Topical Analgesia for Chest Tube Removal in Cardiac Patients

Management of procedural pain in the intensive care unit

Pain is a common experience for inpatients, and intensive care unit (ICU) patients undergo more pain than other departmental patients, with an incidence of 50% at rest and up to 80% during common care procedures. At present, the management of persistent pain in ICU patients has attracted considerable attention, and there are many related clinical studies and guidelines. However, the management of transient pain caused by certain ICU procedures has not received sufficient attention. We reviewed the different management strategies for procedural pain in the ICU and reached a conclusion. Pain management is a process of continuous quality improvement that requires multidisciplinary team cooperation, pain-related training of all relevant personnel, effective relief of all kinds of pain, and improvement of patients' quality of life. In clinical work, which involves complex and diverse patients, we should pay attention to the following points for procedural pain: (1) Consider not only the patient's persistent pain but also his or her procedural pain; (2) Conduct multimodal pain management; (3) Provide combined sedation on the basis of pain management; and (4) Perform individualized pain management. Until now, the pain management of procedural pain in the ICU has not attracted extensive attention. Therefore, we expect additional studies to solve the existing problems of procedural pain management in the ICU.

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

OBJECTIVE

To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU.

DESIGN

Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017.

METHODS

Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified.

RESULTS

The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation.

CONCLUSIONS

We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.

The Impact of Using Ice on Quality of Pain Associated with Chest Drain Removal in Postcardiac Surgery Patients: An Evidence-Based Care

Background:

Patients undergoing cardiothoracic surgery require the placement of at least one chest drain. Chest Drain Removal (CDR) has been considered to be a painful event in patient’s postoperative recuperation.

Objective:

This study aimed to evaluate the impact of using ice on quality of pain associated with CDR in adult patients undergoing cardiac surgery

Materials and Methods:

This randomized, observer-blind, crossover trial was done on 51 post-cardiac surgery patients who had two chest drains in the Mashhad Heart Center in Iran. The patients were assigned to ice, placebo, and control groups. Ice and placebo bags were used over the region around the chest drains for 20 minutes prior to CDR. The quality of pain was assessedviaShort-Form McGill Pain Questionnaire (SF-MPQ) before and after CRT. The data were analyzed through the SPSS software using ANOVA, Kruskal-Wallis, and Chi-square tests.

Results:

The study findings revealed that the three groups were not significantly different regarding pain quality before CDR (p=0.24). However, the ice bag group (4.6±4.4) was significantly different from the placebo (8.1±6.9) and control groups (7.1±5.3) concerning the pain quality score immediately after CDR (p<0.05). The results of chi-square test also showed that the three groups were significantly different regarding “hot-burning” (p=0.009). However, no significant differences were observed with regard to other items of SF-MPQ.

Conclusion:

The results indicated that ice bag application could be used as an effective, safe, and inexpensive non-pharmacological intervention to reduce patients’ pain and increase their comfort during CDR.

The use of cold therapy, music therapy and lidocaine spray for reducing pain and anxiety following chest tube removal

AIM

To determine the effect of cold therapy, music therapy and lidocaine spray on pain and anxiety following chest tube removal (CTR).

METHODS

This study was a randomized clinical trial. The participants were randomly assigned either one of four groups: control group, cold therapy, music therapy, and lidocaine spray. The primary outcome of the study was to measure pain using Visual Analog Scale. Anxiety was used as secondary outcome.

RESULTS

Thirty patients in each arm completed the study. There was no difference in pain scores between groups immediately after and 20 min after CTR (F = 2.06, p = 0.108). However, there was a significant difference between the anxiety scores of control and intervention groups 20 min after CTR (p < 0.05).

CONCLUSIONS

Cold therapy reduced anxiety levels after the procedure. A multimodal approaches, such as the administration of pharmacologic agents in conjunction with non-pharmacological interventions including cold therapy may also be suggested.

Transcutaneous nerve stimulation for pain relief during chest tube removal following cardiac surgery

Background and Aims

In patients undergoing open heart surgery, chest tubes are removed postoperatively when patients are well awake and stable. Pain during chest tube removal can be moderate to severe and can be the worst experience of hospitalization. Various modalities of pain relief during chest tube removal have been tried with variable results. We sought to examine the effect of transcutaneous electrical nerve stimulation (TENS) as an intervention for pain relief during chest tube removal after cardiac surgery.

