Management of Chest Pain in CVICU Post Open Heart Surgery
Intravenous opioids should be considered as the first-line treatment for chest pain management in patients after open heart surgery, supplemented with non-pharmacological interventions such as cold therapy and relaxation techniques. 1, 2
Assessment of Post-Cardiac Surgery Chest Pain
- Pain is common and often poorly treated in cardiac surgery patients, with women experiencing more pain than men 1
- Utilize validated behavioral pain scales such as the Behavioral Pain Scale (BPS) or Critical-Care Pain Observation Tool (CPOT) for patients unable to self-report pain 1
- Do not rely solely on vital signs for pain assessment, though they may serve as a cue to begin further pain assessment 1
- Consider both procedural pain (related to interventions) and non-procedural pain (at rest) in your assessment 1
Pharmacological Management
First-Line Treatment:
- IV opioids are the recommended first-line treatment for non-neuropathic pain in critically ill patients 1, 2
- Morphine sulfate injection: initial dose 0.1-0.2 mg/kg IV every 4 hours as needed 2
- Administer morphine slowly to avoid chest wall rigidity and cardiovascular instability 2
- Individualize dosing based on patient factors including prior analgesic treatment, opioid tolerance, general condition, and pain severity 2
Adjunctive Medications:
- Consider IV acetaminophen (650-1000 mg every 4-6 hours, maximum 4g/day) in conjunction with opioids for postoperative pain 1
- For neuropathic pain components, add gabapentin (starting dose 100 mg PO three times daily) or carbamazepine to the opioid regimen 1
- Non-opioid analgesics may decrease the required amount of opioids and reduce opioid-related side effects 1
Non-Pharmacological Interventions
Cold therapy: Apply cold ice packs wrapped in dressing gauze for 10 minutes to the painful area 1
- Particularly effective for procedural pain management such as chest tube removal
- Provides clinically important pain reduction with minimal side effects
Relaxation techniques: Implement breathing-focused relaxation techniques 1
- Instruct patients to inhale slowly through the nose and exhale slowly through pursed lips
- Can be initiated 5 minutes before painful procedures and continued throughout
- Reduces pain intensity by a clinically significant margin
Music therapy: Consider offering music as a safe intervention for pain management 1
- Take into account patient preferences
- Though pain reduction may be modest, the benefit outweighs potential harm
Transcutaneous electrical nerve stimulation (TENS): May be beneficial for persistent chest pain 3
- Particularly useful for older patients and those with chronic lung disease
- Can improve deep breathing capability and reduce analgesic requirements
Special Considerations
Monitor for potential cardiac complications, which occur in approximately 3% of post-cardiac surgery patients 4
Distinguish between ischemic and non-ischemic causes of chest pain 5
- Obtain ECG and troponin measurements for patients with concerning symptoms
- Approximately 17% of surgical patients with postoperative chest pain may have elevated troponin levels 6
For chest tube removal or other invasive procedures, implement preemptive analgesia and non-pharmacological interventions 1
- Strong recommendation for preemptive treatment before chest tube removal
- Consider both pharmacological and non-pharmacological approaches
Consider thoracic epidural analgesia for patients with traumatic rib fractures if present 1
Implementation Tips
- Develop written protocols for non-pharmacological interventions such as cold therapy 1
- Provide written information to patients about relaxation techniques 1
- Ensure continuous reassessment of pain management efficacy 2
- Adjust dosing for patients with hepatic or renal impairment 2
- Start with lower doses of morphine and titrate slowly while monitoring for side effects in patients with cirrhosis or renal failure 2