PAIN CARE
Chest Tube Removal: An Expanded Role for the Bedside Nurse Brenda S. Hood, APRN, MS, CCNS, Whitney Henderson, RN, BSN, Chris Pasero, MS, RN-BC, FAAN CHEST TUBE REMOVAL is a common procedure performed in critical care units and post-coronary care units (PCCUs). Research has shown that the procedure is associated with moderate-tosevere pain, but it is performed often without preemptive supplemental analgesia.1-3 This is in large part because chest tubes are removed most often by physicians, physician assistants, and advanced practice registered nurses (APRNs) in an unscheduled fashion, usually during patient rounds, which limits the bedside nurse’s ability to plan ahead and premedicate for pain.
CT drainage measurements of less than 100 cc within an 8-hour period; Re-expansion of lung (s) on chest radiograph; Equal bilateral breath sounds; Improved respiratory status; Absence of fluctuations or bubbling in the water seal chamber. Generally, if the patient meets these requirements, the CT is ready to be removed.4 However, the duration of CT therapy varies widely and depends entirely on patient response to treatment.
Chest Tubes
Pain and Anxiety Associated With CTR
Chest tubes (CTs) are long (8 to 40 Fr gauge), clear, plastic semi-stiff tubes that are placed in the space between the fourth and fifth intercostals (Figure 1). The tube allows for drainage and collection of fluids and/or air from the pleural space. Lungs can become compressed with excess fluid and air; with the insertion of a CT, lungs are able to re-expand. CTs are placed for a variety of conditions, including major thoracic surgical procedures and trauma, pleural effusion, infection, and cardiac tamponade.
In landmark research conducted decades ago, Kinney, Kirchoff, and Puntillo identified CTR as a considerable source of pain.5 Later research showed similar results.3 Patients use the words ‘‘burning,’’ ‘‘sharp,’’ ‘‘stinging,’’ ‘‘pulling,’’ and ‘‘awful’’ to describe the sensations they feel during CTR.3,6,7
Indications for chest tube removal (CTR) after reexpansion of the lungs has occurred include the following:
Brenda S. Hood, APRN, MS, CCNS, is the Clinical Nurse Manager of the Post Coronary Care Unit and the Telemetry Unit at Integris Southwest Medical Center in Oklahoma City, OK; Whitney Henderson, RN, BSN, is a Team Manager of the Post Coronary Care Unit at Integris Southwest Medical Center in Oklahoma City, OK; and Chris Pasero, MS, RN-BC, FAAN, is a Pain Management Educator and Clinical Consultant in El Dorado Hills, CA. Conflict of interest: None to report. Address correspondence to Chris Pasero, 1252 Clearview Drive, El Dorado Hills, CA 95762; e-mail address: cpasero@ aol.com. Ó 2014 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2013.11.001
Journal of PeriAnesthesia Nursing, Vol 29, No 1 (February), 2014: pp 53-59
Decades ago, researchers encouraged the development of protocols for the pharmacologic management of CTR pain.5 Nevertheless, a literature review of 14 studies conducted 10 years later concluded that current protocols for the management of pain associated with CTR are nonexistent or unsatisfactory, and practice in this area should be revised.8 Current evidencebased critical care guidelines recommend the provision of preemptive supplemental analgesia and the use of nonpharmacologic interventions for CTR.9 Research is lacking regarding the relationship between anxiety and pain, and only a few studies have evaluated anxiety specifically related to CTR. However, research has shown that patients describe the procedure using words such as ‘‘distressing.’’10 The majority (44.8%) of patients in another study (N 5 74) selected the word ‘‘fearful’’ to describe the quality of CTR pain,
53
54
HOOD, HENDERSON, AND PASERO
Pharmacologic Interventions There is no consensus regarding the ideal analgesic approach for the prevention and treatment of CTRrelated pain.8 Research has been conducted on the use of a variety of pain medications, but with inconclusive results. A number of researchers have investigated the use of opioids. One study randomized 141 adults who underwent cardiac surgery to receive intravenous (IV) fentanyl 2 mcg/kg, IV sufentanil 0.2 mcg/kg, or IV normal saline (placebo) 10 minutes before CTR.11 Pain was assessed using a 0 to 100 mm visual analogue scale (VAS) 10 minutes before CTR and at 5 and 20 minutes after CTR. Before CTR, mean pain scores were similar among those who received fentanyl (23.88), sufentanil (25.10), and placebo (23.64). Post CTR pain scores in those who received sufentanil were significantly lower (13.6) than those who received fentanyl (20.11) and placebo (27.97). Heart rate, arterial pressure, and respiratory rate varied the least in those who received sufentanil. All patients remained alert and none experienced any adverse effects.
Figure 1. Chest tube placement. Published in Potter P, Perry A, Stockert P, Hall A. Fundamentals of Nursing, 8th Edition. Mosby, 2013: 849. Figure 4015. Copyright Elsevier 2013. Reprinted with permission.
indicating a high degree of anxiety related to the procedure.2 There is no doubt that poorly managed procedural pain results in considerable stress for many patients. An individualized approach should be taken to address anxiety related to CTR. It is important for clinicians to adequately address pain with appropriate analgesics before the procedure and recognize that some may benefit from mild sedation as well.
