Pain Levels - Open Cardiac Surgery - Essay Writing - Nursing Assignment Help

Assignment Task:

Pain levels after open cardiac surgery can be severe and are often undertreated (Cogan 2010). If the post-operative pain management is not adequate, the patient may develop complications resulting in a longer hospital stay and higher overall costs (Goehner & Bigeleisen, 2015). Pain from cardiac surgery can be of visceral, musculoskeletal and neurogenic origin. Risk factors for acute pain can be younger age, pre-procedure anxiety, extensive surgery and longer procedure (Cogan 2010). Ineffective analgesic therapy of post-operative pain can cause severe complications and are dangerous to the patients. Some of the complications include chronic pain, immunosuppression, infections, depression and less effective wound healing. (Zubrzycki etal 2018). The incidence of chronic pain post cardiac surgery varies between 21% and 55% (Cogan 2010).

The success of a cardiosurgical procedure largely depends upon the proper pain management during the first few days of the surgery. The pain is found to be very severe in the first 24 hours following the surgery and decreases in the subsequent days, as it is a “self-limiting” phenomenon (Zubrzycki etal 2018).Pain control can be achieved in a better and effective way by regular and systemic assessment(Cogan 2010).Adopting the most suitable method of alleviating pain while observing the patient closely for complications from the analgesia plays a vital role in post-operative pain management(Zubrzycki etal 2018).Post cardiothoracic surgical pain should be effectively managed using multidimensional method based on three main therapeutic principles. They are administration of combination of analgesic drugs, multimodal analgesia and regional anaesthesia methods (Zubrzycki etal 2018).

Critical care units in South Australia is widely supporting the use of Intravenous administration of paracetamol (acetaminophen) in the immediate post-operative period as an adjunct to an opioid following a cardiac surgery. Although, it is found to be effective in managing the post-surgical pain, some experts within the critical care setting do not support this treatment. Their argument is the hypotension risk associated with it and the acquisition cost.

The PICO method is used to generate an answerable question about this clinical issue. Hoffman etal suggests that, it is important to develop an answerable question as it stops the healthcare professionals from forgetting any of the key clinical components of the clinical issue/question.

The question is:

Does intravenous administration of acetaminophen as an adjunct to an opioid enables better pain management and reduces post-operative nausea and vomiting in patients following a cardiothoracic procedure? 

The four components of the question are

Population-Patients who underwent cardiac procedure.

Intervention-Intravenous administration of acetaminophen.

Comparison-No intravenous acetaminophen in the immediate post procedure period

Outcome-Better pain management and decreased nausea and vomiting.

There are a lot of statistically significant studies conducted on the effectiveness of intravenous administration of acetaminophen in managing the pain post cardiac surgery. The clinical significance of these studies should need to be explored a little further. Clinical significance is set on by judgement. It is important to assess whether the outcome of a study is relevant, useful and important for the patients (Hoffman etal 2013).

The 6s model of organisation of evidence-based information services is used in this paper to determine the clinical significance of studies conducted to assess the efficacy of intravenous administration of acetaminophen in post cardiac surgical patients.

The 6s model is hierarchical in nature and has 6 levels of organisation of evidence from various healthcare researches (Hoffman etal 2013). These levels include original Studies in the base, followed by Synopses of studies, Syntheses, Synopses of syntheses, Summaries and Systems (DiCenso, Bayley, & Haines 2009).

There are different study designs. Meta-analysis, systematic review, randomized controlled trial, cohort study, case-control study, cross sectional study, qualitative, case reports and series etc. According to Hoffman etal. randomised controlled studies are exceptionally good in addressing intervention questions. Systematic reviews of multiple randomised controlled studies are even better as they combine the results of many randomised trials to provide a much clearer answer about the effectiveness of an intervention. Systematic review can summarise the results from quantitative and qualitative studies or combination of these two, depending on the clinical question and method used to review (Hoffman etal 2013). Meta-analyse gives a better overall effect of a clinical intervention than looking at the individual studies (Hoffman etal 2013).

