Chronic pain in survivors of critical illness: a retrospective analysis of incidence and risk factors

Meeting complex multidimensional needs in older patients and their families during and beyond critical illness

PURPOSE OF REVIEW

To highlight the emerging crisis of critically ill elderly patients and review the unique burden of multidimensional morbidity faced by these patients and caregivers and potential interventions.

RECENT FINDINGS

Physical, psychological, and cognitive sequelae after critical illness are frequent, durable, and robust across the international ICU outcome literature. Elderly patients are more vulnerable to the multisystem sequelae of critical illness and its treatment and the resultant multidimensional morbidity may be profound, chronic, and significantly affect functional independence, transition to the community, and quality of life for patients and families. Recent data reinforce the importance of baseline functional status, health trajectory, and chronic illness as key determinants of long-term functional disability after ICU. These risks are even more pronounced in older patients.

SUMMARY

The current article is an overview of the outcomes of older survivors of critical illness, putative interventions to mitigate the long-term morbidity of patients, and the consequences for families and caregivers. A multimodal longitudinal approach designed to follow patients for one or more years may foster a better understanding of multidimensional morbidity faced by vulnerable older patients and families and provides a detailed understanding of recovery trajectories in this unique population to optimize outcome, goals of care directives, and ongoing informed consent to ICU treatment.

The impact of musculoskeletal ill health on quality of life and function after critical care: a multicentre prospective cohort study

Physical disability is a common component of post-intensive care syndrome, but the importance of musculoskeletal health in this population is currently unknown. We aimed to determine the musculoskeletal health state of intensive care unit survivors and assess its relationship with health-related quality of life; employment; and psychological and physical function. We conducted a multicentre prospective cohort study of adults admitted to intensive care for > 48 h without musculoskeletal trauma or neurological insult. Patients were followed up 6 months after admission where musculoskeletal health state was measured using the validated Musculoskeletal Health Questionnaire score. Of the 254 participants, 150 (59%) had a musculoskeletal problem and only 60 (24%) had received physiotherapy after discharge. Functional Comorbidity Index, Clinical Frailty Scale, duration of intensive care unit stay and prone positioning were all independently associated with worse musculoskeletal health. Musculoskeletal health state moderately correlated with quality of life, rs = 0.499 (95%CI 0.392-0.589); anxiety, rs = -0.433 (95%CI -0.538 to -0.315); and depression, rs = -0.537 (95%CI -0.631 to -0.434) (all p < 0.001). Patients with a musculoskeletal problem were less physically active than those without a problem (median (IQR [range]) number of 30 min physical activity sessions per week 1 (0-3.25 [0-7]) vs. 4 (1-7 [0-7]), p < 0.001, respectively). This study found that musculoskeletal health problems were common after intensive care unit stay. However, we observed that < 25% of patients received physical rehabilitation after discharge home. Our work has identified potential high-risk groups to target in future interventional studies.

Pain and psychopathology after intensive care unit admission

Pain and psychopathology are observed in 18% and 55% of patients, respectively, 1 year after intensive care unit (ICU) admission. It is well known that chronic pain and psychopathology have a bidirectional relation in the general population, but it is not known whether this holds true for ICU survivors. The aim of this study was to investigate whether pain before, during and after ICU admission is related to psychopathology in ICU survivors 1 year after discharge. We performed a cohort study in a mixed ICU in the Netherlands between 2013 and 2016. At 1-year follow-up, patients completed the Hospital Anxiety and Depression Scale, the Impact of Event Scale/Impact of Event Scale-Revised, and answered standardised questions regarding pain. Psychopathology was defined as having anxiety, depressive and/or post-traumatic stress disorder symptoms. We used multivariable logistic regression analysis to evaluate the association of pain before, during and after ICU admission with psychopathology at 1 year follow-up. We included 1105 patients of whom 558 (50%) (95% confidence interval (CI) 0.48 to 0.54) had psychopathology at 1 year follow-up. Pain before ICU admission (odds ratio (OR) 1.18; 95% CI 1.10 to 1.26) and pain after ICU admission (OR 2.38; 95% CI 1.68 to 3.35) were associated with psychopathology. Pain during ICU stay was not associated with psychopathology, but the memory of insufficient pain management during ICU stay was (OR 2.19; 95% CI 1.39 to 3.45). Paying attention to pain and pain treatment experiences related to ICU admission may therefore contribute to early identification of ICU survivors at risk of psychopathology development.

Post-Intensive Care Syndrome in Neurocritical Care Patients

Post-intensive care syndrome (PICS) refers to unintended consequences of critical care that manifest as new or worsening impairments in physical functioning, cognitive ability, or mental health. As intensive care unit (ICU) survival continues to improve, PICS is becoming increasingly recognized as a public health problem. Studies that focus on PICS have typically excluded patients with acute brain injuries and chronic neurodegenerative problems. However, patients who require neurocritical care undoubtedly suffer from impairments that overlap substantially with those encompassed by PICS. A major challenge is to distinguish between impairments related to brain injury and those that occur as a consequence of critical care. The general principles for the prevention and management of PICS and multidomain impairments in patients with moderate and severe neurological injuries are similar including the ICU liberation bundle, multidisciplinary team-based care throughout the continuum of care, and increasing awareness regarding the challenges of critical care survivorship among patients, families, and multidisciplinary team members. An extension of this concept, PICS-Family (PICS-F) refers to the mental health consequences of the intensive care experience for families and loved ones of ICU survivors. A dyadic approach to ICU survivorship with an emphasis on recognizing families and caregivers that may be at risk of developing PICS-F after neurocritical care illness can help improve outcomes for ICU survivors. In this review, we will summarize our current understanding of PICS and PICS-F, emerging literature on PICS in severe acute brain injury, strategies for preventing and treating PICS, and share our recommendations for future directions.

Critical illness-associated limb and diaphragmatic weakness

PURPOSE OF REVIEW

In the current review, we aim to highlight the evolving evidence on the diagnosis, prevention and treatment of critical illness weakness (CIW) and critical illness associated diaphragmatic weakness (CIDW).

RECENT FINDINGS

In the ICU, several risk factors can lead to CIW and CIDW. Recent evidence suggests that they have different pathophysiological mechanisms and impact on outcomes, although they share common risk factors and may overlap in several patients. Their diagnosis is challenging, because CIW diagnosis is primarily clinical and, therefore, difficult to obtain in the ICU population, and CIDW diagnosis is complex and not easily performed at the bedside. All of these issues lead to underdiagnosis of CIW and CIDW, which significantly increases the risk of complications and the impact on both short and long term outcomes. Moreover, recent studies have explored promising diagnostic techniques that are may be easily implemented in daily clinical practice. In addition, this review summarizes the latest research aimed at improving how to prevent and treat CIW and CIDW.

SUMMARY

This review aims to clarify some uncertain aspects and provide helpful information on developing monitoring techniques and therapeutic interventions for managing CIW and CIDW.

Non-Neuraxial Chest and Abdominal Wall Regional Anesthesia for Intensive Care Physicians-A Narrative Review

Multi-modal analgesic strategies, including regional anesthesia techniques, have been shown to contribute to a reduction in the use of opioids and associated side effects in the perioperative setting. Consequently, those so-called multi-modal approaches are recommended and have become the state of the art in perioperative medicine. In the majority of intensive care units (ICUs), however, mono-modal opioid-based analgesic strategies are still the standard of care. The evidence guiding the application of regional anesthesia in the ICU is scarce because possible complications, especially associated with neuraxial regional anesthesia techniques, are often feared in critically ill patients. However, chest and abdominal wall analgesia in particular is often insufficiently treated by opioid-based analgesic regimes. This review summarizes the available evidence and gives recommendations for peripheral regional analgesia approaches as valuable complements in the repertoire of intensive care physicians' analgesic portfolios.

