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Pain management is a big concern for most people who undergo heart surgery. There are many things to think about and we want you to know that you are not alone! Nikhil Kumar MD and Angelia Nadiak, CNP, talk about how your care team works together to make sure your pain is managed. Each person is different and each pain plan is unique to each patient.

Kevin Hodges MD, joins the discussion to add a surgeon’s perspective on pain management and goals for helping our patients have a smooth recovery.

Learn more about pain control after heart surgery.

Visit the Heart Surgery Program at Cleveland Clinic to learn alternative methods to ease your recovery.

Watch more Cleveland Clinic Heart, Vascular and Thoracic Institute Education Videos

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What to Expect After Open Heart Surgery – Pain Management

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute. These podcasts will help you learn more about your heart, thoracic and vascular systems, ways to stay healthy, and information about diseases and treatment options. Enjoy.

Nikhil Kumar, MD:

Hi, my name is Dr. Nikhil Kumar.

Angelia Nadiak, CNP:

And I'm Angelia Nadiak. I'm a nurse practitioner on the cardiac step-down units.

Nikhil Kumar, MD:

I'm an anesthesiologist. I work with the Department of Cardiothoracic Anesthesiology. And will be involved in your care immediately during the surgery and immediately postoperative as well. And I want to thank you for taking the time to listen to our discussion regarding pain management after surgery so that we can help guide you through your surgery and make sure that all your needs from a pain standpoint are managed. Regarding pain with cardiac surgery, a lot of it is, has to do with managing expectations. And so when you come and see us, when you come through the TCI clinic, or when you meet with your surgeon, please be sure to ask how your pain management's going to proceed during surgery, and don't be shy. And please share with us your concerns.

Nikhil Kumar, MD:

One of the things I think it's important to point out to our patients is that the incision down the middle from your sternotomy, which is the incision from which we enter your chest cavity, is actually not quite as painful as a lot of people might think. And in addition to that incision, you will have some drainage tubes that will be inserted near your ribs. And sometimes those will be a little bit uncomfortable, but the good news is that those are removed pretty quickly after surgery, after a few days.

Nikhil Kumar, MD:

So you'll be managed quite closely by the ICU team, as well as our experienced nurse practitioners on the floor, to make sure that you are comfortable after surgery. But we have to make sure that we find a good medium to make sure that you're breathing well after surgery, and don't have too much pain medication on board, but also that your pain is well controlled. One thing I would suggest to our patients is to also make sure that their pain does not get out of control. Because I do feel like if it gets out of control, it's very difficult to manage afterward. Would you agree?

Angelia Nadiak, CNP:

I would agree. It almost takes a little bit more medication then, at that point, to catch up. So pain management is really important in your healing process and it is that fine line. We need you to not be too sedated, but also be able to get up, move around, take deep breaths, and work with physical therapy and with occupational therapy.

Angelia Nadiak, CNP:

I do know once you come to the floor after the ICU, sometimes you still do come with an IV pain, or an intravenous pain, pump. We do wean that as soon as possible. And we do that by first offering you some oral pain medication. And then once that takes effect, then we start to think about taking the intravenous pain medication away. Sometimes there are circumstances where there's a chest tube maybe remaining. And if that's the case, we will leave the intravenous pain medicine in until we can get those chest tubes out. That isn't a hundred percent, but we will do that sometimes. Once you get to the floor, the oral pain medications are, we use some narcotics, as least as possible. We also alternate that with Tylenol. And in some situations, we do use an NSAID, IV Toradol. And that seems to bring really good pain relief as well.

Nikhil Kumar, MD:

And I think what's important to point out, as Angelia said, we treat it in what we call a multimodal approach. So pain can originate for several different reasons. It can be from inflammation. It can be from the nerve being affected. It can be from an incision, which is normal to have pain when you have an incision. So not only do we treat the pain with pain medications, with opioids, which is which may include fentanyl, Dilaudid, and oxycodone, which is the pill Angelia was talking about. But we also treat it with acetaminophen, which acts centrally, and affects the nerves as well. And we also treat it with the anti-inflammatories, with a medication called Toradol or ibuprofen, because there is inflammation that occurs in any of the tissues after surgery as well. So we approach it from a multimodal standpoint to make sure we can attack all those different pathways for how pain occurs.

