"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.

1. Acute Pain
in ICUs
Dr James Sartain FANZCA, FRCA
Cairns Base Hospital

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. Recently in
Critical Care Medicine…
January 2013; 41: 263-306

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. 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. 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. 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. 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. Impact of an APS
-Sequential Pain Outcomes
Sartain and Barry 1999; APS database

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. 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. 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. 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. 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. 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. 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. 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. NRS-V in ICU patients
Chanques et al Pain 2010

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. 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. Effect of sedation on pain perception
Frolich et al Anesthesiology 2013
Dexmed
Midaz
Propofol

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. 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. 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. 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. 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. 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. 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. 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