Pain Assessment and Management in Critically ill Adults
Transcript of Pain Assessment and Management in Critically ill Adults
![Page 1: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/1.jpg)
Pain Assessment and Management in Critically
Louise RoseLawrence S. Bloomberg Professor in Critical Care Nursing, University of Toronto
Adjunct Scientist, Mt Sinai Hospital and Li Ka Shing Institute, St Michael’s HospitalDirector of Research, Provincial Centre of Weaning Excellence, Toronto East General Hospital
![Page 2: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/2.jpg)
BEHAVIOURAL PAIN ASSESSMENT TOOLS
![Page 3: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/3.jpg)
Pain Behaviour Assessment Tool (Puntillo)
Behaviour Pain Score (Payen)
Adult Nonverbal Pain Scale (Odhner) Checklist of Non-Verbal Pain Indicators (Feldt)
![Page 4: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/4.jpg)
Critical-Care Pain Observation Tool
![Page 5: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/5.jpg)
Uni-dimensional�Use single or several domains e.g. behaviour
Multi-dimensional �e.g. behaviour and physiologic signs
Indicate pain presence NOT severity BPS (Payen) and CPOT (Gelinas) valid and reliable Some issues with existing tools�ambiguity of items�lack of specificity for pain�need for further psychometric testing
![Page 6: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/6.jpg)
Patients must be able to exhibit all behaviours�no limb movement will under represent pain
Various scales use different total scores and cutoffs�misinterpretation and confusion
Numeric scale too similar to NRS �which describes pain intensity as well as identifies pain
presence
Available Tools: Cautions
![Page 7: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/7.jpg)
PAIN ASSESSMENT
![Page 8: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/8.jpg)
![Page 9: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/9.jpg)
3711 observation hours
=1213 pain assessment intervals
Total 377 pain assessments
= 223 intervals with pain assessments
Pain assessment in 10.2% of hours
= 18.4% of mandated painassessments documented
![Page 10: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/10.jpg)
PAIs: Behavioural descriptors(N = 679)
![Page 11: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/11.jpg)
PAIs: Behavioural descriptors(N = 679)
![Page 12: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/12.jpg)
3442 surveys sent1251 ON
1251 AB, QC, BC1251 all other
842 surveys receivedResponse rate 24.5%
YT 33%, QC 32%, AB 26%, MB 24%NS 23%, SK 22%, BC 19%, ON 18%,
NF 18%, NB 17%, PEI 17%, NWT/Nu 3%
802 evaluable surveys
![Page 13: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/13.jpg)
Frequent assessment and documentation of pain considered equally important for patients able and unable to communicate (94% vs 94%)
Less likely to use behavioural pain assessment tool compared to self-report tool (33% vs 89% P <0.001)
Behavioural pain assessment tools considered less important in guiding pain assessment compared to self-report tools
(74% vs 88% P <0.001)
61.3% reported pain scores discussed often or routinely during nurse-to-nurse handover
41.5% nurses described targeting of analgesic administration (pain score/other assessment parameters) as prescribed by Drs
![Page 14: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/14.jpg)
Most likely suggestive of pain Least likely suggestive of pain
![Page 15: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/15.jpg)
Use of a behavioural pain tool > 50% of the time was associated with:
awareness of published guidelines odds ratio 2.5 (95% CI 1.7-3.7)
tool availability in the clinical setting OR 2.6 (95% CI 1.6-4.3)
No association with education on pain tools, availability of a protocol, ICU experience, hospital type or province
![Page 16: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/16.jpg)
Knowledge of published guidelines 29% had read any published guidelines or practice
recommendations for pain assessment and management
8% familiar with SCCM Sedation and Analgesia Guidelines (2002)
8% familiar with American Society of Pain Management Nursing (ASPMN) Recommendations (2006)
22% familiar with Registered Nurses Association of Ontario Best Practice Guidelines on pain (2007)
![Page 17: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/17.jpg)
Nurses were less likely to use a behavioural pain assessment tool for patients unable to communicate, rated them less important, and had low awareness of practice recommendations
Suggests inadequate uptake of evidence and practice recommendations for pain assessment and management of critically ill patients, particularly for those unable to communicate pain
Low penetration of practice recommendations may impact availability of pain assessment tools, practice norms and patient outcomes at the local level
Need for novel knowledge-translation interventions to improve routine pain assessment and management practices
![Page 18: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/18.jpg)
LINKING PAIN ASSESSMENT TO MANAGEMENT
![Page 19: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/19.jpg)
Nurse satisfaction
![Page 20: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/20.jpg)
Nurse satisfaction
![Page 21: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/21.jpg)
EFFECT OF THE CRITICAL-CARE PAIN OBSERVATION TOOL ON PAIN ASSESSMENT AND MANAGEMENT: BEFORE AND AFTER STUDY
Data recorded max 72 hours
CVICU: PAIs with PA documented ↑ from 15.2% to 64.2% (P<0.0001)
median total dose of opioid analgesia ↓ from 5 mg to 4 mg in the CVICU patients (P=0.02)
MSICU: PAIs with PA documented ↑ from 21.9% to 79.7% (P<0.0001)
median total dose of opioid analgesia ↑ from 27 mg to 75mg (P = 0.002)
130 patients before and 132 after CPOT (CVICU)59 patients before and 52 after (MSICU)
![Page 22: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/22.jpg)
![Page 23: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/23.jpg)
![Page 24: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/24.jpg)
![Page 25: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/25.jpg)
![Page 26: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/26.jpg)
![Page 27: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/27.jpg)
![Page 28: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/28.jpg)
![Page 29: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/29.jpg)
![Page 30: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/30.jpg)
All health professionals should advocate for effective pain control
Ongoing assessment using a systematic approach is essential
Presume pain is present when patients unable to self-report
Early recognition and control = easier to prevent pain escalation
Start analgesia prior to or with sedation that has little to no analgesic effect
Basic Tenets of Pain Management
ERSTAD et al. Chest 135(4) 2009
![Page 31: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/31.jpg)
405 symptom assessments in 171 pts
![Page 32: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/32.jpg)
405 symptom assessments in 171 pts
![Page 33: Pain Assessment and Management in Critically ill Adults](https://reader034.fdocuments.in/reader034/viewer/2022042800/587b6d411a28abd2568b9f8a/html5/thumbnails/33.jpg)
405 symptom assessments in 171 pts