Researchers conducted three separate studies in children at a large tertiary pediatric hospital in England.1 One of the three studies evaluated the prevalence and characteristics of pain and analgesic practices and found that 76% of 135 children experienced moderate-to-severe pain during CTR. The second study evaluated self-administered 50% nitrous oxide and oxygen (Entonox) and found that pain increased despite the treatment during CTR. The third study randomized 14 children aged 3.5 months to 2.75 years to receive IV morphine or continuous flow Entonox for CTR. Results showed that both groups experienced moderate-to-severe pain and exhibited no differences in pain scores. The researchers concluded that morphine or Entonox alone do not provide adequate analgesia for CTR and further research is needed to determine the most effective interventions for the procedure. A study in adults reported similar results with the use of Entonox after randomizing 66 patients following coronary artery bypass graft and/or valve surgery to receive one of three analgesic interventions for CTR: 1) 0.1 mg/kg of IV morphine; 2) 20 mL of 0.5% bupivacaine via subcutaneous
PAIN CARE
infiltration at the drain site; or 3) inhaled 50% nitrous oxide in oxygen (Entonox) via a demand valve.12 Median pain scores were lowest in those who received bupivacaine and morphine. There were no differences among groups in arterial blood pressure (BP), heart rate, PaCO2, oxygenation, or sedation. An early randomized, placebo-controlled trial evaluated interpleural bupivacaine for CTR.13 There were no differences in pain intensity and pain distress before, immediately after, and at 1 hour after CTR between those who received the local anesthetic and those who received placebo. However, 13 patients in this study received the nonsteroidal anti-inflammatory drug (NSAID) ketorolac (Toradol) intramuscularly 3.5 hours before CTR and reported significantly lower pain intensity scores at the time of CTR than the 26 patients who did not receive ketorolac. This research underscores the inflammatory nature of CT pain and suggests a role for an NSAID as an analgesic for CTR. Researchers have also studied the use of topical agents for CTR over the years. 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
Non-pharmacologic Interventions 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. One study found no significant differences in pain or distress scores among 50 patients who were randomly assigned to receive a cold pack or room-temperature pack before CTR.16 Better pain relief was noted in a later study in which 140 patients were randomized to receive cold pack application or no application before CTR.17 Mean pain intensity (0 to 10 scale) immediately after the procedure was 3.85 in those who received cold therapy compared with 5.60 in those without. Another study randomized 90 patients to receive no application, cold pack, or room-temperature pack application for 20 minutes
55
before CTR.10 All patients received IV acetaminophen 60 minutes before the procedure. Cold application reduced pain immediately after and 15 minutes after CTR, while room-temperature application and no application resulted in similar significantly higher mean pain intensity ratings. However, it is important to note that despite the application of cold, patients experienced moderate pain levels (mean 6.77) immediately after the procedure. This suggests that IV acetaminophen and cold application are not adequate alone for prevention of CTR pain. There was no significant effect on anxiety levels. One study evaluated the effects of music therapy for CTR pain by randomizing 156 patients to listen to music of their choosing, white noise, or no intervention.18 There were no differences among the groups in pain intensity, changes in BP and heart rate, and length of time to first request for analgesia. Another study taught 24 patients to use relaxation breathing during CTR and found that men 70 years and older who performed relaxation breathing reported less than half the amount of pain experienced by those who did not receive relaxation breathing.19 Conversely, women 70 years and older reported higher pain intensity scores when relaxation breathing was used.
Multimodal Approaches As with other types of pain, it may be that the pain associated with CTR is complex and best handled using a multimodal approach. Multimodal analgesia combines nonpharmacologic methods and pharmacologic agents such as nonopioids, opioids, and local anesthetics, all with different underlying mechanisms of action to attack pain transmission at different areas along the pain pathway.20 One of the first studies to examine CTR pain evaluated the effect of combining an opioid and local anesthetic by randomizing 80 patients to receive IV morphine, IV morphine plus subfascial lidocaine, IV morphine plus subfascial normal saline, or subfascial lidocaine.21 Pain intensity was highest in those who received morphine alone and lowest in those who received morphine plus subfascial normal saline and those who received subfascial lidocaine alone. An important finding is that the percentages of patients who rated CTR as ‘‘not bad’’ or ‘‘not bad at all’’ were highest in
HOOD, HENDERSON, AND PASERO
56
those who received morphine plus lidocaine (83%) and lidocaine alone (75%) compared with those who received morphine alone (56%) and morphine plus normal saline (47%). In a letter to the editor, one group of clinicians described using oral dextropropoxyphene plus acetaminophen (similar to Darvocet and not available in the United States), subcutaneous infiltration of lidocaine at the CT site, and nurse-provided ‘‘psychological preparation and explanations’’ before CTR.22 They reported that their patients tolerate CTR well with a consistent range of pain intensities between 0 and 20 mm per 100 mm VAS. A multicenter study compared IV morphine alone with IV morphine plus a relaxation exercise (slow deep breathing) in 50 patients following CABG.23 Pain ratings immediately after and 15 minutes after CTR were significantly lower in those who received the combination of morphine and relaxation exercise compared with those who received morphine alone. Puntillo and Ley conducted a study that involved four combinations of pharmacologic and nonpharmacologic pre-procedure interventions for CTR in 74 cardiac surgery patients.2 The pharmacologic interventions were IV morphine and IV ketorolac. The nonpharmacologic interventions were the provision of procedural information, which included describing to the patient the steps of the procedure and what to expect, and the provision of sensory information, which included telling the patient what sensations might be felt during the procedure. Patients were randomized to receive: 1) 4 mg of IV morphine plus procedural information; 2) 30 mg of IV ketorolac plus procedural information; 3) 4 mg of IV morphine plus both procedural and sensory information; or 4) 30 mg of IV ketorolac plus both procedural and sensory information. Although analysis revealed no statistically significant differences among the four groups in pain intensity, pain distress, and sedation levels, those who received IV morphine plus both procedural and sensory information had the highest mean pain (4.53) and distress (4.40) scores (0 to 10 scale) immediately after CTR. An important finding was that the combined groups’ procedural mean pain intensity (3.26) and mean pain distress (2.98) scores were low, indicating that all of the interventions were generally successful in reducing
pain and anxiety.2 Although one method was not shown to be superior to another, this study suggests the need for further research examining the effectiveness of multimodal approaches that combine both pharmacologic and nonpharmacologic interventions for CTR.
