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American Journal of Critical Care. 2004;13: 292-302
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CE Article and Journal Club Feature

Appropriately Timed Analgesics Control Pain Due to Chest Tube Removal

By Kathleen Puntillo, RN, DNSc and S. Jill Ley, RN, MS. From the School of Nursing, University of California, San Francisco (KP), and the Cardiac Surgery Service, California Pacific Medical Center (SJL), San Francisco, Calif.


   Abstract
Top
 Abstract
Background
 Specific Aim
 Research Design and Methods
 Results
 Discussion
 Limitations
 Conclusions
 References
 
• Background Pain during chest tube removal can be moderately to severely intense and distressful to patients. Little evidence-based research has guided clinicians in attempts to alleviate such pain.

• Objective To test pharmacological and nonpharmacological interventions to alleviate pain during chest tube removal in cardiac surgery patients.

• Methods Four interventions were tested in 74 patients in a randomized, double-blind study: (1) 4 mg intravenous morphine and procedural information; (2) 30 mg intravenous ketorolac and procedural information; (3) 4 mg intravenous morphine plus procedural and sensory information; and (4) 30 mg intravenous ketorolac plus procedural and sensory information. Analgesics were administered to correspond to peak effect, and scripted information was provided. Pain intensity and pain distress were measured before analgesic administration, immediately after chest tube removal, and 20 minutes later. Pain quality was measured immediately after chest tube removal. Level of sedation was measured before and 20 minutes after chest tube removal. Repeated-measures analyses of variance were used to test differences among groups over time.

• Results Pain intensity, pain distress, and sedation levels did not differ significantly among groups. However, procedural pain intensity (mean 3.26, SD 3.00) and pain distress (mean 2.98, SD 3.18) scores for all were low. Patients remained alert, regardless of which analgesic was administered.

• Conclusions If used correctly, either an opioid (morphine) or a nonsteroidal anti-inflammatory (ketorolac) can substantially reduce pain during chest tube removal without causing adverse sedative effects. Thus, clinicians may choose among several safe and effective analgesic interventions during chest tube removal.

Each year in the United States as many as 363 000 patients undergo cardiac surgery,1 which often requires the insertion of chest tubes to facilitate lung expansion and drainage of fluids. When no longer needed, the tubes are removed during the early recuperative phase. Determining an optimal intervention to relieve pain during such a frequently performed procedure may help promote pain control in critically ill patients.


   Background
Top
 Abstract
 Background
Specific Aim
 Research Design and Methods
 Results
 Discussion
 Limitations
 Conclusions
 References
 
Patients describe chest tube removal as a painful event in their postoperative recuperation2–5 and report that the pain is poorly managed.5–9 No national standards have been set for management of pain associated with chest tube removal. In fact, in a national survey10 of more than 500 nurses, only 16.3% of these nurses’ patients had a routine prescription for pain medication before chest tube removal.


According to a national survey of nurses, few patients have a routine prescription for pain medication before chest tube removal.

 

Morphine is one of the most often, if not routinely, used opioids for treating pain due to chest tube removal.5,10 Acting at central µ1 and µ2 opioid receptors,11 morphine has a rapid onset of action (<5 minutes) after intravenous administration and has its peak analgesic effect in 20 minutes. However, when morphine was used in small doses (ie, a mean ≤ 3 mg), pain associated with chest tube removal was rated as moderate to severe.5,6 Higher morphine doses have not been tested for their effect on such pain.

Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) with moderate anti-inflammatory properties. Its analgesic properties are even more pronounced than its anti-inflammatory properties.12 Thirteen patients who received a mean dose of 51 mg intramuscular ketorolac for general surgical inflammation before chest tubes were removed had significantly (P = .02) lower scores for pain intensity (mean 2.8, SD 2.9) than did 26 patients who did not receive ketorolac (mean 5.4, SD 3.9).6 This finding suggests that ketorolac may be an effective analgesic for pain due to chest tube removal.

Ketorolac inhibits prostaglandin synthesis by reversibly blocking cyclooxygenase.12 Prostaglandins promote the development of hyperalgesia by sensitizing nociceptive neurons. Although the exact mechanism of action of NSAIDs remains to be elucidated, they work both peripherally12 and centrally.13 Unlike opioids, ketorolac does not depress the central nervous system at usual therapeutic doses and has no adverse hemodynamic or ventilatory effects.14 These considerations are important in the treatment of physiologically vulnerable cardiac surgery patients.

