Appropriately Timed Analgesics Control Pain Due to Chest Tube Removal

Abstract

• 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.

Postoperative pain experience and barriers to pain management in Chinese adult patients undergoing thoracic surgery

“…Fifty-eight patients' chest drains (61AE7%) were discontinued and removed during the above postoperative time period. Pain management for chest-tube removal was explored in western studies (Puntillo & Ley 2004, Bruce et al 2006, Friesner et al 2006, and appropriate analgesia was recommended with a combination of pharmacological and non-pharmacological methods such as breathing techniques, relaxation and premedication before the procedure to minimise this distressing experience for patients. No routine analgesics were prescribed for patients to manage the pain caused by chest-tube removal via retrospective review of patients' medical records in the study.…”

Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

“…Rationale: In a randomized double-blind study (124), the effects of two types of analgesics with different mechanisms of action were tested on CTR pain: a single 4-mg dose of IV morphine (an opioid) or a single 30-mg dose of IV ketorolac (a non-COX-1-specific NSAID). Procedural pain intensity scores did not differ significantly among the groups, although pain intensity was mild in both groups and the quality of evidence was limited by imprecision (small number of patients).…”

A randomized controlled trial of fentanyl in the pre‐emptive treatment of pain associated with turning in patients under mechanical ventilation: research protocol

“…Puntillo et al (2002b) reported that only 15% of patients in ICUs were given supplementary analgesia before nursing procedures. The use of pre-emptive analgesia before nursing procedures has been studied in the withdrawal of arterial lines after cardiac catheterization (Fulton et al 2000, Puntillo et al 2002a, the withdrawal of chest drainage tubes (Puntillo & Ley 2004) and the aspiration of secretions through the endotracheal tube (Brocas et al 2002, Arroyo-Novoa et al 2008. Results are diverse and do not allow a definite conclusion.…”

“…They found no differences between groups on pain scores and concluded that the procedure was not sufficiently painful to reflect the benefit of pharmacological treatments. Puntillo and Ley (2004) also performed a randomized study on withdrawal of chest drainage tubes. They compared the effect of three interventions: pre-emptive administration of morphine, pre-emptive administration of ketorolac and verbal information to the patient concerning the procedure.…”

“…Furthermore, it is a painful process in most patients. These points are especially important because, as explained above, several authors who have performed studies on pre-emptive analgesia found negative results and considered this was due to the relatively low pain induced by the selected procedure (Fulton et al 2000, Puntillo et al 2002a, Puntillo & Ley 2004.…”