PAIN AND SEDATION IN CRITICALLY ILL PATIENTS,

TYPES OF PAIN, PAIN ASSESSMENT, SYSTEMIC RESPONSE

TO PAIN.
 DEFINITION OF PAIN
“An unpleasant sensory and emotional experience associated with actual or potential damage or described in
terms of such damage”
-International Association for the Study of Pain, 1979
Pain is subjective reaction to an objective stimulus.

NATURE OF PAIN
 Pain is subjective and highly individualized.
 Its stimulus is physical and/or mental in nature.
 It interferes with personal relationships and influences the meaning of life.
 Only the patient knows whether pain is present and how the experience feels.
 May not be directly proportional to amount of tissue injury

SIGNS AND SYMPTOMS OF PAIN

 Increased respiratory rate
 Increased heart rate
 Peripheral vasoconstriction
 Pallor
 Elevated B.P.
 Increased Blood Glucose Levels
 Diaphoresis
 Dilated pupils

FACTORS THAT INCREASE PAIN PERCEPTION.

 Fear in strange surroundings
 Inability to remember or understand the situation
 Anxiety & uncertainty about oneself, one’s family and about present & future
 Background aggravation’s—noise, alarms
 Ongoing activity throughout the night
 Inability to communicate
 Lack of sleep
 Fatigue after surgery
 Boredom & lack of distraction

FACTORS INFLUENCING PAIN

1. Developmental factors:
 Age: Age influences pain, particularly in infants and older adults.
 Young children have trouble understanding pain and the procedures that cause it.
 If they have not developed full vocabularies, they have difficulty verbally describing and expressing pain to
parents or caregivers with the developmental factors in mind assessment should be done for pain in children.
 older adults have a greater likelihood of developing pathological conditions, which are accompanied by pain.

2 Physiological factors
 Fatigue: Fatigue heightens the perception of pain and decreases coping abilities.
 If it occurs along with sleeplessness, the perception of pain is even greater.
 Pain is often experienced less after a restful sleep than at the end of a long day.
  . Genes.: Research on healthy human subjects suggests that genetic information passed on by parents
possibly increases or decreases the person’s sensitivity to pain and determines pain threshold or pain
tolerance.
 . Neurological Function. • Any factor that interrupts or influences normal pain reception or perception
(e.g., spinal cord injury) affects the patient’s awareness of and response to pain.

3. Social factors-
 Attention: The degree to which a patient focuses attention on pain influences pain perception. Increased
attention is associated with increased pain, whereas distraction is associated with a diminished pain
response
 Previous Experience.: If a person repeatedly experiences the same type of pain that was relieved
successfully in the past, the patient finds it easier to interpret the pain sensation. If a person is having worst
previous experience, he may experience much pain.
 Family and Social Support: The presence of family or friends can often make the pain experience less
stressful. The presence of parents is especially important for children experiencing pain.
 Spiritual Factors: Spiritual questions include “Why has this happened to me?” “Why am I suffering?”
Spiritual pain goes beyond what we can see. “Why has God done this to me?” “Is this suffering teaching
me something?” If the person is experiencing like this feeling it makes much painful.

4. Psychological factors
 Anxiety: Anxiety often increases the perception of pain, and pain causes feelings of anxiety. Critically ill
or injured patients who perceive a lack of control over their environment and care have high anxiety levels.
This anxiety leads to severe pain
 Coping Style. Persons with better coping levels perceives less pain than the person with lower coping
levels

5. Cultural factors
 Cultural beliefs and values affect how individuals cope with pain. Individuals learn what is expected and
accepted by their culture, including how to react to pain.
 Culture affects pain expression. Some cultures believe that it is natural to be demonstrative about pain.
Others tend to be more introverted.

PATHOPHYSIOLOGY
 Pain:
• Involves four physiological processes:
 - Transduction
 - Transmission
 - Modulation
 - Perception
 30%-70% of patients are bothered by pain during their ICU stay
 50% complain of moderate, severe, or excruciating pain
 Need to determine the etiology of pain, treat it, and eliminate potential barriers to adequate pain control.

