CE Article and Journal Club Feature

APPROPRIATELY TIMED ANALGESICS CONTROL PAIN DUE TO CHEST TUBE REMOVAL By Kathleen Puntillo, RN, DNSc, and S. Jill Ley, RN, MS. From the School of Nursing, University of California, San Francisco (KP), and the Cardiac Surgery Service, California Pacific Medical Center (SJL), San Francisco, Calif.

• BACKGROUND Pain during chest tube removal can be moderately to severely intense and distressful to patients. Little evidence-based research has guided clinicians in attempts to alleviate such pain. • OBJECTIVE To test pharmacological and nonpharmacological interventions to alleviate pain during chest tube removal in cardiac surgery patients. • METHODS Four interventions were tested in 74 patients in a randomized, double-blind study: (1) 4 mg intravenous morphine and procedural information; (2) 30 mg intravenous ketorolac and procedural information; (3) 4 mg intravenous morphine plus procedural and sensory information; and (4) 30 mg intravenous ketorolac plus procedural and sensory information. Analgesics were administered to correspond to peak effect, and scripted information was provided. Pain intensity and pain distress were measured before analgesic administration, immediately after chest tube removal, and 20 minutes later. Pain quality was measured immediately after chest tube removal. Level of sedation was measured before and 20 minutes after chest tube removal. Repeated-measures analyses of variance were used to test differences among groups over time. • RESULTS Pain intensity, pain distress, and sedation levels did not differ significantly among groups. However, procedural pain intensity (mean 3.26, SD 3.00) and pain distress (mean 2.98, SD 3.18) scores for all were low. Patients remained alert, regardless of which analgesic was administered. • CONCLUSIONS If used correctly, either an opioid (morphine) or a nonsteroidal anti-inflammatory (ketorolac) can substantially reduce pain during chest tube removal without causing adverse sedative effects. Thus, clinicians may choose among several safe and effective analgesic interventions during chest tube removal. (American Journal of Critical Care. 2004;13:292-304)

CE

Notice to CE enrollees:

A closed-book, multiple-choice examination following this article tests your understanding of the following objectives: 1. Identify pharmacological and nonpharmacological interventions for patients undergoing chest tube removal 2. Discuss pain management options for patients undergoing chest tube removal 3. Extrapolate useful information for application to own practice

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ach year in the United States as many as 363 000 patients undergo cardiac surgery, 1 which often requires the insertion of chest tubes to facilitate lung expansion and drainage of fluids. When no longer needed, the tubes are removed during the early recuperative phase. Determining an optimal intervention to relieve pain during such a frequently performed procedure may help promote pain control in critically ill patients.

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AMERICAN JOURNAL OF CRITICAL CARE, July 2004, Volume 13, No. 4

Background Patients describe chest tube removal as a painful event in their postoperative recuperation2-5 and report that the pain is poorly managed.5-9 No national standards have been set for management of pain associated with chest tube removal. In fact, in a national survey10 of more than 500 nurses, only 16.3% of these nurses’ patients had a routine prescription for pain medication before chest tube removal.

According to a national survey of nurses, few patients have a routine prescription for pain medication before chest tube removal. Morphine is one of the most often, if not routinely, used opioids for treating pain due to chest tube removal.5,10 Acting at central µ1 and µ2 opioid receptors,11 morphine has a rapid onset of action (124 umol/L [1.4 mg/dL]), (3) allergies to NSAIDs or morphine, (4) history of gastric bleeding, (5) cardiac transplantation, and (6) inability to speak or read English. Exclusion criteria 2 through 5 were included because use of ketorolac would be contraindicated in such instances. The study site was a tertiary care teaching hospital that performs approximately 250 adult cardiac surgical procedures annually. Measures

Demographic and Surgical Characteristics. Demographic information collected through chart review included the following: age, sex, and ethnicity of each patient; diagnosis; specific type of cardiac surgery; specific type of chest tube (mediastinal or pleural); and postoperative pain medications other than study drugs administered in the hour preceding chest tube removal. Self-report Measure of Pain Intensity. Pain intensity was measured by using a horizontal numeric rating scale (NRS) from 0 to 10, with higher numbers meaning greater pain intensity. This type of NRS is used widely in clinical practice and research because of its ease of use. Even critically ill patients, some of whom were intubated, were able to rate their surgical26 and procedural5,6 pain intensity by using an NRS, providing support for its feasibility of use with the acutely ill patients in our study. Validity and reliability of the NRS have been established.27-29 Self-report Measure of Pain Distress. Pain distress is the pain dimension that relates to negative emotional responses.20,25 Pain distress was measured by using a horizontal NRS from 0 to 10, with higher numbers meaning greater pain distress. Pain distress scales have been used to test effectiveness of interventions for experimental21,22 and clinical21,25 pain. Self-report Measure of Pain Quality. The word list of the McGill Pain Questionnaire, Short Form (MPQ-

