Pain in the ICU: a psychiatric perspective

Pain management of adult sedated and ventilated patients in the intensive care units: A survey with free text responses

BACKGROUND

Pain management of sedated and ventilated patients in intensive care units lacks consistency.

OBJECTIVES

To investigate nurses' training, governance, practices, knowledge and attitudes relating to pain management in consideration of published guidelines and explore nurses' perspectives.

METHODS

A survey design, using an online questionnaire with free text responses, was employed. Quantitative and qualitative data from nurses working across different hospitals were collated and saved on Qualtrics platform. Quantitative data were analysed non-parametrically and narrative responses thematically. CROSS and SRQR reporting guidelines were adhered to.

OUTCOME MEASURES

Demographics, training, governance, clinical practice, knowledge, and attitudes.

RESULTS/FINDINGS

108 nurses participated with ninety-two completed surveys analysed. Analgesia was used to complete nursing tasks regardless of comfort needs (n = 49, 53.3 %). Changes in vital signs prompted opioid administration (n = 48, 52.1 %). Choice of analgesia depended on doctor's preference (n = 63, 68.5 %). Non-opioid therapy was administered before opioids (n = 42, 45.7 %). Sedatives were used to alleviate agitation(n = 50,54.3 %). No statistically significant difference in nurses' knowledge existed between hospitals. Weak positive relationship: r = [0.081], p = [0.441] between "knowledge scores" and "years of ICU experience" and weak negative relationship r = [-0.119], p = [0.260] between "knowledge scores" and "hours of clinical practice" was detected. Lack of training, resources, policies, high patient acuity and casual employment were acknowledged barriers to pain management. Two overarching themes emerged from narrative responses: "Pain assessment, where is it?" And "Priorities of critical illness."

CONCLUSION

The study uncovered pain management situation and examined nurses' demographics, training, governance, practices, knowledge and attitudes. Narrative responses highlighted barriers to pain management.

IMPLICATIONS FOR CLINICAL PRACTICE

Health organisations should provide education, institute governance and develop policies to inform pain management. Nurses' role encompasses updating knowledge, adhering to interventions and overcoming biases. This subsequently manifests as improvement in patient outcomes.

Pain assessment and analgesic management in patients admitted to intensive care: an Australian and New Zealand point prevalence study

Objective: To describe pain assessment and analgesic management practices in patients in intensive care units (ICUs) in Australia and New Zealand. Design, setting and participants: Prospective, observational, multicentre, single-day point prevalence study conducted in Australian and New Zealand ICUs. Observational data were recorded for all adult patients admitted to an ICU without a neurological, neurosurgical or postoperative cardiac diagnosis. Demographic characteristics and data on pain assessment and analgesic management for a 24-hour period were collected. Main outcome measures: Types of pain assessment tools used and frequency of their use, use of opioid analgesia, use of adjuvant analgesia, and differences in pain assessment and analgesic management between postoperative and non-operative patients. Results: From the 499 patients enrolled from 45 ICUs, pain assessment was performed at least every 4 hours in 56% of patients (277/499), most commonly with a numerical rating scale. Overall, 286 patients (57%) received an opioid on the study day. Of the 181 mechanically ventilated patients, 135 (75%) received an intravenous opioid, with the predominant opioid infusion being fentanyl. The median dose of opioid infusion for ventilated patients was 140 mg oral morphine equivalents. Of the 318 non-ventilated patients, 41 (13%) received patient-controlled analgesia and 76 (24%) received an oral opioid, with the predominant opioid being oxycodone. Paracetamol was administered to 63 ventilated patients (35%) and 164 non-ventilated patients (52%), while 2% of all patients (11/499) received a non-steroidal anti-inflammatory drug. Ketamine infusion and regional analgesia were used in 15 patients (3%) and 17 patients (3%), respectively. Antineuropathic agents (predominantly gabapentinoids) were used in 53 patients (11%). Conclusions: Although a majority of ICU patients were frequently assessed for pain with a validated pain assessment tool, cumulative daily doses of opioids were high, and the use of multimodal adjuvant analgesia was low. Our data on current pain assessment and analgesic management practices may inform further research in this area.