Angelia Nadiak, CNP:

And I think the important thing to remember as well, is that you need to be discussing this with your provider. As we said, don't let the pain get out of control. Let's talk with your nurses, and talk with your providers to make sure that your pain is being controlled.

Nikhil Kumar, MD:

Yeah. I think one group of patients, some of our patients may have a history of requiring some pain medication for their other pain needs, whether or not they have a back injury or have a requirement for other reasons. And that group of patients, how do you think it is to manage their pain after surgery?

Angelia Nadiak, CNP:

So sometimes the pain medicine that we're giving them for their heart surgery is actually taking care of that sort of pain or their chronic pain. If it's chronic pain that we are not able to get under control, we do have a Pain Management service. We have a Chronic Pain Management service and an Acute Pain Management service that we will consult if need be.

Nikhil Kumar, MD:

Yeah. So there are a lot of resources available here at the Cleveland Clinic to ensure that all of our patients, whatever their needs may be, that we can approach it from different angles and make sure that we utilize different teams to make sure that their pain is under control. And if you do have concerns, again, regarding how your pain will be controlled, if you are on pain medication regimens for other needs, please share that information with us and share with us your concerns so that we can make sure that we're addressing all of your needs appropriately.

Nikhil Kumar, MD:

One of the other groups of patients, I think, that it's worth discussing is our robotic surgery patients, as well as any patient who is getting minimally invasive cardiac surgery. And we do offer a lot of different approaches to cardiac surgery. It's not always from an incision down the middle. And so those patients have kind of a unique incision, which is different. And so one thing that's nice is that the incisions, while they're smaller, they do create different kinds of pain because it is in between the ribs and in the chest. One thing that we do offer these patients is something called nerve blocks, which is we provide numbing medicine in between the muscle layers, which covers a lot of pain distributions. And so while that's useful after surgery, the unfortunate part is that it only lasts for about 10 to 12 hours. So when that pain medication wears off from the injection, it is again, important to stay on top of the pain and to make sure it doesn't get out of control. Would you agree, Angelia?

Angelia Nadiak, CNP:

I would agree. Yes. So again, speak to your provider, speak to your nurse so that that pain does stay under control. I do find that sometimes patients have a little bit more pain at night. So especially before trying to rest at night, speak to your provider.

Nikhil Kumar, MD:

Yeah. Would you say also patients have a lot of pain from coughing as well? Does that cause a lot of pain too?

Angelia Nadiak, CNP:

Correct. And your nurse, when you get to the floor and maybe even in the ICU, will provide you with a pillow that they will show you how to place at your incision line, and then hug it, and be able to cough safely. And that does also decrease the amount of pain you'll have with coughing. But coughing is very, very important along with ambulation. And like I said, if you are having so much pain that you can't do either of those, we need to get that pain under control.

Nikhil Kumar, MD:

That's always nice to have something to hug and something soft, I guess, to help cushion, I suppose. So regarding the chest tubes, I know they come out a few days after surgery, but generally how long do those stay in for?

Angelia Nadiak, CNP:

So a majority of the chest tubes are out before you come to the floor. There are occasions when that chest tube needs to stay in for reasons. Sometimes there's a little air surrounding the lung, called a pneumothorax, that we'll have to keep the chest tube in. And then sometimes there's some fluid that is also being that is coming from those chest tubes that we will also keep that in for. So once you meet the, so the drainage isn't a lot, we'll go ahead and get that tube out. But we do get them out as soon as possible. And we will give you some pain medication prior to that so that the act of removing those isn't as bad.

Nikhil Kumar, MD:

Yeah. Again, the chest tubes sit slightly below the ribs or near the ribs. And so while they are temporary, they can be a little bit sore, but it is something that may require additional pain medications. So please don't be shy. If you need the pain medication let your nurse know or let the physician know who is rounding on you to please address that, and we'll make sure something's administered.

