Brazilian Journal of Pain
https://brjp.org.br/journal/brjp/article/doi/10.5935/2595-0118.20220024-en
Brazilian Journal of Pain
Review Article

Acute pain in the critically ill patient: revisiting the literature

Dor aguda no paciente crítico: revisitando a literatura

Jose Mauro Vieira Junior; Laura Herranz Prinz

http://dx.doi.org/10.5935/2595-0118.20220024-en BrJP, vol.5, n2, p.147-153, 2022
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Abstract

BACKGROUND AND OBJECTIVES: According to the redefinition, acute pain is a somatic experience, with individual perception of physical or existential threat, comprising affective, cognitive and behavioral components. In critically ill patients, pain is a frequent and poorly controlled symptom, causing worse outcomes. The objective of this study was to explore the topic of acute pain in critically ill adult patients, focusing on some aspects of pathophysiology, in addition to updates regarding diagnosis, multimodal therapy and discussion of its control as a marker of good care practice.

CONTENTS: A search strategy was performed with the descriptors previously defined in the Pubmed and Cochrane portals, in the period from 2011 to 2021, without a language restriction filter. Acute pain represents a physiological response to a nociceptive stimulus, with high relevance due to its ability to activate complex pathways (inflammatory, hormonal and immune), with systemic repercussions. Pain assessment is often performed using recognized scales, but with limited validation in patients with traumatic brain injury, burns and patients with severe delirium and/or dementia. Studies considering these patients point to the use of new technologies in an attempt to target this diagnosis, such as bedside pupillometry and the use of platforms capable of integrating multiparametric measurements. Regarding therapy, the concept of analgosedation, aiming at prioritizing analgesia in critically ill patients, presents an approach capable of improving clinical outcomes. In addition, there is a preference for multimodal therapy as a good medical practice through the association of different drugs with different mechanisms of no-ciceptive blockade as a strategy to achieve pain control and facilitate the reduction of opioid consumption.

CONCLUSION: Due to its systemic effects and prevalence, acute pain is still a relevant problem in intensive care units. New diagnostic methods are being marketed with the aim of targeting this evaluation in complex patients. The approach to acute pain should prioritize the use of multimodal techniques, which present more consistent clinical responses, in addition to reducing the consumption of opioids. The existence of multidisciplinary teams specialized in pain control in the hospital environment is able to assist in difficult cases and help in quality audits.

Keywords

Acute pain, Critical care, Analgesia, Opioids analgesics, Pain management, Quality of health care

Resumo

JUSTIFICATIVA E OBJETIVOS: Conforme redefinição, a dor aguda é uma experiência somática, com percepção individual de ameaça física ou existencial, compreendendo componentes afetivos, cognitivos e comportamentais. Em pacientes críticos, a dor representa um sintoma frequente e mal controlado, ocasionando piores desfechos. O objetivo deste estudo foi explorar a temática da dor aguda nos pacientes críticos adultos, com enfoque em alguns aspectos de fisiopatologia, além de atualizações em relação a diagnóstico, terapêutica multimodal e discussão de seu controle como um marcador de boa prática assistencial.

CONTEÚDO: Foi realizada estratégia de busca com os descritores previamente definidos nos portais Pubmed e Cochrane, no período de 2011 a 2021, sem filtro de restrição para idioma. A dor aguda representa uma resposta fisiológica a um estímulo nociceptivo, tendo alta relevância por sua capacidade de ativar vias complexas (inflamatórias, hormonais e imunes), com repercussões sistêmicas. A avaliação da dor é frequentemente realizada através de escalas reconhecidas, porém com validação limitada em pacientes com trauma cranioencefálico, queimados e portadores de delirium e/ou demência acentuados. Os estudos considerando esses pacientes apontam para o uso de novas tecnologias na tentativa de objetivar esse diagnóstico, como a pupilometria à beira leito e o uso de plataformas capazes de integrar medidas multiparamétricas. Em relação à terapêutica, o conceito de analgosedação, objetivando priorização de analgesia nos pacientes críticos, apresenta abordagem capaz de melhorar desfechos clínicos. Além disso, há preferência da terapêutica multimodal como boa prática médica através da associação de diferentes fármacos com diversos mecanismos de bloqueio nociceptivo como estratégia para alcançar controle álgico e facilitar a redução do consumo de opioides.

