Adriana Sanches Garcia AraujoI; Jyrson Guilherme KlamtII; Walter Villela de Andrade VicenteII; Luis Vicente GarciaII
BP: Blood pressure
HR: Heart rate
RR: Respiratory rate
SpO2: Arterial oxygen saturation
PICU: Pediatric Intensive Care Unit
DBP: Diastolic blood pressure
rs: Spearman correlation coefficient
Pain after pediatric cardiac surgery can be intense if not adequately controlled and may increase due to patient manipulation, coughing and systematically applied physiotherapy procedures[1-3]. The intensification of pain may be associated with hemodynamic responses (acute increases in blood pressure and heart rate), superficial respiration and hypoxia (low SpO2)[1,4].
The efficacy of respiratory physiotherapy in the postoperative routine in the intensive care unit has been well established regarding the respiratory, cardiovascular and psychological rehabilitation of children undergoing cardiac surgery with cardiopulmonary bypass[1,5,6]. However, few reports are available on the intensity of pain and the associated physiological changes during maneuvers of physiotherapy in this clinical situation[1,6,7]. Thus, this question was considered in the present observational study.
The study was approved by the Research Ethics Committee of the University Hospital, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (Faculty of Medicine of Ribeirão Preto, University of São Paulo). Eighteen children aged 1 month to 2 years who had undergone cardiac surgery and with an indication of postoperative physiotherapy were studied. The persons legally responsible for the children signed written informed consent to participate. Exclusion criteria were: sedated, intubated, hemodynamically unstable children, children with neurological, psychological or motor retardation, with previous pneumopathy such as bronchial asthma, bronchiectasis, and cystic fibrosis, and children who had suffered cardiac arrest during surgery and who presented important respiratory discomfort. Data were collected in the Pediatric Intensive Care Unit (PICU) of the University Hospital, Faculdade de Medicina de Ribeirão Preto, during the period from January to November 2004.
The physiological variables systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and arterial oxygen saturation (SpO2) were measured using a multiparameter monitor (Dixtal®). Respiratory rate (RR) was determined according to the number of thoracic expansions. The pain scale used was the FLACC: Face, Legs, Activity, Cry, Consolability, with a maximum score of 10 points.
Routine physiotherapy (chest wall vibration, expiratory flow maneuvers, directed cough, autogenic drainage, and postural drainage) was applied by the cardiorespiratory physiotherapist in charge according to individual necessities. The physiological variables were recorded immediately before the beginning of physiotherapy (Pre time), 5 (Time 5) and 10 (Time 10) minutes after the beginning of physiotherapy, at the end of physiotherapy (Time E), and 5 minutes after the end of physiotherapy (Post 5 Time). The pain scores were recorded at the Pre, 10 and Post 5 Times.
Data were statistically assessed by the nonparametric Friedman test and the correlation between the physiological variables and the pain scale was calculated using the Spearman correlation coefficient (rs). The level of significance was set at 5% (P<0.05).
Eighteen children (11 girls and 7 boys) aged 1 to 24 months (mean±SD: 12.5±10.3) and weighing 3.2 to 16.5 kg (mean±SD: 9.8±6.1) were studied. The diagnoses of the congenital heart diseases are listed in Table 1.
There was a significant increase in pain scores on the FLACC scale during physiotherapy, followed by a reduction after the procedure compared to Pre Time values (Figure 1). SBP and HR increased significantly at Time period 10, whereas DBP and SpO2 did not change. After physiotherapy, SBP and HR returned to the initial values and SpO2 tended to increase (Figure 2). A significant positive correlation was observed at Time 10 (during physiotherapy) between pain scores and SAP (r=0.49; P=0.042) and between pain and HR (r=0.48; P=0.041).
The present prospective cohort study showed a sharp increase in pain during the physiotherapy maneuvers in children extubated in the PICU after cardiac surgery with cardiopulmonary bypass, which was correlated with increased SBP and HR. After physiotherapy, the scores obtained on the FLACC scale showed values that corresponded to the absence of pain, indicating an apparent analgesic effect of physiotherapy. The discrete increase in SpO2 after physiotherapy may indicate improved oxygenation. DBP and RR did not change during physiotherapy.
The hemodynamic responses produced by physiotherapy, although they were within the physiological variation for the respective ages, may have been a consequence of the pain or discomfort felt by the patients during respiratory physiotherapy, although changes in the regulatory mechanisms present in the postoperative period after cardiac surgery may also have contributed. Indeed, some vagal suppression was demonstrated, while the sympathetic system operated on a normal scale. This imbalanced interaction of the neurovegetative nervous system may explain the tendency to a greater hemodynamic response to movement and aspiration and the higher incidence of tachycardia during the postoperative period. On the other hand, the relative stability of BP, HR, RR and SpO2 during the physiotherapy procedures may indicate the quality of analgesia administered and may have been a factor for the correlation with marginal significance between the hemodynamic variables and pain. In contrast to this paradigm, children who are intubated and sedated during the postoperative period frequently show hemodynamic instability and episodes of bradycardia during manipulation, caused by vagal hyperactivity due to intense stimulation.
Respiratory physiotherapy is essential for cardiorespiratory rehabilitation during the postoperative period of cardiac surgery and should be started as soon has hemodynamic stability occurs[1,11]. Manipulation, compression maneuvers and coughing during physiotherapy may intensify pain or discomfort, in agreement with the increase in pain scores. Surprisingly, however, apparent analgesia was detected immediately after the end of physiotherapy. We have no explanation for this finding and we can only propose that the pattern of somatosensory stimulation and affective care may possibly activate mechanisms of endogenous control of pain. The determination of the consistency of this finding requires future investigation.
In conclusion, respiratory physiotherapy after cardiac surgery causes pain associated with tolerable increased systolic blood pressure and heart rate in children. However, the pain may be followed by apparent analgesia.
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Article receive on Tuesday, March 26, 2013