Pain in ICU Patients: State-of-the- Science and Next Steps
Kathleen Puntillo RN, PhD, FAAN, FCCM
University of California, San Francisco
Crit Care Med 2013;41(1):263-306.
SCCM Pain Care Bundle
Barr J et al., Crit Care Med 2013
Assess Treat Prevent
www.iculiberation.org
Self-Report of Pain Intensity
0 – 10 Numeric Rating Scale
0-10 visually enlarged horizontal NRS most valid & reliable
Chanques G Pain 2010;151:711-721. Slide courtesy of J-F Payen
Assess
Assess
Can’t Rely on Vital Signs for Pain Assessment
Vital signs should not be used alone to assess pain (are not valid pain indicators)
Vital signs may be used as a cue to begin further assessment of pain
Gelinas C, Johnston C, Clin J Pain 2007; 23:497-505 Barr et al., Crit Care Med 2013;41(1):263-306
Payen JF et al., Crit Care Med 2001;29: 2258-2263.
Crit Care Med 2013;41(1):263-306.
Behaviors
• THE SILENT PATIENT • THE SILENT SCREAM
Munch
Behavioral Pain Assessment
The Behavioral Pain Scale (BPS) & the Critical-Care Pain Observation Tool (CPOT) are the most valid and reliable scales for pain in medical, postoperative, or trauma (except for brain injury) adult ICU patients who are unable to self-report & in whom motor function is intact & behaviors are observable.
Crit Care Med 2013;41(1):263-306.
Pain Behaviors
• Behavioral Pain Scale (BPS)
(Payen JF et al., CCM, 2001)
• Critical Care Pain
Observation Tool (CPOT)
(Gelinas C et al., AJCC, 2006)
• Behavior Pain Assessment
Tool (BPAT) (Gelinas, Puntillo et al.,
Pain, 2017)
Behavioral Pain Scale
ITEM SCORE
FACIAL EXPRESSION
1 Relaxed2 Partially tightened 3 Fully tightened 4 Grimacing
UPPER LIMBS
1 No movement2 Partially bent
3 Fully bent with finger flexion 4 Permanently retracted
COMPLIANCE WITH VENTILATOR
1 Tolerating movement2 Coughing but tolerating ventilator most of time
3 Fighting ventilator
4 Unable to control ventilation
Score Range 3 – 12. Significant pain = BPS >5
CPOT
INDICATOR SCORE
FACIAL EXPRESSION Relaxed, neutral 0
Tense 1
Grimacing 2
BODY MOVEMENTS Absence of movements 0
Protection 1
Restlessness 2
MUSCLE TENSION (evaluate by passive flexion and extension of upper extremities) Relaxed 0
Tense, rigid 1
Very tense or rigid 2
COMPLIANCE WITH VENTILATOR (intubated patients) OR VOCALIZATION (extubated patients) Alarms not activated; easy ventilation 0
Coughing but tolerating 1
Fighting ventilator 2
Talking in normal tone or no sound 0
Sighing, moaning 1
Crying out, sobbing 2
CPOT score range = 0 – 8; CPOT >2 is significant
Behavior Pain Assessment Tool
Europain ® Study of Procedural Pain
• 4812 procedures among 3851 patients in 192 ICUs in 28 countries
• 2 raters were members of each ICU’s interdisciplinary team (e.g., nurses, physicians, respiratory therapists, physiotherapists, etc.)