Study protocol: development and pilot testing of the Critical Care Pain Observation Tool for families (CPOT-Fam)

Background

Patients in the intensive care unit (ICU) often have limited ability to communicate making it more difficult to identify and effectively treat their pain. Family caregivers or close friends of critically ill patients may be able to identify signs of pain before the clinical care team and could potentially assist in routine pain assessments. This study will adapt the Critical Care Pain Observation Tool (CPOT) for use by family members to create the CPOT-Fam and compare family CPOT-Fam assessments with nurse-provided CPOT assessments for a given patient.

Methods

This study will be executed in two phases:

1) Development of the CPOT-Fam — A working group of patient partners, ICU clinicians, and researchers will adapt the CPOT for use by family caregivers (creating the CPOT-Fam) and produce an accompanying educational module to deliver information on pain and how to use the tool. The CPOT-Fam will undergo preclinical testing with participants (i.e., members of the public and family caregivers of critically ill adults), who will complete the educational module and provide CPOT-Fam scores on sample cases. Feedback on the CPOT-Fam will be collected.

2) Pilot testing the CPOT — Fam family caregivers of critically ill adults will complete the educational module and provide information on the following: (1) demographics, (2) anxiety, (3) caregiving self-efficacy, and (4) satisfaction with care in the ICU. Family caregivers will then provide a proxy assessment of their critically ill loved one’s pain through the CPOT-Fam and also provide a subjective (i.e., questionnaire-based including open-ended responses) account of their loved one’s pain status. A comparison (i.e., agreement) will be made between family caregiver provided CPOT-Fam scores and ICU nurse-provided CPOT scores (collected from the provincial health information system), calculated independently and blinded to one another. Feasibility and acceptability of the CPOT-Fam will be determined.

Discussion

The results of this work will produce a family caregiver CPOT (i.e., CPOT-Fam), determine feasibility and acceptability of the CPOT-Fam, and compare pain assessments conducted by family caregivers and ICU nurses. The results will inform whether a larger study to determine a role for family caregivers in ICU pain assessment using the CPOT-Fam is warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01102-3.

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' use of non-pharmacological pain management methods in intensive care units: A descriptive cross-sectional study

BACKGROUND

Pain is a common and unpleasant feeling among patients in intensive care units. Therefore, the use of proper pain management methods, such as non-pharmacological interventions, is a priority in intensive care units.

OBJECTIVE

This study aimed to ascertain the extent of the use of non-pharmacological pain management methods by intensive care unit nurses in Iran and to identify the obstacles that hindered the use of these methods.

MATERIAL AND METHODS

This study used a descriptive cross-sectional design which involved a convenience sample of 224 nurses who worked in 16 intensive care units across northern Iran. Data were collected using the non-pharmacological pain management questionnaire and a researcher-developed checklist of the obstacles that hindered the use of non-pharmacological pain management methods.

RESULTS

A moderate number of ICU nurses used non-pharmacological pain management methods (55.8 %). The most common method used by nurses was repositioning (M = 2.72), while methods such as acupuncture and reflexology were used less frequently. Furthermore, the most common obstacles to the use of non-pharmacological pain management methods were nurses' fatigue (M = 2.92) and multiple responsibilities (M = 2.91). Demographic variables such as age, gender, educational level, and work experience were not significantly associated with the use of non-pharmacological pain management methods.

CONCLUSIONS

Due to factors such as fatigue, multiple responsibilities, a heavy workload, and an insufficient number of nurses per shift, the rate of utilization of non-pharmacological pain management methods among intensive care unit nurses in Iran was low. Furthermore, most of the participants in this study had not attended courses on non-pharmacological pain management.

Patients´ experiences of pain in the intensive care - The delicate balance of control

AIM

To explore the patients´ experiences of pain when being cared for in the intensive care.

DESIGN

An exploratory, qualitative design was chosen.

