Thoracic Analgesia Protocol

Situation:
The Post Anesthesia Care Unit recovers all different types of surgeries daily. A moderate
amount of patients that we recover have thoracic surgeries. Dr. Mitchell, Dr. Weyant, and Dr.
Meguid perform varieties of thoracic surgeries from bronchoscopies, Video Assisted
Thoracotomies, and Open Thoracotomies. Some of these procedures are considered to be very
painful. The patients come to the PACU after their surgery and have pain not only from their
incision site but also referred ipsilateral shoulder pain.
Background:
When thoracic surgery patients arrive in the Post Anesthesia Care Unit, they are
immediately connected to the monitors for vital signs. Nurses connect chest tubes that are
ordered to suction. After we receive report from Anesthesia, nurses begin a head-to-toe
assessment. Majority of these patients are in a great deal of pain. Once the nurse decides that the
patient is safe and respiratory status is adequate, they will refer to their anesthesia orders and
medicate the patient accordingly. This order set usually involves Fentanyl 25-50 mcg IV PRN
every 3 minutes and Dilaudid 0.2-0.4 mg IV PRN every 5 minutes. Occasionally there may be
1000 mg acetaminophen once PRN or ketorolac 15 or 30 mg once PRN ordered. The PACU
nurse attempts to manage the patients pain and decipher a pain management plan before
transporting the patient to the floor or ICU.


Assessment:
When thoracic surgery patients present with pain, the PACU nurses immediately rely on
narcotics. Narcotics can increase sedation in patients and affect their respiratory status. Impaired
respiratory function can cause pneumonia, atelectasis, or decrease the healing process. These
narcotics would not always alleviate referred ipsilateral shoulder pain; however, non-opioid
medication in adjunct with opioids can decrease shoulder pain.
As a member of the hospitals Pain Champions committee, I decided that a quality
improvement project involving PACU nurses could impact patient satisfaction score about pain
and comfort. I met with Acute Pain Service (APS) members Rob Montgomery, CNS and Matt
Fiegel, MD regarding my concerns with pain management in this patient population. They
expressed interest in the project and decided it also warranted a discussion with the cardio-
thoracic surgeons. APS and I met with CT surgeons to discuss different medication options and
best practice suggestions. I asked the PACU nursing staff to complete a questionnaire
postoperatively identifying medicating practices for every VATS of Thoractomy surgery patient.
I received 66 completed questionnaires and the results displayed that over 80% of these patients
receive only narcotics which only minimally decreases the patients pain score while increasing
their sedation score. I presented a power point illustrating the current practice and
recommendations to the PACU staff regarding this new protocol.
Recommendation:
It was suggested by the Acute Pain Service that a protocol be implemented for thoracic
surgery patients analgesia. I performed a literature review of the current research and identified
a multimodal approach was best for managing this patient populations pain. APS and CT teams
agreed upon the same protocol. The protocol went live in EPIC in August. The order set
identifies pain medication alternatives for Pre-op, intra-op, post-op, and the floor/ICU. These
patients will receive opioids, non-opioids and either an epidural or patient controlled analgesia
for their pain control. PACU nurses were asked to complete the same questionnaire identifying
what medications they gave to reassess consistency and continuity of the protocol on this patient
population. The reevaluation showed that the staff approached pain management with multi
pharmacological approach. More combinations of drugs were added instead of one narcotic.
There is still education that needs to be reinforced but the audits are trending towards fewer
amounts of narcotics, lower pain scores and less sedation. I will act to hold the gain by re-
auditing again now that the protocol is live in EPIC. A consistent practice and plan for
medicating with different types of analgesic has benefited PACU nurses and thoracic surgery
patients.