| Summary: | 博士 === 國立臺灣大學 === 護理學研究所 === 100 === Objectives: The literature has documented that 18% to 56% of patients experience chronic postoperative pain 1 to 4 years after cardiac surgery. Nursing professionals and researchers in Taiwan have limited understanding of how chronic pain develops from acute pain after cardiac surgery. The purposes of this study are to explore (1) the incidence of chronic pain 3 months after surgery; (2) the pain trajectory of pain subpatterns at rest 3 months after surgery; (3) the pain trajectory of pain subpatterns during activity 3 months after surgery; (4) the predictors of pain at rest 3 months after surgery; and (5) the predictors of pain during activity 3 months after surgery.
Method: This study adopted a prospective longitudinal design. Chart review, the Chinese version of the Pain Self-Efficacy Questionnaire, and the Verbal Numerical Rating Scale were used to collect patients’ demographics and therapeutic and pain belief. Data of the maximum level of pain at 7 time points, including day 3, 4, 7, 30, 45, 60, and 90 after surgery, were collected. Patients’ pain belief was collected before surgery and on the seventh day after surgery. Changes of the pain trajectory in 2 periods (week 1 to week 4 after surgery, week 4 to week 12 after surgery) within 3 months after surgery were captured using the piecewise hierarchical linear growth model. Finally, the logistic generalized estimating equation analysis was adopted to identify the predictors of changes in the pain pattern within 3 months after surgery.
Results: We contacted 130 patients who met the inclusion criteria. Of which, 99 patients completed the survey, and the number of valid samples was 77. The incidences of moderate to severe chronic pain at rest and during activity 3 months after surgery were 12% and 4%, respectively. Patterns of change in pain trajectories varied. According to the change rate between day 3 and day 7 after surgery, 4 subpatterns of pain at rest were generated and reported mild-increase (53%), severe- decrease (27%), mild-decrease (12%), and severe-increase (8%).
The mild-increase referred to a pattern of mild pain on the postoperative third day and more pain on the seventh day; the severe-decrease referred to a moderate to severe pain on the postoperative third day and a reduced level of pain on day 7. The mild-decrease referred a mild pain on the third day after surgery and a reduced level of pain on the seventh day. The severe-decrease referred to a moderate to severe pain on the third day after surgery and a reduced level of pain on day 7.
Both pain trajectories of subpatterns at rest and during activity demonstrated a trend of decrease over time, and the pain of fourth week after surgery was the turning point of pain changes. Regarding the subpatterns of pain at rest, except the severe-decrease, rest of the three patterns showed individual variabilities. Patients with the mild-decrease experienced a mild level of pain on day 7, and increased level of pain during first postoperative month. Patients with the severe-increase initially experienced moderate to severe pain on the seventh day after surgery, and then reduced rapidly during first postoperative month. Both patients with the mild- increase and the severe-decrease reduced a mild level of pain after Day 7, and since then reduced level of pain slowly. Regarding the subpatterns of pain during activities, except the mild decrease, the rest of patterns have individual variability and showed a rapidly decreased pain during first postoperative month, and turn to slow rate of pain decreased in one month. Patients with the mild-increasing and severe-decreasing pain pattern have similar pain changes with a high-mild pain at the day 7. Patients with the severe-increase have moderate to severe pain on the seventh day after surgery. Patients with the mild-decreasing pain experienced mild change of their pain level in first postoperative month. Gender and pain self-efficacy after surgery were related to pain at rest within 3 months after surgery. The accumlation amount and time of narcotic analgesic consumption within days 4 to 7 after surgery influenced changes in pain during activity within 3 months after surgery.
Conclusion: The study result indicated pain during three months after cardiac surgery tend to decrease over time. Yet, the incidence of moderate and severe pain three months after surgery were 12% and 4% for the rest and during activity respectively. The pain of fourth week after surgery was the turning point of pain changes, and pain before discharge was associated with the pain three months after surgery. Therefore, when taking care patients with cardiac surgery, caregivers should assess patients’ pain status at different time points (such as pre-operation, seven days post-operation, one month after surgery, and three months after surgery), and provide care as necessary. We also recommend improving patients’ self-efficacy in postoperative pain care to enhance their abilities to cope with pain, so that, the pain may be reduced and the quality of care may be ensured.
Keywords: Pain trajectory after cardiac surgery, acute pain, persistent pain, chronic postoperative pain, predictor, pain nursing
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