Pain management post open heart surgery?

[twinkletoes53]

A very close relative had open heart surgery for an aortic valve replacement 2 days ago. She is 84 years old. She was extubated late the same day, and is now in the cardiac step down unit @ her hospital. According to her sister, she got out of bed with assistance yesterday, and spent 3 hours in a chair. Yikes! I couldn't do that. She still has bilateral chest tubes, a mediastinal tube, pacing wires, 2 IVs and a foley catheter. She said that she was in a lot of pain, but would do whatever they asked her to, so se could get well.

I did have a question. What can I expect as far as what's usually ordered for pain management for someone who is 1-2 days post-op? My experience has been in pediatric med-surg (to age 21) and NICU nursing only. The only thing my relative is receiving for pain is p.o. Percocet every 4 hours prn. She is allergic to Morphine.

She's hesitant to "bother" someone to ask for additional pain meds. She's of the old school that thinks if you ask the nursing staff for too much, they will be upset with you b/c you've "increased their work load", or are a 'high-maintenance" patient.

Is it fairly typical to use Percocet only for someone who's 24 hours post open heart surgery?

[Cynthia Wood, RN]

I've worked in a very large open heart recovery unit for decades. We use morphine/fentanyl/dilaudid for about 48hours, giving it as often as every ten to twenty minutes with max limits. Day two, we add vicodin/percocet every four hours. We use Toradol as well, either as drip or intermittent dose if patents kidneys are healthy and they are not bleeding.

[Reno1978, BSN, RN]

Our standard pain management orders for post-open heart surgery patients are Tylenol 650mg q4 po prn, oxycodone 5-10mg q4 po prn, and dilaudid 0.2mg iv q2 hours prn (may repeat dose once within two hours of first dose).

This typically works well. I find that giving the Tylenol/oxycodone together every 4 hours keeps the pain well under control. The dilaudid seems to take the edge off if they have breakthrough pain. The dilaudid dose is increased depending on patient response, but usually never higher than 0.5mg q2.

Toradol IV is used for those with good kidney function if their pain isn't managed well with the standard regimen.

It sounds like she is progressing well from a cardiopulmonary rehab perspective, but could use more aggressive pain management! Patients typically feel much better upon removal of their chest tubes...especially the left pleural one. It seems like the major complaints of pain from my patients aren't concerning the sternotomy, but the pleural chest tube site, or if their SVG can't be harvested endoscopically and they end up with a significant leg incision. The younger the patient, the more the sternotomy seems to hurt.

[tcvnurse, BSN, RN]

An awful lot of elderly folks are very hesitant to take narcotic pain meds even when their nurse is STRONGLY encouraging them to take it! *Ahem* We are very agressive with pain management post CABG. IVP fentanyl, PO Perc alt with oxy's so the pt can have something Q 2H and more PRN for coughing of activity.

TCV nurses know that the patients will be in a LOT of pain, and that they will have to make the patients do stuff that hurts. We do a lot of educating that it is OK to take the pain meds.

Wishing her a speedy recovery!

[rajirajendran]

hi....im nurse frm india...in our hospital...whn we receive CABG patients..we start fenta sedatin infusion till xmg mrng 4am..thn at 6am.we give T piece trial...thn round the clock analgesic is started...which is tapered...made sos thn..stppd...

[Esme12, ASN, BSN, RN]

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[umcRN, BSN, RN]

I work in a pedi CICU, typically once extubated we will use PR tylenol/morphine/toradol until PO feeding then start on oxycodone. If they are older and we want them getting up and out of bed we might have pain team start them on a PCA either with a low basal rate with on demand dosing or on demand dosing only.

[tracylen]

With the elderly it is about encouraging them to take medicine to promote pulmonary toilet. We must alleviate fears of dependence and addiction. I tell my patients if you cannot use your incentive spirometer than that is too much pain. We use Toradol for 24 -48 hours post-op or for as long as they have chest tubes. We vary our pain meds from Norco or percocet and add ultram prn. It really is about finding the right medication for the patient.

[MegNeoNurse]

How frustrating to have a relative going through this and not receiving adequate pain control! It is SO important for post-op hearts to becomes extubated ASAP and ambulatory! As is pain control. Dilaudid is wonderful!!! As is morphine (but you said she has an allergy). I would think Lortab or Percocet would be ordered PO with the Dilaudid as her IV med for "severe pain".

