PAD Launch Day - Ovakim

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Whats Pain Got To Do With It?

PAD Launch DayMarch 30, 2015

Daniel Ovakim, MD MSc FRCPCCritical Care Medicine, Royal Jubilee and Victoria General HospitalsIsland Health AuthorityMedical Toxicology, BC Drug and Poison Information CentreClinical Assistant Professor, Department of Medicine, UBCdaniel.ovakim@viha.ca

1Whats pain got to do with it?DisclosuresNone

2Toxicologic AntidotesOutlineCase based review of the assessment and treatment of pain in the adult ICUReview the presentation and management of excited deliriumWhats pain got to do with it?3Toxicologic AntidotesOutlineCase based review of the assessment and treatment of pain in the adult ICUReview the presentation and management of excited deliriumWhats pain got to do with it?4Mr. VE37M, multiple gun shot woundsHistory ofPolysubstance abuseChronic opioid useInjuriesBrachial artery laceration Right rib/lung/diaphragm injuriesPenetrating liver and bowel injuryToxicologic AntidotesWhats pain got to do with it?

Brachial artery laceration and repairMultiple rib fractures/flail segment on rightRight lower lobe lacerationRight Diaphragmatic rupturePenetrating injury to liver and ascending colonMultiple ORsMultiple complicationsSevere sepsisRhabdo and renal failure necessitating dialysisProlonged mechanical ventilation and tracheostomyHigh narcotic and sedative requirementsFast forward 3 weeks in hospitalAcute issues resolved Grade IV icuitis (CNS issues, VAP, intraabdominal drains, persistent fever/tachycardia)5Mr. VEMultiple (?8) trips to operating roomMultiple complicationsSevere sepsisRhabomyolysis (PRIS?)Acute kidney injury requiring dialysisHigh narcotic and sedative requirements

Toxicologic AntidotesWhats pain got to do with it?High narcotic and sedative requirements, thought to be reflective ofDependenceToleranceTachyphylaxis to some agents6Mr. VE (3 weeks later)Acute issues resolvedEscalating analgesic requirementsHydromorphone 7 mg po q4h scheduledHydromorphone 1-2 mg IV q1h PRNSwitched-on Tachy/HTN/FebrileReports of poor affect/motivationSevere, unremitting 10/10 abdominal pain

Toxicologic AntidotesWhats pain got to do with it?Fast forward 3 weeks in hospitalAcute issues resolved Grade IV icuitis (CNS issues, VAP, intraabdominal drains, persistent fever/tachycardia)Escalating pain requirementsOn 7 mg hydrmorphone IR q4h for pain, though patient not able to communicateNot cooperative, wont answer questions or follow commandsEventually wakes up and starts complaining of severe 10/10 abdominal painMultiple investigations/scansDespite negative investigations, continues to describe contain 10/10 pain

7Questions on roundsHow can we reliably assess this patients pain?Can we use his vital signs as an indication?Are there other therapeutic options?What about his mood?

Toxicologic AntidotesWhats pain got to do with it?Questions that came upHow can we reliably assess pain in this patientCan we use his vital signs hes constantly tachycardic/febrile/hypertensiveWhat is the best pain scale to use?Are there any other items on the differential

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Which of the following would be an appropriate next step towards managing his pain?https://www.polleverywhere.com/multiple_choice_polls/6B5s3QfC0zgJ2Q39

What is the most common IV analgesic used to treat acute pain in your ICU?https://www.polleverywhere.com/multiple_choice_polls/RPsozuwjSQZZ1BK10Pain in the ICUDefinitionsScope of the problemBarriersConsequencesAssessment toolsApproachIASPUnpleasant sensory and emotional experience associated with actual or potential tissue damageCan only be reported by the person experiencing it

Definition and backgroundPain: a unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (International Association for the Study of Pain)Key points: Subjective nature of pain; Can only be reported by the person experiencing itMost patients in ICU experience pain and identify it as a great source of stressAs well (as per IASP) the inability to communicate verbally does not negative the possibility that an individual experiencing pain and is in need of pain-relieving treatment)

11SCCM50% (or more) of ICU patientsMany types of painRest painSurgical/trauma/cancer painProcedural pain

DefinitionsScope of the problemBarriersConsequencesAssessment toolsApproach

Pain in the ICU

How big is the problemIncidicen of 50% (or higher) in both medical and surgical ICU patients (ref 61,62)Multiple types of painRest pain (61)Pain related to surgery, trauma, or cancerProcedural pain (68) i.e. local anesthetic to do a central line in an intubated patient

12DefinitionsScope of the problemBarriersConsequencesAssessment toolsApproachImpediments to pain reportingUnable to self report painAltered level of consciousnessMechanical ventilationSedation/NMBAPain in the ICU

Nurse!!My back hurts!!!!Inpediments to pain reporting (Why cant ICU patients report pain)Critically ill patients may be unable to self report their painAltered LOCMechanical ventilationSedation/NMBA

