Inhalative Sedation

Informative and target level-controlled

The objective capture of pain in critically ill and intubated patients is difficult. Accordingly, the data from evidence-based investigations are scanty. The following recommendations for the assessment of pain conditions in intensive care patients are based on surveys conducted in alert and sufficiently cooperative patients, for example in chronically ill or postoperative patients. In spite of the restricted validity of pain scores for intensive care patients a systematic and continuous capture and documentation of pain symptoms is necessary.

In spite of the restricted validity of pain scores for intensive care patients a systematic and continuous capture and documentation of pain symptoms is necessary.

The most reliable parameter for the assessment of pain is the information by the patient. Localization, characteristics and intensity should be inquired from alert and cooperative patients. For the capture of the pain intensity the visual analogue scale (VAS) is validated - though not for intensive care patients – and most widely used. Here the patient has to enter the intensity of the pain on a scale 10cm long, the scale ranged from “no pain” to “strongest pain”.

Alternatively, the pain intensity can also be quantified by choosing a number between 0 (no pain) and 10 (strongest pain) (Numeric Rating Scale, NRS).

For practical reasons, for intensive care patients often the quantifying is easier feasible by means of pictogram charts.

 

Image: Die Numeric rating scale

With deep sedated or not cooperative patient’s visual analogue scales for pain quantifying are inappropriate.

Tests to capture unspecific parameters such as body posture, facial expression, motor restlessness, breathing rate and heart-vascular reactions as expression of pain intensity and to evaluate them by means of modified pain scores have proved valid in practice only to a limited extent.

Most suitable for the clinical practice appears to be the behavioural Pain Scale (BPS). In spite of all limitations the observation of these clinical parameters – especially after administration of an analgesic – can provide valuable information on the existence of pain and pain intensity.

Table: Quantifying pain according to the Behavioural Pain Scale

PointsItemDescription
1Facial expressionrelaxed
2partially tightened
3Fully tightened
4Grimacing
1Upper limb movementsNo movement
2Partial movement
3Fully bent with finger flexion
4Permanently retracted
1Compliance with mechanical ventilationTolerance
2rare coughing
3Fighting ventilator
4Unable to control ventilation

The observations by relatives may be helpful: it could be shown that they were able to judge with a high degree of accordance whether their ill relative had pain or not (73,5%). Pain intensity on the other hand was correctly assessed less frequently (53%).