SAN DIEGO – Pain management in critically ill patients is vital because most of them experience pain during their ICU stay, both at rest and during activity, Chris Pasero, R.N., said at the University of California, San Diego Critical Care Summer Session.
Research has demonstrated that 13- to 18-year-old patients in the ICU rate wound care as the most painful, but all other patient populations rate simple turning as the most painful procedure in the ICU, said Ms. Pasero, a pain management educator and clinical consultant based in El Dorado Hills, Calif. "It’s no surprise that patients in the ICU remember their pain, and they identify it as a major source of stress and anxiety," she said. "Pain is often undertreated, and I think it’s because we have so many barriers in the ICU."
Ms. Chris Pasero
Barriers to effective pain management in critically ill patients include comorbidities and coadministered drugs that affect the pharmacodynamics and pharmacokinetics of analgesics. Conflicting goals of care also factor into play. "When we are managing pain, many of the drugs we use sedate," said Ms. Pasero, who cofounded the American Society for Pain Management Nursing. "That may conflict with what you’re trying to accomplish, such as the need to control pain in the presence of respiratory compromise. One of the biggest problems is that many of your patients are unable to report their own pain and a failure to properly assess patients for pain. Our failure to properly assess those who are challenging to assess is a major cause of their unrelieved pain and unnecessary suffering."
She described a framework for assessment known as the Hierarchy of Pain Measures. This includes obtaining a self-report of pain, behaviors, physiologic measures, and the presence of a pathologic condition or procedure that causes pain. "Many institutions are inserting this hierarchy into their policies and procedures," she said. "At the top of the hierarchy is a self-report of pain. Always attempt to obtain this. It will give us much of what you need."
Numerical pain rating scales can help patients tell clinicians their level of discomfort. The most common self-report pain intensity tools are the 0-10 numerical scale and two faces scales, the Faces Pain Scale – Revised tool developed by the International Association for the Study of Pain, and the Wong-Baker FACES Pain Rating Scale.
Another self-report tool used in ICUs is the Iowa Pain Thermometer (Pain Med. 2007;8:585-600). This measure was originally developed for cognitively impaired elderly, but it is useful for assessing pain in all patients who have limited ability to express themselves, Ms. Pasero said.
She emphasized the importance of being sensitive to cultural differences when assessing for pain. "Folks who do not speak the language of the person caring for them are at very high risk for undertreated pain," she said. "We need to be careful about using family members to do our translation. Studies show that family members from some cultures may hesitate to discuss pain. Get as close as you can to the patient’s own report of pain."
Certain patient behaviors are good indicators of pain, such as frowns, grimaces, tears, guarding the site of pain, pulling at tubes, seeking attention, resisting passive movement, being combative, being intolerant of ventilators, and being confused. "Physiologic measures such as increased heart rate and blood pressure are considered very poor indicators of pain," noted Ms. Pasero, who is coauthor along with Margo McCaffery, R.N., of "Pain Assessment and Pharmacologic Management." (St. Louis: Mosby/Elsevier, 2011). "There are multiple factors that influence vital signs. You give a lot of drugs to keep vital signs stable, so to expect a patient to fight against that to show you that they have pain with an elevated heart rate or elevated blood pressure is not a good idea. However, abnormalities or changes in vital signs should serve as a trigger to perform a good pain assessment."
She recommends using reliable and valid behavioral pain assessment tool such as the Critical Care Pain Observation Tool or the Behavioral Pain Scale in those who cannot report pain. "In unresponsive patients who cannot demonstrate behaviors and have underlying pathology or conditions thought to be painful, such as surgery, trauma, or mechanical ventilation, we need to assume they have pain and do the best we can to manage it with the administration of recommended doses of analgesics," she said. "Also assume pain is present in patients undergoing painful activities or procedures such as turning, suctioning, or wound care. It’s important to document the underlying pathology or activity assumed to be painful."