Pain Management

Structured approaches to pain management in the ICU

Pain in patients who are critically ill remains undertreated despite decades of research, guideline development and distribution, and intense educational efforts. By nature of their complex medical conditions, these patients present unique challenges to the delivery of optimal pain treatment. Outdated clinical practices and faulty systems, such as a formulary that allows dangerous prescriptions, present additional obstacles. A multidisciplinary and patient-centered continuous quality improvement process is essential to identifying barriers and implementing evidence-based solutions to the problem of undertreated pain in hospital ICUs. This article addresses barriers common to the ICU setting and presents a number of structured approaches that have been shown to be successful in improving pain treatment in patients who are critically ill.

Clinical tools for the assessment of pain in sedated critically ill adults

AIM

This paper aims to review the evidence regarding pain assessment tools for sedated patients and to establish whether the use of a tool can be recommended in practice.

BACKGROUND

Pain assessment is a challenging area of critical care nursing practice, particularly among sedated patients. Tools to aid in assessing pain among this patient group have been developed and tested recently.

SEARCH STRATEGY

In this systematic review five papers that tested pain assessment tools for sedated patients are discussed. These papers were identified via the CINAHL and MEDLINE databases using the search terms: 'pain assessment' and 'sedated' or 'unconscious' or 'critically ill' or 'critical illness' or 'critical care'.

CONCLUSIONS

The Behavioural Pain Scale (BPS) has been tested among the broadest range of patients and was found to be a reliable and valid tool in three studies. Research is needed to further demonstrate the reliability and validity of the Critical-Care Pain Observation Tool (CPOT), as the paper of Gelinas et al. did not test its internal consistency and domain structure. The CPOT also needs testing among different critical care populations. The design of Odhner et al. study did not allow adequate testing of the Non-verbal Pain Scale (NVPS).

IMPLICATIONS FOR PRACTICE

The implementation of the BPS can be recommended in intensive care units and may improve the management of pain among sedated patients by providing a systematic and consistent approach to pain assessment to guide interventions. The CPOT may also prove useful in assessing pain among sedated patients, but first requires further validation. Also, further research is needed into the effects of pain assessment tools on pain management practices and patient outcomes.

The critically ill patient and regional anesthesia

PURPOSE OF REVIEW

The review presents an overview of indications, limitations and practical aspects of regional anesthesia and analgesia in critically ill medical and surgical patients.

RECENT FINDINGS

A Medline search from 1966 to 2006 with the search terms regional anesthesia, regional analgesia, critically ill and nerve blocks, as well as a search of the Cochrane Library, revealed no studies specifically designed to evaluate the use of regional anesthesia and analgesia in the intensive care unit setting. The available evidence is limited to case reports, cohort studies and expert opinions, and relies heavily on extrapolation from studies primarily designed to examine intraoperative management of surgical patients in whom an intensive care unit admission was part of the perioperative course.

SUMMARY

Regional anesthesia and analgesia in the critically ill can help to improve respiratory function, bowel function, mental status and patient comfort secondary to its opioid-sparing effects. Limitations for the use of regional anesthetic techniques are mainly associated with bleeding risks, hemodynamic side-effects, difficulties in neurologic assessment and the potential of local anesthetic toxicity.