METHOD

Interviews were performed with patients (October 2015-March 2017) within a week of post-intensive care (N = 16). Thematic analysis was used as method for analysis.

RESULTS

The findings generated two themes - a lack of control and to struggle for control. Pain was described as overwhelming, both in body and mind and generating the experience of a lack of control, with feelings of incapacitation, isolation, and having their needs unmet. Feeling in control of the pain and thus in control of the situation was experienced as a constant struggle. Well-planned care, finding ways to handle the pain and good communication were all helpful in this struggle.

CONCLUSION

The participants recalled their experience of pain in the ICU and control seems to be crucial for how pain is experienced. They experienced a lack of control due to not only the pain but also the treatment, which can be avoided by the nurse continuously evaluating and individualising the care. Balanced care, meeting the patients' needs and good communication helps the patient feel more in control when experiencing pain.

IMPACT

The experience of pain is dependent on control for the intensive care patient. The nurse may help them gain control and thereby handle the experience of pain through including the patient, striving for better communication and implementing individualised care that continuously assesses and treats pain.

Using a clinical judgement model to understand the impact of validated pain assessment tools for burn clinicians and adult patients in the ICU: A multi-methods study

BACKGROUND

Intensive care (ICU) patients' burn pain is difficult to assess, communicate and address, risking chronic pain syndromes and psychological morbidity.

AIMS

To understand how the introduction of validated pain tools (Critical Care Pain Observation Tool [CPOT], Numerical Rating Scale [NRS], Pain Assessment in Advanced Dementia [PAINAD]) affected clinical judgement processes, analgesia/sedation administration and the experience of burn-injured patients.

METHODS

Consecutive chart review compared type and amount of analgesia/sedation administered, ventilation time and length of ICU/hospital stay between consecutive burn patients pre- and 6-months post-intervention (n=70). Analysis of 36 qualitative interviews with ICU clinicians (n=12) and burn-injured adults (n=12) pre- and post-intervention was guided by Tanner's (2006) Clinical Judgement Model.

RESULTS

Overall, there was a significant increase in morphine (P=0.04) and propofol (P=0.04) use and a trend towards increased paracetamol (P=0.06) use post-intervention. There was a trend towards greater Midazolam use for TBSA<20% (P=0.06), and significantly increased propofol use for TBSA≥20% (P=0.03). Ventilation time and ICU/hospital length of stay were unchanged. Qualitative analysis revealed complex clinical judgement dependent on the context of the patient's situation, unit culture, background beliefs of clinicians and in knowing the patient. Whilst the CPOT and NRS enhanced analytic reasoning and pain advocacy, the PAINAD appeared redundant.

CONCLUSIONS

Effective pain assessment, management and advocacy are assisted by evidence-based assessment practices.

Strategies for Pain Assessment in Adult Patients With Delirium: A Scoping Review

CONTEXT

Pain and delirium are highly prevalent in the same patient groups. Disturbances in attention, awareness, and cognition are characteristics for delirium and can compromise pain assessment.

OBJECTIVES

The aim of this review was to examine and map models and understandings of pain and delirium as well as pain assessment instruments and strategies for adult patients with delirium.

METHODS

A scoping review of all publications that reported on pain assessment in adult patients with delirium was conducted with no time and language constraints, searching Medline, CINAHL, Scopus, Embase, and PsycINFO and systematically assessing for inclusion. Standardized data extraction and a narrative synthesis followed.

RESULTS

A total of 90 publications were included in the final analysis. Despite being recommended for practice, no evidence for the use of self-report or behavioral pain assessment instruments in patients with delirium was identified, with the exception of limited evidence for the validity of the Critical Care Pain Observation Tool and Behavioral Pain Scale in delirious intensive care patients. Proxy ratings of pain and comprehensive pain assessment hierarchies were also recommended, but not supported by evidence. Current models and/or understandings of pain and delirium were not applied in most publications.

CONCLUSION

The current literature is insufficient to guide clinical practice in pain assessment in patients with delirium. Future research will be needed to address the validity of existing pain assessment instruments, apply theoretical and conceptual understandings of pain and delirium, and build on prior studies to close evidence gaps.