Not only can pain due to chest tube removal be severe, it appears to have a greater negative emotional component than does postoperative pain.15 The beneficial effects of preparatory information before a procedure include a decrease in anxiety,16,17 better hemodynamic status, better physical recovery,18 less overt distress,19 and less pain.20–22 Procedural information provides a description of the sequence of a particular medical or laboratory procedure, or what a patient can expect to have happen during the procedure.23 Sensory information is information about the specific feelings, acquired by way of the senses, that are expected to occur during the procedure.23,24 Providing information about sensations that will be felt during a noxious event (eg, chest tube removal) may help provide a more realistic experience for patients24 and improve coping capacity.21,24,25

A meta-analysis of 21 laboratory (5 studies) and clinical (14 studies in adults and 2 in children) pain studies indicated that sensory information was more effective in reducing procedural pain than was either procedural information or no information.23 Offering both sensory and procedural information seemed to be a superior strategy to providing either type of information alone.


Providing information about sensations felt during procedures is effective in improving patients’ coping capacity.

 

Clearly, treatment of pain during chest tube removal has been inadequate, and systematic investigation is required to determine optimal treatments to decrease pain and reduce negative emotions. Testing 2 types of analgesics with different mechanisms of action as well as 2 types of information provided an opportunity to evaluate the effectiveness of multidimensional treatment interventions.


   Specific Aim
Top
 Abstract
 Background
 Specific Aim
Research Design and Methods
 Results
 Discussion
 Limitations
 Conclusions
 References
 
The specific aim of this study was to answer the following research question: Is there a significant difference over time in pain intensity, pain distress, and sedation levels among 4 treatment groups, and is there a difference in pain quality reported after chest tube removal among the 4 treatment groups? The 4 treatment groups were as follows: (1) 4 mg intravenous morphine and information on the procedure for chest tube removal; (2) 30 mg intravenous ketorolac and information on the procedure for chest tube removal; (3) 4 mg intravenous morphine, information on the procedure for chest tube removal, and sensory information related to chest tube removal; (4) 30 mg intravenous ketorolac, information on the procedure for chest tube removal, and sensory information related to chest tube removal.


   Research Design and Methods
Top
 Abstract
 Background
 Specific Aim
 Research Design and Methods
Results
 Discussion
 Limitations
 Conclusions
 References
 
Design
The study was double-blind, randomized, and quasi-experimental. In order to provide patients an opportunity to be given medications, if they chose to do so, we intentionally did not have a no-analgesic-intervention control group.

Sample and Site
A convenience sample was drawn from patients who had a chest tube inserted during cardiac surgery and met the following inclusion criteria: (1) age greater than 18 years, (2) ability to speak English, and (3) ability to self-report pain. Exclusion criteria were (1) chronic (ie, ≥1 month) exposure to opioids, (2) renal insufficiency (creatinine level >124 umol/L [1.4 mg/dL]), (3) allergies to NSAIDs or morphine, (4) history of gastric bleeding, (5) cardiac transplantation, and (6) inability to speak or read English. Exclusion criteria 2 through 5 were included because use of ketorolac would be contraindicated in such instances. The study site was a tertiary care teaching hospital that performs approximately 250 adult cardiac surgical procedures annually.

Measures
  Demographic and Surgical Characteristics.   Demographic information collected through chart review included the following: age, sex, and ethnicity of each patient; diagnosis; specific type of cardiac surgery; specific type of chest tube (mediastinal or pleural); and postoperative pain medications other than study drugs administered in the hour preceding chest tube removal.

  Self-report Measure of Pain Intensity.   Pain intensity was measured by using a horizontal numeric rating scale (NRS) from 0 to 10, with higher numbers meaning greater pain intensity. This type of NRS is used widely in clinical practice and research because of its ease of use. Even critically ill patients, some of whom were intubated, were able to rate their surgical26 and procedural5,6 pain intensity by using an NRS, providing support for its feasibility of use with the acutely ill patients in our study. Validity and reliability of the NRS have been established.27–29

  Self-report Measure of Pain Distress.   Pain distress is the pain dimension that relates to negative emotional responses.20,25 Pain distress was measured by using a horizontal NRS from 0 to 10, with higher numbers meaning greater pain distress. Pain distress scales have been used to test effectiveness of interventions for experimental21,22 and clinical21,25 pain.

