'Pain in the ICU' report suggests comprehensive approach

(Northbrook, IL, April 7, 2009) – Managing pain in the ICU is an ongoing and significant challenge for the critical care team. However, new reports suggest that taking a comprehensive 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 Critical Care Institute of the ACCP, 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 comprehensive approach to pain management—one that combines pharmacotherapy with behavioral, social, and communication strategies, interdisciplinary teams, and family involvement.

Patients in the ICU have unique characteristics that provide significant challenges for the critical care team. Critically ill patients may suffer disproportionately compared with other patients, experiencing significant pain from their life-threatening illness or injury, and additional pain associated with simple procedures, such as endotracheal suctioning or 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, Virginia Commonwealth University Medical Center, Richmond, VA. "An interdisciplinary critical care team who uses standard and alternative methods of pain assessment, evaluation, and management is essential for optimal patient care."

Standard tools for pain assessment and evaluation, which typically rely on a patient's own verbal report, may be ineffective for critically ill patients who are unable to communicate. In these situations, the critical care team can use alternative methods for pain assessment, including the following:

• Patient Risk Profile—This tool identifies the patient's risk of pain prior to a procedure and allows the team to administer preemptive pain management, whereby decreasing the incidence of pain.
• Nonverbal Communication—Patients who cannot speak or have difficulty 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 ICU team can use "surrogate reports" from family members who may be able assess a loved one's pain based on history.

"Critical care professionals have come to value family members of patients as an integral part of the care process," said Kathleen Puntillo, RN, CNS, DNSc, FAAN, lead author of the Evaluation article and Co-Director of the Critical Care/Trauma Program, Department of Physiological Nursing, University of California, San Francisco, CA. "Although family members' surrogate pain reports may be helpful, their effectiveness still requires more research."

Organ failure, sepsis, and other medical complications can make it difficult to manage pain in the critically ill. The use of opioids or related medications is the standard method of acute pain control, and the choice of which opioid to use is carefully selected based on the uniqueness of each patient's pain management issues, as well as potential side effects and drug interactions.

"Much of the research on pain medications has been conducted in non-ICU settings. The ICU clinician must extrapolate and apply this research to the care of critically ill patients who frequently have tenuous and rapidly changing clinical conditions that complicate pharmacotherapy decisions," said Brian L. Erstad, PharmD, FCCM, lead author of the Pain Management report and Professor, University of Arizona College of Pharmacy, Tucson, AZ.

"Although pain in the ICU is inevitable, there are a number of unique 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 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.

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 www.chestnet.org.