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Semin Respir Crit Care Med 2013; 34(02): 236-243
DOI: 10.1055/s-0033-1342986
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Pain, Sedation, and Delirium Management in the Neurocritically Ill: Lessons Learned from Recent Research

Céline Gélinas
1   Ingram School of Nursing, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
2   Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
,
Kate Klein
3   Department of Neurocritical Care, Cleveland Clinic, Cleveland, Ohio
,
Andrew M. Naidech
4   Department of Neurology, Anesthesiology, and Neurological Surgery, Northwestern University, Chicago, Illinois
,
Yoanna Skrobik
5   Department of Medicine, University of Montreal, Montreal, Quebec, Canada
6   Intensive care unit, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
› Author Affiliations
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Publication History

Publication Date:
28 May 2013 (online)

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Abstract

Critically ill patients with a primary neurological injury or illness pose unique challenges for pain, agitation, and delirium management in intensive care units (ICUs). Detection and monitoring can be limited by contextual level of consciousness (LOC) alterations, cognition, expression, or language deficits. Recent data suggest that existing pain assessment tools may not be applicable to all neurocritically ill patients, especially in those with LOC alterations and atypical pain-associated behaviors. Targeted sedation goals may be neurologically disease specific; for instance, intracranial pressure (ICP) targets will supersede sedation titration by other criteria. Technology such as bispectral index (BIS) may be beneficial in avoiding excessive medication administration in deeply sedated neurologically injured ICU patients. Given the wide variety of pathology in the neurocritically ill patients, it is unclear if delirium can be diagnosed and unequivocally differentiated from symptoms of the underlying neurological pathology. However, delirium symptoms may herald life-threatening primary insult progression or result from a new secondary neurological injury and should be monitored. Patients with neurological injury or illness are often excluded from ICU studies addressing pain, sedation, and delirium, but this need not be the case. We review what is understood in this area based on current evidence.

Keywords

pain - sedation - delirium - neuro - intensive care unit
 

  • References

  • 1 Puntillo KA, White C, Morris AB , et al. Patients' perceptions and responses to procedural pain: results from Thunder Project II. Am J Crit Care 2001; 10 (4) 238-251
    PubMedGoogle Scholar
  • 2 Arroyo-Novoa CM, Figueroa-Ramos MI, Puntillo KA , et al. Pain related to tracheal suctioning in awake acutely and critically ill adults: a descriptive study. Intensive Crit Care Nurs 2008; 24 (1) 20-27
    CrossrefPubMedGoogle Scholar
  • 3 Siffleet J, Young J, Nikoletti S, Shaw T. Patients' self-report of procedural pain in the intensive care unit. J Clin Nurs 2007; 16 (11) 2142-2148
    CrossrefPubMedGoogle Scholar
  • 4 Stotts NA, Puntillo K, Bonham Morris A , et al. Wound care pain in hospitalized adult patients. Heart Lung 2004; 33 (5) 321-332
    PubMedGoogle Scholar
  • 5 Chanques G, Sebbane M, Barbotte E, Viel E, Eledjam JJ, Jaber S. A prospective study of pain at rest: incidence and characteristics of an unrecognized symptom in surgical and trauma versus medical intensive care unit patients. Anesthesiology 2007; 107 (5) 858-860
