pad launch day - ovakim

What’s Pain Got To Do With It?

PAD Launch Day

March 30, 2015

Daniel Ovakim, MD MSc FRCPC

Critical Care Medicine, Royal Jubilee and Victoria General HospitalsIsland Health AuthorityMedical Toxicology, BC Drug and Poison Information CentreClinical Assistant Professor, Department of Medicine, UBCdaniel.ovakim@viha.ca

What’s pain got to do with it?

Disclosures

None

Toxicologic Antidotes

Outline

1. Case based review of the assessment and treatment of pain in the adult ICU

2. Review the presentation and management of excited delirium

What’s pain got to do with it?

Toxicologic Antidotes

Outline

1. Case based review of the assessment and treatment of pain in the adult ICU

2. Review the presentation and management of excited delirium

What’s pain got to do with it?

Mr. VE

• 37M, multiple gun shot wounds

• History of

• Polysubstance abuse

• Chronic opioid use

• Injuries

• Brachial artery laceration

• Right rib/lung/diaphragm injuries

• Penetrating liver and bowel injury

Toxicologic AntidotesWhat’s pain got to do with it?

Mr. VE

• Multiple (?8) trips to operating room

• Multiple complications

• Severe sepsis

• Rhabomyolysis (PRIS?)

• Acute kidney injury requiring dialysis

• High narcotic and sedative requirements

Toxicologic AntidotesWhat’s pain got to do with it?

Mr. VE (3 weeks later)

• Acute issues resolved

• Escalating analgesic requirements

• Hydromorphone 7 mg po q4h scheduled

• Hydromorphone 1-2 mg IV q1h PRN

• “Switched-on” – Tachy/HTN/Febrile

• Reports of poor affect/motivation

• Severe, unremitting “10/10” abdominal pain

Toxicologic AntidotesWhat’s pain got to do with it?

Questions on rounds

1. How can we reliably assess this patient’s pain?

2. Can we use his vital signs as an indication?

3. Are there other therapeutic options?

4. What about his mood?

Toxicologic AntidotesWhat’s pain got to do with it?

Pain in the ICU

Definitions

Scope of the problem

Barriers

Consequences

Assessment tools

Approach

IASP

• Unpleasant sensory and emotional experience associated with actual or potential tissue damage

• Can only be reported by the person experiencing it

SCCM

• 50% (or more) of ICU patients

• Many types of pain

• Rest pain

• Surgical/trauma/cancer pain

• Procedural pain

Definitions

Scope of the problem

Barriers

Consequences

Assessment tools

Approach

Pain in the ICU

Definitions

Scope of the problem

Barriers

Consequences

Assessment tools

Approach

Impediments to pain reporting

• Unable to self report pain

• Altered level of consciousness

• Mechanical ventilation

• Sedation/NMBA

Pain in the ICU

Nurse!!My back hurts!!!!

Definitions

Scope of the problem

Barriers

Consequences

Assessment tools

Approach

Consequences of unrelieved pain

• Inefficient sleep1

• Memories2

• Pain of ETT

• Most recount moderate to severe pain

• Persist up to 6 months

1. Jones et al., Intensive care medicine, 1979; 5:89-922. Gelinas, C. Crit Care Nurs, 2007; 23:298-303

Pain in the ICU

Definitions

Scope of the problem

Barriers

Consequences

Assessment tools

Approach

Physiologic effects

• Increased circulating catecholamines

• Catabolic hypermetabolism

• Hyperglycemia

• Lipolysis

• Muscle breakdown

• Poor wound healing

Pain in the ICU

Definitions

Scope of the problem

Barriers

Consequences

Assessment tools

Approach

The Ideal Pain Assessment

• Reproducible across disciplines

• Enables monitoring over time

• Assesses adequacy of interventions

• Easily implemented and monitored

Pain in the ICU

Definitions

Scope of the problem

Barriers

Consequences

Assessment tools

Approach

Pain Scales

• Most valid and reliable

• Behavioural Pain Scale

• Critical-care Pain Observation Tool

• Useful for all; except brain injury

• Designed for the following

• Unable to self-report

• Intact motor function

• Observable behaviours

Pain in the ICU

Pain the ICU

Score > 5 suggests significant pain

Definitions

Scope of the problem

Barriers

Consequences

Assessment tools

Approach

Pain assessment in the real world

1. Confirm the presence of pain

• Vital signs as a trigger to perform assessment?

• Routine BPS assessment? How often?

2. Consider etiology

3. Individualized treatment

4. Post-treatment assessment

5. Frequent reassessment

Pain in the ICU

Back to Case 1

• 37M, multiple gun shot wounds

• Persistent 10/10 abdominal pain

• “Unresponsive” to narcotics

• What worked for him?

