PRESENTED BY Mr.Laiju joy

lecturer Holy cross college of nursing

What is pain?

• Pain has been defined as an unpleasant

sensory and emotional experience

associated with actual or potential tissue

damage Merskey & Bogduk, 1994,

International Assosiation for study of pain(

(IASP)

• Pain is recognized as a subjective and

multidimensional experience Loeser &

Cousins , 1990

• Multidimensional experience include 5

components.

• Sensory ( intensity, location, quality)

• Affective ( anxiety & fear )

• Cognitive ( personal meaning of pain)

• Behavioral ( way expressing, avoid,

control pain)

• Physiological ( nociception & stress

response)

Pain Vs ICU

• Pain is a predominant stressor in critically ill

patient

• Many source of pain have been identified in

critical care setting, such as the patient illness

& trauma, invasive equipment's, nursing and

medical interventions

• Pain is a major problem in ICU, its detection is

a priority, unfortunately , in ICU many factors

are alter verbal communication with patient,

making pain assessment more complex.

• Pain is a complex set

of responses to

physical stimuli.

• Pain is subjective

experience

Pain is the fifth vital sign.

• American Pain Society (

APS) 2003 refers pain is 5th

vital sings bcoz of the

importance of pain in

physiological response

• Documentation of pain

assessment is now a

prominent as documentation

of the traditional vital signs

• JACHO 2005, has incorporated pain

assessment and management into its

standard. JACHO states that “ pain is

assessed in all patients” and that “ patients

have the right to appropriate assessment

and management of pain”

• The American Pain Foundation developed

the Pain Care Bill of Rights, which

addresses the importance of pain

management.

Physiology of

pain

• Nociception :- It refers to the mechanism

of pain and engages the sensory,

emotional, and cognitive processing area

of the brain.

• Four process are involved in nociception

»Transduction

»Transmission

»Perception

»Modulation

• Transmission : Transmission is the

process of transmission of pain stimuli for

site to brain. This process is being done by

two main fibers that are , A delta fibers &

C fibers

• A delta fibers : It conducts the rapid acute

pain sensation described as prickling,

sharp, and fast. It is activated by thermal

and thermal stimuli.

• C fibers :- It is implicated the transmission

of pain described as dull, diffuse,

prolonged and delayed. It is activated by

chemical and is released when cell

damaged occur.

Types of pain

• Pain can be classified according to its

duration or its onset ( MaCaffery & Pasero,

1999) .

• Based on its duration, pain can be either

acute or chronic.

• Acute pain : acute pain has short duration,

and it usually corresponds to healing

process ( 30 days) but should not exceed

6 months. It implies tissue damage that is

usually from an identifiable cause.

• Chronic pain : It persist for more than 3-6

months after the healing process from the

original injury, it may or may not be

associated with an illness. It develops

when the healing process is incomplete or

when there is permanent damage to

nervous system. It has been also

associated with prolonged stress.

• Nociceptive pain :- acute and chronic type of

pain can have a nociceptive or neurogenic

origin.

• Nociceptive pain refers to the nociception

mechanism, and it can be somatic or

visceral.

• Somatic pain involves superficial tissues,

such as the skin, muscle, joints, and

bones. Its location is well defined.

• Visceral pain:- It involves organs such as the

heart, stomach and liver. Its location is

diffused. And it can be referred to different

location in the body.

• Neuropathic pain:- it describes as an abnormal

sensory process caused by changes in the

excitability of nerve cell. The origin of the pain

are peripheral or central. Central pain eg; after

stroke.

• Neuralgia and phantom pain is peripheral pain

• Pain in critical care : - Pain in critical cares

setting is a subjective and

multidimensional experience.

• Adequate assessment of pain in the

critically ill patients is made more difficult

by the complexity of the critical care

experience.

