Journal of Pain Research Dovepress

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REVIEW

Current Perspectives on the Assessment and

Management of Pain in the Intensive Care Unit

Mina F Nordness 1,2 Abstract: Critical illness is often painful, both from the underlying source of illness, as well
Christina J Hayhurst 2,3 as necessary procedures performed for the monitoring and care of these patients. Pain is
Pratik Pandharipande 1–3 often under-recognized in the critically ill, especially among those who cannot self-report, so
1
accurate assessment and management continue to be major consideration in their care. Pain
Department of General Surgery, Section
of Surgical Sciences, Vanderbilt University management in the intensive care unit (ICU) is an evolving practice, with a focus on accurate
Medical Center, Nashville, TN, USA; and frequent pain assessment, and targeted pharmacologic and non-pharmacologic treatment
2
Critical Illness, Brain Dysfunction and methods to maximize analgesia and minimize sedation. In this review, we will evaluate
Survivorship (CIBS) Center, Vanderbilt
University Medical Center, Nashville, TN, several validated methods of pain assessment in the ICU and present management options.
USA; 3Department of Anesthesiology, We will review the evidence-based recommendations put forth by the largest critical care
Division of Anesthesiology Critical Care
societies and several high-quality studies related to both the in-hospital approach to pain, as
Medicine, Vanderbilt University Medical
Center, Nashville, TN, USA well as the short- and long-term consequences of untreated pain in ICU patients. We
conclude with future directions.
Keywords: pain, critical illness, ICU liberation, PICS

Introduction
Critical illness, regardless of etiology, is a painful condition. Studies have noted that
at least half of all critically ill patients would describe having moderate to severe pain
at rest.1,2 This is despite recommendations from the Society of Critical Care Medicine
(SCCM) to utilize analgosedation, wherein a patient’s pain is treated adequately
before using sedatives.3 As more focus has been directed toward minimizing sedation
and early mobility, renewed attention is being paid to the assessment and treatment of
pain in the critically ill in order to achieve these goals. In a critical care setting where
many patients are mechanically ventilated, and over 30–50% develop delirium4 this
can make an accurate and timely pain assessment difficult, and requires standardized
and objective measurements.5,6 The most common and reliable way to assess pain is
subjectively using self-report numeric scales; however, even in patients who cannot
self-report, there are several validated tools to assess pain.7 Accurate assessment and
treatment of pain can have effects on both short- and long-term outcomes.8 Untreated
pain is associated with added psychological and physiological stress that can worsen
critical medical conditions.9 With our increasing understanding of the importance of
Correspondence: Christina J Hayhurst
Department of Anesthesiology, Division
multi-modal pain regimens, there are many novel options for treatment. The Society
of Anesthesiology Critical Care Medicine, for Critical Care Medicine (SCCM) recently published guidelines in both the most
Vanderbilt University Medical Center,
1211 Medical Center Dr, 422 MAB, recent edition of ICU Liberation,10 as well as the 2018 PADIS Guidelines,3 elements
Nashville, TN, 37212, USA of which will be reviewed in this article, along with potential future directions for
Tel +1 615-343-6268
Email [email protected] research in ICU pain management.

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Epidemiology of Pain in the ICU Assessment of Pain in the ICU

