Objective: To evaluate the quality of pain management in cardiac ICU patients by using a questionnaire. Methodology: All post cardiac surgery patients between 18 and 75 years old were included in this survey. Chronic pain patients, paediatric patients, emergency surgeries were excluded. A predesigned proforma was prepared according to American Pain Society recommendations and distributed among Cardiac ICU patients after 24 hours of extubation. This proforma was explained to the patients and collected later. The questionnaire was related to pain severity, aggravating and relieving factors, side effects of analgesics, affective experience and satisfaction with pain management. Results: Total 308 patients participated in one year period. 243 (78.9%) were male and 65 (21.1%) were female. Multimodal analgesia was used in most of the patients. Severity of pain was described as mild 70% and moderate 28.6%. Most of the patients complained of sharp pain 100 (37.5%), mainly at the site of incision 129 (41.9%). The main aggravating factor associated with increased pain was deep breathing 118 (39.8%) while pain was minimized by taking pain medications 40.6%. A significant association was found between preoperative counseling about pain options and satisfaction. 96.8% reported satisfaction with pain management. Conclusion: Although overall pain control was reported as adequate and patients were highly satisfied, there were areas which need further improvement. These include strategies to provide preoperative information about postoperative pain management and better training of medical staff to assess and manage pain. Additionally, the concerns and fears of patients about pain treatment need to be addressed.
Effective pain management after cardiac surgery is essential to prevent poor outcome. There is a higher incidence of chronic (21% - 55%) [
Pain originates from muscles, bone, ligaments and tendons due to incision and sternal retraction. Fractured ribs and dislocation of costochondral junction and joint between ribs and spine are not uncommon [
Various methods have been used to control post cardiac surgery pain and these include narcotic and non- narcotic analgesic drugs in bolus doses or in infusion forms. Non pharmacological techniques have also been tried to relieve pain. These include distraction techniques, application of cold or hot packs, meditation, and massage. The undertreated acute and severe pain leads to tachycardia, atelectasis and pneumonia, increased oxygen consumption, hyperglycemia and chronic pain.
American Pain Society [
The objective of the survey was to evaluate the quality of postoperative pain management in cardiac surgery patients by using modified American Pain Society’s patient outcome questionnaire.
This prospective survey was conducted in the cardiac intensive care unit (CICU) of Aga Khan University Hospital Karachi. This study was approved by departmental research committee. All post cardiac surgery patients between the age of 18 and 75 were included in this one year survey. Patients excluded from this study were those who required reopening for bleeding, extubated after 24 hours of CICU stay, discharged from CICU within 24 hrs. of extubation, unable to understand the survey form, admitted with IABP, chronic pain patients, patients on antipsychotic drugs and all the emergency cases.
A questionnaire in English and Urdu was distributed among CICU patients after 24 hours of extubation and collected later. The patients were selected using non-probability sampling. If patients cannot fill out the survey form due to any reason, then a resident was allowed to fill it out via face to face interview. Survey form was explained to the patients and consent was taken preoperatively.
All data was recorded on a survey form, which included demographics and 15 questions related to pain severity, its effect on activity, side effects, affective experience and satisfaction. All information on the form was entered in SPSS by a research assistant.
Statistical analysis was performed using Statistical Packages for Social Science version 19 (SPSS Inc., Chicago, IL). Frequency and percentages were computed for categorical observation and analyze by chi-square test while mean and standard deviation were estimated for numeric variables and analyzed by the independent sample test or Mann-Whitney U test. P ≤ 0.05 was considered as significant.
Total 308 patients participated in the survey. Out of these 243 (78.9%) were males while 65 (21.1%) were females. Mean age of all the patients was 56.15 ± 10.85. Most of the patients 248 (80.5%) underwent coronary artery bypass surgery and only 22 (7.14%) had valvular surgery while rest of the patients had combination of procedures. Modalities of pain management included intravenous infusion 41 (13.3%) and PCIA 23 (7.5%). There were 290 (94.2%) patients who received 1 gm of intravenous paracetamol 6 hourly. Multimodal analgesia was used in most of the patients. Fixed and regular dose of narcotics was given in 269 (87.3%) patients while break through pain was managed by intermittent boluses of either morphine or tramadol. Commonly used drugs were tramadol 227 (73.7%), ketorolac 107 (34.7%) and morphine 116 (37.7%).
Left internal mammary artery (LIMA) was harvested in 215 (82.06) patients. These patients included CABG only and combination with other procedures.
A significant reduction of pain was associated with use of morphine and tramadol (P-value < 0.05). Overall pain intensity was described as mild 216 (70.1%) and moderate 88 (28.6%) while aggravating factor for pain was mainly deep breathing 118 (39.8%) and ambulation 86 (27.9%). Pain intensity was minimized by taking pain medications 40.6% or by staying immobile 66 (21.4%). Intensity of pain was relieved further after chest drain removal 80 (26%).
