Pain, Sedation, and Delirium Management in the

Download PDF
0 downloads 0 Views 225KB Size Report
Comment
patients were mechanically ventilated, 439 patient self-as- sessments of pain were ..... such as early progressive mobilization, frequent orientation to time and ...
236

Pain, Sedation, and Delirium Management in the Neurocritically Ill: Lessons Learned from Recent Research Céline Gélinas, RN, PhD1,2 Kate Klein, MS, ACNP-BC, RN, CCRN3 Yoanna Skrobik, MD, FRCP(c)5,6 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 3 Department of Neurocritical Care, Cleveland Clinic, Cleveland, Ohio 4 Department of Neurology, Anesthesiology, and Neurological Surgery, Northwestern University, Chicago, Illinois 5 Department of Medicine, University of Montreal, Montreal, Quebec, Canada 6 Intensive care unit, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada

Andrew M. Naidech, MD, MSPH4

Address for correspondence Yoanna Skrobik, MD, Intensive care unit, Hôpital Maisonneuve-Rosemont, 5415 Boulevard de l’Assomption, Montreal, Quebec, Canada H1T 2M4 (e-mail: [email protected]).

Semin Respir Crit Care Med 2013;34:236–243.

Abstract

Keywords

► ► ► ► ►

pain sedation delirium neuro intensive care unit

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.

Definition of Neurocritically Ill Patients Many academic and regional referral centers specifically designate critical care beds for neurological, neurosurgical, or neurotrauma intensive care unit (ICU) patients. Most North American critical care units admit a case mix of patients to

Issue Theme Pain/Agitation/Delirium; Guest Editors, E. Wesley Ely, MD, MPH, FCCM and Juliana Barr, MD, FCCM.

these ICU beds that include either neurocritically ill patients or ICU patients who, in addition to the admission-causing pathology, also have neurological illness or injury. This chapter is intended to encompass all ICU patients admitted to these specialized units, whether they have experienced a central neurological injury such as traumatic brain injury

Copyright © 2013 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.

DOI http://dx.doi.org/ 10.1055/s-0033-1342986. ISSN 1069-3424.

Pain, Sedation, and Delirium Management in the Neurocritically Ill (TBI), stroke, or intracranial hemorrhage, or have a primary neurological illness with predominantly peripheral manifestations such as Guillain-Barré syndrome or myasthenia gravis. These patients have been included as part of some published ICU studies on pain, agitation, and delirium; only a few studies have uniquely focused on this patient population.

Pain Epidemiology of Pain in Neurocritically Ill Patients Pain occurs commonly in all ICU patients. Turning, wound drain removal, wound care, and endotracheal suctioning are common procedures that have been identified to cause significant pain in critically ill patients.1–4 Being at rest and immobilization can also lead to high levels of pain in surgical, trauma, and medical ICU patients.5 The injury site is invoked as the main cause of pain in surgical-trauma patients, whereas medical ICU patients are most affected by back and limb pain. Most neurosurgical ICU patients describe moderate to severe pain in the first 48 hours, and particularly in the first 12 hours postoperatively.6–8 Pain from brain injury and intracranial procedures has been thought to be minimal, yet recent evidence suggests otherwise.9 Investigations have found such pain to be more intense, and the effect on quality of recovery more profound, than previously thought.10,11 Significant pain should therefore be assumed to be present in neurocritically ill patients as in other ICU patient groups. Assiduous assessment of pain using validated assessment tools is the first step toward appropriate pain management.

Pain Assessment in Neurological Injury Neuropathologies observed in brain-injured patients include cerebral contusion, intracranial hemorrhage, edema, and cerebral ischemia. Pain reactions and their emotional resonance (e.g., anger, anxiety) can be expected to be disturbed in this vulnerable population.12 Moreover, brain-injured patients can experience varying levels of consciousness (LOC), including coma or vegetative state (VS), and minimally conscious state (MCS), which may impact the perception of pain by these patients. Patients in VS present no language production or comprehension,13, whereas patients in MCS may show reproducible but minimal and fluctuating signs of consciousness.14 A recent study has shown that noxious stimuli elicit activation of the midbrain, contralateral thalamus, primary somatosensory cortex, and cingulate cortex in VS patients, suggesting some residual pain perception exists in these patients.15 In addition, MCS patients demonstrate patterns of brain activity in the cingulate region similar to those of healthy volunteers in response to noxious stimulation.16 Therefore, MCS patients may have sufficient brain integration for pain perception as well. This evidence suggests that braininjured patients with altered LOC may have the ability to perceive pain, and highlights the importance of assessing it in this vulnerable group. In addition, the deleterious effects of pain from neurological injury are known to increase intracranial pressure, reduce cerebral venous outflow, and increase brain metabolism.17 Therefore, alleviating pain is vitally important for patients with brain injury.

