Pain management post open heart surgery?

Sugarcoma, RN · Apr 18, 2012

I came from a unit where we had very liberal pain med orders. Most pt.s received Dilaudid 2mg Q3-4 and some as often as Q2 with PO pain meds in between. Many pt.s complained this was not enough. We saw mostly GI, ortho, and neuro-surgery pt.s. When I moved into the SICU I was dumb-founded at how skimpy (compared to my previous floor) the pain med orders were! I have had lap/chole pt.s. receive significantly more pain meds than the CABG pt.s I have now! Even more shocking to me is that the orders we use for post CABG pt.s are usually adequate for most of the pt.s!

Our standard post-op pain control regimen for CABG: 2mg Morphine Q4-6, 15mg Toradol Q8, with Vicodin 5/500 1 q 4 or 2 q 6. Usually by day 2 Morphine is d/c and pt.s are controlled with Toradol and Vicodin, so I would say in my experience your grandmothers pain regimen would be typical of my unit aside from the fact that here she would be getting Vicodin and not Percocet.

When I questioned the pain control regimen it was explained to me that it was to facilitate pulmonary toileting. We also get them up in the chair, tubes and all the a.m. after surgery.

Your grandmother sounds like a very stoic patient. I would always watch for visual clues in these pt.s. I have had them tell me they are a zero even when their faces are contorted and they are white-knuckling the bed rails. Please continue to encourage your grandmother to speak up if she is not getting adequate pain control! Explain to her that she is not increasing our workload, she is in fact helping us do our job, which is to make sure she has a good recovery! I do not know many nurses who would be irritated at a pt. who legitimately needs more pain control! What is her morphine allergy? I see dilaudid substituted frequently for pt.s with morphine allergies. There is always toradol depending on her renal status. Perhaps another po med would control her better? There are many options available to her!

I am glad you asked this question as I am interested to see what other nurses say.

Wishing your grandmother a speedy, uneventful, and comfortable recovery!

Advanced Practice Columnist / Guide · Apr 18, 2012

I'd say that's pretty typical pain management regimen for post-sternotomy patients who had cardiac surgery. You're absolutely right that there is significant pain after cardiac surgery in the sense that the sternum was opened with a bone cutter or saw and then pried open with a retractor during the case and that there are large chest tubed placed to drain the pleura and mediastinum which causes a degree of pressure at the insertion site and the surrounding tissues where the tubes lie.

However, extubation within a reasonable time frame (a target as short as 4 hours post-op is not unusual) is a big priority in the management of post-cardiac surgery patients because it improves post-op recovery and length of stay. Similarly, as in all surgical cases, mobility is also a prime concern and all cardiac surgery programs enforce getting out of bed and ambulation as soon as humanly possible.

As such, one has to balance activity and pain relief. You can't give too much narcotics as to snow the patient and prevent them from mobilizing out of bed and yet you also have to make sure the patient is not guarding his chest incision to the point that interferes with coughing, deep breathing, and other techniques of pulmonary toilet.

Many surgeons like to go light with Percocet or Vicodin or plain Oxycodone for moderate pain and use IV narcotics such as Morphine or Hydromorphone only for severe breakthrough pain. I've seen surgeons prefer that the IV nacotics are DC'd when the patient is transferred out of the ICU. IV NSAIDs such as Toradol are very effective in post-sternotomy pain but their use is limited in the immediate post-op period if there is concern for bleeding and throughout the hospital course if the patient is elderly and has kidney insufficiency.

If your relative is having uncontrolled pain after surgery, it is reasonable to bring it up to the surgery team so that they can consider individualizing management to make sure your family member is comfortable. Just because the surgeon's protocol reads a certain way doesn't mean they are unwilling to make exceptions. It's also worth mentioning that there are newer surgical techniques now that uses smaller incisions that cause less post-op pain. Some surgeons have also started using smaller mediastinal drainage tubes (Blake tubes) that would theoretically cause less tissue pain.

Editorial Team / Admin · Apr 18, 2012

We've started giving some of our patients IV acetaminophen intraop, to be continued q6h postop. At this point it's more of a surgeon trial than definitive going to be this way forever right now, but reports from the docs is that it's working pretty well. Still have narcotics prn and for breakthrough pain.

