differences and the type of graft/s used; the administration of morphine before activity; and the communication of pain experience by patients.

Refusing analgesics: using continuous improvement to improve pain management on a surgical ward

Despite advances in pain control many patients experience moderate to severe pain whilst in hospital. Contributory factors include inadequate assessment and documentation of pain, as well as patient and professional misconceptions. A 28-bedded surgical ward in a District General Hospital in the South of England was the setting for the project. A small preliminary audit of pain on this ward indicated that some patients experienced postoperative pain, which was not effectively controlled. A 'continuous improvement' framework was used to increase understanding of the problem and identify an aim for the project, which was to reduce the number of patients refusing analgesics when offered by nurses. An audit to ascertain how many patients refused analgesia revealed that, of 133 patients offered, 93 (70%) refused. Using the 'Model for Improvement' (Langley et al., 1996) a number of changes were introduced, including a patient information sheet, regular documented pain assessment and an innovative staff education programme. To evaluate if the changes in practice had been successful, further audit data were collected from 167 patients. Sixty-three (44%) accepted analgesics, indicating a significant decrease in the number refusing (P = 0.005). This small project demonstrated that continuous improvement methodology can improve the management of pain and quality of care for patients. Such an approach brings practitioner and patient into meaningful understanding and offers solutions which are realistic, achievable and sustainable over time. Despite finite resources and increased pressure on staff it is possible to motivate people when they feel they have ownership and change is meaningful. Continuous improvement methods offer an exciting, feasible, patient-centred approach to improving care.

Characteristics associated with analgesia ordering in the intensive care unit and relationships with outcome

OBJECTIVE

To describe clinical characteristics associated with analgesia utilization in the intensive care unit.

DESIGN

A prospective cohort study of adult patients admitted to a medical intensive care unit.

SUBJECTS

Four hundred adult patients.

SETTING

Twelve-bed medical intensive care unit of an inner-city, university-affiliated hospital.

MEASUREMENTS AND MAIN RESULTS

Collected data included demographics, sedation and neuromuscular blocking agents used, mechanical ventilation, hemodynamic monitoring, Therapeutic Intervention Scoring System score, Logistic Organ Dysfunction System (LODS) score, and Acute Physiology and Chronic Health Evaluation (APACHE) II score. Hospital outcome was noted. The odds ratio and 95% confidence intervals were determined by using multiple logistic regression analyses. Patients' mean age (+/-sd) was 47.8 +/- 17.1 yrs; 58% were male, 84% African-American. Their APACHE II-predicted hospital mortality rate was 33%. Analgesics were used in 36% of patients. There were no differences in demographics, initial LODS score, APACHE II score, and mechanical ventilation use between patients who did and did not receive analgesics. Multiple logistic regression analysis showed that analgesic use was independently associated with sedation (odds ratio, 2.47; 95% confidence interval, 1.47-4.14), neuromuscular blockade (odds ratio, 4.98; 95% confidence interval, 1.85-13.41), and pulmonary artery flotation catheter utilization (odds ratio, 2.31; 95% confidence interval, 1.27-4.20). The median duration of mechanical ventilation was 5 days for those who received analgesia compared with 2 for those who did not (p =.0001). The median length of stay in the intensive care unit (4 vs. 2, p <.0001) and hospital (11 vs. 7, p <.0001) was higher in patients who received analgesics. There were no significant differences in intensive care unit and hospital mortality rates between patients who did and did not receive analgesics.

CONCLUSIONS

Intensive care unit patients for whom analgesics were prescribed have a higher frequency of hemodynamic monitoring and use of sedative and neuromuscular blocking agents, more mechanical ventilation days, and longer intensive care unit and hospital lengths of stay.

Background pain in fibromyalgia patients affecting clinical examination of the skin

The purpose of this study was to investigate the relationship between on-going pain and acute thermal pain in patients suffering from chronic pain. This experimental study in cold and heat sensitivity was performed in order to test the following hypothesis: that fibromyalgia patients scoring high in current background pain tolerate less experimental thermal pain in the skin than patients with low scores. Ethical aspects of the study are discussed. The level of tolerable experimental thermal stimuli was tested and compared between the 'low-score' and the 'high-score' patients. Background pain seemed to affect the intensity of experimental cold pain. Clinical routine examinations and bodily care of the skin that might interfere with background pain in the fibromyalgia patients are discussed. Clinical practice should be carefully planned in order to assist fibromyalgia patients in understanding and coping with thermal conditions that might influence background pain.

The effect of an acute pain service on nurses' knowledge and beliefs about post-operative pain

The management of post-operative pain has been an area of concern for many years, with many studies focusing on the knowledge and beliefs of nurses working in this area. Following the report of the Royal College of Surgeons & College of Anaesthetists (1990) in the UK, there has been a rapid expansion in the development of Acute Pain Services (APS) in an attempt to counter these concerns. This descriptive study considers the possible impact the introduction of an APS had on the knowledge and beliefs of nurses working in the surgical area. A closed-answer questionnaire was used to replicate an earlier study (Mackintosh, 1994) which took place before the introduction of the APS. Findings demonstrate a consistent but mainly statistically non-significant trend in all areas towards an improved knowledge base and more appropriate beliefs about pain.