Determinants of procedural pain intensity in the intensive care unit. The Europain® study.

RATIONALE: Intensive care unit (ICU) patients undergo several diagnostic and therapeutic procedures every day. The prevalence, intensity, and risk factors of pain related to these procedures are not well known. OBJECTIVES: To assess self-reported procedural pain intensity versus baseline pain, examine pain intensity differences across procedures, and identify risk factors for procedural pain intensity. METHODS: Prospective, cross-sectional, multicenter, multinational study of pain intensity associated with 12 procedures. Data were obtained from 3,851 patients who underwent 4,812 procedures in 192 ICUs in 28 countries. MEASUREMENTS AND MAIN RESULTS: Pain intensity on a 0-10 numeric rating scale increased significantly from baseline pain during all procedures (P < 0.001). Chest tube removal, wound drain removal, and arterial line insertion were the three most painful procedures, with median pain scores of 5 (3-7), 4.5 (2-7), and 4 (2-6), respectively. By multivariate analysis, risk factors independently associated with greater procedural pain intensity were the specific procedure; opioid administration specifically for the procedure; preprocedural pain intensity; preprocedural pain distress; intensity of the worst pain on the same day, before the procedure; and procedure not performed by a nurse. A significant ICU effect was observed, with no visible effect of country because of its absorption by the ICU effect. Some of the risk factors became nonsignificant when each procedure was examined separately. CONCLUSIONS: Knowledge of risk factors for greater procedural pain intensity identified in this study may help clinicians select interventions that are needed to minimize procedural pain. Clinical trial registered with www.clinicaltrials.gov (NCT 01070082).

Prevalence and factors of intensive care unit conflicts: the conflicus study.

RATIONALE: Many sources of conflict exist in intensive care units (ICUs). Few studies recorded the prevalence, characteristics, and risk factors for conflicts in ICUs. OBJECTIVES: To record the prevalence, characteristics, and risk factors for conflicts in ICUs. METHODS: One-day cross-sectional survey of ICU clinicians. Data on perceived conflicts in the week before the survey day were obtained from 7,498 ICU staff members (323 ICUs in 24 countries). MEASUREMENTS AND MAIN RESULTS: Conflicts were perceived by 5,268 (71.6%) respondents. Nurse-physician conflicts were the most common (32.6%), followed by conflicts among nurses (27.3%) and staff-relative conflicts (26.6%). The most common conflict-causing behaviors were personal animosity, mistrust, and communication gaps. During end-of-life care, the main sources of perceived conflict were lack of psychological support, absence of staff meetings, and problems with the decision-making process. Conflicts perceived as severe were reported by 3,974 (53%) respondents. Job strain was significantly associated with perceiving conflicts and with greater severity of perceived conflicts. Multivariate analysis identified 15 factors associated with perceived conflicts, of which 6 were potential targets for future intervention: staff working more than 40 h/wk, more than 15 ICU beds, caring for dying patients or providing pre- and postmortem care within the last week, symptom control not ensured jointly by physicians and nurses, and no routine unit-level meetings. CONCLUSIONS: Over 70% of ICU workers reported perceived conflicts, which were often considered severe and were significantly associated with job strain. Workload, inadequate communication, and end-of-life care emerged as important potential targets for improvement.

Pain distress: the negative emotion associated with procedures in ICU patients.

PURPOSE: The intensity of procedural pain in intensive care unit (ICU) patients is well documented. However, little is known about procedural pain distress, the psychological response to pain. METHODS: Post hoc analysis of a multicenter, multinational study of procedural pain. Pain distress was measured before and during procedures (0-10 numeric rating scale). Factors that influenced procedural pain distress were identified by multivariable analyses using a hierarchical model with ICU and country as random effects. RESULTS: A total of 4812 procedures were recorded (3851 patients, 192 ICUs, 28 countries). Pain distress scores were highest for endotracheal suctioning (ETS) and tracheal suctioning, chest tube removal (CTR), and wound drain removal (median [IQRs] = 4 [1.6, 1.7]). Significant relative risks (RR) for a higher degree of pain distress included certain procedures: turning (RR = 1.18), ETS (RR = 1.45), tracheal suctioning (RR = 1.38), CTR (RR = 1.39), wound drain removal (RR = 1.56), and arterial line insertion (RR = 1.41); certain pain behaviors (RR = 1.19-1.28); pre-procedural pain intensity (RR = 1.15); and use of opioids (RR = 1.15-1.22). Patient-related variables that significantly increased the odds of patients having higher procedural pain distress than pain intensity were pre-procedural pain intensity (odds ratio [OR] = 1.05); pre-hospital anxiety (OR = 1.76); receiving pethidine/meperidine (OR = 4.11); or receiving haloperidol (OR = 1.77) prior to the procedure. CONCLUSIONS: Procedural pain has both sensory and emotional dimensions. We found that, although procedural pain intensity (the sensory dimension) and distress (the emotional dimension) may closely covary, there are certain factors than can preferentially influence each of the dimensions. Clinicians are encouraged to appreciate the multidimensionality of pain when they perform procedures and use this knowledge to minimize the patient's pain experience.