Survey of sensory impairment in critically ill patients after intensive care unit discharge: An ambidirectional cohort study

BACKGROUND

Sensory impairment affects the quality of life after intensive care. However, no studies have comprehensively examined sensory impairment after intensive care.

OBJECTIVES

This study aimed to investigate sensory impairment in critically ill patients.

METHODS

This ambidirectional cohort study was conducted in the intensive care unit (ICU) of a university hospital between April 2017 and January 2020. Patients who survived despite invasive mechanical ventilation for >48 h, with a discharge period of >6 months, participated in the study. A questionnaire was sent to consenting patients to investigate the presence or absence of sensory impairment at that time, and treatment-related data were collected from their medical records.

RESULTS

Of 75 eligible patients, 62 responded to our survey. Twenty-seven (43.6%) patients had some sensory impairment. Nine (14.5%) patients had chronic pain after ICU discharge, 4 (6.5%) had chronic pain and visual impairment, 3 (4.8%) had visual impairment only, and 3 (4.8%) had chronic pain and taste impairment. The most common overlapping symptom was a combination of chronic pain.

CONCLUSIONS

Critically ill patients who survived and were discharged from the ICU accounted for 43.6% of patients with complaints of sensory impairment in the chronic phase. The results of this study suggest the need for follow-up and treatment of possible sensory impairment following ICU discharge.

Post-intensive care syndrome: Recent advances and future directions

Post-intensive care syndrome comprises physical, cognitive, and mental impairments in patients treated in an intensive care unit (ICU). It occurs either during the ICU stay or following ICU discharge and is related to the patients' long-term prognosis. The same concept also applies to pediatric patients, and it can greatly affect the mental status of family members. In the 10 years since post-intensive care syndrome was first proposed, research has greatly expanded. Here, we summarize the recent evidence on post-intensive care syndrome regarding its pathophysiology, epidemiology, assessment, risk factors, prevention, and treatments. We highlight new topics, future directions, and strategies to overcome post-intensive care syndrome among people treated in an ICU. Clinical and basic research are still needed to elucidate the mechanistic insights and to discover therapeutic targets and new interventions for post-intensive care syndrome.

The relationship between pain, anxiety and depression in patients with post-intensive care syndrome

PURPOSE

Survivors of critical illness frequently experience long-term symptoms including physical symptoms such as pain and emotional symptoms such as anxiety and depression. These symptoms frequently co-exist, however, at present there is limited understanding of these relationships. The aim of this study was to quantify the relationship between pain, anxiety and depression across the recovery trajectory.

METHODS

This study is a secondary analysis of data from a multi-centre, prospective, cohort study which followed-up patients recovering from critical illness. Data was available at multiple time points and for 3 distinct cohorts. Structural equation modelling was used to investigate the relationship between outcome measures of pain, anxiety and depression.

RESULTS

Data from 414 patients was analysed. Pain was significantly associated with both anxiety and depression in all cohorts and at all time points sampled. Path coefficients for the covariances between pain and depression ranged between 0.39 and 0.72 (p < 0.01). Path coefficients for the covariances between pain and anxiety ranged between 0.39 and 0.65 (p < 0.01).

CONCLUSIONS

Pain, anxiety and depression are highly correlated in survivors of critical illness. Pharmacological treatments for pain management may be ineffective alone and further research is required to assess interventions targeting these symptoms in combination.

Chronic pain characteristics in COVID-19 survivors after an ICU stay. A cross-sectional study

BACKGROUND

The onset and characteristics of chronic pain following an intensive care unit (ICU) stay for COVID-19 have never been thoroughly investigated.

STUDY DESIGN

A multicenter cohort study was conducted to describe chronic pain, according to ICD-11, among COVID-19 survivors. The chronic pain was assessed during face-to-face consultations with a pain specialist.

RESULTS

Among 204 COVID-19 ICU survivors, 143 patients with mean age of 60 ± 14 years were included nine months after discharge from the ICU. More than half (54%) of patients experienced new-onset chronic pain. In total, 102 different forms of pain were reported in these patients. Secondary pain was the most frequent type, comprising musculoskeletal (40%), post-traumatic (34%), neuropathic (25%), and visceral (13%). Primary chronic pain was rare (7%). The three most common sites of pain were the shoulders, chest, and head. Pain was moderate to severe in 75% of cases, and higher intensity was associated with a greater impact on daily life. Anxiety, depression, post-traumatic stress, perceived stress, and debilitating pain were frequently associated. Intubation was more frequent in patients with chronic pain. Specialized pain centre follow-up was required for 21% of the survivors, which represented 40% of the patients who developed new-onset chronic pain.

CONCLUSION

New-onset chronic pain is common after an ICU stay for COVID-19 and may manifest in various forms. Secondary pain caused by ICU management is the most frequent. Patients should undergo screening after ICU discharge to facilitate prompt, thorough, and personalized pain management.

CLINICAL TRIAL REGISTRATION

NCT04940208.

Impacts of antipsychotic medication prescribing practices in critically ill adult patients on health resource utilization and new psychoactive medication prescriptions

BACKGROUND

Antipsychotic medications are commonly prescribed to critically ill adult patients and initiation of new antipsychotic prescriptions in the intensive care unit (ICU) increases the proportion of patients discharged home on antipsychotics. Critically ill adult patients are also frequently exposed to multiple psychoactive medications during ICU admission and hospitalization including benzodiazepines and opioid medications which may increase the risk of psychoactive polypharmacy following hospital discharge. The associated impact on health resource utilization and risk of new benzodiazepine and opioid prescriptions is unknown.

RESEARCH QUESTION

What is the burden of health resource utilization and odds of new prescriptions of benzodiazepines and opioids up to 1-year post-hospital discharge in critically ill patients with new antipsychotic prescriptions at hospital discharge?

STUDY DESIGN & METHODS

We completed a multi-center, propensity-score matched retrospective cohort study of critically ill adult patients. The primary exposure was administration of ≥1 dose of an antipsychotic while the patient was admitted in the ICU and ward with continuation at hospital discharge and a filled outpatient prescription within 1-year following hospital discharge. The control group was defined as no doses of antipsychotics administered in the ICU and hospital ward and no filled outpatient prescriptions for antipsychotics within 1-year following hospital discharge. The primary outcome was health resource utilization (72-hour ICU readmission, 30-day hospital readmission, 30-day emergency room visitation, 30-day mortality). Secondary outcomes were administration of benzodiazepines and/or opioids in-hospital and following hospital discharge in patients receiving antipsychotics.

RESULTS

1,388 propensity-score matched patients were included who did and did not receive antipsychotics in ICU and survived to hospital discharge. New antipsychotic prescriptions were not associated with increased health resource utilization or 30-day mortality following hospital discharge. There was increased odds of new prescriptions of benzodiazepines (adjusted odds ratio [aOR] 1.61 [95%CI 1.19-2.19]) and opioids (aOR 1.82 [95%CI 1.38-2.40]) up to 1-year following hospital discharge in patients continuing antipsychotics at hospital discharge.

INTERPRETATION

New antipsychotic prescriptions at hospital discharge are significantly associated with additional prescriptions of benzodiazepines and opioids in-hospital and up to 1-year following hospital discharge.

