Topical Analgesia for Chest Tube Removal in Cardiac Patients

doi:10.1053/j.jvca.2005.07.024

Journal of Cardiothoracic and Vascular Anesthesia

Volume 19, Issue 6, December 2005, Pages 719-722

https://doi.org/10.1053/j.jvca.2005.07.024 Get rights and content

Objectives: The aim of this study was to evaluate the efficacy of topical valdecoxib as an analgesic during chest tube removal in postcardiac surgical patients.

Design: A prospective, randomized, double-blind, placebo-controlled study.

Setting: The study was performed in the cardiac intensive care unit.

Participants: Fifty-three patients undergoing elective cardiac surgery were randomized to receive either topical valdecoxib or liquid paraffin on the chest tube exit sites.

Intervention: Topical valdecoxib was applied to 1 of the 2 chest tube sites (mediastinal or pericardial) in a randomized manner before drain removal. Liquid paraffin was used as the control on the other tube site. The patient and observer were blinded to the drug and control.

Measurements and Main Results: Pain was assessed by using the visual analog scale. The heart rate and systolic blood pressure were recorded at each stage by the blinded observer. Statistical analysis of the obtained data was undertaken using the nonparametric Mann-Whitney U test. The median pain scores before, during, and after tube removal in the control group were 2, 5, and 4, respectively. The valdecoxib group had corresponding scores of 1, 2, and 2. The pain scores were significantly lower in the valdecoxib group. No differences were seen in the heart rate and systolic blood pressure between the 2 groups. No adverse effects were noted.

Conclusions: Topical valdecoxib is a safe and effective topical analgesic for chest tube removal in cardiac patients.

Section snippets

Methods

After approval from the hospital ethics committee, 53 consecutive adult patients undergoing cardiac surgery from March to May 2004 were enrolled in the study. Informed consent was obtained from all patients. None of the patients was receiving any inotropic/vasodilator infusions at the time of chest tube removal. No systemic analgesics had been administered for at least 4 hours before the procedure. The visual analog scale (VAS) was explained to each patient by the investigator on the

Results

There were 38 male and 15 female patients, with a median age of 50 years (interquartile range 41-56.5 years). Thirty-four patients underwent coronary revascularization, 10 had valve replacements, and 9 underwent intracardiac repair for septal defects. The chest tubes were removed on the second postoperative day for 19 patients and on the third day for 34 patients. The median time interval between drug application and tube removal was 45 minutes (interquartile range 40-60 minutes).

After

Discussion

Many intensivists would recommend administration of analgesia before chest tube removal; however, there are no specific recommendations in this area.¹ This can be attributed partly to varying institutional practices and partly to this procedure being perceived as a “minor” procedure by the attending staff.

In a study using inhalation agents, Bryden et al⁷ compared entonox alone with entonox and isoflurane (0.25%) during chest tube removal and found that entonox with isoflurane was more effective

Acknowledgment

The authors thank Drs Dilip Kulkarni, Mantha Srinivas, and D. Padmaja for their valuable advice in the statistical analysis used in this article.

References (19)

L. Mimnaugh et al.
Sensation experienced during removal of tubes in acute postoperative patients
Appl Nurs Res
(1999)
J. Scott et al.
Graphic representation of pain
Pain
(1976)
F. Gaston-Johansson et al.
Rheumatoid arthritisDetermination of pain characteristics and comparison of RAI and VAS in its measurement
Pain
(1990)
S.B. Bird et al.
Clinically significant changes in pain along the visual analog scale
Ann Emerg Med
(2001)
K.A. Puntillo
Dimensions of procedural pain and its analgesic management in critically ill surgical patients
Am J Crit Care
(1994)
M.M. Carson et al.
Managing pain during mediastinal chest tube removal
Heart Lung
(1994)
A.G. Gift et al.
Sensations during chest tube removal
Heart Lung
(1991)
B. Paiement et al.
Intubation and other experiences in cardiac surgeryThe consumer’s views
Can Anaesth Soc J
(1979)
T.J. McMurray et al.
Low-dose propofol for chest tube removal
Anaesthesia
(1995)

There are more references available in the full text version of this article.

