The Necessity of Introducing Analgesics or Pain Relief Methods Prior to Chest Drain Removal - Literature review Example

The Necessity of Introducing Analgesics or Pain Relief Methods Prior to Chest Drain Removal Task: Table of Contents Introduction.................................................................................................................................3 Focus Question and Rationale......................................................................................................4 Methodology................................................................................................................................4 Discussion....................................................................................................................................6 Strengths and Weaknesses of Introducing Analgesics Prior to Chest Drain Removal................8 Implications and Recommendations for Practice.........................................................................9 Conclusions.................................................................................................................................10 Reference List.............................................................................................................................12 Introduction Chest drains are tubes inserted into the pleural cavity to drain water or pus that accumulates in that area as a result of a disease or injury. Usually, the external part is would be inserted in water to prevent air suction into the cavity. As the process is painful, local anaesthesia is required to control pain in the patient (Reid, 2009, 1). Patients would require chest tube draining after injuries in case fluid or air accumulates in their pleural cavity. Chest tube is thus recommended for treatment of hemothorax and pneumothorax or pleural effusion. This would require individual patient management that would ensure close monitoring of the patient. This would enable detection of the levels upon which the tube would be removed from the patient (David 2009, 1). Chest drain systems consist of collection chamber and mechanism that prevents air and fluid from re-entering the pleural cavity. They may have wet or dry properties that are aimed at draining the chest and preventing air from getting into the cavity. The wet system use water while the dry system uses suction mechanism instead of water to seal the opening and prevent air from re-entering the pleural cavity (Brunner and Day, 2009, 716). Patients undergo a lot of pain during cardiac surgeries that involve the chest drain removal from the pleural membrane of the chest. This chest drain removal would be aimed at draining fluids and air form the lungs and subsequent expansion of the lungs. These tubes would be often removed when the condition is better within a period of not less than 3 days after the surgery (SH Sane, 2008, 43). The experience is painful and highly unpleasant to the patients (SH Sane, 2008, 43). This would result in development of negative emotions in the patients. Doctors and medical experts, being aware of this have developed their own procedures and methods of relieving pain in the affected patients. Drugs such as topical Valdecoxib, fentanyl and sufentanil, would be used in curbing the problem of controlling pain (SH Sane, 2008, 43). Most patients have confirmed that chest tube removal (CTR) is a painful experience. This would prompt quick action aimed at reducing complications associated with it and reduction of pain. This would be as a result of inadequate management of pain during recuperation. It has also been confirmed that most countries have not set standards that would be used in pain management (Fischer and Bland, 2007, 769). According to Puntillo & Ley (2004, 294), morphine is the most common drug used in the management of pain. When they take morphine, it takes effect within 5 minutes, and peak effect would be achieved after a period of 20 minutes (Puntillo and Ley, 2004, 294). If small doses are used for chest tube removal, the pain experienced would be classified from moderate to severe (Puntillo and Ley, 2004, 294). Ketorolac is a non-steroid drug that has also been used for the same exercise as it has anti-inflammatory qualities. It has exemplary analgesic properties and can be used to contain pain associated with CTR. Ketorolac prevents the synthesis of prostaglandin. This is by blocking the activity of cyclooxygenase. The pain associated with chest tube removal would also have negative impacts on the patients. For instance, they would have negative emotions as a result of surgery for a lengthy time. Therefore, there would be a need to determine adequate methods of pain management associated with chest tube removal. This is because pain management in regard to the above issue is poor and needs efficient analysis. The author explored the methods of relieving pain prior to chest drain, with the following question in mind: are analgesics or pain relieving necessary before removing chest drain? The author explored studies, with a main focus on the reactions of patients who had chest drain and their outcomes after surgery. Methodology Search Strategy and Hand Searching Key Search Terms: Analgesics, chest drain, pain relief. The author explored literature from various databases including PsycINFO, MEDLINE, EMBASE and CINAHL. This strategy involved a hand search based on the search terms reported, from the time of inception to January 2012. Adding to that, relevant articles were searched from EBSCOhost and ProQuest libraries, and the internet was searched for some related articles. The author went through the reference list of articles used in the reviews and the most appropriate sources were cited for review. More so, an assessment of the validity, reliability, integrity, allocation concealment and randomisation of the studies of interventions was carried out. The author carried an independent assessment of the review’s validity and came up with conclusions drawn from critical analysis. Inclusion and Exclusion Criteria In the inclusion and exclusion criteria, various sources were available but only two were considered in this study. Non-pharmacological and analgesic interventions studies with regard to pain realised during chest drain