Performance of two measures of general health-related quality of life, the EQ-5D and the RAND-36 among critically ill patients.

OBJECTIVE: To compare two health-related quality of life measures, the preference-based EQ-5D with five questions and the profile-based RAND-36 with 36 questions, in previous critically ill patients. DESIGN: Prospective observational study. SETTING: A ten-bed medical-surgical intensive care unit (ICU) in a tertiary care university hospital. PATIENTS: Of the 2,709 critically ill patients, treated during the years 1995-2000, the 1,099 patients of the 1,443 still alive who returned both mailed measures were included in the study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The EQ-5D and the RAND-36 correlated well (P <.001). Ceiling effect was more obvious with the EQ-5D; the values of the RAND-36 varied usually from 0 to 100 in all the three levels of the corresponding EQ-5D question, and the weakest statistically significant differences were between the EQ levels 2 and 3. In particular, the RAND-36 proved to differentiate better the levels of mobility, self-care, and poor outcome. CONCLUSIONS: The EQ-5D and the RAND-36 correlated well, but when more precisely stated information is needed, especially regarding mobility, self-care, or low quality of life levels of previous critically ill patients, the profile-based RAND-36 may discriminate better.

Quality of life six years after intensive care.

OBJECTIVE: To assess the degree of change in long-term quality of life (QOL) in critically ill patients 1 and 6 years after discharge from the intensive care unit (ICU). DESIGN: Prospective observational study. SETTING: A ten-bed medical-surgical ICU in a tertiary care hospital. PATIENTS: Of the 591 consecutive patients admitted in 1995 the study comprised those 169 who responded to both QOL questionnaires, sent in 1996 and 2001. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A generic scale assessing health-related QOL, the RAND 36, sent by mail. Six years after discharge 9% of the patients considered their present health status as excellent, 37% as good, 45% as satisfactory and 9% as poor. The absolute values of the different QOL domains revealed worse physical functioning ( p<0.001), pain ( p=0.008) and general health ( p=0.012), but less emotional role limitation ( p=0.006) as compared with the 1996 values. Compared with the age- and gender-matched general population (controls), a marked improvement was detected in physical and emotional role limitations, and in vitality. However, 6 years after ICU discharge pain was worse, and physical functioning and general health were still reduced as compared with controls. CONCLUSIONS: When evaluating the long-term outcome of ICU patients, the timing of QOL assessment is essential; especially the emotional domains seem to improve slowly. Further studies focusing on the effect of time on various QOL domains and the predictive factors for a long-term QOL are therefore warranted.

Long-term survival, quality of life, and quality-adjusted life-years among critically ill elderly patients.

OBJECTIVES: To assess mortality, quality of life (QOL), and quality-adjusted life-years (QALYs) for critically ill elderly patients. DESIGN: Cross-sectional survey. SETTING: A ten-bed medical-surgical intensive care unit (ICU) in a tertiary care university hospital. PATIENTS: The study group included 882 elderly patients (> or =65 yrs of age) and 1,827 controls (<65 yrs of age) treated during the period of 1995 to 2000. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Mortality was assessed during the ICU and hospital stays, and 12, 24, and 36 months after ICU discharge. The cumulative 3-yr mortality rate among the elderly (57%) was higher (p < .05) than that among the controls (40%). The majority (66%) of the elderly nonsurvivors died within 1 month after intensive care discharge. All elderly patients with day-1 Sequential Organ Failure (SOFA) scores >15 died during the ICU stay. QOL was assessed with EQ-5D and RAND-36 measures from 10 months to 7 yrs after discharge. The majority (88%) of the elderly survivors assessed their present health state as good or satisfactory; 66% found it to be similar or better than 12 months earlier, and 48% similar or better than their preadmission state. QOL measures by RAND-36 revealed that aging decreased their competencies most in physical functioning, physical role limitations, and vitality, but the elderly had better values in mental health than the controls. However, QALYs of the elderly respondents were 21% to 35% lower than the mean QALY minus 2 sd units of the age- and gender-adjusted general population. CONCLUSIONS: High age alone is not a valid reason to refuse intensive care, but the benefits perceived by intensive care seem to decrease with aging, if reflected as QALYs. However, 97% of the elderly survivors lived at home and 88% of them considered their QOL satisfactory or good after hospital discharge. Therefore, more reliable information on the outcome for the elderly is clearly needed.