Anesth Analg 2000;90:1025-1028
© 2000 International Anesthesia Research Society
PEDIATRIC ANESTHESIA
Analgesia for Pediatric Thoracostomy Tube Removal
David A. Rosen, MD*,
,
John L. Morris, BS*,
Kathleen R. Rosen, MD*,
Roberto C. Valenzuela, MD*,
Michele G. Vidulich, PA
,
Robert J. Steelman, MD, and
Robert A. Gustafson, MD,
Departments of
*Anesthesia,
Pediatrics, and
Surgery, West Virginia University Children’s Hospital, West Virginia University, Morgantown, West Virginia
Address correspondence and reprint requests to David A. Rosen, MD, Department of Anesthesiology, 3618 Health Sciences Center, Box 9134, Morgantown, WV 26506-9134.
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Abstract
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Eutectic mixture of local anesthetics (EMLA®; Astra Pharmaceuticals, Wayne, PA) has been shown to reduce the pain of blood draws in children. We investigated the use of EMLA® versus IV morphine for providing analgesia during chest tube removal (CTR) in children. One hundred twenty pediatric cardiothoracic surgery patients were enrolled. Patients were randomly assigned to receive either morphine (0.1 mg/kg up to 10 mg IV 30 min before CTR) or EMLA® cream (5 g per chest tube cutaneously 3 h before CTR). A single, trained observer rated the patient’s pain before, during, and after CTR using a 10-cm visual analog scale. The sites were evaluated for adverse effect. Methylhe-moglobin levels were monitored in infants. Before CTR, the pain scores of the children who received morphine were rated lower than those who received EMLA® (P < 0.01). During CTR, there was no difference in the pain score between the morphine or EMLA® group. The change from baseline pain score in the morphine group was significantly larger than in the EMLA® group (P < 0.01). We conclude that EMLA® is safe and useful for blunting the pain of CTR.
Implications: Chest tube removal is one of the most painful parts of the cardiothoracic surgical experience. This study compared EMLA® (Astra Pharmaceuticals, Wayne, PA) cream to morphine in providing pain relief for chest tube removal. EMLA® can be used as a useful means of controlling the pain of chest tube removal.
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Introduction
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Reducing the pain of surgical procedures early in life reduces the pain experienced by children in subsequent procedures (1). This decrease in pain may increase patient willingness to return for further necessary procedures. Pediatric cardiac surgery patients often require multiple hospital visits and therefore may particularly benefit from total comfort during their initial surgery. Eutectic mixture of local anesthetics (EMLA®; Astra Pharmaceuticals, Wayne, PA) reduces the pain of preoperative and outpatient blood draws in children (2–8). Operative and postoperative pain can be managed by systemic analgesics delivered via the IV or spinal routes. The removal of the chest tube (CT) often occurs after the cessation of this systemic analgesia, and therefore represents a painful and memorable experience for the patient. Anecdotally, patients often report the most painful part of cardiac surgery is the removal of the CT. The purpose of this study was to investigate the use of EMLA® cream versus IV morphine for providing analgesia during CT removal in children.
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Methods
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Approval of our institutional review board was obtained for this study. One hundred twenty pediatric patients presenting for cardiac or thoracic surgery were enrolled after obtaining informed parental consent for those less than 7 yr of age, or parental consent as well as patient assent for those over 7 yr of age. Patients were randomly assigned to receive either morphine (0.1 mg/kg up to 10 mg) IV or EMLA® cream (5 g per CT) cutaneously. Three hours before tube removal, EMLA® cream or EMLA® cream placebo was placed around the CT insertion site and on the skin over the tube’s course from insertion site to entry in the pleural/mediastinal cavity. The cream was covered with an occlusive dressing. Thirty minutes before CT removal, the patient received a 1-mL IV injection of either morphine or saline. Every patient received medication by both routes, with one drug being the placebo. A single, trained observer blinded to treatment group rated the patient’s pain before, during, and after tube removal using a 10-cm visual analog scale. Children’s pain during the procedure was also rated by using the objective pain scale and Beyer’s Oucher or Attia’s pain scoring system, depending on the child’s age (9–11). The observer also recorded on videotape every thoracostomy tube removal. These videotapes were reevaluated after 10 patients, after 60 patients, and at the end of the study by the same trained observer to ensure consistency in pain scoring. A number of the videotapes were reviewed by a different observer 3 yr after study completion with similar results. The CT insertion sites were evaluated at 24 h, 48 h, and 1 mo for any signs of infection or other adverse effect. Methylhemoglobin levels were followed in infants who participated in the study. Data were analyzed with Fischer’s exact test, analysis of variance, Wilcoxon/Kruskal-Wallis ranked sums, and power analysis where appropriate. Results were reported as mean ± SD.
