The ICU challenge – translating the

evidence into everyday practice:

managing Pain, Agitation and

Delirium

Yoanna Skrobik MD FRCP(c) MSc.

Conflicts of interest

Member, SCCM Pain, Agitation and Delirium guidelines writing committee

Vice-chair, SCCM Pain, Agitation, Delirium, Early Mobility

and Sleep guidelines

Member, SCCM family-centered care guideline writing committee

Investigator initiated research funding, Hospira

Academic chair, Université de Montréal

Academic chair

Astellas

Merck

Pfizer

Baxter

Hospira

Otsuka

Novartis

Lilly

Why would you evaluate pain,

agitation, delirium?

Painlessness

Reassurance

– Feeling safe Journal of Nursing Scholarship. 32(4):361-7, 2000

– Information, orientation, cognitive abnormalities American

Journal of Critical Care. 9(3):192-8, 2000 May

plan

Pain assessment and management

Sedation and level of consciousness alterations in the ICU

Delirium

Adding mobility and sleep

Why assessing pain, sedation and delirium matters

Why are we not all doing it

pain

pain

– Incidence of pain:

Adult M&S ICU patients consistently experience pain, at rest

and with routine ICU care (mobilization, suctioning).

Pain in adult cardiac surgery patients, especially women, (i.e.,

incisional pain due to coughing, respiratory care procedures,

and mobilization) remains prevalent and poorly treated .

Procedural pain is common in adult ICU patients .

Memories and perceptions in ICU survivors: a

multidimensional questionnaire

G Hernandez, R de la Fuente, C Romero, ME Naranjo, M Zanolli, N Barticevic, L Castillo, G Bugedo

0

10

20

30

40

50

60

70

pain thirst heat tube

sensorial memories

%

never

few

most

always

Thirst (76%), sleep deprivation (66%) and isolated pain (52%)

predominated in factual memories

Pain assessment

Should be routine, right?

Evaluation of pain in my ICU

Even though assessment was done 90% of the time No severity scale used in 17% of patients

Evaluations were not done according to the pain reported by the patient when scales were used 20% of the time

Correlation between “gold standard” adjudicators and nurses was excellent

R= 1,000 (0,88 when using all evaluations)

Obstacles to the use of the NRS: Assumption that the patient has no pain

Nurses relying on their own evaluation of the patient’s pain

pain

Routine pain assessments in adult ICU patients are

associated with improved clinical outcomes.

Assessing Pain Improves

Outcomes

Payen JF, et al. Anesthesiology. 2009;111:1308-1316.

Outcome

Day 2 Pain

Assessment? Unadj. OR P-valueAdjusted

ORP-value

No Yes

ICU Mortality 22% 19% 0.91 0.69 1.06 0.71

ICU LOS 18 d 13 d 1.70 < 0.01 1.43 0.04

MV duration 11 d 8 d 1.87 < 0.01 1.40 0.05

Vent-acquired

pneumonia 24% 16% 0.61 < 0.01 0.75 0.21

Correlation between pain assessments and

analgesic administration in critical care

Less patients evaluated and

more treated with analgesics

without protocol

Pain evaluation done routinely in

21% units surveyed in 2006

0

25

50

100

75

Pati

en

ts (

%)

Protocol No Protocol

*

*

Assessed Treated

1. Payen JF, et al. Anesthesiol. 2007;106:687-695.

2. Martin J, et al. Crit Care. 2007;11:R124.

* P < 0.01 vs. ICUs using a protocol

Measuring pain

Self-reporting of pain remains the gold standard

Patient-directed

pain control.

Patient assessment

And this is what it looks like

And in the patient unable to

self-report

Keep in mind

Routine pain assessments in adult ICU patients are

associated with improved clinical outcomes.

Self-reporting of pain remains the gold standard.

For medical, postoperative or trauma adult ICU patients

unable to self-report, the BPS and CCPOT (French/ English)

pain scales are considered to be the most valid and reliable.

vital signs (or observational pain scales that include vital

signs) are unreliable in pain assessment in adult ICU patients.

Pain assessment value

Compliance and documentation of pain assessments

Impact of pain assessment on analgesic and other medications

Impact of pain assessment on level of pain

Impact of pain assessment on duration of mechanical ventilation

Impact of pain assessment on occurrence of adverse events

and complications

Impact of pain assessment on patient satisfaction

Impact of pain assessment on ICU length of stay (LOS)

Impact of pain assessment on mortality

sedation

sedation

No text

Monitoring sedation

The RASS and SAS scales are valid and reliable for

measuring quality and depth of sedation in adult ICU patients .

Sedation-Agitation Scale (SAS)

Riker RR, et al. Crit Care Med.1999;27:1325-1329.

Brandl K, et al. Pharmacotherapy.2001;21:431-436.