    CrossrefPubMedGoogle Scholar
  • 6 Flexman AM, Ng JL, Gelb AW. Acute and chronic pain following craniotomy. Curr Opin Anaesthesiol 2010; 23 (5) 551-557
    CrossrefPubMedGoogle Scholar
  • 7 Mordhorst C, Latz B, Kerz T , et al. Prospective assessment of postoperative pain after craniotomy. J Neurosurg Anesthesiol 2010; 22 (3) 202-206
    CrossrefPubMedGoogle Scholar
  • 8 Thibault M, Girard F, Moumdjian R, Chouinard P, Boudreault D, Ruel M. Craniotomy site influences postoperative pain following neurosurgical procedures: a retrospective study. Can J Anaesth 2007; 54 (7) 544-548
    CrossrefPubMedGoogle Scholar
  • 9 Gottschalk A. Craniotomy pain: trying to do better. Anesth Analg 2009; 109 (5) 1379-1381
    CrossrefPubMedGoogle Scholar
  • 10 Gottschalk A, Yaster M. The perioperative management of pain from intracranial surgery. Neurocrit Care 2009; 10 (3) 387-402
    CrossrefPubMedGoogle Scholar
  • 11 Leslie K, Troedel S, Irwin K , et al. Quality of recovery from anesthesia in neurosurgical patients. Anesthesiology 2003; 99 (5) 1158-1165
    CrossrefPubMedGoogle Scholar
  • 12 Zasler ND, Horn L, Martelli MF, Nicholson K. Post-traumatic pain disorders: medical assessment and management. In: Zasler ND, Katz D, Zafonte R, , eds. Brain Injury Medicine: Principles and Practice. New York, NY: Demos; 2006: 697-719
    Google Scholar
  • 13 Ashwal S, Cranford R, Bernat JL , et al. Medical aspects of the persistent vegetative state (1). The Multi-Society Task Force on PVS. N Engl J Med 1994; 330 (21) 1499-1508
    CrossrefPubMedGoogle Scholar
  • 14 Giacino JT, Ashwal S, Childs N , et al. The minimally conscious state: definition and diagnostic criteria. Neurology 2002; 58 (3) 349-353
    CrossrefPubMedGoogle Scholar
  • 15 Laureys S, Faymonville ME, Peigneux P , et al. Cortical processing of noxious somatosensory stimuli in the persistent vegetative state. Neuroimage 2002; 17 (2) 732-741
    CrossrefPubMedGoogle Scholar
  • 16 Boly M, Faymonville M-E, Schnakers C , et al. Perception of pain in the minimally conscious state with PET activation: an observational study. Lancet Neurol 2008; 7 (11) 1013-1020
    CrossrefPubMedGoogle Scholar
  • 17 Beretta L, De Vitis A, Grandi E. Sedation in neurocritical patients: is it useful?. Minerva Anestesiol 2011; 77 (8) 828-834
    PubMedGoogle Scholar
  • 18 Recommended by the IASP Subcommittee on Taxonomy . Pain terms: a list with definitions and notes on usage. Pain 1979; 6 (3) 249
    PubMedGoogle Scholar
  • 19 Chanques G, Viel E, Constantin J-M , et al. The measurement of pain in intensive care unit: comparison of 5 self-report intensity scales. Pain 2010; 151 (3) 711-721
    CrossrefPubMedGoogle Scholar
  • 20 Yu AYX, Teitelbaum J, Skrobik Y. Evaluating pain, sedation and delirium in the neurologically critically ill. Poster presented at the 64th Annual Meeting of the American-Academy-of-Neurology (AAN); April 21–28, 2012; New Orleans, LA
    PubMedGoogle Scholar
  • 21 Egerod I, Jensen MB, Herling SF, Welling KL. Effect of an analgo-sedation protocol for neurointensive patients: a two-phase interventional non-randomized pilot study. Crit Care 2010; 14 (2) R71
    CrossrefPubMedGoogle Scholar
  • 22 Puntillo K, Pasero C, Li D , et al. Evaluation of pain in ICU patients. Chest 2009; 135 (4) 1069-1074
    CrossrefPubMedGoogle Scholar
