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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.