Nikhil Kumar, MD:

In the ICU when you wake up, I want to also point out that because you won't be able to tolerate pills yet you'll have a button to press. It's called a PCA, a patient-controlled analgesic, and you can control how much pain medication you're getting by pressing that button. And when you press the button, it'll deliver you a small dose of a medication called fentanyl, or Dilaudid, or hydromorphone, which will deliver you the medicine. And it won't allow you to overdose yourself because it'll lockout after a few minutes. But again, please, don't be shy, if you need some more additional pain medication on top of it, just let your nurse know.

Nikhil Kumar, MD:

Okay. I'd like to introduce Dr. Kevin Hodges, one of our cardiac surgeons who specializes in minimally invasive robotic mitral surgery, as well as general cardiac surgery. So welcome, Kevin. I appreciate you…

Kevin Hodges, MD:

Hi…

Angelia Nadiak, CNP:

Hi, Kevin. Dr. Hodges.

Nikhil Kumar, MD:

I appreciate you taking the time to talk about pain. Yeah. Dr. Hodges, I appreciate you taking the time to discuss pain before, during, and after surgery and what our patients can learn from our team here.

Kevin Hodges, MD:

Well, thanks. It's really important. And it's something that we think about from the first time we see the patient in the clinic, all the way through the operation, and eventually discharged from the hospital. So it's a huge part of our practice and something we take very seriously.

Nikhil Kumar, MD:

Yeah. One thing we pointed out earlier was it's, as you said, is really important for patients to discuss with us their concerns before surgery, to make sure we have a good plan. And that the patients have an understanding and managing expectations of what pain is going to be like after surgery.

Kevin Hodges, MD:

Yeah. That's a great point. Oftentimes that's one of patients’ biggest concerns when they come and see us. Whether we offer surgery minimally invasively or through a traditional open sternotomy approach, we always have a plan in place, from the very beginning, of how we're going to manage that pain. I think often people find, after the operation, that their pain is much less of a concern than they anticipated it being. And I think that's a testament to all the members of our team.

Nikhil Kumar, MD:

We have a lot of resources, not only in the operating room but after surgery as well, in the ICU. But how do you see the management of pain from the first day until a few days out after surgery? Are there any tips or any concepts that might be helpful for our patients, you think?

Kevin Hodges, MD:

Well, I think it starts with the anesthetic team in the operating room. And whenever we can, we offer blocks, as I'm sure you've discussed already, to offer a non-narcotic, non-medication way to control pain early in the post-operative course. Then once patients get into the ICU, they manage their pain initially with a PCA pump, that you described. They press a button to get a small measured dose of IV narcotics. It's very safe, very effective. And offers just enough to control the pain but not too much.

Kevin Hodges, MD:

Then as soon as patients are able to eat and drink, we wean them from those to multimodality strategy. We have prescription opiates, as well as non-narcotic options like Tylenol or NSAIDs that are very effective at controlling those pains. Usually, by the time people are ready for discharge, they're using a very small amount of narcotics, and mostly just Tylenol. Usually, by a week after discharge, it's Tylenol alone is sufficient for pain control.

Angelia Nadiak, CNP:

So, one of the things to remember is that when you are on the floor, you do have an order for pain medication, whether that is a narcotic or a non-narcotic. But the important thing is that you do have to ask for them, they are on an as-needed basis. So the nurses are not going to give you those medications on a scheduled basis, but the need is there for you to ask for them if you need them.

Kevin Hodges, MD:

That's very important. Often, a conversation I have every time we operate on a patient is that the pain control, the most important thing is that you are comfortable enough to get up, walk around, cough, and take deep breaths after surgery. One of the complications that we fear is that people stay in bed too long, they don't cough up secretions, and that can cause some serious problems. People are often apprehensive about taking pain medications, but it's important that we use what's available and that we really focus on mobility and keeping comfortable to sort get moving with your recovery.