The Post-Coronary Care Experience Although an early survey of nearly 1,000 critical care nurses found that 11% of the respondents reported that specially trained nurses were performing CTR,5 the procedure is currently performed by physicians and physician assistants in most institutions in the United States. Concerns about the painful nature of the CTR procedure led a cardiac surgeon and the PCCU clinical nurse manager at a 178-bed Midwest hospital to develop a program to train, support, and ensure continued competency of the bedside RNs in PCCU to remove CTs. A major purpose and ultimate patient benefit of expanding the role of the RN to include removal of CTs is that by controlling the timing of the procedure, medications can be provided to prevent and reduce the associated pain and anxiety. To be deemed competent to remove CTs, PCCU RNs were required to complete a didactic training program, which consisted of an online training module and clinical skill performance.4 The online module included instructions on proper removal of a CT, a list of supplies that would be needed, a checklist used for demonstrating competency as well as patient teaching content. After completion of the online course, nurses were required to observe three CTRs performed by a cardiac surgeon, then remove three CTs on their own under the observation of a cardiac surgeon or the PCCU nurse manager, who is an advanced practice nurse and skilled in CTR (Table 1). After all requirements had been met, a document was signed stating that the nurse had completed the required online training and had demonstrated the proper technique for CTR and was qualified to perform unsupervised CTR. The PCCU nurses began removing CTs independently in the Spring of 2011.
Findings The PCCU staff collected data in an effort to monitor for complications as well as track pain and pain medications that were given before CT
PAIN CARE
Table 1. Procedure for Nurse Removal of Chest Tubes 1. Verify physician’s order for removal. 2. Gather required equipment: a. Suture removal kit b. 2-inch occlusive tape c. Dry 4 3 4 gauze pack d. Biohazard bag (for disposal of the Atrium) 3. Insure personal protection (gloves, mask, gown). 4. Verify patient identification using two identifiers. 5. Explain procedure to patient and answer any questions. 6. Administer pain medication and wait for the appropriate time for pain medication to reach peak effect (refer to pharmacokinetic chart). 7. Turn off wall suction. 8. Clamp chest tube. 9. Remove dressing and stitches. 10. Ask patient to take and hold a deep breath; then, gently and smoothly remove chest tube. 11. Cover insertion site with dressing. 12. Continue to monitor pain and vital signs every 4 hours. Adapted from Elsevier. Chest tube removal. Mosby’s skills. St. Louis, MO, Elsevier, 2011. Retrieved November 6, 2012 from http://mns.elsevierperformancemanager. com. Accessed June 1, 2013.
removal and descriptors used by patients regarding the procedure (Table 2). The word ‘‘pressure’’ was used most often by patients to describe the sensation felt during the procedure. Single-drug therapy with morphine was used more than any other analgesic approach (Table 3). It is concerning that a large number (38%) of the patients did not receive supplemental pain medication before CTR. Nineteen percent of these refused analgesia either because they did not want to take an opioid or they thought additional analgesia was unnecessary for a short procedure despite receiving education regarding the painful nature of CTR. The other 19% were not given additional analgesia because they were receiving maintenance analgesia and their physicians did not think it was necessary to prescribe supplemental analgesia. To date, there have been no complications or adverse events related to nurse-removal of CTs.
Future Direction Data collection revealed that aggressive physician education regarding the research surrounding
57
Table 2. Descriptors Patients Used During Nurse Removal of Chest Tubes Descriptor (n 5 42)
Percentage of Patients
Pressure Throbbing Stabbing Shooting No response recorded
23 12 8 2 37
CTR pain is needed. Education of the physicians will include a medical education program focusing on the use of CTs and the pain associated with CTR as well as the distribution of printed evidencebased literature. At the bedside, nurses will be taught to provide evidence-based suggestions for appropriate analgesia as well. Empowering RNs to remove CTs brought about a greater awareness of patients’ pain related to CTR and the need to be proactive in preventing it in this PCCU. Nurses learned that CTR is an opportunity to educate both patients and the health care team and advocate for the most appropriate pain medication for their patients. More multimodal approaches, such as the administration of an NSAID in conjunction with an opioid, will be encouraged in the future. The use of nonpharmacologic interventions such as relaxation breathing and ice therapy will also be explored. Perhaps most helpful in changing practice will be the multidisciplinary development of a standardized protocol for CTR that incorporates multimodal techniques.
Table 3. Analgesics Administered Before Nurse Removal of Chest Tubes Analgesics (n 5 42) Morphine 4 mg IV Morphine 2 mg IV Dilaudid 2 to 4 mg IV Percocet 5—2 tablet PO Percocet 5—1 tablet PO Tylenol #3—2 tablet PO Tylenol #3—1 tablet PO MS Contin PO Analgesics not prescribed Analgesics refused IV, intravenous; PO, oral.
