Pain Management in the Neuro-Intensive Care Unit (ICU)

16 Pain Management in the Neuro-Intensive Care Unit (ICU)

Amy Shah, David A. Wyler, and Andrew Ng

Abstract

Pain, an unpleasant sensory and emotional experience, presents unique challenges in the neuro-intensive care unit. A recent shift in strategy to address pain has evolved in the general ICU. Providers aim toward maintaining patient arousal while treating their patient’s pain. The ICU liberation collaborative focuses on analgosedation or treating pain first and utilizing numerous tools for continued assessment in distinguishing pain from agitation and delirium (PAD). The endpoint is earlier liberation from ICU and mechanical ventilation by reducing sedative medications and supporting early mobility. This chapter aims to highlight the challenges of managing pain in the neuro-ICU while practicing within the framework of the current ICU liberation movement. Tools for assessment, individualized therapy, patients with neurodegenerative diseases at risk for pain, and special cases that make management of pain in the neuro-ICU particularly difficult will be discussed in this chapter.

Keywords: ICU liberation collaborative, ABCDEF bundle, ongoing assessment, individualized pain therapies, opioid therapy, adjunct medication, regional blocks, nonpharmacologic therapy

16.1 Introduction

Pain, an unpleasant sensory and emotional experience, presents unique challenges to care providers in the neuro-intensive care unit (neuro-ICU). Over the last decade, convincing data has driven a paradigm shift in the general ICU toward maintaining patient arousal while treating pain.¹ The ICU liberation collaborative focuses on treating pain first and utilizing numerous tools for continued assessment in distinguishing pain from agitation and delirium (PAD). The endpoint is earlier liberation from ICU and mechanical ventilation by reducing sedative medications and supporting early mobility.¹^,² The Critical Care Medicine (CCM) collaborative created the ABCDEF bundle to accomplish this purpose which stands for:

• Assess, Prevent, and Manage Pain

• Both spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs)

• Choice of Sedation

• Delirium: Assess, Prevent, and Manage

• Early Mobility and Exercise

• Family Engagement and Empowerment ¹^,²^,³

Several risks limit these strategies of caring for neurologically injured patients, and there is a paucity of data to validate the current trend in the neuro-ICU population.⁴^,⁵ Nonetheless, guidelines recommend whenever it is safe, treat pain judiciously and preserve the neurologic examination, the gold standard monitor for the central nervous system (CNS).¹^,⁴

This chapter aims to highlight the challenges of managing pain in the neuro-ICU while practicing within the framework of the current ICU liberation movement. Individualized therapy will be discussed for postoperative patients, patients with neurodegenerative diseases at risk for pain, and special cases that make management of pain in the neuro-ICU particularly difficult. Although opioid therapy is the mainstay for pain management historically, these medications often over-sedate frail neurologically susceptible patients.⁴ Thus, opioid-sparing therapies such regional anesthesia, adjunct pain medications, and various relaxation techniques are discussed in detail. This chapter intends to provide a quick guide for the A component (assess, prevent, and manage pain) of the ABCDEF bundle in the neuro-ICU.

16.2 Modern Strategy of Pain Management in ICU Liberation

• Joint Commission on Accreditation of Healthcare Organization (JCAHO) mandated in 2002 “implementation of standards” in pain assessment, prevention, and treatment which was termed the “5^th vital sign” in the ICU.¹^,⁴

• Studies supported reducing sedation and mobilizing patients improved ICU outcomes.¹^,²^,³^,⁶

• ABCDEF bundle implemented liberation strategy to address CCM Guideline 2012.¹^,²

• CCM guidelines excluded neurologically injured patients for safety reasons.¹

• Addressing the A component (assess, prevent, and treat pain) of the ABCDEF bundle first was recommended since pain confounds delirium and agitation.¹^,²

• The use of different pain scales for continuous ongoing assessment was recommended.¹^,⁶^,⁷

• Prevent/anticipate pain prior to surgery and painful procedures in ICU.¹

• Opioid adjuncts reduce dose and ultimately neuro-confounding and neurotoxic effects.³^,⁵^,⁶

16.3 Challenges of Pain Management in Neuro-ICU ¹^,⁴^,⁵^,⁷

• Balance maintaining neurologic examination versus providing comfort.

• Balance neurologic examination versus offering enough sedation for “neuro-specific” issues such as reducing cerebral blood volume (CBV), intracranial pressure (ICP), and cerebral metabolic rate for oxygen (CMRO2) and seizure control.⁴^,⁵^,⁸

• Severity of brain injury dictates, and ICP and other multimodality monitoring may be helpful.⁴

• Balance neurologic examination versus offering enough sedation to provide endotracheal tolerance, ventilator synchrony, and shivering control.⁷

• Early mobilization recommended only if neuro-specific issues are well controlled.