james sartain on acute pain in icus #bcc4

Dr James Sartain FANZCA, FRCA Cairns Base Hospital

Acute Pain in ICUs

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

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)*

(*strongly in favour; moderate quality evidence)

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)

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)

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)

Impact of an APS Sartain and Barry AIC 1999

Major surgery Severe rest pain

Severe movement pain

Before APS (n=110)

18.2% 50.0%

After APS (n=144)

3.5% 31.1%

P value 0.0002 0.0037

Impact of an APS -Sequential Pain OutcomesSartain 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 wounds and fractures procedures: tracheal suction,

turning, wound care, drain and line insertion, chest drain removal

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%

Pain and PTSD post ICUGranja 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%

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

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)

Protocolized ICU management of analgesia, sedation and deliriumSkrobik 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)

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…

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

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 NilFrowningTightly shut eyes

Relaxed 0Tense 1

Grimacing 2

2. Body movements Observed activity Absent 0Protection 1Restless 2

3. Muscle tension Test with passive limb movements

Relaxed 0Tense 1Rigid 2

4. Ventilator Compliance

or

Vocalisation

Intubated patients

Extubated patients

Tolerating 0Coughing 1Fighting 2

Normal 0Moaning 1

Crying out 2

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)

Effect of sedation on pain perception Frolich et al Anesthesiology 2013

Dexmed Midaz Propofol

Benzodiazepine vs non-benzo sedation for mechanically ventilated adultsFraser et al CCM 2013

Mechanical ventilation:Non-benzo strategy shorter by 1.9 days (p<0.00001)

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

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)

Gabapentin and carbamazepine for GBSPandey 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)

PainDay 1

Pain Day 3

Sedation Day 1

(1-6)

Fentanyl Day 3 (ug/d)

Gabapentin 8 3.5p<0.05

2p<0.05

2p<0.05

149p<0.05

Carbamaz 8 6 5 3 212

Placebo 8 6 6 4 379

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

Case history 322 yo man with rib and pelvic #s

- Severe pain despite PCA fentanyl

- For pelvic # surgery

• First, quantify pain with NRS

Case history 322 yo man with rib and pelvic #s

Consider:

• morphine/oxycodone for fentanyl

• Regular paracetamol

• Ketamine infusion (0.1mg/kg/hour)

• Gabapentinoids

• Epidural after surgery

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