Percentage of Patients 16 15 5 10 7 4 3 2 19 19
HOOD, HENDERSON, AND PASERO
58
The PCCU also plans to improve the CTR program by developing a questionnaire to administer to patients before and after the procedure. A primary goal is to demonstrate better nursing documentation of patients’ sensations and pain levels. Obtaining answers to the following questions will help nurses strengthen their role as the patient’s primary advocate and pain manager and better meet patients’ needs in an individualized manner: What is the intensity of your pain on a scale of 0 to 10 (ie, before, during, immediately after, and 15 minutes after CTR)? What have you used in the past to relieve pain? Have you ever used methods other than pain medications to relieve your pain? If so, what has been effective? How anxious or worried about CTR are you on a scale of 0 to 10 (ie, before, during, immediately after, and 15 minutes after CTR)? Do you think the procedure was properly explained to you?
Are you satisfied with the way the CT was removed?
Conclusion CTR is a painful procedure performed every day in critical care settings all over the world. A barrier to managing the pain related to CTR is the nurse’s lack of control of the timing of the procedure, which limits the ability to plan ahead and provide proper patient education and preemptive analgesia. There is evidence that nurses can safely perform CTR. Expansion of the RN’s role to include CTR can result in a rewarding opportunity to strengthen the nurse’s role as the patient’s primary pain manager. The American Association of Critical Care Nurses reinforced its longstanding support of the nurse’s role in the management of procedural pain by awarding its 2013 Silver Beacon Award to the nurses spearheading the program to prepare nurses to remove CTs as described in this article.
References 1. Bruce E, Franck L, Howard RF. The efficacy of morphine and entonox analgesia during chest drain removal in children. Paediatr Anaesth. 2006;16:302-308. 2. Puntillo K, Ley SJ. Appropriately timed analgesics control pain due to chest tube removal. Am J Crit Care. 2004;13: 292-302. 3. Puntillo KA, White C, Morris AB, et al. Patients’ perceptions and responses to procedural pain: Thunder Project II. Am J Crit Care. 2001;10:238-251. 4. Elsevier. Chest tube removal. Mosby’s skills. St. Louis, MO: Elsevier. 2011. Available at: http://mns.elsevierperformancema nager.com. Accessed June 1, 2013. 5. Kinney MR, Kirchhoff KT, Puntillo KA. Chest tube removal practices in critical care units in the United States. Am J Crit Care. 1995;4:419-424. 6. Gift AG, Bolgiano CS, Cunningham J. Sensations during chest tube removal. Heart Lung. 1991;20:131-137. 7. Mimnaugh L, Winegar M, Mabrey Y, et al. Sensations experienced during removal of tubes in acute postoperative patients. Appl Nurs Res. 1999;12:78-85. 8. Bruce EA, Howard RF, Franck LS. Chest drain removal pain and its management: A literature review. J Clin Nurs. 2006;15: 145-154. 9. Barr J, Fraser GL, Puntillo KA, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med: 263-325. 2013;41. Available at: http://www.medscape.com/ viewarticle/777388. Accessed August 5, 2013. 10. Demir Y, Khorshid L. 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. Pain Manag Nurs. 2010; 11:186-196. 11. Joshi VS, Chauhan S, Kiran U, et al. Comparison of analgesic efficacy of fentanyl and sufentanil for chest tube removal after cardiac surgery. Ann Card Anaesth. 2007;10:42-45. 12. Akrofi M, Miller S, Colfar S, et al. A randomized comparison of three methods of analgesia for chest drain removal in postcardiac surgical patients. Anesth Analg. 2005;100: 205-209. 13. Puntillo KA. Effects of interpleural bupivacaine on pleural chest tube removal pain: A randomized controlled trial. Am J Crit Care. 1996;5:102-108. 14. Valenzuela RC, Rosen DA. Topical lidocaine-prilocaine cream (EMLA) for thoracostomy tube removal. Anesth Analg. 1999;88:1107-1108. 15. Singh M, Gopinath R. Topical analgesia for chest tube removal in cardiac patients. J Cardiothorac Vasc Anesth. 2005;19:719-722. 16. Sauls J. The use of ice for pain associated with chest tube removal. Pain Manag Nurs. 2002;3:44-52. 17. Ertug N, Ulker S. The effect of cold application on pain due to chest tube removal. J Clin Nurs. 2012;21: 784-790. 18. Broscious SK. Music: An intervention for pain during chest tube removal after open heart surgery. Am J Crit Care. 1999;8:410-415. 19. Houston S, Jesurum J. The quick relaxation technique: Effect on pain associated with chest tube removal. Appl Nurs Res. 1999;12:196-205.
PAIN CARE 20. Pasero C, Portenoy RK. Neurophysiology of pain and analgesia and the pathophysiology of neuropathic pain. In: Pasero C, McCaffery M, eds. Pain assessment and pharmacologic management. St. Louis, MO: Mosby/Elsevier; 2011:1-12. 21. Carson MM, Barton DM, Morrison CC, et al. Managing pain during mediastinal chest tube removal. Heart Lung. 1994;23:500-505.
59
22. Haddad F, Zeeni C, Yazigi A, et al. Multimodal analgesia for chest tube removal after cardiac surgery. J Cardiothorac Vasc Anesth. 2006;20:760-761. 23. Friesner SA, Curry DM, Moddeman GR. Comparison of two pain-management strategies during chest tube removal: Relaxation exercise with opioids and opioid alone. Heart Lung. 2006;35:269-276.