Material and Methods

In a tertiary care center, fifty patients undergoing open heart surgery were randomized into two groups. Group TENS (n = 25) received TENS from 30 min before and continued up to 30 min after chest tube removal. Control Group (n = 25) did not receive TENS. In both the groups, additional analgesic medication was provided on demand, besides the standard analgesic regime which was injection ketorolac 30 mg intramuscularly every 8 h. Patients were studied for pain during chest drain removal and pain related nausea, vomiting, and sense of well-being.

Results

Mean visual analog pain score assessed for chest tube removal was significantly less 4.1 ± 1.2 (P < 0.05) in TENS Group as compared to 6.1 ± 0.8 in Control Group. Significantly greater number of patients (n = 14) (P < 0.05) in Control Group demanded additional analgesia as compared to TENS Group (n = 5). Feeling of well-being, improvement in appetite, and sleep was better in TENS Group as compared to Control Group.

Conclusion

We conclude that TENS might not replace the conventional analgesics but has definite adjuvant role in decreasing pain scores and improves sense of well-being during chest tube removal after cardiac surgery.

Comparison of Ice Packs Application and Relaxation Therapy in Pain Reduction during Chest Tube Removal Following Cardiac Surgery

Background:

Usually the chest tube removal (CTR) has been described as one of the worst experiences by patients in the intensive care unit.

Aim:

This study aimed to compare the effects of cold therapy and relaxation on pain of CTR among the patients undergoes coronary artery bypass graft surgery.

Materials and Methods:

This single-blinded clinical trial was done on 80 post-cardiac surgery patients in the heart hospital of Sari-Iran. The patients were assigned to three randomized groups that included cold therapy, relaxation, and control groups. Data analysis was done by T-test, Chi-square, generalized estimating equations and repeated measures analysis variance tests.

Results:

The groups had no significant differences in pain intensity before CTR (P = 0.84), but immediately after CTR there was a significant difference between the treatment (cold application and relaxation groups) and control groups (P = 0.001). There was no significant difference between relaxation and cold therapy groups.

Conclusion:

Regarding the relaxation and cold application methods showed relatively equal effects on reducing the pain owing to CTR. Thus, the use of relaxation because of economics, without side effects, easy to use and effective is recommended by the authors to the practitioners.

Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41:263-306. [PMID: 23269131 DOI: 10.1097/ccm.0b013e3182783b72]

OBJECTIVE

To revise the "Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult" published in Critical Care Medicine in 2002.

METHODS

The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over 6 yr in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method (http://www.gradeworkinggroup.org) to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey (http://www.esurvey.com). All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against (-) an intervention. A strong recommendation (either for or against) indicated that the intervention's desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase "We recommend …" is used throughout. A weak recommendation, either for or against an intervention, indicated that the trade-off between desirable and undesirable effects was less clear. For all weak recommendations, the phrase "We suggest …" is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflict of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding.

CONCLUSION

These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.

Supercooling agent icilin blocks a warmth-sensing ion channel TRPV3

Transient receptor potential vanilloid subtype 3 (TRPV3) is a thermosensitive ion channel expressed in a variety of neural cells and in keratinocytes. It is activated by warmth (33–39°C), and its responsiveness is dramatically increased at nociceptive temperatures greater than 40°C. Monoterpenoids and 2-APB are chemical activators of TRPV3 channels. We found that Icilin, a known cooling substance and putative ligand of TRPM8, reversibly inhibits TRPV3 activity at nanomolar concentrations in expression systems like Xenopus laeves oocytes, HEK-293 cells, and in cultured human keratinocytes. Our data show that icilin's antagonistic effects for the warm-sensitive TRPV3 ion channel occurs at very low concentrations. Therefore, the cooling effect evoked by icilin may at least in part be due to TRPV3 inhibition in addition to TRPM8 potentiation. Blockade of TRPV3 activity by icilin at such low concentrations might have important implications for overall cooling sensations detected by keratinocytes and free nerve endings in skin. We hypothesize that blockage of TRPV3 might be a signal for cool-sensing systems (like TRPM8) to beat up the basal activity resulting in increased cold perception when warmth sensors (like TRPV3) are shut off.