13DefinitionsScope of the problemBarriersConsequencesAssessment toolsApproachConsequences of unrelieved painInefficient sleep1Memories2Pain of ETTMost recount moderate to severe painPersist up to 6 monthsJones et al., Intensive care medicine, 1979; 5:89-92Gelinas, C. Crit Care Nurs, 2007; 23:298-303Pain in the ICU

Consequence of unrelieved painLeading cause of insufficient sleep (and hence prescription of more medications (72)Most patients remember pain of ETTMost remember experiencing moderated to severe pain in ICU (73)Persisted upto 6 months after their ICU stay (in ~ 1/3)Physiologic consequences of painEvokes a stress response that can have a variety of deleterious physiologic effectsIncreased circulating catecholamines (which can cause arteriolar vasoconstriction, impair tissue perfusion, and reduce tissue-oxygen deliveryCatabolic hypermetabolism HyperglycemiaLipolysisBreakdown of muscleImpaired wound healingImmune dysfunction (suppresses NK cell activity)

14DefinitionsScope of the problemBarriersConsequencesAssessment toolsApproachPhysiologic effectsIncreased circulating catecholaminesCatabolic hypermetabolismHyperglycemiaLipolysisMuscle breakdownPoor wound healingPain in the ICUUnresolved pain evokes a stress response that can have a variety of deleterious physiologic effectsIncreased circulating catecholamines (which can cause arteriolar vasoconstriction, impair tissue perfusion, and reduce tissue-oxygen deliveryCatabolic hypermetabolism HyperglycemiaLipolysisBreakdown of muscleImpaired wound healingImmune dysfunction (suppresses NK cell activity)

15DefinitionsScope of the problemBarriersConsequencesAssessment toolsApproachThe Ideal Pain AssessmentReproducible across disciplinesEnables monitoring over timeAssesses adequacy of interventionsEasily implemented and monitoredPain in the ICUAssessing pain in ICU patientsPrinciplesClinicians need to perform a reproducible pain assessmentMonitor pain over time Determine the adequacy of therapeutic interventionsImplementing behavioral pain scales improves both ICU pain management and clinical outcomes, including better use of analgesic and sedative agents, and shorter durations of mechanical ventilation and ICU stay

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Which of the following pain scales is used in your ICU?https://www.polleverywhere.com/multiple_choice_polls/3KKLqSE1ZMc3kg917DefinitionsScope of the problemBarriersConsequencesAssessment toolsApproachPain ScalesMost valid and reliableBehavioural Pain Scale Critical-care Pain Observation ToolUseful for all; except brain injuryDesigned for the followingUnable to self-reportIntact motor functionObservable behavioursPain in the ICUBehavioural pain scale (3-12 total score BPS)Critical Care Pain observation tool (0-8 total score CPOT)Most valid and reliable behavioiural pain scales for monitoring pain in medical, post-operative, or trauma patients) except for brain injured patients Who can use theseUnable to self-report (intubated, sedated)Intact motor fuctionObservable behavioursBoth BPS and CPOT have been successfully implemented following short training sessions.

18Pain the ICU

Score > 5 suggests significant pain Behavioural pain scale (3-12 total score BPS)Critical Care Pain observation tool (0-8 total score CPOT)Most valid and reliable behavioiural pain scales for monitoring pain in medical, post-operative, or trauma patients) except for brain injured patients Who can use theseUnable to self-report (intubated, sedated)Intact motor fuctionObservable behavioursBoth BPS and CPOT have been successfully implemented following short training sessions.

19DefinitionsScope of the problemBarriersConsequencesAssessment toolsApproachPain assessment in the real worldConfirm the presence of painVital signs as a trigger to perform assessment?Routine BPS assessment? How often?Consider etiologyIndividualized treatment Post-treatment assessmentFrequent reassessment

Pain in the ICUEvery patient is different what ever approach works for one patient not work for anotherShould assessment be part of routine patient assessment, and if so, how often. Can vital signs be used certainly can provide clues that there may be pain, but little correlation between changes in Vitals and reports of pain. Consider the etiology may help indiviualize pain is it realted to rib fractures or chest tube (suggesting an NSAID or gabapentin may be helpful), or is it due to chronic pain, or post-surgical pain, is it in anticipation of a procedure such as a dressing changeImportant to redo the scale a short time after a drug is given but how long after IV? How long after PO? Need to know the dispositional characteristics of the drugs. 20Back to Case 137M, multiple gun shot woundsPersistent 10/10 abdominal painUnresponsive to narcoticsWhat worked for him?Scaled back regular hydromorphone to 2 mg q4hStopped routine bowel careAggressive mobilizationDramatic response to trial of methylphenidate (Ritalin)Pain in the ICUStarted methylphenidate able to focus on other things other than pain21Toxicologic AntidotesOutlineCase based review of the assessment and treatment of pain in the adult ICUReview the presentation and management of excited deliriumWhats pain got to do with it?