Chest Tube Removal: An Expanded Role for the Bedside Nurse Brenda S. Hood, APRN, MS, CCNS, Whitney Henderson, RN, BSN, Chris Pasero, MS, RN-BC, FAAN CHEST TUBE REMOVAL is a common procedure performed in critical care units and post-coronary care units (PCCUs). Research has shown that the procedure is associated with moderate-tosevere pain, but it is performed often without preemptive supplemental analgesia.1-3 This is in large part because chest tubes are removed most often by physicians, physician assistants, and advanced practice registered nurses (APRNs) in an unscheduled fashion, usually during patient rounds, which limits the bedside nurse’s ability to plan ahead and premedicate for pain.
CT drainage measurements of less than 100 cc within an 8-hour period; Re-expansion of lung (s) on chest radiograph; Equal bilateral breath sounds; Improved respiratory status; Absence of fluctuations or bubbling in the water seal chamber. Generally, if the patient meets these requirements, the CT is ready to be removed.4 However, the duration of CT therapy varies widely and depends entirely on patient response to treatment.
Chest Tubes
Pain and Anxiety Associated With CTR
Chest tubes (CTs) are long (8 to 40 Fr gauge), clear, plastic semi-stiff tubes that are placed in the space between the fourth and fifth intercostals (Figure 1). The tube allows for drainage and collection of fluids and/or air from the pleural space. Lungs can become compressed with excess fluid and air; with the insertion of a CT, lungs are able to re-expand. CTs are placed for a variety of conditions, including major thoracic surgical procedures and trauma, pleural effusion, infection, and cardiac tamponade.
In landmark research conducted decades ago, Kinney, Kirchoff, and Puntillo identified CTR as a considerable source of pain.5 Later research showed similar results.3 Patients use the words ‘‘burning,’’ ‘‘sharp,’’ ‘‘stinging,’’ ‘‘pulling,’’ and ‘‘awful’’ to describe the sensations they feel during CTR.3,6,7
Indications for chest tube removal (CTR) after reexpansion of the lungs has occurred include the following:
Brenda S. Hood, APRN, MS, CCNS, is the Clinical Nurse Manager of the Post Coronary Care Unit and the Telemetry Unit at Integris Southwest Medical Center in Oklahoma City, OK; Whitney Henderson, RN, BSN, is a Team Manager of the Post Coronary Care Unit at Integris Southwest Medical Center in Oklahoma City, OK; and Chris Pasero, MS, RN-BC, FAAN, is a Pain Management Educator and Clinical Consultant in El Dorado Hills, CA. Conflict of interest: None to report. Address correspondence to Chris Pasero, 1252 Clearview Drive, El Dorado Hills, CA 95762; e-mail address: cpasero@ aol.com. Ó 2014 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2013.11.001
Journal of PeriAnesthesia Nursing, Vol 29, No 1 (February), 2014: pp 53-59
Decades ago, researchers encouraged the development of protocols for the pharmacologic management of CTR pain.5 Nevertheless, a literature review of 14 studies conducted 10 years later concluded that current protocols for the management of pain associated with CTR are nonexistent or unsatisfactory, and practice in this area should be revised.8 Current evidencebased critical care guidelines recommend the provision of preemptive supplemental analgesia and the use of nonpharmacologic interventions for CTR.9 Research is lacking regarding the relationship between anxiety and pain, and only a few studies have evaluated anxiety specifically related to CTR. However, research has shown that patients describe the procedure using words such as ‘‘distressing.’’10 The majority (44.8%) of patients in another study (N 5 74) selected the word ‘‘fearful’’ to describe the quality of CTR pain,
53
54
HOOD, HENDERSON, AND PASERO
Pharmacologic Interventions There is no consensus regarding the ideal analgesic approach for the prevention and treatment of CTRrelated pain.8 Research has been conducted on the use of a variety of pain medications, but with inconclusive results. A number of researchers have investigated the use of opioids. One study randomized 141 adults who underwent cardiac surgery to receive intravenous (IV) fentanyl 2 mcg/kg, IV sufentanil 0.2 mcg/kg, or IV normal saline (placebo) 10 minutes before CTR.11 Pain was assessed using a 0 to 100 mm visual analogue scale (VAS) 10 minutes before CTR and at 5 and 20 minutes after CTR. Before CTR, mean pain scores were similar among those who received fentanyl (23.88), sufentanil (25.10), and placebo (23.64). Post CTR pain scores in those who received sufentanil were significantly lower (13.6) than those who received fentanyl (20.11) and placebo (27.97). Heart rate, arterial pressure, and respiratory rate varied the least in those who received sufentanil. All patients remained alert and none experienced any adverse effects.
Figure 1. Chest tube placement. Published in Potter P, Perry A, Stockert P, Hall A. Fundamentals of Nursing, 8th Edition. Mosby, 2013: 849. Figure 4015. Copyright Elsevier 2013. Reprinted with permission.
indicating a high degree of anxiety related to the procedure.2 There is no doubt that poorly managed procedural pain results in considerable stress for many patients. An individualized approach should be taken to address anxiety related to CTR. It is important for clinicians to adequately address pain with appropriate analgesics before the procedure and recognize that some may benefit from mild sedation as well.
