Movements and trends in intensive care pain treatment and sedation: What matters to the patient?

Improving Pain Management in the Intensive Care Unit by Assessment

PURPOSE

Patients in the intensive care unit suffer from pain caused by life-threatening illness or injury but also treatments such as surgery and nursing procedures such as venipuncture. Unconsciousness following head trauma or sedation stage complicates self-report, and both under- and over-management of pain can occur. Inadequate assessment and treatment might follow from unsuitable pain assessment practices. The aim of this study was to evaluate the effect of the implementation of a pain assessment tool on nurses` documentation of pain and the administration of analgesia and sedation.

DESIGN

Quantitative pre-post design.

METHODS

The study was conducted at one intensive care unit at a university hospital and involved 60 patient records and 30 pre-implementations and 30 post-implementations of the Critical-Care Pain Observation Tool (CPOT).

RESULTS

After implementation, a 38% adherence rate was found. The frequency of nurses' pain evaluations increased significantly from 1.3 to 2.3 per nursing shift. The implementation of CPOT also improved how often nurses identified pain by use of facial expressions, muscle tension, and cooperation with the mechanical ventilator, whereas focus on vital signs dropped (p = .014). A larger proportion of patients (17%) received paracetamol after the CPOT implementation compared with before (8%). Findings were statistically significant at p < .01.

CONCLUSIONS

Implementation of CPOT increased the frequency of pain evaluations, and the observable patient behavior was more often interpreted as pain-related. Nurses' adherence rate to sustained patient behavior focus being modest highlights the essential need for ongoing improvements in practice. Implementation of a new tool must be followed by non-pharmacological and pharmacological pain management steps.

CLINICAL IMPLICATIONS

Implementing the CPOT as a pain assessment tool has the potential to enhance assessment practices. However, it is important to note that simply increasing assessment frequency does not guarantee nursing interventions to alleviate pain. This indicates the need for additional steps to be taken in order for nurses to complete the pain assessment cycle and effectively address interventions and reassessments.

Pain management interventions of the non-communicating patient in intensive care: What works for whom and why? A rapid realist review

AIM

The utility and uptake of pain management interventions across intensive care settings is inconsistent. A rapid realist review was conducted to synthesise the evidence for the purpose of theory building and refinement.

DESIGN

A five-step iterative process was employed to develop project scope/ research questions, collate evidence, appraise literature, synthesise evidence and interpret information from data sources.

METHODS

Realist synthesis method was employed to systematically review literature for developing a programme theory.

DATA SOURCES

Initial searches were undertaken in three electronic databases: MEDLINE, CINHAL and OVID. The review was supplemented with key articles from bibliographic search of identified articles. The first 200 hits from Google Scholar were screened.

RESULTS

Three action-oriented themes emerged as integral to successful implementation of pain management interventions. These included health facility actions, unit/team leader actions and individual nurses' actions.

CONCLUSION

Pain assessment interventions are influenced by a constellation of factors which trigger mechanisms yielding effective implementation outcomes.

IMPLICATIONS

The results have implications on policy makers, health organisations, nursing teams and nurses concerned with optimising the successful implementation of pain management interventions.

IMPACT

The review enabled formation of a programme theory concerned with explaining how to effectively implement pain management interventions in intensive care.

REPORTING METHOD

This review was informed by RAMESES publication standards for realist synthesis.

PUBLIC CONTRIBUTION

No patient or public contribution. The study protocol was registered in Open Science Framework. 10.17605/OSF.IO/J7AEZ.

Clinical Impact of the Implementation Strategies Used to Apply the 2013 Pain, Agitation/Sedation, Delirium or 2018 Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption Guideline Recommendations: A Systematic Review and Meta-Analysis

OBJECTIVES

To summarize the effectiveness of implementation strategies for ICU execution of recommendations from the 2013 Pain, Agitation/Sedation, Delirium (PAD) or 2018 PAD, Immobility, Sleep Disruption (PADIS) guidelines.