[IDoNotGiveOut]

I get the feeling that you are concerned about the activity level as well as the pain meds. When I worked in the other part of the surgical ICU that didn't get the cardiothoracic patients, it always used to seem crazy to me too that the open heart patients were gotten up out of bed at 0600 the day after surgery with about 20 invasive lines/wires/tubes still in. But that is typical and standard care for this type of surgery. Sometimes patients are even extubated and have swans out the same afternoon of the surgery and are in the chair for dinner that evening, and they are out to the floor by 9 am POD 1 with orders to ambulate and a general diet. The activity level may seem like a lot but it is appropriate and necessary to prevent complications for this type of surgery. From your description, it sounds like your relative is recovering very well and receiving standard care.

It's a delicate balance, especially with an older patient, and especially with this type of surgery. I mention age because you said you work in peds. Older adults are at risk of being undermedicated for their pain, for a variety of reasons, including because they are hesitant to report pain and because staff are afraid to overmedicate. This fear of overmedicating is somewhat justified, in the sense that older patients are at a higher risk of overdose because they may be more sensitive to the effects and/or may not clear the drugs as well. We all know the adverse effects and dangers of too much opiate/opioid. This, along with her morphine allergy, may be the reason they are content with only giving her percocet, especially if she is not complaining. On the other hand, undermedicating for pain in a patient who has had chest surgery can also cause patients to breathe shallowly because it hurts to take deep breaths and discourages pulmonary toilet, so that also increases pneumonia risk.

It's hard for outsiders to comment on what would be appropriate orders for a particular patient, as it must be individualized for that patient, and there is not a one-size-fits-all approach. I am only guessing at what may be a part of the staff's reasoning, if they have any reasoning. If she is stoic and does not report her pain, it is possible the nurses/doctors may just be undermedicating her unwittingly. If it were my relative I would make sure the staff knows she's afraid to report pain.

Typically where I work post-op hearts have PRN orders for either IV morphine or IV dilaudid, and PO dilaudid, which is preferred once they are extubated, as well as tylenol. Sometimes they have do have oxycodone/tylenol (percocet) ordered instead of the PO dilaudid and tylenol. We only use PCAs very rarely with open heart patients, although we use them fairly often on most other surgical patients. If the doctors are opposed to letting her have more/stronger opioids, there are other options. We sometimes use IV toradol, a non-narcotic anti-inflammatory, but it can be harmful to the kidneys so some patients can't have it. Flexiril (muscle relaxant) helps sometimes. Methocarbomol (sp?) is another muscle relaxant that is less sedating. Hydroxyzine can also help with muscle spasms, but it is an antihistamine and some older people can have bad reactions to it, and it can be sedating (it is sometimes given for anxiety or for insomnia). Ketamine works wonders, but I don't know if they would do that on the floor or not. Neurontin is usually for neuropathic pain but is sometimes also ordered as part of a pain regimen. Even if there are contraindications to this or that, they should be able to work something out to get her pain to an acceptable level for her. It is not possible for her to have no pain, and hopefully they told her that before surgery. That being said, it is so sad to think of an elderly person who is sitting in pain because they don't want to be a bother. I wish you and your relative the best.

[brainkandy87]

Oxy 5-10 mg q4h was pretty standard when I was taking care of CABG's as a floor nurse. Some people had morphine 1-2 mg q2-4h to stagger it. Some people only used their oxy once a day. It really varied as to how each pt tolerated the pain, but the treatment orders were fairly standard with oxycodone and sometimes morphine IV.

[twinkletoes53]

I'd like to thank the people who responded to my note about post-operative pain management. I WAS very concerned about pain management in my grandma; she's the type that would say she was "fine" even when she was in significant pain. She recovered remarkably well from this surgery. She was discharged to inpatient cardiac rehab. for a week, then home. She says that she doesn't feel any different and wishes she had not had the surgery, but I can hear a difference in her voice; she is stronger, not out of breath, and we've actually been able to have a couple of 1 hour conversations that we had not been able to have in a long time, because she would be out of breath. :heartbeat

More importantly, I have another close relative who has 3 stents in his heart, and had previously refused open heart surgery if it came to that point. But b/c he saw our grandma go through this major surgery, survive, and do well, he has agreed that if the time came that he needed open heart surgery, he would agree to it. I am SO glad. He's only 60; never smoked; rarely drinks, is not overweight (actually needs to gain about 10lbs) and has been a runner since he was 16. I have lost 4 close family members in the last 5 years, and can't face losing another one.

[CalvinJ]

In our institution we use Tramadol as a drip for our post open heart patients. This is to eliminate the risk of bleeding with Toradol and to help decrease chances for drowsiness in patients for more chances to rehabilitate the lungs post op. We preferred it to be a drip to have a continuous dose and coverage to make up for its halflife and other pharmacokinetics. If still with pain acetaminophen IV as adjunct will be added to the regimen. But, since pain is very much relative to each person knowing that the patient has a low threshold for pain, we usually have them on Fentanyl via PCA then titrated down to the least of the patient's requirement. :)