Researchers conducted three separate studies in children at a large tertiary pediatric hospital in England.1 One of the three studies evaluated the prevalence and characteristics of pain and analgesic practices and found that 76% of 135 children experienced moderate-to-severe pain during CTR. The second study evaluated self-administered 50% nitrous oxide and oxygen (Entonox) and found that pain increased despite the treatment during CTR. The third study randomized 14 children aged 3.5 months to 2.75 years to receive IV morphine or continuous flow Entonox for CTR. Results showed that both groups experienced moderate-to-severe pain and exhibited no differences in pain scores. The researchers concluded that morphine or Entonox alone do not provide adequate analgesia for CTR and further research is needed to determine the most effective interventions for the procedure. A study in adults reported similar results with the use of Entonox after randomizing 66 patients following coronary artery bypass graft and/or valve surgery to receive one of three analgesic interventions for CTR: 1) 0.1 mg/kg of IV morphine; 2) 20 mL of 0.5% bupivacaine via subcutaneous
PAIN CARE
infiltration at the drain site; or 3) inhaled 50% nitrous oxide in oxygen (Entonox) via a demand valve.12 Median pain scores were lowest in those who received bupivacaine and morphine. There were no differences among groups in arterial blood pressure (BP), heart rate, PaCO2, oxygenation, or sedation. An early randomized, placebo-controlled trial evaluated interpleural bupivacaine for CTR.13 There were no differences in pain intensity and pain distress before, immediately after, and at 1 hour after CTR between those who received the local anesthetic and those who received placebo. However, 13 patients in this study received the nonsteroidal anti-inflammatory drug (NSAID) ketorolac (Toradol) intramuscularly 3.5 hours before CTR and reported significantly lower pain intensity scores at the time of CTR than the 26 patients who did not receive ketorolac. This research underscores the inflammatory nature of CT pain and suggests a role for an NSAID as an analgesic for CTR. Researchers have also studied the use of topical agents for CTR over the years. 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
Non-pharmacologic Interventions 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. One study found no significant differences in pain or distress scores among 50 patients who were randomly assigned to receive a cold pack or room-temperature pack before CTR.16 Better pain relief was noted in a later study in which 140 patients were randomized to receive cold pack application or no application before CTR.17 Mean pain intensity (0 to 10 scale) immediately after the procedure was 3.85 in those who received cold therapy compared with 5.60 in those without. Another study randomized 90 patients to receive no application, cold pack, or room-temperature pack application for 20 minutes
55
before CTR.10 All patients received IV acetaminophen 60 minutes before the procedure. Cold application reduced pain immediately after and 15 minutes after CTR, while room-temperature application and no application resulted in similar significantly higher mean pain intensity ratings. However, it is important to note that despite the application of cold, patients experienced moderate pain levels (mean 6.77) immediately after the procedure. This suggests that IV acetaminophen and cold application are not adequate alone for prevention of CTR pain. There was no significant effect on anxiety levels. One study evaluated the effects of music therapy for CTR pain by randomizing 156 patients to listen to music of their choosing, white noise, or no intervention.18 There were no differences among the groups in pain intensity, changes in BP and heart rate, and length of time to first request for analgesia. Another study taught 24 patients to use relaxation breathing during CTR and found that men 70 years and older who performed relaxation breathing reported less than half the amount of pain experienced by those who did not receive relaxation breathing.19 Conversely, women 70 years and older reported higher pain intensity scores when relaxation breathing was used.
Multimodal Approaches As with other types of pain, it may be that the pain associated with CTR is complex and best handled using a multimodal approach. Multimodal analgesia combines nonpharmacologic methods and pharmacologic agents such as nonopioids, opioids, and local anesthetics, all with different underlying mechanisms of action to attack pain transmission at different areas along the pain pathway.20 One of the first studies to examine CTR pain evaluated the effect of combining an opioid and local anesthetic by randomizing 80 patients to receive IV morphine, IV morphine plus subfascial lidocaine, IV morphine plus subfascial normal saline, or subfascial lidocaine.21 Pain intensity was highest in those who received morphine alone and lowest in those who received morphine plus subfascial normal saline and those who received subfascial lidocaine alone. An important finding is that the percentages of patients who rated CTR as ‘‘not bad’’ or ‘‘not bad at all’’ were highest in
HOOD, HENDERSON, AND PASERO
56
those who received morphine plus lidocaine (83%) and lidocaine alone (75%) compared with those who received morphine alone (56%) and morphine plus normal saline (47%). In a letter to the editor, one group of clinicians described using oral dextropropoxyphene plus acetaminophen (similar to Darvocet and not available in the United States), subcutaneous infiltration of lidocaine at the CT site, and nurse-provided ‘‘psychological preparation and explanations’’ before CTR.22 They reported that their patients tolerate CTR well with a consistent range of pain intensities between 0 and 20 mm per 100 mm VAS. A multicenter study compared IV morphine alone with IV morphine plus a relaxation exercise (slow deep breathing) in 50 patients following CABG.23 Pain ratings immediately after and 15 minutes after CTR were significantly lower in those who received the combination of morphine and relaxation exercise compared with those who received morphine alone. Puntillo and Ley conducted a study that involved four combinations of pharmacologic and nonpharmacologic pre-procedure interventions for CTR in 74 cardiac surgery patients.2 The pharmacologic interventions were IV morphine and IV ketorolac. The nonpharmacologic interventions were the provision of procedural information, which included describing to the patient the steps of the procedure and what to expect, and the provision of sensory information, which included telling the patient what sensations might be felt during the procedure. Patients were randomized to receive: 1) 4 mg of IV morphine plus procedural information; 2) 30 mg of IV ketorolac plus procedural information; 3) 4 mg of IV morphine plus both procedural and sensory information; or 4) 30 mg of IV ketorolac plus both procedural and sensory information. Although analysis revealed no statistically significant differences among the four groups in pain intensity, pain distress, and sedation levels, those who received IV morphine plus both procedural and sensory information had the highest mean pain (4.53) and distress (4.40) scores (0 to 10 scale) immediately after CTR. An important finding was that the combined groups’ procedural mean pain intensity (3.26) and mean pain distress (2.98) scores were low, indicating that all of the interventions were generally successful in reducing
pain and anxiety.2 Although one method was not shown to be superior to another, this study suggests the need for further research examining the effectiveness of multimodal approaches that combine both pharmacologic and nonpharmacologic interventions for CTR.