The commonest pain type was described as cutting or sharp 100 (37.5%) followed by pressure 77 (25%) and burning 68 (22.1%). Pain was presented at the site of incision (Median sternotomy) in 129 (41.9%) patients followed by chest drain site 104 (33.8%) (
Pain related investigation | n (%) |
---|---|
Factors associated with pain during CICU stay after extubation | |
Deep breathing | 118(39.8%) |
Ambulation | 86(27.9%) |
Turning or change of position | 29(9.4%) |
Chest tube removal | 62(20.1%) |
Back pain | 1(0.3%) |
Deep breathing + Ambulation | 9(2.9%) |
Deep breathing + Turning or change of position | 3(1%) |
Pain intensity since extubation | |
Mild | 216(70.1%) |
Moderate | 88(28.6%) |
Severe | 4(1.3%) |
What percentage of time, you were in severe pain during ICU stay | |
≤30% | 239(77.6%) |
30% to 50% | 59(19.2%) |
>50% | 10(3.2%) |
Did your pain relived or minimized by | |
Rest/staying immobile | 66(21.4%) |
Pain medications | 125(40.6%) |
Breathing superficially | 33(10.7%) |
Rubbing the pain site or holding a pillow on the chest | 4(1.3%) |
After chest tube removal | 80(26%) |
What type of pain did you experienced | |
Cutting/sharp | 100(32.5%) |
Burning | 68(22.1%) |
Throbbing | 63(20.5%) |
Pressure | 77(25%) |
Where did you feel the pain mostly | |
Site of incision | 129(41.9%) |
Chest tube site | 104(33.8%) |
Back pain | 22(7.1%) |
Throat | 1(0.3%) |
Everywhere | 3(1%) |
Site of incision + Chest tube site | 22(7.1%) |
Site of incision + Back pain | 1(0.3%) |
Chest tube site + Back Pain | 14(4.5%) |
Site of incision + Chest tube site + Limbs | 1(0.3%) |
Back Pain + Throat | 1(0.3%) |
Options for pain control were discussed in only 120 (39%) patients during preoperative visit by the anaesthetists. These patients also had higher satisfaction levels 89.2% than those who did not receive information about pain control (P-value < 0.004). Nausea 90 (29.2%) and drowsiness 91 (29.5%) were the major side effects mentioned by the patients (
The association of gender and type of surgery with overall pain control was also assessed by chi-square test but no statistical significance was found.
There were 96.8% patients found to be satisfied with the pain management, despite the fact that 44.8% would have liked to receive more pain medications and 30% complained of moderate to severe pain. Significant association was found among satisfaction and intensity of pain, type of pain and percentage of time participants experienced the pain (P-value < 0.05). Satisfaction grades were significantly increased when pain options were discussed preoperatively, patients received pain killers and when asked whether they would have liked to receive more pain killers (
Intensity of pain was significantly reduced when patient asked for pain killers (P-value = 0.005) but preoperative information about pain management options had no influence on the intensity of pain (P-value = 0.32). Anxiety was also associated with pain in about 50% of patients while few patients suffered depression. Out of 216 patients who complained of mild or no pain, about 129 also felt that it was pain causing the anxiety. There seems to be no correlation between the anxiety and severity of pain.
There were 138 patients who would like to receive more pain medications but they never called the nurses to provide them with the pain killers. Out of 44 patients who asked for pain killers, about 35 said they wanted more pain medication.
