Acute Pain
in ICUs

Dr James Sartain FANZCA, FRCA
Cairns Base Hospital
Recently in our ICU…
1. 54 yo man with severe CAP
- Frowning, moving, coughing, straining
- On fentanyl 50 ug/h + midazola...
Recently in
Critical Care Medicine…

January 2013; 41: 263-306
Acute Pain in ICUs
ACCCM PAD Guidelines 2013
1. ‘We recommend that pain be routinely
monitored in adult ICU patients’ (+1B...
However…
• Pain is not assessed formally
in 35-50% of US and
Australian ICUs
(eg Hewson-Conroy 2011; Barr et al CCM 2013)
...
Why is pain in ICU discounted?
- a straw poll of views
• ‘There are more important issues’
• ‘Treating pain causes side ef...
Are the ACCCM guidelines wrong?
Or is it a case of:

• ‘If you don’t take a temperature,
you can’t find a fever’
Shem S 19...
Impact of an APS
Sartain and Barry AIC 1999
Major surgery
Before APS
(n=110)
After APS
(n=144)
P value

Severe
rest pain

...
Impact of an APS
-Sequential Pain Outcomes
Sartain and Barry 1999; APS database
Acute Pain in ICUs
ACCCM PAD Guidelines - CCM 2013
Level B (moderate) evidence:

• Acute Pain is common in ICUs
 ETT
 wo...
ETT pain in ICUs
Rotondi et al CCM 2002
– 150 patients ventilated ≥ 48 hours
– Interviewed after ICU discharge
– 50% remem...
Pain and PTSD post ICU
Granja et al CCM 2008
• 599 ICU survivors 6/12 post discharge
• 313 respondents to questionnaire
• ...
Acute Pain in ICUs
ACCCM PAD Guidelines 2013
Level B (moderate) evidence:

• Assessing and treating pain is
associated wit...
Impact of evaluation of pain and
agitation in an ICU
Chanques et al CCM 2006
• Pre- and post- study of 230 patients
• tds ...
Protocolized ICU management of
analgesia, sedation and delirium
Skrobik et al Anesth Analg 2010
• Pre- and post- study of ...
But are we just better?
-Sedation protocols in Aussie ICUs
• Elliott R et al Int Care Med 2006
– 322 patients, before and ...
It seems fair to assess and treat
ACCCM PAD Guidelines 2013
• Routinely monitor pain
• Self report if possible (eg by NRS#...
NRS-V in ICU patients
Chanques et al Pain 2010
Critical Care Pain Observation Tool (CPOT)
Gelinas et al 2006
Indicator

Description

Score

1. Facial expression

Nil
Fro...
Case history 1
54 yo man with severe CAP
- Frowning, moving, coughing, straining
- On fentanyl 50ug/h+ midazolam
5mg/h
• F...
Effect of sedation on pain perception
Frolich et al Anesthesiology 2013

Dexmed

Midaz

Propofol
Benzodiazepine vs non-benzo sedation for
mechanically ventilated adults
Fraser et al CCM 2013

Mechanical ventilation:
Non...
Case history 1
54 yo man with severe CAP
- Frowning, moving, coughing
- On fentanyl + midazolam
∀ ↑ and/or change IV opioi...
Case history 2
67 yo woman with recovering GBS
- Grimacing/tears with passive physio
- on oxycodone and paracetamol

• Fir...
Gabapentin and carbamazepine for GBS
Pandey et al Anesth Analg 2005
• 36 ventilated ICU patients with GBS
• Gaba 300mg tds...
Case history 2
2. 67 yo woman with recovering GBS
- Grimacing/tears with passive physio
- on oxycodone and paracetamol
• A...
Case history 3
22 yo man with rib and pelvic #s
- Severe pain despite PCA fentanyl
- For pelvic # surgery

• First, quanti...
Case history 3
22 yo man with rib and pelvic #s
Consider:
• morphine/oxycodone for fentanyl
• Regular paracetamol
• Ketami...
ACCCM PAD Guidelines 2013
• Pain should be routinely assessed
• NRS or BPS/CPOT
• Treat if NRS ≥4/10, CPOT ≥3/8 and
before...
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James Sartain on Acute Pain in ICUs #BCC4

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"If you don't take a temperature, you can't find a fever...(The House of God)" James Sartain cleverly uses case studies to highlight attitudes, issues and management of acute pain in ICUs. He'll make you think as he uncovers the discrepancies between guidelines and clinical practice. This podcast was recorded at BCC4.