Bolus remifentanil for chest drain removal in ICU: a randomized double-blind comparison of three modes of analgesia in post-cardiac surgical patients

PURPOSE

We compared 1 versus 0.5 microg/kg bolus remifentanil versus placebo in alleviating pain due to chest drain removal. Effects on sedation, respiratory rate (RR), oxygen saturation, heart rate (HR) and blood pressure were also evaluated.

METHODS

Sixty patients following cardiac surgery were enrolled in this prospective, randomized, double-blind clinical trial. Patients were randomized to 1 or 0.5 microg/kg remifentanil or placebo. All received standardized analgesia. Visual analog scale (VAS) pain scores and cardio-respiratory data were recorded pre-procedure, at drain removal and at 2 min intervals post procedure.

RESULTS

Patients receiving remifentanil had statistically significantly less pain than placebo at drain removal [median (25-75%) VAS: 0.5 microg/kg remifentanil 1 (0-2) versus placebo 5 (3-6), P = 0.001; 1.0 microg/kg remifentanil 0 (0-2) versus placebo 5 (3-6), P = 0.0001]. VAS scores between remifentanil groups were equivalent. Remifentanil 1 microg/kg versus placebo at drain removal revealed significant reductions in HR [mean +/- standard deviation (SD): 76 +/- 15 versus 92 +/- 10, P = 0.01], blood pressure [mean +/- SD: 103 +/- 22 versus 131 +/- 14, P = 0.01] and RR [median (25-75%): 10 (8-12) versus 16 (14-18), P = 0.001]. Remifentanil 0.5 microg/kg versus placebo at drain removal revealed significant reductions in blood pressure [mean +/- SD: 116 +/- 19 versus 131 +/- 14, P = 0.02] and RR [median (25-75%): 12 (10-13) versus 18 (16-18), P = 0.001]. SpO(2) at drain removal was significantly reduced when comparing 1 microg/kg remifentanil versus placebo [median (25-75%): 94 (88-97) versus 97 (96-98), P = 0.049] but not 0.5 microg/kg remifentanil versus placebo. Two patients became apnoeic following 1 microg/kg remifentanil, necessitating respiratory support. Sedation scores in all groups were similar.

CONCLUSIONS

Bolus remifentanil at the tested doses delivers excellent analgesia, but 1 microg/kg remifentanil results in respiratory depression. Remifentanil bolus at 0.5 microg/kg is safe and effective for chest drain removal after heart surgery in ICU.

Comparison of analgesic efficacy of fentanyl and sufentanil for chest tube removal after cardiac surgery

Chest tube removal in the postcardiac surgical patients is a painful and distressful event. Fentanyl and sufentanil have not been used for pain control during chest tube removal in the postoperative period. We compared efficacy offentanyl and sufentanil in controlling pain due to chest tube removal. One hundred and forty one adult patients undergoing cardiac surgery were recruited in a prospective, randomized, double blind, placebo controlled study. Patients were randomized to receive either 2 microg/Kg fentanyl IV or 0.2 microg/Kg sufentanil IV or 2 ml isotonic normal saline, 10 min before removing chest tubes. Pain intensity was assessed by measuring visual analog scale pain score 10 minutes before removing chest tubes and 5 min and 20 min after removing chest tubes. Level of sedation, heart rate, arterial pressure, oxygen saturation, and respiratory rate were recorded by a blinded observer at the same time intervals. Mean pain intensity scores 10 minutes before removal of chest tubes infentanyl, sufentanil and control groups were 23.88+/-5.2, 25.10+/-5.39 and 23.64+/-6.10 respectively. The pain scores 5 minutes after chest tube removal were reduced to 20.11+/-6.9 (p<0.05) in the fentanyl group and 13.60+/-6.60 (p<0.05) in the sufentanil group, whereas in control group pain scores increased to 27.97+/-8.39 (p<O.05). The pain scores in sufentanil group were significantly lower compared with fentanyl or control group. Sedation scores remained low in all groups and patients remained alert and none of the patients showed any adverse effects of opioids. Heart rate, arterial pressure and respiratory rate had least variations in sufentanil group than fentanyl or control group.