Gélinas et al.

Peripheral neurological injury such as Guillain-Barré syndrome or myasthenia gravis leading to critical care admission has not been studied independently. Our ability to comment on its detection and management is limited by the lack of targeted studies; the publications where such patients have been included will be referred to specifically when relevant in the studies cited here.

Pain Assessments: Self-Report versus Behavioral Pain Scales A patient’s self-report of pain has long been considered to be the “gold standard” of pain assessment.18 Indeed, patients’ rating of their own pain is associated with better pain management outcomes than with surrogate forms of pain assessment, and has the advantage of rapidly matching pain perception and effective analgesic intervention given the interpatient differences in both. A study of medical/surgical ICU patients demonstrated that a visually enlarged vertical numeric rating scale (NRS-V) ranging from 0 to 10 is the most valid and feasible pain assessment tool out of five pain intensity rating scales tested in over 100 patients.19 In a recent study20 of 151 patients admitted to specialized neuro ICUs (nICUs), following neurotrauma or neurosurgery, or with peripheral neurological lesions, in which 43% of the patients were mechanically ventilated, 439 patient self-assessments of pain were performed using a numerical rating scale (NRS) in these patients. An NRS score based on patients’ self-report of pain could be obtained in 70% of the evaluations, suggesting that self-report is feasible in a majority of these patients. Another study looked at the feasibility, efficacy, and patient outcomes of implementing the 6-point descriptive Pain Intensity Scale for assessing pain in nICU patients, and demonstrated a significant reduction in sedative use, an increase in the amount of analgesics administered, and an improvement in the proportion of patients reporting no pain.21 Structured, valid, and feasible tools must be used to assess critically ill patients’ self-report of pain whenever possible,22 even when the patient’s ability to fulfill this task is questioned. Patients’ self-reporting of pain is considered the gold standard of pain assessment and should be attempted first. When self-reporting is impossible to elicit from patients, clinicians should consider valid and reliable behavioral pain scales specifically developed for critically ill patients.23 Although several behavioral pain scales have been developed and validated for use in nonverbal critically ill adults, very few studies have tested their utility in neurocritically ill patients. So far, only the Behavioral Pain Scale (BPS), the Critical-Care Pain Observation Tool (CPOT), and the Nonverbal Pain Scale (NVPS) have been studied in nICU settings. A recent study20 addressing the feasibility of behavioral pain assessments in nICU patients with either central or peripheral neurological illness/injury (i.e., intracranial and subarachnoid hemorrhage, TBI, ischemic stroke, Guillain-Barré, and myasthenia gravis) found that the BPS was successfully substituted to a self-report scale in all 30% of patients who presented with an altered LOC (i.e., were arousable to pain or other stimuli) and who were unable to self-report, with very good interrater Seminars in Respiratory and Critical Care Medicine