Esme12, ASN, BSN, RN · Apr 18, 2012

That is pretty typical. Toradol does great with all the inflammation from the surgery. She will feel much better when the chest/mediastinal tubes are removed. But she needs to take the meds to feel better. Encourage her to take the Rx for pain.

My prayers for her continued recovery.

Nursetastic · Apr 18, 2012

Percocet as mentioned is great. Our hearts keep Morphine 2-6mg q1h PRN for breakthrough pain for 48 hours post op. Good pain management teaching is imperative both before surgery and after. The patient needs to be honest about pain so we can stay on top of it. If the patient refuses Morphine for breakthrough, our surgeons will order Toradol. Personally, I think Toradol gives better pain control.

raskol · Apr 19, 2012

My unit takes hearts post op day 2. We rely on percocet 5 or 7.5 q4 (1 tablet) or q6 (2 tablet). If that is not adquate, we get IV morphine, dilaudid, toradol, or talwin depending on the surgeon. We get our patients to the chair on day of transfer and walking by day 3, ideally. The RNs pull our own chest tubes usually when they put out less than 100cc in 8 hours when not walking or surgeon preference.

meandragonbrett · Apr 19, 2012

Morphine 2mg Q5min up to 16mg/hr. Percocet 1-2 tabs Q4 and Toradol IV. Up to chair within a few hours of being extubated. All meals in chair.

TexAg09 · Apr 19, 2012

Most of our patients come out and follow our Rapid Extubation Protocol unless there are complications or the surgeon wants to sleep them overnight r/t some past issues. If they don't have an IABP or something preventing them from getting up (high dose of levo, etc), we usually get them up at 0500 the day after their surgery and prepare them to go up to the tele unit. We usually have morphine ordered q2hours and norco q4hours. Most of our patients go up with at least 2 mediastinal chest tubes and a foley (depending on what the MD orders on the transfer orders--meaning we take it out before they go up, or they take it out, or they keep it in for other reasons) We keep a tight rein on blood glucose as well. It has to be below 200 by post op day 2 or we get dinged. Most of them come out on an insulin drip and is d/c'd before they go up and they are transitioned to subq sliding scale.

Vespertinas · Apr 19, 2012

Sometimes the pain is musculoskeletal from their positioning during surgery. This will usually arise in the shoulders and upper back. Instead of increased narcotics, your relative may benefit from a lidocaine patch to the area, a heating pad, massage, or a skeletal muscle relaxant.

Also sometimes the pain is associated with the chest tubes as they can be very uncomfortable. I find that my patients experience significant relief after their removal.

I hope your relative has an uncomplicated post-op course!

nursej22, MSN, RN · Apr 19, 2012

Percocet 1-2 q3 or 4h is typical. Fresh hearts have a morphine PCA for the first 24 hours, but it is dc'd once they leave ICU. Toradol is rare because of renal concerns. Elderly folks will get plain tylenol and/or Tramadol. Once their chest tubes are out, they often don't want anything at all. Usually younger pts have a great deal of pain with chest tubes, and they make get scheduled tylenol q4h and oxcodone 10-15 mg q3-4 hr. Very rarely, they may get IV narcotics if their pain is out of control.

bpomeroy · Apr 21, 2012

For 2 days post-op usually Vicodin 5-7.5/ 500 (1-2) or Percocet 1-2 every 4-6 is usually sufficient. May use Dilaudid 1-2 mg IVP q 2 prn for severe breakthrough pain if allergic to Morphine . Toradol 30 mg IVP every 6 helps quite a bit, just watch for bleeding. I agree the pain will be MUCH better after the chest tubes are out (they hurt like hell). Need to have her sit up in a chair at least TID. Need to ambulate at least QID starting the day before the chest tubes plan to be removed and every day after that. Zofran or Phenergan help control the nausea from the pain meds and Senokot S is vital while on pain meds to prevent constipation !!!! Hope this helps !!! God Bless !!!!

Sent from Bruce M. Pomeroy, MSN, RN