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

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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.

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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

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