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© 2004 European Association of Cardio-Thoracic Surgery
Can any intervention effectively reduce the pain associated with chest drain removal?Department of Cardiothoracic Surgery, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK jamesbbarnard{at}doctors.org.uk * Corresponding author. Tel.: +44-780-154-8122; fax: +44-161-276-8538 Received November 19, 2003; accepted November 24, 2003
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether any intervention effectively reduces the pain associated with chest drain removal. Altogether 94 papers were found using the reported search, of which 6 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that there is minimal evidence for the effectiveness of a single approach to providing analgaesia for chest drain removal. Studies in the literature contain small numbers and are underpowered to address the questions they ask.
Key Words: Evidence-based medicine; Thoracic surgery; Chest tubes; Device removal
A Best Evidence Topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].
You are a senior house officer in cardiothoracic surgery and are contacted to prescribe analgaesia for a patient, who is recovering from coronary artery bypass surgery, who is about to have his chest drains removed. You are not familiar with the type of pain that this induces and wonder what evidence there is that the unpleasant sensation of drain withdrawal can be ameliorated.
In [patients with chest drains post-cardiac surgery] can any [pharmaceutical or other intervention] reduce [pain on removal].
Medline 1966–Nov 2003 using the OVID interface [exp chest tubes/OR chest drain.mp] AND [exp device removal/or removal.mp.].
Ninety-four papers were found of which six were deemed to be relevant [2–7]. These are presented in Table 1.
A study performed by Carson et al. looked at the differences in pain rating scores in patients randomized to have either morphine, morphine and subfascial lignocaine, morphine and subfacial normal saline and subfascial lignocaine alone and found no statistical difference between the groups. Though as with all of the studies the number of patients involved were small. Only one study randomized an analgaesic with a placebo. This study, performed by Puntillo et al. randomized intrapleural injections of 30 ml of 0.25% bupivicaine via pleural chest tubes to giving 30 ml of normal saline. No significant difference was found in levels of pain intensity between the two groups. Administration of intrapleural injections via the chest drain had little benefit when compared with placebo. Only one study found a statistically significant benefit of one form of analgaesia over another. Valenzuela et al. found that EMLA cream applied 3 h prior to chest drain removal was more effective than i.v. morphine (0.1 mg/kg) in reducing the patient's response to chest drain removal when observed by an independent observer. There was a very high drop-out rate from this study due to the impatience of the medical staff who were not willing to wait for the 3 h it took for the EMLA cream to take effect. EMLA cream can give analgaesia to a depth of 5 mm. This study might suggest that the majority of the pain sensation associated with chest drain removal is generated from the motion of the chest drain against the skin.
The evidence in favour of one form of analgaesia over another in this area is poor due to small, poorly powered studies. There is some evidence for the efficacy of topical analgaesics such as EMLA cream over morphine, but in clinical practice this seemed to be impractical.
ICVTS on-line discussion Author: Dr. Helmut Mair, University of Leuven, Department of Cardiac Surgery, Gasthuisberg, Herestraat 49, Leuven, 3000 Belgium Date: 24-Dec-2003 Message: Barnard and colleagues raised in their article an interesting question: "Can any intervention effectively reduce the pain associated with chest drain removal?" The authors focus on analgesia for chest drain removal. But in our opinion it is more important to use modern drainage techniques for pain reduction while removing drains after thoracic and cardiac surgery [1]. Traditionally surgery has been accomplished by placing rigid and large-bore chest tubes (28F to 36F) in the mediastinal and pleural spaces, allowing accumulating fluid to drain. Removal of these tubes is certainly painful [2] and may provoke hypoventilation, atelectasis, and increased use of analgesic agents. In addition, these large and rigid drains themselves may cause large amounts of serous fluid due to inflammation, often associated with prolonged use of the drains and prolonged immobilisation of the patient. Another adverse scenario is air-leaks due to large percutaneous incisions or damage of the lungs caused by the rigid material of the drains. This again results in prolonged drainage, immobilisation and may produce large skin-emphysema. Smaller silastic drains avoid the mentioned drawbacks, provide better cosmetic results and give more comfort to the patients. But most surgeons fear early clotting of small-diameter drains followed by inadequate drainage and tamponade. The silastic "BLAKE" drain system (Ethicon, Inc, A Johnson & Johnson Company, Somerville, NJ) provides a small-diameter drainage-concept (10–19F) [3–6] that prevents clotting or kinking of the drains, but being at least as effective as conventional drains with no significant risk of bleeding or pericardial tamponade. The recessed channels along the sides of the Blake-drain (Fig. A1) allows greater tissue contact area, diminish tissue invagination into the drain and function by capillary action. The small and more flexible silastic drains may also be less likely to injure adjacent structures or unsettle coronary grafts.
The benefits of the silastic drains over the conventional chest tubes contribute to a less complicated and better tolerated postoperative recovery course. This drainage technique is less painful [1,7], allows more mobility with functioning drains in place if necessary and earlier discharge [6]. In our unit 10–19 F Blake Drains are used in all patients (1200 pts/year). Usually we place two drains. Exceptions are e.g. more extensive aortic surgery (< two drains) or minimally invasive surgery (only one drain). Our observations are consistent with the literature: the Blake drains are as effective as conventional drains with no increased risk of retained blood in the chest or tamponade and significantly less pain for the patient. We therefore advocate their use in patients undergoing thoracic or cardiac surgery. References [1]Akowuah E, Ho EC, George R, Brennan K, Tennant S, Braidley P, Cooper G. Less pain with flexible fluted silicone chest drains than with conventional rigid chest tubes after cardiac surgery. J Thorac Cardiovasc Surg. 2002 Nov;124(5):1027–8. [2]Paiement B, Boulanger M, Jones CW, Roy M. Intubation and other experiences in cardiac surgery: the consumer's views. Can Anaesth Soc J. 1979 May;26(3):173–80. [3]Payne M, Magovern GJ Jr, Benckart DH, Vasilakis A, Szydlowski GW, Cardone JC, Marrone GC, Burkholder JA, Magovern JA. Left pleural effusion after coronary artery bypass decreases with a supplemental pleural drain. Ann Thorac Surg. 2002 Jan;73(1):149–52. [4]Gundry SR, Shattuck OH, Razzouk AJ, del Rio MJ, Sardari FF, Bailey LL. Facile minimally invasive cardiac surgery via ministernotomy. Ann Thorac Surg. 1998 Apr;65(4):1100–4. [5]Lancey RA, Gaca C, Vander Salm TJ. The use of smaller, more flexible chest drains following open heart surgery: an initial evaluation. Chest. 2001 Jan;119(1):19–24. [6]Frankel TL, Hill PC, Stamou SC, Lowery RC, Pfister AJ, Jain A, Corso PJ. Silastic drains vs conventional chest tubes after coronary artery bypass. Chest. 2003 Jul;124(1):108–13. [7]Obney JA, Barnes MJ, Lisagor PG, Cohen DJ. A method for mediastinal drainage after cardiac procedures using small silastic drains. Ann Thorac Surg. 2000 Sep;70(3):1109–10. doi:10.1016/j.icvts.2003.11.004
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Abstract
1. Introduction