Effects of Massage in Reducing the Pain and Anxiety of the Cardiac Surgery Critically Ill-a Randomized Controlled Trial

Objective

To evaluate the effectiveness of hand massage on the pain and anxiety of the cardiac surgery critically ill.

Design

A three-arm randomized controlled trial.

Setting

This study was conducted in a medical-surgical intensive care unit in Canada.

Subjects

Adult patients who underwent elective cardiac surgery, who were able to speak French/English and to self-report symptoms, without a high risk of postoperative complications were eligible.

Methods

Patients were randomly allocated to standard care plus either two 20-minute hand massages (experimental), two 20-minute hand holdings (active control), or two 20-minute rest periods (passive control/standard care). Pain intensity, pain unpleasantness, anxiety, muscle tension, and vital signs were evaluated before, after, and 30 minutes later for each intervention.

Results

From the 83 patients recruited, 60 were randomized (20 massage, 19 hand holding, 21 standard care). After controlling for baseline scores, the massage group reported significantly lower pain intensity, pain unpleasantness, and anxiety for the first data collection set compared with both hand holding and standard care (analysis of covariance, P < 0.02), with an average decrease of two points on a 0-10 scale. No statistically significant differences were noted between hand holding and standard care for any of the symptoms. Similar results were observed for the second data collection set (N = 43). Patients had decreased muscle tension post massage. Vital signs did not differ significantly between groups.

Conclusions

Findings suggest that a 20-minute hand massage in addition to routine postoperative pain management can concomitantly reduce pain intensity, pain unpleasantness, and anxiety by two points on average on a 0-10 scale.

Validation of a Chinese version critical-care pain observation tool in nonintubated and intubated critically ill patients: Two cross-sectional studies

AIMS AND OBJECTIVES

To validate the Chinese version of the Critical-Care Pain Observation Tool (CPOT) in nonintubated and intubated ICU patients.

BACKGROUND

While CPOT was found to have the best psychometric properties among objective pain assessment scales, there is no Chinese version CPOT for nonintubated patients.

DESIGN

Cross-sectional design was used in these two observational studies.

METHODS

Seventy-six nonintubated patients and 53 intubated patients were assessed to examine internal consistency, criterion-related and discriminative validity of CPOT in the first study. Pain assessment during low pain condition as well as increased pain condition was performed by Numeric Rating Scale (NRS) and the Chinese version COPT. Forty nonintubated patients and 43 intubated patients were assessed to examine inter-rater reliability in the second study. A bedside nurse and a researcher independently executed paired pain assessments with CPOT in the same conditions. The STROBE Statement was followed to guide these studies.

RESULTS

The Cronbach's α in nonintubated patients and intubated patients was 0.903-0.930 and 0.868-0.870. The intraclass correlation coefficients (ICCs) in nonintubated patients ranged from 0.959-0.982, and the ICC in intubated patients ranged from 0.947-0.959, confirming the inter-rater reliability. The moderately positive Pearson's correlations between CPOT and NRS scores (r = 0.757-0.838 in nonintubated patients, r = 0.574-0.705 in intubated patients) indicated the criterion-related validity. A significant increase in CPOT scores in the increased pain condition compared with those acquired in the low pain condition verified the discriminative validity.

CONCLUSIONS

The Chinese version of CPOT was presented to be valid and reliable for both nonintubated and intubated critically ill adults, which could be applicable for pain assessment in patients in ICU.

RELEVANCE TO CLINICAL PRACTICE

This study provides an applicable pain assessment tool for both nonintubated patients and intubated patients in ICU.

Chronic Pain and Chronic Opioid Use After Intensive Care Discharge - Is It Time to Change Practice?