CONCLUSÃO: Por seus efeitos sistêmicos e sua prevalência, a dor aguda ainda é problemática relevante nas unidades de terapia intensiva. Novos métodos diagnósticos estão sendo comercializados com a proposta de objetivar essa avaliação em pacientes complexos. A abordagem da dor aguda deve priorizar o emprego de técnicas multimodais, que apresentam respostas clínicas mais consistentes, além de redução no consumo de opioides. A existência de equipes multidisciplinares especializadas no controle da dor no ambiente hospitalar é capaz de auxiliar em casos difíceis e ajudar nas auditorias de qualidade.

Palavras-chave

Analgesia, Cuidados críticos, Dor aguda, Manejo da dor, Qualidade da assistência à saúde

References

Puntillo KA. Pain experiences of intensive care unit patients. Heart Lung. 1990;19(5 Pt 1):526-33.

Morone NE, Weiner DK. Pain as the 5th vital sign: exposing the vital need for pain education. Clin Ther. 2013;35(11):1728-32.

Gan TJ. Poorly controlled postoperative pain: prevalence, consequences and prevention. J Pain Res. 2017;10:2287-98.

Cohen M, Quintner J, van Rysewyk S. Reconsidering the International Association for the Study of Pain definition of pain. Pain Rep. 2018.

Devlin JW, Skrobik Y, Vice-chair F, Gélinas C, Needham DM, Slooter AJC. Clinical practice guidelines for the prevention and management of pain, agitation / sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018;46(9):e825-73.

Basbaum AI, Bautista DM, Scherrer G, Julius D. Cellular and molecular mechanisms of pain. Cell. 2009;139(2):267-84.

Gregory J, McGowan L. An examination of the prevalence of acute pain for hospitalised adult patients: a systematic review. J Clin Nurs. 2016;25(5-6):583-98.

Puntillo KA, Max A, Timsit J, Vignoud L, Chanques G, Robleda G. Determinants of procedural pain intensity in the intensive care unit. Am J Respir Crit Care Med. 2014;189(1):39-47.

Puntillo KA, Max A, Timsit J F, Ruckly S, Chanques G, Robleda G. Pain distress: the negative emotion associated with procedures in ICU patients. Intensive Care Med. 2018;44(9):1493-501.

Olsen B F, Rustøen T, Sandvik L, Jacobsen M, Valeberg BT. Results of implementing a pain management algorithm in intensive care unit patients: the impact on pain assessment, length of stay, and duration of ventilation. J Crit Care. 2016:207-11.

Hoc A P. Pain Assessment is associated with decreased duration of mechanical ventilation in the intensive care unit. Crit Care Med. 2009;111(6):1308-16.

Sebbane M, Perrigault P, Mann C. Impact of systematic evaluation of pain and agitation in an intensive care unit. 2006;34(6):1691-9.

Vaurio LE, Sands L P, Wang Y, Mullen EA, Leung JM. Postoperative delirium: the importance of pain and pain management. Anesth Analg. 2006;102(4):1267-73.

Georgiou E, Hadjibalassi M, Lambrinou E, Andreou P, Papathanassoglou ED. The impact of pain assessment on critically ill patients outcomes: a systematic review. Bio-med Res Int. 2015;2015:503830.

Puntillo KA, Naidu R. Chronic pain disorders after critical illness and ICU-acquired opioid dependence. Curr Opin Crit Care. 2016;22(5):506-12.

Pöpping D. Impact of epidural analgesia on mortality and morbidity after surgery - systematic review and meta-analysis of randomized controlled trials. Ann Surg. 2014;259(6):1056-67.

Seers T, Derry S, Seers K, Moore RA. Professionals underestimate patients’ pain: a comprehensive review. Pain. 2018;195(5):811-8.

Burry LD, Williamson DR, Perreault MM, Rose L, Cook DJ, Ferguson ND. Analgesic, sedative, antipsychotic, and neuromuscular blocker use in Canadian intensive care units: a prospective, multicentre, observational study. Can J Anesth. 2014;61(7):619-30.

Ahlers SJ, van Gulik L, van der Veen AM, van Dongen H P, Bruins P, Belitser S V. Comparison of different pain scoring systems in critically ill patients in a general ICU. Crit Care. 2008;12(1):R15.

Arbour C, Gélinas C. Are vital signs valid indicators for the assessment of pain in postoperative cardiac surgery ICU adults?. Intensive Crit Care Nurs. 2010;26(2):83-90.

