Pain assessment in critical patients unable to communicate


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Abstract

Introduction. Poor assessment of analgesic therapy in critical patients is associated with a deterioration in the prognosis of treatment and a decrease in the quality of life after discharge. One of the reasons is the lack of a unified pain assessment methodology applicable to patients who are unable to communicate, demonstrate emotions and voluntary movements. Goal. To increase the effectiveness of assessing the adequacy of analgesic therapy in critical patients who are unable to communicate. Materials and methods. Within the framework of this article, scales and methods for assessing pain in non-verbal patients are considered and analyzed: SROT, PBS, NVPS, COMFORT, RASS, ANI, PDR. Results. Their comparative analysis was carried out, the most informative criteria were identified and a modified scale for evaluating analgesic therapy was developed. Conclusions. Further study of the effectiveness of this scale is required and confirmation of the validity of the results in the conditions of anesthesiology and intensive care units, military hospitals, operating rooms.

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Introduction. Millions of people around the world have experienced intensive care unit hospitalization. More than 80% of patients consider pain to be the most common experience during their stay in the ICU [1]. The intensive care patient experiences pain from the underlying disease, invasive medical procedures (placement of catheters and probes, the presence of drains, sanitation of the respiratory tract, change of bed linen), prolonged immobilization, and mechanical ventilation. Untimely relief leads to chronic acute pain in 14% - 77% of patients [2], post-traumatic stress disorders in 15-27% [3], as well as hypermetabolism, increased oxygen consumption, hyperglycemia and worsened wound healing, which significantly reduces the prognosis of treatment and quality of life in the future. In turn, excessive sedation is associated with the risk of delirium, pneumonia, intestinal dysfunction, thromboembolic complications, and unjustifiably prolonged mechanical ventilation [3].
Diagnosing and effectively managing pain is both critical and difficult in unconscious, critically ill patients due to their inability to communicate and show emotion. To objectify the pain syndrome, instrumental methods (ANI monitoring, pupillometry) and pain assessment scales in non-verbal patients are recommended. However, these methods are not always available and generally applicable due to the lack of equipment, as well as sedation, fixation of patients, the presence of injuries, paresis, aphonia, and other neurological disorders.

Goal of the work. To improve the effectiveness of assessing the adequacy of analgosedation in critically ill patients unable to communicate. To achieve the goal, the following tasks are set:
1. Conduct a comparative analysis of recommended methods for assessing pain, identifying advantages and disadvantages.
2. Identify the most reliable and informative criteria for assessing pain for non-verbal patients
3. Develop a modified scale for assessing analgosedation in critically ill patients based on the most reliable indicators.

Materials and methods of research. To write this article, a review of a number of scientific articles, dissertations, clinical studies, and manuals related to methods of pain objectification was conducted. Seven tools for assessing pain and sedation, including rating scales and instrumental methods, were analyzed in detail.

Research results. A critical nonverbal patient is a patient who is not available for contact and is unable to communicate pain in any way due to the fact that: he is sedated; intubated/on an endotracheal tube; has facial injuries; has neurological disorders; fixed; unconscious;
This group of patients is often encountered by an intensive care unit doctor, a military doctor transporting soldiers from the battlefield, and an ambulance doctor from the scene of an accident. The lack of a universal “gold standard” makes it difficult to objectify pain; below we consider recommended methods for assessing it.
The Critical Care Pain Observation Tool (CPOT) scale is based on the assessment of behavioral reactions: facial expression, movement, muscle tension and synchronization with the respirator (for intubated patients) or speech reactions (for extubated patients). This scale has been proposed for implementation in The Critical Care Society Guidelines for Analgesia, Sedation and Delirium Management have been shown to be valid and reliable in many categories of intensive care unit patients.
The Behavioral pain scale (PBS) was developed for intubated patients and assesses three parameters: facial expression, upper limb movements, and compliance with mechanical ventilation. According to the results, scores ≤3 indicate no pain, 4-5 points moderate pain, 6-11 unacceptable intense, ≥12 indicate maximum pain [4]
The Nonverbal Pain Scale (NVPS) provides a standardized assessment of pain in intubated and other nonverbal patients. Its assessment includes behavioral indicators (facial expressions, movements, defensive reactions), as well as physiological indicators (SBP, heart rate) and breathing (RR, SPO₂, synchrony with the ventilator) [5]. When assessing the validity and reliability of the scale, the study group included patients on mechanical ventilation for more than 24 hours; able to hear and respond by moving the head, eyes or eyebrows; -3 to + 1 on the Richmond scale; 8 or higher on the Glasgow Coma Scale [6].
The COMFORT Score is designed to provide a more accurate and detailed assessment of pain and sedation levels in critically ill and ventilated children. In studies evaluating the effectiveness of the scale, most participants were children under 4 years of age, but this scale can be used in children up to 18 years of age. This scale proposes to evaluate 9 criteria, which include both behavioral and vital signs [7].

