Health care professionals' experiences of pain management in the intensive care unit: a qualitative study.

Despite the existence of evidence-based guidelines for the assessment and management of pain in the critical care setting, the prevalence of acute pain remains high. Inadequate pain management is associated with longer duration of mechanical ventilation, reduced capacity for rehabilitation and long-term psychological sequelae. This study aimed to describe the experiences of pain management from healthcare professionals working in intensive care units. Healthcare professionals were recruited from intensive care units in London, UK using a purposive sampling technique. Semi-structured interviews were transcribed verbatim. Transcripts were analysed using an inductive thematic analysis technique. Thirty participants were recruited from eight diverse intensive care units. Five themes were identified. First, there was a lack of consensus in pain assessment in the ICU where nursing staff described more knowledge and confidence of validated pain measures than physicians, and concerns over validity and usability were raised. Second, there was a universal perception of resource availability impacting the quality of pain management including high clinical workload, staff turnover and availability of certain pain management techniques. Third, acknowledgement of the importance of pain management was highest in those with experience of interacting with critical care survivors. Fourth, participants described their own emotional reaction to managing those in pain which influenced their learning. Finally, there was a perception that, due to the complexity of the intensive care unit population, pain was de-prioritised and there were conflicting views as to whether standardised analgosedation algorithms were useful. This study provides evidence to suggest interdisciplinary training, collaboratively designed decision-making tools, prioritisation initiatives and research priorities are areas that could be targeted to improve pain management in critical care.

State-of-the-art management of the acutely unwell child.

Children make up around one-fifth of all emergency department visits in the USA and UK, with an increasing trend of emergency admissions requiring intensive care. Anaesthetists play a vital role in the management of paediatric emergencies contributing to stabilisation, emergency anaesthesia, transfers and non-technical skills that optimise team performance. From neonates to adolescents, paediatric patients have diverse physiology and present with a range of congenital and acquired pathologies that often differ from the adult population. With increasing centralisation of paediatric services, staff outside these centres have less exposure to caring for children, yet are often the first responders in managing these high stakes situations. Staying abreast of the latest evidence for managing complex low frequency emergencies is a challenge. This review focuses on recent evidence and pertinent clinical updates within the field. The challenges of maintaining skills and training are explored as well as novel advancements in care.

Acute postoperative pain management.

BACKGROUND: Acute postoperative pain is common. Nearly 20 per cent of patients experience severe pain in the first 24 h after surgery, a figure that has remained largely unchanged in the past 30 years. This review aims to present key considerations for postoperative pain management. METHODS: A narrative review of postoperative pain strategies was undertaken. Searches of the Cochrane Library, PubMed and Google Scholar databases were performed using the terms postoperative care, psychological factor, pain management, acute pain service, analgesia, acute pain and pain assessment. RESULTS: Information on service provision, preoperative planning, pain assessment, and pharmacological and non-pharmacological strategies relevant to acute postoperative pain management in adults is presented, with a focus on enhanced recovery after surgery pathways. CONCLUSION: Adequate perioperative pain management is integral to patient care and outcomes. Each of the biological, psychological and social dimensions of the pain experience should be considered and understood in order to provide optimum pain management in the postoperative setting.

ANTECEDENTES: El dolor agudo postoperatorio es frecuente. Casi el 20% de los pacientes experimentan dolor intenso durante las primeras 24 horas después de la cirugía, una cifra que se ha mantenido prácticamente sin cambios en los últimos 30 años. Esta revisión tiene como objetivo presentar las consideraciones clave a tener en cuenta en el tratamiento del dolor postoperatorio. MÉTODOS: Se realizó una revisión descriptiva de las estrategias para el tratamiento del dolor postoperatorio. Se efectuó una búsqueda bibliográfica en las bases de datos Cochrane Library, PubMed y Google Scholar utilizando los términos: 'cuidado postoperatorio' (postoperative care); 'factor psicológico' (psychological factor); 'tratamiento del dolor' (pain management); 'servicio de dolor agudo' (acute pain service); 'analgesia' (analgesia); 'dolor agudo' (acute pain); y 'evaluación del dolor' (pain assessment). RESULTADOS: En el tratamiento del dolor agudo postoperatorio en adultos son relevantes: la prestación de servicios, la planificación preoperatoria, la evaluación del dolor y los tratamientos farmacológicos y no farmacológicos haciendo énfasis en los programas de rehabilitación multimodal tras la cirugía. CONCLUSIÓN: El tratamiento adecuado del dolor perioperatorio es parte integral en la atención del paciente y en los resultados obtenidos. Se deben considerar y entender cada una de las dimensiones biológica, psicológica y social del dolor para proporcionar un tratamiento óptimo durante el postoperatorio.

