Association between organizational characteristics and adequate pain management at the intensive care unit

This article by Roos-Blom and others was first published online in the Journal of Critical Care during November 2019.
Purpose:  Half of the patients experience pain during their ICU stay which is known to influence their outcomes. Nurses and physicians encounter organizational barriers towards pain assessment and treatment. We aimed to evaluate the association between adequate pain management and nurse to patient ratio, bed occupancy rate, and fulltime presence of an intensivist.
Materials and methods:  We performed unadjusted and case-mix adjusted mixed-effect logistic regression modeling on data from thirteen Dutch ICUs to investigate the association between ICU organizational characteristics and adequate pain management, i.e. patient-shift observations in which patients’ pain was measured and acceptable, or unacceptable and normalized within 1 h.
All ICU patients admitted between December 2017 and June 2018 were included, excluding patients who were delirious, comatose or had a Glasgow coma score < 8 at the first day of ICU admission.
Results:  Case-mix adjusted nurse to patient ratios of 0.70 to 0.80 and over 0.80 were significantly associated with adequate pain management (OR [95% confidence interval] of respectively 1.14 [1.07–1.21] and 1.16 [1.08–1.24]). Bed occupancy rate and intensivist presence showed no association.
Conclusion:  Higher nurse to patient ratios increase the percentage of patients with adequate pain management especially in medical and mechanically ventilated patients.
The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Non-opioid analgesics as adjuvants to opioid for pain management in adult patients in the ICU: A systematic review and meta-analysis

This research by Zhao and colleagues was published online in the Journal of Critical Care during August 2018.
Purpose:  To identify the impact of non-opioid analgesics as adjuvants to opioid on opioid consumption and its side effects, as well as the analgesic effectiveness in adult patients in the ICU.
Methods:  Only randomized clinical trials using non-opioid analgesics for analgesia in the ICU were included. Pooled analyses with 95% CI were determined.
Results:  Twelve studies (mainly surgical and Guillain-Barre syndrome patients) were included. Non-opioid analgesics as adjuvants to opioid were associated with a significant reduction in the consumption of opioids when compared with opioid use alone at Day 1 (MD -15.40; 95% CI -22.41 to −8.39; P< .001) and Day 2 (MD -22.93; 95% CI -27.70 to −18.16; P< .001). Non-opioid analgesics as adjuvants to opioid were associated with a significantly lower incidence of nausea and vomiting when compared with opioid use alone (RR 0.46; 95% CI 0.30 to 0.68; P< .001). Non-opioid analgesics as adjuvants to opioid significantly decreased the pain score at Day 1 (MD -0.68; 95% CI -1.28 to −0.08; P = .03) and Day 2 (MD -1.36; 95% CI -2.47 to −0.24; P = .02).
Conclusions:  Non-opioid analgesics as adjuvants to opioid reduced the consumption and the side effects of opioids in adult surgical and Guillain-Barre syndrome patients in the ICU.
The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Current practice and perceptions regarding pain, agitation and delirium management in patients receiving venovenous extracorporeal membrane oxygenation

This article by Dzierba and colleagues was first published in the Journal of Critical Care during May 2019.
Purpose:  To characterize monitoring of pain, agitation, and delirium; investigate opioid and sedative choices; and describe prevention and treatment of delirium in adults receiving venovenous extracorporeal membrane oxygenation (vv-ECMO) for respiratory failure.
Materials and methods:  International, cross-sectional survey distributed January 2018 to members of the Society of Critical Care Medicine.
Results:  Respondents were predominately physicians (58%) from North America (89%). Fentanyl (77%) and hydromorphone (48%) were the most common intravenous opioids used to manage pain. A deep level of sedation was targeted in the first 24-h after initiation of vv-ECMO 64% of the time. When deep sedation was targeted, propofol (70%) and benzodiazepines (41%) were the most common sedatives. The most common sedatives for light sedation were dexmedetomidine (45%) and propofol (39%). Delirium prevention included avoidance of benzodiazepines (73%), whereas the most common treatment strategy was scheduled atypical antipsychotics (83%). Centers that extubated patients during vv-ECMO used dexmedetomidine as the second preferred sedative as compared to benzodiazepines at non-extubating centers (p = 0.04).
Conclusions:  Most respondents use validated scales and protocols to assess and manage pain, agitation/sedation, and delirium. The majority of respondents reported targeting a deep level of sedation with propofol being used for both deep and light levels of sedation.
The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Regional anesthesia and analgesia after surgery in ICU

The aim is to demonstrate that ICU physicians should play a pivotal role in developing regional anesthesia techniques that are underused in critically ill patients despite the proven facts in perioperative and long-term pain, organ dysfunction, and postsurgery patient health-related quality of life improvement | Current Opinion in Critical Care

Regional anesthesia and/or analgesia strategies in ICU reduce the surgical and trauma–stress response in surgical patients as well as complications incidence. Recent studies suggested that surgical/trauma ICU patients receive opioid–hypnotics continuous infusions to prevent pain and agitation that could increase the risk of posttraumatic stress disorder and chronic neuropathic pain symptoms, and chronic opioid use. Regional anesthesia use decrease the use of intravenous opioids and the ectopic activity of injured small fibers limiting those phenomena. In Cochrane reviews and prospective randomized trials in major surgery patients, regional anesthesia accelerates the return of the gastrointestinal transit and rehabilitation, decreases postoperative pain and opioids use, reduces ICU/hospital stay, improves pulmonary outcomes, including long period of mechanical ventilation and early extubation, reduces overall adverse cardiac events, and reduces ICU admissions when compared with general anesthesia and intravenous opiates alone. The reduction of long-term mortality has been reported in major vascular or orthopedic surgeries.