The Richmond Agitation-Sedation Scale (RASS) is used to describe the degree of psychomotor agitation of a patient or the level of depth of sedation. The scale allows the assessment of sedation therapy and improves communication among health care providers. It is easy to use and can be used to assess the level of sedation or agitation for 30 to 60 seconds, using three sequential stages: observation, response to auditory stimulation, and response to physical stimulation.
Since pain activates the sympathetic nervous system and inhibits the parasympathetic system, and pain relief, on the contrary, is characterized by low sympathetic and high parasympathetic tone, HRV, the variability of the intervals between myocardial contractions, which is an indicator of the autonomic regulation of the heart, can be used to assess the adequacy of analgesia. [8].
The Analgesia Nociception Index (ANI, Analgesia Nociception Index, ANI-Monitor "MetroDoloris", France) is a numerical index based on HRV. ANI ranges from 100 to 0, where 100 is no pain, 0 is maximum pain, and 50 to 70 is adequate analgesia. ANI has been shown to be an informative parameter for monitoring intraoperative analgesia. The method has certain limitations: it cannot be interpreted in the absence of breathing, for example, with apnea during tracheal intubation; when using anticholinergic drugs that affect heart rate and blood pressure; for arrhythmias and the presence of an artificial pacemaker; during heart surgery, due to the impossibility of placing the electrode on the sternum.
Another instrumental method for assessing pain levels is pupillometry, based on the pupil dilatation reflex (PDR). In response to nocioceptive stimulation, the pupil diameter increases by 1-2 mm from the original due to the pupillary dilator, which is innervated by sympathetic fibers and the pupillary sphincter, innervated by the parasympathetic nervous system. However, in conditions such as ptosis, strabismus, anisocoria, corneal opacity, as well as when using large doses of opioid analgesics, metoclopramide, droperidol, dexmedetomidine, pupillometry is difficult.
Table 1. Comparative characteristics of pain assessment methods.
CPOT criterion PBS NVPS COMFORT RASS ANI PDR
Availability of application + + + + + - -
Accounting of behavioral reactions, number 5 3 4 7 3 0 0
Accounting of physical indicators, quantity 0 0 1 2 0 1 1
Accounting for respiratory support + + + + + - -
Applicable for:
- sedation - - - - +/- +++ +/-
- neurological conditions
- facial injuries
- extensive injuries
- forced fixation
- level of consciousness 8 points or less according to the GCS

Thus, we can conclude that the scales are aimed at critical patients who are on respiratory support, but conscious and able to respond (facial expressions, movements). With the exception of ANI monitoring and pupillomeria, which are based solely on physical indicators, are applicable for sedated patients, as well as with neurological and traumatic disorders, but require specialized equipment, which makes them difficult to access. Based on the analysis, we have developed a modified scale for assessing pain and sedation in critically ill patients unable to communicate (Table 2).

Table 2. Modified pain rating scale for critically ill patients.
Breath
Is on a ventilator Fully synchronized / not breathing on his own Fully synchronized Actively breathing in addition to the machine and/or coughs regularly Severe resistance / cough
Breathes spontaneously Bradypnea/apnea Normal breathing,
(variability up to 10% of the initial level) Tachypnea, frequent increases
(from 10 to 20% of the original) Sustained tachypnea,
(more than 20% of the initial level)
Hemodynamics
SBP Frequent decreases/sustained decreases (more than 10%) Variable
(within 10% of baseline) Frequent increases
(from 10 to 20% of the original) Sustained increase
(more than 20% of the initial level)
Heart rate
Behavioral reactions (if any)
Movements

 

Does not respond to voice or physical stimulation. Calm. Movements to voice and physical stimulation. Excited. Frequent non-purposeful movements Extremely agitated, aggressive, purposeful movements towards the source of pain
Pupil reaction
Miosis. No reaction to light Reaction to light preserved
ASSESSMENT Risk of overdose, monitoring/antidote required Analgesia adequate Insufficient analgesia, consider dose increase Analgesia inadequate. Requires complete pain relief

The scale allows you to assess both the degree of analgesia and the level of sedation with the risk of overdose in unconscious patients. It is not focused on motor and speech reactions, which makes it universal and applicable for patients with severe neurological disorders and extensive injuries, however, if the patient is able to move, this indicator is taken into account. It has a simple scoring system, does not involve counting points, or the use of specialized equipment,

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About the authors

Kristina Romanovna Razumovskaya

FEDERAL STATE INSTITUTION OF HIGHER EDUCATION "Donetsk State Medical University named after M.Gorky" of the Ministry of Health of the Russian Federation

Email: kris.ksy777@gmail.com

student

Russian Federation, 283001, Russia, DPR, Donetsk, Ilyich Ave., 16

Alexandra Olegovna Gaivoronskaya

FEDERAL STATE INSTITUTION OF HIGHER EDUCATION "Donetsk State Medical University named after M.Gorky" of the Ministry of Health of the Russian Federation

Email: lena.gayvoronskaya.73@mail.ru

student

Russian Federation, 283001, Russia, DPR, Donetsk, Ilyich Ave., 16

Oleg Vladimirovich Demchuk

FEDERAL STATE INSTITUTION OF HIGHER EDUCATION "Donetsk State Medical University named after M.Gorky" of the Ministry of Health of the Russian Federation

Author for correspondence.
Email: kris.ksy777@gmail.com

Doc. Sci. (Med.), Head of the Department of Emergency Medicine and Extreme Medicine M. Gorky Donetsk National Medical University

Russian Federation, 283001, Russia, DPR, Donetsk, Ilyich Ave., 16

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