• Scaled back regular hydromorphone to 2 mg q4h

• Stopped routine bowel care

• Aggressive mobilization

• Dramatic response to trial of methylphenidate (Ritalin®)

Pain in the ICU

Toxicologic Antidotes

Outline

1. Case based review of the assessment and treatment of pain in the adult ICU

2. Review the presentation and management of excited delirium

What’s pain got to do with it?

Mr. WF

• 41M, suicide attempt after romantic crisis

• Voluntary ingestion of 6500 mg bupropion XL, and self-injection of 3 epi-pens

• Acutely agitated, disoriented, aggressive

• Midazolam x 50 mg in ER and infusion in ICU

• Remained extremely agitated

• Physically restrained

Toxicologic AntidotesWhat’s pain got to do with it?

Mr. WF

• Received bolus doses of propofol

• Settled in am after MDZ turned off

• Severe rhabdomyolysis• CK > 45,000

• Started isotonic fluid hyper-hydration

• Consequence?

• Complication?

Toxicologic AntidotesWhat’s pain got to do with it?

Excited Delirium (ExDS)

Definitions

Pathophysiology

Clinical Features

Causes

Complications

Management

Excited (Agitated) Delirium

• Delirium involving violent behaviour

• Associated with

• Drug intoxication (or withdrawal)

• Psychiatric illness

• Classically a forensic diagnosis

• SCD in police custody

• No evidence of injury of disease

Excited Delirium (ExDS)

Definitions

Pathophysiology

Clinical Features

Causes

Complications

Management

• Complex and poorly understood

• Likely involves excessive striatal dopamine stimulation

• Death usually as a result of SCD in the setting of severe acidosis

Excited Delirium (ExDS)

Definitions

Pathophysiology

Clinical Features

Causes

Complications

Management

Minimal features

• Delirium (traditional definition)

• Excitation/Agitation

• Sympathetic hyperactivity

• Tachycardia/tachypnea

• Hypertension (late hypotension)

• Hyperthermia (may be > 41oC)

• Rhabdomyolysis

Excited Delirium (ExDS)

Definitions

Pathophysiology

Clinical Features

Causes

Complications

Management

Pre-terminal features

• Period of tranquility/sudden calm

• Sudden collapse while restrained

• Respiratory arrest

• Stress-induced cardiomyopathy in survivors

Excited Delirium (ExDS)

Definitions

Pathophysiology

Clinical Features

Causes

Complications

Management

Two main causes

1. Drug intoxication/withdrawal

2. Psychiatric illness

Excited Delirium (ExDS)

Definitions

Pathophysiology

Clinical Features

Causes

Complications

Management

Two main causes

1. Drug intoxication/withdrawal

• Ethanol/Benzodiazepines

• Sympathomimetic agents

• Anticholinergic agents

2. Psychiatric illness

Excited Delirium (ExDS)

Definitions

Pathophysiology

Clinical Features

Causes

Complications

Management

Two sources

1. ExDS itself

2. Management

Excited Delirium (ExDS)

Definitions

Pathophysiology

Clinical Features

Causes

Complications

Management

Two sources

1. ExDS itself

• SCD – acidosis/catecholamines

• Rhabdomyolysis

• Complications due to hyperthermia

2. Management

Excited Delirium (ExDS)

Definitions

Pathophysiology

Clinical Features

Causes

Complications

Management

Two sources

1. ExDS itself

2. Management

• Physical restraints

• Therapies

• Hypotension

• Downstream delirium

• Therapeutic inertia

Excited Delirium (ExDS)

Definitions

Pathophysiology

Clinical Features

Causes

Complications

Management

Goal: Minimize physical struggle

1. Aggressive chemical sedation

2. Physical restraint as needed

3. Aggressive cooling (?NMBA)

4. Treat acidosis and hypovolemia

Aggressive

Excited Delirium (ExDS)

Definitions

Pathophysiology

Clinical Features

Causes

Complications

Management

Benzodiazpines

• Diazepam

• Midazolam

• Lorazepam

Propofol (IMV)

• Failure of BDZ

• Extreme agitation

• Safer to put down

Antipsychotics(Caution)

• QT prolongation

• NaC-blockade

• Anticholinergic

Other

• Ketamine

• Dexmed

Toxicologic Antidotes

Take home points

1. Pain assessment is far from objective

2. Protocolized use of pain scales is an effective trigger for pain assessment

3. Agitated delirium is a rare though lethal entity

4. All ICUs need to comfortable with the aggressive treatment required

What’s pain got to do with it?