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  • Is this a pain problem or not? What would you do?
    Tracheostomy, breathing spontaneously
    Previous intubated. 4 days since injury, surgery tomorrow.
  • Acute pain management is contentious in ICUs
    Is this correct, or does it fit with the philosophy in the House of God?
  • Pre-loading, regular assessment, patient education, staff education
  • 1st point about the guidelines wrt pain is the claim that it is common in ICUs
  • And it’s not hard to find evidence to substantiate that.
  • It also appears that patients have long memories of ICU pain
    Humanitarian grounds it seems reasonable to treat pain in ICU
  • The 2nd point is the claim that assessing and treating pain is associated with a range of benefits in addition to relief of pain and suffering.
  • French study
    Richmond agitation sedation scale
  • Canadian study
  • Elliott – RNSH Sydney
    Already using a sedation scale before introduction of the algorithm; increased sedation after. (Ramsay quality score 7.7/20; SAS 16.5/20; Richmond Agitation Sedation Scale 19/20)
    Bucknall – RMH Melbourne
    Copying what they are doing in the patient next door.
    Neither specifically assess pain.
  • So it seems at least reasonable that we should attempt to assess pain, and treat it if present.
  • Not only may benzo sedation be antalgesic (cf analgesic), but benzos are associated with higher incidence of delirium and prolonged ventilator stay.
  • James Sartain on Acute Pain in ICUs #BCC4

