Effect of Cold Application on Chest Incision Pain Due to Deep Breathing and Cough Exercises

BackgroundWe determined the effect of cold application after coronary artery bypass graft surgery on chest incision pain due to deep breathing and coughing exercises. Thoracotomy performed for coronary artery bypass graft surgery is one of the most painful surgical procedures. This pain prevents deep breathing and effective coughing. These problems increase the risk of morbidity in the postoperative period.AimsThis study aimed to determine the effect of cold application after CABG surgery on chest incision pain due to deep breathing and cough exercises.DesignExperimental study with control group and repeated measurements.SettingsPatients were selected through convenience sampling in the Cardiovascular Surgery Intensive Care Unit at a hospital.ParticipantsThe study was conducted with 57 patients who underwent open heart surgery (29 and 28 in the experimental and control groups, respectively).MethodsRepeated pain assessment was performed before, immediately after, and 5 min after deep breathing and coughing exercises performed in 4 periods at 2-h intervals. The first pain assessment was performed 24 h postoperatively. In the first and third assessments of the experimental group, pain was recorded before the exercise; the exercise was performed 15 min after cold gel pack application to the incision area. Pain was assessed before, immediately after, and 5 min after exercise using the Short- Form McGill Melzack Pain Questionnaire.ResultsReduction in pain severity within and between the groups was statistically significant in the first and third evaluations (p = .001).ConclusionsThe results provide evidence to support the use of cold gel pack.     

Abdominal surgery, pain and anxiety: preoperative nursing intervention

AIM: This paper reports a study examining the effects of preoperative nursing intervention for pain on abdominal surgery preoperative anxiety and attitude to pain, and postoperative pain. METHOD: In a randomized controlled study conducted between January and August 2001, patients undergoing abdominal surgery in a medical center in southern Taiwan were randomly assigned to an experimental (n = 32) or control group (n = 30). The experimental group received routine care and preoperative nursing intervention for pain, while the control group received routine care only. A structured questionnaire including an anxiety scale, pain attitude scale, and Brief Pain Inventory was used to assess the results. RESULTS: Participants in the experimental group experienced a significant decrease in preoperative anxiety and a significant improvement in preoperative pain attitude. They also had statistically significantly lower postoperative pain intensity for 4 hours after surgery and lower highest pain intensity within the first 24 hours after surgery. Perceived pain interference during position changes, deep breathing/coughing, and moments of emotion in the experimental group was statistically significantly lower than that of the control group in the same situations. The experimental group also started out-of-bed activities 1.5 days earlier. CONCLUSION: Preoperative nursing intervention for pain has positive effects for patients undergoing abdominal surgery. The intervention used in this study could serve as a guide for nurses to improve the pain care of these patients.     

Intrathecal morphine after cardiac surgery

OBJECTIVE: To assess whether intrathecal (IT) analgesia facilitates early extubation and provides superior pain control after cardiac surgery compared with patient-controlled analgesia (PCA) or nurse-administered SC injections. METHODS: Sixty-two patients undergoing elective cardiac surgery participated in this prospective, randomized, partly-blinded study. Perioperative care was standardized, and patients were assigned to receive IT morphine (ITM group) followed by PCA, IT placebo (ITP group) followed by PCA, or SC injections of morphine every 4 hours as needed (SC group). Rating scales and questionnaires were used to assess clinical outcomes. RESULTS: ITM did not favor earlier extubation, and there was even a tendency for longer extubation times in the ITM group compared with the ITP and SC groups. Pain scores, adverse effects, postoperative recovery, and patient satisfaction were also comparable in the 3 groups. CONCLUSIONS: Considering that the administration of IT morphine is more costly and can be riskier than conventional analgesic regimens, we conclude that its use is not indicated in patients undergoing cardiac surgery if early extubation is planned.     