TYPES OF PAIN
Pain is classified
 Based on duration
 Based on location
 Based on intensity
 Based on etiology

 BASED ON DURATION
 acute chronic
 Chronic non cancer pain
 Chronic cancer pain
 Chronic episodic pain

 Acute pain
 When pain lasts only through the expected recovery period, it is described as acute pain.
 Acute pain is protective, has an identifiable cause, is of short duration, and has limited tissue damage and
emotional response.
 It eventually resolves, with or without treatment, after an injured area heals.
 Complete pain relief is not always achievable, but reducing pain to a tolerable level is realistic.
 Unrelieved acute pain can progress to chronic pain.

 Chronic pain
 Chronic pain is the pain that lasts longer than 6 months and is constant or recurring with a mild-to-severe
intensity.
 It does not always have an identifiable cause and leads to great personal suffering. Examples: arthritic pain,
head ache, peripheral neuropathy
 The possible unknown cause of chronic pain, combined with the unrelenting nature and uncertainty of its
duration, frustrates a patient, frequently leading to psychological depression and even suicide.
 Associated symptoms of chronic pain include fatigue, insomnia, anorexia, weight loss, hopelessness, and
anger.
Chronic pain may be:
 Chronic non cancer pain
 Chronic cancer pain
 Chronic episodic pain.
Chronic non cancer pain:
 The chronic pain that resulted due to non-cancer disease conditions is termed as chronic non cancer pain.
Chronic cancer pain:
 Cancer pain is the pain that is caused by tumor progression and related pathological processes, invasive
procedures, toxicities of treatment, infection, and physical limitations.
 Approximately 70% to 90% of patients with advanced cancer experience pain
Chronic episodic pain:
 Pain that occurs sporadically over an extended period of time is episodic pain.

 BASED ON LOCATION:
This is based on the site at which the pain is located.
 Headache
 Back pain
 Joint pain
 Stomach pain
 Cardiac pain
 Referred pain: pain due to problems in other areas manifest in different body part. For example, cardiac
pain may be felt in the shoulder or left arm, with or without chest pain. Pain episodes last for hours, days,
or weeks. Examples are migraine headaches.

 BASED ON INTENSITY
 Mild pain
 Moderate pain
 Severe pain
Mild pain:
 Pain scale reading from 1 to 3 is considered as mild pain
Moderate pain:
 Pain scale reading from 4 to 6 is considered as moderate pain
Severe pain:
 Pain scale reading from 7 to 10 is considered as severe pain.
  Based on etiology
 Nociceptive pain
 Somatic pain
 Visceral pain
 Neuropathic pain
 Peripheral neuropathic pain
 Central neuropathic pain

Nociceptive pain:
 Nociceptive pain is experienced when an intact, properly functioning nervous system sends signals that
tissues are damaged, requiring attention and proper care.
 For example, the pain experienced following a cut or broken bone alerts the person to avoid further damage
until it is properly healed.
 Once stabilized or healed, the pain goes away
Somatic pain:
 This is the pain that is originating from the skin, muscles, bone, or connective tissue.
 The sharp sensation of a paper cut or aching of a sprained ankle are common examples of somatic pain.
Visceral pain:
 Visceral pain is pain that results from the activation of nociceptors of the thoracic, pelvic, or abdominal
viscera (organs).
 Characterized by cramping, throbbing, pressing, or aching qualities.
 Examples: labour pain, angina pectoris, or irritable bowel.
Neuropathic pain
 Neuropathic pain is associated with damaged or malfunctioning nerves due to illness, injury, or
undetermined reasons.
 Examples: Diabetic peripheral neuropathy
 Phantom limb pain
 Spinal cord injury pain
It is usually chronic.
 It is described as burning, “electric-shock,” and/or tingling, dull, and aching.
 Neuropathic pain tends to be difficult to treat.
 Neuropathic pain is of two types based on which parts of the nervous system is damaged.
1. Peripheral Neuropathic Pain
2. Central Neuropathic Pain.
Peripheral neuropathic pain:
 Due to damage to peripheral nervous system
E.g.: phantom limb pain
Central neuropathic pain:
 Results from malfunctioning nerves in the central nervous system (CNS).
E.g.: spinal cord injury pain, Post-stroke pain.