  • 23 Herr K, Coyne PJ, McCaffery M, Manworren R, Merkel S. Pain assessment in the patient unable to self-report: position statement with clinical practice recommendations. Pain Manag Nurs 2011; 12 (4) 230-250
    CrossrefPubMedGoogle Scholar
  • 24 Topolovec-Vranic J, Canzian S, Innis J, Pollmann-Mudryj MA, McFarlan AW, Baker AJ. Patient satisfaction and documentation of pain assessments and management after implementing the adult nonverbal pain scale. Am J Crit Care 2010; 19 (4) 345-354 , quiz 355
    CrossrefPubMedGoogle Scholar
  • 25 Gélinas C, Fillion L, Puntillo KA, Viens C, Fortier M. Validation of the critical-care pain observation tool in adult patients. Am J Crit Care 2006; 15 (4) 420-427
    CrossrefPubMedGoogle Scholar
  • 26 Kapoustina O, Echegaray-Benites C, Gélinas C , et al. Physiological and behavioral pain indicators exhibited by post-craniotomy patients exposed to common nursing procedures in the neurological intensive care unit [abstract]. IASP Press; 2012
    Google Scholar
  • 27 Gélinas C, Johnston C. Pain assessment in the critically ill ventilated adult: validation of the Critical-Care Pain Observation Tool and physiologic indicators. Clin J Pain 2007; 23 (6) 497-505
    CrossrefPubMedGoogle Scholar
  • 28 Puntillo KA, Morris AB, Thompson CL, Stanik-Hutt J, White CA, Wild LR. Pain behaviors observed during six common procedures: results from Thunder Project II. Crit Care Med 2004; 32 (2) 421-427
    CrossrefPubMedGoogle Scholar
  • 29 Payen JF, Bru O, Bosson JL , et al. Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med 2001; 29 (12) 2258-2263
    Google Scholar
  • 30 Gélinas C, Arbour C. Behavioral and physiologic indicators during a nociceptive procedure in conscious and unconscious mechanically ventilated adults: similar or different?. J Crit Care 2009; 24 (4) e7-e17
    CrossrefPubMedGoogle Scholar
  • 31 Le Q, Gelinas C, Arbour C, Rodrigue N. Description of behaviors in traumatic brain injury patients when exposed to common procedures in the intensive care unit: A pilot study. Pain Manag Nurs 2012; ; In press
    PubMedGoogle Scholar
  • 32 Arbour C, Gélinas C, Loiselle CG, Bourgault P, Choinière M. Nonverbal indicators of pain in ICU patients with a traumatic brain injury: Similar or different from other critically ill populations?. [abstract] IASP Press; 2012
    Google Scholar
  • 33 American Educational Research Association (AERA), American Psychological Association (APA), National Council in Measurement in Education (NCME).. Standards for Educational and Psychological Testing. Washington, DC: AERA; 1999
    Google Scholar
  • 34 I. nternational Association for the Study of Pain (IASP). Pain Terminology. 2011. http://www.iasp-pain.org/AM/Template.cfm?Section=Pain_Defi...isplay.cfm&ContentID=1728 . Accessed September 30, 2012
    PubMedGoogle Scholar
  • 35 Aïssaoui Y, Zeggwagh AA, Zekraoui A, Abidi K, Abouqal R. Validation of a behavioral pain scale in critically ill, sedated, and mechanically ventilated patients. Anesth Analg 2005; 101 (5) 1470-1476
    CrossrefPubMedGoogle Scholar
  • 36 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
    CrossrefPubMedGoogle Scholar
  • 37 Young J, Siffleet J, Nikoletti S, Shaw T. Use of a Behavioural Pain Scale to assess pain in ventilated, unconscious and/or sedated patients. Intensive Crit Care Nurs 2006; 22 (1) 32-39
    CrossrefPubMedGoogle Scholar