Catastrophizing: a risk factor for postsurgical pain

OBJECTIVE: This research was designed to test the hypothesis that presurgery "catastrophizing" would predict postsurgical pain and postsurgical analgesic consumption. METHODS: A sample of 48 individuals who underwent anterior cruciate ligament repair participated in the study. All participants completed the Pain Catastrophizing Scale (described by Sullivan et al in 1995) prior to surgery. Measures of pain (pain scores on a scale of 0-10) were obtained in the postanesthetic care unit, as well as 1, 2, and 7 days after surgery. Opioid and nonopioid analgesic consumption was tabulated while patients were in the hospital and after discharge. RESULTS: Results showed that the Pain Catastrophizing Scale was a significant predictor of acute postsurgical pain in the postanesthetic care unit (r = 0.48, P = 0.004 for maximum pain in the postanesthetic care unit). Maximum pain ratings in patients with high Pain Catastrophizing Scale scores (> median of 13) were 33% to 74% higher numerically than in patients with low Pain Catastrophizing Scale scores (< or = median), and the duration of moderate-severe pain (>3/10) was more prolonged (45 minutes versus 28 minutes in patients with high and low Pain Catastrophizing Scale scores, respectively; P < 0.05). The Pain Catastrophizing Scale was also predictive of pain with activity at 24 hours (r = 0.65 for pain on walking, P < or = 0.0001). The Pain Catastrophizing Scale did not predict postoperative analgesic use. CONCLUSION: The pattern of findings suggests that high catastrophizing scores may be a risk factor for heightened pain following surgery. Clinical and theoretical implications of the findings are addressed.     

两种不同镇痛方法对开胸手术术后恢复的影响

目的:比较经静脉自控镇痛、肋间神经冷冻术两种镇痛方法对开胸手术患者术后恢复的影响。方法:60例开胸手术患者随机分为肋间神经冷冻组(INC组)和患者静脉自控镇痛组(PCA组)。疼痛强度评分法(NRS)评估术后疼痛程度。结果:(1)两组比较,术后并发症、下床时间、正常活动时间差异无统计学意义(P>0.05)。而术后副反应比较,PCA组较INC组严重(P<0.05);INC组较PCA组术后胸引管引流量大,胸引管拔除时间长(均P<0.05)。INC组术后肺功能恢复明显好于PCA组(P<0.05)。(2)术后前2d内,疼痛指数及镇痛药物使用方面两组差异无统计学意义(P>0.05);术后第3～7天,INC组较PCA组疼痛明显减轻(P<0.05),但药物使用方面差异无统计学意义(P>0.05)。结论:肋间神经冷冻术是比较好的胸部手术术后镇痛治疗方法,副作用小,但术后胸引管引流量增加,拔除胸引管时间延长。     

Incentive spirometry does not enhance recovery after thoracic surgery

OBJECTIVE: To investigate the additional effect of incentive spirometry to chest physiotherapy to prevent postoperative pulmonary complications after thoracic surgery for lung and esophageal resections. DESIGN: Randomized controlled trial. SETTING: University hospital, intensive care unit, and surgical department. PATIENTS: Sixty-seven patients (age, 59 +/- 13 yrs; forced expiratory volume in 1 sec, 93% +/- 22% predicted) undergoing elective thoracic surgery for lung (n = 40) or esophagus (n = 27) resection. INTERVENTIONS: Physiotherapy (breathing exercises, huffing, and coughing) (PT) plus incentive spirometry (IS) was compared with PT alone. MEASUREMENTS AND MAIN RESULTS: Lung function, body temperature, chest radiograph, white blood cell count, and number of hospital and intensive care unit days were all measured. Pulmonary function was significantly reduced after surgery (55% of the initial value) and improved significantly in the postoperative period in both groups. However, no differences were observed in the recovery of pulmonary function between the groups. The overall score of the chest radiograph, based on the presence of atelectasis, was similar in both treatment groups. Eight patients (12%) (three patients with lobectomy and five with esophagus resection) developed a pulmonary complication (abnormal chest radiograph, elevated body temperature and white blood cell count), four in each treatment group. Adding IS to regular PT did not reduce hospital or intensive care unit stay. CONCLUSIONS: Pulmonary complications after lung and esophagus surgery were relatively low. The addition of IS to PT did not further reduce pulmonary complications or hospital stay. Although we cannot rule out beneficial effects in a subgroup of high-risk patients, routine use of IS after thoracic surgery seems to be ineffective.     