Vol. 34

No. 2/2013

237

238

Pain, Sedation, and Delirium Management in the Neurocritically Ill reliability in the reported BPS scores between nurses and physicians for 47 assessments (interclass coefficient ¼ 0.83). In another study, patient and nurse satisfaction were measured before and after implementing the NVPS in a trauma/ neurosurgical ICU.24 Most nurses (78%) found the tool easy to use and felt more confident in assessing pain in nonverbal, sedated nICU patients postimplementation of the tool. Pain assessments were more frequent, patients reported decreased levels of pain retrospectively, and there was a trend toward a decrease in the time required to receive analgesics. On the other hand, the use of the tool did not increase the nurses’ confidence in managing pain in this patient group. Although behavioral pain scales seem to be feasible to use in neurocritically ill patients, their psychometric properties remain to be demonstrated, especially in those patients with an altered LOC or unconscious state. The CPOT25 has recently been validated in nICU patients after elective oncological neurosurgery.26 Discriminant validation was supported with higher CPOT scores during a painful procedure (i.e., turning) compared with a nonpainful procedure (i.e., noninvasive blood pressure [NIBP] using cuff inflation). CPOT scores and patients’ self-reports of pain were correlated to a moderate degree (r ¼ 0.52, p < 0.001) showing criterion validation. These findings were consistent with previous studies in medical, surgical, and trauma ICU patients.25,27,28 Even though the validity related to the use of the CPOT is shown to be similar in stable neurosurgery ICU patients compared with those with medical/surgical/trauma diagnoses, the situation is different in mechanically ventilated and sedated brain-injured ICU patients with an altered LOC.27,29 The study by Payen et al29 compared BPS scores in patients with TBI (n ¼ 16), with BPS scores in trauma and surgical ICU patients (n ¼ 14). Although a 2-point increase in the BPS score was noted during nociceptive procedures (e.g., endotracheal suctioning and mobilization) in trauma and surgical ICU patients, only a 1-point BPS score change was observed in the subgroup of TBI patients undergoing the same procedures. Although the authors did not discuss this finding further, these results led to speculation that TBI patients react less intensively or differently in comparison with other patients, or that nonverbal responsiveness should be adjusted and adjudicated for sedation. Similar observations were reported in Gélinas and Johnston’s study in which 19 critically ill TBI patients and 36 trauma, surgical, or medical ICU patients (total n ¼ 55) were assessed using the CPOT.27 Observed changes in CPOT scores following turning were about half the values in unconscious patients, with an average increase of only 2 points (n ¼ 25, including 14 TBI patients), when compared with CPOT scores in conscious patients (n ¼ 30, including 5 mild TBI patients), which increased by nearly 4 points, regardless of whether the LOC was attributable to either brain pathology or medication. Recent descriptive studies have sought to better understand behavioral responses to pain in brain-injured ICU patients with an altered LOC. During turning in unconscious ICU patients with a TBI (n ¼ 43), the following behaviors were noted: a relaxed face (70%), weeping eyes (14%), eye opening (16%), and relaxed muscles (72%).30 In a recent pilot study, 10 critically ill TBI patients were videorecorded before, during, Seminars in Respiratory and Critical Care Medicine

Vol. 34

No. 2/2013

Gélinas et al.

and after a painful procedure (turning), and a nonpainful procedure (NIBP).31 A behavioral checklist combining individual items of the CPOT25 and the Pain Behavior Assessment Tool (PBAT)28 was used as a guide for data collection. The following behaviors were observed during turning: levator contraction (n ¼ 7), frowning (n ¼ 5), opening eyes (n ¼ 5), weeping eyes (n ¼ 5), elevating eyebrows (n ¼ 5), ventilator alarm triggering (n ¼ 7), and muscle tension (n ¼ 5). An increase in the number of behaviors (median ¼ 4) was observed during turning (p < 0.001; Friedman test), in contrast to NIBP when no behavioral changes were noted (p ¼ 0.61; Friedman test). Following educational training and videos, the agreement for observed behaviors between two trained research assistants was 96%. An ongoing study using similar methods in 30 critically ill TBI patients reported the following behaviors during turning: a relaxed face (56.7%), opening eyes (50%), weeping eyes (33.3%), and repetitive flexion of upper and/or lower limbs (33.3%).32 In this group, only 4 TBI patients (13.3%) exhibited grimacing in response to pain. Based on these data, the endorsement of the currently available behavioral pain scales should be approached with caution in the centrally neurocritically ill.33 Indeed, braininjured ICU patients seem to exhibit different responses to painful procedures (►Table 1) than typical behaviors shown by other critically ill patients. The content of these scales or the value of new ones will require validation in brain-injured ICU patients with altered LOC. According to the current standards in measurement,33 a scale should be validated in a specific population and in a definite context. Research in scale development and measurement is urgently needed to fulfill this need to adequately detect pain in this vulnerable group of ICU patients. This is also in alignment with the International Association for the Study of Pain (IASP)34 position that “the inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate painrelieving treatment.”