Gelinas C, Puntillo K, Levin P, Azoulay E. Pain, 2017
Present Absent Behavior Definition Photos of Behaviors
Neutral expression
Muscles relaxed
Grimace A sharp contortion of the face
Wince To shrink away from, or start
Eyes closed Lids are shut
Moaning Low, soft
indistinguishable sounds
Verbal
complaints of pain
Words used to describe pain,
e.g., it hurts, ouch
Rigid Stiff, tensed muscles of extremities and torso
Clenched fists Act of forming a fist
B
P
A
T
Present Absent Behavior Definition Photos of Behaviors
Neutral expression
Muscles relaxed
Grimace A sharp contortion of the face
Wince To shrink away from, or start
Eyes closed Lids are shut
Moaning Low, soft
indistinguishable sounds
Verbal
complaints of pain
Words used to describe pain,
e.g., it hurts, ouch
Rigid Stiff, tensed muscles of extremities and torso
Clenched fists Act of forming a fist
B
P
A
T
Results
Discriminant validation
Each behavior according to sedation level (i.e., RASS score, from -5 to +4)
Most behaviors (except for neutral expression) were more likely to be present during the procedure
RASS scores were found to influence the likelihood of observing the
presence of all behaviors
BPAT score >3.5 = severe pain
Behavioral Pain Scale – Non-intubated (BPS-NI)
ITEM SCORE
FACIAL EXPRESSION
1 Relaxed2 Partially tightened 3 Fully tightened 4 Grimacing
UPPER LIMBS
1 No movement 2 Partially bent3 Fully bent with finger flexion 4 Permanently retracted
VOCALIZATION
1 No pain vocalization
2 Moaning, not frequent or prolonged 3 Moaning, frequent or prolonged
4Howling or verbal complaint including “ow,”
“ouch,” or breath-holding
Chanques G, Payen JF, Mercier G. ICM, 2009
Pain Behaviors in Delirious Patients
CPOT
• Psychometric properties of CPOT tested
– 40 CAM-ICU + patients – Multiple diagnoses; 90%
ventilated
– During painful and non- painful procedures
– Excellent validity and reliability; better than vital signs
BPS-NI
• Psychometric properties BPS-NI tested
– Vocalization vs ventilator – 120 observations in 30
patients, 84% CAM-ICU + – During painful and non-
painful procedures
– Good discriminant validity, internal consistency, inter- rater reliability
Kanji et al., Crit Care Med, 2016 Chanques G et al.,Inten Care Med, 2009
BPS – NI in Non-ventilated Patients
• 30 paired assessments
• Discriminant validation: Lower scores at rest than during turning
• Inter-rater reliability
– Fair to good at rest: weighted kappas = 0.21 to 0.63 – Moderate to good during turning: weighted kappas =
0.38 – 0.63
• “Training is important!”
Olsen BF, Rustoen T, Sandvik L et al., Heart & Lung 2015
Pain Behaviors in Brain-injured Patients
On-going research on modification of CPOT for brain-injured and brain surgery patients
(Echegaray-Benites et al., 2014; Wibbenmeyer et al., 2011; Gelinas C et al., 2016)
– 45 patients hospitalized for moderate or severe TBI.
• TBI patients’ pain behaviors were mostly
“atypical”:
» uncommon responses such as flushing, sudden eye opening, eye weeping, and flexion of limbs.
(Arbour C et al., 2014)
Notes about Pain Behaviors Scales
• Be cautious: behavioral score self-report score
– For example: 8/10 self-report NRS 6.4/8 CPOT score
• Behaviors detect presence/absence of pain and
detect pain at moderate-to-severe level but not cut- off scores for mild, moderate, severe
– CPOT : ‘’significant’’ - score 3 - 8
– BPS : ‘’significant‘’ score 6 – 12
– BPAT: ‘ ’significant‘’ score 4 – 8
Does Use of a Behavioral Pain Scale Make a Difference in Practice?
PROCESS MEASURES OUTCOME MEASURES More frequently
documented pain assessments
Decreased use of
analgesics and sedatives in cardiac ICU
More frequently documented pain reassessments after therapy
Decreased use of sedatives
Gelinas et al., 2011; Rose et al., 2013
Study of CPOT
SCCM Pain Care Bundle
Recommended in Barr J Crit Care Med 2013;41(1):263-306
Assess Treat Prevent
www.iculiberation.org
Treatment of Pain in ICU Patients
IV opioids as the first-line drug class of choice
All available IV opioids, when titrated to similar pain intensity endpoints, are equally effective
Suggest non-opioid analgesics to replace or decrease the opioid amounts
Crit Care Med 2013;41(1):263-306.