Pain status and sedation level in Chinese children after cardiac surgery: an observational study

Aims and objectives. This study explored current pain status, sedation level and their trajectories in Chinese children after cardiac surgery. Background. Pain and sedation management are fundamental care practices in the critical care setting, yet they both are frequently under‐implemented for children after major surgery. Design. Repeated observational design. Methods. This study was conducted in a paediatric medical centre in Shanghai, China where 170 children who underwent cardiac surgery were recruited. Pain was measured with the face, legs, activity, cry, consolability scale and sedation levels with the COMFORT Behaviour Scale at 18 fixed time‐points for three consecutive postoperative days. Results. The study indicated that 95 children (55·9%) received continuous opioids for pain relief, and 61 children (35·9%) received no analgesics. Multiple sedatives were used for these children, including bolus phenobarbital for 117 children (68·8%), phenergan for 81 children (47·6%) and midazolam for three children (1·8%). The mean pain scores significantly decreased throughout the operation day (POD‐0) to the 2nd postoperative day (POD‐2) with the lowest score on POD‐2. Less than 5% of pain assessments were identified as moderate to severe across all 2815 observations. The sedation scores significantly increased through POD‐0 to POD‐2 with the highest score on POD‐2. The rate of over‐sedation was 50·3% with <1% under‐sedation occurring among all the observations. Results also suggested that the length of stay in the cardiac intensive care unit was a predictor of increased analgesic usage in the critical care setting (odds ratio: 1·72). Conclusions. Usage of analgesic and sedative agents in cardiac intensive care unit was variable and children experienced low pain scores but a high rate of over‐sedation, indicating that healthcare providers should address ways to improve postoperative pain and sedation management in this population. Relevance to clinical practice. The pain and sedation status for children after cardiac surgery changed across the postoperative days. Healthcare providers should be trained in the use of reliable tools to accurately monitor children’s pain and sedation levels.     

Validation of the critical-care pain observation tool in adult patients.

BACKGROUND: Little research has been conducted to validate pain assessment tools in critical care, especially for patients who cannot communicate verbally. OBJECTIVE: To validate the Critical-Care Pain Observation Tool. METHODS: A total of 105 cardiac surgery patients in the intensive care unit, recruited in a cardiology health center in Quebec, Canada, participated in the study. Following surgery, 33 of the 105 were evaluated while unconscious and intubated and 99 while conscious and intubated; all 105 were evaluated after extubation. For each of the 3 testing periods, patients were evaluated by using the Critical-Care Pain Observation Tool at rest, during a nociceptive procedure (positioning), and 20 minutes after the procedure, for a total of 9 assessments. Each patient's self-report of pain was obtained while the patient was conscious and intubated and after extubation. RESULTS: The reliability and validity of the Critical-Care Pain Observation Tool were acceptable. Interrater reliability was supported by moderate to high weighted kappa coefficients. For criterion validity, significant associations were found between the patients' self-reports of pain and the scores on the Critical-Care Pain Observation Tool. Discriminant validity was supported by higher scores during positioning (a nociceptive procedure) versus at rest. CONCLUSIONS: The Critical-Care Pain Observation Tool showed that no matter their level of consciousness, critically ill adult patients react to a noxious stimulus by expressing different behaviors that may be associated with pain. Therefore, the tool could be used to assess the effect of various measures for the management of pain.     

Incentive spirometry: 2011

We searched the MEDLINE, CINAHL, and Cochrane Library databases for articles published between January 1995 and April 2011. The update of this clinical practice guideline is the result of reviewing a total of 54 clinical trials and systematic reviews on incentive spirometry. The following recommendations are made following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) scoring system. 1: Incentive spirometry alone is not recommended for routine use in the preoperative and postoperative setting to prevent postoperative pulmonary complications. 2: It is recommended that incentive spirometry be used with deep breathing techniques, directed coughing, early mobilization, and optimal analgesia to prevent postoperative pulmonary complications. 3: It is suggested that deep breathing exercises provide the same benefit as incentive spirometry in the preoperative and postoperative setting to prevent postoperative pulmonary complications. 4: Routine use of incentive spirometry to prevent atelectasis in patients after upper-abdominal surgery is not recommended. 5: Routine use of incentive spirometry to prevent atelectasis after coronary artery bypass graft surgery is not recommended. 6: It is suggested that a volume-oriented device be selected as an incentive spirometry device.     