Vital Signs Are Invalid Indicators of Pain Vital signs as surrogate indicators of pain have received little attention in pain research in adult ICU patients. In most studies, heart rate (HR) and/or blood pressure (BP) were found to increase when patients were exposed to painful procedures.2,4,27,29,30,35,36 However, these increases (< 20%) were not considered to be clinically significant by the authors. Conversely, similar changes in vital signs occurred during both painful and nonpainful procedures37 or remained stable during painful ones.3 In other studies, respiratory rate (RR) and end-tidal CO2 were found to increase during painful procedures,30,36 whereas arterial oxygen saturation (SpO2) was found to decrease.27 Except for associations between HR, SpO2, and the self-report of pain in a sample of postoperative cardiac surgery ICU adults,36 vital signs failed to correlate with the patients’ self-reports of pain.27,30 In nICU patients, correlations between painful stimuli and changes in vital signs were evaluated in TBI and in elective neurosurgical patients. Critically ill TBI patients (n ¼ 43) showed similar changes in vital signs during painful

Pain, Sedation, and Delirium Management in the Neurocritically Ill

Gélinas et al.

Table 1 Description of common behavioral responses in ICU patients in relation to brain injury and level of consciousness during painful procedures Behavioral category

ICU patients with no brain injury who are fully conscious27,28,30

ICU patients with no brain injury and altered LOC or unconsciousness27,30

ICU patients with brain injury and fully conscious26

ICU patients with brain injury and altered LOC or unconsciousness27,30–32

Facial expressions

Frowning, grimacing, wincing, shutting eyes

Frowning

Frowning, opening eyes or shutting eyes

Relaxed face, opening eyes, weeping eyes, elevating eyebrows, levator contraction

Body movements

Protective movements

Immobile, protective movements

Slow cautious movements, holding hands or legs in the air

Immobile, repetitive flexion of upper and/or lower limbs

Muscle rigidity

Rigidity, clenching fists

Relaxed muscles

Relaxed muscles

Relaxed muscles

Other

Verbal complaints, sighing, moaning, coughing on endotracheal tube (ET)

Tolerating ventilator, coughing on ET

No sound, moaning

Tolerating ventilator, coughing on ET

procedures when compared with other medical/surgical ICU patients.30 Of note, vital signs data were transcribed by hand from bedside monitors in this study, and one single set of vital sign values was collected for each pain assessment. More recent studies employing continuous recordings of vital signs data have shown different findings in small groups of different patient populations. Significant increases in HR and RR were found in elective oncology neurosurgical ICU patients during a painful procedure (i.e., turning) compared with a nonpainful one (i.e., NIBP).26 By contrast, no significant changes in vital signs were reported during similar procedures in 30 critically ill TBI patients with an altered LOC.32 Despite their lack of validity for pain assessment purposes, vital signs are still considered as moderately to extremely important for assessing pain by a high proportion of ICU nurses (92%), as shown in a recent large Canadian survey.38 Because vital signs are commonly used by clinicians for pain detection and very few studies have addressed the sensitivity and specificity of using vital signs to assess pain in ICU patients, particularly the neurocritically ill, clinicians should follow current guideline recommendations and only consider vital signs as cues to begin further assessment of pain until further studies support the validity (or not) of vital sign alteration as an indicator of nociceptive stimulus.23

Alternative Measure Strategies In patients unable to communicate, and in those with minimal or absent behavioral responses, some alternative physiological measurements are of potential interest for the measurement of pain. Although little evidence is available to date, we enumerate them to reflect the recent interest in the area. The measurement of pupil size (i.e., pupillometry) appeared more sensitive than traditional behavioral indicators in a population of sedated postoperative cardiac surgery ICU patients undergoing nociceptive procedures (i.e., endotracheal suctioning or turning),39 although pupillometry’s value in comparison to behavioral parameters during suctioning appeared unconvincing in another study.40 However,

changes observed in pupil size were small (i.e., 0.3 mm), and the use of a pupillometer is therefore necessary to obtain reliable measurements. The bispectral index (BIS) was first examined in postoperative cardiac surgery ICU patients who were sedated and mechanically ventilated during a noxious or painful procedure (endotracheal suctioning or turning) by Li and colleagues.39 Significant increases in the BIS index (þ10%) were observed from baseline (rest) compared with a noxious procedure, and remained elevated 5 minutes postprocedure (p < 0.001; F test). No significant changes in the BIS index were observed during a nonnoxious stimulation (i.e., gentle touch). More recently, the bilateral BIS was studied in a pilot study with critically ill TBI patients, and significant changes in BIS values were obtained during a painful procedure (i.e., turning).41 Interestingly, the increases in BIS values appeared more pronounced in the intact side of the brain. Of course, more research is needed to confirm these results.

