Structured Approaches to Pain Management in the ICU

Pain Management Educator and Clinical Consultant, 1252 Clearview Dr, El Dorado Hills, CA 95762, USA.
Chest (Impact Factor: 7.48). 07/2009; 135(6):1665-72. DOI: 10.1378/chest.08-2333
Source: PubMed


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 Outdated clinical practices and faulty systems, such as a formulary that allows dangerous prescriptions, present additional obstacles.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.

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    • "About controlling pain in ICU patients, Tittle's results indicated that ICU nurses inject only 30% of the maximum ordered dosage of analgesics drugs (14). In general, infusion of analgesics drugs is not sufficient (2), which means that in spite of decades of researches and guidelines distribution, pain cannot be treated completely in patients with critical illness (15). "
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    ABSTRACT: Background:Estimating pain in patients of intensive care unit (ICU) is essential, but because of their special situation, verbal scales cannot be used. Therefore, to estimate the level of pain, behavioral pain scale was developed by Payen in 2001.Objectives:The aim of this study was to investigate the validity and reliability of behavioral pain scale in patients with low level of consciousness due to head trauma hospitalized in ICU.Patients and Methods:This descriptive prospective study was performed in Yazd in 2013. In this study, fifty patients, including thirteen women and thirty seven men, were involved. To collect the data a questionnaire including demographic and Glasgow coma scale (GCS) information as well as a list of behavioral pain scale (BPS) were used. SPSS software (version 18) was used to analyze the data.Results:There was no significant difference in reliability proving of average score of BPS recorded by two day and night assessors (P > 5). Cronbach’s alpha was 85 for painful procedures and 76 for non-painful procedures. In addition, known groups’ technique (painful and non-painful procedures) was used to assess validity. The average scores were 7.75 during painful procedures and 3.28 during non-painful procedures (P = 0.001). The results stated that BPS scores during these two procedures were significantly different.Conclusions:BPS in patients with low level of consciousness due to head trauma has strong reliability and validity. Therefore, this scale can be used for patients hospitalized in ICU to assess the level of pain.
    Full-text · Article · Mar 2014
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    • "Indeed, myalgia and arthralgia are common clinical features associated with sepsis and fever [53], partly because of inflammation and muscle hypercatabolism induced by thermogenesis [54]. Inflammatory cytokines and sympathetic amines are associated with a nociceptive state associated with inflammation and sepsis [55,56]. "
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    ABSTRACT: The recently published Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit differ from earlier guidelines in the following ways: literature searches were performed in eight databases by a professional librarian; psychometric validation of assessment scales was considered in their recommendation; discrepancies in recommendation votes by guideline panel members are available in online supplements; and all recommendations were made exclusively on the basis of evidence available until December of 2010. Pain recognition and management remains challenging in the critically ill. Patient outcomes improve with routine pain assessment, use of co-analgesics and administration as well as dose adjustment of opiates to patient needs. Thoracic epidurals help ease patients undergoing abdominal aortic surgery. Little data exists to guide clinicians as to the type or dose of co-analgesics; no opiate choice is associated with better patient outcomes. Lighter or no sedation is beneficial, and interruption is desirable in patients who require deep sedation for specific pathologic states. Delirium screening is probably useful; no treatment modality can be unequivocally recommended, and the benefit of prophylaxis is established only for early mobilization. The details of these recommendations, as well as more recent publications that complement the guidelines, are provided in this commentary.
    Full-text · Article · Apr 2013 · Annals of Intensive Care
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    • "Given the range of barriers to effective management of pain in the ICU setting, structured approaches may improve ICU pain treatment [60]. Suggestions include involvement of an interdisciplinary team to develop an improvement process, implementation of tools, such as clinical paths and checklists, incorporation of analgesic management approaches within electronic health records and computerized provider order entry systems, and referrals for specialist input on particularly challenging cases [60], Clinicians on the ICU team should have basic knowledge of equianalgesic opioid dosing; this information is easily incorporated in computer-based ordering systems and/or on pocket cards for clinicians [61]. In addition, recognition and proactive management of common side effects of opioid treatment are important competencies for critical care practice. "
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    ABSTRACT: With newer information indicating more favorable outcomes of intensive care therapy for lung cancer patients, intensivists increasingly are willing to initiate an aggressive trial of this therapy. Concerns remain, however, that the experience of the intensive care unit for patients with lung cancer and their families often may be distressing. Regardless of prognosis, all patients with critical illness should receive high-quality palliative care, including symptom control, communication about appropriate care goals, and support for both patient and family throughout the illness trajectory. In this article, we suggest strategies for integrating palliative care with intensive care for critically ill lung cancer patients. We address assessment and management of symptoms, knowledge and skill needed for effective communication, and interdisciplinary collaboration for patient and family support. We review the role of expert consultants in providing palliative care in the intensive care unit, while highlighting the responsibility of all critical care clinicians to address basic palliative care needs of patients and their families.
    Full-text · Article · Feb 2012 · Annals of Intensive Care
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