Prevalence and risk factors of significant persistent pain symptoms after critical care illness: a prospective multicentric study

BACKGROUND

Prevalence, risk factors and medical management of persistent pain symptoms after critical care illness have not been thoroughly investigated.

METHODS

We performed a prospective multicentric study in patients with an intensive care unit (ICU) length of stay ≥ 48 h. The primary outcome was the prevalence of significant persistent pain, defined as a numeric rating scale (NRS) ≥ 3, 3 months after admission. Secondary outcomes were the prevalence of symptoms compatible with neuropathic pain (ID-pain score > 3) and the risk factors of persistent pain.

RESULTS

Eight hundred fourteen patients were included over a 10-month period in 26 centers. Patients had a mean age of 57 (± 17) years with a SAPS 2 score of 32 (± 16) (mean ± SD). The median ICU length of stay was 6 [4-12] days (median [interquartile]). At 3 months, the median intensity of pain symptoms was 2 [1-5] in the entire population, and 388 (47.7%) patients had significant pain. In this group, 34 (8.7%) patients had symptoms compatible with neuropathic pain. Female (Odds Ratio 1.5 95% CI [1.1-2.1]), prior use of anti-depressive agents (OR 2.2 95% CI [1.3-4]), prone positioning (OR 3 95% CI [1.4-6.4]) and the presence of pain symptoms on ICU discharge (NRS ≥ 3) (OR 2.4 95% CI [1.7-3.4]) were risk factors of persistent pain. Compared with sepsis, patients admitted for trauma (non neuro) (OR 3.5 95% CI [2.1-6]) were particularly at risk of persistent pain. Only 35 (11.3%) patients had specialist pain management by 3 months.

CONCLUSIONS

Persistent pain symptoms were frequent in critical illness survivors and specialized management remained infrequent. Innovative approaches must be developed in the ICU to minimize the consequences of pain.

TRIAL REGISTRATION

NCT04817696. Registered March 26, 2021.

Post-Intensive Care Syndrome in Patients Suffering From Acute Subarachnoid Hemorrhage: Results From an Outpatient Post-ICU Aftercare Clinic

Introduction Survivors of an acute subarachnoid hemorrhage (aSAH) may suffer from a long-term neurological disability, cognitive impairment, anxiety, and depression, which can also be related to post-intensive care syndrome (PICS). The aim of this study was to examine the prevalence of PICS symptoms in post-intensive care (ICU) aftercare aSAH patients. Methods We conducted an observational cohort study in aSAH patients from a post-ICU aftercare clinic (ICU-AC). PICS symptoms were evaluated using the Impact of Event Scale-Revised (IES-R), Hospital Anxiety and Depression Scale (HADS), and a medical questionnaire for physical and cognitive functioning. Results A total of 110 patients were included. The prevalence of anxiety and depressive symptoms was 23.6% and 19.1%, respectively. Post-traumatic stress disorder (PTSD) was seen in 26.4%. Cognitive complaints were lack of concentration (63.6%), short-term memory loss (45.8%), and reduced speed of thinking (60.9%). The most reported physical complaints were fatigue (73.6%), limitations in daily activity (72.7%), muscle weakness (41.8%), pain (36.4%), and weight loss (30.9%). PICS symptoms related to all three domains were present in 30% of patients. Conclusion The prevalence of PICS in patients after aSAH is high. Even in patients without aSAH-related neurological impairment who were discharged home, a high prevalence of PICS symptoms was reported. Early screening for PICS should comprise all three domains and is important to facilitate a better tailored rehabilitation of these patients.

Prevalence, Location, and Interference With Daily Life of Chronic Pain in Long-Term Survivors After Discharge From a Tertiary Emergency Center

Background This study aimed to investigate the prevalence, location, and characteristics of new-onset chronic pain by using a new definition in long-term survivors after discharge from a tertiary emergency center. Materials and methods We conducted a single-center ambidirectional cohort study from January to May 2022. A survey of patients was conducted by postal mail two to 2.5 years after their discharge from a tertiary emergency center. We used the Brief Pain Inventory to investigate chronic pain parameters, and the painDETECT questionnaire to investigate neuropathic pain. Patient information during hospitalization was collected retrospectively from medical records. Results The survey was sent to 78 patients, 63 (81%) of whom responded and were included in the analysis. Nine of the 63 patients (14%) had new-onset chronic pain. Of these, six (67%) had chronic pain of moderate or severe intensity which interfered with daily life. The most frequent location of chronic pain was the foot/ankle (n=4, 44%). Neuropathic pain was present in four (44%) patients with new-onset chronic pain. Conclusion New-onset chronic pain may occur for up to two to 2.5 years after discharge from a tertiary emergency center, and this may interfere with daily life. Therefore, a follow-up system for chronic pain is warranted.

Depressive and Anxiety Symptoms in Severe COVID-19 Survivors: A Prospective Cohort Study

The coronavirus disease 2019 (COVID-19) has rapidly spread worldwide, leading to increased concerns about long-term patients' neuropsychiatric consequences. This study aims to describe the presence of depressive and anxiety symptoms in severe COVID-19 survivors and to identify associated baseline, in-hospital and post-discharge factors. This study is part of the MAPA longitudinal project conducted with severe COVID-19 patients admitted in Intensive Care Medicine Department (ICMD) of a University Hospital (CHUSJ) in Porto, Portugal. Patients with ICMD length of stay ≤ 24 h, terminal illness, major auditory loss or inability to communicate at follow-up assessment were excluded. All participants were assessed by telephone post-discharge (median = 101 days), with a comprehensive protocol assessing depressive and anxiety symptoms, cognition, Intensive Care Unit (ICU) memories recall and health-related quality of life. Out of a sample of 56 survivors (median age = 65; 68% males), 29% and 23% had depressive and anxiety symptoms, respectively. Depressive and anxiety symptoms were significantly more prevalent among younger survivors and were associated with cognitive complaints, emotional and delusions ICU memories and fear of having COVID-19 sequelae, sleep problems and pain after discharge (all p < 0.05). An important proportion of these survivors suffers from depression and anxiety symptoms post-discharge, namely younger ones and those who reported more cognitive complaints, ICU memories, fear of having COVID-19 sequelae, sleep problems and pain. These findings highlight the importance of psychological consequences assessment and planning of appropriate and multidisciplinary follow-up care after hospitalization due to COVID-19.

Sepsis-associated neuroinflammation in the spinal cord

Septic patients commonly present with central nervous system (CNS) disorders including impaired consciousness and delirium. Today, the main mechanism regulating sepsis-induced cerebral disorders is believed to be neuroinflammation. However, it is unknown how another component of the CNS, the spinal cord, is influenced during sepsis. In the present study, we intraperitoneally injected mice with lipopolysaccharide (LPS) to investigate molecular and immunohistochemical changes in the spinal cord of a sepsis model. After LPS administration in the spinal cord, pro-inflammatory cytokines including interleukin (IL)-1β, IL-6, and tumor necrosis factor alpha mRNA were rapidly and drastically induced. Twenty-four-hour after the LPS injection, severe neuronal ischemic damage spread into gray matter, especially around the anterior horns, and the anterior column had global edematous changes. Immunostaining analyses showed that spinal microglia were significantly activated and increased, but astrocytes did not show significant change. The current results indicate that sepsis induces acute neuroinflammation, including microglial activation and pro-inflammatory cytokine upregulation in the spinal cord, causing drastic neuronal ischemia and white matter edema in the spinal cord.

