Safety is in the details
Safety in the ICU

The Challenges of Pain Management

May 9, 2016

 

Pain Management is a “Conflict” of Interests


Dan Arieli [1], the author of “predictably irrational” who is the James B. Duke Professor of Psychology and Behavioral Economics, writes about his personal experiences with pain management by hospital staff detailing the pain he suffered when nurses had to change his bandages, treating his severe burns, which were caused by an accident that occurred in his youth.


He mentions that the nurses went about this task quickly and even roughly, because they were affected by the pain they were causing him. Prof. Arieli’s suffering was very visible and easily heard by the staff, and they were in fact taking part in inflicting it on him for the sake of his treatment. He raises an interesting question about the possibility of conflicting interests between the caring nurses and the patient when it comes to pain assessment, evaluation, control and management [2].


A nurse’s difficulty to perform certain procedures that are painful to patients, even when it's for their own good is not discussed or studied often. Contrary to what some unfortunate patients might think, medical professionals generally can't stand the idea of harming their patients (as prof. Arieli found out in his research on the subject). This conundrum becomes even more difficult for nurses in the ICU and in anesthesia units.


The Challenges of Pain Management in the ICU and Anesthesia Units


Pain management is one of the biggest challenges for nurses in critical care and surgery settings, as there are many considerations to be considered when deciding on the correct treatment.


Patients who end up in the ICU often suffer from multiple conditions, making pain management more complex than it would seem [7].  In addition to the variety of ailments that need to be treated, pain management in the ICU can also be challenging because of inadequate tools, a high ratio of patients to healthcare staff, and poor response to pain medications. Another issue is the communication with patients regarding their pain levels, which one cannot always take for granted. Critically ill patients are not always able to communicate verbally, making pain assessment by the staff even more challenging.


Pain management and sedation during and after surgery is complex as one must consider limitations due to the surgery as well as drug interactions that might be caused by medication that the patient takes for other conditions [8]. Another challenge in postoperative care is selecting the best analgesic protocols for helping patients tolerate the discomfort after surgery [10]. A research recommends an evidence-based evaluation as well as collaboration of all the involved healthcare staff (e.g. anesthesiologists, surgeons, nurses, and physiotherapists) for the development and integration of specific surgical procedures [9]. Such a research would also help further develop advanced approaches for postoperative patient-controlled analgesia (PCA).


A study [3] found that pain management continues to be a serious challenge that many hospitals need to address. However, methodic documentation and intervention for pain management has been found effective. Guidelines and assessment scales were developed to help nursing staff conduct better pain management interventions.


Guidelines for Effective Pain Management in the ICU


Each healthcare facility is responsible for developing their own protocols, but there are several guidelines [4], which are considered standard (and even mandatory) by the medical community. Here are some examples:


Asses pain routinely – four times per shift


Nurses are advised to assess their patients’ pain levels on a routine basis. Doing so several times per shift will ensure that nurses are up to date and able to respond to the changes of these levels and the patients’ reaction (or lack thereof) to any treatment of their pain.


Get a personal report whenever possible, if the patient can communicate.


There will be times when a patient's self-described pain level is different than what a nurse typically sees in someone suffering from the same condition. It's generally best to take the word of the patients – no one knows what they're feeling as well as they do.


Use scales and tools for pain assessment of nonverbal patients.


Unfortunately, many patients in the ICU will be unable to communicate clearly or at all. In these scenarios, medical professionals should rely on scales (or scores) to assess the level of pain.
A study finds [5] that using a nonverbal pain scale in the ICU improved patients’ satisfaction with regards to their pain experience during their hospitalization. The study also found that pain is documented better and the nurses feel more secure in their assessment of pain levels.


The Behavioral Pain Scale (BPS) and Critical Care Pain Observation Tool (CPOT) are considered reliable scores by the medical community.


Treat pain with or without drugs, as the case warrants.


Pain management doesn't always require drugs. In fact, some patients would prefer to avoid taking unnecessary drugs due to side effects or personal inclinations. Relaxation therapy, heat and cold therapy, and similar techniques are all valid options for managing mild pain. For more severe pain drugs may be administered.


Treat pain first, then sedate.


You want to avoid sedating a patient while they are still in pain. Ideally, they should be comfortable before and after sedation to reduce stress and trauma.


Know when to use an incremental bolus or continuous infusion during intravenous fluid regulation for pain management.


The goal of pain management in the ICU and in anesthesia units is to get your patients as comfortable as possible, quickly. Therefore, a continuous infusion isn't appropriate for patients in severe pain because the time it takes for them to get relief will be miserable. Instead, an incremental bolus should be used to get the effective dose in their system quickly so you can assess their pain and make adjustments sooner.


However, in cases of which there is a need to maintain deep sedation, a study finds [6] advantages in the continuous infusion technique (the research examined maintaining sedation during surgery), although both techniques showed satisfactory conditions.


Switching between an incremental bolus and continues infusion, especially when administering multiple drugs, is not only a hassle – it creates more opportunities for safety risks and human error. Pain management can be easier, safer, and far more effective with a minimal residual volume luer-activated stopcock, such as the MarvelousTM stopcock.


How the MarvelousTM  Stopcock Assists with Pain Management


The MarvelousTM stopcock helps with drug administration due to its self-flushing function and the fact that its internal volume has little "dead space" for drug accumulation. This prevents any residue from a previously used drug from remaining in the stopcock, as well as preventing any liquid from remaining and creating a breeding ground for bacteria.


Working with MarvelousTM also reduces stopcock manipulations and with it the room for medical errors. By eliminating some of the required tasks associated with traditional stopcocks, medical staff can provide more attention to their patients, assessing their pain levels, and knowing for certain that the drugs are being administered properly.


"I like MarvelousTM/ due to its self-flushing feature that helps us flush out any potential drops of Propofol or other medications that may be left behind in the luer before the patient goes to the PACU”, says Dr. Mike Bradstock, Maricopa Medical center, Phoenix, Arizona, USA.
“Currently it is reportable if we do not completely flush the side ports of the stopcocks before sending the patient to the step down unit. Using MarvelousTM helps us avoid this error and makes it safer for the patient" he adds.


Pain Management Improvement is an Ongoing Challenge


Pain management is a continuous effort which involves all healthcare professionals. An academic research on the subject of structured approaches to pain management in the ICU [7] finds that an ongoing, regular and open discussion between doctors, nurses and pharmacists is key to the continued improvement of pain management approaches. The effort is worth it, as improved pain management is beneficial to both patients and nursing staff.


To learn more about Marvelous and how it can help you with pain management in the ICU and anesthesia units, come visit us at NTI at New Orleans booth #3226 and at WCNA in Glasgow booth #4.


CONTACT US  to schedule a meeting at these conferences.


Resources:
1. http://danariely.com/all-about-dan/
2. http://people.duke.edu/~dandan/webfiles/mypain.pdf
3. http://ajcc.aacnjournals.org/content/3/1/25.short
4. http://www.learnicu.org/SiteCollectionDocuments/Pain,%20Agitation,%20Delirium.pdf
5. http://ajcc.aacnjournals.org/content/19/4/345.abstract
6.  http://www.ncbi.nlm.nih.gov/pubmed/9734766
7. http://journal.publications.chestnet.org/article.aspx?articleid=1089867
8. http://www.webmd.com/pain-management/features/managing-pain-after-surgery
9. http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1932602
10. http://anesthpain.com/?page=article&article_id=3443

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