DATA SOURCES

PubMed, CINAHL, Scopus, and Web of Science were searched from January 2012 to August 2023. The protocol was registered with PROSPERO (CRD42020175268).

STUDY SELECTION

Articles were included if: 1) design was randomized or cohort, 2) adult population evaluated, 3) employed recommendations from greater than or equal to two PAD/PADIS domains, and 4) evaluated greater than or equal to 1 of the following outcome(s): short-term mortality, delirium occurrence, mechanical ventilation (MV) duration, or ICU length of stay (LOS).

DATA EXTRACTION

Two authors independently reviewed articles for eligibility, number of PAD/PADIS domains, quality according to National Heart, Lung, and Blood Institute assessment tools, implementation strategy use (including Assess, prevent, and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment [ABCDEF] bundle) by Cochrane Effective Practice and Organization of Care (EPOC) category, and clinical outcomes. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation.

DATA SYNTHESIS

Among the 25 of 243 (10.3%) full-text articles included ( n = 23,215 patients), risk of bias was high in 13 (52%). Most studies were cohort ( n = 22, 88%). A median of 5 (interquartile range [IQR] 4-7) EPOC strategies were used to implement recommendations from two (IQR 2-3) PAD/PADIS domains. Cohort and randomized studies were pooled separately. In the cohort studies, use of EPOC strategies was not associated with a change in mortality (risk ratio [RR] 1.01; 95% CI, 0.9-1.12), or delirium (RR 0.92; 95% CI, 0.82-1.03), but was associated with a reduction in MV duration (weighted mean difference [WMD] -0.84 d; 95% CI, -1.25 to -0.43) and ICU LOS (WMD -0.77 d; 95% CI, -1.51 to 0.04). For randomized studies, EPOC strategy use was associated with reduced mortality and MV duration but not delirium or ICU LOS.

CONCLUSIONS

Using multiple implementation strategies to adopt PAD/PADIS guideline recommendations may reduce mortality, duration of MV, and ICU LOS. Further prospective, controlled studies are needed to identify the most effective strategies to implement PAD/PADIS recommendations.

Nurses' Assessments Versus Patients' Self-Assessments of Postoperative Pain: Knowledge and Skills of Nurses for Effective Pain Management

Postoperative pain is the most common form of acute pain. Nurses contribute to effective pain management with their knowledge and skills. The aims of this research were to examine differences between nurses' assessments and patients' self-assessments of postoperative pain, differences in the mentioned (self) assessments with respect to characteristics of both groups of respondents, and the correlation between the NRS and the VRS scale. The study included 103 nurses employed at a hospital and 103 patients treated in the surgical departments after the surgical procedures. Data were collected using the standardized Numerical rating scale (NRS) and Verbal rating score (VRS). The median of patients' self-assessments of pain intensity on the NRS scale was 4, while the nursing assessment of patients' pain was 3, with no significant difference (p = 0.083). No significant differences were found on the VRS scale between nurse assessments and patient self-assessments of current pain intensity. The pain was described as moderate by 35% of participants, including 35.9% nurses and 35% patients. Significant positive correlations were recorded between values on the VRS and NRS scales for nurses (Rho = 0.812; p < 0.001) and patients (Rho = 0.830; p < 0.001). The results of this study may have implications for the improvement of postoperative pain management protocols, with regular use of pain assessment scales and individualization of analgesic prescriptions.

Pain Assessment with the BPS and CCPOT Behavioral Pain Scales in Mechanically Ventilated Patients Requiring Analgesia and Sedation

BACKGROUND

Intensive Care Unit (ICU) patients often experience pain, especially during diagnostic, nursing, and therapeutic interventions. Pain assessment using the Behavioral Pain Scale (BPS) and Critical Care Pain Observation Tool (CCPOT) are recommended, but they are difficult to do in patients undergoing deep sedation. This study analyzed the usefulness of the BPS and CCPOT scales in assessing pain among patients with varying degrees of sedation.