The complications of opioid use during and post-intensive care admission: A narrative review

Opioids are a commonly administered analgesic medication in the intensive care unit, primarily to facilitate invasive mechanical ventilation. Consensus guidelines advocate for an opioid-first strategy for the management of acute pain in ventilated patients. As a result, these patients are potentially exposed to high opioid doses for prolonged periods, increasing the risk of adverse effects. Adverse effects relevant to these critically ill patients include delirium, intensive care unit-acquired infections, acute opioid tolerance, iatrogenic withdrawal syndrome, opioid-induced hyperalgesia, persistent opioid use, and chronic post-intensive care unit pain. Consequently, there is a challenge of optimising analgesia while minimising these adverse effects. This narrative review will discuss the characteristics of opioid use in the intensive care unit, outline the potential short-term and long-term adverse effects of opioid therapy in critically ill patients, and outline a multifaceted strategy for opioid minimisation.

Characteristics and influence on quality of life of new-onset pain in critical COVID-19 survivors

Background

Pain is a clinical feature of COVID‐19, however, data about persistent pain after hospital discharge, especially among ICU survivors is scarce. The aim of this study was to explore the incidence and characteristics of new‐onset pain and its impact on Health‐Related Quality of Life (HRQoL), and to quantify the presence of mood disorders in critically ill COVID‐19 survivors.

Methods

This is a preliminary report of PAIN‐COVID trial (NCT04394169) presenting a descriptive analysis in critically ill COVID‐19 survivors, following in person interview 1 month after hospital discharge. Pain was assessed using the Brief Pain Inventory, the Douleur Neuropathique 4 questionnaire and the Pain Catastrophizing Scale. HRQoL was evaluated with the EQ 5D/5L, and mood disorders with the Hospital Anxiety and Depression Scale (HADS).

Results

From 27 May to 19 July 2020, 203 patients were consecutively screened for eligibility, and 65 were included in this analysis. Of these, 50.8% patients reported new‐onset pain; 38.5% clinically significant pain (numerical rating score ≥3 for average pain intensity); 16.9% neuropathic pain; 4.6% pain catastrophizing thoughts, 44.6% pain in ≥2 body sites and 7.7% widespread pain. Patients with new‐onset pain had a worse EQ‐VAS and EQ index value (p < 0.001). Pain intensity was negatively correlated to both the former (Spearman ρ: −0.546, p < 0.001) and the latter (Spearman ρ: −0.387, p = 0.001). HADS anxiety and depression values equal or above eight were obtained in 10.8% and 7.7% of patients, respectively.

Conclusion

New‐onset pain in critically ill COVID‐19 survivors is frequent, and it is associated with a lower HRQoL.

Trial registration No.: NCT04394169. Registered 19 May 2020. https://clinicaltrials.gov/ct2/show/NCT04394169.

Significance

A substantial proportion of severe COVID‐19 survivors may develop clinically significant persistent pain, post‐intensive care syndrome and chronic ICU‐related pain. Given the number of infections worldwide and the unprecedented size of the population of critical illness survivors, providing information about the incidence of new‐onset pain, its characteristics, and its influence on the patients’ quality of life might help establish and improve pain management strategies.

Chronic pain in the 11th revision of the International Classification of Diseases: users' questions answered

ABSTRACT

The upcoming 11th revision of the International Classification of Diseases (ICD-11) will include a comprehensive classification of chronic pain for the first time, which is based on the biopsychosocial definition of chronic pain. This presents a great opportunity for pain research and clinical practice. The new classification consists of seven main diagnostic categories of chronic pain, which are further divided into increasingly specific levels of diagnoses. Each diagnosis is characterized by clearly defined operationalized criteria. Future users will need to familiarize themselves with the new system and its application. The aim of the present publication is to provide users of the ICD-11 chronic pain classification with answers to frequently asked questions regarding the ICD-11 as a whole, the ICD-11 chronic pain classification, and its application to common pain syndromes. The questions compiled here reached the International Association for the Study of Pain Task Force via different routes (e.g., at conferences, by letter, or during field testing). Furthermore, the authors collected questions posted to the ICD-11 browser and contacted early users of the classification to enquire about their most frequent difficulties when applying the new diagnoses. The authors of the present publication prepared answers to these frequently asked questions. This publication intends to act as a guide for the future users of the new ICD-11 chronic pain classification, hence facilitating its implementation.

Musculoskeletal complications following critical illness: A scoping review

PURPOSE

To explore the extent to which musculoskeletal (MSK) complications have been reported following critical illness, identifying evidence gaps and providing recommendations for future research.

MATERIALS AND METHODS

We searched five databases from January 1st 2000 to March 31st 2021. We included published original research reporting MSK complications in patients discharged from hospital following an admission to an intensive care unit (ICU). Two reviewers independently screened English language articles for eligibility. Data extracted included the MSK area of investigation and MSK outcome measures. The overall quality of study was evaluated against standardised reporting guidelines.

RESULTS

4512 titles were screened, and 32 met the inclusion criteria. Only one study included was interventional, with the majority being prospective cohort studies (n = 22). MSK complications identified included: muscle weakness or atrophy, chronic pain, neuromuscular dysfunction, peripheral joint impairment and fracture risk. The quality of the overall reporting in the studies was deemed adequate.

CONCLUSIONS

We identified a heterogenous body of literature reporting a high prevalence of a variety of MSK complications extending beyond muscle weakness, therefore future investigation should include evaluations of more than one MSK area. Further investigation of MSK complications could inform the development of future post critical illness rehabilitation programs.

Pain Assessment and Management in Intensive Care Unit: Nurses' Practices, Perceived Influencing Factors, and Educational Needs

Background:

Critically ill patients and those mechanically ventilated or unable to communicate may not be able to report any pain they experience. Consequently, pain assessment and management (PAM) is challenging and underestimated in intensive care units (ICUs), where patients suffer alteration of consciousness, sedation, invasive procedures and mechanical ventilation.

Aim:

This study aimed to investigate ICU nurses’ PAM practices, their perceptions of influencing factors, and their related educational needs.

Methods:

A descriptive cross-sectional design was employed, using a valid self-reported questionnaire.

Results:

Among the sample of 171 nurses, 55% were male and 83% held a bachelor’s degree. 60% reported performing pain assessment for patients able to report pain and 50% for those unable to do so. Almost 40% of participants reported that pain management plans and scores were not discussed in medical rounds. Workload and lack of guidelines were reported as the most common barriers to PAM, while the most common enablers were perceived to be prescribing analgesia and considering pain a priority. Nurses recognized the need for education regarding pain, especially the physiological (50%) and psychological (47%) consequences of untreated pain.

Conclusion:

Nurses’ reported performance of pain assessment for ICU patients remains suboptimal. Therefore, healthcare professionals, organizations, nursing schools, and policymakers should work together to improve nurses’ PAM knowledge and practices.

Post Intensive Care Syndrome (PICS): an overview of the definition, etiology, risk factors, and possible counseling and treatment strategies

INTRODUCTION

Post-intensive care syndrome (PICS) has only recently been recognized as a new clinical entity in patients surviving their intensive care unit (ICU) stay due to critical illness. With increasing survival rates of ICU patients worldwide, there is a rising interest regarding post-ICU recovery.

AREAS COVERED

First, based on the current literature a definition is provided of PICS, including the domains of impairments that comprise PICS along with the etiology and risk factors. Second, preventive measures and possible treatment strategies integrated in the follow-up care are described. Third, the authors will discuss the current SARS-Cov-2 pandemic and the increased risk of PICS in these post-ICU patients and their families.

