The Egyptian Journal of Hospital Medicine (October 2017) Vol.

69 (4), Page 2323-2328

Management of Pain in The Intensive Care Unit

Fatimah Abdulwahab Alhawaj1, ZohairRadi Alghazal1, Mohammed Saleh Alonazi2, Nura Nasser
Alahmadi3, AlmutariAbdulmajed4, Ali Mohammed Alhijab1, Imtinan Abdulrahman Malawi5,
Sohaib Osama Baarimah6, Abdulhadi salem Towairqi7
1 Imam Abdulrahman Bin Faisal University, 2 Imam Muhammad Bin Saud University, 3 Taibah
University, 4 Semmelwies University, 5 Batterjee Medical College, 6 Umm Al-Qura University, 7
University of Jeddah
Corresponding Author: Fatimah AbdulwahabAlhawaj– 00966546644766
ABSTRACT
Background: Pain assessment in ICU patients turns out to be a daily challenge for the attending teams,
particularly in those patients who are intubated endotracheally; on mechanical ventilation or
analgosedated as such patients are unable to self-assess existence and intensity of pain. Guidelines to
identify pain in these patients are crucial for physicians for effective management.
Methodology: We conducted this review using a comprehensive search of MEDLINE, PubMed, and
EMBASE, January 1994, through March 2017. The following search terms were used: pain management
in ICU, pain in ICU, pain assessment by behavior, pain assessment in intubated patients.
Aim: Our aim in this study was to understand how to assess and manage pain in an intensive care unit
patient, particularly those patients who are unable to self-report or assess.
Conclusion: Physical clues given by comatose or intubated patients in critical care unit must be used as a
method to identify existence of pain, and must be managed effectively to decrease discomfort and prevent
short and long term adverse effects.
Keywords: Intensive care unit pain assessment, ICU pain management, guidelines to pain management.

INTRODUCTION We conducted this review using a

Pain is defined by the International comprehensive search of MEDLINE, PubMed,
Association for Study of Pain (IASP) as “an and EMBASE, January 1992, through March
unpleasant sensory and emotional experience 2017. The following search terms were used:
associated with actual or potential tissue damage pain management in ICU, pain in ICU, pain
or described in terms of such damage”[1]. The assessment by behavior, pain assessment in
description highlights that pain is of subjective intubated patients
nature, and also highlights that only the person • Data Extraction
experiencing the pain can assess its intensity. Two reviewers have independently reviewed the
However, unfortunately, as many of the patients studies, abstracted data, and disagreements were
who are treated in intensive care units (ICUs), resolved by consensus. Studies were evaluated
especially, those who are intubated and on for quality and a review protocol was followed
mechanical ventilation, do not fit this definition throughout.
as they are unable to self-report pain sensations The study was done after approval of ethical
nor assess the pain intensity. Pain assessment in board of King Abdulaziz University.
ICU patients turns out to be a daily challenge for
the attending teams, particularly in those patients Incidence of pain in ICU patients
who are intubatedendotracheal, on mechanical The World Health Organization (WHO)
ventilation or analgosedated. Adding to those estimation show us that nearly 83% of the
challenges are other co-existing mental and people in the world live in nations with either
neurological disorders such aspsychoses, deprivedaccess, or no access at all to pain
dementia, aphasia,critical condition-related management [3]. However, pain experienced by
delirium[2]. patients of ICU is a common finding and is well
documented. In the course of treatment in ICU,
METHODOLOGY up to 40–70% of patients have experienced
• Data Sources and Search terms moderate to severe pain. According to some
studies, around 30% of patients have
2323
Received: 14 /8 /2017 DOI : 10.12816/0041536
Accepted: 23 /8 /2017
 Management of Pain in The Intensive Care Unit