• Pain assessment in the critically ill

population has three major components

»Assessment technique

»Patients barriers to assessment

»Professional barriers to complete

or accurate assessment

Assessment technique

• Subjective component: -

• Pain is entirely subjective phenomenon. It

refers to the self report by the patient

regarding pain ( sensorial, affective, and

cognitive experience)

• McGill Pain Questionnaire , patient is self

report of pain can also be obtained by

questioning the patient using the

mnemonic PQRSTU

U – Understanding

Objective assessment

Critical care pain 0bseravation tool

Direction for using CPOT

• Observe the patient at rest for 1 mints.

• Observe during nociceptive procedures

• Evaluate the patient before and at peak

effect of analgesic agent.

• Muscle tension is evaluated last,

especially at rest. ( touch will stimulate the

behavioral response)

• Give score for each behavior.

Physiological indicators

• Vital signs values generally increase

during painful state.

• Changes in vitals signs should rather be

considered a cue t o begin further

assessment of pain

• Physiological measures other than vital

signs can support for detecting the

presence of pain in critically ill, nonverbal

patient ( Recommended by ASPMN)

Cerebral monitoring n pain

assessment

• Somatosensory cortex, frontal cortex, and

thalamus are involved in pain perception.

• By using PET, MRI , can understand brain

activity elucidate how pain inputs are first

received and processed within the

cerebral cortex, offering direct and precise

indicator of pain.

Near-infrared spectroscopy

• NIRS is used to noninvasively measures

change in regional cerebral oxygenation in

a specific cortical region.

• The studies found that positive and strong

correlation among cortical activity, facial

expression, and nociceptive procedures.

• NIRS electrodes

• This require further research .

BiSpectral index (BIS)

• It is noninvasive monitor used electrodes

placed on the forehead, and displays a

signal processed EEG with digital number

that relates to depth of sedation.

• The study reveals that BIS value

significantly increased when patients were

exposed to noxious stimulations and pain

related behavior.

SYSTEMIC

RESPONSES

TO

PAIN

PAIN

MANAGEMENT

• The management of pain in the critically ill

patient is as multidimensional as the

assessment.

• The control of pain can be

pharmacologic, nonpharmacologic, and

combination of the two therapies.

Pharmacologic control of pain

How can you manage

SEDATION IN CRITICAL CARE UNIT

• One of the challenges facing clinicians is

how to provide a therapeutic environment

for patient is CCU.

• 74% of patients are showing some degree

of agitation during there Critical Care

Hospitalization.

• Many reports upsetting dreams,

hallucinations, nightmares etc…..

• The many causes of agitation include

painful procedure, invasive tubes, sleep

deprivations, fear, anxiety, and stress

associated with critical illness.

• The goal of recent clinical practice guidline

is to increase the awareness of these

issues the in medical and nursing

community.

• The need for analgesics and sedative to

maintain the patient safety and comfort is

important.

• But it is increasingly recognized that

excessive sedation can prolong the

duration of mechanical ventilation, create

physical and psychological dependence,

increase the length of the hospital stay.

• The goal is to find the

balance between providing

compassionate patient care

and avoiding over sedation

Levels of seadation

The Commission; and Jacobi J et al, 2000, Joint Commission on Accreditation of

Health Care Organization, JCAHCO

Light sedation

• Drug induced state during which

patient respond normally to verbal

command.

• Although the cognitive and

coordination may be impaired,

ventilator and cardiovascular

functions unaffected.

Moderate sedation with analgesia

• Drug induced depression of consciousness

during which patients responds

purposefully to verbal command, either or

along with the tactile stimulation.

• No interventions are required to maintain

patient airway and spontaneous ventilation

is adequate .

• Cardiovascular function is usually

unaffected

Deep sedation n analgesia

Drug induced depression of

consciousness during which

patients cannot be easily aroused

bye respond purposefully after

repeated or painful stimulation

The ability to maintain ventilator

function independently is

impaired.

Patient require assistance in

maintaining a patent airway n

spontaneous ventilation may be

inadequate

CVS function is usually

maintained

General anesthesia

• Drug induced loss of

consciousness during which

patients are not reusable, even

by painful stimulation.