  Self-report Measure of Pain Quality.   The word list of the McGill Pain Questionnaire, Short Form (MPQ-SF)30 was used to measure the quality of pain during chest tube removal immediately after chest tubes were removed. The list contains 11 sensory words, such as "sharp" and "stabbing," and 4 affective words, such as "punishing-cruel" and "fearful." The magnitude of each word is graded on a 4-point scale, from none (0) to severe (3). Sensory scores range from 0 to 33; affective scores range from 0 to 12. Concurrent validity between the MPQ-SF and the MPQ-Long Form has been reported.30 Summation of sensory and affective word scores is the method used by the developers of the MPQ-SF to evaluate treatment effects.30 The {alpha} reliability coefficients for the sensory and affective dimensions of the MPQ-SF range from .75 to .83.26 In order to determine what words were used most often to describe the painful sensations associated with chest tube removal, composite scores were calculated from 2 previous studies of pain associated with chest tube removal.5,6 Words with the highest mean scores and, thus, the highest rankings were "sharp," "tender," "shooting," "heavy," "hot-burning," and "stabbing." The MPQ-SF was administered after chest tube removal.

  Sedation Assessment.   Level of sedation was assessed to determine if differences existed between patients who received morphine and those who received ketorolac because sedation may be an adverse outcome of analgesic interventions for pain due to chest tube removal. Clinicians may be hesitant to administer an analgesic before chest tube removal that makes a patient too sedated. Level of sedation was determined by using the Observer’s Assessment of Alertness/Sedation (OAA/S) Scale.31 The scale has 4 categories: responsiveness, speech, facial expression, and eyes, with 3 to 5 options in each category from which to choose. The sum score ranges from 1 to 20, with lower scores indicating a deeper level of sedation. Validity and reliability of the OAA/S Scale were tested in 18 subjects who received either placebo or a titrated dose of midazolam to produce heavy or light sedation.31 Interrater reliability of the composite scores was from .87 to .94 and of the sum scores was from .86 to .96. Criterion and construct validity were established as well. The OAA/S Scale can be administered in approximately 1 minute. Training sessions were conducted in the manner described by Chernik et al31 to establish a high degree of interrater reliability. A minimal level of 100% agreement between a pair of research nurses was obtained before a research nurse conducted study sedation assessments independently.

Procedure
Approval was obtained from the institutional review board of California Pacific Medical Center, San Francisco, Calif, where the study was performed, and from the board of the University of California, San Francisco. Informed consent was obtained from patients by a member of the research team before chest tube removal. California Pacific Medical Center has no routine method of medicating patients for chest tube removal. We thought that any differences among patients in the type and amount of postoperative analgesics would be evenly distributed across groups through randomization.

The clinical research pharmacy service at California Pacific Medical Center was responsible for the randomization and blinding of study drugs and information scripts. (See scripts in Table 1Go.) Upon notification that chest tube removal was planned for a study subject, a pharmacist furnished a packet containing a syringe with 1 of the 2 study drugs (4 mg morphine or 30 mg ketorolac), a syringe containing a placebo (isotonic sodium chloride solution), and a sealed envelope with either a procedural information script or both procedural and sensory information scripts. All syringes had a similar appearance. A 4-mg dose of morphine was chosen because 3 mg or less is ineffective for blocking pain due to chest tube removal,5,6 and a 4-mg intravenous dose of morphine is within the reported equivalency range for 30 mg of intravenous ketorolac.32


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  		Table 1
 
Patients were given specific directions on how to use the NRS to rate their pain intensity. These ratings were done before, immediately after, and 20 minutes after chest tube removal (when recovery from the event was expected). Pain distress was rated at the same time as pain intensity. All patients were extubated by the time of data collection and could, therefore, verbalize their responses.

