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    Abstract
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ORIGINAL ARTICLE Table of Contents   
Year : 2007  |  Volume : 10  |  Issue : 1  |  Page : 42-45
Comparison of analgesic efficacy of fentanyl and sufentanil for chest tube removal after cardiac surgery


Department of Cardiothoracic & Vascular Anaesthesia and Department of Cardiothoracic & Vascular Surgery All India Institute of Medical Sciences, New Delhi., India

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   Abstract 

Chest tube removal in the postcardiac surgical patients is a painful and distressful event. Fentanyl and sufentanil have not been used for pain control during chest tube removal in the postoperative period. We compared efficacy of fentanyl and sufentanil in controlling pain due to chest tube removal.
One hundred and forty one adult patients undergoing cardiac surgery were recruited in a prospective, randomized, double blind, placebo controlled study. Patients were randomized to receive either 2 µg/Kg fentanyl IV or 0.2 µg/Kg sufentanil IV or 2 ml isotonic normal saline, 10 min before removing chest tubes. Pain intensity was assessed by measuring visual analog scale pain score 10 minutes before removing chest tubes and 5 min and 20 min after removing chest tubes. Level of sedation, heart rate, arterial pressure, oxygen saturation, and respiratory rate were recorded by a blinded observer at the same time intervals.
Mean pain intensity scores 10 minutes before removal of chest tubes in fentanyl, sufentanil and control groups were 23.88±5.2, 25.10±5.39 and 23.64±6.10 respectively. The pain scores 5 minutes after chest tube removal were reduced to 20.11±6.9 (p<0.05) in the fentanyl group and 13.60±6.60 (p<0.05) in the sufentanil group, whereas in control group pain scores increased to 27.97±8.39 (p<0.05). The pain scores in sufentanil group were significantly lower compared with fentanyl or control group. Sedation scores remained low in all groups and patients remained alert and none of the patients showed any adverse effects of opioids. Heart rate, arterial pressure and respiratory rate had least variations in sufentanil group than fentanyl or control group.

Keywords: Fentanyl, Sufentanil, Chest tube removal, Cardiac surgery

How to cite this article:
Joshi V S, Chauhan S, Kiran U, Bisoi A K, Kapoor PM. Comparison of analgesic efficacy of fentanyl and sufentanil for chest tube removal after cardiac surgery. Ann Card Anaesth 2007;10:42-5

How to cite this URL:
Joshi V S, Chauhan S, Kiran U, Bisoi A K, Kapoor PM. Comparison of analgesic efficacy of fentanyl and sufentanil for chest tube removal after cardiac surgery. Ann Card Anaesth [serial online] 2007 [cited 2019 Sep 23];10:42-5. Available from: http://www.annals.in/text.asp?2007/10/1/42/37923



   Introduction Top


Chest tubes are inserted to facilitate drainage of fluid and lung expansion after cardiac surgery and these are removed on the second or third postoperative day. [1] Patients describe chest tube removal as a painful and distressful event in their postoperative recuperation. [2],[3] Some patients describe it as the worst event during their hospital stay. [4]

A number of pharmacological and non­pharmacological interventions have been tried in alleviating pain due to chest tube removal. Among these, morphine, [5] ketorolac, [5] entonox, [6] isoflurane, [7] propofol, [8] bupivacaine, [9] quick relaxation technique, [10] music [11] and topical valdecoxib [12] have been mentioned in the literature. Pain due to chest tube removal is of moderate intensity lasting for a brief period. [2] The use of short acting potent opioids such as sufentanil and fentanyl, administered intravenously as a bolus could alleviate such pain in a simple and effective manner, but has not been studied. The aim of our study was to compare the efficacy of sufentanil and fentanyl in obtunding pain due to chest tube removal using visual analog scale (VAS), which is widely used for measuring pain. [13] In addition Ramsay sedation score, [14] heart rate, arterial pressure, respiratory rate and oxygen saturation variations were also studied.


