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Three Part Question

In [patients with chest drains post-cardiac surgery] can any [pharmaceutical or other intervention] reduce [pain on removal]?

Clinical Scenario

You are a senior house officer in cardiothoracic surgery and are contacted to prescribe analgesia 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.

Search Strategy

Medline 1966-11/2003 using the Ovid interface.
[exp chest tubes OR chest drain.mp] AND [exp device removal OR removal.mp]

Search Outcome

Ninety-four papers were found of which 6 were deemed to be relevant. Relevant papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Carson MM et al, 1994, USA	80 adult patients who underwent heart surgery with two mediastinal drains	PRCT (2b)	IV morphine pain rating score	43.2 +/-30.4	Small patient population Study underpowered
			IV morphine and subfascial lignocaine pain rating score	40.9 +/- 30.9
			IV morphine and subfacial normal saline pain rating score	36.4 +/- 26.3
			Subfascial lignocaine pain rating score	38.1 +/- 29.6 No significant difference between groups P=0.5396
Valenzuela R & Rosen D, 1999, USA	100 ASA physical status III or IV patients randomized to either morphine (0.1 mg/kg) IV or EMLA cream (5g per chest tube) cutaneously who had cardiac or thoracic surgery. The cream was applied 3 hours prior to chest drain removal	Double blind RCT (level 2b)	Pain behaviour before, during and after chest drain removal rated by an observer and the McGill pain questionnaire	Change in pain rating during removal EMLA 4.4 +/- 1.9 Morphine 6.0 +/- 0.38 P<0.01 EMLA cream is more effective than IV morphine at preventing the pain associated with chest drain removal	Small sample size 48 patients excluded from the study due to impatience of medical staff in removing the drain
Puntillo KA, 1996, USA	41 post-op cardiothoracic patinents. 21 patients given intrapleural injections of 30 ml 0.25% bupivicaine via their pleural chest tube. 20 control patients given normal saline via the same route	Double blind PRCT (level 2b)	Pain intensity scores on a numerical rating score and the McGill pain questionnaire	No significant differences in pain intensity, distress, sensation or affect scores were found between the two treatment groups	Administration of opiate and non-steroidal analgesia was not uniform between the two groups Small sample size
Bryden FM et al, 1997 UK	35 adult cardiac surgery patients with two chest drains. 15 patients received Isoflurane 0.25% mixed in Entomox as the first gas and Entonox alone as the gas for removal of the second drain 20 patients received Entonox alone for removal of the first drain and Isoflurane 0.25% mixed in Entonox for removal of the second drain	RCT (level 2b)	Scoring by nursing staff on a 4 point scale for discomfort, sedation, cooperation and reaction to removal of the drains	Nursing 4 point score scale showed that pain scores obtained when entonox alone was used for the second drain were higher (P=0.012) than during the other three conditions	Small study population No differentiation within the groups between mediastinal and pleural drain removal Observer not standardised
			Patients completed a pain questionnaire 100mm visual analogue scale	No other differences were found between the two groups
Rosen D et al, 2000, USA	120 paediatric patients presenting for cardiac surgery	RCT (level 2b)	IV morphine (0.1mg/kg up to 10mg)	7.16 +/-0.32
			EMLA cream (5g per chest tube) cutaneously applied 3h prior to chest tube removal	7.40 +/-0.30
Houston S & Jerurum J, 1999, USA	24 patients post-CABG surgery. 12 patients were taught a quick relaxation technique to perform during chest drain removal. 12 patients acted as a control group	Prospective controlled cohort study (level 4)	Pain score in patients who used a quick relaxation technique in addition to standard analgesia	Not statistically significant	Small sample size Failure to standardize background analgesia
			Pain score in patients who had standard analgesia alone	NSD

Comment(s)

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 analgesic with a placebo. This study, performed by Puntillo et al. randomized intrapleural injections of 30ml of 0.35% 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 analgesia over another. Valenzuela et al. found that EMLA cream applied 3 hr prior to chest drain removal was more effective than IV morphine (0.1mg/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 3h it took for the EMLA cream to take effect. EMLA cream can give analgesia to a depth of 5mm. 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.

Clinical Bottom Line

The evidence is in favour of one form of analgesia over another in this area is poor due to small, poorly powered studies. There is some evidence for the efficacy of topical analgesics such as EMLA cream over morphine, but in clinical practice this seemed to be impractical.

References

1. Carson MM, Barton DM, Morrison CC et al. Managing pain during mediastinal chest drain removal. Heart Lung 1994;23:500-5.
2. Valenzuela R, Rosen D. Topical Lidocaine - Prilocaine Cream (EMLA) for thoracostomy tube removal. Anesth Analg 1999;88:1107-8.
3. Puntillo KA. Effects of interpleural bupivicaine on pleural chest tube pain removal: a randomized controlled trial. Am J Crit Care 1996;5(2):102-8.
4. Bryden FM, McFarlane H, Tunstall ME et al. Isoflurane for the removal of chest drains after cardiac surgery. Anaesth Analg 2000;90(5):1025-8.
5. Rosen D, Morris J, Rosen K et al. Analgesia for pediatric thoracostomy tube removal. Anaesth Analg 2000;90(5):1025-8.
6. Houston S, Jerurum J. The quick relaxation technique: effect on pain associated with chest tube removal. Appl Nurs Res 1999;12(4):196-205.