A randomized controlled trial of fentanyl in the pre-emptive treatment of pain associated with turning in patients under mechanical ventilation: research protocol

Individualised analgesia, sedation, delirium and comfort management strategies in the ICU: a narrative review

This group is a product of the collaboration agreement signed by SOMIAMA (Sociedad de Medicina Intensiva de Madrid) and SAR MADRID (Sociedad de Anestesiología, Reanimación y Terapéutica del Dolor de Madrid) under which the organisations agreed to create joint working groups to improve critical patient care. Pain, discomfort, agitation, and delirium cause suffering, delay discharge, and can lead to serious complications in patients admitted to medical and surgical critical care units and post-anaesthesia care units. The main objectives in this type of unit include: Ensuring the comfort of patients suffering or recovering from a critical illness.Avoiding complications associated with the measures, particularly pharmacological, taken to ensure that comfort.

Importance of preemptive analgesia and pain assessment as perceived by intensive care unit nurses

Background

The importance and efficacy of Preemptive analgesia in reducing pain for patients undergoing painful procedures still debatable and seldom investigated. The aim of this study was to describe intensive care nurses' perception of the importance of pain assessment and Preemptive analgesia prior painful procedures in critical care settings in Jordan.

Method

A cross-sectional descriptive design was used. The sample consisted of 300 registered nurses recruited from 22 intensive care units in Jordan. The data was gathered using a self-administered questionnaire.

Results

The results showed that nurses considered pain assessment moderately and extremely important for surgical (n = 263, 87.7%), burn (n = 261, 87%), and trauma patients (n = 256, 85.3%). The majority of nurses rated pain assessment as moderately to extremely important for invasive line placement 80.3%, wound care 78.3%, and drain removal 69%. Nurses assessed the need for Preemptive analgesia more frequently before wound care 70.7%, and before invasive line placement 69.7%. Nurses perceived pain assessment for Preemptive analgesia as less priority for unconscious patients.

Conclusion

Effective assessment and management of pain for critically ill patients is mandatory. Thus, it is important to improve nurses' knowledge regarding the Preemptive analgesia and its effects in relieving post-procedural pain in critically ill patient. It is recommended to ensure proper clinical training on how to assess critically ill patients and auditing system.

Specificity and sensibility of the Spanish version of the COMFORT Behaviour Scale for assessing pain, grade of sedation and withdrawal syndrome in the critically ill paediatric patient. Multicentre COSAIP study (Phase 1)

AIM

The main aim of this investigation was to analyse the specificity and sensibility of the COMFORT Behaviour Scale (CBS-S) in assessing grade of pain, sedation, and withdrawal syndrome in paediatric critical care patients.

METHOD

An observational, analytical, cross-sectional and multicentre study conducted in Level III Intensive Care Areas of 5 children's university hospitals. Grade of sedation was assessed using the Spanish version of the CBS-S and the Bispectral Index on sedation, once per shift over one day. Grade of withdrawal was determined using the CBS-S and the Withdrawal Assessment Tool-1, once per shift over three days.

RESULTS

A total of 261 critically ill paediatric patients with a median age of 5.07 years (P25:0.9-P75:11.7) were included in this study. In terms of the predictive capacity of the CBS-S, it obtained a Receiver Operation Curve of .84 (sensitivity of 81% and specificity of 76%) in relation to pain; .62 (sensitivity of 21% and specificity of 78%) in relation to sedation grade, and .73% (sensitivity of 40% and specificity of 74%) in determining withdrawal syndrome.

CONCLUSIONS

The Spanish version of the COMFORT Behaviour Scale could be a useful, sensible and easy scale to assess the degree of pain, sedation and pharmacological withdrawal of critically ill paediatric patients.