The efficacy of incentive spirometers in post-operative protocols for low-risk patients

Incentive spirometry offered no statistically significant advantages to pulmonary function when compared to unstructured or structured deep breathing and coughing exercise programs, for patients at low risk of developing pulmonary complications. The additional cost of incentive spirometer equipment does not seem warranted in these patients. Furthermore, patients with or without an incentive spirometer were willing to comply with a structured breathing exercise program with the same frequency of practice sessions. Patients in this diagnostic category did not require a technical device to reward and motivate them for performing maximal inspiratory manoeuvres.     

Nature and intensity of the pain following thoracotomy

The aim of this study is to clearly define and describe the pain characteristics that disturb the patients having thoracotomy in postoperative period. It can be possible to manage to get pains under control according to pain characteristics. The study included 70 patients who underwent thoracotomy (lobectomy or segmentectomy and mean duration of surgery was 90 min) and were hospitalized in the intensive care unit of the Thoracic Surgery Department of Akdeniz University Hospital between November 2007 and November 2008. In this study, 68.6% of the patients were male and mean age was 49.90. The study was achieved. Consider that the patients have pain in the first 24 h postoperatively and the effect of sedation, the Behavioural Pain Scale, which is filled out by a researcher, and the Verbal Category Scale, which allows the patient to define his/her pain with short responses, were used for pain assessment. Pain was assessed at the postoperative 4th, 8th, 16th, 24th and 48th hours, following extubation. The patients mostly reported throbbing (65.7%), stabbing (65.7%) and stinging (62.9%) pain in the incision site, while 40% of them (n = 28) reported a 'sharp', 'exhausting' and 'splitting' pain. The investigation of the factors increasing pain during the postoperative period revealed that most of the patients (85.7%) reported that their pain increased due to movement in bed and/or walking, while 74.3%, 68.6%, 54.3% and 37.1% of them stated that their pain increased due to breathing, coughing, chest tube movement and noisy environment, respectively. Each pain characteristics, throbbing, stabbing and stinging, can be specifically relief using one or more methods such as touching on the incision site, little press on the thoracotomy region, talking to the patient about pain, etc. We determined that the patients experienced a sharp, stabbing and unbearable pain in the first 48 postoperative hours. Therefore, our study suggests that some interventions such as pressure exertion and touching to the painful area were stated to provide pain relief to the patients.     

成人心脏外科术后患者实施早期拔管策略效果观察与护理

目的探讨ICU护士主导实施的早期拔管策略在成人心脏外科术后机械通气患者中的应用效果及护理要点。方法回顾心脏术后经口气管插管入胸心外科ICU行机械通气治疗的156例患者的拔管情况,按照时间顺序分为传统组和干预组（早期拔管组）, 2组患者机械通气模式及参数、撤机方式、撤机后治疗护理等方法均相同,干预组是在传统组基础上以ICU护士主导实施综合早期拔管策略。观察撤机30 min 2组心率、呼吸、血压、PaO2/FiO2、PaCO2及拔管后无创正压通气（NPPV）例数、24 h再插管例数、拔管前机械通气时间及撤机时间等指标。结果撤机后30 min 2组患者心率、呼吸、血压、（53＊2PaCO2及拔管后NPPV例数、24 h再插管例数等指标无统计学差异（P＞0.05）, 干预组PaO2/FiO2则较传统组显著改善）（P＜0.05）, 且干预组拔管前机械通气时间、撤机时间显著短于传统组（P＜0.05）。结论ICU护士实施的早期拔管策略对心脏外科术后撤机患者是安全的,能提高早期拔管成功率,减少机械通气并发症。     

Interference of Postoperative Pain on Women's Daily Life after Early Discharge from Cardiac Surgery