  Time 1: Before Chest Tube Removal.   On the first postoperative morning, patients’ readiness for chest tube removal was determined by the critical care intensivist according to standard criteria (ie, chest tube drainage <100 mL for the previous 8 hours and absence of air leak). Two members of the research team participated in the study protocol each time. Research team member 1 (K.P. or a research assistant) taught patients to use the NRS scales, asking patients to rate pain intensity and distress, and did a sedation assessment by using the OAA/S Scale. Sixty minutes before chest tube removal was scheduled, research team member 1 administered the first intravenous injection (either the placebo or 30 mg of ketorolac). The syringes were marked according to the time the medications should be administered, time 1 or time 2. The 60-minute time for the first injection was chosen because 60 minutes is the estimated time to peak effectiveness for intravenous ketorolac.32 Twenty minutes before chest tube removal, research team member 1 administered the second intravenous injection (either the placebo or 4 mg of morphine). Twenty minutes was the estimated time to peak analgesic effect for intravenous morphine.33 At this time, each patient’s nurse was asked to prepare the patient for chest tube removal according to standard procedure. The patient’s nurse also read either the procedural information or the procedural plus sensory information script to the patient. Research team members were not present during the reading of the scripts.

  Time 2: During Chest Tube Removal.   All chest tubes were removed by research team member 2 (S.J.L.), the study coinvestigator who is the clinical nurse specialist on the cardiac surgery service. This practice helped to control for the potential confounding variable of procedure technique. The clinical nurse specialist directed patients to take a deep breath and to hold it to the count of 1 . . . 2 . . . 3 . . . until told to breathe out. Patients were asked to practice this maneuver. Patients were then asked to take a deep breath and hold it as the chest tube was pulled out rapidly. Although the literature contains no specific recommendations for chest tube removal and no national standards exist for the procedure,10 the instructions used in this study are often given to patients and were routine in this setting.

The clinical nurse specialist then left the patient’s room, and research team member 1 remained to collect the remaining data. That is, immediately after chest tube removal, or as soon as they were able, patients were asked to rate the pain intensity and pain distress of chest tube removal. They were also asked to choose relevant sensory and affective words on the MPQ-SF and to rate the magnitude of each of these words on the 0 to 4 scale.

  Time 3: After Chest Tube Removal.   Twenty minutes after the MPQ-SF was administered, research team member 1 asked patients to rate their current pain intensity and pain distress, and a sedation assessment was completed.

Data Analysis
Data were entered into the SPSS statistical software package (SPSS Inc, Chicago, Ill) from each patient’s data collection files. The initial phase of data analysis was calculation of descriptive statistics of demographic variables, NRS pain intensity, NRS pain distress, pain quality, and sedation level. Repeated-measures analysis of variance (RM-ANOVA) was used to investigate the effects of the 4 treatments on the changes in pain intensity and pain distress at 3 times: before, immediately after, and 20 minutes after the chest tube was removed. The RM-ANOVA had 1 between-subjects factor (treatment group) with 4 levels, and 1 within-subjects factor (time) with 3 levels. This design allowed testing the main effect of group, the main effect of time, and the group-by-time-interaction effect. Testing the interaction was used to determine if the change in the dependent variables over time was the same for each treatment group. A total of 2 RM-ANOVAs were run, 1 each for pain intensity and pain distress. Thus, the level of significance criterion was {alpha} = .025 (.05/2). One-way ANOVAs were used to test differences among groups in mean sensory word scores, affective word scores, and total MPQ-SF quality word scores. Finally, an RM-ANOVA was used to test differences among groups in levels of sedation.


   Results
Top
 Abstract
 Background
 Specific Aim
 Research Design and Methods
 Results
Discussion
 Limitations
 Conclusions
 References
 
Characteristics of the Sample
The final sample consisted of 74 cardiac surgery patients (Table 2Go) who had their chest tubes removed a mean of 26 (SD = 12) hours after surgery. The sample included mostly white men who underwent coronary artery bypass grafting and had mediastinal tubes removed. Only 6 patients received any additional, non-study analgesics in the hour before having their chest tubes removed. The mean (SD) additional amount of morphine-equivalent opioid dose administered to the 6 patients was 3.4 (1.4) mg. The ketorolac plus procedure information group and the ketorolac plus procedure and sensory information group had 2 patients each who received additional analgesics, and each of the other groups who received this additional morphine had 1 patient who received additional analgesics.