  • 38 Rose L, Smith O, Gélinas C , et al. Canadian critical care nurses' pain assessment and management practices: A national survey. Am J Crit Care 2012; 21 (4) 247-255
    PubMedGoogle Scholar
  • 39 Li D, Miaskowski C, Burkhardt D, Puntillo K. Evaluations of physiologic reactivity and reflexive behaviors during noxious procedures in sedated critically ill patients. J Crit Care 2009; 24 (3) e9-e13
    PubMedGoogle Scholar
  • 40 Jeitziner M-M, Schwendimann R, Hamers JPH, Rohrer O, Hantikainen V, Jakob SM. Assessment of pain in sedated and mechanically ventilated patients: an observational study. Acta Anaesthesiol Scand 2012; 56 (5) 645-654
    CrossrefPubMedGoogle Scholar
  • 41 Arbour C, Gelinas C, Loiselle C , et al. Detecting pain in nonverbal ICU patients with a traumatic brain injury (TBI) and altered level of consciousness using the bilateral Bispectral Index (BIS): A pilot study. [abstract] Pain Res Manag 2012; 17 (3) 203
    PubMedGoogle Scholar
  • 42 Barr J, Fraser GL, Puntillo K , et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41 (1) 263-306
    CrossrefPubMedGoogle Scholar
  • 43 Schweickert WD, Pohlman MC, Pohlman AS , et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009; 373 (9678) 1874-1882
    CrossrefPubMedGoogle Scholar
  • 44 Teitelbaum JS, Ayoub O, Skrobik Y. A critical appraisal of sedation, analgesia and delirium in neurocritical care. Can J Neurol Sci 2011; 38 (6) 815-825
    PubMedGoogle Scholar
  • 45 Watling SM, Dasta JF, Seidl EC. Sedatives, analgesics, and paralytics in the ICU. Ann Pharmacother 1997; 31 (2) 148-153
    PubMedGoogle Scholar
  • 46 Rapanos T, Murphy P, Szalai JP, Burlacoff L, Lam-McCulloch J, Kay J. Rectal indomethacin reduces postoperative pain and morphine use after cardiac surgery. Can J Anaesth 1999; 46 (8) 725-730
    PubMedGoogle Scholar
  • 47 Hynninen MS, Cheng DCH, Hossain I , et al. Non-steroidal anti-inflammatory drugs in treatment of postoperative pain after cardiac surgery. Can J Anaesth 2000; 47 (12) 1182-1187
    PubMedGoogle Scholar
  • 48 Skrobik Y, Ahern S, Leblanc M, Marquis F, Awissi DK, Kavanagh BP. Protocolized intensive care unit management of analgesia, sedation, and delirium improves analgesia and subsyndromal delirium rates. Anesth Analg 2010; 111 (2) 451-463
    CrossrefPubMedGoogle Scholar
  • 49 Chanques G, Jaber S, Barbotte E , et al. Impact of systematic evaluation of pain and agitation in an intensive care unit. Crit Care Med 2006; 34 (6) 1691-1699
    CrossrefPubMedGoogle Scholar
  • 50 Robinson BR, Mueller EW, Henson K, Branson RD, Barsoum S, Tsuei BJ. An analgesia-delirium-sedation protocol for critically ill trauma patients reduces ventilator days and hospital length of stay. J Trauma 2008; 65 (3) 517-526
    CrossrefPubMedGoogle Scholar
  • 51 Puntillo KA, Neuhaus J, Arai S , et al. Challenge of assessing symptoms in seriously ill intensive care unit patients: can proxy reporters help?. Crit Care Med 2012; 40 (10) 2760-2767
    CrossrefPubMedGoogle Scholar
  • 52 Gottschalk A, Berkow LC, Stevens RD , et al. Prospective evaluation of pain and analgesic use following major elective intracranial surgery. J Neurosurg 2007; 106 (2) 210-216
    CrossrefPubMedGoogle Scholar
  • 53 Karabinis A, Mandragos K, Stergiopoulos S , et al. Safety and efficacy of analgesia-based sedation with remifentanil versus standard hypnotic-based regimens in intensive care unit patients with brain injuries: a randomised, controlled trial [ISRCTN50308308]. Crit Care 2004; 8 (4) R268-R280
    CrossrefPubMedGoogle Scholar