In this paper I chose to start gathering the best current evidences from the summaries, which is the level 5 of the 6s hierarchy. Summaries provides guidelines and or recommendations regarding particular practice and also provide materials to learn further about the other aspects of the disease (Hoffman etal 2013). Summaries can be accessed from various databases like TRIP (Turning Research Into Practice), Dynamed Plus, UpToDate, Australian clinical guidelines and clinical guidelines. TRIP offers very recent and relevant list of online resources for the best evidence-based practice.

Clinical guidelines are the basis of the efforts to improve the healthcare. It synthesise and integrates various evidence based researches to formulate most reliable recommendations (Woolf etal 2012). 

Devlin etal have formulated a clinical guideline on the use of intravenous (IV) administration of acetaminophen in post-operative patients by comparing two single centred parallel -group randomized trials conducted on 113 post cardiac surgery patients and in an open design in 40 post abdominal surgical patients in ICU. The studies evaluated the IV acetaminophen 1 gm every 6 hourly versus placebo in a double blinded fashion. The pain intensity is evaluated after 24 hours using visual analog scale (VAS). The trials pointed out decreased pain intensity at rest in the acetaminophen groups. There was a great reduction in the opioid use, time to extubation, nausea and sedation was also reduced in the acetaminophen group.

In cardiac critical care unit, it is equally important to control the opioid use along with managing pain. Increased opioid use prolong the time on ventilator. Ventilator dependence increases the risk of lung atelectasis and associated complications including pulmonary infections. Active breathing and coughing prevent lung complications. Increased opioid use makes the patient weak and drowsy and increases the risk of nausea and vomiting.

The studies found that IV acetaminophen causes hypotension in about 50% patients. A decrease in the mean arterial pressure of  > 15mmhg was noted. This occurs quite often in our critical care setting too. IV acetaminophen should be used cautiously or avoided in those patients. However, Devlin etal has come up with a conditional recommendation that IV acetaminophen can be used in critically ill patients as an adjunct to an opioid for pain management.

In United States, the use of IV acetaminophen has been approved as it is found to be safe and effective when used along with opioids for post-operative pain following a major or cardiac surgery.(Barr etal 2013).In a clinical guide line set by Barr etal, they suggest that non opioid analgesics should be considered to decrease or even to eliminate the need for IV opioids and decrease side-effects related to opioids.

Moving down the 6s pyramid are the synopses of synthesis and synthesis. Synthesis integrates evidences from different studies on the same topic. Systematic reviews and meta- analysis are examples of synthesis (Hoffman etal 2013). When systematic reviews and meta-analysis are properly implemented using the right methodology and without any bias ,they can yield powerful results (Ahn & Kang 2018)

Apfel etal conducted a systematic review and meta-analysis on the effect of   IV acetaminophen on the post-operative patients. They conducted a systematic search  using Medline and Cochrane databases. Apfel etal used 30 randomized-controlled trials of IV acetaminophen for their systematic review. The study in total includes 2364 patients ,1223 in the acetaminophen group and 1141 in the placebo group.The relative risk was 0.73 for nausea and 0.63 for vomiting.

This systematic review and meta-analysis is not specific for cardiac patients, but have included about 113 cardiac patients ,56 in the acetaminophen group and 57 in the placebo group. The large volume of participants and the number of single studies chosen for review makes it relevant.

IV acetaminophen is preferred to oral and rectal applications in the immediate post-operative period as it is found that 1g of IV acetaminophen has about twice the plasma and effect site concentrations, resulting in greater central nervous system penetration ( Singla etal 2012).According to the systematic review and meta-analysis, opioid use is also reduced in patients who received IV acetaminophen (Apfel etal 2013).Deep sensitivity analysis revealed that  prophylactically administered IV acetaminophen ,decreases the post-operative nausea and vomiting, regardless whether it was initiated pre operatively, intraoperatively or immediately after surgery. Reduction of post-operative requirement of opioids did not contribute to the less incidence of nausea and vomiting. The considerable reduction in the post-operative pain caused the significant reduction in post-operative nausea (Apfel etal 2013).