removal in intensive care were included in the review process. These interventions underwent critical evaluation in the cited studies whereby; analgesics covered the evaluation of desflurane and isoflurane versus nitrous oxide, placebo versus local anaesthetics, and local anaesthetics versus morphine. On the other hand, non-pharmacological evaluated tepid water versus ice, no relaxation versus relaxation and the music choices by patients versus white noise. Similarly, pethidine, paracetamol and morphine were ranked under co-interventions. In the case of participants included in the review, the author had a keen eye on the studies, which covered paediatric, and adults, who had had chest drain removal. Thus, many studies explored by the review were conducted in adults, although some studies that explored chest drain removal in patients have also been covered by the author’s review. Generally, in cases where the outcomes of patients were not assessed by some studies, such studies were excluded. Only the studies which had an assessment of pain through the use of observation scales, verbal comments from patients, the McGill questionnaire of pain, numeric scale of rating patients and visual analogue scale of rating patients, were included in the review. However, the authors of the studies covered by the review did not highlight information on the exact number of persons who were involved in the selection, as well as the criteria for selecting the papers for their reviews. Number of Articles Found, Articles Kept for Analysis and Reason for Rejection The author found a total of 20 relevant articles from the searches conducted. Of the twenty articles, 8 were set aside for investigation, as they were found to be more relevant to the topic of study. The articles that were rejected had covered part of the topic (chest drain removal), but the focus of the topic at hand – methods of relieving respiratory pain during the process of chest drain removal – was not covered by such articles. Common Terms in the Selected Articles All the articles that the review analysed had the following common terms: Chest tube removal, chest drain, pleural cavity, anaesthetic, pharmacological and non-pharmacological. Discussion Morphine has been identified as the main medicine that would be used to relief pain during the whole exercise of chest drain removal. Patients below seven years would require continuous infusion of morphine. Pain management would be achieved if each patient is assessed and their level of responses to anaesthesia determine so that they are giving required care. There exist two types of anaesthesia in use, in the field of medicine for pain management, during the whole process of chest drain removal. These would be either tropical agents or epidural anaesthesia. Epidural agents can be applied at various sections along the epidural area. Some of the drugs within this category include; lidocaine, ropivacaine and bupivavaine. When using these drugs, thorough prescription would be given, and administration procedures followed to ensure no under dose or overdoses. There also exist tropical anaesthesia such as gels and heat activated patch systems (HAPS). Creams can also be used as pain reduction medicines. The commonly used treatment in the tropics makes use of liposomal and lidocaine. These control the levels of pain (Boxwell, 2010, 245). Quite a number of researchers agree with the issue of using liposomal, morphine and lidocaine in pain reduction during the exercise mentioned above. A good example is Boxwell (2010, 245) and Puntillo and Ley (2004, 294). In addition to this, there has not been any objection on the research done by these writers. Moreover, extra research is being done to found out if there are other types of anaesthesia. Nurses in the institutions where such operations are carried out should give comfort to the patients. This would be by taking an interest in the process and being able to comprehend the patient’s pain. During this period, the responsibility of the nurse is assisting the patient control the discomfort associated with the surgery. This would be possible if the nurse would be qualified, knowledgeable and experienced in the field. They would also be required to have to understand the patient’s experience during the operation so as to perform their duties with diligence. Therefore, pain would be controlled by two approaches, which would be, pharmacological approach or non-pharmacological methods. Non-pharmacological methods include the use of music and aspects related to slow relaxation. Taking breaths in an unusually deep manner would also be associated with non-pharmacological methods. The use of pharmacological methods such as uploads alone would not be sufficed in terms of pain management. They would be effective when accompanied by slow, deep relaxation (Friesner, Curry and Moddeman, 2006, 274). According to Taylor and Gupta (2009, 07), the procedure of inserting the tube should be painless so that there is no discomfort on patients. This requires adequate time and sufficient anaesthesia approximately about 3mg/kg. Supplementary oxygen should also be available to counter any complications that would occur during the exercise. To reduce pain to levels that can be handled by the patient would also be achieved anaesthetizing the pleural cavity. This would be achieved by the use of a needle that would be inserted to withdraw the fluid and remove it appropriately; when levels of fluid or air reduce. Given that the surgery has to be conducted when the patients have not had any meals from the previous night (Laws, Neville and Duffy, 2003, 55), the introduction of analgesics or methods of relieving pain prior to chest drain is vital in calming down the patients, who may have discomforts to greater levels due hunger. The methods of pain relief eventually lower the reactions of patients during the process of chest drain (Given, 2010, 37). However, the introduction of analgesics prior to chest drain may not be successful in making the patients avoid all discomforts during the process. For instance, in cases where the general anaesthetics are applicable, there is a tendency of the gag reflex being lost for some time (JGIM, 2010, 296), bringing the implications of food finding its way into the lungs in