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Pain, Agitation & Delirium
(2013)
Immobility & Sleep (2018)
Catherine Jones
Practice Educator – GICU
October 2018
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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
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WHY IS THIS IMPORTANT? 3
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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
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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
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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)
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7 Barr(2013)
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N Engl J Med 2014; 370:444-454
Causes & Interactions of PAD
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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
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Assessing agitation at SGH:
Richmond Agitation Sedation Score
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Assessing delirium at SGH:
Confusion assessment
Method for the ICU
• CAM-ICU
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• Valeria Page cam – icu
assessment: https://www.youtube.com/wa
tch?v=6WyJ0zL7VkI
• 3mins 30 secs
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PAD guidelines (Barr 2013)
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PADIS guidelines
(Devlin et al 2018)
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ABCDEF Bundle
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eCASH:
26 Vincent et al (2016) Comfort & patient centred care without excessive sedation: the eCASH concept Intensive care
Medicine
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SPECIFIC MANAGEMENT FOR
PAD (IS).
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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
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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:
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Alfentenyl Lorazepam
Propofol Midazolam
Dexdor Haloperidol
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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
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Immobility Management
• Early Mobilisation &
rehabilitation
• Even on intubated patients!
• In bed activities eg
Motomed
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Sleep Management
• Ear Plugs & Eye Shades
• Relaxing music
• Reduction in night time light, noise, intervention
• ? Melatonin, ?dexdor
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Summary
• Pain
• Agitation
• Delirium
• Immobility
• Sleep Disruption
• CAN ALL BE IMPROVED BY
COMMITTED, HOLISTIC, PATIENT
FOCUSED CARE 36