EXPERT OPINION

PICS is a relatively new entity, which not only encompasses various physical, cognitive, and psychological impairments but also impacts global health due to long-lasting detrimental socioeconomic burdens. Importantly, PICS also relates to caregivers of post-ICU patients. Strategies to reduce this burden will not only be needed within the ICU setting but will also have to take place in an interdisciplinary, multifaceted approach in primary care settings. Additionally, the SARS-Cov-2 pandemic has a high burden on post-ICU patients and their relatives.

Management of Sedation and Analgesia in Critically Ill Patients Receiving Long-Acting Naltrexone Therapy for Opioid Use Disorder

The explosion of the opioid epidemic in the United States and across the world has been met with advances in pharmacologic therapy for the treatment of opioid use disorder. Long-acting naltrexone is a promising strategy, but its use has important implications for critical care, as it may interfere with or complicate sedation and analgesia. Currently, there are two available formulations of long-acting naltrexone, which are distinguished by different administration routes and distinct pharmacokinetics. The use of long-acting naltrexone may be identified through a variety of strategies (such as physical examination, laboratory testing, and medical record review), and is key to the safe provision of sedation and analgesia during critical illness. Perioperative experience caring for patients receiving long-acting naltrexone informs management in the intensive care unit. Important lessons include the use of multimodal analgesia strategies and anticipating patients' demonstrating variable sensitivity to opioids. For the critically ill patient, however, there are important distinctions to emphasize, including changes in drug metabolism and medication interactions. By compiling and incorporating the currently available literature, we provide critical care physicians with recommendations for the sedation and analgesia for critically ill patients receiving long-acting naltrexone therapy.

Occurrence and characteristics of pain after ICU discharge: A longitudinal study

BACKGROUND

Pain is a serious problem for intensive care unit (ICU) patients, but we are lacking data on pain at the hospital ward after ICU discharge.

AIMS AND OBJECTIVES

To describe pain intensity, -interference with function and -location in patients up to 1 year after ICU discharge. To identify demographic and clinical variables and their association with worst pain intensity and pain interference.

DESIGN

A longitudinal descriptive secondary analysis of a randomized controlled trial on nurse-led follow-up consultations on post-traumatic stress and sense of coherence after ICU discharge.

METHODS

Pain intensity, -interference, and -location were measured using Brief Pain Inventory at the hospital ward and 3, 6, and 12 months after ICU discharge. For associations, data were analysed using multivariate linear mixed models for repeated measures.

RESULTS

Of 523 included patients, 68% reported worst pain intensity score above 0 (no pain) at the ward. Estimated means for worst pain intensity and -interference (from 0 to 10) after ICU discharge were 5.5 [CI 4.6-6.5] and 4.5 [CI 3.7-5.3], and decreased to 3.8 [CI 2.8-4.8] (P ≤ .001) and 2.9 [CI 2.1-3.7] after 12 months (P ≤ .001). Most common pain locations were abdomen (43%), lower lumbar back (28%), and shoulder/forearm (22%). At 12 months, post-traumatic stress (PTS) symptoms ≥25 (scale 10-70), female gender, shorter ICU stay, and more traumatic ICU memories were significantly associated with higher worst pain intensity. PTS symptoms ≥25, female gender, more traumatic ICU memories, younger age, and not having an internal medical diagnosis were significantly associated with higher pain interference.

CONCLUSIONS

Early after ICU discharge pain was present in 68% of patients. Thereafter, pain intensity and -interference declined, but pain intensity was still at a moderate level at 12 months. Health professionals should be aware of patients' pain and identify potentially vulnerable patients.

IMPLICATION FOR PRACTICE

Longitudinal assessment of factors associated with pain early after ICU discharge and the following year is a first step that could improve follow-up focus and contribute to reduced development of chronic pain.

Current Perspectives on the Assessment and Management of Pain in the Intensive Care Unit

Critical illness is often painful, both from the underlying source of illness, as well as necessary procedures performed for the monitoring and care of these patients. Pain is often under-recognized in the critically ill, especially among those who cannot self-report, so accurate assessment and management continue to be major consideration in their care. Pain management in the intensive care unit (ICU) is an evolving practice, with a focus on accurate and frequent pain assessment, and targeted pharmacologic and non-pharmacologic treatment methods to maximize analgesia and minimize sedation. In this review, we will evaluate several validated methods of pain assessment in the ICU and present management options. We will review the evidence-based recommendations put forth by the largest critical care societies and several high-quality studies related to both the in-hospital approach to pain, as well as the short- and long-term consequences of untreated pain in ICU patients. We conclude with future directions.

Occurrence and Risk Factors of Chronic Pain After Critical Illness

OBJECTIVES

Occurrence, risk factors, and impact on daily life of chronic pain after critical illness have not been systematically studied.

DESIGN

Cohort study.

SETTING

A tertiary ICU in The Netherlands.

PATIENTS

We surveyed patients who had been discharged from our ICU between 2013 and 2016. Three cohorts were defined as follows: 1) ICU survivors; 2) one-year survivors reporting newly-acquired chronic pain; and (3) one-year survivors with pain who lived within 50 km from the study hospital. In cohort 1, we estimated the prevalence of new chronic pain 1 year after ICU discharge and constructed a prediction model for its occurrence incorporating three outcomes: death during follow-up, surviving without new pain, and surviving with newly-acquired pain. In cohort 2, we determined clinical features of pain and its impact on daily life. In cohort 3, we assessed the presence of neuropathic characteristics of pain.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The three cohorts contained 1,842, 160, and 42 patients, respectively. Estimated occurrence of new chronic pain was 17.7% (95% CI, 15.8-19.8%; n = 242) in 1-year survivors (n = 1,368). Median pain intensity on the numeric rating scale was 4 (interquartile range, 2-6) in the week before survey response, with impact being most evident on activities of daily living, social activities, and mobility. Neuropathic pain features were present in 50% (95% CI, 37-68%) of affected subjects. Among nine predictor variables included in a multinomial model, only female gender and days in ICU with hyperinflammation were associated with pain.

CONCLUSIONS

Newly-acquired chronic pain is a frequent consequence of critical illness, and its impact on daily life of affected patients is substantial.

Bodily pain in survivors of acute respiratory distress syndrome: A 1-year longitudinal follow-up study

PURPOSE

Acute respiratory distress syndrome (ARDS) survivors frequently experience bodily pain during recovery after the intensive care unit. Longitudinal course, risk factors and associations with physical and neuropsychological health is lacking.

METHODS

We collected self-reported pain using the Short Form-36 Bodily Pain (SF-36 BP) scale, normalized for sex and age (range: 0-100; higher score = less pain), along with physical and mental health measures in a multi-center, prospective cohort of 826 ARDS survivors at 6- and 12-month follow-up. We examined baseline and ICU variables' associations with pain via separate unadjusted regression models.

RESULTS

Pain prevalence (SF-36 BP ≤40) was 45% and 42% at 6 and 12 months, respectively. Among 706 patients with both 6- and 12-month data, 34% reported pain at both timepoints. Pre-ARDS employment was associated with less pain at 6-months (mean difference (standard error), 5.7 (0.9), p < 0.001) and 12-months (6.3 (0.9), p < 0.001); smoking history was associated with greater pain (-5.0 (0.9), p < 0.001, and - 5.4 (1.0), p < 0.001, respectively). In-ICU opioid use was associated with greater pain (-6.3 (2.7), p = 0.02, and - 7.3 (2.8), p = 0.01, respectively). At 6 months, 174 (22%) patients reported co-occurring pain, depression and anxiety, and 227 (33%) reported co-occurring pain and impaired physical function.