   Methods Top


After obtaining approval from the Institute Ethics Committee and written informed consent, 141 adult patients of either sex, who had undergone coronary artery bypass graft surgery, valve surgery or other cardiac surgery were included in the study. The sample size was selected as per power calculation carried out. The inclusion criteria were 1. age greater than 18 years, 2. ability to speak/ read English / Hindi, and 3. ability to self report pain; and exclusion criteria were 1. chronic exposure to opioids, 2. allergy to opioids and 3. renal, hepatic, neurological or respiratory failure. The patients were randomly allocated to three groups of fentanyl, sufentanil and control by using sealed envelope method. All patients received injection ketorolac 8 hourly in the intensive care unit (ICU). The last dose was administered at least 4 hours before chest tube removal. Fentanyl group received fentanyl (2 µg/Kg), sufentanil group received sufentanil (0.2 µg/Kg) and control group received 2 ml of normal saline as intravenous bolus injection. The injections were administered by an ICU sister as per the name of the drug mentioned in the sealed envelope, 10 minutes before removal of mediastinal and pleural chest tubes.

Before chest tube removal, patients were explained the procedure of chest tube removal both verbally and through a written information sheet. Ten minutes after injecting the drug, chest tubes were removed one after the other as per the hospital's standard practice.

The 100 mm VAS was explained to each of the patients by the investigator before the removal of chest tubes, as 0 corresponding to no pain and 100 as worst imaginable pain. The patients were asked to mark on the VAS scale the pain experienced before removal (baseline) and 5 min and 20 min after chest tube removal. Twenty minutes after chest tube removal, patients were asked if the pain relief during chest tube removal was adequate or they would have preferred further analgesia. The number of such patients in each group was recorded. Level of sedation was observed using Ramsay sedation score, which has defined 6 points, 3 awake and 3 asleep levels, and higher the level of sedation the higher is the score [Table 1]. Apart from these, heart rate, arterial pressure and respiratory rate and oxygen saturation (SpO 2 ) were recorded before administering the analgesic and 5 minutes and 20 minutes after removal of chest tubes. Patients were closely monitored for any adverse effects of opioids like respiratory depression, nausea or vomiting.

Statistical analysis was performed using repeated-measure analysis of variance (RM­ANOVA) for comparison of pain intensity score, level of sedation, haemodynamic data and respiratory variables among the three groups. Data was expressed as mean ± SD. A P value of less than 0.05 was taken as statistically significant.


   Results Top


Patients characteristics [Table 2], intraoperative analgesic dosage, postoperative use of ketorolac analgesia in the 4 hours preceding chest tube removal and variables relating to the surgical procedure were similar among the three groups.

The mean VAS pain scores in fentanyl, sufentanil and control groups at baseline, before removal of chest tubes, and 20 minutes after removal of chest tubes are given in [Table 3]. Comparison between groups revealed that sufentanil group had significantly lower pain scores at 5 min and 20 min after chest tube removal when compared with fentanyl group and control group. The pain scores in control group were significantly higher than the fentanyl and sufentanil group at 5 and 20 minutes. The number of patients who would have preferred to have further analgesia at the time of chest tube removal was 25% in fentanyl group, 10% in sufentanil group and 45% in control group. Sufentanil group had significantly lower heart rate and arterial pressure values than fentanyl and control group at 5 minutes after removal of chest tubes [Table 4]. None of the patients had adverse effects like nausea, vomiting or respiratory depression in all the three groups. There were no significant differences in sedation scores and respiratory parameters among the three groups [Table 4].


   Discussion Top


This study was designed to compare efficacy of fentanyl and sufentanil in alleviating pain during chest tube removal. The pain scores at 5 min after removal of chest tube were significantly higher in the control group and between sufentanil and fentanyl groups, sufentanil group patients had significantly lower pain scores. This suggests that sufentanil is more effective in relieving pain due to chest tube removal. The pain scores of 13.6±6.06 observed in the sufentanil group in our study represent much better pain relief than reported by Jensen and colleagues. [15]

Puntillo in her study on pain management in critically ill surgical patients has reported that pain relief was inferior with morphine if its administration was not timed to peak effect. [1],[9]

VAS pain intensity scores at 20 min after removal of chest tubes were lower than the baseline in all the three groups suggesting that chest tubes were a source of pain as revealed by studies of Puntillo, [9] Houston [10] and Broscious. [11]

Sedation scores were low for all the three groups. Patients were quite alert before administration of either study drug and remained alert up to 20 minutes after the procedure mitigating the concerns of sedation. Sufentanil group had significantly lower heart rate and arterial pressure values at 5 min after removal of chest tubes suggesting that sufentanil was more effective in suppressing sympathetic increase in heart rate and arterial pressure in response to pain stimuli associated with chest tube removal. Respiratory rate and oxygen saturation values did not differ significantly among the three groups indicating maintenance of satisfactory respiratory parameters while using fentanyl or sufentanil during chest tube removal.