The influence of first author sex on acceptance rates of submissions to Anaesthesia Cases.

More than 50% of medical students and 45% of practising doctors are female in the UK. In the specialty of anaesthesia, 32% of consultants are female. However, compared with males, females are under-represented as authors of articles published in high-impact journals. We investigated the proportion of female first authors by examining the case reports submitted to Anaesthesia Cases since its inception in 2013. We defined authors by their sex (male or female), that is, biological characteristics, rather than their gender. There were a total of 802 submissions to Anaesthesia Cases over 4.5 years. Sixteen submissions were excluded and of the remaining 786 submissions, 279 were accepted and 507 rejected, an acceptance rate of 35.5%. Twenty (2.5%) authors' sex could not be identified. The overall proportion of female first authors was 37.1%. The proportion of female first authors of accepted case reports was 42.1% and females were first authors of rejected case reports in 34.4%. We found that, compared with previous studies on female sex and gender bias in publishing, there was a relatively high proportion of female first authors publishing in Anaesthesia Cases and female first authors were more likely to be accepted than male first authors. Authorship is considered to reflect career success and there continues to be sex/gender inequity that must be tackled at all levels, from application to medical school, through research funding, journals and Editorial Boards.

Pain Assessment in INTensive care (PAINT): an observational study of physician-documented pain assessment in 45 intensive care units in the United Kingdom.

Pain is a common and distressing symptom experienced by intensive care patients. Assessing pain in this environment is challenging, and published guidelines have been inconsistently implemented. The Pain Assessment in INTensive care (PAINT) study aimed to evaluate the frequency and type of physician pain assessments with respect to published guidelines. This observational service evaluation considered all pain and analgesia-related entries in patients' records over a 24-h period, in 45 adult intensive care units (ICUs) in London and the South-East of England. Data were collected from 750 patients, reflecting the practice of 362 physicians. Nearly two-thirds of patients (n = 475, 64.5%, 95%CI 60.9-67.8%) received no physician-documented pain assessment during the 24-h study period. Just under one-third (n = 215, 28.6%, 95%CI 25.5-32.0%) received no nursing-documented pain assessment, and over one-fifth (n = 159, 21.2%, 95%CI 19.2-23.4)% received neither a doctor nor a nursing pain assessment. Two of the 45 ICUs used validated behavioural pain assessment tools. The likelihood of receiving a physician pain assessment was affected by the following factors: the number of nursing assessments performed; whether the patient was admitted as a surgical patient; the presence of tracheal tube or tracheostomy; and the length of stay in ICU. Physician-documented pain assessments in the majority of participating ICUs were infrequent and did not utilise recommended behavioural pain assessment tools. Further research to identify factors influencing physician pain assessment behaviour in ICU, such as human factors or cultural attitudes, is urgently needed.

Assessing pain objectively: the use of physiological markers.

Pain diagnosis and management would benefit from the development of objective markers of nociception and pain. Current research addressing this issue has focused on five main strategies, each with its own advantages and disadvantages. These encompass: (i) monitoring changes in the autonomic nervous system; (ii) biopotentials; (iii) neuroimaging; (iv) biological (bio-) markers; and (v) composite algorithms. Although each strategy has shown areas of promise, there are currently no validated objective markers of nociception or pain that can be recommended for clinical use. This article introduces the most important developments in the field and highlights shortcomings, with the aim of allowing the reader to make informed decisions about what trends to watch in the future.