  • 54 Olson DM, Thoyre SM, Peterson ED, Graffagnino C. A randomized evaluation of bispectral index-augmented sedation assessment in neurological patients. Neurocrit Care 2009; 11 (1) 20-27
    CrossrefPubMedGoogle Scholar
  • 55 Hansen-Flaschen J, Cowen J, Polomano RC. Beyond the Ramsay scale: need for a validated measure of sedating drug efficacy in the intensive care unit. Crit Care Med 1994; 22 (5) 732-733
    CrossrefPubMedGoogle Scholar
  • 56 Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalone-alphadolone. BMJ 1974; 2 (5920) 656-659
    CrossrefPubMedGoogle Scholar
  • 57 Marinella MA. Propofol for sedation in the intensive care unit: essentials for the clinician. Respir Med 1997; 91 (9) 505-510
    CrossrefPubMedGoogle Scholar
  • 58 Farling PA, Johnston JR, Coppel DL. Propofol infusion for sedation of patients with head injury in intensive care. A preliminary report. Anaesthesia 1989; 44 (3) 222-226
    CrossrefPubMedGoogle Scholar
  • 59 Johnston AJ, Steiner LA, Chatfield DA , et al. Effects of propofol on cerebral oxygenation and metabolism after head injury. Br J Anaesth 2003; 91 (6) 781-786
    CrossrefPubMedGoogle Scholar
  • 60 Aryan HE, Box KW, Ibrahim D, Desiraju U, Ames CP. Safety and efficacy of dexmedetomidine in neurosurgical patients. Brain Inj 2006; 20 (8) 791-798
    CrossrefPubMedGoogle Scholar
  • 61 Grof TM, Bledsoe KA. Evaluating the use of dexmedetomidine in neurocritical care patients. Neurocrit Care 2010; 12 (3) 356-361
    CrossrefPubMedGoogle Scholar
  • 62 Mirski MA, Lewin III JJ, Ledroux S , et al. Cognitive improvement during continuous sedation in critically ill, awake and responsive patients: the Acute Neurological ICU Sedation Trial (ANIST). Intensive Care Med 2010; 36 (9) 1505-1513
    CrossrefPubMedGoogle Scholar
  • 63 Mitasova A, Kostalova M, Bednarik J , et al. Poststroke delirium incidence and outcomes: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2012; 40 (2) 484-490
    CrossrefPubMedGoogle Scholar
  • 64 Skrobik Y. Delirium in patients with stroke: the dark side of the moon?. Crit Care Med 2012; 40 (2) 676-677
    CrossrefPubMedGoogle Scholar
  • 65 Bergeron N, Skrobik Y, Dubois M-J. Is disturbance of consciousness an important feature of ICU delirium?. Intensive Care Med 2005; 31 (6) 887
    CrossrefPubMedGoogle Scholar
  • 66 Bergeron N, Dubois M-J, Dumont M, Dial S, Skrobik Y. Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med 2001; 27 (5) 859-864
    CrossrefPubMedGoogle Scholar
  • 67 Van Rompaey B, Elseviers MM, Schuurmans MJ, Shortridge-Baggett LM, Truijen S, Bossaert L. Risk factors for delirium in intensive care patients: a prospective cohort study. Crit Care 2009; 13 (3) R77
    CrossrefPubMedGoogle Scholar
  • 68 Dubois M-J, Bergeron N, Dumont M, Dial S, Skrobik Y. Delirium in an intensive care unit: a study of risk factors. Intensive Care Med 2001; 27 (8) 1297-1304
    CrossrefPubMedGoogle Scholar
  • 69 Grover S, Chakrabarti S, Shah R, Kumar V. A factor analytic study of the Delirium Rating Scale-Revised-98 in untreated patients with delirium. J Psychosom Res 2011; 70 (5) 473-478
    CrossrefPubMedGoogle Scholar
  • 70 Frontera JA. Delirium and sedation in the ICU. Neurocrit Care 2011; 14 (3) 463-474
    CrossrefPubMedGoogle Scholar
  • 71 Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y. Incidence, risk factors and consequences of ICU delirium. Intensive Care Med 2007; 33 (1) 66-73
    CrossrefPubMedGoogle Scholar