Angelia Nadiak, CNP:

And we do have some non-medication kinds of pain relievers. Such as you could do meditation. There are some heat options. We also have patches that can be used around the incision that can cause some numbing. They're lidocaine patches. That's something else that we can use.

Nikhil Kumar, MD:

Those must be really helpful I would imagine, the lidocaine patches.

Angelia Nadiak, CNP:

Very helpful for incisional pain.

Nikhil Kumar, MD:

Yeah. One of the concerns that we hear a lot in the preoperative clinic is patients are concerned about being dependent on narcotics afterward. There's rightfully...there's been a lot of concerns lately about addiction to opiates and just given everything that's happened in our country. But I think one thing that's important to point out to our patients is that if you are actually in pain, and if there's an indication for an opiate, then you won't get addicted to these medications. The question is, and what's important is, that if you don't need them anymore, that we don't continue to utilize them.

Angelia Nadiak, CNP:

And at discharge, if you are requiring some narcotic pain medication, we do give you some of those to go home with. And we suggest that you wean them. Using the narcotics at home, we suggest taking the narcotic and then in between taking a Tylenol, some Tylenol, acetaminophen, and alternating those medications. And as the days go by, we ask you to wean those down. So instead of taking them four times a day, go to three times a day, and then go to two times a day, and then go to just one time a day. And I recommend that one time of day narcotic if you're still requiring it, be at nighttime before bed.

Kevin Hodges, MD:

That's a good point. And most people don't require a refill of that prescription. If they do, actually regulations require that a patient be seen by a provider to get a refill, but it's a good opportunity to discuss why patients are still having pain and offer us an opportunity to get a strategy in place to control it, often without narcotics.

Angelia Nadiak, CNP:

Correct. And after you are discharged, we do want to see you back here within five days or so. So that we can not only look at your incision, and see your chest X-ray, and listen to your heart, but also to answer any of those questions you might have, and then also address any pain needs that still are there.

Nikhil Kumar, MD:

Angie, would you recommend utilizing ibuprofen or Advil for pain after, once they get home, as well?

Angelia Nadiak, CNP:

We typically don't advise that just because of some of the bleeding risks that might happen, but we are saying that it's not out of the question. Sometimes we do have to use some anti-inflammatories for some instances after surgery. Little pericarditis that might occur, we will give an NSAID, but we would rather you use acetaminophen or Tylenol.

Nikhil Kumar, MD:

So we've touched on a lot of topics today regarding your pain discussions with your providers before surgery, as well as how your pain management will go during surgery and immediately afterward in the ICU, all the way through your voyage throughout the hospital, on your way home. Kevin, Dr. Hodges, do you have any other thoughts or anything else to share with our patients regarding pain management after surgery?

Kevin Hodges, MD:

Yeah, I think the most important thing to know is that your team, whether it be your surgeon, your ICU team, your team on the step-down, or your anesthesia team, are all thinking about pain management. We know it's a big concern. And we want you to know that it's in the forefront of our minds, and we want to make you as comfortable as possible. You have enough to worry about with heart surgery and we don't think pain needs to be one of those major concerns.

Nikhil Kumar, MD:

You're absolutely right. It's on the forefront of our minds because it does directly affect our patients and their experience while they're having surgery and afterward as well. Angie, do you have any other thoughts or anything else we can share?

Angelia Nadiak, CNP:

I agree with both of you. Pain management is a very important part of your recovery. And again, if you feel your pain isn't being managed or that you are having pain, an important thing is that you are speaking to your providers and your team so that we can get that under control.

Kevin Hodges, MD:

Absolutely.

Nikhil Kumar, MD:

I want to thank you again for taking the time today to listen to us and hear our thoughts regarding pain management after surgery and during surgery. Thanks for choosing the Cleveland Clinic. And please let us know if you have any other thoughts or concerns.

Announcer:

Thank you for listening. We hope you enjoyed the podcast. We welcome your comments and feedback. Please contact us at [email protected]. Like what you heard? Subscribe wherever you get your podcasts or listen at clevelandclinic.org/loveyourheartpodcast.

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