Pain Management after Open Cardiac Surgery
Safety of Intravenous administration of acetaminophen and PICO Method
Assessing the efficacy of intravenous administration of acetaminophen through 6s Model
Systems and Summaries (6s Model)
Acetaminophen as an adjunct to opioid
Synopses and synthesis of synopsis (6s Model)
Role of Acetaminophen in reducing nausea and vomiting
Studies and synopses of studies (6s Model)
Barriers affecting the administration of IV acetaminophen
The level of pain after open-heart surgeries are very severe and are generally not appropriately treated (Cogan 2010). It has been observed that patients with untreated pain after surgeries can develop high complications that require hospitalizations and costly treatments (Goehner & Bigeleisen 2015). Some of the risk factors that are associated with acute pain include pre-procedure anxiety, extensive surgery, and younger age (Cogan 2010). As per Zubrzycki et al. (2018), ineffective analgesic therapy for the post-operative pain is dangerous for patients. The chances of chronic pain in patients undergoing cardiac surgery due to ineffective pain management are between 21 to 55 percent (Cogan 2010). This paper discusses pain management methods that can be used after open cardiac surgeries. It also provides an analysis of the safety of the intravenous method for the administration of acetaminophen using the PICO technique. This paper also discusses the role of the 6s model for assessing the efficacy of intravenous administration of acetaminophen. It also discusses the role of acetaminophen in reducing post-surgical complications such as vomiting and nausea.
Pain after the cardio surgical operations must be adequately treated by using the techniques of pain management. It is observed that the severity of the pain is very high after the first 24 hours of the operation. However, it decreases after a few days because it acts as a “self-limiting” process (Zubrzycki et al. 2018). Pain control can be achieved in a better and effective way by regular and systemic assessments (Cogan 2010). Adopting the most suitable technique for alleviating pain and observing the patient closely for complications due to analgesia are very significant in postoperative pain management (Zubrzycki et al. 2018). Post cardiothoracic surgical pain should be effectively managed using multidimensional methods. These methods are the administration of a combination of analgesic drugs, multimodal analgesia, and regional anesthesia methods (Zubrzycki et al. 2018).
Critical care units in South Australia are widely supporting the use of Intravenous administration of paracetamol (acetaminophen) as an adjunct to an opioid during the immediate post-operative period. Although it is found to be effective in managing post- surgical pain, some experts within the critical care units do not support this type of treatment. They argue that hypotension risks are associated with this type of treatment. The PICO method is used to generate an answerable question about this clinical issue. Hoffman et al. (2013) suggest that it is essential to develop an answerable question as it stops the healthcare professionals from forgetting any of the critical clinical components of the issue/question.
The PICO question is:
Does intravenous administration of acetaminophen enables better pain management and reduces post-operative health complications such as nausea and vomiting in the patients following a cardiothoracic procedure?
Four components of the above question are:
Population - Patients who underwent cardiac procedure.
Intervention - Intravenous administration of acetaminophen.
Comparison - No intravenous acetaminophen in the immediate post-procedure period
Outcome - Better pain management and decreased nausea and vomiting.
This paper uses the 6s model of the organisation of evidence-based information services to determine the clinical significance of studies that are conducted to assess the efficacy of intravenous administration of acetaminophen. The efficacy of intravenous administration is analyzed in the post-cardiac surgical patients. The 6s model is hierarchical and has 6 levels of organization of evidence from various healthcare researches (Hoffman et al. 2013). As per DiCenso, Bayley & Haines (2009), the 6s of this model includes are:
Synopses of syntheses
Synopses of the study
According to Hoffman et al. (2013), randomized controlled studies are exceptionally good at addressing intervention questions. However, the systematic reviews for conducting multiple randomized controlled studies are even better as they combine the results of many randomized trials to provide a much clearer answer about the effectiveness of an intervention. A systematic review can summarise both quantitative and qualitative studies to review multiple randomized controlled studies (Hoffman et al. 2013). On the contrary, the meta-analysis method gives a better overall effect of a clinical intervention than looking at the individual studies (Hoffman et al. 2013).
I started this paper by gathering the best current evidences from the summaries, which is level 5 of the 6s hierarchy. These summaries provide guidelines and recommendations regarding particular practices. They also provide materials to learn further about the other aspects of the disease (Hoffman et al. 2013). They can be accessed through databases such as Dynamed Plus, Australian clinical guidelines, and TRIP. Devlin et al. (2018) have formulated a clinical guideline on the use of intravenous administration of acetaminophen. They compared the two single centered parallel-group randomized trials conducted on 113 post-cardiac surgery patients. These trials were also conducted in 40 post abdominal surgical patients in ICU. The studies evaluated the results of 1 gm of IV acetaminophen taken every six hourly and placebo in a double-blinded fashion. The pain intensity was then evaluated after 24 hours using the visual analog scale (VAS). The trials showed decreased pain intensity in the patients taking acetaminophen intravenously. There was a great reduction in opioid use, nausea, and sedation in the acetaminophen group.
In the cardiac critical care unit, it is equally important to control opioid use along with pain management. Increased opioid use prolong the time on the ventilator. Ventilator dependence increases the risk of lung atelectasis and associated complications, including pulmonary infections. Active breathing and coughing prevent lung complications. Increased opioid use makes the patient weak and tired and increases the risk of nausea and vomiting. However, Devlin et al. (2018) have come up with a conditional recommendation that IV acetaminophen can be used in critically ill patients as an adjunct to an opioid for pain management. Although studies show that IV acetaminophen causes hypotension in about 50% patients and decreases the mean arterial pressure, but it can still be recommended as an adjunct if used cautiously. United States has approved the use of IV acetaminophen for postoperative pain management. This is because it is safe as well as effective if used cautiously, along with opioids (Barr et al. 2013).