22Mr. WF

41M, suicide attempt after romantic crisisVoluntary ingestion of 6500 mg bupropion XL, and self-injection of 3 epi-pensAcutely agitated, disoriented, aggressiveMidazolam x 50 mg in ER and infusion in ICURemained extremely agitatedPhysically restrainedToxicologic AntidotesWhats pain got to do with it?23

Which of the following would be an appropriate next step in managing this patient?https://www.polleverywhere.com/multiple_choice_polls/3Fo5CF1VPJN26ZO24Mr. WF

Received bolus doses of propofolSettled in am after MDZ turned offSevere rhabdomyolysisCK > 45,000Started isotonic fluid hyper-hydrationConsequence?Complication?

Toxicologic AntidotesWhats pain got to do with it?

25Excited Delirium (ExDS)DefinitionsPathophysiologyClinical FeaturesCausesComplicationsManagementExcited (Agitated) DeliriumDelirium involving violent behaviourAssociated withDrug intoxication (or withdrawal)Psychiatric illnessClassically a forensic diagnosisSCD in police custodyNo evidence of injury of diseaseDebatable existence and definition

26Excited Delirium (ExDS)DefinitionsPathophysiologyClinical FeaturesCausesComplicationsManagementComplex and poorly understoodLikely involves excessive striatal dopamine stimulationDeath usually as a result of SCD in the setting of severe acidosis

Debatable existence and definition

27Excited Delirium (ExDS)DefinitionsPathophysiologyClinical FeaturesCausesComplicationsManagementMinimal featuresDelirium (traditional definition)Excitation/AgitationSympathetic hyperactivityTachycardia/tachypneaHypertension (late hypotension)Hyperthermia (may be > 41oC)Rhabdomyolysis

Excitation/AgitationSuperhuman strengthImpervious to painDiaphoreticHallucination/yelling/Disrobin/yelling/Nonsensical speech, callng out, Abnorabl erratic heaviour

28Excited Delirium (ExDS)DefinitionsPathophysiologyClinical FeaturesCausesComplicationsManagementPre-terminal featuresPeriod of tranquility/sudden calmSudden collapse while restrainedRespiratory arrestStress-induced cardiomyopathy in survivors

Debatable existence and definition

29Excited Delirium (ExDS)DefinitionsPathophysiologyClinical FeaturesCausesComplicationsManagementTwo main causesDrug intoxication/withdrawalPsychiatric illness

Debatable existence and definition

30Excited Delirium (ExDS)DefinitionsPathophysiologyClinical FeaturesCausesComplicationsManagementTwo main causesDrug intoxication/withdrawalEthanol/BenzodiazepinesSympathomimetic agentsAnticholinergic agentsPsychiatric illness

Ethanol intoxication/withdrawalSympathomimetic agents cocaine/meth/bath salts/bupropion/methylphenidateHallucinogens/dissociative agents: PCP, ketamine, LSDAnticholinergic drugs: Benadryl/Gravol/Jimson weed31Excited Delirium (ExDS)DefinitionsPathophysiologyClinical FeaturesCausesComplicationsManagementTwo sourcesExDS itselfManagement

Debatable existence and definition

32Excited Delirium (ExDS)DefinitionsPathophysiologyClinical FeaturesCausesComplicationsManagementTwo sourcesExDS itselfSCD acidosis/catecholaminesRhabdomyolysisComplications due to hyperthermiaManagement

Debatable existence and definition

33Excited Delirium (ExDS)DefinitionsPathophysiologyClinical FeaturesCausesComplicationsManagementTwo sourcesExDS itselfManagementPhysical restraintsTherapiesHypotensionDownstream deliriumTherapeutic inertia

Debatable existence and definitionTherapeutic intertia: Failure to recognize when chemical and physican restraints are no longer protecting the patient and that aggressive sedatin/intubation are required.

34Excited Delirium (ExDS)DefinitionsPathophysiologyClinical FeaturesCausesComplicationsManagementGoal: Minimize physical struggleAggressive chemical sedationPhysical restraint as neededAggressive cooling (?NMBA)Treat acidosis and hypovolemiaTwo sources Aggressive Chemical SedadddtionPhysical restraint: Use only as needed to ensure the safety of the staff and patient needs to be done in conjunction with number 1. If there are physically restrained and still figthing against the restraints, then the chemical sedation is NOT sufficient. Physical struggle is a much greater contributor to the catecholamine surge than any drug or withdrawal that the may be experiencing. These patients are usually dry thus all should receive fluid resuscitation

Al

35Excited Delirium (ExDS)DefinitionsPathophysiologyClinical FeaturesCausesComplicationsManagementPhysical restraint: Use only as needed to ensure the safety of the staff and patient needs to be done in conjunction with number 1. If there are physically restrained and still figthing against the restraints, then the chemical sedation is NOT sufficient....