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Results
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We evaluated the removal of thoracostomy tubes from 118 patients who completed the study protocol. There were no demographic differences between the two study groups. The median age was 24 mo, with a range of 1 mo to 18 yr. The median weight was 9.85 kg with a range of 340 g to 103 kg. There were no differences between the groups in sites of the thoracostomy tubes. Forty-eight percent of the thoracostomy tubes were placed into the mediastinum. Fifty-one percent of the patients had one tube. Ninety-eight percent of the tubes were placed by the same surgeon. Before the removal of the CTs, the pain scores of the children who received morphine were rated lower than those who received EMLA® (2.16 ± 0.27 vs 4.10 ± 0.25 P < 0.01, range 0–8; Table 1). During CT removal, there was no difference in the pain score between the morphine or EMLA® group (7.16 ± 0.32 vs 7.40 ± 0.30 NS, range 0–10, 13 of 63 EMLA® patients scored 10, 12 of 55 morphine patients scored 10, Power 0.61 for pain score difference of 1; Table 2). After CT removal, there was no difference between the morphine or EMLA® group (1.96 ± 0.24 vs 2.33 ± 0.22 NS, range 0–6, Power 0.87 for pain score difference of 1, Table 3). The change in pain score from before CT removal to during CT removal for the morphine group was significantly greater than in the EMLA® group (5.00 ± 0.23 vs 3.30 ± 0.22, P < 0.01; Table 4). Whether a patient was older or younger than 7 yr of age did not seem to affect the change in pain score in patients receiving EMLA® (3.63 ± 0.48 vs 3.25 ± 0.18 NS, power 0.82 for change in the score of 1). Change in pain score was not related to age in either the EMLA® or morphine group (Power 0.75 for change in age of 3 mo for EMLA®, Power 0.52 for a change in age of 4 mo for morphine). Attia’s, Oucher®, and the objective pain scale pain scores correlated with the visual analog scale (P < 0.01). There were no temporal trends in pain score distribution during the study. No adverse effects requiring removal of EMLA® cream at the time of application were noted. Four of 59 (6.8%) patients receiving EMLA® and 1 of 54 (1.9%) receiving placebo cream demonstrated redness at the site of application. No infections were noted at any of the follow-up visits at CT sites. Extended follow up with a limited number of patients up to 3 yr after the study has demonstrated no adverse effects.
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Discussion
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Although neither method totally eliminated the patient’s discomfort, both EMLA® cream and morphine may be used to enhance comfort during removal of thoracostomy tubes. Although during CT removal both study groups were rated as moderate to severe pain, the change in pain score on removal of the CT was greater in the morphine group than in the EMLA® group. An apparent benefit of analgesia could have been more clearly demonstrated by using a control group that received no analgesia; however, this was judged to be unnecessary, given the established standard of pain control. Approximately 8% of patients in both groups were rated as experiencing minimal pain during CT removal. The EMLA® group was rated as having less pain than the morphine group, when compared with their baseline state. During the study, there were a few patients who had thoracostomy tubes on different days during the same admission. Two of these patients were randomized to the EMLA® group one time and the morphine group another time. Both of these patients subjectively reported a benefit with one technique over another, with the patients returning to an active, playful state faster with one medication compared with another. When the treatment code was broken, it was found that the patients both returned to baseline behavior and physiology faster with the EMLA® treatment. This quicker return to baseline behavior can be advantageous in patients in which a return to activity is beneficial, such as those receiving CT removal in anticipation of discharge. At West Virginia University Children’s Hospital, it has become common practice to apply EMLA® cream three to four hours before thoracostomy tube removal. Exceptions to this practice are patients who are particularly anxious around healthcare workers. In these patients, the discomfort/anxiety caused by applying EMLA® cream may outweigh the benefit.
Although both the EMLA® cream and the placebo cream are unsterile, neither supports bacterial growth. No evidence of infection was found at any of the thoracostomy tube sites at 24 or 48 hours or at the one-month follow-up visit. Although some investigators have noted local adverse effects with EMLA® application, such as redness and blistering, (12,13), others have found EMLA® beneficial for reducing the inflammation of partial thickness burns (14). No signs of methemoglobinemia were noted in any study patients (15). In this series, EMLA® was found to be safe for application on and around thoracostomy tube wound sites. Although the manufacturer has found a decrease in the efficacy of EMLA® in children under seven years, this was not the case in this series (16). Local anesthesia varies with length of time of application of EMLA®, with maximum anesthesia achieved in three hours and four hours being the longest recommended duration (17,18). The requirement of applying EMLA® more than three hours before CT removal, although necessitating a measure of preplanning and patience for surgeons, was not found to limit its use as it can be safely applied by nonphysicians operating under protocol (19,20). The greater expense of EMLA® (US $6.85 per tube versus US $0.68 for 10 mg of morphine hospital cost) is perhaps offset by the reduction in risk afforded by avoiding the further use of opioids. In addition, the costs of morphine are greater than the drug cost because of the legal requirements of morphine administration, compared with EMLA®, which can be applied by persons other than registered nurses. EMLA® cream’s efficacy in blunting the pain response to thoracostomy tube removal combined with its lack of systemic effects or adverse reactions makes it a reasonable choice in the process of enhancing patient comfort in children undergoing cardiothoracic procedures.
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Acknowledgments
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This study was supported by a Patient Comfort Grant from West Virginia University Hospital.
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Accepted for publication January 18, 2000.
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Abstract
Introduction