Current Practice Neurocritical care society members working in dedicated nICUs in 12 centers in Canada38 and 42 centers in the United States20 were surveyed electronically for their ICU’s pain routine. In the U.S. survey, pain scales are routinely used in 86.0% of neurocritically ill patients, including the NRS as the most common self-report scale of pain intensity. Behavioral pain scales such as the BPS and the CPOT are not routinely used (less than 40%). No other pain detection method was reported. These findings were similar to those of the Canadian survey with nurses working in adult ICUs including neuro settings.38 Although the majority of ICU nurses (94%) stated that regular assessment of pain was equally important for patients able and unable to self-report, they were less likely to use a behavioral pain scale than a self-report tool. The preferred self-report scale was the 0 through 10 NRS, and was identified as used by 98% of ICU nurses. The most common behavioral pain scales used were the BPS (41%), the NVPS (38%), and the CPOT (33%). Few nurses (7 to 22%) Seminars in Respiratory and Critical Care Medicine

Vol. 34

No. 2/2013

239

240

Pain, Sedation, and Delirium Management in the Neurocritically Ill were aware of the available recommendations and guidelines in pain. These findings of pain practices are not encouraging for nonverbal critically ill adults, including those with neurological illness. Educational and novel translation interventions are needed to improve compliance with clinical recommendations and guidelines related to pain assessment in adult ICUs.

Pain Management Remarkably little is known about critical analgesia management, such as thresholds above which pain should be treated, or which approaches—pharmacological or nonpharmacological—should be used first, and no molecule or class of drug can be said to be preferable to another in terms of effectiveness.42 Although early physiotherapy43 has been touted as a potential solution to this plight, its implementation into practice remains limited and challenging. A recent systematic review suggests there are no studies addressing the therapeutic effectiveness or outcomes of analgesics in the neurologically critically ill.44 In the medical/surgical ICU population, opioids are the most commonly used analgesic45 but when pain is systematically assessed over 30 to 40% of patients have reported no pain and therefore do not require the administration of pharmacological intervention, even in surgical patients, leading to considerable cost savings. When opioids are compared with anti-inflammatory agents46,47 the evidence favors better pain control when an anti-inflammatory is administered; however, there were only two studies, and they included small numbers of patients. Coanalgesia, with acetaminophen or anti-inflammatory agents, appears to reduce opioid requirements in the ICU; however, acetaminophen has not been prospectively evaluated. Intravenous acetaminophen has just been approved by the U.S. FDA but is not currently available in Canada. Opioid use in the medical/surgical ICU population is recommended based on adequate pain assessments, and titrated in accordance with patient needs.48 Routine pain assessments in ICU patients are associated with improved pain management practices and clinical outcomes. Several studies performed in surgical, trauma and medical ICUs report that a protocolized approach to assess and manage pain, agitation, and delirium is associated with a reduced duration of mechanical ventilation, ICU-acquired infections, length of stay in the ICU and hospital, as well as 30-day mortality.44,48–50 The current neurocritical care evidence suggests that patients can be assessed almost 100% of the time.20 Pain should be assessed routinely in every patient. Patients able to self-report should get pain evaluated with visual NRS, which were described earlier, appear as feasible, and are the instrument of choice in patients able to selfreport. Behavioral pain scales appear better than not assessing pain at all when the self-report is impossible to obtain; we still recommend they be applied to procure analgesia when deemed appropriate, and to avoid the administration of excessive opioids or unnecessary other analgesics. Pain detection and the assessment of analgesic needs is feasible in all neurocritically ill patients20 and should be done to palliate the current underrecognition and treatment of pain22 and the unreliability of surrogate assessments.51 Optimal characterSeminars in Respiratory and Critical Care Medicine

Vol. 34

No. 2/2013

Gélinas et al.

istics for analgesic agents in an nICU are those with a short half-life and least sedative effects for preservation of a clear neurological exam. Although there is little evidence to guide therapy, fentanyl and particularly remifentanil are agents offering these characteristics while having minimal effect on ICP, cerebral blood flow, or hemodynamic stability.52,53 Combining opioids and nonopioids such as acetaminophen and dexmedetomidine for their opioid-sparing effects may be of interest but has not been studied as a favorable approach in the nICU. Finally, technology-based assessments require further study to complement behavioral assessments in this patient population for feasibility, validity, and correlation with outcomes based on protocolized analgesia.