Specificity and sensibility of the Spanish version of the COMFORT Behaviour Scale for assessing pain, grade of sedation and withdrawal syndrome in the critically ill paediatric patient. Multicentre COSAIP study (Phase 1)

AIM

The main aim of this investigation was to analyse the specificity and sensibility of the COMFORT Behaviour Scale (CBS-S) in assessing grade of pain, sedation, and withdrawal syndrome in paediatric critical care patients.

METHOD

An observational, analytical, cross-sectional and multicentre study conducted in Level III Intensive Care Areas of 5 children's university hospitals. Grade of sedation was assessed using the Spanish version of the CBS-S and the Bispectral Index on sedation, once per shift over one day. Grade of withdrawal was determined using the CBS-S and the Withdrawal Assessment Tool-1, once per shift over three days.

RESULTS

A total of 261 critically ill paediatric patients with a median age of 5.07 years (P25:0.9-P75:11.7) were included in this study. In terms of the predictive capacity of the CBS-S, it obtained a Receiver Operation Curve of .84 (sensitivity of 81% and specificity of 76%) in relation to pain; .62 (sensitivity of 21% and specificity of 78%) in relation to sedation grade, and .73% (sensitivity of 40% and specificity of 74%) in determining withdrawal syndrome.

CONCLUSIONS

The Spanish version of the COMFORT Behaviour Scale could be a useful, sensible and easy scale to assess the degree of pain, sedation and pharmacological withdrawal of critically ill paediatric patients.

Pain among non-verbal critically Ill mechanically ventilated patients: Prevalence, correlates and predictors

PURPOSE

To investigate pain levels and factors that are predictive of pain for mechanically ventilated patients during rest and during routine nursing procedures.

MATERIAL AND METHODS

Pain levels were assessed using Behavioral Pain Scale (BPS) and physiological measures among 247 mechanically ventilated patients.

RESULTS

At rest, 33.2% of patients suffered pain, with a BPS > 3; of these, 10% presented significant pain levels (BPS ≥ 5). Variables that correspondingly predicted resting pain were age (β = -0.010, p < 0.001), sedation score (β = -0.153, p < 0.01), and method of ventilation (β = -0.281, p = 0.021). During the procedures, 90% of patients suffered pain, with a median BPS of 6 (IQR: 4-8), and 83% of patients experienced significant pain levels. Age (β = -0.022, p = 0.001), sedation score (β = -0.355, p < 0.001), receiving sedation and/or analgesia in last hour (β = 0.483, p = 0. 01), resting pain levels (β = -0.742, p < 0.001) and the type of painful procedure (β = -0.906, p < 0.001) were significant predictors of procedural pain.

CONCLUSIONS

Many mechanically ventilated patients suffer resting and procedural pain. Many variables were found to play a role. Clinicians need to consider these variables and intervene to decrease pain among patients at risk.

Care-related Pain in Critically Ill Mechanically Ventilated Patients

Despite advances in pain management, critically ill patients continue to have unacceptably high rates of uncontrolled pain. Using the Behavioural Pain Scale and physiological indicators of pain, this study examines pain levels in mechanically ventilated patients prior to and during routine nursing procedures. A prospective descriptive design was used to assess and describe care-related pain associated with nociceptive procedures (repositioning, endotracheal suctioning, and vascular punctures) and non-nociceptive procedures (mouth care, eye care and dressing change). A sample of 247 mechanically ventilated Jordanian patients was recruited from intensive care units in a military hospital. The overall mean procedural pain score of 6.34 (standard deviation [SD] 2.36) was significantly higher than the mean preprocedural pain score of 3.43 (SD 0.67, t[246] = 20.82, P <0.001). The highest mean procedural pain scores were observed during repositioning (9.25, SD 1.29). Few patients received analgesics and/or sedatives in the hour prior to the procedures. The mean Ramsay Scale score was 2.49 (SD 0.95), indicating that patients were either anxious or responsive to command only. The mean physiological indicators of pain increased during repositioning and endotracheal suctioning and decreased during the rest of the procedures. Mechanically ventilated patients experience pain prior to and during routine nursing procedures. Harmless and comfort procedures are actually painful. When caring for nonverbal critically ill patients, clinicians need to consider care-related pain associated with their interventions. Relying on changes in vital signs as a primary indicator of pain can be misleading.