experienced pain at rest, and about 50% of Consequence of ICU Pain

patients reported pain during numerous nursing The adverse physiological and psychological
interventions [4]. A big number of patients who results associated with insufficient management
were discharged from an ICU recognize that the of pain are chronic and particularly serious. It
pain felt during the stay was a huge source of has been recognized for a long time that the
distress. Most of the patients were not able to many of the patients pinpoint the pain that they
verbally assess their pain because of reasons had experienced while being treated in ICU as
such as altered levels of consciousness in ICU, a cause of sleep-related problems after getting
mechanical ventilation, and sedatives or discharged from the ICU [9]. The existing study
relaxants given in high doses. The failure to findings show that up to 82% of patients
communicate verbally does not rule out that discharged from ICU recall the pain or
a patient is not experiencing pain or is not in discomfort which was as a result of the presence
need of appropriate analgesic management. of endotracheal tubes, while 77% remember
Consequently, the job of clinicians is to evaluate unceasing moderate to severe pain. According to
consistently the pain in patients with Granja et al.,[10] 17% of patients recall severe
whatever limited opportunities of discomfort during ICU management that later
[5]
communication by assessing pain substitutes . lasts up to six months after discharge, while 18%
show a high risk of post-traumatic stress
Types of Pain experienced by ICU patients disorder.
The pain that occurs at rest experienced by The stress response induced by pain can lead to
critically ill patients can be related to tragic consequences, as well as amplified
surgical procedures, burns, injuries, neoplastic concentrations of catecholamine (nor-
diseases or therapeutic nursing-interventions. epinephrine and epinephrine), vasoconstriction,
Pain, therefore, can be classified into four decreased tissue perfusion and impaired partial
categories [6]: pressure of oxygen in the tissues. The other
I. Continuous pain or discomfort that disorders activated by pain are hyper-
is associated with invasive metabolism that results in hyperglycemia,
procedures. lipolysis, or protein catabolism, leading to
II. Acute pain associated with an impaired wound healing. That up surges the risk
ongoing disease. of infections [8]. Pain causes immune system
III. Intermittent pain due to ICU disorders by inhibiting the natural killer cell
procedures. activity, decreasing the cytotoxic T-lymphocyte
IV. Chronic pain the patient has before cell count and decreasing the phagocytic activity
ICU admission. of neutrophils. Finally, acute pain felt by
The subsequent procedures and interventions patients in several circumstances can be the
which can possibly result in pain or crucial risk factor of chronic pain, such as
discomfort comprise changing patients’ neuropathic in nature[11].
positions, suction of the oral cavity or bronchial
tree, care of wound, drain removal or catheter Assessment of Pain in the ICU
insertion, intubation or intravenous accesses[7]. The first step in the management of pain
Further concerns includes continued long for those patients who are critically ill is the
period of acute pain, which significantly appropriate assessment. Self- reports of patients
worsens the quality of life of patients managed were found to be of the utmost importance in
in ICUs, and also after discharge. The pain measuring pain for those patients [12].
which is caused by ICU procedures is yet a vital Unfortunately, pain is tough to be assessed
matter in critically ill patients. It differs with age inside the ICU atmosphere because patients are
and sex, depends on the level of pain before frequently not able to communicate in words due
interventions and, most essentially, is managed to several reasons, for example, the severity of
only in 25% of patients; and so, it needs the current disease, the presence of an
distinctive attention and pre-emptive treatment endotracheal tube, and sedating agents given to
[8]
. the patient. Assessment with the help of