Sedation Management of sedation is particularly challenging in the nICU because brain injury alone can beget alterations in LOC. The feasibility and methods of sedation assessment in the neurocritically ill have been assessed in very few studies. In the first (18), the BIS was compared with three clinical assessment scales on an hourly basis for 6 hours: the Richmond Agitation-Sedation Scale (RASS), the Sedation-Agitation Scale (SAS), and the Glasgow Coma Scale (GCS). In the 15 patients monitored with the BIS XP version, a high correlation of BIS score was found with the RASS score (R2 ¼ 0.810; p < 0.0001), SAS score (R2 ¼ 0.725; p < 0.0001), and moderate correlation with the GCS score (R2 ¼ 0.655; p < 0.0001). By psychometric standards, both RASS and SAS scales are sound corollaries of sedation levels, whereas the GCS is not. This study was limited by its small number of patients and the wide range of neurological disorders. A second study asked whether adding BIS measurements to a clinical assessment tool, the Ramsay scale, would alter the amount of propofol administered over a 12-hour period.54 Nurses assessed 35 patients with the Ramsay scale and 32 patients with both the Ramsay and a targeted BIS level. The BIS-titrated group received less drug by volume and infusion rate. However, the clinical scale comparator in this study, the Ramsay scale, has never been validated psychometrically in this population. Its shortcomings are described elsewhere.55 The initial scale was created in 197456 for the purpose of a study while comparing one sedative drug to another, and not further tested otherwise despite its widespread use. These methodological differences might explain why this study did not show any benefit to adding a clinical scale when compared with the BIS alone, and why it contrasts to the one described earlier, where validated sedation scales were used as a comparator, but the amount of administered medication was not compared. Finally, how often sedation can be assessed in a concordant manner in the neurocritically ill was addressed in a recent study20 that suggests assessing sedation level is feasible in the centrally and peripherally injured neurocritically ill and reproducible among caregivers.

Medications for Sedation Medication choices can be based on clinical benefit or on pharmacoeconomic considerations or both. In general

Pain, Sedation, and Delirium Management in the Neurocritically Ill medical-surgical ICU populations variable outcome measurements, methodologies, and conflicting evidence do not allow recommending one molecule over another. The neurocritical care evidence is all the more inconclusive when one considers the dearth of studies addressing sedative choice. The ideal sedative for use in the nICU has a rapid onset and short halflife and is able to reduce ICP, maintain cerebral blood flow, reduce brain metabolic demands, and preserve a clear neurological exam.17 No study has assessed benzodiazepine use for sedation in the neurocritically ill, and the long-term effects of this agent for this population are poorly understood. Propofol has also been utilized for ICU sedation, status epilepticus, tetanus, and as an antiemetic and antipruritic.57 Its effectiveness as a sedative is well established in current practice in the ICU including the neuro population. Propofol reduces ICP without deleterious effect on early heart rate or mean arterial pressure measurements in brain-injured ICU patients,58 and allows for predictable wake-up tests. Step increases in propofol doses lead to a large increase in EEG burst-suppression ratio in patients with moderate to severe head injury; tissue gas levels, tissue chemistry, and AVDO2 remain unchanged.59 Dexmedetomidine use in the neurocritically ill is described, but the low quality of the studies does not allow any conclusions to be drawn from their observations.60,61 This agent’s time to effect is mitigated by its time to effect (> 20 minutes), but it has been described as effective as an adjunct to analgesics, for weaning heavy sedation, and for facilitating successful and timely extubation. One small study addressing cognitive function in awake, brain-injured ICU patients receiving sedatives suggests that cognition may be better preserved with dexmedetomidine than with propofol.62 Nonpharmacological techniques of reducing agitation such as early progressive mobilization, frequent orientation to time and situation, optimizing levels of stimulation, reducing restraint use, and preservation of sleep/wake cycles likely have a favorable effect on averting and mitigating agitation, yet investigation into the real benefit of these techniques needs to be explored.

Current Practice Current practice was evaluated in a survey of Neurocritical Care Society members.20 Sedation scales are in use for 91.8% of patients, but titration of sedatives to a sedation scale goal is not routinely performed; the RASS was the most commonly reported, and the SAS the second most popular.