The Post-Coronary Care Experience Although an early survey of nearly 1,000 critical care nurses found that 11% of the respondents reported that specially trained nurses were performing CTR,5 the procedure is currently performed by physicians and physician assistants in most institutions in the United States. Concerns about the painful nature of the CTR procedure led a cardiac surgeon and the PCCU clinical nurse manager at a 178-bed Midwest hospital to develop a program to train, support, and ensure continued competency of the bedside RNs in PCCU to remove CTs. A major purpose and ultimate patient benefit of expanding the role of the RN to include removal of CTs is that by controlling the timing of the procedure, medications can be provided to prevent and reduce the associated pain and anxiety. To be deemed competent to remove CTs, PCCU RNs were required to complete a didactic training program, which consisted of an online training module and clinical skill performance.4 The online module included instructions on proper removal of a CT, a list of supplies that would be needed, a checklist used for demonstrating competency as well as patient teaching content. After completion of the online course, nurses were required to observe three CTRs performed by a cardiac surgeon, then remove three CTs on their own under the observation of a cardiac surgeon or the PCCU nurse manager, who is an advanced practice nurse and skilled in CTR (Table 1). After all requirements had been met, a document was signed stating that the nurse had completed the required online training and had demonstrated the proper technique for CTR and was qualified to perform unsupervised CTR. The PCCU nurses began removing CTs independently in the Spring of 2011.
Findings The PCCU staff collected data in an effort to monitor for complications as well as track pain and pain medications that were given before CT
PAIN CARE
Table 1. Procedure for Nurse Removal of Chest Tubes 1. Verify physician’s order for removal. 2. Gather required equipment: a. Suture removal kit b. 2-inch occlusive tape c. Dry 4 3 4 gauze pack d. Biohazard bag (for disposal of the Atrium) 3. Insure personal protection (gloves, mask, gown). 4. Verify patient identification using two identifiers. 5. Explain procedure to patient and answer any questions. 6. Administer pain medication and wait for the appropriate time for pain medication to reach peak effect (refer to pharmacokinetic chart). 7. Turn off wall suction. 8. Clamp chest tube. 9. Remove dressing and stitches. 10. Ask patient to take and hold a deep breath; then, gently and smoothly remove chest tube. 11. Cover insertion site with dressing. 12. Continue to monitor pain and vital signs every 4 hours. Adapted from Elsevier. Chest tube removal. Mosby’s skills. St. Louis, MO, Elsevier, 2011. Retrieved November 6, 2012 from http://mns.elsevierperformancemanager. com. Accessed June 1, 2013.
removal and descriptors used by patients regarding the procedure (Table 2). The word ‘‘pressure’’ was used most often by patients to describe the sensation felt during the procedure. Single-drug therapy with morphine was used more than any other analgesic approach (Table 3). It is concerning that a large number (38%) of the patients did not receive supplemental pain medication before CTR. Nineteen percent of these refused analgesia either because they did not want to take an opioid or they thought additional analgesia was unnecessary for a short procedure despite receiving education regarding the painful nature of CTR. The other 19% were not given additional analgesia because they were receiving maintenance analgesia and their physicians did not think it was necessary to prescribe supplemental analgesia. To date, there have been no complications or adverse events related to nurse-removal of CTs.
Future Direction Data collection revealed that aggressive physician education regarding the research surrounding
57
Table 2. Descriptors Patients Used During Nurse Removal of Chest Tubes Descriptor (n 5 42)
Percentage of Patients
Pressure Throbbing Stabbing Shooting No response recorded
23 12 8 2 37
CTR pain is needed. Education of the physicians will include a medical education program focusing on the use of CTs and the pain associated with CTR as well as the distribution of printed evidencebased literature. At the bedside, nurses will be taught to provide evidence-based suggestions for appropriate analgesia as well. Empowering RNs to remove CTs brought about a greater awareness of patients’ pain related to CTR and the need to be proactive in preventing it in this PCCU. Nurses learned that CTR is an opportunity to educate both patients and the health care team and advocate for the most appropriate pain medication for their patients. More multimodal approaches, such as the administration of an NSAID in conjunction with an opioid, will be encouraged in the future. The use of nonpharmacologic interventions such as relaxation breathing and ice therapy will also be explored. Perhaps most helpful in changing practice will be the multidisciplinary development of a standardized protocol for CTR that incorporates multimodal techniques.
Table 3. Analgesics Administered Before Nurse Removal of Chest Tubes Analgesics (n 5 42) Morphine 4 mg IV Morphine 2 mg IV Dilaudid 2 to 4 mg IV Percocet 5—2 tablet PO Percocet 5—1 tablet PO Tylenol #3—2 tablet PO Tylenol #3—1 tablet PO MS Contin PO Analgesics not prescribed Analgesics refused IV, intravenous; PO, oral.