Pain is a risk factor for post-operative nausea and vomiting. Reducing the pain intensity decreases the chances of nausea and vomiting (Afpel 2013). Acetaminophen is metabolized in the brain into AM404.AM404 is a metabolite that inhibits the reuptake of anandamide. (Afpel 2013). Increased level of anandamide is associated decreased rate of nausea and vomiting in humans (Chouker etal 2010). Therefore, acetaminophen has a direct effect in reducing post-operative nausea and vomiting by increasing the anandamide levels (Apfel etal 2013)

Apfel etal concluded that the prophylactic administration of IV acetaminophen reduced post-operative nausea and vomiting. IV acetaminophen initiated after the onset of pain was not effective against post-operative nausea and vomiting. In our work setting IV acetaminophen is started just after anaesthesia induction and is repeated after 6 hours intra operatively if the procedure is long. It is given regularly every 6 hours in the post-operative period until the patient is able to start taking oral acetaminophen.

Moving down the 6s pyramid is single studies at the bottom. Random -controlled trial, cohort study, case control study, qualitative study, case series etc are some examples of single studies. 

A double-blind, randomized placebo-controlled trial was conducted in an academic medical centre by Jelacic etal to assess the efficacy of IV acetaminophen as an adjunct analgesic in cardiac surgery. The study was small comprising only 68 adults undergoing cardiac surgery. Patients were assigned randomly into two groups, one receiving placebo treatment and the other group receiving 1g IV acetaminophen immediately after the induction of anaesthesia, at the end of the surgery and every 6 hourly for the next 24 hours in the critical care unit. The primary outcome was monitored after 24 hours and the secondary outcome was assessed after 48 hours. The outcomes assessed were, post-operative opioid consumption, incisional pain score, adverse effects from the opioids, time to extubate the patient, length of critical care stay and the extent of wound hyperalgesia. The study showed a 27%reduction in the opioid consumption in the acetaminophen group. There was no difference in the pain score between the placebo group and acetaminophen group. The study showed nil difference in the opioid related side effects. The patients in the acetaminophen group were more satisfied with the pain management compared to the placebo group.

Acetaminophen is preferred to non-steroidal anti-inflammatory drug in cardiac surgery patients as it has minimal impact on platelet, gastro intestinal and renal function (Jelacic etal 2016).The absorption of oral acetaminophen is poor in surgical patients due to reduced gastro intestinal motility and gastric emptying in the first few days post-surgery. The therapeutic concentration of acetaminophen in plasma can be achieved quicker by the IV administration, especially in cardiac patients (Jelacic etal 2016).

IV acetaminophen is usually ordered for all the cardiac patients in our work setting as either regularly or as whenever-needed doses (PRN). The IV administration starts soon after the induction of anaesthesia in theatre. However, if it is ordered as whenever needed doses, some nurses fail to administer regularly when the patient is sedated and ventilated. This is the crucial period where the administration of IV acetaminophen is needed. A regular 6 hourly dose of IV acetaminophen in the first 24 hours post-surgery and oral administration in the next 48 hours in addition to the opioid doses found to be very effective in managing the surgical pain. The critical care consultants have varying opinion on the effectiveness of IV acetaminophen. Most of them has started ordering regular IV acetaminophen these days. There need to be further education and research on the importance of administration of IV acetaminophen in the first 24 hours of cardiac surgery.

There are some barriers which affects the regular administration of IV acetaminophen. It causes a transient decrease in blood pressure and it is very evident from the work experience too.

Secondly, IV acetaminophen is a costly drug. Oral acetaminophen is much cheaper than the IV form.

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