REASONS FOR PAIN IN ICU

 Primary pathology such as burns, traumatic injuries, fractures, wounds (surgical or traumatic)
 Complications of original condition or new problems such as bowel perforation, ischemic, pancreatitis
 Other symptoms such as abscesses, skin inflammation, wound infection
 Support systems & monitoring—peripheral, central venous line insertions, catheters, drains, regular
suctioning, dressing changes, physiotherapy
 Tissue hypoxia as a result of low cardiac output, low o2 saturation.
 Painful joints, pressure points, pain on changing, position in bed.

Respiratory complications
 Decrease of pulmonary compliance
 Retention of secretion
 Atelectasis, pneumonia
 Hypoxia, hypercarbia
 Increase in oxygen consumption
Cardio vascular complications
 Increase in sympathetic tone.
 Tachycardia, hypertension
 Myocardial ischemia, myocardial infarction.
 Deep vein thrombosis
Gastrointestinal complications
 Ileus, nausea, vomiting.
Neuroendocrine and metabolic complications.
 Increase in sympathetic tone.
 Stimulation of the hypothalamus.
 Increase of catabolic hormones
 Decrease of anabolic hormones.

PSYCHOLOGICAL CONSEQUENCES.
 Anxiety, fear, anger.
Adversarial relationship with doctors and nurses
ASSESSMENT SCALE.
 The behavioral pain assessment scale for patients unable to provide self-report of pain.

Erdek M A , Pronovost P J Int J Qual Health Care

2004;16:59-64
© International Society for Quality in Health Care and Oxford University Press 2004; all rights
reserved

PAIN ASSESSMENT AND MANAGEMENT

PAIN ASSESSMENT
 Un paralyzed patient with altered mental status:
 0 -Painful stimuli necessary to gain attention or solicit movement
 1 -No grimacing or guarding with spontaneous movement or repositioning
 2 -Grimacing or guarding with vigorous movement
 3 -Grimacing or guarding with slight movement, takes greater than 1 min for the patient to relax
 4 -Grimacing or guarding at rest; not able to relax despite rest

DIFFICULTY IN PAIN ASSESSMENT AND MANAGEMENT IN ICU

 Unable to communicate effectively
 Cognitive impairment
 Sedation
 Paralysis
 Mechanical ventilation

METHODS OF DRUG ADMINISTRATION

 Oral
 Intramuscular
 Intravenous
 Per rectal-suppositories
 Subcutaneous-patches
 Oral Transmucosal-lolly pops
 Inhalational
 Nasal spray
 Regional blocks
 Epidural

PRINCIPLES OF SEDATION AND ANALGESIA

 Consider individual patient characteristics when selecting analgesic and sedative medications
– Correct underlying conditions
– Considering underlying metabolic/excretion capacities
– Considering adverse effects of sedatives/Analgesics
 Using an algorithm or guideline to assist the practitioners
 Tools to assess sedative/pain status
 Prompting several questions related to patient characteristics
 When/how to do / what need to do
 Exclusion of treatable causes of discomfort
 Exclusion of warning signs
 Goal of sedation/ analgesia should be established
 Priority of pain management is highlighted
 Re-assessment of sedation/ analgesia
 Analgesics are not 100% of sedatives, and vice versa

Guideline: Benefit!
 Evidence-based; "best practice"
 Standardize care
 Reduce variability
 Reduce complications
 Can decrease costs

Principles of Pain Management

 Anticipate pain
 Recognize pain
 Ask the patient
 Look for signs
 Find the source
 Quantify pain / Assess the pain
 Set the goal
 Treat:
 Quantify the patient’s perception of pain
 Correct the cause where possible
 Give appropriate analgesics regularly as required
 Remember, most sedative agents do not provide analgesia
 Reassess………Reassess…………Reassess………… Reassess