SF)30 was used to measure the quality of pain during chest tube removal immediately after chest tubes were removed. The list contains 11 sensory words, such as “sharp” and “stabbing,” and 4 affective words, such as “punishing-cruel” and “fearful.” The magnitude of each word is graded on a 4-point scale, from none (0) to severe (3). Sensory scores range from 0 to 33; affective scores range from 0 to 12. Concurrent validity between the MPQ-SF and the MPQ-Long Form has been reported.30 Summation of sensory and affective word scores is the method used by the developers of the MPQ-SF to evaluate treatment effects.30 The α reliability coefficients for the sensory and affective dimensions of the MPQ-SF range from .75 to .83.26 In order to determine what words were used most often to describe the painful sensations associated with chest tube removal, composite scores were calculated from 2 previous studies of pain associated with chest tube removal.5,6 Words with the highest mean scores and, thus, the highest rankings were “sharp,” “tender,” “shooting,” “heavy,” “hot-burning,” and “stabbing.” The MPQ-SF was administered after chest tube removal. Sedation Assessment. Level of sedation was assessed to determine if differences existed between patients who received morphine and those who received ketorolac because sedation may be an adverse outcome of analgesic interventions for pain due to chest tube removal. Clinicians may be hesitant to administer an analgesic before chest tube removal that makes a patient too sedated. Level of sedation was determined by using the Observer’s Assessment of Alertness/Sedation (OAA/S) Scale. 31 The scale has 4 categories: responsiveness, speech, facial expression, and eyes, with 3 to 5 options in each category from which to choose. The sum score ranges from 1 to 20, with lower scores indicating a deeper level of sedation. Validity and reliability of the OAA/S Scale were tested in 18 subjects who received either placebo or a titrated dose of midazolam to produce heavy or light sedation.31 Interrater reliability of the composite scores was from .87 to .94 and of the sum scores was from .86 to .96. Criterion and construct validity were established as well. The OAA/S Scale can be administered in approximately 1 minute. Training sessions were conducted in the manner described by Chernik et al31 to establish a high degree of interrater reliability. A minimal level of 100% agreement between a pair of research nurses was obtained before a research nurse conducted study sedation assessments independently. Procedure

Approval was obtained from the institutional review board of California Pacific Medical Center, San Fran-

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Table 1

Table 2 Demographics of patients in the study (N = 74)* Script With Procedural Information Only

You are going to have your chest tube removed in a little while. It will be done while you are lying in bed with the head of your bed up a little bit. The dressing that is over your chest tube will be taken off. You’ll be asked to take a deep breath and to hold it to the count of three: like this—1 . . . 2 . . . 3. . .—until you’re told that you can breathe out. You’ll be asked to practice. Then you’ll be asked to take a deep breath and hold it as the chest tube is pulled out rapidly. After the tube comes out, you’ll have a bandage put over the area where the chest tube was, and that will be the end of the procedure. The procedure is brief, and you will receive pain medication before the chest tube is removed. Script With Both Procedural and Sensory Information You are going to have your chest tube removed in a little while. It will be done while you are lying in bed with the head of your bed up a little bit. The dressing that is over your chest tube will be taken off. You’ll be asked to take a deep breath and to hold it to the count of three: like this—1 . . . 2 . . . 3 . . .—until you’re told that you can breathe out. You’ll be asked to practice. Then you’ll be asked to take a deep breath and hold it as the chest tube is pulled out rapidly. You can expect to feel certain sensations while the chest tube is being removed. Other people who have had their chest tubes removed have sometimes described the sensations as sharp, or tender, or shooting, or heavy, or hotburning, or stabbing. After the tube comes out, you’ll have a bandage put over the area where the chest tube was, and that will be the end of the procedure. The procedure is brief, and you will receive pain medication before the chest tube is removed.

cisco, Calif, where the study was performed, and from the board of the University of California, San Francisco. Informed consent was obtained from patients by a member of the research team before chest tube removal. California Pacific Medical Center has no routine method of medicating patients for chest tube removal. We thought that any differences among patients in the type and amount of postoperative analgesics would be evenly distributed across groups through randomization. The clinical research pharmacy service at California Pacific Medical Center was responsible for the randomization and blinding of study drugs and information scripts. (See scripts in Table 1.) Upon notification that chest tube removal was planned for a study subject, a pharmacist furnished a packet containing a syringe with 1 of the 2 study drugs (4 mg morphine or 30 mg ketorolac), a syringe containing a placebo (isotonic sodium chloride solution), and a sealed envelope with either a procedural information script or both procedural and sensory information scripts. All syringes 296

Characteristic Age, mean (SD), years Sex, No. (%) of patients Male Ethnicity, No. (%) of 73 patients reporting White Asian Hispanic African American Other Surgical procedure, No. (%) of patients Coronary artery bypass graft Valve Both procedures Other Type of chest tube(s) removed, No. (%) of patients Mediastinal Pleural and mediastinal Unknown

Value 65.9 (11.4) 55 (74.3)

49 (67.1) 15 (20.5) 3 (4.1) 2 (2.7) 4 (5.5)

52 (70.3) 13 (17.6) 6 (8.1) 3 (4.1)

54 (73.0) 19 (25.7) 1 (1.4)

*Because of rounding, percentages do not total 100.

had a similar appearance. A 4-mg dose of morphine was chosen because 3 mg or less is ineffective for blocking pain due to chest tube removal,5,6 and a 4-mg intravenous dose of morphine is within the reported equivalency range for 30 mg of intravenous ketorolac.32 Patients were given specific directions on how to use the NRS to rate their pain intensity. These ratings were done before, immediately after, and 20 minutes after chest tube removal (when recovery from the event was expected). Pain distress was rated at the same time as pain intensity. All patients were extubated by the time of data collection and could, therefore, verbalize their responses. Time 1: Before Chest Tube Removal. On the first postoperative morning, patients’ readiness for chest tube removal was determined by the critical care intensivist according to standard criteria (ie, chest tube drainage