Women report more postoperative pain and problems performing domestic activities than men in the first month of recovery after cardiac surgery. The purpose of this article is to describe how women rate and describe pain interference with daily life after early discharge from cardiac surgery. A qualitative study was conducted in 2004-2005 with ten women recruited from a large Norwegian university hospital before discharge from their first elective cardiac surgery. Various aspects of the women's postoperative experiences were collected with qualitative interviews in the women's homes 8-14 days after discharge: a self-developed pain diary measuring pain intensity, types and amount of pain medication taken every day after returning home from hospital; and the Brief Pain Inventory–Short Form immediately before the interview. Qualitative content analysis was used to identify recurring themes from the interviews. Data from the questionnaires provided more nuances to the experiences of pain, pain management, and interference of postoperative pain. Postoperative pain interfered most with sleep, general activity, and the ability to perform housework during the first 2 weeks after discharge. Despite being advised at the hospital to take pain medication regularly, few women consumed the maximum amount of analgesics. Early hospital discharge after open cardiac surgery implies increased patient participation in pain management. Women undergoing this surgery need more information in hospital on why postoperative pain management beyond simple pain relief is important.     

Effect of Rectal Diclofenac in Reducing Postoperative Pain and Rescue Analgesia Requirement after Cardiac Surgery

Background:   Adequate analgesic medication is mandatory after coronary artery bypass grafting (CABG) surgery. The aim of this study was to assess the analgesic efficacy, side effects, and need for rescue analgesia after CABG surgery comparing diclofenac and placebo rectal suppository.
Methods:   Thirty-seven consenting adults undergoing elective CABG surgery were randomly assigned in a double-blind fashion to receive either rectal diclofenac 100 mg (Group 1, n  = 19) or placebo suppository (Group 2, n  = 18) postoperatively, just after extubation. Both groups were given intravenous tramadol as a rescue analgesic. Pain scores in the two groups were assessed on a 10-cm visual analog scale at 0, 0.5, 1, 1.5, 2, 6, 12, 18, and 24 hours after suppository administration. Rescue analgesic consumption, sedation, nausea, and vomiting in both the groups were also recorded.
Results:   Twenty-four-hour tramadol consumption in Group 1 was 92.5 ± 33.5 mg compared to 157.5 ± 63.4 mg in Group 2 ( P  = 0.002). Patients in the placebo group had significantly greater pain scores 1.5 to 12 hours after extubation. Group 1 patients were significantly more awake compared to Group 2 ( P  < 0.05). The incidence of postoperative nausea was less in Group 1 than in Group 2 ( P  = 0.001). Though not statistically significant, three patients in Group 2 each had a single episode of vomiting, whereas no patient had vomiting in Group 1.
Conclusion:   Rectal diclofenac suppository with tramadol provides adequate pain relief after cardiac surgery, and also reduces tramadol consumption and side effects commonly associated with tramadol.     

Women suffer more short and long-term pain than men after major thoracotomy

OBJECTIVES: Prolonged activation of pain centers is a proposed cause of chronic pain syndromes. Women are at particular risk for chronic pain as they tend to more readily detect pain and to attenuate it less than men. We set out to determine whether sex affected pain and recovery after major surgery by analyzing data originally collected to determine the effect of the timing of epidural analgesia on long-term outcome after thoracotomy. METHODS: Patients presenting for lobectomy, segmentectomy, or bilobectomy, but not pneumonectomy or chest wall resection, were enrolled. Pain, physical activity, and the extent that pain interfered with activities after surgery were prospectively assessed with standard questionnaires (Brief Pain Inventory and physical component score of SF-36) on postoperative days 1 to 5, and at postoperative weeks 4, 8, 12, 24, 36, and 48 by a blinded research assistant. Perioperative care was standardized and included patient-controlled thoracic epidural analgesia until thoracostomy tube removal. RESULTS: Fifty eight men and 62 women were enrolled. Women reported more pain than men throughout the entire study period, and they had a higher rate of nonsteroidal anti-inflammatory drug use, but not opioid use. This increased pain was not explained by incision type, surgeon, tumor type, or tumor stage. Older patients reported less pain after discharge than younger patients. Postoperative physical activity levels were significantly less than those reported preoperatively, but did not differ by sex. DISCUSSION: Women have a distinctly different pain experience than men after thoracic surgery and probably require novel and/or multimodal analgesic regimens to improve their comfort.     

