Movements and trends in intensive care pain treatment and sedation: What matters to the patient?

Abstract

Background Oversedation, delirium and immobilisation in the intensive care unit are associated with increased length of stay in the unit. Routines of systematic pain and sedation assessment and the use of valid tools are highly stressed in international guidelines. For improving the quality of pain treatment and sedation in a Norwegian intensive care unit, in 2009–2015, we compared supplementation with an analgosedation approach and the existing systematic approach, measured by the adherence to current international pain, sedation and delirium guidelines. Methods In a longitudinal study following the Standards for Reporting Implementation Studies, pain, sedation, delirium and mobilisation data from patients' complete intensive care unit stays, encompassing three separate periods of 4–6 months, were compared. The primary outcome was adherence to current protocol including assessment and documentation of patients' level of pain, sedation and prevalence of delirium at least every 8 hr, early mobilisation and titration towards a light level of sedation. Results We included 205 patients, corresponding to 1,607 patient intensive care unit days. The patient sedation levels, measured by the Richmond Agitation and Sedation Scale, decreased significantly, from −2.2 in 2009–−1.7 in 2015, so did the amount of administrated propofol. Mean pain scores measured by the numeric rating scale during activity were maximum 3.1 in 2014, decreasing to 2.2 in 2015. In patients not able to self‐report, pain mean scores were 1.7 in 2014 and 1.6 in 2015, measured by the Critical Care Pain Observational Tool. The number of patients unable to assess for delirium decreased significantly. By discounting the group of patients unable to assess, the prevalence of delirium varied from 32%, 25% and 33%. Conclusion The goal of having an awake patient able to cooperate, with acceptable levels of pain, was gradually achieved during a 6‐year period. The results showed that pain treatment and sedation in the intensive care unit primarily succeeded in the setting of an established routine of systematic assessment and documentation. Relevance to clinical practice The results of the study draw attention to pain treatment, sedation and delirium in intensive care patients, as well as implementation strategies aimed at achieving healthcare personnel's adherence to international guidelines in clinical practice.

Nurses’ Perceived Barriers to and Facilitators of Pain Assessment and Management in Critical Care Patients: A Systematic Review

“…Four studies were qualitative, 13–16 six were correlational, 17–22 three were quasi-experimental, 23–25 six were descriptive, 26–31 and one was longitudinal. 21 The included studies were conducted on critical care patients admitted to various clinical settings, including cardiac units, 13 , 18 oncology units, 28 emergency critical care units, 29 and neurosurgical units. 22 In addition to the abovementioned clinical settings, the majority of the studies also included other settings, such as medical-surgical units, medical units, and burn units.…”

“… 22 In addition to the abovementioned clinical settings, the majority of the studies also included other settings, such as medical-surgical units, medical units, and burn units. 21 , 27 Only Wang and Tsai 20 and Asman et al 17 were conducted in medical centers.…”

“…Six of the studies were conducted in European countries. 13 , 15 , 16 , 21 , 26 , 32 Of the remaining studies, five were conducted in Asia, 14 , 17 , 20 , 27 , 28 five in North America, 18 , 19 , 22 , 23 , 25 and four in East Africa. 24 , 29–31 Critical care nurses’ pain assessment and management practices used among intensive care unit patients were measured using the Pain Assessment and Management for the Critically Ill survey in three of the studies.…”

“… VI Asman et al, 17 Israel Prospective cross-sectional To examine how nurses’ knowledge of pain in mechanically ventilated patients & self‐perceived collaboration between nurses & physicians affect pain management 84.67% 187 ICU nurses The Strengthening the Reporting of Observational Studies in Epidemiology EQUATOR checklist Improved knowledge among nurses of behavioral pain indicators and self‐perceived collaboration between nurses and physicians promote adequate pain management. IV Wøien, 21 Norway Prospective before/after study with a longitudinal design To compare between the effect of regular care protocols & analog sedation on the levels of pain & sedation among critically ill patients. 81% 205 ICU patients Numeric rating scale, Critical Care Pain Observational Tool Systematic assessment & documentation succeeded in establishing effective pain management & sedation in critical care units.…”

“Please mind the gap”: A secondary analysis of discomfort and comfort in intensive care

“…The quantitative study showed a significant decrease in sedation levels, sedatives administered and in number of patients unable to be assessed for delirium (Wøien, 2020). The delirium prevalence, however, remained unchanged and pain scores were low.…”