Treat
A Current View of Approaching ICU Pain Management
• Multimodal analgesia: Use of opioids and/or non-opioid analgesics and/or non-
pharmacologic analgesic interventions
• Analgosedation: “Analgesia-based-sedation”
- priority given to use of analgesics before
sedatives (“analgesia first”).
Multimodal Analgesia
A “balanced approach” to minimize opioids and their related side-effects
titration of opioids and non-opioids
opioid weaning over time
prevent adverse effects of large doses of opioids and enhance pain relief
White & Kehlet, 2100; Erstad et al., 2009
Analgosedation
“Analgesia first” or “analgesia-based” sedation
Priority given to pain relief
Decrease sedative doses and their potential negative consequences
Agitation could be from pain and discomfort
related to tracheal tube, ventilator, and inability of patient to communicate pain.
May also lead to lighter sedation; more awake, responsive patients; and better clinical outcomes
Faust et al., Anesth & Analg, 2016; Devabhakthuni et al., Crit Care, 2012
Effects of Analgo-Sedation Protocol
• Before-and-after study of neuro patients (n= 106 vs n = 109)
• 1 st : assess pain & analgesic needs; rx with opioid infusions (remifentanil or fentanyl)
• 2 nd : assess for agitation & sedative needs:
rx with propofol, midazolam, barbiturates
Also consider HOB, daily sedation interruption, SBT & extubation, DVT
prevention
Egerod I et al., Criti Care, 2010
Results
• Protocol feasible
• propofol, midazolam
• fentanyl, remifentanil
• Daily wake-ups faster
• More “oriented and cooperative”
• Mean pain score from 1.54 + .73 to 1.24 + .61
• % pain-free patients from 57% to 83%, estimated by nurses
• No change in ICU, hospital LOS, MV time, mortaity
Egerod I et al., Crit Care, 2010
Analgosedation: Next Steps
• Develop and test institutional assessment- driven protocols in heterogeneous patient populations
• Make treating pain a priority
• Use validated pain and agitation/sedation scales
• Provide guidance about medication choices
• Consider safety concerns
SCCM Pain Care Bundle
Recommended in Barr J Crit Care Med 2013;41(1):263-306
Assess Treat Prevent
www.iculiberation.org
A Study of Procedural Pain:
Europain
®Hôpital St. Louis, Paris
Funded by Established Investigator Award, ESICM, 2009 (K Puntillo, PI)
28 countries, 192 ICUs, 4,812 procedures
Europain ® Procedures
1. Chest tube removal 2. Wound drain removal 3. Arterial line insertion 4. ET suction
5. Trach suction
6. Peripheral IV insertion
7. Peripheral blood draw 8. Turning
9. Respiratory exercises 10. Positioning
11. Wound care
12. Mobilization
Europain ®
0 1 2 3 4 5 6
CTR Wound Drain Removal Art Line Insertion Mobilization
Before During
Median P rocedur al Pain Sc or es
Puntillo K et al. Am J Respir Crit Care Med. 2014;189(1):39-47
.
Europain ®
Risk Factors for Increased Procedural Pain Intensity
• The specific procedure (RR 1.06 – 1.67)
• Degree of pre-procedural pain intensity (RR 1.06) and distress (RR 1.04)
• Degree of worst pain before the procedure (RR 1.07)
• Person performing the procedure- MD, therapists compared to nurse (RR 1.10 – 1.22)
• Whether patients received opioids specifically for the procedure (RR 1.22)
Puntillo K et al., AJRCCM, 2014
Procedural Pain Has Consequences
Severe procedural pain is was associated with severe adverse events:
• Tachycardia, bradycardia
• Hypertension, hypotension
• Desaturation, bradypnea
• Ventilator distress
De Jong A et al., Crit Care, 2013
Prevent Procedural Pain in ICU Patients
Recommend pre-emptive analgesia and/or non- pharmacologic interventions (e.g., relaxation) be administered prior to chest tube removal
Suggest pre-emptive analgesic therapy and/or non- pharmacologic interventions prior to
other procedures Prevent
Crit Care Med 2013;41(1):263-306.