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Pain Management in the Setting of Language Barriers and Global Health 201
nerve structures, but there is not clear evidence on needle type with relation to nerve
injury. However, needle tips can be blunted sterilely if the provider prefers. Needle
echogenicity/visibility on ultrasound can be increased by roughening the outer needle
layer with a surgical blade, using a guidewire, or performing the block with saline
hydrodissection [2]. Ultrasound imaging equipment remains limited and costly in
LMICs. This imaging modality has become more affordable with handheld devices
that can be connected to cell phones or laptops. Recent ultrasound technology has
also become more durable, portable, and equipped with longer battery lives, which
is helpful in resource-limited settings where electricity can be unreliable. Some
machines are also more streamlined with fewer and more user-friendly controls to
help with the learning curve. Ultrasound maintenance can also be expensive and this
is a required consideration if equipment donation is contemplated [37]. Lastly, basic
monitors still need to be available for regional anesthesia as well [50].
In addition to equipment shortages, medications in LMICs are frequently in
shortage as well. Local anesthetics are not always readily available and can have
quality control issues resulting from inadequate storage conditions, inconsistent
sourcing, or utilization beyond printed expiration dates. The actual concentration
of the prepared local anesthetic may be different from the concentration reported
on the label. There may not be standard concentrations of local anesthetics avail-
able either, so diluting the medication and paying close attention to the drug label is
important. Single-use vials may need to be used across multiple patients and reused
over several days, putting patients at elevated risk for infection. Furthermore, the
amount of local anesthetic needed to perform a single peripheral block can be used
for multiple spinals, which then contributes to the shortage of local anesthetics. The
local anesthetic is arguably more beneficial if saved for neuraxial anesthesia [2, 50].
In a study of anesthesia resources in Uganda, 30% of anesthesia professionals stated
that they never had local anesthetic for neuraxial anesthesia and 28% stated that they
only sometimes had local anesthetic available [51]. Lipid emulsion and vasopressors
are also frequently unavailable, which affects the safety of performing regional and
neuraxial anesthesia. Vasopressors are often needed during neuraxial anesthesia.
Using smaller volumes, short-acting, and lower concentration of local anesthetics
may be the safer option when lipid emulsion is not readily available [2, 50].
There are additional logistical and safety considerations associated with imple-
menting regional anesthesia programs in resource-limited areas. Although regional
anesthesia has the potential to increase efficiency, it can also have the opposite effect if
appropriate workflow and protocols are not in place. This needs to be tailored to indi-
vidual healthcare settings by local healthcare professionals. There is a huge learning
curve and logistical barriers, which can decrease efficiency with initial implemen-
tation of regional techniques. Discussions also need to be held on if the benefits
of regional anesthesia outweigh the risks and how to ensure adequate supply and
quality of equipment and medications. Medical professionals need to learn both how
to perform the regional techniques and how to manage complications, such as Local
Anesthetic Systemic Toxicity (LAST) or loss of an airway. Although regional anes-
thesia, particularly under ultrasound-guidance, is generally considered to be low risk,
the data on the safety of regional anesthesia is mainly in well-resourced settings with
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202 M. Kuei et al.
trained medical professionals. More studies need to be conducted on the safety of
regional anesthesia in resource-limited settings. The degree of safety that is accept-
able and “bare minimum” requirements to administer regional anesthesia needs to
be established. There needs to be guidelines on who can provide regional anesthesia,
how much training is needed, and if lipid emulsion and vasopressors need to be
present [2].
Other factors include institutional practices and healthcare professional pref-
erences. For example, a study in Ghana demonstrated that local surgeons were
performing inguinal hernia repairs under local anesthetic infiltration half as
frequently as visiting surgeons from abroad [52]. Healthcare professionals are more
comfortable with techniques they are familiar with. For example, anesthesia profes-
sionals prefer to use ketamine, even if neuraxial anesthesia or local anesthetic
infiltration would be appropriate [50].
Regional anesthesia in LMICs has the potential to reduce morbidity and mortality,
while increasing efficiency. However, there needs to be adequate resources, trained
medical professionals, and workflow and safety protocols. More studies need to be
performed on safety and access to supplies in resource-limited settings.
