Pain management after cardiac surgery: experience with a nurse-driven pain protocol

Management of post-operative pain is important for decreasing post-operative morbidity and mortality. After evaluating our pain score database of patients undergoing cardiac surgery (2007-2009) we revised our pain protocol. The new protocol allows nurses to administer analgesic medication without consulting the attending physician. The setting was a medium care unit, a nursing ward with additional monitoring of heart rate and rhythm. We investigated the effects of this revised pain protocol in a prospective consecutive cohort study.

We evaluated 193 patients treated according to the revised protocol (RP group) during the first 72 hours post-cardiac surgery on the medium care unit. A visual analogue scale (VAS) was used as pain scoring system. These patients were compared with a control group (Ctrl group) consisting of 1535 patients.

Patients from the RP group had a mean VAS of 2.2 compared to a mean VAS of 2.8 in the Ctrl group (p < 0.0001). In the Ctrl group 44% of patients with a VAS ≥ 4 maintained this score for 8 hours afterwards. In contrast, in the RP group 81% had a reduction in VAS score within 3 hours. Using the new protocol there were no adverse events requiring intervention such as medication or readmission to an intensive care unit.

This study shows that in post-cardiac surgery patients a significant reduction in VAS scores can be safely realized by a nurse-driven protocol. Furthermore, a reduction in time to achieve an acceptable pain score (VAS < 4) was realized.