CONCLUSION

Nearly half of ARDS survivors reported bodily pain at 6- and 12-month follow-up; one-third reported pain at both time points. Pre-ARDS unemployment, smoking history, and in-ICU opioid use may identify patients who report greater pain during recovery. Given its frequent co-occurrence, clinicians should manage both physical and neuropsychological issues when pain is reported.

COVID-19: Patient Characteristics in the First Phase of Postintensive Care Rehabilitation

Objective

To describe clinical characteristics of patients after intensive care unit (ICU) treatment for coronavirus disease 2019 (COVID-19) who were admitted for inpatient rehabilitation.

Design

A cross-sectional design.

Setting

Inpatient rehabilitation care in the Netherlands.

Participants

All post-ICU patients with COVID-19 admitted to the rehabilitation center between April 2 and May 13, 2020, were invited to participate in the study. Included were patients older than 18 years needing inpatient rehabilitation after ICU treatment for COVID-19 (N=60; mean age, 59.9y; 75% male).

Interventions

Not applicable.

Main Outcome Measures

The following information was collected in the first week of inpatient rehabilitation care: (1) demographics; (2) ICU stay parameters; (3) medical, physical, and functional characteristics; and (4) self-reported symptoms.

Results

The most important findings for rehabilitation were the following: in the first week after discharge to the rehabilitation center, 38.3% of all patients experienced exercise-induced oxygen desaturation, in 72.7% muscle weakness was present in all major muscle groups, and 21.7% had a reduced mobility in 1 or both shoulders. Furthermore 40% had dysphagia, and 39.2% reported symptoms of anxiety.

Conclusion

Post-ICU patients with COVID-19 display physical and anxiety symptoms as reported in other post-ICU patient groups. However, this study showed some remarkable clinical characteristics of post-ICU patients with COVID-19. Rehabilitation programs need to anticipate on this. Long-term follow-up studies are necessary.

Neurobiology of SARS-CoV-2 interactions with the peripheral nervous system: implications for COVID-19 and pain

SARS-CoV-2 is a novel coronavirus that infects cells through the angiotensin-converting enzyme 2 receptor, aided by proteases that prime the spike protein of the virus to enhance cellular entry. Neuropilin 1 and 2 (NRP1 and NRP2) act as additional viral entry factors. SARS-CoV-2 infection causes COVID-19 disease. There is now strong evidence for neurological impacts of COVID-19, with pain as an important symptom, both in the acute phase of the disease and at later stages that are colloquially referred to as "long COVID." In this narrative review, we discuss how COVID-19 may interact with the peripheral nervous system to cause pain in the early and late stages of the disease. We begin with a review of the state of the science on how viruses cause pain through direct and indirect interactions with nociceptors. We then cover what we currently know about how the unique cytokine profiles of moderate and severe COVID-19 may drive plasticity in nociceptors to promote pain and worsen existing pain states. Finally, we review evidence for direct infection of nociceptors by SARS-CoV-2 and the implications of this potential neurotropism. The state of the science points to multiple potential mechanisms through which COVID-19 could induce changes in nociceptor excitability that would be expected to promote pain, induce neuropathies, and worsen existing pain states.

Microglia: A Potential Therapeutic Target for Sepsis-Associated Encephalopathy and Sepsis-Associated Chronic Pain

Neurological dysfunction, one of the severe manifestations of sepsis in patients, is closely related to increased mortality and long-term complications in intensive care units, including sepsis-associated encephalopathy (SAE) and chronic pain. The underlying mechanisms of these sepsis-induced neurological dysfunctions are elusive. However, it has been well established that microglia, the dominant resident immune cell in the central nervous system, play essential roles in the initiation and development of SAE and chronic pain. Microglia can be activated by inflammatory mediators, adjacent cells and neurotransmitters in the acute phase of sepsis and then induce neuronal dysfunction in the brain. With the spotlight focused on the relationship between microglia and sepsis, a deeper understanding of microglia in SAE and chronic pain can be achieved. More importantly, clarifying the mechanisms of sepsis-associated signaling pathways in microglia would shed new light on treatment strategies for SAE and chronic pain.

Opioid Prescribing After Discharge in a Previously Mechanically Ventilated, Opioid-Naïve Cohort

BACKGROUND

Opioids are utilized for pain management during and after mechanical ventilation in the intensive care unit (ICU).

OBJECTIVE

The purpose of this study was to determine the percentage of potentially unnecessary opioid prescriptions on discharge in previously opioid-naïve patients.

METHODS

This retrospective cohort study included mechanically ventilated, opioid-naïve ICU patients who received opioids. The primary outcome of this study was the discrepancy between the amounts of opioids prescribed at discharge versus those likely required based on actual 24-hour prehospital discharge opioid requirements.

RESULTS

A total of 71 patients were included. Of these, 63.3% (n = 45) of discharge prescriptions were in alignment with 24-hour predischarge requirements, and 36.7% (n = 26) of discharge prescriptions were in excess of calculated predischarge requirements. At discharge, 57.7% (n = 41) of patients received a nonopioid analgesic. Multivariable linear regression revealed that cardiothoracic ICU admission was associated with an increased risk of inappropriate discharge opioid prescribing, whereas a shorter duration of inpatient oral opioid therapy decreased risk of inappropriate discharge prescribing.

CONCLUSION AND RELEVANCE

Opioid prescribing for previously mechanically ventilated patients warrants improvement as a part of the discharge planning process. Application of these data may aid in the reduction of opioid overprescribing at discharge after an ICU stay.

Cathepsin E in neutrophils contributes to the generation of neuropathic pain in experimental autoimmune encephalomyelitis

Pain is a frequent and disabling symptom in patients with multiple sclerosis (MS); however, the underlying mechanisms of MS-related pain are not fully understood. Here, we demonstrated that cathepsin E (CatE) in neutrophils contributes to the generation of mechanical allodynia in experimental autoimmune encephalomyelitis, an animal model of MS. We showed that CatE-deficient (CatE) mice were highly resistant to myelin oligodendrocyte glycoprotein (MOG35-55)-induced mechanical allodynia. After MOG35-55 immunization, neutrophils immediately accumulated in the dorsal root ganglion (DRG). Adoptive transfer of MOG35-55-stimulated wild-type neutrophils into the dorsal root ganglion induced mechanical allodynia in the recipient C57BL/6 mice. However, the pain threshold did not change when MOG35-55-stimulated CatE neutrophils were transferred into the recipient C57BL/6 mice. MOG35-55 stimulation caused CatE-dependent secretion of elastase in neutrophils. Behavioral analyses revealed that sivelestat, a selective neutrophil elastase inhibitor, suppressed mechanical allodynia induced by adoptively transferred MOG35-55-stimulated neutrophils. MOG35-55 directly bound to toll-like receptor 4, which led to increased production of CatE in neutrophils. Our findings suggest that inhibition of CatE-dependent elastase production in neutrophil might be a potential therapeutic target for pain in patients with MS.

Characteristics of Nonpharmacological Interventions for Pain Management in the ICU: A Scoping Review

Pain relief in the intensive care unit (ICU) is of particular concern since patients are exposed to multiple painful stimuli associated with care procedures. Considering the adverse effects of pharmacological approaches, particularly in vulnerable populations such as the elderly, the use of non-pharmacological interventions has recently been recommended in the context of critical care. The main goal of this scoping review was to systematically map the research done on non-pharmacological interventions for pain management in ICU adults and describe the characteristics of these interventions. A wide variety of non-pharmacological interventions have been tested, with music and massage therapies being the most frequently used. An interesting new trend is the use of combined or bundle interventions. Lastly, it was observed that these interventions have not been studied in specific subgroups, such as the elderly, women, and patients unable to self-report.

