ABSTRACT & COMMENTARY
A Worldwide Assessment of Procedure-Related Pain Intensity and Distress in ICU Patients
By Linda L. Chlan, RN, PhD, FAAN
Dean's Distinguished Professor of Symptom Management Research, The Ohio State University, College of Nursing
Dr. Chlan reports that she receives grant/research support from Hospira.
This article originally appeared in the February 2014 issue of Critical Care Alert. It was edited by David J. Pierson, MD, and peer reviewed by William Thompson, MD. Dr. Pierson is Professor Emeritus, Pulmonary and Critical Care Medicine, University of Washington, Seattle, and Dr. Thompson is Associate Professor of Medicine, University of Washington, Seattle. Drs. Pierson and Thompson report no financial relationships relevant to this field of study.
SYNOPSIS: Results from a large, multinational study indicate that ICU patients worldwide experience moderately intense pain, most commonly from chest tube removal, wound drain removal, and arterial line insertion.
SOURCE: Puntillo KA, et al. Determinants of procedural pain intensity in the Intensive Care Unit: The Europain Study. Am J Respir Crit Care Med 2014;189:39-47.
Attention to pain management for intensive care unit (ICU) patients remains a priority for critical care clinicians. The pain intensity and distress associated with common ICU procedures, such as positioning, has not been evaluated since 2001 with the Thunder II project.1 As pointed out by the authors, pain management has come a long way since the Thunder II report was published, with clinical practice guidelines for managing ICU pain, agitation, and delirium much more prominent.2 Further, pain intensity from ICU patients around the world has not been previously reported. Thus, a large group of investigators, led by U.S. pain expert Dr. Kathleen Puntillo, conducted a prospective, cross-sectional, multinational designed study to assess the characteristics and determinants of pain associated with 12 common ICU procedures. Participating investigators and ICUs were recruited through the European Society of Intensive and Critical Care Medicine, and included those who had previously participated in international studies.
A predefined list of common ICU procedures such as positioning, device and line insertion and removal, wound care, mobilization, endotracheal suctioning, and respiratory exercises was used to guide the pain intensity and pain distress ratings, based on a 0 = no pain or no distress to 10 = worst pain or severe distress numeric rating scale. Patients were also observed during the procedures. Patients were enrolled from the participating ICUs for one or two procedures performed on the same day, or over 2 consecutive days. Patients were eligible if they were ≥ 18 years, met the institutional review board requirements, and were to experience at least one of the 12 study procedures during their stay. Patients' pain was assessed prior to and immediately after the selected procedures.
Overall, 28 countries participated with a total of 192 ICUs worldwide. A majority of the participating hospitals were university or university-affiliated centers (66%) and public facilities (82%). ICUs were classified as medical/surgical (60%), medical (12%), surgical (8%), trauma (7%), other (8%), or cardiac (5%). A total of 4812 procedures experienced by 3851 patients were included in the analysis. Median patient age was 62 years with median Sequential Organ Failure Assessment (SOFA) and Richmond Agitation-Sedation Scale (RASS) scores of 3 and 0, respectively. Across the list of specified ICU procedures, the most common was positioning and the least common was wound drain removal. When considering all of the pre-procedure pain assessments, patients reported mild pain intensity, but they experienced a significant increase in pain intensity during a procedure. The most painful procedures were chest tube removal, wound drain removal, and arterial line insertion. Factors that contributed to higher pain intensity ratings included the specific procedure, high pre-procedure pain intensity and distress ratings, higher intensity of "worst" pain on the evaluation day, whether opioids were administered for the specific procedure, and procedures not being performed by a nurse.
Pain intensity and distress emanating from common ICU procedures is a worldwide phenomenon, regardless of country or culture. As reported by Puntillo and colleagues, patients evaluated their pain intensity as moderate, and this pain was associated with a variety of common procedures that ICU patients experience daily. While clinicians may aim to "do no harm," these necessary procedures do cause pain and distress in ICU patients.
The findings from this paper should be a reminder to all ICU clinicians that patients experience pain very individually, and that a majority of ICU patients can evaluate their pain intensity and distress using a simple numeric rating scale. Pain assessment evaluations should be standard practice in all ICUs, regardless of a patient's RASS score! Further, while ICU clinicians may think that short-duration procedures such as chest tube removal may not "bother" patients, the findings from this large study remind us that despite a common ICU procedure not being lengthy, it can be extremely painful and distressing for patients.
ICU clinicians should strive to work collaboratively with patients to assess pain and premedicate patients with the appropriate medication for the specific pain associated with common procedures (e.g., topical anesthetic or intravenous opioid). Remember, ICU patients frequently recall painful experiences while in the ICU that can be psychologically detrimental. ICU clinicians around the world should strive to implement best practices for pain assessment and pain management in their ICUs to ensure this common ICU symptom is not distressful for patients.
Puntillo KA, et al. Patients' perceptions and responses to procedural pain: Results from Thunder Project II. Am J Crit Care 2001;10:238-251.
Barr J, et al; American College of Critical Care Medicine. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013;41:263-306.