Structured Approaches to Pain Management in the ICU

Pasero, Chris; Puntillo, Kathleen; Li, Denise; Mularski, Richard A.; Grap, Mary Jo; Erstad, Brian L.; Varkey, Basil; Gilbert, Hugh C.; Medina, Justine; Sessler, Curtis N.

doi:10.1378/chest.08-2333

Cited by 75 publications

(52 citation statements)

References 71 publications

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“…Pasero, Puntillo, Li et al (2009) discovered some barriers towards pain management, e.g. knowledge deficits and communication difficulties [29] . Strategies for continuous quality improvement must focus on the individual ICU to overcome knowledge deficits, e.g.…”

Section: Discussionmentioning

confidence: 99%

Influence of clinical practice guidelines on pain management in german intenive care units – A state wide survey

Gnass

Nimako-Doffour²,

Meyer³

2013

Clinical Nursing Studies

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Systematic pain assessment in critically ill patients might reduce the number of days with mechanical ventilation as well as the length of hospital stay. Clinical practice guidelines recommend the use of standardized instruments as part of a structured pain assessment strategy for mechanically ventilated patients in intensive care units. Since it is unknown whether clinicians adhere to the recommendations, we conducted a survey focusing the main recommendation of pain and sedation assessment for critically ill patients with mechanical ventilation. A questionnaire consisting of eight items was developed, piloted and sent out to 457 intensive care units in North Rhine-Westphalia, Germany. Nursing directors were asked to forward the questionnaire to the ward nurses or the physicians in charge of the intensive care units. The response rate was 37.4% (n=171). Nurses from 68 out of 171 intensive care units indicated the use of a pain assessment tool; identified as n=39 used self-reporting tools or n=29 proxy rating tools; n=88 answered to use sedation assessment tools. A total of 801 physiological parameters for pain assessment were stated, most often blood pressure (19.5%), heart rate (18.6%), body language (16.7%), and respiratory rate (16.0%). Although recommended in the guidelines, our survey indicates that pain assessment tools are rarely used at German intensive care units. It remains unclear how nurses and physicians use pain assessment tools in combination with other parameters for systematic pain assessment. Further research is needed on the barriers of guideline implementation to intensive care units.

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Section: Discussionmentioning

confidence: 99%

Influence of clinical practice guidelines on pain management in german intenive care units – A state wide survey

Gnass

Nimako-Doffour²,

Meyer³

2013

Clinical Nursing Studies

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“…However, pain may also be caused or worsened by routine medical procedures, nursing care, or by the ICU environment itself [2]. Many ICU patients also suffer from chronic pain prior to their ICU admission [8].…”

Section: Causes Of Pain On Icu and Its Under-recognition (Table 2)mentioning

confidence: 99%

Unrecognised, undertreated, pain in ICU—Causes, effects, and how to do better

Alderson¹,

McKechnie²

2013

OJN

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Methods: a literature review from 1990 to August 2012. Introduction: pain and its recognition can be a particular problem for patients in intensive care units (ICUs). Studies have suggested that around 70% of ICU patients have unrecognised or undertreated pain. Pain has serious physical and psychological effects, and can impair patient recovery and discharge. Pain relief is also an ethical and professional responsibility of doctors and nurses-and we may be failing in this. Causes: pain may be due to medical and nursing procedures, and the ICU environment. Pain can be under-recognised because ICU patients are often impaired in their ability to communicate (e.g. secondary to confusion from acute illness, endotracheal intubation, or reduced conscious level from sedative agents). Tools for pain assessment: in patients able to communicate verbally, the Numerical Rating Scale (NRS) can be used to rate pain severity. In non-verbal, conscious, patients, the Visual Analogue Scale (VAS) can be used as a visual alternative. Both are well-established. For unconscious/sedated patients, the Behavioural Pain Scale (BPS) and Critical Care Pain Observation Tool (CPOT) have been developed and validated. Changes in practice: where possible, sedation practice can be changed to allow better recognition of pain. Constant deep sedation can be interrupted with daily "sedation holds" to allow pain assessment. "Analgo-sedation" may also be used, with drug regimes which prioritise analgesia over sedation. "No-sedation" approaches may also be considered, but further research is required.

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“…Administering medications PRN has been found to be less effective when treating acute or postoperative pain. 27 Using this strategy in the context of acetaminophen, however, may increase the risk of exceeding the safe dosing threshold by as much as an order of magnitude. Indeed, a typical regimen for extra-strength acetaminophen-1 g scheduled every 6 hours-allows no room for error in timing of acetaminophen administration.…”

Section: Commentmentioning

confidence: 99%