Percentage of Patients 16 15 5 10 7 4 3 2 19 19
HOOD, HENDERSON, AND PASERO
58
The PCCU also plans to improve the CTR program by developing a questionnaire to administer to patients before and after the procedure. A primary goal is to demonstrate better nursing documentation of patients’ sensations and pain levels. Obtaining answers to the following questions will help nurses strengthen their role as the patient’s primary advocate and pain manager and better meet patients’ needs in an individualized manner: What is the intensity of your pain on a scale of 0 to 10 (ie, before, during, immediately after, and 15 minutes after CTR)? What have you used in the past to relieve pain? Have you ever used methods other than pain medications to relieve your pain? If so, what has been effective? How anxious or worried about CTR are you on a scale of 0 to 10 (ie, before, during, immediately after, and 15 minutes after CTR)? Do you think the procedure was properly explained to you?
Are you satisfied with the way the CT was removed?
Conclusion CTR is a painful procedure performed every day in critical care settings all over the world. A barrier to managing the pain related to CTR is the nurse’s lack of control of the timing of the procedure, which limits the ability to plan ahead and provide proper patient education and preemptive analgesia. There is evidence that nurses can safely perform CTR. Expansion of the RN’s role to include CTR can result in a rewarding opportunity to strengthen the nurse’s role as the patient’s primary pain manager. The American Association of Critical Care Nurses reinforced its longstanding support of the nurse’s role in the management of procedural pain by awarding its 2013 Silver Beacon Award to the nurses spearheading the program to prepare nurses to remove CTs as described in this article.
References 1. Bruce E, Franck L, Howard RF. The efficacy of morphine and entonox analgesia during chest drain removal in children. Paediatr Anaesth. 2006;16:302-308. 2. Puntillo K, Ley SJ. Appropriately timed analgesics control pain due to chest tube removal. Am J Crit Care. 2004;13: 292-302. 3. Puntillo KA, White C, Morris AB, et al. Patients’ perceptions and responses to procedural pain: Thunder Project II. Am J Crit Care. 2001;10:238-251. 4. Elsevier. Chest tube removal. Mosby’s skills. St. Louis, MO: Elsevier. 2011. Available at: http://mns.elsevierperformancema nager.com. Accessed June 1, 2013. 5. Kinney MR, Kirchhoff KT, Puntillo KA. Chest tube removal practices in critical care units in the United States. Am J Crit Care. 1995;4:419-424. 6. Gift AG, Bolgiano CS, Cunningham J. Sensations during chest tube removal. Heart Lung. 1991;20:131-137. 7. Mimnaugh L, Winegar M, Mabrey Y, et al. Sensations experienced during removal of tubes in acute postoperative patients. Appl Nurs Res. 1999;12:78-85. 8. Bruce EA, Howard RF, Franck LS. Chest drain removal pain and its management: A literature review. J Clin Nurs. 2006;15: 145-154. 9. Barr J, Fraser GL, Puntillo KA, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med: 263-325. 2013;41. Available at: http://www.medscape.com/ viewarticle/777388. Accessed August 5, 2013. 10. Demir Y, Khorshid L. 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. Pain Manag Nurs. 2010; 11:186-196. 11. Joshi VS, Chauhan S, Kiran U, et al. Comparison of analgesic efficacy of fentanyl and sufentanil for chest tube removal after cardiac surgery. Ann Card Anaesth. 2007;10:42-45. 12. Akrofi M, Miller S, Colfar S, et al. A randomized comparison of three methods of analgesia for chest drain removal in postcardiac surgical patients. Anesth Analg. 2005;100: 205-209. 13. Puntillo KA. Effects of interpleural bupivacaine on pleural chest tube removal pain: A randomized controlled trial. Am J Crit Care. 1996;5:102-108. 14. Valenzuela RC, Rosen DA. Topical lidocaine-prilocaine cream (EMLA) for thoracostomy tube removal. Anesth Analg. 1999;88:1107-1108. 15. Singh M, Gopinath R. Topical analgesia for chest tube removal in cardiac patients. J Cardiothorac Vasc Anesth. 2005;19:719-722. 16. Sauls J. The use of ice for pain associated with chest tube removal. Pain Manag Nurs. 2002;3:44-52. 17. Ertug N, Ulker S. The effect of cold application on pain due to chest tube removal. J Clin Nurs. 2012;21: 784-790. 18. Broscious SK. Music: An intervention for pain during chest tube removal after open heart surgery. Am J Crit Care. 1999;8:410-415. 19. Houston S, Jesurum J. The quick relaxation technique: Effect on pain associated with chest tube removal. Appl Nurs Res. 1999;12:196-205.
PAIN CARE 20. Pasero C, Portenoy RK. Neurophysiology of pain and analgesia and the pathophysiology of neuropathic pain. In: Pasero C, McCaffery M, eds. Pain assessment and pharmacologic management. St. Louis, MO: Mosby/Elsevier; 2011:1-12. 21. Carson MM, Barton DM, Morrison CC, et al. Managing pain during mediastinal chest tube removal. Heart Lung. 1994;23:500-505.
59
22. Haddad F, Zeeni C, Yazigi A, et al. Multimodal analgesia for chest tube removal after cardiac surgery. J Cardiothorac Vasc Anesth. 2006;20:760-761. 23. Friesner SA, Curry DM, Moddeman GR. Comparison of two pain-management strategies during chest tube removal: Relaxation exercise with opioids and opioid alone. Heart Lung. 2006;35:269-276.
