Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade

management often require an individualized approach to optimize treatment. The interdisciplinary team

should complete a comprehensive review of all variables such as acute and chronic pain, routine nursing

care that may cause discomfort, and procedural-based pain.

Common causes of pain in the ICU include, but are not limited to, acute trauma, injury or burns,

postoperative pain, exacerbation of chronic pain, heart disease, ischemia, acute or chronic underlying

disease state pain such as cancer pain, pancreatitis, or other abdominal pathology.

life-sustaining measures: presence of an endotracheal tube and endotracheal tube suctioning, wound

care, tube or Foley insertion, immobility, bed repositioning, bathing, medication administration, and

physical and occupational therapy. Other examples of painful invasive procedures include intravenous

line placement, endoscopy and bronchoscopy, chest tube placement or removal, paracentesis, lumbar

puncture, biopsies, and fracture reductions.

Acute pain can invoke a stress response, resulting in a hypercatabolic state, decreased tissue perfusion,

and impaired wound healing. Uncontrolled pain decreases a patient’s immune response to infection by

suppressing natural killer cell activity and neutrophil function.

in patients who recall significant pain during their hospitalization, particularly in patients admitted with

Health-related quality of life is decreased in up to 20% of patients.

Chronic pain is reported in up to 40% of patients.

Posttraumatic stress disorder is reported in 5%–20% of patients.

The gold standard for assessing pain remains the patient’s self-report of pain. Several scenarios in the

ICU make the self-reporting of pain challenging for clinicians (e.g., mechanical ventilation, presence

of sedation and/or delirium). SCCM guidelines currently recommends two validated behavioral pain

scales to be done in a repetitive and routine manner: the Behavioral Pain Scale (BPS) (Table 1) and the

Critical-Care Pain Observation Tool (CPOT) (Table 2).

Assessment scales should be used routinely in all ICU patients. Most nursing protocols assess

pain every 4–6 hours while the patient is awake. In addition, it is important to reassess the degree

of pain within about 30 minutes to 1 hour after administering an “as-needed” pain medication to

determine the appropriateness of the pain medication or dose.

Pain scores should be documented in the medical chart and then used to help formulate daily

titrations in pain medications.

Patients should be treated within 30 minutes of a “significant pain” score. A BPS greater than 5 or

a CPOT score of 3 or greater, or a numeric rating scale score of 4 or greater is indicative of pain.

signs such as tachycardia and hypertension are appropriate for use as a prompt to further investigate

the need for pain control.

Further research is needed to determine the effectiveness of a preprocedural pain assessment tool and

the ways in which this assessment will affect analgesic administration. A study by Puntillo et al. in

2014 found the procedures most likely to double the patient’s pain intensity score (from preprocedure to

during-procedure scoring) were chest tube removal, wound drain removal, and arterial line insertion.

This study found that higher-intensity pain and pain distress before the procedure were associated with