Page 296 Guide to Pain Management in Low-Resource Settings

284 Josephine M. Th orp and Sabu James

• Other symptoms, such as abscesses, skin infl am- • Pain in itself will result in poor-quality sleep.
mation, wound infection, rashes, itches
• Support systems and monitoring—peripheral and What are the advantages of adequate pain
relief?
central intravenous line insertions and sites, cath-
eters, drains, regular suctioning, physiotherapy, • Improved tolerance of endotracheal tube, me-
dressing changes chanical ventilation, tracheal suctioning, and oth-
• Tissue hypoxia as a result of low cardiac output, er distressing maneuvers.
low oxygen saturation, or a sharp fall in hemoglo- • During weaning and after extubation, if chest ex-
bin may result in myocardial ischemia cursion is limited by pain, adequate analgesia will
• Painful joints, pressure points, pain on changing result in larger tidal volumes, better gas exchange,
position in bed improved sputum clearance, and cooperation
with physiotherapy.
What exacerbating factors may increase pain • Reduction in the stress response.
perception? • Less disturbing memories of therapy in the ICU.

• Fear in strange surroundings associated with
What is the compromise between too much
helplessness and lack of control
analgesia and too little?
• Inability to remember or understand the situation
resulting in intensive care Th e middle ground, to gain the benefi ts without the dis-
• Anxiety and uncertainty about oneself, one’s fam- advantages can only be achieved by regular assessment
ily, and about the present and the future of pain along with a “sedation vacation” (a break from
• Background aggravations—noise, machine sedation) and adjustment of the regime on a daily basis.
alarms, phones ringing
How can you assess pain and sedation?
• Ongoing activity through the night, other pa-
tients being admitted or resuscitated Even under normal circumstances, assessment and
• Inability to communicate, to move, to change po- quantifi cation of pain are diffi cult. Th ese diffi culties are
sition obviously far greater in the patient in the ICU, with an
• Lack of sleep, disturbed sleep patterns endotracheal tube often present, preventing speech and
• Other sensations:—thirst, hunger, hot, cold, empathic discussion. A state of paralysis in an aware pa-
cramps, itching, nausea tient should be avoided in the ICU just as in the operat-
• Fatigue after surgery; even after uncomplicated ing room, as this is a terrifying experience for a patient.
surgery, fatigue is normal If the patient is paralysed, it is important to ensure that
• Boredom and lack of distraction adequate sedation and analgesics are given to avoid a
Addressing these aspects will make the pain it- patient who is awake but unable to move!
self more tolerable and manageable. If the patient is able to speak, a routine history
about the pain and its severity can be taken. A patient
What are the eff ects of untreated pain? who is able to understand, but unable to speak, may

• Pain induces increased sympathetic drive, result- be able to gesture or to indicate severity on a simple
ing in cardiovascular changes (increased cardiac evaluation tool such as a visual analogue scale (VAS)
work and oxygen consumption). or numeric rating scale (NRS). Th e NRS is a 10-point
• An increased stress hormone response results in scale: the patient chooses a number from 0 to 10, with
catabolism, with sodium and water retention and 10 being the worst pain imaginable. Where no com-
hyperglycemia, which in turn leads to immuno- munication is possible, signs of sympathetic drive can
suppression and delayed wound healing. be noted—tachycardia, hypertension, and lacrimation.
• Ineff ective cough and retention of secretions, re- Clinical practice guidelines state: “Patients who cannot
sulting in reduced oxygenation, infection. communicate should be assessed through subjective
• Chest wounds and abdominal incisions decrease observation of pain related behaviors (movement, facial
chest wall and abdominal movements, which may expression and posturing) and physiological indicators
delay weaning from ventilation, increase the risk (heart rate, blood pressure and respiratory rate) and the
of chest infection, and prolong ICU stay. change in these variables following analgesic therapy.”