The next steps of the 6s pyramid are the synopses of synthesis and synthesis. The role of synthesis is to integrate the evidences from different studies about the question or issue. The examples of synthesis include systematic reviews (Hoffman et al. 2013). However, meta-analysis is also a type of synthesis that can be used to integrate evidences. Powerful results can be obtained by merging systematic reviews with meta-analysis properly without any biasness (Ahn & Kang 2018). Apfel et al. (2013) used both these syntheses to understand the effect of IV acetaminophen on post-operative patients. They used the databases Medline and Cochrane and used 30 random trials of IV acetaminophen. The study in total includes 2364 patients in which 1223 patients used the acetaminophen group, while the rest of 1141 belonged to the placebo group. The relative risk for nausea was 0.73, while for vomiting, it was 0.63. Out of 2364 patients, 113 were having cardiac issues, and out of these 113, 56 used acetaminophen while the rest 57 belonged to placebo group.
IV acetaminophen is preferred for oral and rectal applications during the immediate post-operative period. This is because it is found that 1g of IV acetaminophen results in greater central nervous system penetration (Singla et al. 2012). According to the systematic review and meta-analysis, opioid use is also reduced in patients who received IV acetaminophen (Apfel et al. 2013). Deep sensitivity analysis has shown that prophylactically administered IV acetaminophen decreases nausea and vomiting. It is believed that a considerable reduction in post-operative pain caused a significant reduction in postoperative nausea (Apfel et al. 2013).
Reducing pain intensity can significantly decrease the chances of nausea and vomiting (Afpel 2013). Acetaminophen reaches the brain and gets metabolized into AM404 that inhibits the reuptake of the neurotransmitter, anandamide (Afpel 2013). Increased level of anandamide is associated with a decreased rate of nausea and vomiting in humans (Chouker et al. 2010). Therefore, acetaminophen has a direct effect in reducing post-operative nausea and vomiting (Apfel et al. 2013). The prophylactic administration of IV acetaminophen reduced post-operative nausea and vomiting. It is given regularly every 6 hours in the post-operative period until the patient can start taking oral acetaminophen.
Moving down the 6s pyramid is the single study at the bottom, which is of various types such as random -controlled trials, qualitative study, and case series. Jelacic et al. (2016) conducted a double-blind, placebo-controlled trial, which was randomized in an academic medical center. The aim of this trial was to assess the efficacy of IV acetaminophen as an adjunct in cardiac surgery. In this study, only 68 adults undergoing cardiac surgeries were used as participants. They were randomly divided into two groups, one group with patients receiving placebo treatment while the other getting 1g IV acetaminophen immediately after the induction of anesthesia. The patients were given these drugs every 6 hours for the next 24 hours. After this, the secondary outcome was assessed after 48 hours. The outcomes assessed were postoperative consumption of opioids, adverse effects from the opioids, time to extubate the patient, incisional pain score, and length of critical care. The patients that were given 1g IV acetaminophen showed a pain reduction of 27%. The study showed nil difference in the opioid-related side effects. The patients in the acetaminophen group were satisfied with their pain management than the placebo group.
Acetaminophen is preferred to the non-steroidal drug in the patients who undergone cardiac surgery as it has low impacts on the platelet and gastrointestinal system (Jelacic et al. 2016). The absorption of oral acetaminophen is poor in surgical patients due to reduced gastrointestinal motility and gastric emptying. The therapeutic concentration of acetaminophen in plasma can be achieved quicker by the IV administration, especially in cardiac patients (Jelacic et al. 2016). IV acetaminophen is usually ordered for all the cardiac patients as either regularly or as whenever-needed doses (PRN). A regular dose of IV acetaminophen after every 6 hours in the first 24 hours post-surgery and oral administration in the next 48 hours in addition to the opioid doses is found to be very useful in managing the surgical pain. The critical care consultants have varying opinions on the effectiveness of IV acetaminophen. Most of them have started ordering regular IV acetaminophen these days. There need to be further education and research on the importance of administration of IV acetaminophen in the first 24 hours of cardiac surgery.
Although there are various benefits of IV acetaminophen, there are some barriers that affect the regular administration of IV acetaminophen. The first barrier is the cost of acetaminophen due to which not all the patients can afford it. The other types of acetaminophen, such as the ones that are administrated orally, are cheaper than the IV acetaminophen. Patients with financial support also suffer from post-surgical pain, and they cannot afford such expensive treatments for pain management. This acts as an essential barrier to the IV acetaminophen administration. The other barrier that is observed is its long administration time. It has been observed that oral acetaminophen take less time to show their effect. However, the IV acetaminophen on a general takes 15 minutes to show their effect. This is the reason that the doctors prefer the usage of oral acetaminophen in emergency cases when the instant effect is needed. The oral acetaminophen is faster, acting as compared to the acetaminophen. Thus, it is necessary for the doctors to consider both the positive effects as well as the side-effects of IV acetaminophen before using it in any patient.
Pain management is essential for all types of patients, especially the ones who have undergone any type of cardiac surgery. Vomiting and nausea are very common in patients post surgeries. Various types of drugs can be given to such patients to reduce their pain, but one of the drugs that are mostly recommended is acetaminophen. This drug can be given as an oral drug or as IV acetaminophen. IV acetaminophen is used in critically ill patients as an adjunct to opioids as it helps in better pain management. This paper concludes that patients with placebo treatment are less satisfied with their pain management than the patients who are given1g IV acetaminophen every six hours. The 6s model can help in assessing the efficacy of intravenous administration of acetaminophen. IV acetaminophen has great advantages, but it also has specific barriers such as it requires most time for showing its effect and is costly than the oral acetaminophen. Thus, administration of IV acetaminophen is beneficial after open cardiac surgeries as it helps in better pain management.
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