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Pain Management in Cardiac Surgery

Pain is an unpleasant sensation caused by noxious stimulation of sensory nerve endings. Moseby Dictionary (1990), p 866. A nursing diagnosis accepted by the fourth National Conference on Classification of Nursing Diagnosis.

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As a symptom pain is defined as a state in which an individual experiences and reports the presence of severe discomfort or an uncomfortable sensation. Moseby Dictionary (1990), p 866. Pain assessment is an evaluation of the factors that alleviate or exacerbate a patient’s pain. The patient where possible is asked to describe the cause of pain and its intensity and location. Moseby Dictionary (1990), p 866.

Response to pain varies widely among individuals and depends on many different physical and psychological factors, such as pain threshold, fear and anxiety, and ethnicity of the individual involved and the way that they experience their pain. Clinical judgment in pain management in patients, appears to be inadequate as many research papers have shown over time. Lauder (1990) p 15.

Post-operative pain for adult cardiac surgical patients has many facets. Mueller et al (2000) p 391. Pain can be caused by the incision, chest tubes, multi-intravenous cannulations; just to name a few.

There have been numerous literature reviews and research on pain management within the last three decades, but few studies that have focussed on Cardiac Surgical patients. Meehan (1994) p 39.


Research studies of pain management of cardiac surgical patients has focussed in five major areas, and they are:
1. Types of Pain Management and its Effectiveness
2. The Knowledge of Nurses and Doctors of Pain Management
3. Education on Pain Management for Patients Pre-surgery
4. Long Terms Effects of Cardiac Surgery and Pain
5. Complications relating to Pain Management

Types of Pain Management and its Effectiveness

Participants in five studies used either, PCA (Patient controlled analgesia) NCA (Nurse controlled analgesia) or Epidural in the post-operative period, post-cardiac surgery. Pettersson et al (2000), Turfrey et al (1997), Tsang and Brush (1997), Boldht et al (1998), Melzack et al (1987). Unfortunately there has been only a few clinical trials on the use of PCAs among post-operative cardiac patients that have been carried out to date.

Study by Tsang and Brush, used the comparative analyst in design that compared the two groups of patients receiving pain relief. The first group used the PCA the second group used the NCA. The sample size of the study, and compared well with the clinical trials of sixty to eighty sample sizes.

In this study a negative attitude and lack of knowledge amongst nursing staff in ICU was recognised. Also the study of Chuck (1997), found similar results. Although scepticism among nurses existed on the use of the PCA. Tsang and Brush (1997).

Also due to lack of knowledge, nurses underrated pain or expressed unreasonable concerns regarding opiate induced respiratory depression. In contrast the study of Boldt et al (1998), which was a perspective randomised study and the study of Pettersson et al (2000), which was a comparative study, both found that better pain management was obtained by using the PCA without the increased side effects compared with the traditional NCA treatment.
The study of Turfrey et al (1997), performed a retrospective analysis of patients undergoing cardiac surgery which received a thoracic epidural for their pain management which resulted in good pain management without any complications. This was only one study, and further studies in this type of pain management are warranted to back up the findings of Turfrey et al.

The study of Melzack (1987), reviewed patients that underwent many different types of surgery, with only nine having cardiac surgery. The study used questionnaires and observational methods as well as the pain-rating index. The results from the data collected indicated that post surgical pain is poorly controlled; Melzack (1987) p72, and can impede the patient’s recovery. Overall the method of managing post-operative pain favoured the PCA over the NCA.

The Knowledge of Nurses and Doctors of Pain Management

Increased knowledge about availability of resources for pain management could be expected to reduce incidents of uncontrolled pain. Instead, evidence indicates that moderate to severe pain continues to be sub-optimal throughout the world. Lauder (1990), Heath (1998), Van Niekerk et al (2000), Watt-Watson et al (2000), McCaffery and Ferrell (1999), Dahlman et al (1999).

The study of Heath (1998), used the methodology of descriptive / exploratory design, which utilised the established questionnaire, by McCaffery and Ferrell (1993). In the study by Lauder (1990), it was identified that one major problem of pain management was medical practitioners under prescribing analgesia, and that nurses compounded the problem by under-administrating the medication.

Studies by Lauder (1990) and Van Niekerk et al (2000) and Watt-Watson et al (2000), all identified that further education for both medical practitioners and nurses on pain management would improve their knowledge base, and break down some of the barriers to ineffective pain management in the future. Vignette and Surveys were used in studies by McCaffery and Ferrell (1997), Van Niekerk et al (2000) and Watt-Watson (2000), and questionnaires were used by Lauder (1990) and Dahlman (1999) to question nurses’ knowledge on pain management.

All studies had a variety of problems that needed to be addressed. Some of these problems were nurses’ inability to make decisions on pain management when ordered PRN, the lack of knowledge on pain management to their attitudes on pain. Also inadequate policies in many hospitals on guidelines for effective pain management. In the study by Lauder (1990), the ethnic background of medical practitioners of their method of pain identification was biased in many cases.

Some studies suggest that a callous disregard for the plight of the patient. Fagerhaugh and Strauss cited in Lauder (1990) p18.

Education on Pain Management for Patients Pre-surgery

This area of pain management has been neglected in the past. Kuperberg et al (1999). There were three studies that reviewed the education that was given to patients, pre-cardiac surgery. Watt-Watson et al (2000) did a pilot study of a randomised controlled trial in design of pre-admission educational booklet and a questionnaire was used to obtain feedback, prior to discharge.

The results were that the educational booklet provided adequate education. In contrast Kuperberg et al (1999), using a quanatative research method, using a ten point numerical rating scale of severity of pain pre-operatively and post operatively, also descriptive questions assess beliefs, expectations and perception of pain. The results for this study, indicated that health care professionals generalised, and should individualise pain management.