This study has several limitations. Post cardiac surgery patients receive various analgesics for patient comfort. Because it was our intension to start from a baseline of patient comfort, we attempted to examine efficacy of fentanyl and sufentanil against background analgesia of ketorolac, which all patients received in ICU at least 4 hours before chest tube removal. This pre-existing analgesic effect would have masked some of the differences in efficacy among three study manoeuvres. Also, pain being a subjective symptom, it is difficult to measure pain and intra­subject variability in VAS scoring is a well recognized phenomenon. [16] The relationship between changes in pain severity and changes in pain score is not always constant. [17]

The use of opioids like fentanyl and sufentanil can obtund anxiety, distress and other such negative emotions associated with pain. This may be one of the reasons that patients in fentanyl and sufentanil group, remained calm and comforted. However further studies should be undertaken in order to determine the emotional aspect of pain.

We conclude that patients receiving fentanyl and sufentanil for chest tube removal had adequate pain relief and sufentanil seems to be more effective analgesic than fentanyl in controlling pain due to chest tube removal. Hence sufentanil can be safely used for alleviating pain during chest tube removal in ICU.

 
   References Top

1.Puntillo KA. Dimensions of procedural pain and its analgesic management in critically ill surgical patients. Am J Crit Care 1994; 3 : 116-122.  Back to cited text no. 1  [PUBMED]  
2.Gift AG, Bolgiano CS, Cunningham J. Sensations during chest tube removal. Heart Lung 1999; 20:131-137.  Back to cited text no. 2    
3.Carson MM, Barton DM, Morrison CG ,Tribble CG. Managing pain during chest tube removal. Heart Lung 1994; 23 : 500-505.  Back to cited text no. 3    
4.Paiement B, Boulanger M, Jones CW, Roy M. Intubation and other experiences in cardiac surgery: The consumers view. Can Anaesth Soc J 1979; 26 : 173-180.  Back to cited text no. 4  [PUBMED]  
5.Puntillo KA. Appropriately timed analgesics control pain due to chest tube removal. Am J Crit Care 2004;13:292­304.  Back to cited text no. 5    
6.Maria AK, Scot Miller. A randomized comparison of three methods of analgesia for chest drain removal in post cardiac surgical patients. Anesth Analg 2005;100: 205-209.  Back to cited text no. 6    
7.Bryden FMM. Isoflurane for removal of chest drains after cardiac surgery. Anaesthesia 1997; 52: 169-178.  Back to cited text no. 7    
8.McMurray TJ, Bhanumurty S. Low dose propofol for chest tube removal. Anaesthesia 1995; 50: 556.  Back to cited text no. 8    
9.Puntillo KA. Effect of interplural bupivacaine on pleural chest pain; a randomized controlled trial. Am J Crit Care 1996; 5: 102-108.  Back to cited text no. 9  [PUBMED]  
10.Houston S, Jesurum J. The quick relaxation technique. Effect on pain associated with chest tube removal. Appl Nurs Res 1999; 12: 196-205.  Back to cited text no. 10    
11.Broscious S. Music; an intervention for pain during chest tube removal after open heart surgery. Am J Crit Care 1999; 8, 410-415.   Back to cited text no. 11    
12.Singh M, Gopinath R. Topical analgesia for chest tube removal in cardiac patients. J Cardiothorac Vas Anesth, 2005; 19; 719-722.   Back to cited text no. 12    
13.Huskisson EC. Measurement of pain. Lancet 1974; 2: 1127­-1131.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]
14.Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalone and alphadolone. Br Med J 1974; 2: 656-59.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]
15.Jensen MP, Smith DG, Ehde DM, Robinson LR. Pain site and the effects of amputation pain: further clarification of the meaning of mild, moderate and severe pain. Pain 2001; 91: 317-322.  Back to cited text no. 15    
16.DeLoach LJ, Higgins MS, Caplan A. The visual analog scale in the immediate post operative period: Intrasubject variability and correlation with numeric scale. Anesth Analg 1998; 86: 102-106.  Back to cited text no. 16    
17.Bird SB, Dickson EW. Clinically significant changes in pain along the visual analog scale. Ann Emerg Med 2001; 38: 639-643.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]

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Correspondence Address:
V S Joshi
Department of Cardiothoracic and Vascular Anaesthesia, CN Centre, AIIMS, New Delhi.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.37923

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]

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