Pain Management in the Critically ill Patient

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1 Pain Management in the Critically ill Patient Jim Ducharme MD CM, FRCP President-Elect, IFEM Clinical Professor of Medicine, McMaster University Adjunct Professor of Family Medicine, Queens University

2 Learning points Recognize pain in the patient unable to respond, but Assume that the critically ill patient will suffer from severe pain Include pain care in your initial resuscitation algorithm Treatment modalities

3 You are intubating someone with acute respiratory failure. Did you consider how much the act of intubation (and subsequent ventilation) will be painful? Have they received any analgesia? Will they?

4 And what are the chances you thought even less about pain management in your stressful resuscitation period of this patient?

5 You would think we would treat this patient s pain automatically but we don t His BP is 70/50, pulse 120. He has 2 open femur fractures and a crush fracture of L2 Priorities: -resuscitate (ABC) -reduce and stabilize fractures -get him into the hands of a surgeon

6 In none of these patients will a pain scale be of value, so how do you know if they are in pain?

7 How have we done in the past? AJEM 2008;26: Inadequate pain relief post intubation IN ED 62/117 received NO analgesic 23 received no analgesia or sedation 67/70 who were paralyzed after intubation received no or inadequate analgesia or sedation

8 It has been no better in the ICU AM J Crit Care 2014;23: In ICU 14 restrained and ventilated patients interviewed: Lack of memory of being restrained Being intubated was horrific Sedation masked uncontrolled pain and prevented patients from telling nurses of their pain

9 Crit Care Resusuc 2013;15: patients in 41 ICUs Pain assessment done in only 46% of patients in 4 hours prior to study observation 16% had moderate pain, 6% severe pain none had received an analgesic Only 42% had sedation titrated to a target level

10 Flail Chest Injuries J Trauma Acute Care Surg 2014;76: From a Canadian national trauma data bank 8% received aggressive pain management (epidural catheters) despite 59% requiring ventilation

11 . Moving forward to 2016 Nurs Clin North Am Mar;51(1): Pain and Agitation Management in Critically Ill Patients Recommendations: Assess regularly, using a validated behavioural tool (RASS, SAS) Minimize sedation to only control agitation Treat pain more, sedate less

12 A first step towards safer sedation and analgesia: A systematic evaluation of outcomes and level of sedation and analgesia in the mechanically ventilated critically ill patient. Jan 2016 Sedation monitored using the Richmond agitation-sedation scale Analgesia effect measured using the numeric rating scale, or behavioural indicators of pain scale Standardized approach on all patients

13 Still not easy however it is a permanent challenge for nurses to discriminate situations requiring sedation from situations requiring analgesia Aust Crit Care Feb;28(1):2-8 Necessary assumption: in agitated patients or in those with increased BP and pulse, these changes are due to pain

14 Ger Med Sci Nov 12;13:Doc19. doi: / Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine

15 Why have emergency departments not taken similar steps? STANDARDIZED PAIN ASSESSMENT AND MANAGEMENT IN ALL CRITICALLY ILL PATIENTS

16 Failure to manage pain has consequences Longer duration of mechanical ventilation Longer ICU length of stay Open Cardiovasc Med J Jun 26;9:91-5

17 . Biomed Res Int. 2015;2015: doi: /2015/ The Impact of Pain Assessment on Critically Ill Patients' Outcomes: A Systematic Review Favorable effects on: pain intensity, duration of mechanical ventilation, length of ICU stay, mortality, adverse events, complications

18 Failure to control pain: the long term consequence of short term failure J Pain Research 2013;6: USA study of 100 post trauma/post surgery patients with neuropathic pain 82 taking 2 or more pain meds Annualized indirect costs: $29,617, with direct costs of $11,846 Interference in Function Sleep Depression Health utility

19 Known for 15 years: trauma pain and PTSD Biol Psychiatry 2009;65: patients admitted for trauma 17 met PTSD criteria at 3 months These patients received significantly less morphine and had greater pain scores during their hospitalization J Am Acad Child Adolesc Psych 2001;40: Children aged 6-16 with burns requiring admission Significant association between the dose of morphine received in hospital and a 6 month reduction in PTSD symptoms. Similar finding reproduced in 2009 for children aged 1-4 years.

20 Some other myths Crit Care Med 2015; 43: Accurate pain assessment cannot be performed in critically ill patients because pain is subjective Opioids are all that is needed for effective pain control Sedation is the same as analgesia when in fact sedation results in worse pain management

21 Baseline and protocolized steps TREATMENT MODALITIES FOR PAIN

22 Establish protocols for regional anesthesia in trauma patients Fractures of femurs or hips U/S guided femoral nerve blocks Epidurals or intercostal nerve blocks for flail chest

23 No intubated patient should leave the ED without an infusion of some analgesic Fentanyl 3 mcg/kg 3-5 minutes prior to intubation mcg/kg/hr Ketamine mg/kg/hr No patient should be intubated without analgesia!

24 No intubated patient should undergo a painful procedure without prior analgesia Suctioning Major line placement Re-positioning a trauma patient Fracture reduction and casting Burn management Etc

25 Sedation is rarely the better answer Sedating does not provide pain relief. Rather it masks it. Treat pain first: only then identify if sedation is required (usually much less) Being intubated was horrific due to uncontrolled pain Easy to forget in such a complex system

26 Summary Pain management should be an integral part of our care It needs to be included in every algorithm for our sickest and most injured patients as it is too easy to overlook EVERY critically ill patient will suffer pain

27 Thank you! Time for any questions An amazing city, an even better conference!

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