Payen J, Bru O, Bosson J, Lagrasta A. Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med. 2001;29(12):2258-63.

Fillion L, Puntillo KA, Viens C, Fortier M, City Q. Validation of the critical-care pain observation tool in adult patients. Am J Crit Care. 2006;15(4):420-7.

Lukaszewicz A, Dereu D, Gayat E, Payen D. The relevance of pupillometry for evaluation of analgesia. Anesth Analg. 2015;120(6):1297-300.

Aubrun F, Beaussier M. Objective assessment of the immediate postoperative analgesia using pupillary reflex measurement. a prospective and observational study. Anes-thesiology. 2012;116(5):1006-12.

Daccache G, Jeanne M, Fletcher D. The analgesia nociception index: tailoring opioid administration. Anesth Analg. 2017;125(1):15-7.

Upton HD, Hons B, Ludbrook GL, Wing A, Hons B, Hons B. Intraoperative “analgesia nociception index”– guided fentanyl administration during sevoflurane anesthesia in lumbar discectomy and laminectomy: a randomized clinical trial. Anesth Analg. 2017;125(1):81-90.

Edry R, Recea V, Dikust Y, Sessler D. Preliminary intraoperative validation of the nociception level index. Anesthesiology. 2016;125(1):193-203.

Bargshady G, Zhou X, Deo RC, Soar J, Whittaker F, Wang H. Enhanced deep learning algorithm development to detect pain intensity from facial expression images. Expert Syst Appl. 2020:149.

Martyn JAJ, Mao J, Bittner EA. Opioid tolerance in critical illness. N Engl J Med. 2019;380(4):365-78.

Stevens J P, Wall MJ, Novack L, Marshall J, Hsu DJ, Howell MD. The critical care crisis of opioid overdoses in the United States. Ann Am Thorac Soc. 2017;14(12):1803-9.

Kosciuczuk U, Knapp P, Lotowska-Cwiklewska AM. Opioid-induced immunosuppression and carcinogenesis promotion theories create the newest trend in acute and chronic pain pharmacotherapy. Clinics. 2020;75.

Hutchinson MR, Shavit Y, Grace PM, Rice KC, Maier S F, Watkins LR. Exploring the neuroimmunopharmacology of opioids: an integrative review of mechanisms of central immune signaling and their implications for opioid analgesia. Pharmacol Rev. 2011;63(3):772-810.

Faust A, Rajan P, Sheperd LA. Impact of an analgesia-based sedation protocol on mechanically ventilated patients in a medical intensive care unit. Anesth Analg. 2016;123(4):903-9.

Vincent JL, Shehabi Y, Walsh TS, Pandharipande PP, Ball JA, Spronk P. Comfort and patient-centred care without excessive sedation: the eCASH concept. Intensive Care Med. 2016;42(9):962-71.

Marra A, Ely E, Pandharipande P. The ABCDEF Bundle in Critical Care. Crit Care Clin. 2017;33(2):225-43.

Rustam JS, Kongsuwan W, Kitrungrote L. Comfort in patients receiving mechanical ventilation : a literature review. Crit Care Nurs J. 2018;11(2):1-7.

Hamrick KL, Beyer CA, Lee JA, Cocanour CS, Duby JJ. Multimodal analgesia and opioid use in critically ill trauma patients. J Am Coll Surg. 2019;228(5):769-75.

Frauenknecht J, Kirkham KR, Albrecht E. Analgesic impact of intra-operative opioids vs opioid-free anaesthesia: a systematic review and meta-analysis. Anaesthesia. 2019:651-62.

Wampole CR, Smith KE. Beyond opioids for pain management in adult critically ill patients. J Pharm Pract. 2019;32(3):256-70.

Harvin JA, Kao LS. Pain management in the surgical ICU patient. Curr Opin Crit Care. 2020;26(6):628-33.

Kaye AD, Chernobylsky DJ, Thakur P, Siddaiah H, Kaye RJ, Eng LK. Dexmedetomidine in enhanced recovery after surgery (ERAS) protocols for postoperative pain. Curr Pain Headache Rep. 2020;24(5):21.

Panchgar V, Shetti AN, Sunitha HB, Dhulkhed VK, Nadkarni AV. The effectiveness of intravenous dexmedetomidine on perioperative hemodynamics, analgesic requirement, and side effects profile in patients undergoing laparoscopic surgery under general anesthesia. Anesth Essays Res. 2017;11(1):72-7.