Delirium There is minimal investigation specifically validating the use of delirium assessments in the neurocritically ill, save one description of Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) screening in a stroke unit where the majority of patients did not require mechanical ventilation.63 The study’s limitations make it challenging to extrapolate the findings because the screening was only considered feasible in half the patients admitted to the unit64 and because LOC may be a challenge in CAM-ICU screening of patients with altered

Gélinas et al.

LOC.65 Some delirium studies have included neurological patients,66,67 and a lower delirium incidence was detected in patients admitted with a primary neurological diagnosis than in other groups68 using the ICDSC and a psychiatric validation of the diagnosis.66 More recently the feasibility of delirium symptom assessments was demonstrated in over 75% of central- and peripheral-illness-related neurocritically ill patients in three nICUs; incremental numbers of ICDSC points correlated with longer ICU and hospital length of stay. Delirium diagnosis was not validated in this study. Delirium diagnosis in this population is a challenge given the patient characteristics and the lack of psychometrically validated diagnostic criteria in this setting. Indeed, the DSM IV on which current tools are based was validated in outpatients and stable geriatric medical inpatients. The critically ill and patients with neurological lesions, and other populations, in whom these criteria have not been validated, highlight the need for validation of these criteria in such vulnerable populations.69 When Neurocritical Care Society members were surveyed as part of the same study, respondents reported that delirium scales are implemented in 54.4% of nICU patients, with the CAM-ICU being most common; the ICDSC is also used. For those who do use a delirium scale, its application is systematic in 76.4% of the cases. If a delirium scale is not used at the respondent’s center, 40.4% believed that there was a lack of evidence showing an effect on patient outcome, and 29.8% thought that it was not feasible in this population. Delirium screening and management in the nICU are problematic. Delirium is a syndrome, and some attribute its symptoms to disruption in centers of the brain responsible for attention, arousal, memory, and executive function.70 This cognitive derangement is associated with prolonged ICU stay and ventilator days, and significantly increases health care cost.71 Patients with neurological injury have been largely excluded from this work for two reasons; neurological injury confounds the diagnosis and investigation of delirium, and neurointensivists are wary of missing underlying neurological events if changes in mental status are labeled delirium without further investigation. The recommendation by governmental organizations to screen for delirium in all ICUs has initiated investigation in delirium prevalence, the most reliable screening methods, and treatment for patients with neurological injury. An interesting and prudent approach to detecting delirium in the nICU may be to acknowledge the current practice of serial abbreviated neurological exams as both a method for identifying subtle changes in brain injury and an effective method for identifying delirium.70 Decline in any of the measured functions can be considered, depending on the clinical context, to be due to cerebral pathology. Depending on the neurological injury, imaging, continuous electroencephalography, and lumbar puncture may be performed to rule out extension of primary injury or acute secondary injury. With only scant evidence to support delirium detection with conventional screening tools in patients with neurological injury, using these additional assessments to detect delirium for this population makes sense but needs to be further investigated. Seminars in Respiratory and Critical Care Medicine

Vol. 34

No. 2/2013

241

242

Pain, Sedation, and Delirium Management in the Neurocritically Ill

Conclusions

14 Giacino JT, Ashwal S, Childs N, et al. The minimally conscious state:

Pain and sedation assessments should be systematically integrated in the care of neurocritically ill patients given that the few studies available suggest outcome benefit in the systematic application of these tools. Even if some available behavioral pain scales (e.g., BPS, CPOT) may support assessment practices, their content may not be specific and representative of brain-injured ICU patients. Research efforts are urgently needed for the development and validation of more appropriate pain assessment tools for this highly vulnerable patient population. Also, outcome studies related to pain and sedation assessment and management in neurocritically ill patients are sorely lacking. Screening for delirium symptoms appears to be feasible in a significant proportion of neurocritically ill patients; focus on symptoms rather than the diagnosis of a delirium syndrome may be more methodologically sound and may provide more generalizable findings than diagnostic categories in this population with many potential confounders.

definition and diagnostic criteria. Neurology 2002;58(3):349–353 15 Laureys S, Faymonville ME, Peigneux P, et al. Cortical processing of