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The chest tube can prevent severe pulmonary complications. This device usually comes out within 24–48 h after surgery [2,3]. The presence of a chest tube is vital for patients [2] however, patients are often unable to breathe deeply due to pain at the site of chest surgery [4], therefore patients with chest tube are at risk for atelectasis.
Hugo point is the most important pain control point in the body, so the study was performed to determine the effect of Hugo point massage on respiratory volume and the pain intensity after chest tube placement.
The study was performed as a randomized crossover clinical trial on 61 patients with a chest tube. Patients were placed in every 2 h through the ternary permutation block once under a false point pressure, once under a Hugo point pressure, and once without intervention. Data were collected using a questionnaire of demographic, clinical information, the Numerical Pain Rating Scale, and spirometry. Analysis of variance with repeated measures was used to analyze the data.
There was no significant difference in the pain intensity before and during the intervention between the three groups. However, after the intervention, the mean pain intensity in the control group was higher than the Hugo and placebo groups (P < 0.001), and the mean pain intensity in the placebo group was higher than in the Hugo group (P < 0.001). There was no significant difference between the three groups in terms of the rate of ascent and retention time of spirometry ball the three times before, during, and after the intervention.
Hugo point massage reduces the pain intensity; however, has no significant effect on their respiratory volume. Hugo point massage is recommended to reduce the severity of pain in patients with chest tube.
The use of cold therapy, music therapy and lidocaine spray for reducing pain and anxiety following chest tube removal
2019, Complementary Therapies in Clinical Practice
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The results of this study are in agreement with those of aforementioned research. In contrast, early randomized-controlled trials found that the application of the topical pharmacological agents was more effective in reducing pain associated with CTR [5,10]. This discrepancy may be explained by differences in patient profile.
To determine the effect of cold therapy, music therapy and lidocaine spray on pain and anxiety following chest tube removal (CTR).
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.
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).
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.
Evaluation of pain during mobilization and endotracheal aspiration in critical patients
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1) Evaluar la prevalencia de dolor durante 2 procedimientos de enfermería, y 2) analizar la utilidad de ciertos signos vitales y del índice biespectral (BIS) para detectar dolor.
Estudio prospectivo, observacional y analítico de medidas repetidas en pacientes con ventilación mecánica y sedación. Los procedimientos evaluados fueron la aspiración endotraqueal y la movilización con giro. El dolor se evaluó mediante la Behavioral Pain Scale. Valores ≥ 3 se consideraron dolorosos. Se registraron distintos signos fisiológicos y los valores del BIS. Una variación porcentual > 10% se consideró clínicamente relevante.
Se analizaron 146 procedimientos en 70 pacientes. La prevalencia de dolor durante los procedimientos fue del 94%. Los signos vitales y los valores del BIS aumentaron significativamente durante los procedimientos respecto el reposo, pero solo la variación del BIS alcanzó relevancia clínica. En un subgrupo de pacientes que recibieron analgesia preventiva antes de los procedimientos, el dolor disminuyó significativamente respecto a los pacientes que no recibieron analgesia preventiva (−2 [RIQ: {−5}-0] vs. 3 [RIQ: 1-4]; p < 0,001, respectivamente).
Los procedimientos evaluados son dolorosos. La variación de los signos vitales no es un buen indicador de dolor. La variación del BIS podría ser útil, pero precisa nuevas investigaciones. La administración de analgesia preventiva disminuye la prevalencia de dolor durante los procedimientos.
1) To assess the prevalence of pain during nursing care procedures, and 2) to evaluate the usefulness of certain vital signs and the bispectral index (BIS) in detecting pain.
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The procedures evaluated in this study are painful. Changes in vital signs are not good indicators of pain. Changes in BIS may provide useful information about pain, but more research is needed. The administration of preemptive analgesia decreases pain during the procedures.
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An early randomized-controlled trial found that the application of the topical lidocaine-prilocaine cream (EMLA) was more effective than IV morphine in preventing CTR pain.14 A later study found that pain intensity was significantly lower in patients who received a topical application of the NSAID valdecoxib (Bextra) compared with placebo (liquid paraffin) over the CT site before CTR.15 Very little research has been done on the use of nonpharmacologic methods for management of CTR pain; however, a few studies have evaluated the effects of cold application.
The Effect of Cold Application in Combination with Standard Analgesic Administration on Pain and Anxiety during Chest Tube Removal: A Single-Blinded, Randomized, Double-Controlled Study
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The aim of this study was to investigate the effect of cold application on pain and anxiety during chest tube removal (CTR) in patients who had undergone cardiac surgery. A single-blinded randomized design was used in this study. Ninety patients aged 18-74 years, hospitalized in the intensive care unit (ICU), who had a chest tube for a duration of at least 24hours were used for this convenience sample. The application of cold, placebo, or control therapies was randomized into three different groups. Sixty minutes before CTR was scheduled, an ICU nurse administered 10mg/kg paracetamol intravenously to all study subjects. Cold and warm packs covered with gauze dressing were applied to the area surrounding the chest tubes for 20minutes. Pain intensity, pain quality and situational anxiety for CTR were measured. Variance analysis and the latent growth model were used in the analysis of the data. Patients in the cold group had significantly lower pain intensity than the placebo group. The perception of pain intensity measured by visual analog scores of patients in the cold group showed the least variation. There was no statistically significant difference in McGill Melzack Pain Questionnaire scores or in change of anxiety level between the three groups. The application of cold prolonged the length of time until analgesics were needed after CTR. Results showed that cold application reduced patients' intensity of pain due to CTR but did not affect anxiety levels or the type of pain. Cold application is recommended as a pain-relieving technique during CTR.
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Original articleTopical Analgesia for Chest Tube Removal in Cardiac Patients

Section snippets

Methods

Results

Discussion

Acknowledgment

Appl Nurs Res

Pain

Pain

Ann Emerg Med

Dimensions of procedural pain and its analgesic management in critically ill surgical patients

Am J Crit Care

Managing pain during mediastinal chest tube removal

Heart Lung

Sensations during chest tube removal

Heart Lung

Intubation and other experiences in cardiac surgeryThe consumer’s views

Can Anaesth Soc J

Low-dose propofol for chest tube removal

Anaesthesia

Original article
Topical Analgesia for Chest Tube Removal in Cardiac Patients