scenarios where the patients vomit. Furthermore, anaesthesia carries the risks of allergic reactions, issues of blood pressure, headaches, nausea and vomiting (Ege, 2004, 1560), which can severely affect the patients. Implications and Recommendations for Practice With regard to nursing practitioners in hospitals where chest drain removal is carried out, some ethics have to guide the way in which the process is conducted. Given that the process of chest drain removal involves the insertion of tubes between the lung and the chest through the cutting of the chest wall (Howard, 2008, 24); the implication of pain is brought to light, as the penetration of the skin and muscles is involved. The author asserts that the nurses should know that the process of chest drain removal has to be conducted in such a way that the patients do not experience much severe pain, if not painless (Bruce, Howard, and Franck, 2006, 150). There are several methods for relieving the painful experience that patients undergoing cardiac surgeries are subjected to, prior to the process of chest drain removal, as explored by the author. The various methods, as studied by different authors of the literatures covered by the review, subject the patients to different intensities of pain during chest drain removal (Allegaert, 2004, 310). For instance, the author states that a combination of agents as opposed to single agent should be used in the revision of the painful procedures and specifically for the analgesic protocols, given that the patients who are subjected to local anaesthetics or morphine are still vulnerable to different intensities of pain (Handy, 2002, 24). Similarly, the author identifies the use of a chest tube as the best method for treating cases of pleural effusion, hemothorax and pneuthorax, because this method is efficient for a good monitoring of the patients’ condition. The author recommends the use of both pharmacological and non-pharmacological methods in addressing the issue of painful experiences during chest drain removal. For instance, employing methods that are aimed at slowing reactions, such as the introduction of soft music and relaxation (Helms and Barone, 2008, 42) can be ranked among the non-pharmacological methods. The non-pharmacological methods are vital for reinforcing the pharmacological methods, so that the overall process of chest drain removal does not turn out to be painful in overall. Other than non-pharmacological methods, the author recommends that the nurses should primarily play a part in comforting the patients, as this will greatly shape their psychology (Briggs, 2010, 50), thus reducing the patients’ perception of pain. In this case, the patients deserve the tender care and assistance from nurses, in a bid to avoid discomforts that can result, prior to the surgery process. Conclusions After reviewing literature relevant to the topic, it can be concluded that pain relieving or analgesics is required prior to removing chest drains. This is supported by the fact that the patients’ psychology will automatically be affected when their perceptions of the chest drain removal are generally negative, with regard to the painful experience attached to the process. Therefore, to avoid cases of trauma, introduction of analgesics before chest drain removal is needed by patients. In addition, the author has noted that critically, patients who were subjected to local anaesthetics or morphine still had a painful experience (ranging from severe to moderate), when the chest drains were being removed. This brings the implication that this procedure’s analgesic protocols should undergo revision, thus the research on this topic should be carried out further. Reference List Allegaert, K., Jande H., 2004, The use of methohexital during chest tube removal in neonates. Pediatric Anesthesia, 14(4), pp.308-312. Boxwell, G., 2010, Neonatal intensive care nursing, Routledge: New York. Briggs, D., 2010, Nursing care and management of patients with intrapleural drains. Nursing Standard, 24(21), pp.47-55. Bruce, E., Howard, R., and Franck, L., 2006, Chest drain removal pain and its management: A literature review. Journal of Clinical Nursing, 15(2), pp.145-154. David, A., 2009, Analgesia for pediatric thoracostomy tube removal. Retrieved 17 January, 2012 from: < http://www.anesthesia-analgesia.org/content/90/5/1025.full.pdf+html>. Day, R., Brunner, L., and Day, R., 2009, Brunner and Suddarths textbook of Canadian medical-surgical nursing, Philadelphia: Lippincott Williams & Wilkins. Ege, T. 2004, The importance of intrapericardial drain selection in cardiac surgery. Chest, 126(5), pp.1559-1562. Ferguson, M., 2011, Difficult decisions in thoracic surgery: an evidence-based approach, London Springer. Friesner, A., Curry, M. and Moddeman, G., 2006, Comparison of two pain-management strategies during chest tube removal: Relaxation exercise with opioids and opioids alone, Retrieved 17 January, 2012 from: < http://www.consensus-conference.org/data/Upload/Consensus/1/pdf/799.pdf >. Fischer, J. and Bland, K., 2007, Mastery of surgery, Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Given, J., 2010, Management of procedural pain in adult patients, Nursing Standard, 25(14), pp.35-40. Handy, J. 2002, What happens to patients undergoing lung cancer surgery? Outcomes and quality of life before and after surgery, Chest 122(1), pp.21-30. Helms, J. and Barone, C., 2008, Physiology and treatment of pain, Critical Care Nurse, 28(6), pp.38-50. Howard, R. 2008, Medical Procedures, Pediatric Anesthesia, 18, pp.19-35. JGIM, 2010, Scientific abstracts, Journal of General Internal Medicine, 25, pp.205-567, doi: 10.1007/s11606-010-1338-5. Laws, D., Neville, E. and Duffy, J., 2003, BTS guidelines for the insertion of a chest drain. Thorax, 58, pp.53-60. Puntillo, K. and Ley, S., 2004, Appropriately timed analgesics control pain due to chest tube removal. Retrieved 17 January, 2012 from: . Reid, E., 2009, Chest drain insertion, Retrieved 17 January, 2012 from: . SH Sane, G., 2008, Comparison of fentanyl with sufentanil for chest tube removal, Retrieved 17 January, 2012 from: < http://www.icrj.ir/Files/AuthArts/1060+.Pdf > Taylor, C., and Gupta, K., 2009, Guidelines for insertion and management of chest drains, Retrieved 17 January, 2012 from: . Read More