Physical therapy management for adult patients undergoing cardiac surgery: a canadian practice survey

Purpose: To determine current Canadian physical therapy practice for adult patients requiring routine care following cardiac surgery.Methods: A telephone survey was conducted of a selected sample (n=18) of Canadian hospitals performing cardiac surgery to determine cardiorespiratory care, mobility, exercises, and education provided to patients undergoing cardiac surgery.Results: An average of 21 cardiac surgeries per week (range: 6-42) were performed, with an average length of stay of 6.4 days (range: 4.0-10.6). Patients were seen preoperatively at 7 of 18 sites and on postoperative day 1 (POD-1) at 16 of 18 sites. On POD-1, 16 sites performed deep breathing and coughing, 7 used incentive spirometers, 13 did upper-extremity exercises, and 12 did lower-extremity exercises. Nine sites provided cardiorespiratory treatment on POD-3. On POD-1, patients were dangled at 17 sites and mobilized out of bed at 13. By POD-3, patients ambulated 50-120 m per session 2-5 times per day. Sternal precautions were variable, but the lifting limit was reported as ranging between 5 lb and 10 lb.Conclusions: Canadian physical therapists reported the provision of cardiorespiratory treatment after POD-1. According to current available evidence, this level of care may be unnecessary for uncomplicated patients following cardiac surgery. In addition, some sites provide cardiorespiratory treatment techniques that are not supported by evidence in the literature. Further research is required.     

Effect of screen-based computer simulation on knowledge and skill in nursing students' learning of preoperative and postoperative care management: a randomized controlled study

Screen-based computer simulations are considered a method of skill teaching in health education. This study examined the effect of screen-based computer simulation on knowledge, skill, and the clinical decision-making process in teaching preoperative and postoperative care management to second-year students in an undergraduate school of nursing. It is a randomized controlled study. The study sample was composed of 82 students. They received education in screen-based computer simulation (n = 41) and skill laboratories (n = 41). Three instruments were used: a preoperative and postoperative care management cognitive level assessment test, skill control lists of preoperative and postoperative care management, and the Clinical Decision Making in Nursing Scale. There was not a significant difference between the students' posteducation knowledge levels (P = .421), practical deep breathing and coughing exercise education skills (P = .867), or clinical decision-making scale total and subscale scores (P = .065). However, a significant difference was found between the admission of the patient in the surgical clinic after surgery skill scores of the students (P = .04). Education provided in the screen-based computer simulation laboratory was equivalent to that provided in the skill laboratory.     

Pain intensity,interference and patient pain management strategies the first 12 weeks after coronary artery bypass graft surgery

BackgroundPain is a distressing and often undertreated symptom of cardiac surgery. Little is known about pain levels, interference and treatment strategies beyond the 9 week period.AimThe purpose of this study was to describe pain intensity, interference and strategies used to manage pain in post-operative CABG patients.MethodsBaseline data were collected by interview in the hospital after CABG surgery using the Modified Brief Pain Inventory. One to 12 weeks after discharge, weekly telephone interviews were conducted to collect data.ResultsPain levels and interference with activities of daily living were greatest during hospitalization and decreased over 12 weeks. Pain interfered the most with coughing and sleep. Once opioid medications ran out, activity modification was primarily used to manage pain.ConclusionsActivity modification below recommended levels was reported as a pain management strategy. Patients reported pain lasting longer than they expected and the need for more education about activity and pain management strategies.     

冰敷缓解开胸术后疼痛的效果

目的探讨冰敷缓解开胸术后疼痛的效果。方法便利选取2012年1月至2013年3月在温州医学院附属第二医院行开胸肺切除术的80例患者,采用随机数字表法将患者分为对照组和试验组,各40例。对照组术后行常规护理,试验组在此基础上加用切口和引流管置管处冰敷。分别于术后第24、48和72h评估两组患者的疼痛强度、应用镇痛药物情况及因疼痛影响胸部活动的情况。结果试验组术后24、48和72h的疼痛评分均低于对照组,术后48、72h应用镇痛药物者少于对照组,术后因疼痛加重而停止深呼吸和咳嗽者少于对照组,差异均有统计学意义（均P〈0．05）。结论冰敷能够有效缓解开胸术后疼痛,有利于减少镇痛药物的使用,促进术后康复运动的有效实施。