Brown K, Tucker C. Ketamine for acute pain management and sedation. Crit Care Nurse. 2020;40(5):26-33.

Lipscomb J. Subanesthetic ketamine for acute pain in critically ill patients. US Pharm. 2020;45(4):1-10.

Brinck EC, Tiippana E, Heesen M, Bell R F, Straube S, Moore RA. Perioperative intravenous ketamine for acute postoperative pain in adults (Review). Cochrane Database Syst Rev. 2018.

Mo Y, Thomas MC, Antigua AD, Ebied AM, Karras Jr GE. Continuous lidocaine infusion as adjunctive analgesia in intensive care unit patients. J Clin Pharmacol. 2017;57(7):830-6.

Foo I, Macfarlane AJR, Srivastava D, Bhaskar A, Barker H, Knaggs R. The use of intravenous lidocaine for postoperative pain and recovery: international consensus statement on efficacy and safety. Anaesthesia. 2021;76(2):238-50.

Weibel S, Jelting Y, Pace NL, Helf A, Eberhart LH, Hahnenkamp K. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults. Cochrane Database Syst Rev. 2018.

Wiebalck A, Grau T. Ultrasound imaging techniques for regional blocks in intensive care patients. Crit Care Med. 2007;35(^s5 Suppl):S268-74.

Albrecht E, Chin KJ. Advances in regional anaesthesia and acute pain management: a narrative review. Anaesthesia. 2020;75(^sSuppl 1):e101-10.

Cata J P. Outcomes of regional anesthesia in cancer patients. Curr Opin Anaesthesiol. 2018:593-600.

Perlas A, Chan VW, Beattie S. Anesthesia technique and mortality after total hip or knee arthroplasty: a retrospective. Propensity score-matched cohort study. Anesthesiology. 2016;125(4):724-31.

Shaker TM, Carroll JT, Chung MH, Koehler TJ, Lane BR, Wolf AM. Efficacy and safety of transversus abdominis plane blocks versus thoracic epidural anesthesia in patients undergoing major abdominal oncologic resections: a prospective, randomized controlled trial. Am J Surg. 2018;215(3):498-501.

Sari S, Kumar J, Turan A. New peripheral nerve blocks and local anesthetics. Curr Opin Crit Care. 2021;27(6):732-42.

Mudumbai SC, Auyong DB, Memtsoudis SG, Mariano ER. A pragmatic approach to evaluating new techniques in regional anesthesia and acute pain medicine. Pain Manag. 2018;8(6):475-85.

Savard X, Pinard A. Perioperative use of gabapentinoids for the management of postoperative acute pain. Anesthesiology. 2020;133(2):265-79.

McNicol ED, Ferguson MC, Hudcova J. Patient controlled opioid analgesia versus non-patient controlled opioid analgesia for postoperative pain. Cochrane Database Syst Rev. 2015.

Morlion B, Schäfer M, Betteridge N, Kalso E, Morlion B, Schäfer M. Non-invasive patient-controlled analgesia in the management of acute postoperative pain in the hospital setting. Curr Med Res Opin. 2018;34(7):1179-86.

Bai Y, Miller T, Tan M, Law LS, Gan TJ. Lidocaine patch for acute pain management: a meta-analysis of prospective controlled trials. Curr Med Res Opin. 2015:575-81.

Farooq F, Khan R, Ahmed A. Assessment of patient satisfaction with acute pain management service: Monitoring quality of care in clinical setting. Indian J Anaesth. 2016:248-52.

Knezevic NN, Yekkirala A, Yaksh TL. Basic/translational development of forthcoming opioid- and nonopioid-targeted pain therapeutics. Anesth Analg. 2017;125(5):1714-132.

Ren C, Tong YL, Li JC, Lu ZQ, Yao YM. The protective efect of alpha 7 nicotinic acetylcholine receptor activation on critical illness and its mechanism. Int J Biol Sci. 2017;13(1):46-56.

Gélinas C. Pain assessment in the critically ill adult : recent evidence and new trends. Intensive Crit Care Nurs. 2016;34:1-11.

Niculescu AB, Le-Niculescu H, Levey D F, Roseberry K, Soe KC, Rogers J, Jones FK. Towards precision medicine for pain: diagnostic biomarkers and repurposed drugs. Mol Psychiatry. 2019;24(24):501-22.

Submitted date:
06/21/2021

Accepted date:
04/22/2022

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