5 Training Opportunities in Global Health
As anesthesiology residency programs have become more common and well devel-
oped in many LMICs, the desire for subspecialty anesthesia training has expectedly
grown. There are two main options for residents and attendings in LMICs to obtain
this subspecialty training: 1) out-of-country fellowship training, and 2) in-country/
local fellowship training. Both training options have advantages and disadvantages
for anesthesia personnel of LMICs. Since many LMICs do not have the availability of
in-country subspecialty training yet, the only available option is pursuing an out-of-
country fellowship. Out-of-country fellowship training requires an anesthesiologist
to leave one’s country to join an established fellowship program usually in a higher-
income country for a period of time in order to become an expert in that subspecialty
before returning. The advantage of this particular avenue is that the trainee can
learn at an established program with subspecialty experts usually without a substan-
tial lack of local resources and/or teaching impairing their fellowship training [53].
The World Federation of Societies of Anaesthesiologists (WFSA) has established a
number of subspecialty training programs (critical care, pediatric anesthesia, regional
anesthesia, cardiac anesthesia, pain management, thoracic anesthesia, and obstetric
anesthesia) of varying durations for anesthesiologists from LMICs with the goal of
providing subspecialty training for applicants in local geographic regions [54].
The major disadvantages of out-of-country fellowship training include: 1) lack
of funding, 2) lack of opportunities, 3) medical migration, 4) learning outside of
one’s home context, and 5) inability to translate the learning upon returning [55].
While WFSA has greatly increased the available training opportunities, positions
remain limited in many geographic regions and cannot accommodate the number
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Pain Management in the Setting of Language Barriers and Global Health 203
of LMIC anesthesiologists interested in subspecialty training. There remains the
concern that these external fellowship programs could promote medical migration,
which affects medical care in many LMICs [56]. The ability to successfully retain
locally trained anesthesiologists is a core component of increasing the quality of
anesthesia care in LMICs. In addition to concerns of medical migration that may
arise, subspecialty learning in a foreign medical environment with greater resources
can limit the applicability of one’s learning upon return to the home country. Unless
the training program carries a heavy emphasis on resource building and program
development (rather than pure medical knowledge and procedural expertise), an out-
of-country trainee may return and be unable to apply what their subspeciality learning
to the local context for a multitude of reasons, including lack of resources, leadership
buy-in, and barriers to change current practices and processes. For instance, for
regional anesthesia training, learning at an established program with a well-developed
regional block room workflow might facilitate understanding of how to perform the
relevant blocks but the training may not provide the necessary expertise of how to set
up that block room workflow in a low-resource setting that does not currently have
one.
In-context, in-country subspeciality training could address these issues and
provide fellowship learning and subspecialty expertise while focusing heavily on
process improvement and the leadership skills necessary to translate the medical
knowledge in one’s home context. However, the development of subspecialty training
programs in LMICs is hampered mainly by a lack of local expertise and teaching
in these subspecialties. With the recent focus on anesthesiology residency program
development by certain societies (American Society of Anesthesiologists, Canadian
Anesthesiologists’ Society International Education Foundation, International Asso-
ciation for the Study of Pain, to name a few), the opportunity to subsequently use
the educational infrastructure to develop subspecialty training programs has grown
due to local desire for such training. The main challenges faced in developing these
in-country fellowship programs in LMICs include funding, resources, obtaining dedi-
cated fellowship time for trainees, and availability of expert teaching. If no local in-
country subspeciality expert exists, a multi-institutional collaboration is commonly
needed to provide the level of expert teaching necessary for a near-continuous pres-
ence during the fellowship time. Growing these multi-institutional collaborations
to provide the necessary teaching expertise takes a considerable amount of time
and effort since many institutions may not provide the funding or academic time to
partake. The initial efforts of such in-country fellowships can focus on the develop-
ment of a local expert who then can lead subsequent fellowship efforts with ideally
less reliance on external teaching. The ultimate goal of such fellowship programs
should be to not only become an expert in a particular subspecialty but also to
understand how to apply that expertise to low-resource settings with an emphasis on
program development, process improvement, and improving quality of care while
under the constraint of limited resources.