The study of Nay et al (1996), also used questionnaires and the ten point numerical rating scale, which gave results of a poor standard of pain management. Interesting enough 95% of patients surveyed were very satisfied with their post operative analgesic management. Nay et al (1996), suggests that this maybe related to patients pre-operatively overestimation of post-operative pain severity.

Long Terms Effects of Cardiac Surgery and Pain

A study by Hunt et al (1998) reviewed the quality of life, after coronary artery by-pass surgery, as we are only researching Pain Management we will only review part of this study. The other study by Hunt et al (1998), used a cross-sectional study in design, of 123 patients that were given a questionnaire and were followed up twelve months post-surgery.

17% of those patients, still had severe to very severe sternotomy wound pain and 12.8% leg / arm wound pain, and the researchers were surprised at the high incidence after twelve months. The study by Rowe et al (1998), was a perspective repeated measure in design, the sample size was of 107 women, who had coronary artery by-pass surgery, and data was collected twelve and eighteen months post-surgery.

Like the study of Hunt et al (1998), Rowe et al (1998) used the discomfort scale of 0 (No Pain) to 10 (Unbearable Pain) to the rate the patients’ pain / discomfort. The study was part of a much larger study. Due to different reasons, only 51 patients participated in this study. Rowe et al (1998), also used the satisfaction with life scale, which was a five-item scale which used to measure of cognitive evaluation of life satisfaction.

The results of this study were quite high. At twelve months 47% of women who had had IMA (Internal Mammary Artery) used for grafting experienced chest wall discomfort, and 18% of the women who had Saphenous Veins for grafting.

The findings found that women were able to perform the activities of daily living, but they couldn’t identify what would relive their pain, which was not helpful to the Clinician looking for interventions to relief such pain. Rowe et al (1998)

Complications relating to Pain Management

The study by O’Connor (1999), used randomised control trial in design examined 120 patients undergoing coronary artery by-pass surgery; they were randomly split into three separate groups. Group one used the PCA, group two used a combination of PCA and non-steroidal anti-inflammatory drugs prescribed three time daily, group three used the NCA. The assessment was using VAS (Visual Analogue Scale) and chest X-rays, the radiographer is blinded to which group the patient belongs.

Findings reveal that patients with poor pain management were at greater risk of developing respiratory complications, such as, Atelectasis. O’Connor (1999).
The study of Moore et al (1994), indicated the instance of sternotomy fractures, although only 10% in the study experienced greater pain, and 1% of these suffered major respiratory compromise, due to pain and further intervention of more effective pain management to improved their pulmonary function.

This was measured by arterial blood gases, oxygen requirements before and after pain relief and respiratory rate. A study by Stenseth et al (1996) which was also a randomised control trial had similar findings of reduced pulmonary function following cardiac surgery due to poor pain relief which prevented effective breathing and coughing. This was also verified by arterial blood gases and oxygen before and after pain relief.


Additional research is essential in the regard to more effective pain management in cardiac surgical patients, as over the last thirty years little research has been done in this area. Meehan (1994) p 39. Many of the research studies reviewed have examined fairly small sample sizes compared to the number of people undergoing cardiac surgery. Australian Bureau of Statistics (1998).

Hence replication of studies, in the clinical settings with larger sample sizes would be beneficial and findings may influence the way pain is managed in the future, such as educational programs for both nurses and medical practitioners to improve their knowledge base.

“Education is probably the single most important tool for improving pain management”, Lauder (1990).

Pain which prolongs can affect the quality of life after cardiac surgery, and listening to our patients and giving them a better understanding of what to expect when undergoing cardiac surgery , hopefully this will not give them unrealistic expectations of the pain that they are likely to experience. Although conflicting research is evident in which pain management method is more effective, Tsang and Brush (1997), Pettersson et al (2000), Boldt et al (1998), further research in this area could improve the pain management of further cardiac surgical patients especially as the length of stay in hospital after this surgery has shortened over the last ten years. Naughton et al (1999).

The studies of Watt-Watson et al (2000) and Kuperberg et al (2000) indicated that pre-op education and a booklet on their surgery gave patients an insight of what to expect but larger sample sizes in this area need to be undertaken. Although complications related to pain management is only a small percentage of patients undergoing cardiac surgery. O’Connor (1999). Further research in this area could possibly reduce those findings even further.

Some of the possible research questions for investigation are:
o How could further patient education on pain management improve their quality of life?
o What education do both medical practitioners and nurses require to improve their knowledge?
o What is the most effective pain management for patients undergoing cardiac surgery?


Although pain management in cardiac surgery is under researched in the past, there is evidence in the research that has been done to date, which indicates a slightl improvement of the knowledge base of nurses and medical practitioners. Heath (1998). There is still need for change within the nursing profession’s current practice pain management and it must be actively pursued at the educational, institutional, ward and personal level to optimise the management of patient’s pain. Heath (1998).

Further research should also be designed with a view to developing and assessing interventions which increase knowledge and also reduce faulty judgments about pain management. Lauder (1990). Patient education in recent years has been actively pursued and it is important that further research be continued to give the patient a better understanding of the prospects post-cardiac surgery but not giving them unrealistic expectations regarding their quality of life.

The research on the types of pain management from the NCA to the PCA / Epidural all have a place in obtaining optimal pain management for the patients undergoing cardiac surgery. Although only a small percentage of patients undergoing cardiac surgery develop respiratory problems, due to unmanaged pain further research is warranted to look at preventing this in the future.

Hence in summary, all the areas reviewed about pain management in patients undergoing cardiac surgery require further research to provide optimal care to our patients.

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