2324
 Fatimah Alhawaj et al.

physiological factors such as heart rate, arterial of pain due to the above mentioned factors,
pressure, and respiration rate can be deceptive some other methods have been formulated.They
because they can be a manifestation of the are based on clinical observation done by
underlying cause of admission, such as sepsis, physicians and nurses about the condition of
hemorrhage, or hypoxia.[13].Furthermore, it must patients[16].
be emphasized that changes in the basic vital The authors of the PAD (Pain,
parameters can only propose whether pain is Agitation, and Delirium) from Society of
present or not. There is a necessity to have Critical Care Management (SCCM) guidelines
an appropriate tool for its identification. of 2013 investigated six behavioral pain scales
Unfortunately, in the majority of studies (BPS): BPS-non-intubated, Critical Care Pain
dedicated to this topic, high arterial pressure or Observation Tool (CPOT), and the Non-verbal
increased heart rate did not prove to be Pain Scale (NVPS), the Pain Behavioral
associated with the incidence of pain. Assessment Tool (PBAT) and the Pain
Tachycardia and increased arterial pressure may assessment Intervention and Notation (PAIN)
both occur through painful and painless algorithm [17]. In the opinion of the authors, the
procedures. Besides, these parameters have most trustable and best authenticated behavioral
shown no association with the patient`s pain scales in patients who are unable to report pain
assessment and results of behavioral tests[12]. As by themselves are the BPS and CPOT.
a result, such parameter s must not be used as The family of the patient is of extreme
a basis for pain assessment with respect to significance for assessment of pain in ICU
occurrence and intensity in patients who are patients; the family recognizes the pain-related
being treated in ICUs. behaviors much faster and must be engaged in
Management of Pain the assessment. Both the BPS and CPOT are
The management of pain in the critically convenient to use and as a result are manageable
ill patients admitted in ICU is established on for members of family[13].
trustable and repeatable recording of intensity Critical Care Pain Observation Tool (CPOT):
and monitoring of pain at a given time to assess The CPOT was designed by Gelinas et
the magnitude and level of interventions al.[18]in the French language and soon after that
essential for treating it. The backbone of pain was translated into and authenticated in other
management is the patient`s own self- languages. The assessment was intended to
assessment; therefore, self-assessment must perceive pain in critically ill patients and
at all times be considered. The patients includes four behavioral categories
are involved in deciding the level of intensity of - facial expressions,
pain. The best method to measure pain are the - body movements,
ones based on patient`s self-assessment, for - muscle tension,
example, the visual analogue scale (VAS)[14]. On - compliance with a ventilator in case of an
Another scale called the numeric rating scale intubated patient
(NRS), which, however, assume patient- - verbalizationin case of an extubated patient
caregiver collaboration can be used[15]. Further Every category is counted on a scale of 0–2 (in a
problems arise due to the effects of sedation, total of 0–8 points). According to the data
delirium, the treatment options of delirium, and described, the cut-off point is 2–3, whereas
other issues that interfere with the central a score of > 2 points out the existence of pain.
nervous system. It is important to understand The scale is a decent tool in order to distinguish
that even the best tool may be unsuitable for between pain-related procedures such as the
some groups of patients, which include children, variations in body position, and painless
patients who are unable to verbally procedures like non-invasive arterial pressure
communicate, patients with dementia, and measurement (P ≤ 0.001)[18].
patients with other mental illness. As we see [Table 1]
many patients are incapable of self-assessment

2325
 Management of Pain in The Intensive Care Unit

Table 1: Critical Care Pain Observation Tool (CPOT)

Indicator Description Interpretation score

Facial expression -no muscle observed - Relaxed 0
-frowning, brow
lowering, orbit - Tense 1
tightening, other
changes (eye opening,
tearing)
-all above facial
movements plus eyelids - grimacing 2
tightly closed or biting
endotracheal tube)

Body movements -No movement or - relaxed 0

normal position
-slow, cautious - protection 1
movement, attempting
to touch pain site,
attention seeking
movements
-pulling tube, - agitation 2
attempting to sit-up,
striking staff, trying to
climb out of bed
Muscle tension -No resistance to -relaxed 0
passive movements
-resistance to passive -tense, rigid 1
movements
-strong resistance -Very tense or rigid 2
Compliance with -easy ventilation, no -Tolerating ventilator 0
ventilator active alarms
or -alarms may be active, -coughing but tolerating 1
vocalization coughing but stops ventilator
spontaneously
-sighing, moaning, -fighting ventilator 2
crying out
Total 0-8

Behavioral Pain Scale (BPS):

The BPS was designed by Paten et al.[19]in order to measure pain in unconscious, mechanically
ventilated patients. The scale is founded on three types depending on ranges of behavior:
1) facial expressions,
2) movements of the upper extremities and
3) compliance with a ventilator
The family or physician scores each of these ranges. The total score differs from 3 (which indicate no
pain) to 12 (severe pain). The accessible study outcomesreveal that the BPS has worthy psychometric
properties (Cronbach`s α 0.64–0.79) and moderate to high indices of family-staff agreement (κ = 0.67–
0.89; [ICC] = 0.58–0.95).[Table 2]