Almost half of patients treated on intensive care unit (ICU) experience moderate to severe pain. Managing pain in the critically ill patient is challenging, as their pain is complex with multiple causes. Pharmacological treatment often focuses on opioids, and over a prolonged admission this can represent high cumulative doses which risk opioid dependence at discharge. Despite analgesia the incidence of chronic pain after treatment on ICU is high ranging from 33-73%. Measures need to be taken to prevent the transition from acute to chronic pain, whilst avoiding opioid overuse. This narrative review discusses preventive measures for the development of chronic pain in ICU patients. It considers a number of strategies that can be employed including non-opioid analgesics, regional analgesia, and non-pharmacological methods. We reason that individualized pain management plans should become the cornerstone for critically ill patients to facilitate physical and psychological well being after discharge from critical care and hospital.

The Effectiveness of Hand Massage on Pain in Critically Ill Patients After Cardiac Surgery: A Randomized Controlled Trial Protocol

Background

Postoperative pain is common in the intensive care unit despite the administration of analgesia. Some trials suggest that massage can be effective at reducing postoperative pain in acute care units; however, its effects on pain relief in the intensive care unit and when pain severity is highest remain unknown.

Objective

The objective is to evaluate the effectiveness of hand massage on the pain intensity (primary outcome), unpleasantness and interference, muscle tension, anxiety, and vital signs of critically ill patients after cardiac surgery.

Methods

A 3-arm randomized controlled trial will be conducted. A total of 79 patients who are 18 years or older, able to speak French or English and self-report symptoms, have undergone elective cardiac surgery, and do not have a high risk of postoperative complications and contraindications to hand massage will be recruited. They will be randomly allocated (1:1:1) to standard care plus either 3 20-minute hand massages (experimental), 3 20-minute hand holdings (active control), or 3 20-minute rest periods (passive control). Pain intensity, unpleasantness, anxiety, muscle tension, and vital signs will be evaluated before, immediately after, and 30 minutes later for each intervention administered within 24 hours postoperatively. Peer-reviewed competitive funding was received from the Quebec Nursing Intervention Research Network and McGill University in December 2015, and research ethics approval was obtained February 2016.

Results

Recruitment started in April 2016, and data collection is expected to be complete by January 2017. To date, 24 patients were randomized and had data collection done.

Conclusions

This study will be one of the first randomized controlled trials to examine the effect of hand massage on the pain levels of critically ill patients after cardiac surgery and to provide empirical evidence for the use of massage among this population.

ClinicalTrial

ClinicalTrials.gov NCT02679534; https://clinicaltrials.gov/ct2/show/NCT02679534 (Archived by WebCite at http://www.webcitation.org/6l8Ly5eHS)

Analgesia in Neurocritical Care: An International Survey and Practice Audit

OBJECTIVE

To characterize analgesic administration in neurocritical care.

DESIGN

ICU pharmacy database analgesic delivery audits from five countries. A 31-question analgesic agent survey was constructed, validated, and e-distributed in four countries.

SETTING

International multicenter neuro-ICU database audit and electronic survey.

PATIENTS

Six ICUs provided individual, anonymized analgesic delivery data in primary neurological diagnosis patients. Prescriber surveys were disseminated by neurocritical care societies.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Analgesic delivery data from 173 patients in French, Canadian, American, and Australian and New Zealand ICUs suggest that acetaminophen/paracetamol is the most common first-line analgesic (49.1% of patients); opiates are the "second line" in 31.5% of patients; however, 33% patients received no second agent. In the 2.3% with demyelinating disease, gabapentin was the most likely second analgesic (50.0%). Third-line analgesics were scarce across sites and neuropathologies. Few national or regional differences were found. The analgesic preference rankings noted by the 95 international physicians who completed the survey matched the audits. However, self-reported analgesic prescription rates were much higher than pharmacy records indicate, with self-reported prescribing of both acetaminophen/paracetamol and opiates in 97% of patients and gabapentin in 45% of patients. Third-line analgesic variability appeared to be driven by neuropathology; ibuprofen was preferred for traumatic brain injury, postcraniotomy, and thromboembolic stroke patients, whereas gabapentin/pregabalin were favored in subarachnoid hemorrhage, intracranial hemorrhage, spine, demyelinating disease, and epileptic patients.