16

17 18

19

20

21

22 23

References 1 Puntillo KA, White C, Morris AB, et al. Patients’ perceptions and

2

3

4 5

6 7

8

9 10 11

12

13

responses to procedural pain: results from Thunder Project II. Am J Crit Care 2001;10(4):238–251 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 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 Stotts NA, Puntillo K, Bonham Morris A, et al. Wound care pain in hospitalized adult patients. Heart Lung 2004;33(5):321–332 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 Flexman AM, Ng JL, Gelb AW. Acute and chronic pain following craniotomy. Curr Opin Anaesthesiol 2010;23(5):551–557 Mordhorst C, Latz B, Kerz T, et al. Prospective assessment of postoperative pain after craniotomy. J Neurosurg Anesthesiol 2010;22(3):202–206 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 Gottschalk A. Craniotomy pain: trying to do better. Anesth Analg 2009;109(5):1379–1381 Gottschalk A, Yaster M. The perioperative management of pain from intracranial surgery. Neurocrit Care 2009;10(3):387–402 Leslie K, Troedel S, Irwin K, et al. Quality of recovery from anesthesia in neurosurgical patients. Anesthesiology 2003;99 (5):1158–1165 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 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

Seminars in Respiratory and Critical Care Medicine

Gélinas et al.

Vol. 34

No. 2/2013

24

25

26

27

28

29

30

31

32

33

noxious somatosensory stimuli in the persistent vegetative state. Neuroimage 2002;17(2):732–741 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 Beretta L, De Vitis A, Grandi E. Sedation in neurocritical patients: is it useful? Minerva Anestesiol 2011;77(8):828–834 Recommended by the IASP Subcommittee on Taxonomy . Pain terms: a list with definitions and notes on usage. Pain 1979; 6(3):249 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 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 Egerod I, Jensen MB, Herling SF, Welling KL. Effect of an analgosedation protocol for neurointensive patients: a two-phase interventional non-randomized pilot study. Crit Care 2010;14(2):R71 Puntillo K, Pasero C, Li D, et al. Evaluation of pain in ICU patients. Chest 2009;135(4):1069–1074 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 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 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 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 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 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 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 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 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 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 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

Pain, Sedation, and Delirium Management in the Neurocritically Ill

Gélinas et al.

34 International Association for the Study of Pain (IASP). Pain

52 Gottschalk A, Berkow LC, Stevens RD, et al. Prospective evaluation

Terminology. 2011. http://www.iasp-pain.org/AM/Template. cfm?Section¼Pain_Defi...isplay.cfm&ContentID¼1728. Accessed September 30, 2012 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 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 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 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 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 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 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 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 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 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 Watling SM, Dasta JF, Seidl EC. Sedatives, analgesics, and paralytics in the ICU. Ann Pharmacother 1997;31(2):148–153 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 Hynninen MS, Cheng DCH, Hossain I, et al. Non-steroidal antiinflammatory drugs in treatment of postoperative pain after cardiac surgery. Can J Anaesth 2000;47(12):1182–1187 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 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 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 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

of pain and analgesic use following major elective intracranial surgery. J Neurosurg 2007;106(2):210–216 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 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 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 Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalone-alphadolone. BMJ 1974;2(5920): 656–659 Marinella MA. Propofol for sedation in the intensive care unit: essentials for the clinician. Respir Med 1997;91(9):505–510 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 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 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 Grof TM, Bledsoe KA. Evaluating the use of dexmedetomidine in neurocritical care patients. Neurocrit Care 2010;12(3):356–361 Mirski MA, Lewin JJ III, 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 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 Skrobik Y. Delirium in patients with stroke: the dark side of the moon? Crit Care Med 2012;40(2):676–677 Bergeron N, Skrobik Y, Dubois M-J. Is disturbance of consciousness an important feature of ICU delirium? Intensive Care Med 2005;31 (6):887 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 Van Rompaey B, Elseviers MM, Schuurmans MJ, ShortridgeBaggett LM, Truijen S, Bossaert L. Risk factors for delirium in intensive care patients: a prospective cohort study. Crit Care 2009;13(3):R77 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 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 Frontera JA. Delirium and sedation in the ICU. Neurocrit Care 2011;14(3):463–474 Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y. Incidence, risk factors and consequences of ICU delirium. Intensive Care Med 2007;33(1):66–73

35

36

37

38

39

40

41

42

43

44

45 46

47

48

49

50

51

53

54

55

56

57 58

59

60

61 62

63

64 65

66

67

68

69

70 71

Seminars in Respiratory and Critical Care Medicine

Vol. 34

No. 2/2013

243