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  		Table 2 Demographics of patients in the study (N = 74)*

 
Pain Intensity, Pain Distress, and Sedation Levels
Tables 3Go, 4Go, and 5Go present pain intensity, pain distress, and sedation scores for the 4 treatment groups across time. RM-ANOVAs indicated that pain intensity (F = 0.82; P = .49), pain distress (F = 2.48; P = .07), and levels of sedation (F = 0.47; P = .71) did not differ signif icantly across time among the 4 treatment groups. These analyses were done after 74 patients in our intended sample of 148 patients had been accrued into the sample. At that time, the study’s biostatistician used a power analysis to calculate the effect sizes of differences among groups in these 3 outcomes and found that the sizes were extremely small (eg, 0.03 for pain intensity). Because of the small effect sizes, a sample of 344 patients (86 per group) would have been required to achieve statistical significance. The actual clinical significance of differences among treatment groups would be negligible for most patients.


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  		Table 3 Mean (SD) pain intensity scores per numeric rating scale*

 

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  		Table 4 Mean (SD) pain distress scores per numeric rating scale*

 

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  		Table 5 Mean (SD) sedation scores per observer assessment of alertness/sedation scale*

 
Because of lack of significant differences among treatment groups, the group data were combined. Differences in pain intensity, pain distress, and levels of sedation before and after chest tube removal were calculated for the entire sample of 74 patients (see Tables 3Go, 4Go, and 5Go). Mean (SD) scores for pain intensity and pain distress at the time of chest tube removal were 3.26 (3.00) and 2.98 (3.18), respectively. The mean (SD) sedation score 20 minutes after chest tube removal was 19.04 (2.39).

Pain Quality
The words selected by at least 25% of the total sample to describe pain during chest tube removal were as follows: fearful (44.8%), sharp and tender (40.3% each), and hot-burning (26.9%). No significant differences were found among the 4 treatment groups in mean sensory, affective, and total MPQ-SF quality word scores (Table 6Go).


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  		Table 6 Differences among 4 treatment groups in mean (SD) sensory, affective, and total quality word scores per McGill Pain Questionnaire–Short Form

 

Chest tube removal caused mild pain intensity and mild distress but was described as fearful, sharp and tender, and hot-burning.

 


   Discussion
Top
 Abstract
 Background
 Specific Aim
 Research Design and Methods
 Results
 Discussion
Limitations
 Conclusions
 References
 
This sample of 74 cardiac surgery patients reported minimal pain intensity and distress associated with removal of their chest tubes after surgery. Specifically, their mean pain intensity and distress scores of 3.26 and 2.98, respectively, fall within a 0 to 10 NRS range of 1 to 4, which is equivalent to mild pain.34,35 These low pain intensity and pain distress scores represent much better pain relief than reported in previous studies on chest tube removal, in which mean pain intensity scores ranged from moderate3,6–8 (ie, NRS scores of 5–634,35) to severe5 (ie, NRS scores of 7–1034,35) or strong.36 In other studies of analgesics in which patients received small amounts of morphine with administration not timed to peak effect, pain relief was inferior.5,6 The pain relief we noted was also better than when local anesthetics were injected into pleural chest tubes6 or when morphine was administered alone or in combination with subfascial lidocaine injections lateral to chest tube insertion sites.4 This finding of comparatively better pain relief confirmed our a priori assumption that timing a procedure to correspond to peak effect of an analgesic is an optimal approach to minimizing expected pain, a method referred to as preemptive analgesia.37 The minimal pain experienced by patients in our study dispels a previously held assumption that the short, intense nature of a procedure may preclude the ability to prevent negative sensations such as pain.3

Pain intensity and distress scores reported 20 minutes after chest tube removal were extremely low. That pain intensity and distress decreased to less than even baseline pain is not an unusual finding6–9 and suggests that removal of the source of potentially constant irritation improves comfort.


For effective pain reduction, chest tube removal must be timed to coincide with peak analgesic effect.

 

Pharmacological Interventions
Our findings do not confirm the relative superiority of either morphine or ketorolac as an analgesic preparation for chest tube removal. Rather, they reinforce the analgesic properties of 4 mg morphine and 30 mg ketorolac for pain during chest tube removal when those drugs were administered intravenously 20 and 60 minutes, respectively, before the procedure. This finding is encouraging because it offers clinicians marked leeway in individualizing analgesic choices. For example, morphine could be administered to patients for whom an NSAID such as ketorolac is contraindicated because of coagulopathies, peptic ulcer disease, or renal impairment. On the other hand, ketorolac may be a better choice for a patient who has a true allergy to opioids or a patient who has not experienced adequate pain relief with morphine. If patients have marked background pain, clinicians could consider administering both types of analgesics before chest tube removal in order to capitalize on the different mechanisms of action of the 2 drugs.

