Report Suggests Holistic Approach To Reduce Pain In The ICU

(Northbrook, IL, April 6, 2009) – Managing pain in the intensive care unit (ICU) is an ongoing and significant challenge for the critical care team. However, new reports suggest that taking a holistic approach to pain management may be the key to managing pain in the ICU and even decreasing the incidence of preventable pain.

Published in the April issue of CHEST, the peer-reviewed journal of the American College of CHEST Physicians (ACCP) the two reports titled, Evaluation of Pain in ICU Patients and Pain Management Principles in the Critically Ill, are the first in a series of five papers developed by critical care experts from the American College of CHEST Physicians Critical Care Institute, American Association of Critical-Care Nurses, and the American Society of Health-System Pharmacists. As a whole, the article series reviews the complex nature of pain experienced by a critical care patient and details the benefits of taking a holistic approach to pain management, one that combines pharmacological interventions with behavioral, social, and communication strategies, interdisciplinary teams, and family involvement.

The Complex Nature of Pain in the ICU
Patients in the ICU present with unique characteristics that provide significant challenges for the critical care team. Critically ill patients may suffer disproportionately from other patients, experiencing significant pain from their life-threatening illness or injury, and additional pain associated with simple procedures, such as the removal of a CHEST tube. Furthermore, critically ill patients are often unable to effectively communicate pain to their caregivers, making it difficult to assess and manage pain sufficiently.

“The complex nature of caring for the critically ill, particularly in the area of pain management, requires a more holistic approach to patient care,” said Curtis N. Sessler, MD, FCCP, author of an accompanying editorial and Medical Director of Critical Care, Medical College of Virginia Hospitals, Richmond, VA. “An interdisciplinary critical care team who utilizes standard and alternative methods of pain assessment, evaluation, and management, is essential for optimal patient care.”

Assessing Pain In Critically Ill Patients
A basic tenet of pain management is that preventing pain or the escalation of pain through early recognition and control is easier than managing the pain effectively after it is out of control. However, standard tools for pain assessment and evaluation, which rely on a patient’s verbal self-report, may be ineffective in critically ill patients who are unable to communicate. In these situations, the critical care team can use alternative methods for pain assessment, including:

• Patient Risk Profile – Prior to any procedure, the critical care team can complete a patient risk profile, which identifies the patient’s risk of pain. This allows the team to administer preemptive pain management, whereby decreasing the incidence of pain.
• Nonverbal Communication – A patient who can’t speak or has difficult speaking may be able to point or blink when referring to a pain scale.
• Analgesic Trial – To verify the presence of pain, the ICU team can administer a low dose of first-line analgesic followed by observation of the patient’s pain-related behaviors.
• Surrogate Reporting – If patients are unable to communicate, the critical care team can use “surrogate reports” from family members who may be able to offer their perspectives about the patient’s current pain status or to provide a description of behaviors that might be indicative of pain based upon their history with the patient.

“Pain is becoming more recognizable in the critically ill patient through the use of alternative pain assessment, including the use of family members’ surrogate pain reports,” said Kathleen Puntillo, RN, CNS, DNSc, FAAN, author of the Evaluation article and Co-Director of the Critical Care/Trauma Program, Department of Physiological Nursing, University of California, San Francisco, CA. “Critical care professionals have come to value family members of patients as an integral part of the care process. Whether assisting with pain assessment or standing vigil by a loved one’s side, family members can work together with the health-care team to improve patient care.”

Managing Pain in Critically Ill Patients
Organ failure, sepsis, and other medical complications can make it difficult to manage pain in the critically ill. The use of opioids or related derivatives is the standard method of acute pain control and the choice of opioid is carefully selected based on the uniqueness of each patient’s pain management issues. The critical care team must also consider the numerous side effects of opioids, including allergy, arrhythmias, induced bowel dysfunction, and opioid withdrawal, as well as drug interactions. In addition to opioids, the critical care team may elect to use complementary interventions for pain management, including music intervention, relaxation techniques, or sensory and procedural information, informing the patient of impending painful procedures.

“Complementary therapies can promote a supportive, caring environment and help increase comfort and reduce stress,” said Brian L. Erstad, PharmD, FCCM, author of the Pain Management article and Professor, University of Arizona College of Pharmacy, Tucson, AZ. “However, we should remain cautious about their effectiveness and use them to complement traditional pain management therapy.”

The additional three papers in the critical care series will appear in the May and June issues of CHEST and discuss interdisciplinary teams, regional anesthetic options, and palliative and end-of-life care.

“Although pain in the ICU is inevitable, there are a number of new interventions that critical care professionals can use to anticipate, manage, and even prevent pain from occurring,” said James A.L. Mathers, Jr., MD, FCCP, President of the American College of Chest Physicians. “Physicians, nurses, pharmacists, and other members of the extended critical care team should continue to make effective pain assessment and management a priority in the ICU.”

The ACCP represents 17,400 members who provide patient care in the areas of pulmonary, critical care, and sleep medicine in the United States and throughout the world. The ACCP’s mission is to promote the prevention and treatment of diseases of the chest through leadership, education, research, and communication. For more information about the ACCP, please visit the ACCP Web site at www.chestnet.org.