Development of in-country regional anesthesia and acute pain medicine fellow-
ship programs in LMICs represents a significant need in these countries in order
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204 M. Kuei et al.
to advance anesthesia care for local residents and provide local residency gradu-
ates with further education and expertise for their professional advancement. While
pharmacologic perioperative analgesia can be limited due to certain drug availability
and inadequate postoperative monitoring, regional anesthesia and peripheral nerve
blocks can be performed in a cost-effective manner in many LMICs given the prolif-
eration of ultrasound access and local anesthetic availability. While specialized block
needles might not always be available in many LMIC settings, less expensive Tuohy
needles can commonly be purchased with pre-existing supply chains (i.e. from same
spinal needle supplier) and used for peripheral nerve blocks with already available
syringes and intravenous tubing. The resultant avoidance of general anesthesia for
many brachial plexus and lower extremity blocks can increase patient safety, improve
perioperative analgesia, and decrease the need for perioperative opioids. While there
is no perfect substitute for in-person, hands-on teaching, the newly available tele-
ultrasound component of portable ultrasound devices can allow for hands-on, real-
time, remote procedural teaching when gaps in in-person teaching occur during the
fellowship year [57]. Lastly, the addition of required scholarly activity and quality
improvement to these fellowship programs benefits the local anesthesia department
and patient care by increasing scholarship and academic opportunities.
6KeyPoints
With the increasing linguistic, cultural, and ethnic diversity worldwide, healthcare
professionals need to be cognizant of pain disparities that can affect different popu-
lations. Healthcare professionals should aim to improve pain communication, public
health education focused on pain management, and cultural competence to effectively
treat pain in patients of various backgrounds.
Globally, substantial pain management disparities exist in LMICs and are associ-
ated with variability in medication/equipment availability and a paucity of healthcare
professionals specifically trained in the provision of regional anesthesia and acute
pain medicine. Regional anesthesia can provide safe, effective, and less costly anal-
gesia and anesthesia with the appropriate resources. Therefore, it is imperative that
anesthesia professionals in LMICs be trained in regional anesthesia and acute pain
medicine to improve perioperative pain control and enhance public health.
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Pain Management Considerations
in Critical Care
Clare Hasken, Kenji Tanabe, and Sarah M. Alber
Abstract Pain management is an essential component of critical care medicine, and
effective treatment improves short and long-term patient outcomes. At the forefront
is the need for regular assessments of pain using validated tools, a few of which
are validated for patients able to communicate, or alternative tools for patients who
are unable to effectively communicate. With a recent recognition of harm resulting
from heavy sedation and immobility, current trends in critical care have transitioned
to the concept of “analgosedation.” This treatment paradigm prioritizes the use of
multimodal analgesia prior to the administration of sedating medications to facil-
itate early mobilization and participation with rehabilitation exercises. While the
administration of opioids remains a common practice in the intensive care unit,
multimodal anesthesia using non-opioid medications, as well as regional anesthetic
techniques have demonstrated improved outcomes and, in some cases, a decreased
incidence of chronic pain syndromes. The critically ill population provides several
unique challenges to pain management that are discussed in this chapter.
Keywords Critical care
· Numeric rating scale · Behavioral pain scale · Critical
care pain observation tool
· Analgosedation · Acetaminophen · Non-steroidal
anti-inflammatory drugs
· Neuropathic pain · Opioids · Ketamine · Lidocaine ·
Dexmedetomidine · Regional anesthesia · Epidural · Peripheral nerve block
C. Hasken
Department of Anesthesiology, University of Colorado, Aurora, Colorado, USA
e-mail: Clare.Hasken@cuanschutz.edu
K. Tanabe · S. M. Alber (
B
)
University of Colorado, Aurora, Colorado, USA
e-mail: Sarah.Alber@cuanschutz.edu
K. Tanabe
e-mail: Kenji.Tanabe@cuanschutz.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
A. Abd-Elsayed and K. Schroeder (eds.), Perioperative Pain Management,
https://doi.org/10.1007/978-3-031-67648-2_14
209
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210 C. Hasken et al.
1 Introduction
Pain management is a fundamental human right and is an essential component of
critical care medicine [1]. Pain in the critically ill patient is complex, and affects
the vast majority of patients [2]. Pain may be acute, chronic, or acute-on-chronic
in nature; it may arise from visceral, neuropathic, or somatic etiologies or may be
a combination of these. Pain may be associated with underlying pathologies, post-
surgical, and/or procedural as the result of the standard course of treatment in the
intensive care unit. Most patients experience pain both at rest and with procedures
[3]. Add to this the vast differences in the perception or tolerability of pain and it is
evident that patients require an individualized approach for effective management.