Unlike ketorolac, morphine may cause sedation. This drug characteristic may be of concern to clinicians who would hesitate to administer this opioid for a relatively quick procedure such as chest tube removal. However, we found that a 4-mg intravenous bolus of morphine had no effect on levels of sedation. Patients were quite alert before administration of either study drug and remained alert up to 20 minutes after the procedure. We recommend use of a valid, reliable sedation scale such as the OAA/S Scale31 before and after administration of an analgesic agent that might promote sedation. Sedation assessment findings may help to alleviate clinicians’ concerns and direct clinicians to selecting the best analgesic for a particular patient before chest tube removal.

Nonpharmacological Interventions
Previously, researchers tested the effects of non-pharmacological interventions on decreasing patients’ pain during chest tube removal. Neither ice applied around the chest tube,7 nor use of a quick relaxation technique,9 nor white noise or music8 was effective in decreasing pain intensity below moderate levels of pain. We thought that our nonpharmacological intervention, preparing patients by providing information about a procedure, would help minimize pain intensity and distress during chest tube removal. However, pain intensity and distress did not differ significantly between patients who received procedural information and patients who received both procedural and sensory information. Thus, the benefits of providing sensory information before a procedure, as reported by other researchers,18–22 were not replicated in this study. This lack of effect most likely is not due to patients’ receiving irrelevant sensory information because words chosen most often by our patients (eg, hot-burning, sharp, and tender) were on the preparatory script. Conversely, patients did not select all of the words on the sensory information script (eg, heavy or stabbing) with any degree of frequency. This finding suggests that clinician suggestion was not a strong motivator for word selection.

The word chosen most often (by 44% of respondents) from the MPQ-SF by patients in this study was fearful, an affective word not included on our preparatory list. In 3 previous studies on chest tube removal, the frequency of selection of fearful from the MPQ-SF varied considerably. In a study by Owen and Gould,36 none of 18 patients chose fearful to describe the patients’ chest tube pain experience. Yet, in a study by Puntillo,5 more than 50% of 18 patients selected the word fearful as descriptive of their pain during chest tube removal. Sauls,7 who tested the effectiveness of topically applied ice for alleviating pain during chest tube removal, found that fearful was chosen less often than another affective descriptor: punishing-cruel.

Reasons for this variation in selection of the word fearful are unknown, although background anxiety may influence the perception of fearfulness. Mimnaugh et al38 found significant correlations between patients’ anxiety and their perception of sensations during chest tube removal, although neither mean anxiety and sensation scores nor correlation coefficients were reported. Presence of anxiety may have increased the perception of fearfulness during the procedure. Anxiety also may have made it difficult for patients to concentrate on the preparatory procedural and sensory information and use this information to their advantage.36 Indeed, anxiety may also have been increased by the information received about the procedure and the sensations to be expected during removal of the chest tube. The relationship of anxiety to patients’ information and/or patients’ sensory experiences during chest tube removal warrants further research.


   Limitations
Top
 Abstract
 Background
 Specific Aim
 Research Design and Methods
 Results
 Discussion
 Limitations
Conclusions
 References
 
Because we did not include a no-treatment or standard-care control group in our design, we cannot say with absolute confidence that the minimal pain experienced by patients in our study was due to the morphine or ketorolac that they received. Yet, the superiority of pain control compared with that observed in other studies on chest tube removal strongly suggests the benefits of these analgesic interventions. Limiting our study to a single institution and having a single clinician remove all chest tubes enhanced internal validity but decreased the generalizability of the findings. Testing a similar intervention in multiple settings could help confirm the effectiveness of these analgesics for pain during chest tube removal.


   Conclusions
Top
 Abstract
 Background
 Specific Aim
 Research Design and Methods
 Results
 Discussion
 Limitations
 Conclusions
References
 
Patients in this study had excellent pain control during removal of chest tubes. This finding helps confirm that either an opioid (morphine sulfate) or an NSAID (ketorolac) can substantially minimize pain due to chest tube removal without causing adverse sedative effects, if administered appropriately. Appropriate administration includes using sufficient doses and performing the procedure at a time that corresponds to the drug’s peak effect. Thus, clinicians have latitude in planning pain management interventions for patients undergoing chest tube removal that are both safe and effective.