Evidence-Based Strategies for the Prevention of Chronic Post-Intensive Care and Acute Care-Related Pain

Chronic pain is prevalent in intensive care survivors and in patients who require acute care treatments. Many adverse consequences have been associated with chronic post-intensive care and acute care-related pain. Hence, interest in interventions to prevent these pain disorders has grown. To improve the understanding of the mechanisms of action of these interventions and their potential impacts, this article outlines the pathophysiology involved in the transition from acute to chronic pain, the epidemiology and consequences of chronic post-intensive care and acute care- related pain, and risk factors for the development of chronic pain. Pharmacological, nonpharmacological, and multimodal preventive interventions specific to the targeted populations and their levels of evidence are presented. Nursing implications for preventing chronic pain in patients receiving critical and acute care are also discussed.

Persistent pain in intensive care survivors: a systematic review

BACKGROUND

According to earlier studies where the main aim has been quality of life, there is growing evidence of increased levels of persistent pain in survivors of critical illness. The cause of admission and several factors during intensive care may have associated risk factors for pain persistence. This systematic review aims to determine the incidence or prevalence of persistent pain after critical illness and to identify risk factors for it.

METHODS

Six databases were searched, and eventually nine studies were included in the final systematic process. The validity of observational and cross-sectional studies was analysed using the National Institute of Health 'Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies'.

RESULTS

The incidence of persistent pain after intensive care varied from 28% to 77%. Risk factors for persistent pain were acute pain at discharge from ICU, higher thoracic trauma score, surgery, pre-existing pain, organ failure, longer length of ventilator or hospital stay, and sepsis. No difference in incidence between medical and surgical patients was found.

CONCLUSIONS

New systematic, observational studies are warranted to identify persistent pain-related factors in intensive care to improve pain management protocols and thereby diminish the risk of persistent pain after ICU stay.

Impact of Patient and Family Involvement in Long-Term Outcomes

Surviving a critical illness can have long-term effects on both patients and families. These effects can be physical, emotional, cognitive, and social, and they affect both the patient and the family. Family members play a key role in helping their loved one recover, and this recovery process can take considerable time. Transferring out of an intensive care unit, and discharging home from a hospital, are important milestones, but they represent only the beginning of recovery and healing after a critical illness. Recognizing that these challenges exist both for patients and families is important to improve critical illness outcomes.

The effectiveness of systematic pain assessment on critically ill patient outcomes: A randomised controlled trial

BACKGROUND

Evidence suggests that critically ill patients' pain may still be underestimated. Systematic approaches to pain assessment are of paramount importance for improving patients' outcomes.

OBJECTIVES

To investigate the effectiveness of a systematic approach to pain assessment on the incidence and intensity of pain and related clinical outcomes in critically ill patients.

METHODS

Randomized controlled study with consecutive critically ill patients allocated to either a standard care only or a systematic pain assessment group. The Behavioral Pain Scale (BPS) and the Critical Pain Observation Tool (C-POT) were completed twice daily for all participants. In the intervention group, clinicians were notified of pain scores. Linear Mixed Models (LMM) for the longitudinal effect of the intervention were employed.

RESULTS

A total of 117 patients were included (control: n=61; intervention: n2=56). The incidence of pain (C-POT >2) in the intervention group was significantly lower compared to the control group (p < .001). The intervention had a statistically significant effect on pain intensity (BPS, p = 0.01). The average total morphine equivalent dose in the intervention group was higher than in the control group (p = 0.045), as well as the average total dose of propofol (p = 0.027). There were no statistically significant differences in ICU mortality (23.4% vs 19.3%, p=0.38, odds ratio 0.82 [0.337-1.997]) and length of ICU stay (13.5, SD 11.1 vs 13.9, SD 9.5 days, p= 0.47).

CONCLUSION

Systematic pain assessment may be associated with a decrease in the intensity and incidence of pain and influence the pharmacological management of pain and sedation of critically ill patients.

The Influence of Pain and Analgesia in Rodent Models of Sepsis

Sepsis is a multifaceted host response to infection that dramatically affects patient outcomes and the cost of health care. Animal models are necessary to replicate the complexity and heterogeneity of clinical sepsis. However, these models entail a high risk of pain and distress due to tissue trauma, inflammation, endotoxin-mediated hyperalgesia, and other mechanisms. Several recent studies and initiatives address the need to improve the welfare of animals through analgesics and standardize the models used in preclinical sepsis research. Ultimately, the goal is to provide high-fidelity, humane animal models that better replicate the clinical course of sepsis, to provide more effective translation and advance therapeutic discovery. The purpose of this review is to discuss the current understanding of the roles of pain and analgesia in rodent models of sepsis. The current definitions of sepsis along with an overview of pain in human sepsis are described. Finally, welfare concerns associated with animal models of sepsis and the most recent considerations for relief of pain and distress are reviewed.

Impact of a pharmacist intervention at an intensive care rehabilitation clinic

Objective

While disruptions in medications are common among patients who survive critical illness, there is limited information about specific medication-related problems among survivors of critical care. This study sought to determine the prevalence of specific medication-related problems detected in patients, seen after critical care discharge.

Design

Consecutive patients attending an intensive care unit (ICU) follow-up programme were included in this single-centre service evaluation.

Setting

Tertiary care regional centre in Scotland (UK).

Participants

47 patients reviewed after critical care discharge at an ICU follow-up programme.

Interventions

Pharmacists conducted a full medication review, including: medicines reconciliation, assessing the appropriateness of each prescribed medication, identification of any medication-related problems and checking adherence.

Measurements

Medication-related problems in patients following critical care discharge. Interventions and medication-related problems were systematically graded and risk factors were identified using an adapted version of the National Patient Safety Agency Risk Matrix.

Main results

69 medication-related problems were identified in 38 (81%) of the 47 patients. The most common documented problem was drug omission (29%). 64% of the medication-related problems identified were classified as either moderate or major. The number of pain medications prescribed at discharge from intensive care was predictive of medication-related problems (OR 2.02, 95% CI 1.14 to 4.26, p=0.03).

Conclusions

Medication problems are common following critical care. Better communication of medication changes both to patients and their ongoing care providers may be beneficial following a critical care admission. In the absence of highly effective communication, a pharmacy intervention may contribute substantially to an intensive care rehabilitation or recovery programme.

Shoulder Impairment Following Critical Illness: A Prospective Cohort Study

Supplemental Digital Content is available in the text.

Objectives:

Identify the prevalence of shoulder impairment in ICU survivors within 6 months of discharge from ICU. Evaluate the impact of shoulder impairment on upper limb functional status in patients treated on an ICU. Identify risk factors for the development of shoulder impairment.

Design:

Prospective cohort study.

Setting:

A tertiary care medical-surgical-trauma ICU at a U.K. hospital over 18 months, with a further 6-month follow-up after hospital discharge.

Subjects:

Adult patients with an ICU length of stay of greater than 72 hours with no preexisting or new neurologic or traumatic upper limb injury.

Interventions:

None.

Measurements and Main Results:

Patients underwent targeted shoulder assessments (pain, range of movement, Constant-Murley Score, shortened version of the disabilities of the arm, shoulder, and hand [DASH] score [QuickDASH] score) at hospital discharge, 3 and 6 months after hospital discharge. Assessments were undertaken on 96 patients, with 62 patients attending follow-up at 3 months and 61 patients at 6 months. Multivariate regression analysis was used to investigate risk factors for shoulder impairment. ICU-related shoulder impairment was present in 67% of patients at 6 months following discharge from hospital. Upper limb dysfunction occurred in 46%, with 16% having severe dysfunction (equivalent to shoulder dislocation). We were unable to identify specific risk factors for shoulder impairment.

