Pain management post open heart surgery? - page 3

by 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,... Read More


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    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.
    twinkletoes53 likes this.
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    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 likes this.
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    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.
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    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.
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    Quote from 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.
    A Tramadol gtt? BARF. What psycho MD thought up that idea? Tramadol shouldn't even be on the market IMO, let alone as the method for post open heart pain relief. A seizure is just what a post open heart patient needs. /rant
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    I do understand where you're coming from about tramadol however as a drip, nausea is boiled down to a minimum since its administration goes in real slow. From experience pain associated with the sternotomy is resolved by tram in 80% of our patients. Most of the pain complaints come from thr chest tubes. The tramadol drip would run for a max of 24 hrs immediate post op and shifted to orals. We make it a point that any cause of drowsiness be eliminated to facilitate lung rehab as early as possible post extubation. So there. Lol.
    twinkletoes53 likes this.
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    Lol. Yeah I understand the rationale. I'm just a stickler when it comes to Tramadol. I think it's highly misused by physicians. Anyway, /rant.
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    l was so glad that l was able to read other stories very similar to our own recent experiences ongoing....our dad has just had a double bypass ,and the nursing care etc. has been outstanding,which is not said very often now a days due to many many reasons... the only worry l have is the misunderstanding of the powers of paracetmol !!!! after 5 1/2 hours in surgery, ICU was fab, HDU was fab but then less than 24hrs later paracetmol appears again to take charge.after 24yrs in the nhs, even l know that pain management is the key to either a successful / poor recovery of the patient. so why does it keep getting over looked? during the last 10 days,and talking to others of a simaular position,it really is a key problem. most of the patients who have had poor pain management "appear "to develop chest infections within 72.hrs of surgery. l know there is always this risk but,if a patient is not able to do his/her breathing excerises,mobilize as soon as possible then they are not able to help inflate their lungs,or mobilize gradually,again to ward off all those post op nasties as successfully as they could do in order to promote well-being and discharge home as soon as able. l know the flip side of this is pain masking, dependancy and other pain medication related problems,but surely there must be some common ground that could be aimed for together helping the patient "get better"as we hoped? A lot of the children's services seem to have got there heads around this paracetmol
    myth,so why can't the adult services do the same? has anyone got any stats. re;this matter as l'd love to read/study them?
    many thanks for the other letters,support comes in many varieties.....
    twinkletoes53 likes this.


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