CONCLUSIONS

Opiates and acetaminophen are preferred analgesic agents, and gabapentin is a contextual third choice, in neurocritically ill patients. Other agents are rarely prescribed. The discordance in physician self-reports and objective audits suggest that pain management optimization studies are warranted.

Pathophysiology, assessment, and management of pain in critically ill adults

PURPOSE

The pathophysiology of pain in critically ill patients, the role of pain assessment in optimal pain management, and pharmacologic and nonpharmacologic strategies for pain prevention and treatment are reviewed.

SUMMARY

There are many short- and long-term consequences of inadequately treated pain, including hyperglycemia, insulin resistance, an increased risk of infection, decreased patient comfort and satisfaction, and the development of chronic pain. Clinicians should have an understanding of the basic physiology of pain and the patient populations that are affected. Pain should be assessed using validated pain scales that are appropriate for the patient's communication status. Opioids are the cornerstone of pain treatment. The use of opioids, administered via bolus dosing or continuous infusion, should be guided by patient-specific goals of care in order to avoid adverse events. A multimodal approach to pain management, including the use of regional analgesia, may improve patient outcomes and decrease opioid-related adverse events, though there are limited relevant data in adult critically ill patient populations. Nonpharmacologic strategies have been shown to be effective adjuncts to pharmacologic regimens that can improve patient-reported pain intensity and reduce analgesic requirements. Analgesic regimens need to take into account patient-specific factors and be closely monitored for safety and efficacy.

CONCLUSION

Acute pain management in the critically ill is a largely underassessed and undertreated area of critical care. Opioids are the cornerstone of treatment, though a multimodal approach may improve patient outcomes and decrease opioid-related adverse events.

Ten Myths and Misconceptions Regarding Pain Management in the ICU

OBJECTIVES

The aim of this article is to expose common myths and misconceptions regarding pain assessment and management in critically ill patients that interfere with effective care. We comprehensively review the literature refuting these myths and misconceptions and describe evidence-based strategies for improving pain management in the ICU.

DATA SOURCES

Current peer-reviewed academic journals, as well as standards and guidelines from professional societies.

STUDY SELECTION

The most current evidence was selected for review based on the highest degree of supportive evidence.

DATA EXTRACTION

Data were obtained via medical search databases, including OvidSP, and the National Library of Medicine's MEDLINE database via PubMed.

DATA SYNTHESIS

After a comprehensive literature review, conclusions were drawn based on the strength of evidence and the most current understanding of pain management practices in ICU.

CONCLUSIONS

Myths and misconceptions regarding management of pain in the ICU are prevalent. Review of current evidence refutes these myths and misconceptions and provides insights and recommendations to ensure best practices.

Mutual relationship between anxiety and pain in the intensive care unit and its effect on medications

PURPOSE

Little is known about the relationship between anxiety and pain in intensive care unit (ICU) patients despite its importance. The aims of the present study are to examine the correlation between pain and anxiety during ICU care and to investigate its effects on the dose of opioids and anxiolytics administered.

METHODS

The study subjects were awake critically ill patients admitted to an ICU over a 2-month period. Trained psychiatrists evaluated the nondelirious, noncomatose patients daily for anxiety and pain using the Numeric Rating Scale for Pain (NRS-Pain), Faces Anxiety Scale (FAS), and Hamilton Anxiety Rating Scale.

RESULTS

Daily alterations of anxiety and pain were significantly correlated with one another among 123 patients. Both the FAS and the Hamilton Anxiety Rating Scale were positively correlated with the NRS-Pain (P < .001 for both). The NRS-Pain score (P = .016) and the FAS score (P = .007) both significantly correlated with the dose of anxiolytics. The dose of opioids was unaffected by the severity of pain or anxiety.

CONCLUSIONS

Pain and anxiety among critically ill patients in the ICU were closely correlated. Pain and anxiety influenced the dose of anxiolytics administered. Therefore, a precise evaluation and comprehensive approach to the management of pain and anxiety are important for treating ICU patients.