Conclusions:

Shoulder impairment is a highly prevalent potential source of disability in ICU survivors. This persists at 6 months after discharge with a significant impact on upper limb function. More research is needed into potential mechanisms underlying shoulder impairment and potential targeted interventions to reduce the prevalence.

Pain and Its Long-term Interference of Daily Life After Critical Illness

BACKGROUND

Persistent pain likely interferes with quality of life in survivors of critical illness, but data are limited on its prevalence and risk factors. We sought to determine the prevalence of persistent pain after critical illness and its interference with daily life. Additionally, we sought to determine if intensive care unit (ICU) opioid exposure is a risk factor for its development.

METHODS

In a cohort of adult medical and surgical ICU survivors, we used the brief pain inventory (BPI) to assess pain intensity and pain interference of daily life at 3 and 12 months after hospital discharge. We used proportional odds logistic regression with Bonferroni correction to evaluate the independent association of ICU opioid exposure with BPI scores, adjusting for potential confounders including age, preadmission opioid use, frailty, surgery, severity of illness, and durations of delirium and sepsis while in the ICU.

RESULTS

We obtained BPI outcomes in 295 patients overall. At 3 and 12 months, 77% and 74% of patients reported persistent pain symptoms, respectively. The median (interquartile range) pain intensity score was 3 (1, 5) at both 3 and 12 months. Pain interference with daily life was reported in 59% and 62% of patients at 3 and 12 months, respectively. The median overall pain interference score was 2 (0, 5) at both 3 and 12 months. ICU opioid exposure was not associated with increased pain intensity at 3 months (odds ratio [OR; 95% confidence interval], 2.12 [0.92-4.93]; P = .18) or 12 months (OR, 2.58 [1.26-5.29]; P = .04). ICU opioid exposure was not associated with increased pain interference of daily life at 3 months (OR, 1.48 [0.65-3.38]; P = .64) or 12 months (OR, 1.46 [0.72-2.96]; P = .58).

CONCLUSIONS

Persistent pain is prevalent after critical illness and frequently interferes with daily life. Increased ICU opioid exposure was not associated with worse pain symptoms. Further studies are needed to identify modifiable risk factors for persistent pain in the critically ill and the effects of ICU opioids on patients with and without chronic pain.

Understanding what matters to patients in critical care: An exploratory evaluation

BACKGROUND

The delivery of person-centred care is a key priority for managers, policy makers, and clinicians in health care. The delivery person-centred care in critical care is challenging because of competing demands.

AIMS AND OBJECTIVES

The aim of this quality improvement project was to understand what mattered to patients on a daily basis within the critical care environment. It aimed to understand personal goals and what patients needed to improve their experience. This paper reports on the outputs from this quality improvement project.

DESIGN AND DATA ANALYSIS

During each daily ward round, patients were asked "what matters to you today?" Outputs from this were entered into the Daily Goals Sheet, which is utilized for every patient in our critical care unit or in the nursing notes. Using Framework Analysis, prevalent themes were extracted from the patient statements documented.

RESULTS

A total of 196 unique patients were included in this analysis alongside 592 patient statements. Four broad themes were generated: medical outcomes and information, the critical care environment, personal care, and family and caregivers.

CONCLUSION

The analysis of the data from this quality improvement project has demonstrated that, by asking a simple question within the context of a ward round, care can be enhanced and personalized and long-term outcomes potentially improved. More research is required to understand what the optimal methods are of implementing these requests.

RELEVANCE TO CLINICAL PRACTICE

Two main recommendations from practice emerged from this quality improvement project: asking patients "what matters to you?" on a daily basis may help support the humanization of the critical care environment, and visiting and access by families must be discussed with patients to ensure this is appropriate for their needs.

Chronic pain in critical care survivors: a narrative review

Chronic pain is an important problem after critical care admission. Estimates of the prevalence of chronic pain in the year after discharge range from 14% to 77% depending on the type of cohort, the tool used to measure pain, and the time point when pain was assessed. The majority of data available come from studies using health-related quality of life tools, although some have included pain-specific tools. Nociceptive, neuropathic, and nociplastic pain can occur in critical care survivors, but limited information about the aetiology, body site, and temporal trajectory of pain is currently available. Older age, pre-existing pain, and medical co-morbidity have been associated with pain after critical care admission. No trials were identified of interventions to target chronic pain in survivors specifically. Larger studies, using pain-specific tools, over an extended follow-up period are required to confirm the prevalence, identify risk factors, explore any association between acute and chronic pain in this setting, determine the underlying pathological mechanisms, and inform the development of future analgesic interventions.

Regional analgesia techniques for pain management in patients admitted to the intensive care unit

Controlling pain should be a priority in the clinical practice of intensive care units (ICUs). Monomodal analgesic approaches, such as the administration of opioids, are widely employed; however, the widespread use of opioids has catastrophic consequences, given their multiple side effects and the development of dependence. Regional analgesia (RA), with single or continuous dosing using neuraxial and peripheral catheters, can play an important role in multimodal analgesia for management of pain in critical care patients. RA provides superior pain control, as compared to systemic treatments, and is associated with a lower rate of side effects. Nevertheless, RA remains underused in ICUs. Many critically ill, post-surgical or traumatically injured patients would benefit from these techniques. For these reasons, we aim to establish a set of potential indications integrating the use of RA in analgesia protocols routinely used in ICUs. We performed a review of literature sources with contrasted evidence levels to present RA techniques and their potential applications in ICU patients.

Follow-up program after intensive care unit discharge

INTRODUCTION

Patient follow-up after intensive care unit (ICU) discharge allows the early recognition of complications associated to post-intensive care syndrome (PICS). The aim of this project is to standardize outcome variables in a follow-up program for patients at risk of suffering PICS.

METHODS

The Rehabilitation and Patient Follow-up Committee of the Argentine Society of Intensive Care Medicine (Sociedad Argentina de Terapia Intensiva, SATI) requested the collaboration of different committees to design the present document. A thorough search of the literature on the issue, together with pre-scheduled meetings and web-based discussion encounters were carried out. After comprehensive evaluation, the recommendations according to the GRADE system included in the follow-up program were: frequency of controlled visits, appointed healthcare professionals, basic domains of assessment and recommended tools of evaluation, validated in Spanish, and entire duration of the program.

CONCLUSION

The measures herein suggested for patient follow-up after ICU discharge will facilitate a basic approach to diagnosis and management of the long-term complications associated to PICS.

Chronic Pain and Chronic Opioid Use After Intensive Care Discharge - Is It Time to Change Practice?

Almost half of patients treated on intensive care unit (ICU) experience moderate to severe pain. Managing pain in the critically ill patient is challenging, as their pain is complex with multiple causes. Pharmacological treatment often focuses on opioids, and over a prolonged admission this can represent high cumulative doses which risk opioid dependence at discharge. Despite analgesia the incidence of chronic pain after treatment on ICU is high ranging from 33-73%. Measures need to be taken to prevent the transition from acute to chronic pain, whilst avoiding opioid overuse. This narrative review discusses preventive measures for the development of chronic pain in ICU patients. It considers a number of strategies that can be employed including non-opioid analgesics, regional analgesia, and non-pharmacological methods. We reason that individualized pain management plans should become the cornerstone for critically ill patients to facilitate physical and psychological well being after discharge from critical care and hospital.