2326
 Fatimah Alhawaj et al.

Table 2: Behavioral Pain Scale (BPS)

Item Description Score
Facial expression -relaxed 1
-partially tightened 2
-fully tightened 3
-grimace 4
Upper limb movements -no movement 1
-partially bent 2
-fully bent with finger flexion 3
-permanently retracted 4
Compliance with mechanical -tolerating movement 1
ventilation -coughing but tolerating 2
-fighting ventilator 3
-unable to control ventilation 4

Medications Used to Treat Pain in the ICU gastrointestinal absorptive ability and motility.
Opioids which include fentanyl, Regional or neuraxial which includes spinal or
methadone, morphine, hydromorphone, and epidural modalities may as well be used for
remifentanil, are the principal medications for post-operative pain relief after a number of
treatment of pain in the critically ill patients surgical procedures[23].On the other hand, non-
residing in ICU [20]. The ideal selection of opioid pharmacologic interventions are also used for
and the dosing schedule which is used for an pain management. Examples include music
individual patient of ICU relies on many therapy, massage, and relaxation techniques,
elements, together with the drug’s may benefit as opioid-sparing and analgesia-
pharmacodynamics and pharmacokinetic enhancing.Interestingly, they are low cost,
properties. The consumption of meperidine is economic, safe, and easy to provide[24].
commonly avoided in ICU patients due to its
possibility for neurologic toxicity. A number of CONCLUSION
other types of analgesics or pain-modulating Pain suffered by patient in the ICU is
drugs, for example the local and regional not an uncommon phenomenon. It could be due
anesthetics like bupivacaine; or non-steroidal to the underlying cause or due to the procedures
anti-inflammatory medications such as they undergo during the management. As many
ketorolac, ibuprofen; intravenous patients are unable to verbalize or report pain,
acetaminophen; and anti-convulsants, may be physical clues given by comatose or intubated
given as adjunctive pain medications to decrease patients in critical care unit must be used as a
opioid requirements and lessen dependence[21]. method to identify existence of pain. These clues
Intravenous acetaminophen has been can be used to notice the intensity of pain as
lately accepted for use in the United States and well. The physicians and other staff working
has proven to be harmless and effective when with such patients must be made aware of such
used in combination with opioids, especially for guidelines. It is important to provide relief
post-operative pain in patients admitted in effectively in order to decrease discomfort and
surgical ICU subsequent to major surgeries like prevent short and long term adverse effects, as
cardiac surgery[22].Neuropathic pain which well as, improve the quality of life.
unfortunately is poorly handled with opioids
unaided can be managed when administered per- REFERENCES
enteral with gabapentin and carbamazepine in 1. IASP Taxonomy - IASP (1994): Definition of
ICU patients, provided they have sufficient Pain Terms. https://www.iasp-pain.org/Taxonomy
gastrointestinal absorption as well as motility. 2. Hajiesmaeili MR and Safari S(2012): Pain
Enteral route of administration of opioids as well management in the intensive care unit: do we need
special protocols? Anesth Pain Med., 1: 237-238.
as other pain medications would be limited
particularly to patients with sufficient

