Pain, Agitation & Delirium

(2013)

Immobility & Sleep (2018)

Catherine Jones

Practice Educator – GICU

October 2018

1

Plan for session

• Why Pain Agitation & Delirium are

important considerations in critical care

population?

• Describe assessment tools available for

– Pain – CPOT

– Agitation/sedation – RASS

– Delirium – CAM-ICU

• Guidelines & Bundle(s)

• Specific management for PAD (IS). 2

WHY IS THIS IMPORTANT? 3

Pain

• Pain is a common memory for most ICU

patients (Reade & Finfer, 2014)

• Critical care population may not be able to

‘self-report’ their experience of pain so it

may go undetected

• Consequences of uncontrolled pain

– Immunosuppression

– PTSD

– Delayed wound healing

4

Agitation & Sedation

• Early mechanical ventilation required deep

sedation due to problems with patient

synchrony & comfort

• Advances in vent technology &

medications means this isn’t always

necessary now

• But common feature of ICU patients as

they experience a frightening & stressful

stimuli during their ‘stay’ with us 5

Delirium

• Affects up to 80% of mechanically

ventilated adult ICU patients

• Acute onset of cerebral dysfunction

• Characterised by

– Change/fluctuation from baseline mental

status

– Inattention

– Either disorganised thinking or altered level

of consciousness

6 Barr(2013)

7 Barr(2013)

8

N Engl J Med 2014; 370:444-454

Causes & Interactions of PAD

ASSESSMENT TOOLS

10

Assessing pain at SGH:

1. Self Report (gold standard)

• Pain Assessment chart used by whole trust

for patients able to tell us if it hurts

2. Continuous Pain Observation Tool

(CPOT)

• Adult ICU patients who are unable to self

report

3. Abbey Pain Scale

• Pain assessment chart used in trust for

patients unable to self report such as LD

11

12

13

14

15

16

Assessing agitation at SGH:

Richmond Agitation Sedation Score

17

Assessing delirium at SGH:

Confusion assessment

Method for the ICU

• CAM-ICU

18

• Valeria Page cam – icu

assessment: https://www.youtube.com/wa

tch?v=6WyJ0zL7VkI

• 3mins 30 secs

20

GUIDELINES & BUNDLES

21

PAD guidelines (Barr 2013)

22

PADIS guidelines

(Devlin et al 2018)

24

ABCDEF Bundle

25

eCASH:

26 Vincent et al (2016) Comfort & patient centred care without excessive sedation: the eCASH concept Intensive care

Medicine

SPECIFIC MANAGEMENT FOR

PAD (IS).

27

Pain management in ICU:

• Consistent approach to pain assessment

• Analgesia first sedation or a analgesia based sedation

• IV opioids – 1st line

• BUT important considerations include:

– Sedation, Delirium, Resp despression, Ileus,

immunosuppression…

• SO.. Think about adjuncts to spare/minimise opioid use

– IV PARACETAMOL, low dose ketamine,

– Massage, music

– Gabapentin, Carbamazepine, Pregablin – neuropathic pain

• Remember reduced morphine clearance in renal failure -

?switch to Fentanyl

• Relative potency to morphine

28

Agitation management:

• Agitation is a feature of ICU admission

• Traditionally managed with deep sedation

• Paradigm shift to light sedation..

• Titrated to Sedation Score

• Daily Sedation Hold (unless contraindicated)

• Sedation strategy that avoids benzo:

29

Alfentenyl Lorazepam

Propofol Midazolam

Dexdor Haloperidol

Delirium management:

• Routine screening for delirium – CAM-ICU

• Reduce modifiable risk factors

• Hearing aids & spectacles – easy fix & quick win

• Re-orientation (Clocks), Cognitive stimulation

• Improve Sleep

• Increase wakefulness (reduce sedation)

• Early rehab/mobilsation

• ABCDEF Bundle…

• Pharmacology?

• Restraint? 30

31

Immobility Management

• Early Mobilisation &

rehabilitation

• Even on intubated patients!

• In bed activities eg

Motomed

32

33

Sleep Management

• Ear Plugs & Eye Shades

• Relaxing music

• Reduction in night time light, noise, intervention

• ? Melatonin, ?dexdor

34

35

Summary

• Pain

• Agitation

• Delirium

• Immobility

• Sleep Disruption

• CAN ALL BE IMPROVED BY

COMMITTED, HOLISTIC, PATIENT

FOCUSED CARE 36