Pain after cardiac surgery is often undertreated [
In the present survey, the overall pain control was good to excellent and most of the survey participants were satisfied with the pain management in CICU. Patient’s opinion at the time of survey could be affected by several unmeasured factors like mood at the time of survey, understanding of questions and unrelated aspects of patient care. This source of error most likely would be distributed equally throughout the cohort. The intubation period was excluded from the survey because previous studies had also shown that some of the patients were not able to recall the intubation period [
Response regarding information and satisfaction of pain | n (%) | |
---|---|---|
Did you receive any information about pain treatment options before surgery | Yes Responses | 120(39%) |
Did you feel that the pain was interfering with your mobility or movement | Yes Responses | 196(63.6%) |
Did you wake up by pain during CICU stay | Yes Responses | 53(17.2%) |
Have you had any of these side effects | Nausea Vomiting Itching Dizziness Drowsiness | 90(29.2%) 32(10.4%) 13(4.2%) 73(23.7%) 91(29.5%) |
Did the pain cause you to feel | Anxious Depressed Frightened helpless | 166(53.9%) 36(11.7%) 30(9.7%) 20(6.5%) |
How satisfied you are with your pain treatment during CICU stay | Excellent Good Satisfactory Poor | 114(37%) 132(42.9%) 52(16.9%) 10(3.2%) |
Would you have liked to have received more pain medication | Yes Responses | 138(44.8%) |
Have you asked for pain killers during this time | Yes Responses | 44(14.3%) |
Variables | Satisfaction with your pain treatment during CICU stay | P-value | ||||
---|---|---|---|---|---|---|
Total | Excellent | Good | Satisfactory | Poor | ||
Pain intensity | 0.0005 | |||||
Mild | 216 | 105(48.6%) | 97(44.9%) | 13(6%) | 1(0.5%) | |
Moderate to severe | 92 | 9(9.8%) | 35(38%) | 39(42.4%) | 9(9.8%) | |
Type of Pain | ||||||
Cutting/sharp | 100 | 23(23%) | 36(36%) | 33(33%) | 8(8%) | 0.0005 |
Burning | 68 | 23(33.6%) | 38(55.9%) | 7(10.3%) | 0(0%) | 0.032 |
Throbbing | 63 | 19(30.2%) | 33(52.4%) | 8(12.7%) | 3(4.8%) | 0.25 |
Pressure | 77 | 49(63.6%) | 24(31.2%) | 4(5.2%) | 0(0%) | 0.0005 |
What percentage of time, you were in severe pain during ICU stay | 0.0005 | |||||
≤ 30% | 239 | 104(43.5%) | 107(44.8%) | 25(10.5%) | 3(1.3%) | |
30% to 50% | 59 | 10(16.9%) | 23(39%) | 23(39%) | 3(5.1%) | |
>50% | 10 | 0(0%) | 2(20%) | 4(40%) | 4(40%) | |
Did you receive any information about pain treatment options before surgery | 0.0005 | |||||
Yes | 120 | 65(54.2%) | 42(35%) | 12(10%) | 1(0.8%) | |
No | 188 | 49(26.1%) | 90(47.9%) | 40(21.3%) | 9(4.8%) | |
Would you have liked to have received more pain medication | 0.0005 | |||||
Yes | 138 | 30(21.7%) | 62(44.9%) | 38(27.5%) | 8(5.8%) | |
No | 170 | 84(49.4%) | 70(41.2%) | 14(8.2%) | 2(1.2%) | |
Have you asked for pain killers during this time | 0.0005 | |||||
Yes | 44 | 8(18.2%) | 14(31.8%) | 16(36.4%) | 6(13.6%) | |
No | 264 | 106(40.2%) | 118(44.7%) | 36(13.6%) | 4(1.5%) |
Multimodal pain management is essential for effective pain management. It also reduces the side effects of individual drugs. Combination of paracetamol and tramadol was the most commonly used therapy in this study. Morphine was administered for breakthrough pain on as per need basis. Yorke et al. [
Moderate type of pain was experienced by 33.6% of patients in whom left IMA was harvested while only 24% complaint of moderate pain when left IMA was not used for coronary artery bypass. This difference did not reach to a statistically significant level. It has been identified in previous studies as well [
The majority of the patients described their pain as cutting or sharp in contrast to the study of Aslan et al. [
Pain was increased by deep breathing, ambulation and chest tube removal. This observation is also endorsed by Mello et al. who described coughing and deep breathing as the aggravating factors for pain in most of the cardiac surgical patients [
Pain intensity was moderate to severe in most of the older studies [
Patients felt pain mostly at the site of incision and at the chest tube insertion site. Janelle et al. also noticed in their survey that 92% participants experience pain at the site of incision on chest [
Most of the participants did not receive any information about the intensity of pain after surgery and pain management options. Of those who complained of moderate or severe pain, 65% did not receive any information on pain management prior to surgery. Preoperative counseling concerning postoperative pain management had an impact on the satisfaction level [
Drowsiness and nausea were the most common side effects noticed by the patients. Incidence of nausea in one of the study was 12% [
Studies have indicated that patients are reasonably satisfied with their pain management in CICU [
Pain medications played a major role in relieving pain while patients were also more comfortable after the chest tube removal and by staying immobile and breathing superficially. Almost 45% would have wanted to receive more pain medications during their stay in CICU. Patients usually have many misconceptions and beliefs about pain medications [
As shown in previous studies that patients usually wait for nurses/physician to assess their pain which makes it very important for staff to assess pain and treat them early [
Overall pain management was perceived as adequate and patients were highly satisfied in our survey. Areas which still need improvement include strategies to provide preoperative information about postoperative pain management and better training of medical staff to assess and manage pain. Additionally, the concerns and fears of patients about analgesics, especially narcotics, need to be addressed.