Pain is common in the intensive care unit and increases with routine procedures
performed in the critical care setting. Procedures associated with greatest intensity of
pain include arterial line insertion, chest tube removal, wound drain removal, turning/
repositioning, and tracheal suctioning [3]. The Europain Study evaluated the severity
of pain associated with procedures in 3,851 patients in 192 intensive care units
(ICUs) in 28 countries [4]. Patients were asked to rate the severity of pain i nduced by
frequently performed ICU procedures on a Numeric Rating Scale of 0–10 (0 being
no pain, 10 being the worst possible pain). Over 37% of patients in the study were
receiving mechanical ventilation during the procedure. All procedures were associ-
ated with a significant increase in pain scores. The most painful procedures identi-
fied in this investigation were chest tube removal, wound drain removal and arterial
line insertion. The least painful procedure was mobilization, and the most common
procedure performed was turning. Patients with higher pre-procedure pain scores
were more likely to report more severe pain during the procedure. Given the rela-
tively low mortality of 10% in the patients participating in this study compared to the
general ICU population, this may indicate an enrollment bias towards patients with
less severe acute illness. However, this large international investigation highlights
the ubiquity and importance of pain management in the critical care setting.
Healthcare professionals working in an intensive care setting may be hesitant to
treat pain, particularly with opioid analgesics, as this population commonly develops
altered pharmacokinetics and pharmacodynamics and an increased susceptibility to
side effects including vasoplegia (and subsequently worsening end-organ dysfunc-
tion), respiratory depression, inhibition of cough and risk for development of pneu-
monia, constipation, and altered mentation[5]. Contrary to this traditional thought
process, the adequate treatment of pain is more likely correlated with an improve-
ment in short and long-term patient outcomes [4]. Acutely, inadequate pain manage-
ment can result in hemodynamic alterations, hypoxia, decreased oxygen delivery
to essential organ systems, increased myocardial work and catabolism, psycho-
logical stress, sleep disturbance with increased risk for development of delirium,
and may limit participation with mobility and rehabilitation therapies [6]. Untreated
pain contributes to immunosuppression, hypercoagulability, nosocomial infections,
and the downstream development of anxiety, depression, and post-traumatic stress
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Pain Management Considerations in Critical Care 211
disorder [4]. Indeed, multiple studies have determined that adequate pain manage-
ment is associated with improvements in several clinical variables including a
decreased duration of mechanical ventilation, reduced agitation and sedation admin-
istration, ICU length of stay, and in-hospital mortality [2, 6]. With an increasing
recognition of the importance of light sedation and early mobilization in patients
on mechanical ventilation, adequate pain control is paramount in reducing seda-
tive mediations and facilitating participation and performance during rehabilitation
therapies [3, 6].
Clinical practice guidelines recommend that all critically ill patients be assessed
for pain routinely using appropriate assessment tools [1, 6]. In this chapter, we
review validated tools to assess pain and treatment strategies for this unique patient
population.
2 Patient Population & Demographics
A 2017 population-based study by Halpern et al. evaluated the growth of critical care
beds in the United States between 2000 and 2010, specifically comparing these trends
with the age and utilization trends of critical care beds during that timeframe [7].
While the number of critical care beds increased, Medicaid beneficiaries used a larger
proportion of critical care beds compared to Medicare beneficiaries. This delineation
suggests a shift towards critical care treatment of a younger patient population, with
likely decreased access to healthcare and subsequently poorly managed medical
conditions, being treated in the ICU setting. This contrasts with the traditional “aging
population” model [7]. Predictors of higher pain scores in the ICU setting include
pre-existing anxiety or depression, younger age, female sex, non-white ethnicity,
presence of comorbidities, the expectation of poor future quality of life, ICU length
of stay, and patients with a history of prior surgery or trauma [3]. These findings
suggest that pain will continue to be an important and pervasive component of critical
care medicine in the future.
The makeup of patients in the critical care setting varies widely depending on the
subspecialty focus of the ICU. Smaller or more rural ICUs may consist of a mix of crit-
ically ill patients with medical, surgical, or traumatic pathology. In larger hospitals,
ICUs may be separated into specialized medical, oncologic, surgical, cardiothoracic,
trauma, burn, and neurologic care. The patient populations of specialized ICUs have
unique drivers of pain, different frequencies of routine procedures, and variable use
of pain management strategies. This clinical diversity further emphasizes the need
for thoughtful and individualized care for the critically ill patient.
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Соседние файлы в папке Библиотека им академика М.И. Перельмана