METHODS

In 81 mechanically ventilated and sedated ICU patients, 1005 measurements were performed using the BPS and CCPOT scales. The study was conducted by 3 trained observers 3 times a day (each measurement at rest, during painful nursing interventions, and after the intervention). The Richmond Agitation-Sedation Scale (RASS), the Simplified Acute Physiology Score (SAPS II), and the Acute Physiology and Chronic Health Evaluation (APACHE II) were also analyzed from medical records as well as information on the length of hospitalization and treatment.

RESULTS

It was shown that signs of pain increased significantly (p < 0.001) during interventions in patients on both scales (BPS and CCPOT), and then returned to values close to the resting period. RASS results correlated significantly (p < 0.05) and positively with the results of the BPS and CCPOT. A strong correlation was found between the results of both scales at each stage of the study (R = 0.622-0.907).

CONCLUSIONS

Nursing procedures are a source of pain in analgosedated patients. The BPS and CCPOT scales are useful tools for assessing the occurrence of pain in mechanically ventilated patients, including those in deep sedation.

The complications of opioid use during and post-intensive care admission: A narrative review

Opioids are a commonly administered analgesic medication in the intensive care unit, primarily to facilitate invasive mechanical ventilation. Consensus guidelines advocate for an opioid-first strategy for the management of acute pain in ventilated patients. As a result, these patients are potentially exposed to high opioid doses for prolonged periods, increasing the risk of adverse effects. Adverse effects relevant to these critically ill patients include delirium, intensive care unit-acquired infections, acute opioid tolerance, iatrogenic withdrawal syndrome, opioid-induced hyperalgesia, persistent opioid use, and chronic post-intensive care unit pain. Consequently, there is a challenge of optimising analgesia while minimising these adverse effects. This narrative review will discuss the characteristics of opioid use in the intensive care unit, outline the potential short-term and long-term adverse effects of opioid therapy in critically ill patients, and outline a multifaceted strategy for opioid minimisation.

Nurses' Perceived Barriers to and Facilitators of Pain Assessment and Management in Critical Care Patients: A Systematic Review

Aim

This review aims to examine nurses’ perceived barriers to and facilitators of pain assessment and management in adult critical care patients.

Background

Pain is one of the worst memories among critically ill patients. However, pain among those patients is still undertreated due to several barriers that impede effective management. Therefore, addressing the perceived barriers and facilitators to pain assessment management among critical care nurses is crucial.

Methods

A systematic search of pain assessment and management in critical care patient-relevant literature from four databases was done, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

The barriers and facilitators were categorized into four groups: nurse-related, patient-related, physician-related, and system-related. The most frequently reported barriers in this study included nurses’ lack of knowledge regarding the use of pain assessment tools, patients’ inability to communicate, physicians’ prescription of analgesics being independent of pain scores evaluation, and absence of standardized guidelines and protocols for pain evaluation and control. For the facilitators, the most reported ones include ongoing education and professional training related to pain assessment and management, patients’ ability to self-report pain, effective collaboration between physicians and nurses, and productive discussion of patients’ pain scores during nurse-to-nurse handovers.

Conclusion

Various barriers and facilitators to pain assessment and management were identified and examined in this review. However, future research is still needed to further investigate these barriers and facilitators and examine any other potential associated factors among critical care nurses.

Relevance to Clinical Practice

The findings of our study could help hospital managers in developing continuous education and staff development training programs on assessing and managing pain for critical care patients. Also, our findings could be used to develop an evidence-based standard pain management protocol tailored to effectively assess and promptly treat pain in critical care patients.

Pain assessment of the adult sedated and ventilated patients in the intensive care setting: A scoping review

BACKGROUND

Pain is frequently encountered in the intensive care setting. Given the impact of pain assessment on patient outcomes and length of hospital stay, studies have been conducted to validate tools, establish guidelines and cast light on practices relating to pain assessment.