SIGNS OF PAIN IN ICU

 Hypertension
 Tachycardia
 Lacrimation
 Sweating
 Pupillary dilation

NONPHARMACOLOGICAL
Nonpharmacologic Interventions
 Proper position of the patient
 Stabilization of fractures
 Elimination of irritating stimulation
 Proper positioning of the ventilator tubing to avoid traction on endotracheal tube
 OPIOIDS
 Activating opioid receptors in the midbrain & turning on the Descending inhibitory system
 Activating opioid receptors on the second order pain transmission cells to prevent the Ascending
transmission of pain signals
 Activating opioid receptors at the central terminals of C fibers in the spinal cord
 Activating opioid receptors in the periphery to inhibit the activation of nociceptors & to inhibit cells that
may release inflammatory mediators
BENEFITS
 Relieve pain or the sensibility to noxious stimuli
 Sedation trending toward a change in sensorium, especially with more lipid soluble forms including
morphine and hydromorphone.
RISKS
 Respiratory depression
 NO amnesia
 Pruritus
 Ileus
 Urinary retention
 Histamine release causing vasodilation predominantly from morphine
 Morphine metabolites which accumulate in renal failure can be analgesic and anti-analgesic.
 Meperidine should be avoided due to neurotoxic metabolites which accumulate, especially in
renal failure, but also produces more sensorium changes and less analgesia than other opioids

OPIOID ANALGESICS CLASSIFICATION

AGONIST
 Morphine
 Codeine, oxycodone
 Dihydrocodeine
 Oxymorphone
 Pethidine, methadone
 Hydromorphone
 Fentanyl
 Diamorphine (heroin)
 Tramadol
 Tapentadol

AGONIST-ANTAGONIST
Pentazocine
Butorphanol
Dezocine
Nalbuphine
Meptazinal
Partial agonist
Buprenorphine
Antagonist
Naloxone
Naltrexone

Systemic response to pain:

 Increased sympathetic tone
 Vasoconstriction
 Increased cardiac output through increases in stroke volume and heart rate
 Decreased gastrointestinal and urinary tone
 Increased skeletal muscle tone
  Hormonal changes
 Increased secretion of cortisol, ADH, catecholamine, renin, angiotensin II, aldosterone.
 Decreases in insulin and testosterone.
 Endocrine changes result in a catabolic state
 Hyperglycaemia
 Increased protein catabolism and lipolysis,
 Renal retention of water and sodium,
 Increased potassium excretion
 Decreased GFR.
Stress response markers for pain assessment
 Heart rate
 Respiratory rate
 Blood pressure
 Posture
 Attitude
 Food and water intake
 Patterns of defecation, urination
 Change in activity levels
 Natural behaviours – inquisitive, grooming
 Provoked behaviour
 Aggression
 Gait-/posture
 Vocalization
 Appearance of stereotypical behaviours

General Approaches to Pain Management

 Minimize debilitating pathologic pain while maintaining the protective and adaptive aspects associated
with physiologic pain.
 A single drug administered at a standard dose for different pain syndromes is not an effective pain
management strategy.
 Pre-emptive analgesia -initiating treatment prior to acute insult helps to limit the development of peripheral
and central sensitization
 Multimodal/balanced analgesia: – combining analgesic drugs and techniques to achieve beneficial
General classes for analgesics drugs
 Opioids
 Local Anaesthetics
 Non-Steroidal Anti-Inflammatory Drugs
 Alpha 2 adrenergic agonists
 NMDA Antagonists
 Others
• Gabapentin
• Tramadol

Conclusion
A major challenge in providing patients the most effective treatments for pain lies in the difficulty of
translating research to practice. Examples of barriers include developing new analgesics, applying evidence-
based approaches in practice, and the integration of interdisciplinary team approaches. The interdisciplinary
team approach in pain management is a complex yet fundamental part of providing excellence in patient
care. The team approach provides important insight for patients and is highly correlated with improved
patient recovery, outcomes, knowledge, and satisfaction.
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NET REFERENCES
 www.onlinelibrary.org
 Careertrend.com
 En.wikipedia.org
 Slideshare.net/medical surgical nursing
 www.webmed.org

JOURNEL REFERENCE
 www.nejm.org
 Www.ncbi.nlm.nih.gov.org
 https://scholar.google.co.in
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 http://journals.lww.com
 SEMINAR

ON
PAIN AND SEDATION IN
CRITICALLY ILL PATIENTS,
TYPES OF PAIN, PAIN ASSESSMENT,
SYSTEMIC RESPONSE TO PAIN.

SUBMITTED TO:
MRS. SINDHU. C. PHILIP
ASSO. PROFESSOR
TMM COLLEGE OF NURSING

SUBMITTED BY:
MS. THANUJA ELEENA MATHEW
SECOND YEAR MSC NURSING
TMM COLLEGE OF NURSING