    1. 1. Acute Pain in ICUs Dr James Sartain FANZCA, FRCA Cairns Base Hospital
    2. 2. Recently in our ICU… 1. 54 yo man with severe CAP - Frowning, moving, coughing, straining - On fentanyl 50 ug/h + midazolam 5mg/h 2. 67 yo woman with recovering GBS - Grimacing/tears with passive physio - on oxycodone and paracetamol 3. 22 yo man with rib and pelvic #s - Severe pain despite PCA fentanyl - For pelvic # surgery
    3. 3. Recently in Critical Care Medicine… January 2013; 41: 263-306
    4. 4. Acute Pain in ICUs ACCCM PAD Guidelines 2013 1. ‘We recommend that pain be routinely monitored in adult ICU patients’ (+1B)* (*strongly in favour; moderate quality evidence)
    5. 5. However… • Pain is not assessed formally in 35-50% of US and Australian ICUs (eg Hewson-Conroy 2011; Barr et al CCM 2013) because • ‘It’s not a problem’ (Wenck D 2013, personal communication)
    6. 6. Why is pain in ICU discounted? - a straw poll of views • ‘There are more important issues’ • ‘Treating pain causes side effects’ • ‘It’s hard to assess’ • ‘No one ever died of pain’ • ‘The nurses do what they want anyway’ • ‘We do ICU better here’ (in our unit; in Brisbane; in Australia etc)
    7. 7. Are the ACCCM guidelines wrong? Or is it a case of: • ‘If you don’t take a temperature, you can’t find a fever’ Shem S 1978 (House of God)
    8. 8. Impact of an APS Sartain and Barry AIC 1999 Major surgery Before APS (n=110) After APS (n=144) P value Severe rest pain Severe movement pain 18.2% 50.0% 3.5% 31.1% 0.0002 0.0037
    9. 9. Impact of an APS -Sequential Pain Outcomes Sartain and Barry 1999; APS database
    10. 10. Acute Pain in ICUs ACCCM PAD Guidelines - CCM 2013 Level B (moderate) evidence: • Acute Pain is common in ICUs  ETT  wounds and fractures  procedures: tracheal suction, turning, wound care, drain and line insertion, chest drain removal
    11. 11. ETT pain in ICUs Rotondi et al CCM 2002 – 150 patients ventilated ≥ 48 hours – Interviewed after ICU discharge – 50% remembered ETT in situ – ETT pain average 6/10 (IQR 4,8) worst 8/10 (6,10) – ETT pain moderate to extreme 41%
    12. 12. Pain and PTSD post ICU Granja et al CCM 2008 • 599 ICU survivors 6/12 post discharge • 313 respondents to questionnaire • Severe pain recalled in 17% • PTSD high-risk score in 18%
    13. 13. Acute Pain in ICUs ACCCM PAD Guidelines 2013 Level B (moderate) evidence: • Assessing and treating pain is associated with:     ↓ ventilator days ↓ morbidity ↓ ICU LOS and ↓ mortality
    14. 14. Impact of evaluation of pain and agitation in an ICU Chanques et al CCM 2006 • Pre- and post- study of 230 patients • tds pain (NRS, BPS) and agitation (RASS) observations and treatment protocol ∀ ↓ severe pain (36% vs 16%, p<0.001) ∀ ↓ agitation (18% vs 5%, p=0.002) ∀ ↓ ventilator time (120 vs 65h, p=0.01) ∀ ↓ nosocomial infections (17% vs 8%, p<0.05)
    15. 15. Protocolized ICU management of analgesia, sedation and delirium Skrobik et al Anesth Analg 2010 • Pre- and post- study of 1214 patients • 8-hourly assessments of pain, sedation and delirium • Individualised prescriptions with instructions • APACHE II 17.1 pre- vs 18.1 post- (p=0.03) ∀ ↓ ICU LOS (6.3 to 5.3d, p=0.009) ∀ ↓ ventilator time (7.5 to 5.9d, p=0.01) ∀ ↓ mortality (29.4% vs 22.9%, p=0.009)
    16. 16. But are we just better? -Sedation protocols in Aussie ICUs • Elliott R et al Int Care Med 2006 – 322 patients, before and after study – Sedation algorithm (existing Ramsay scale) – 1day ↑ duration ICU stay! (p=0.04) • Bucknall T et al CCM 2008 – – – – 312 patients, randomised unblinded study Sedation agitation scale and protocol vs none Propofol use 83% in both groups No effect We just don’t know, so…
    17. 17. It seems fair to assess and treat ACCCM PAD Guidelines 2013 • Routinely monitor pain • Self report if possible (eg by NRS#) • Otherwise use BPS* or the CPOT** • Treat if NRS ≥ 4/10 or CPOT ≥ 3/8 Numerical Rating Scale *Behavioural Pain Scale **Critical Care Pain Observation Tool #
    18. 18. NRS-V in ICU patients Chanques et al Pain 2010
    19. 19. Critical Care Pain Observation Tool (CPOT) Gelinas et al 2006 Indicator Description Score 1. Facial expression Nil Frowning Tightly shut eyes Relaxed 0 Tense 1 Grimacing 2 2. Body movements Observed activity Absent 0 Protection 1 Restless 2 3. Muscle tension Test with passive limb movements Relaxed 0 Tense 1 Rigid 2 4. Ventilator Compliance Intubated patients Tolerating 0 Coughing 1 Fighting 2 or Extubated patients Normal 0 Moaning 1 Crying out 2 Vocalisation
    20. 20. Case history 1 54 yo man with severe CAP - Frowning, moving, coughing, straining - On fentanyl 50ug/h+ midazolam 5mg/h • First, assess his pain by CPOT score • Treat as ≥ 3/8 ∀↑ and/or change IV opioids (tolerance)
    21. 21. Effect of sedation on pain perception Frolich et al Anesthesiology 2013 Dexmed Midaz Propofol
    22. 22. Benzodiazepine vs non-benzo sedation for mechanically ventilated adults Fraser et al CCM 2013 Mechanical ventilation: Non-benzo strategy shorter by 1.9 days (p<0.00001)
    23. 23. Case history 1 54 yo man with severe CAP - Frowning, moving, coughing - On fentanyl + midazolam ∀ ↑ and/or change IV opioids • Consider sedative change to dexmedetomidine or propofol
    24. 24. Case history 2 67 yo woman with recovering GBS - Grimacing/tears with passive physio - on oxycodone and paracetamol • First, assess pain with NRS or CPOT (or trial of treatment)
    25. 25. Gabapentin and carbamazepine for GBS Pandey et al Anesth Analg 2005 • 36 ventilated ICU patients with GBS • Gaba 300mg tds vs carbamaz 100mg tds vs placebo Pain Day 0 (0-10) Pain Day 1 Pain Day 3 Sedation Fentanyl Day 1 Day 3 (ug/d) (1-6) Gabapentin 8 3.5 2 2 p<0.05 p<0.05 p<0.05 149 p<0.05 Carbamaz 8 6 5 3 212 Placebo 8 6 6 4 379
    26. 26. Case history 2 2. 67 yo woman with recovering GBS - Grimacing/tears with passive physio - on oxycodone and paracetamol • Add gabapentin/pregabalin (pregabalin 75mg bd to 300mg bd) ∀ ± tramadol ∀ ± Targin for oxycodone
    27. 27. Case history 3 22 yo man with rib and pelvic #s - Severe pain despite PCA fentanyl - For pelvic # surgery • First, quantify pain with NRS
    28. 28. Case history 3 22 yo man with rib and pelvic #s Consider: • morphine/oxycodone for fentanyl • Regular paracetamol • Ketamine infusion (0.1mg/kg/hour) • Gabapentinoids • Epidural after surgery
    29. 29. ACCCM PAD Guidelines 2013 • Pain should be routinely assessed • NRS or BPS/CPOT • Treat if NRS ≥4/10, CPOT ≥3/8 and before procedures • IV opioids ± non-opioids • Consider non-benzo sedation • Gabapentinoids for neuropathic pain • Consider epidural for specific situations

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