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

Indicator

Description

Score

Compliance with 
the

ventilator 
(intubated

patients)

Alarms not activated, easy ventilation

Tolerating ventilator or

movement

Alarms stop spontaneously

Coughing but tolerating

Asynchrony: Blocking ventilation, alarms often

activated

Fighting ventilator

OR

Vocalization 
(extubated

patients)

Talking in normal tone or no sound

Talking in normal tone

or no sound

Sighing, moaning

Sighing, moaning

Crying out, sobbing

Crying out, sobbing

Total, range

0–8

aA CPOT score ≥ 3 indicates presence of pain.

Adapted with permission from: Lippincott Williams and Wilkins/Wolters Kluwer Health. Gelinas C, Fillion L, Puntillo K, et al. Validation of the Critical-Care Pain

In a patient whose pain is inadequately controlled in the ICU, intravenous opioids are considered first-

line treatment for nonneuropathic pain. The PADIS guidelines suggest acetaminophen as an adjunct

to an opioid to decrease pain intensity and opioid consumption for pain management in critically ill

patients.

to 60% of patients did not receive preprocedural systemic pain medication for common procedures

and wound care in the ICU, although 89% of patients received a topical anesthetic for central venous

The PADIS guidelines suggest using an opioid at the lowest effective dose for procedural pain

management in critically ill patients undergoing a procedure. The American Society for Pain

Management Nursing (ASPMN) published recommendations for preprocedural pain management

in 2011. The ASPMN recognizes both the psychological and the physical elements of procedural

pain and agrees with combining nonpharmacologic and pharmacologic methods. Examples of

nonpharmacologic options recommended by ASPMN include relaxation and breathing techniques,

imagery, massage, music, thermal measures, and positioning (Pain Manag Nurs 2011;12:95-111).

The PADIS guidelines recommend not using inhaled volatile anesthetics for procedural pain

management in critically ill adults. The PADIS guidelines also suggest using a nonsteroidal anti-

inflammatory drug (NSAID) administered intravenously, orally, or rectally as an alternative to

opioids for pain management during discrete and infrequent procedures in critically ill adults. Use

of an NSAID topical gel for procedural pain management in critically ill adults is not recommended

by the PADIS guidelines.

Preemptive analgesia for chest tube removal is recommended together with nonpharmacologic

relaxation techniques. The PADIS guidelines suggest neither local analgesia nor nitrous oxide for

pain management during chest tube removal in critically ill patients.

Postoperative thoracic epidural anesthesia/analgesia is recommended for patients undergoing abdominal

aortic aneurysm treatment. Thoracic epidural anesthesia is “suggested” for traumatic rib fractures in

the ICU.