Comparison of Bispectral Index Monitoring With the Critical-Care Pain Observation Tool in the Pain Assessment of Intubated Adult Patients After Cardiac Surgery

Background

Detecting pain is crucial in sedated and mechanically ventilated patients, as they are unable to communicate verbally.

Objectives

This study aimed to compare Bispectral index (BIS) monitoring with the Critical-care pain observation tool (CPOT) and vital signs for pain assessment during painful procedures in intubated adult patients after cardiac surgery.

Materials and Methods

Seventy consecutive patients who underwent cardiac surgery (coronary artery bypass graft or valvular surgery) were enrolled in the study. Pain evaluations were performed early after the operation in the intubated and sedated patients by using BIS and CPOT, and also checking the vital signs. The pain assessments were done at three different times: 1) baseline (immediately before any painful procedure, including tracheal suctioning or changing the patient’s position), 2) during any painful procedure, and 3) five minutes after the procedure (recovery time).

Results

The mean values for CPOT, BIS, and mean arterial pressure (MAP) scores were significantly different at different times; they were increased during suctioning or changing position, and decreased five minutes after these procedures (CPOT: 3.98 ± 1.65 versus 1.31 ± 1.07, respectively (P ≤ 0.0001); BIS: 84.94 ± 10.52 versus 63.48 ± 12.17, respectively (P ≤ 0.0001); MAP: 92.88 ± 15.37 versus 89.77 ± 14.72, respectively (P = 0.003)). Change in heart rate (HR) was not significant over time (95.68 ± 16.78 versus 93.61 ± 16.56, respectively; P = 0.34). CPOT scores were significantly positively correlated with BIS at baseline, during painful stimulation, and at recovery time, but were not correlated with HR or MAP, except at baseline. BIS scores were significantly correlated with MAP but not with HR.

Conclusions

It appears that BIS monitoring can be used for pain assessment along with the CPOT tool in intubated patients, and it is much more sensitive than monitoring of hemodynamic changes. BIS monitoring can be used more efficiently in intubated patients under deep sedation in the ICU.

Measurement of Heart Rate Variability to Assess Pain in Sedated Critically Ill Patients: A Prospective Observational Study

Introduction

The analgesia nociception index (ANI) assesses the relative parasympathetic tone as a surrogate for antinociception/nociception balance in sedated patients. The aim of this study is to determine the effectiveness of ANI in detecting pain in deeply sedated critically ill patients.

Methods

This prospective observational study was performed in two medical ICUs. All patients receiving invasive mechanical ventilation and deep sedation were eligible. In all patients, heart rate and ANI were continuously recorded using the Physiodoloris^® device during 5 minutes at rest (T1), during a painful stimulus (T2), and during 5 minutes after the end of the painful stimulus (T3). The chosen painful stimulus was patient turning for washstand. Pain was evaluated at T2, using the behavioral pain scale (BPS). The primary objective was to determine the effectiveness of ANI in detecting pain. Secondary objectives included the impact of norepinephrine on the effectiveness of ANI in detecting pain, and the correlation between ANI and BPS.

Results

Forty-one patients were included. ANI was significantly lower at T2 (Med (IQR) 69(55–78)) compared with T1 (85(67–96), p<0.0001), or T3 (81(63–89), p<0.0001). Similar results were found in the subgroups of patients with (n = 21) or without (n = 20) norepinephrine. ANI values were significantly higher in patients with norepinephrine compared with those without norepinephrine at T1, and T2. No significant correlation was found between ANI and BPS at T2.

Conclusions

ANI is effective in detecting pain in deeply sedated critically ill patients, including those patients treated with norepinephrine. No significant correlation was found between ANI and BPS.