2327
 Management of Pain in The Intensive Care Unit

3.WHO(2012): WHO Guidelines on the Polish version of the CPOT (Critical Care Pain
Pharmacological Treatment of Persisting Pain in Observation Tool) and BPS (Behavioral Pain
Children with Medical Illnesses. Geneva. Scale). Anaesthesiol Intensive Ther., 49: 66-72.
http://www.who.int/medicines/areas/quality_safety 14.Breivik H(2016): Fifty years on the Visual
/children_persisting_pain/ Analogue Scale (VAS) for pain-intensity is still
4. Skrobik Y and Chanques G(2013): The pain, good for acute pain. But multidimensional
agitation, and delirium practice guidelines for adult assessment is needed for chronic pain. Scand J
critically ill patients: a post-publication Pain, 11: 150-152.
perspective. Ann Intensive Care, 3: 9. 15.Lee JJ et al.(2015): Pain relief scale is more
5.Pudas-Tahka SM, Axelin A, Aantaa R, Lund V highly correlated with numerical rating scale than
and Salantera S(2009): Pain assessment tools for with visual analogue scale in chronic pain patients.
unconscious or sedated intensive care patients: a Pain Physician, 18: E195-200.
systematic review. J Adv Nurs., 65: 946-956. 16.Ayasrah SM, O'Neill TM, Abdalrahim MS,
6.Baumbach P, Gotz T, Gunther A, Weiss T and Sutary MM and Kharabsheh MS(2014): Pain
Meissner W(2016): Prevalence and Characteristics Assessment and Management in Critically ill
of Chronic Intensive Care-Related Pain: The Role Intubated Patients in Jordan: A Prospective Study.
of Severe Sepsis and Septic Shock. Crit Care Med., Int J Health Sci (Qassim), 8: 287-298.
44: 1129-1137. 17.Barr Jet al.(2013): Clinical practice guidelines
7.Puntillo KA et al.(2014): Determinants of for the management of pain, agitation, and delirium
procedural pain intensity in the intensive care unit. in adult patients in the intensive care unit. Crit Care
The Europain(R) study. Am J Respir Crit Care Med., 41: 263-306.
Med., 189: 39-47. 18.Gelinas C, Fillion L, Puntillo KA, Viens C and
8. Georgiou E, Hadjibalassi M, Lambrinou E, Fortier M(2006): Validation of the critical-care
Andreou P and Papathanassoglou ED(2015): pain observation tool in adult patients. Am J Crit
The Impact of Pain Assessment on Critically Ill Care, 15: 420-427.
Patients' Outcomes: A Systematic Review. Biomed 19.Payen JF et al.(2001): Assessing pain in critically
Res Int., DOI: 10.1155/2015/503830. ill sedated patients by using a behavioral pain
9.Puntillo KA, Max A, Chaize M, Chanques G scale. Crit Care Med., 29: 2258-2263.
and Azoulay E(2016): Patient Recollection of ICU 20.Ehieli E, Yalamuri S, Brudney CS and Pyati
Procedural Pain and Post ICU Burden: The S(2017): Analgesia in the surgical intensive care
Memory Study. Crit Care Med., 44: 1988-1995. unit. Postgrad Med J., 93: 38-45.
10.Granja C et al.(2005): Patients' recollections of 21.Jefferies S, Saxena M and Young P(2012):
experiences in the intensive care unit may affect Paracetamol in critical illness: a review. Crit Care
their quality of life. Crit Care, 9: 96-109. Resusc., 14: 74-80.
11.Freye E and Latasch L(2003):Development of 22. Mahshidfar B et al.(2016): Can intravenous
opioid tolerance -- molecular mechanisms and acetaminophen reduce the needs to more opioids to
clinical consequences. Anasthesiol Intensivmed., control pain in intubated patients? Indian J Crit
38: 14-26. Care Med., 20: 465-468.
12.Morandi Aet al.(2017): Worldwide Survey of the 23.Zgaia AOet al.(2017): Improvement of recovery
"Assessing Pain, Both Spontaneous Awakening parameters using patient-controlled epidural
and Breathing Trials, Choice of Drugs, Delirium analgesia after oncological surgery. A prospective,
Monitoring/Management, Early Exercise/Mobility, randomized single center study. Rom J Anaesth
and Family Empowerment" (ABCDEF) Bundle. Intensive Care, 24: 29-36.
Crit Care Med., doi: 24.Ames N et al.(2017): Music Listening Among
10.1097/CCM.0000000000002640. Postoperative Patients in the Intensive Care Unit: A
13.Kotfis K, Zegan-Baranska M, Szydlowski L, Randomized Controlled Trial with Mixed-Methods
Zukowski M and Ely WE(2017): Methods of pain Analysis. Integr Med Insights, DOI:
assessment in adult intensive care unit patients - 10.1177/1178633717716455.

2328