   ACKNOWLEDGMENTS
 
This study was performed at the University of California, San Francisco, and California Pacific Medical Center, San Francisco, Calif. This study was supported by a grant from the American Association of Critical-Care Nurses. We are grateful to the following research assistants: Denise Li, RN, MS, Gretchen Wolf, RN, MS, and Garrett Chan, RN, MS, who are PhD students at the university. We also acknowledge Dr Steven Paul, biostatistician in the University of California, San Francisco, School of Nursing, for his expert assistance. We are also grateful to the many intensive care nurses who participated in this study.

To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.


   REFERENCES
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 Abstract
 Background
 Specific Aim
 Research Design and Methods
 Results
 Discussion
 Limitations
 Conclusions
 References
 

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Journal Club Article Discussion Points

In a journal club, research articles are reviewed and critiqued. General and specific questions help to aid journal club participants in probing the quality of the research study, the appropriateness of the study design and methods, the validity of the conclusions, and the implications for practice.

When critically appraising this issue’s AJCC journal club article, "Appropriately Timed Analgesics Control Pain Due to Chest Tube Removal," consider the questions and discussion points listed below.

Study Synopsis: This randomized double-blind study tested the use of pharmacological and nonpharmacological interventions for pain related to chest tube removal in 74 cardiac surgery patients. Patients were randomized to 1 of 4 groups to receive either (1) intravenous (IV) morphine 4 mg and procedure information; (2) IV ketorolac 30 mg and procedure information; (3) IV morphine 4 mg, procedure, and sensory information; or (4) IV ketorolac 30 mg, procedure, and sensory information. Pain intensity, pain distress, pain quality, and level of sedation were assessed and compared among the groups. There were no differences in pain intensity, pain distress, and sedation levels among the groups. The study results indicate that either an opioid (morphine) or a nonsteroidal anti-inflam-matory drug (ketorolac) can minimize pain caused by chest tube removal.

  1. Description of the Study
  2. Literature Evaluation
  3. Sample
  4. Methods and Design
  5. Results
  6. Clinical Significance

Information From the Authors: Kathleen Puntillo, RN, DNSc, lead author of this journal club article, provided additional information about the study. Puntillo explained that the research team chose to study painfulness of chest tube removal because one of her previous studies had found that the use of ketorolac decreased pain caused by chest tube removal. She shared, "We decided to test 2 analgesics that are commonly used in critical care practice (morphine and ketorolac) so that findings would be clinically relevant."

Puntillo explained that the study procedure was based on usual practice. She related, "The procedure part of the scripts was developed from the cardiac surgery clinical nurse specialist’s usual practice of information given to patients before the chest tube was removed. The sensory part of the script was developed by using words chosen most frequently by patients in my previous studies to describe their chest tube-related pain. This is in keeping with Jean Johnson’s theory that providing accurate information about painful sensations may decrease pain intensity and/or distress."

Puntillo explained that the nurses who were research assistants received specific training for the study. She shared, "In addition to training about the specifics of doing pain assessments, administering the study drugs, chart data retrieval, etc., we did training on the use of the sedation scale. We did interrater reliability by having 2 study nurses administer the tool together and compare scores. When an interrater reliability of 100% was reached, the nurses could do it on their own thereafter."

Implications for Practice: The results of the study have significant implications for nursing practice because chest tube removal is a common procedure, often performed by nurses. Promoting patient comfort and implementing interventions to relieve pain are direct nursing care responsibilities. The study demonstrated that either an opioid (morphine) or a non-steroidal anti-inflammatory drug (ketorolac) can decrease pain caused by chest tube removal without causing adverse sedative effects. The study results can be used in practice and provide evidence to substantiate nursing care practices. Pun-tillo concluded, "I would recommend that if the study were to be replicated, that a standard care control group be included and that fentanyl IV be tested instead of morphine since IV fentanyl has a more rapid onset and offset. I would like to see an intervention study be conducted at more than 1 site that teaches more nurses to remove chest tubes and medicate before the procedure and test outcomes."

Journal Club feature commentary is provided by Ruth Kleinpell.





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