Promoting regional anesthesia/analgesia in ICU surgical/trauma patients could undoubtedly limit the risk of complications, ICU/hospital stay, and improve patient’s outcome. The use of regional anesthesia permits a high doses opioid use limitation which is mandatory and should be considered as feasible and well tolerated in ICU.

Full reference: Capdevila, M. et al. (2017) Regional anesthesia and analgesia after surgery in ICU. Current Opinion in Critical Care. Vol. 23 (Issue 5) pp. 430–439

Pain Assessment in INTensive care (PAINT)

Kemp, H.I. et al. Anaesthesia. Published online: 19 February 2017

Pain is a common and distressing symptom experienced by intensive care patients. Assessing pain in this environment is challenging, and published guidelines have been inconsistently implemented. The Pain Assessment in INTensive care (PAINT) study aimed to evaluate the frequency and type of physician pain assessments with respect to published guidelines.

The likelihood of receiving a physician pain assessment was affected by the following factors: the number of nursing assessments performed; whether the patient was admitted as a surgical patient; the presence of tracheal tube or tracheostomy; and the length of stay in ICU. Physician-documented pain assessments in the majority of participating ICUs were infrequent and did not utilise recommended behavioural pain assessment tools. Further research to identify factors influencing physician pain assessment behaviour in ICU, such as human factors or cultural attitudes, is urgently needed.

Read the full abstract here

Nurses’ Beliefs Regarding Pain in Critically Ill Children

LaFond, C.M. et al. Journal of Pediatric Nursing. Published online: September 3 2016

Highlights

  • Nurses’ beliefs regarding critically ill children’s pain was described and compared.
  • Most beliefs were consistent with effective pain management practices.
  • Inaccurate beliefs included pharmacokinetics and use of behavior to verify pain.
  • Divergent and conflicting beliefs related to the legitimacy of a child’s pain report.
  • Nurses believe that unrelieved pain is harmful but also concerned about use of opioids.

Abstract

Purpose: The purpose of this study was to provide a current and comprehensive evaluation of nurses’ beliefs regarding pain in critically ill children.

Design and Methods: A convergent parallel mixed-methods design was used. Nurse beliefs were captured via questionnaire and interview and then compared.

Results: Forty nurses participated. Most beliefs reported via questionnaire were consistent with effective pain management practices. Common inaccurate beliefs included the need to verify pain reports with physical indicators and the pharmacokinetics of intravenous opioids. Beliefs commonly shared during interviews concerned the need to verify pain reports with observed behavior, the accuracy of pain reports, the need to respond to pain, concerns regarding opioid analgesics, and the need to “start low” with interventions. Convergent beliefs between the questionnaire and interview included the use of physical indicators to verify pain, the need to take the child’s word when pain is described, and concerns regarding negative effects of analgesics. Divergent and conflicting findings were most often regarding the legitimacy of a child’s pain report.

Conclusions: Findings from this study regarding the accuracy of nurses’ pain beliefs for critically ill children are consistent with past research. The presence of divergent and conflicting responses suggests that nurses’ pain beliefs are not static and may vary with patient characteristics.

Practice Implications: While most nurses appreciate the risks of unrelieved pain in children, many are concerned about the potential adverse effects of opioid administration. Interventions are needed to guide nurses in minimizing both of these risks.

Read the abstract here

Results of Implementing a Pain Management Algorithm in Intensive Care Unit Patients

Olsen, B.F. et al. Journal of Critical Care.Published online: 16 July 2016

B0003338 Artwork - pain and disturbance
Image source: Chris Nurse – Wellcome Images // CC BY-NC-ND 4.0

Image shows artwork representing pain and disturbance

Purpose: To measure the impact of implementing a pain management algorithm in adult intensive care unit (ICU) patients able to express pain. No controlled study has previously evaluated the impact of a pain management algorithm both at rest and during procedures, including both patients able to self-report and express pain behavior, intubated and non-intubated patients, throughout their ICU stay.

Materials and methods: The algorithm instructed nurses to assess pain and guided in pain treatment, and was implemented in three units. A time period after implementing the algorithm (intervention group) was compared with a time period the previous year (control group) on the outcome variables pain assessments, duration of ventilation, length of ICU stay, length of hospital stay, use of analgesic and sedative medications, and the incidence of agitation events.

Results: Totally 650 patients were included. The number of pain assessments was higher in the intervention group compared with the control group. Additionally, duration of ventilation and length of ICU stay decreased significantly in the intervention group compared with the control group. This difference remained significant after adjusting for patient characteristics.

Conclusion: Several outcome variables were significantly improved after implementation of the algorithm compared with the control period.

Read the abstract here