Pain management for patients in cardiac surgical intensive care units has not improved over time
Stolic, S & Mitchell, ML 2010, 'Pain management for patients in cardiac surgical intensive care units has not improved over time', Australian Critical Care, vol. 23, pp. 298-303.
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Pain levels are a source of stress for patients in critical care settings. Patients frequently undergo procedures such as repositioning and suctioning and these are known to cause considerable pain. Recommendations and guideline have been developed for patients in critical care areas, however, pain continues to be a problem. The purpose of Gelina’s study1 ‘‘was to describe the experiences of pain in postoperative cardiac surgery patients during their stay in the intensive care unit (ICU).’’ (p. 299)
The research design was descriptive with a semistructured interview guide with five questions. The study sample was drawn from 105 cardiac surgical patients from a tertiary hospital in Quebec, Canada. Individuals were included if they were over 18 years of age, admitted for cardiac surgery, understood French and remained in the ICU for at least 12 h. Individuals were excluded if they were to undergo heart transplants or thoracic surgery, had postoperative complications or had pre-existing psychiatric concerns. Patients were recruited the day prior to surgery. Ethical approved was received for this study. The interview guide was based on one developed by Puntillo2 and consisted of 3 open-ended and two closed-ended questions asking them if they remembered being ventilated or had pain during their stay in ICU. They were asked to describe their experiences of these two areas and how they communicated with the nurses when they were ventilated. The interviews were conducted approximately 3 days after surgery by a nurse or research assistant after the patient was transferred to the ward. The average length of ICU stay was two days. Descriptive analysis was conducted and frequencies calculated.
Of the original 105 cardiac surgical patients, 93 completed the post ICU discharge interview. The majority were male, with a mean age of 60.4 years (SD = 8.31). All patients received sternal incisions, 77.4% underwent coronary artery bypass graft surgery (CABG), 11.9% valve surgery, 8.6% underwent both CABG and valve surgery and 2.2% underwent septal repair. Surgical methods and analgesia received were similar for all patients. Sixty-one patients (65.6%) remembered their experiences of ventilation, only a small percentage (<15%) remembered the presence of a nurse or the nurse assessing pain. The experience of pain was recalled by 72 patients (77%) whilst in ICU. There was no relationship detected for those who recalled experiencing pain and their length of stay in ICU. The sources of pain for those who recalled the experience of pain were mostly due to turning and the act of breathing. Pain intensity was severe for 25 patients, moderate for 21 and mild for 16 patients. Other findings for this study provided information in regards to how patients communicated to health staff. These included amongst others, physical gestures such as head nodding, moving upper limbs, facial expressions, tracing letters on hands, moving lips and writing. Most of the time patients waited until they were asked by the nurse if they were experiencing pain.
This study’s findings are similar to other studies in that around 75% of patients experience some level of pain whilst in ICU and more than 50% reported moderate to severe pain intensities. In addition, patient turning remained the primary source of pain for these patients as has been reported elsewhere.3 Other studies also described the used of similar methods of patient communication but this study1 highlights the need to individualise communication strategies to suit the patient. Patients continue to wait to be asked if they have pain and do not initiate reports of pain. Regular pain assessments and patient information on ways to communicate their level of pain was recommended.
Despite advances in pain management the presence of pain and its intensity for cardiac surgical intensive care patients remains similar to those of earlier studies some 17 years previously.
This area of study focuses on an important and relevant area of critical care nursing. Critically ill patients frequently incur procedures that produce responses to noxious stimuli. The negative physiological effects of pain are well documented and include a sympathetic response with increased cardiac work thus potentially compromising cardiac stability.4 In addition, a reduction in respiratory effort may produce retention of secretions and nosocomial infection.5 Added to this is the potential for patients to feel fear, experience sleep deprivation6 and feelings of isolation.7 This study is similar to previous, now outdated work2 and informs health care professionals that, alarmingly, little has improved over two decades in regards to pain management for this group of people. The study is well conducted and received ethical approval. An interview guide using five questions provided the base for data collection. Although it was stated that it was based on a previous tool, the changes implemented are not documented. The changes may have been to translate into French but no details are given to the reader. There may have been an opportunity to discover more information in regards to the patient’s beliefs, expectations or assumption of pain management but further interview time needed to be balanced with the patients’ clinical situations. The need for self-reporting of pain experiences is an indication of the subjective nature of pain and the limitations of the use of biochemical or objective measures. From the 105 potential participants, 93 completed the interview, thus giving a high response rate. Single sites do not allow for generalisation of results but give some baseline data for future comparison. The potential participants’ method of selection is not discussed. The amount of analgesia delivered was not given except that it is reported that four patients received a bolus of fentanyl prior to some procedures. The tables are clearly presented but may have benefited from the inclusion of percentages in addition to the frequencies. Demographic data were limited to age, gender and surgical procedure and may have been more clearly presented in a table format. This study recognises that these patients remain under managed in regards to their pain management but does not offer ways to improve their clinical management. More recent work by this researcher and colleagues has advanced investigations into the reliability and validity of pain tools and thus progresses research on pain assessment and management.8,9 Regular pain assessment has been found to be crucial to improve patient outcomes such as decreased duration of mechanical ventilation and length of stay in ICU10. Although many factors including personal experiences, expectations, anxiety levels, beliefs, cultural background, age and gender may all have effects on pain perceptions, if the patient is not asked, it seems that the patient will not initiate pain relief.1 Further research is needed into how best to improve the use of pain assessment guidelines (using reliable and valid tools), which include regular pain assessment, management and prophylactic pain medication prior to known painful procedures in order to improve critically ill patient care.