American Society of Regional Anesthesia and Pain Medicine November 2017 - 31

A Review of Pain Management in the Intensive Care Unit

P

ain in critically ill patients is often underdiagnosed and
undertreated. In this population, there are many potential
barriers to pain recognition and management. Untreated and
undertreated pain is distressing for patients, family members, and
caregivers; in addition, neglected pain may contribute to increased
morbidity and mortality.
Assessment of pain in the intensive care unit (ICU) can be difficult;
many critically ill patients cannot communicate their discomfort
because of intubation, sedation, or cognitive impairment. However,
in its "Clinical Practice Guidelines for the Management of Pain,
Agitation and Delirium in Adult Patients in the Intensive Care Unit,"
the Society of Critical Care Medicine (SCCM) recommends that pain
be routinely monitored in all adult ICU patients.
Unfortunately, it is difficult to estimate the incidence of pain in critically
ill patients because pain assessment tools and protocols for the
management of pain are rarely applied. A Canadian study of 51 ICUs
found that less than 20% of ICUs used pain assessment tools and only
25% of ICUs used pain protocols. A separate multicenter observational
study found that 90% of patients in the ICU were being actively treated
with opioids whereas only 42% had undergone a pain assessment.
Similarly, Payen et al
reported that pain was
not assessed in 53% of
patients who were receiving
analgesia, and when pain
was assessed, specific pain
tools were used only 28% of
the time.1-3

Jagan Ramamoorthy, MD
Assistant Professor
Medical Director of
Cardiothoracic ICU
Department of Anesthesiology
University of Wisconsin, Madison
Madison, Wisconsin

Noreen E. Murphy, MD
Fellow in Critical Care Medicine
University of Wisconsin, Madison
Madison, Wisconsin

Section Editor: Kristopher Schroeder

viewed worldwide
as poor medicine,
unethical practice,
and an abrogation
of a fundamental
human right."8 FaberLangendoen et al wrote,
"Many believe the
obligation of clinicians
to tend to patients'
suffering is the essence of the medical profession." In addition to
the ethics of pain management, medical outcomes are improved
when pain is optimally managed.9

"It is difficult to estimate the incidence of
pain in critically ill patients because pain
assessment tools and protocols for the
management of pain are rarely applied."

However, studies have
aimed to quantify the incidence of pain in critically ill patients. We
know from prospective descriptive studies that the presence of
an endotracheal tube has been reported as a constant source of
discomfort at rest and that routine procedures-such as tracheal
suctioning, position changes, and line removal-cause pain.4 One
study suggested that pain is frequent with an incidence of 50% in
medical and surgical patients at rest and 80% during common care
procedures.5 Another study showed similar results when patients
recently discharged from the ICU were interviewed about their pain
during hospitalization. Nearly 50% of patients reported recall of
pain during their ICU stay. Fifteen percent of ICU patients reported
extremely severe pain or moderately severe pain occurring at
least half the time. Not surprisingly, nearly 15% of patients were
dissatisfied with pain control during their ICU stay.6 Another study
showed that 63% of patients received no analgesics before or
during painful procedures.7
WHY SHOULD WE CARE?
In the article "Pain Management: A Fundamental Human Right,"
Brenan et al wrote, "Unreasonable failure to treat pain is

Pain assessment in patients on mechanical ventilation has been
independently associated with a decrease in hypnotic drug dosing,
duration of mechanical ventilation, and duration of ICU stay.10 Pain
contributes to hypoventilation and reduced cough, which increases
atelectasis and sputum retention. These mechanisms are thought
to be responsible for the increased rate of ventilator-associated
pneumonia (VAP) in patients who are not routinely assessed for
pain. Payen et al demonstrated decreased risk of VAP in patients
routinely assessed and treated for pain.10 Chanques et al validated
those findings when they reported significantly decreased risk of
VAP and duration of mechanical ventilation when pain was routinely
assessed and treated.11 Without using validated pain assessment
tools and protocols, patients in the ICU are often managed
inappropriately with sedation medications. Continuous sedation,
titrated to a light level and with daily sedation interruptions,
has been associated with an increased duration of mechanical

American Society of Regional Anesthesia and Pain Medicine
2017

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