what’s pain got to do with it? disclosures none toxicologic antidotes outline 1.case based review...
TRANSCRIPT
What’s Pain Got To Do With It?
PAD Launch DayMarch 30, 2015
Daniel Ovakim, MD MSc FRCPCCritical Care Medicine, Royal Jubilee and Victoria General HospitalsIsland Health AuthorityMedical Toxicology, BC Drug and Poison Information CentreClinical Assistant Professor, Department of Medicine, [email protected]
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
DefinitionsScope of the problem
BarriersConsequences
Assessment toolsApproach
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
DefinitionsScope of the problem
BarriersConsequences
Assessment toolsApproach
Pain in the ICU
DefinitionsScope of the problem
BarriersConsequences
Assessment toolsApproach
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!!!!
DefinitionsScope of the problem
BarriersConsequences
Assessment toolsApproach
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
DefinitionsScope of the problem
BarriersConsequences
Assessment toolsApproach
Physiologic effects• Increased circulating catecholamines• Catabolic hypermetabolism• Hyperglycemia• Lipolysis• Muscle breakdown• Poor wound healing
Pain in the ICU
DefinitionsScope of the problem
BarriersConsequences
Assessment toolsApproach
The Ideal Pain Assessment• Reproducible across disciplines• Enables monitoring over time• Assesses adequacy of interventions• Easily implemented and monitored
Pain in the ICU
DefinitionsScope of the problem
BarriersConsequences
Assessment toolsApproach
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
DefinitionsScope of the problem
BarriersConsequences
Assessment toolsApproach
Pain assessment in the real world1. Confirm the presence of pain• Vital signs as a trigger to perform
assessment?• Routine BPS assessment? How often?
2. Consider etiology3. Individualized treatment 4. Post-treatment assessment5. 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)
DefinitionsPathophysiologyClinical Features
CausesComplicationsManagement
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)
DefinitionsPathophysiologyClinical Features
CausesComplicationsManagement
• 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)
DefinitionsPathophysiologyClinical Features
CausesComplicationsManagement
Minimal features• Delirium (traditional definition)• Excitation/Agitation• Sympathetic hyperactivity• Tachycardia/tachypnea• Hypertension (late hypotension)• Hyperthermia (may be > 41oC)• Rhabdomyolysis
Excited Delirium (ExDS)
DefinitionsPathophysiologyClinical Features
CausesComplicationsManagement
Pre-terminal features• Period of tranquility/sudden calm• Sudden collapse while restrained• Respiratory arrest• Stress-induced cardiomyopathy in
survivors
Excited Delirium (ExDS)
DefinitionsPathophysiologyClinical Features
CausesComplicationsManagement
Two main causes1. Drug intoxication/withdrawal2. Psychiatric illness
Excited Delirium (ExDS)
DefinitionsPathophysiologyClinical Features
CausesComplicationsManagement
Two main causes1. Drug intoxication/withdrawal• Ethanol/Benzodiazepines• Sympathomimetic agents• Anticholinergic agents
2. Psychiatric illness
Excited Delirium (ExDS)
DefinitionsPathophysiologyClinical Features
CausesComplicationsManagement
Two sources1. ExDS itself2. Management
Excited Delirium (ExDS)
DefinitionsPathophysiologyClinical Features
CausesComplicationsManagement
Two sources1. ExDS itself• SCD – acidosis/catecholamines• Rhabdomyolysis• Complications due to hyperthermia
2. Management
Excited Delirium (ExDS)
DefinitionsPathophysiologyClinical Features
CausesComplicationsManagement
Two sources1. ExDS itself2. Management• Physical restraints• Therapies• Hypotension• Downstream delirium
• Therapeutic inertia
Excited Delirium (ExDS)
DefinitionsPathophysiologyClinical Features
CausesComplicationsManagement
Goal: Minimize physical struggle1. Aggressive chemical sedation2. Physical restraint as needed3. Aggressive cooling (?NMBA)4. Treat acidosis and hypovolemia
Two sources Aggressive Chemical Sedadddtion
Excited Delirium (ExDS)
DefinitionsPathophysiologyClinical Features
CausesComplicationsManagement
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 objective2. Protocolized use of pain scales is an effective
trigger for pain assessment3. Agitated delirium is a rare though lethal entity4. All ICUs need to comfortable with the aggressive
treatment required
What’s pain got to do with it?