• CVS function may be impaired

• The ability to maintain ventilation

function independently impaired ,

need positive assistance to

maintain a patient airway is

required becoz drug induced

depression of neuromuscular

function

Complication of sedation

• OVERASEDATION :- it is recognized as a

state of unintended patient

unresponsiveness in which patient resides

in the state of general anesthesia.

• Prolonged deep sedation is associated

with complication of immobility , includes

• Pressure ulcers

• Thromboemboli

• Gastric ileus

• Nosocomial pneumonia

• Delayed weaning from mechanical

ventilation

Too little sedation; unexpected removal of

endotracheal or nasogastric tube.

Unplanned extubation is restless, anxious,

agitation occur in 8-10% of intubated patient.

Selecting medicine for

sedation

• No sedative having property of analgesics so that the patient

may feel pain

• Analgesic should administered along with the sedative.

•

Benzodiazepines

• Benzodiazepines: These are sedative

hypnotics with powerful amnesic property

( partial or total loss of memory) that

inhibits reception of new sensory

information.

• It does not have analgesic property

• The most frequently use benzodiazepines

are diazepam, midazolam, and

lorazepam

• Midazolam: it control acute short-term

agitation ( onset of action in IV in 3

mints.)

• Lorazepam: long term action is

getting through continuous infusion.

Contributing overall sedation. It

having slow onset, but is very potent.

• The main complication of these

drugs are respiratory depression

and hypotension

• Flumazenil is the antidote used

to reserve benzodiazepine

overdose

Anesthetic agents

• Propofol is an IV general anesthetic agent.

• In CCU propofol is prescribed to induce a

state of deep sedation.

• Advantage ; short half life period.

• Propofol slows cerebral metabolism and

decrease elevated ICP.

• Short term administration can be avoided

bcoz the patient will wake up with in 30

mints.

• Propofol will increase the serum

triglycerides level

Central alpha agonists

• Two drugs are available

• Clonidine ( used in withdrawal

syndrome)

• Dexmedetomidine ( short acting <24

Hrs) for mechanically ventilated

patients. Its using for the patient for

weaning for short term ventilation.

Managing drug dependence

n withdrawal

• When the patient is reduce from the

sedation, they become physically and

psychologically dependent and they

become highly agitated.

• Physical symptoms of agitation

• Increased PULSE, RESPIRTION, BLOOD

PRESSURE .

• Other symptoms: lack of self awareness,

unawareness of surroundings, very short

term memory, irritably , anxiety, delirium,

seizures

• One innovative strategy

• Daily Drug Holiday

• Daily sedative interruption

Collaborative management

• Critical care nurse remain challenged by

limitations in the medication and

monitoring tool availably.

• sedative for short term is fairly delineated.

• No ideal agent is for long term use

• Collaborative mgt of anxiety, agitation, and

sedation is a responsibility shared by all

members of the health care team

• Recognition of the problem is the first step

towards a solution to establish a more

effective standard of patient care in

sedation/analgesic management

PATIENT CONTROLL ANALGESIA

EPIDURAL ANAGESIA

References

• Linda D. Urden, Kathleen M.Stacy and Mary E.

Lough 2010“ Critical Care Nursing Diagnosis

and Management” Mosby Publications, 6th

edition, Page:135-157.

• Linda D. Urden, Kathleen M.Stacy and Mary E.

Lough, 2003, “ Priorities in Critical Care Nursing”

4th edition, Evolve publications, page no;80-101

• Roberta Kaplow and Sonya R. Hardin 2007, “

Critical Care Nursing surgery for optimal out

comes” Jones and Bartlett publications, page

no:41-48

• Brunner & Suddarth’s ,2008, “Text book of

Medical Surgical Nursing”, Vol-1, 11th

edition, Lippincott Williams And Wilkins

Publications, page no: 259- 295.