OBJECTIVE

To examine the extent, range and nature of the evidence around pain assessment practices in adult patients who cannot self-report pain in the intensive care setting and summarise the findings from a heterogenous body of evidence to aid in the planning and the conduct of future research and management of patient care. The specific patient cohort studied was the sedated/ ventilated patient within the intensive care setting.

DESIGN

A scoping review protocol utilised the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping review checklist (PRISMA-ScR).

METHODS

The review comprised of five phases: identifying the research question, identifying relevant studies, study selection, charting the data and collating, summarizing, and reporting the results. Databases were systematically searched from January to April 2020. Databases included were Scopus, Web of Science, Medline via Ovid, CINAHL COMPLETE via EBSCO host, Health Source and PUBMED. Limits were applied on dates (2000 to current), language (English), subject (human) and age (adult). Key words used were "pain", "assessment", "measurement", "tools", "instruments", "practices", "sedated", "ventilated", "adult". A hand search technique was used to search citations within articles. Database alerts were set to apprise the availability of research articles pertaining to pain assessment practices in the intensive care setting.

RESULTS

The review uncovered literature categorised under five general themes: behaviour pain assessment tools, pain assessment guidelines, position statements and quality improvement projects, enablers and barriers to pain assessment, and evidence appertaining to actual practices. Behaviour pain assessment tools are the benchmark for pain assessment of sedated and ventilated patients. The reliability and validity of physiologic parameters to assess pain is yet to be determined. Issues of compliance with pain assessment guidelines and tools exist and impact on practices. In some countries like Australia, there is a dearth of information regarding the prevalence and characteristics of patients receiving analgesia, type of analgesia used, pain assessment practices and the process of recording pain management. In general, pain assessment varies across different intensive care settings and lacks consistency.

CONCLUSION

Research on pain assessment practices requires further investigation to explore the causative mechanisms that contribute to poor compliance with established pain management guidelines. The protocol of this review was registered with Open Science Framework (https://osf.io/25a6) Tweetable abstract: Pain assessment in intensive care settings lacks consistency. New information is needed to understand the causative mechanisms underpinning poor compliance with guidelines.

"Please mind the gap": A secondary analysis of discomfort and comfort in intensive care

AIMS AND OBJECTIVES

To explore in depth discomfort in intensive care as experienced by patients and attended to by critical care nurses.

BACKGROUND

Discomfort in illness is complex and persistent, and its alleviation is a challenge for nurses working in intensive care units (ICU). In previous studies, we showed that ICU patients described little actual pain but suffer from much discomfort. Critical care nurses had a systematic approach to the treatment of pain, but were more haphazard in dealing with other types of discomfort.

DESIGN

Secondary qualitative analysis of data from two previous exploratory studies.

METHODS

Content analysis was used on existing data from 28 interviews with ICU patients, and 16 field notes and interviews with critical care nurses. Kolcaba's Comfort Theory was applied for further analysis. The COREQ checklist was used.

RESULTS

Three themes, "Being deprived of a functioning body", "Being deprived of a functioning mind" and "Being deprived of integrity" characterised the discomfort experienced by ICU patients. The nurses appeared to attend to all areas of discomfort expressed by patients. In need of, and providing acknowledgment and alleviation became a common overarching theme. We identified a comfort gap caused by the discrepancy between the patients' needs and the nurses' achievements in fulfilling these needs.

CONCLUSIONS

A gap exists between ICU patients' comfort needs and nurses' achievements in fulfilling these, indicating that discomfort currently is an inevitable part of the critical illness trajectory. Increased knowledge about how the brain is affected in ICU patients and more systematic approaches to assessing comfort needs and enhancing comfort may support nurses in fulfilling patient needs and possibly diminish the existing comfort gap.

RELEVANCE FOR CLINICAL PRACTICE

An increased understanding of the complex experience of discomfort in ICU patients may bring about more systematic approaches to enhance comfort and direct for education and further research.