Score State Behaviors

7Dangerous

Agitation

Pulling at ET tube, climbing over bedrail, striking at staff,

thrashing side-to-side

6 Very AgitatedDoes not calm despite frequent verbal reminding,

requires physical restraints

5 AgitatedAnxious or mildly agitated, attempting to sit up, calms

down to verbal instructions

4Calm and

CooperativeCalm, awakens easily, follows commands

3 SedatedDifficult to arouse, awakens to verbal stimuli or gentle

shaking but drifts off

2 Very SedatedArouses to physical stimuli but does not communicate or

follow commands

1 UnarousableMinimal or no response to noxious stimuli, does not

communicate or follow commands

Richmond Agitation

Sedation Scale (RASS)Score State

+ 4 Combative

+ 3 Very agitated

+ 2 Agitated

+ 1 Restless

0 Alert and calm

-1 Drowsy eye contact > 10 sec

-2 Light sedation eye contact < 10 sec

-3 Moderate sedation no eye contact

-4 Deep sedation physical stimulation

-5 Unarousable no response even with physical

Verbal Stimulus

Physical Stimulus

sedation

– Depth of sedation vs. clinical outcomes:

Maintaining lighter levels of sedation in adult ICU patients is

associated improved clinical outcomes ( duration of

mechanical ventilation and length of stay).

Maintaining lighter sedation levels increases physiologic

stress response, but not incidence of myocardial ischemia .

The relationship between depth of sedation and psychological

stress in these patients is unclear .

sedative medications titrated to maintain light (vs. deep) levels

of sedation in adult ICU patients are associated with better

outcomes .

consciousness

Alteration of consciousness and

outcome

Coma is bad for you

In my ICU the baseline RASS is -0.4

‘wake up and breathe’

‘Why is it that when an ICU

caregiver digs himself into a

hole he talks about the light

at the end of the tunnel?’

Who benefits the most?

adjustment vs. interruption

Outcomes related to sedation

sedation strategies using non-benzodiazepine sedatives have

better outcomes than benzodiazepine infusions in

mechanically ventilated adult ICU patients.

analgesia should be evaluated prior to sedation in adult ICU

patients who are mechanically ventilated .

delirium

Van der Mast. PhD Thesis, Delirium After Cardiac Surgery, Erasmus University, Rotterdam,

1994

Delirium and outcomes

Delirium is strongly associated with increased mortality and

LOS in adult ICU patients.

delirium and distress

Breitbart W et al. Psychosomatics 2002;43:183

CAM-ICU

(Confusion Assessment Method-ICU)

Delirium scales

ICDSC

(Intensive Care Delirium Screening

Checklist)

http://www.icudelirium.co.uk/ www.icudelirium.org

Delirium nomenclature

Delirium and its consequences

Delirium prevention

early mobilization of adult ICU patients reduces the incidence

and duration of delirium.

Protocol to address patient views

on what is important in the ICU

Painlessness

Reassurance

– Feeling safe Journal of Nursing Scholarship. 32(4):361-7, 2000

– Information, orientation, cognitive abnormalities American

Journal of Critical Care. 9(3):192-8, 2000 May

Analgesia Sedation Delirium Protocol

ANALGESIA•Subjective Pain Scale

•Short acting narcotics

SEDATION•Subjective Sedation Scale (ex RASS)

•Avoidance of oversedation and caution with benzodiazepines

DELIRUM•Subjective Delirium Scale (ICDSC or CAM-ICU)

“Agitation”

Before After

Going home 45.2% 52.2% P=0.024

…Patient-driven analgesia, sedation and

delirium management in 1200 patients

Delirium symptoms

Specifically, level of consciousness

wakefulness

Does it influence delirium assessment?

CAM-ICU

(Confusion Assessment Method-ICU)

Delirium scales

ICDSC

(Intensive Care Delirium Screening

Checklist)

http://www.icudelirium.co.uk/ www.icudelirium.org

Assessment of Delirium Relative to Daily

Sedative Interruption

JT Poston MD, MW Sjoding MD, AS Pohlman RN MSN, BK Gehlbach MD, JB Hall MD, JP

Kress MD

Assessment of Delirium Relative to Daily

Sedative Interruption

JT Poston MD, MW Sjoding MD, AS Pohlman RN MSN, BK Gehlbach MD, JB Hall MD, JP

Kress MD

48%higher delirium identification during sedation administration

when compared to assessments made in the same patients

after sedation was lightened to the point of wakefulness.

This difference persisted for analysis of MV days, ICU days, and

total hospital days

wakefulness

Delirium assessment is sensitive to the timing of evaluation

relative to sedative/analgesic infusion and interruption

This robust effect can significantly impact assessed days of

delirium well beyond the administration of sedatives/analgesics

Implications

A standardized assessment accounting for sedatives/analgesics

and daily interruption should be part of future investigations

Delirium due solely to sedative/analgesic infusion may portend a

different prognosis than delirium that persists in its absence

Awake patients mean

Pain can be assessed

Sedation is adjusted

Delirium is minimized

Mobility can be implemented

Sleep can be optimized

How can optimal patient care be

provided?

a multidisciplinary ICU team approach, that includes

provider education, preprinted and/or computerized

sedation protocols and order forms, and a quality rounds

checklist, can be used to facilitate analgesia, sedation and

delirium management in adult ICUs...

But we all know…

…. it takes an average of 17 years for new knowledge to

have an impact on bedside standards of practice

change

Canadian collaborative

Measuring and implemening

change

Champions

Realistic plan and follow through

Objective measures

alternatives

Web-based teaching

Web-based benchmark comparisons

Engaging staff

Engaging patients and families

Engaging staff

Engaging patients:

Mrs M’s taking stick

recap

Pain assessment and management

Sedation and level of consciousness alterations in the ICU

Delirium

Adding mobility and sleep

Why combining pain, sedation and delirium matters

Why are we not all doing it

Making patient care better

Thank you