Following the realisation of the prevalence of very high levels of pain after cardiac surgery in our institution we undertook the establishment of an Acute Pain Service (APS) and began ope-ration in November 2009. Now 2 years latter we present the results of our efforts.

The methods used in our practice have been approved by the IRB of our institution. The ser-vice is nurse run and anesthesiologist super-vised. All patients are seen daily for the first four days after surgery. In the early morning the APS nurse rounds on each patient, then a second set of rounds occurs with the APS team that includes the APS nurse, the bedside nurse, the pharmacist and the anesthesiologist. Pain levels are evaluat-ed using a numerical rating scale (NRS) of 0 to 10. The mainstay of our program is multimodal medi-cation combined with regular dosing. Medication adjustments and rescue techniques are provided as necessary. Patient data and medications are entered into a database and used as the basis for daily patient reports.

Over the past 2 years we have evaluated over 3,900 patients and have over 14,000 pain scores in the database. The results presented in this pos-ter reflect the change between pre-APS (March 2009) and 2 ½ years after inception. Average pain scores at rest, for patients who have pain, hover between 3.9 (from 4.0) on Day 1 to 2.9 (from 3.7) on Day 4. Pain on movement for patients with pain is now between 4.2 (from 5.3) on Day 1 to 3.1 (from 4.6) on Day 4. The number of pain free patients on Day 1 has increased from 27% to 50% and from 34% to 77% on Day 4. A smaller long-term follow up of patients has shown that levels of chronic pain have also declined. Of a total of 489 patients, at an average of 10 months after surgery, 19.8% of men (68/343) and 25% of women (37/146) had pain in the last 24 hours. Pain scores with movement, using the NRS of 0 to 10, were mostly in the lower ranges with 6.7% of patients between 1 and 3, 4.7% of patients between 4 and 6 and only 2.2% of patients stated 7 or more.

J. COGAN 1 G. VARGAS SCHAFFER 2 Z. YEGIN 3 M.-F. OUIMETTE 3 A. DESCHAMPS 1 A. ROCHON 1 J.-S. LEBON 1 P. COUTURE 1 C. AYOUB1 A. DENAULT 1 J. TAILLEFER 1 R. BLAIN 1 B. QIZILBASH 1 K. TOLEDANO 1 Anesthesia, Institut de Cardiologie de Montréal, Université de Montréal 1, Anesthesia, Pain Center of Hôtel-Dieu du CHUM, Université de Montréal 2, Nursing, Intstitut de Cardiologie de Montréal, Université de Montréal 3, QC, Canada

TABLE 1

TOOLS OF THE TRADE Mainstay

Post-operative pain team: Zeynep, Veronique, Bertha and 3 of our 11 anesthesiologists

Post-operative pain protocol: early post surgery

Post-operative pain protocol: step down unit

Supporting techniques

Lyrica, ketamine PO, lido/ketamine cream, Voltaren gel

Injecting in pleural drains and trigger points

Paravertebral blocs

PCA pumps

Repeated teaching sessions

TABLE 2

CONTINUING EDUCATION Short teaching sessions (15 min)

Ketamine

Introduction of new protocols

Opioid surveillance

Formal teaching

Pain Education Program for newly hired nurses (1 1/2 hours, 15 sessions for 7 to 30 people

Formal programme on treatment of pain for nurses in the ICU (1 hour for 5 nurses at a time, 6 sessions)

Review sessions for protocol changes (1hour for 150 nurses, 12 sessions)

Introduction of PCA pumps (1 hour for 150 nurses, 12 sessions)

0 10 20 30 40 50 60 70 80 90

100

Day 1 Day 2 Day 3 Day 4

0

10

20

30

40

50

60

70

80

Day 1 Day 2 Day 3 Day 4

Day 1 Day 2 Day 3 Day 4

Day 1 Day 2 Day 3 Day 4

Nov 2010 to Jan 2011 (n = 300)

Nov 2011 to Jan 2012 (n = 335)

Apr 2012 to Jul 2012 (n = 371)

Dec 2008Audit 1 (n = 58)

Nov 2010 to Jan 2011 (n = 300)

Nov 2011 to Jan 2012 (n = 335)

Apr 2012 to Jul 2012 (n = 371)

Nov 2009to janv 2010 (n = 253)

Nov 2010 to Jan 2011 (n = 300)

Nov 2011 to Jan 2012 (n = 335)

Apr 2012 to Jul 2012 (n = 371)

Nov 2009to janv 2010 (n = 253)

Nov 2010 to Jan 2011 (n = 300) Nov 2011 to Jan 2012 (n = 335) Apr 2012 to Jul 2012 (n = 371)

0 10 20 30 40 50 60 70 80 90

Day 1 Day 2 Day 3 Day 4Day 1 Day 2 Day 3 Day 4

0

1 to 3 4 to 6

7 to 10

0

1 to 3 4 to 6

7 to 10

0

10

20

30

40

50

60

70

mvt Day 1 Day 2 Day 3 Day 4

0 0,5

1 1,5

2 2,5

3 3,5

4 4,5

5

WomenRest

MenRest

WomenMovement

MenMovement

0

10

20

30

40

50

60

70

80

Day 1 Day 2 Day 3 Day 4

Pre SAPO2008

SAPO2011

SAPO2012

0

2

4

6

8

10

12

14

16

Pain 1 - 3 Pain 4 - 6 Pain 7 -10 Total

Men % Women %

0 0,5

1 1,5

2 2,5

3 3,5

4 4,5

0

1

2

3

4

5

6

TABLE 3 TABLE 7 TABLE 10

TABLE 4 TABLE 8 TABLE 11

TABLE 9 TABLE 5

TABLE 6

Percentage of patients who are pain free at rest days 1 to 4 Distribution of pain scores at rest over days 1 to 4 for all 3930 patients since November 2009

Percent of patients who had pain during the first week Average pain ≥ 4/10 in 2008 (1247 pts) and pain on movement ≥ 4/10 in 2011 (300 pts) and in 2012 (371 pts)

Percentage of patients who are pain free on movement days 1 to 4

Pain at rest on days 1 to 4 for patients with pain

Pain on movement on days 1 to 4 for patients with pain

Distribution of pain scores on movement over days 1 to 4 for all 3930 patients since November 2009

Percent of patients with pain at an average of 10 months post surgery (N= 486)

Pain scores for days 1 to 4 for men and women at rest and on movement April 2012 to July 2012 (N= 371)

We feel that our success in managing acute postoperative cardiac pain is directly related to the structure of our APS service. It combines both “low tech” and “personalized therapy”. Our APS nurse and the APS team see each patient daily, to ensure that the multimodal protocol is adhered to as closely as possible. Where this is not sufficient additional medication and techniques are used such as oral ketamine, topical medications and regional anesthesia where applicable. The other major factor is the support that the APS nurse has garnered from the general nursing staff. They are the patient’s advocates for pain relief and ensure the application of 24-hour coverage.

Markman P, J Thorac Cardiovasc Surg. 2009 Sep 21Searle R, Interact CardioVasc Thorac Surg. 2009:9;999-1002