More than 5 million patients are admitted to ICUs in the The first element in the Society of Critical Care Medicine
United States annually, with an average length of stay of (SCCM) ICU Liberation Bundle10 and the 2018 Pain,
3.8 days.11 Unfortunately, over half of these patients will Agitation/Sedation, Delirium, Immobility and Sleep
experience moderate to severe pain at rest associated with Disruption (PADIS) Clinical Practice Guideline3 is the
their admission, and 80% will have pain during assessment and appropriate management of pain in ICU
procedures.1,3,12–15 The rates of pain do not differ patients. Pain is a basic physiological pathway evolutiona­
between the causes of admission – either medical or rily developed for the avoidance of tissue injury. What
surgical – and this is likely related to the various etiolo­ makes pain in the ICU unique, more complex, and poten­
gies of pain.1,2,16 In medical admissions, patient often tially more harmful, is that critically ill patients typically
have inflammatory or ischemic pain related to their under­ cannot communicate, whether due to delirium, sedation, or
lying disease. There can also be components of mechanical ventilation, and cannot withdraw as they
neuropathic pain with many disease processes and post- would normally do secondary to physical or chemical
procedural, incisional, and traumatic pain in surgical and restraints. Pain is also a profoundly subjective experience
trauma patients. All these contribute to pain at rest. In such that no two individuals likely experience, or react to,
addition to that, procedures add discrete episodes of acute the same painful event identically. These complex ele­
pain. Recent studies have demonstrated that patients rate ments require a systematic and thoughtful approach to
ICU-related procedures such as arterial line insertion, the assessment and management of pain in the ICU.
chest tube and drain removal as the most painful for The appropriate assessment and management of pain in
the ICU has been associated with improved patient outcomes
ICU survivors.14,17 Other procedures rated as uncomfor­
such as fewer days of mechanical ventilation, decreased ICU
table include mechanical ventilation, endotracheal tube
length of stay, delirium and mortality rates.3,8,15,20
suctioning, and repositioning.14
Appropriate analgesia can reduce sedation use,8,21 which
To fully understand the etiology of pain in critically
might reduce delirium and its negative long-term effects.22
ill patients, one should consider the definition of pain
established by the International Association for the
Study of Pain (IASP). IASP has defined pain as “an
Assessment Methods
There are a variety of validated tools for the assessment of
unpleasant sensory and emotional experience asso­
pain in hospitalized patients. Many of these are anchored
ciated with actual or potential tissue damage, or
to a subjective assessment that is typically a numeric or
described in terms of such damage.”16 This definition
visual scale. As suggested in the 2018 PADIS Guidelines3
allows that the experience of pain is multi-dimensional
and the ICU Liberation Bundle,10 providers should elicit
and not a purely physical entity, helping illuminate the
a self-report of pain first. If the patient’s ability to com­
experience of pain in the ICU. In the critical care
municate is limited by either sedation, mechanical ventila­
setting, pain may be commonly augmented by the psy­
tion or altered mental status, then one can use one of the
chological distress of being hospitalized and the loss of
objective, validated measures of pain assessment.
a sense of control. In addition to the sudden
dependence on others for survival that is inherent in
Subjective or Self-Report Assessment
the ICU, many patients must contend with pain while
experiencing a limited ability to communicate, or in
Tools
Upon admission to the ICU, a thorough pain assessment
some cases, a near total loss of the ability to commu­
including the character (dull vs lancinating, etc.,) duration,
nicate (eg, while receiving mechanical ventilation).
location and severity of pain should be attempted. The
Evidence also suggests that “pain distress,” an emo­
PQRSTUV mnemonic can be helpful in this initial intake.
tional component of pain, may be experienced by
patients undergoing procedures.18 Untreated pain in PQRSTUV
the ICU has even been associated with higher risk of Provocative/Palliative factors: Pain cause; pain-relieving
death,19 and thus the prompt assessment, treatment and strategies.10
mitigation management of pain in the ICU is Quality: Pain sensation.
paramount. Region: Pain location.

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Severity: Pain intensity. Objective/Behavioral Assessment Tools

Time: Pain duration or temporality (constant, Vital Sign Assessment
intermittent). Vital sign derangements should be considered sensitive,
Understand: Previous pain experience and known but not specific, for predicting pain in critically ill
problems. patients.3,24–27 Vital signs are not adequate for the assess­
Values: Values and preferences for pain treatment. ment of pain and should never be used as the sole mea­
This assessment tool is recommended in the ICU surement. Non-painful ICU experiences and underlying
Liberation Bundle10 for use on initial admission to the pathology such as sepsis may also trigger vital sign
ICU, to be followed by numerical scale or objective pain changes such as tachycardia that are unrelated to pain
assessment measures. but may be inappropriately attributed to pain by
Subsequently, after the initial intake, pain should be providers.3,24,25 The wide variation of physiologic
assessed regularly. Pain can fluctuate over time, can be derangements of critically ill patients limits the use of
present at rest and escalate during procedures or move­ vital signs as the sole method for assessing pain.
ment. SCCM recommends pain be assessed every two to
three hours at rest, and during procedures or other mobility
Validated Behavioral Pain Assessments
Given the complexity of communicating with non-verbal
events.3
ICU patients, several, now well-validated, behavioral
assessment tools have been developed for pain.28 There
Numeric Scales
are two primary tools that we will discuss here: the
The most common self-report method for pain assess­
Behavioral Pain Scale (BPS)5 and the Critical-Care Pain
ments are numeric rating scales, typically from 0 to 10,
Observation Tool (CPOT).7
with 0 representing no pain and 10 representing severe
The Behavioral Pain Scale ranges from 3 to 12 and has
pain.23 A preferred scale for ICU patients who may not
3 domains: facial expression, upper limb movement, and
be able to verbalize but are interactive is the Numeric
compliance with mechanical ventilation (see Figure 2).
Pain Rating Scale-Visual Component (NRS-V), in which
A BPS score ≥ 6 signifies pain that should be addressed
patients report their pain on a scale from 0 to 10. An
with treatment.5
example of the NRS-V is shown in Figure 1. The visual Behavioral pain scales have been validated in a variety
component shows the scale in large font, with “no pain” of critically ill patient populations,6,29,30 but are not
next to the number 0 on the left side of the scale and directly interchangeable with patient-reported scales, and
“extreme pain” next to the number 10 on the right side should be used only when patient reported scales are
of the scale. Intubated patients can point to their corre­ unable to be assessed or obtained or as an adjunct to
sponding pain level with the use of a large communica­ patient report.3,6
tion board including the NRS-V scale, or providers can The CPOT scoring system is similar, including facial
hold up the scale and ask the patient to nod when they expression, body movements, compliance with the venti­
point at the accurate rating of their pain. Practical lim­ lator or, for extubated patients, vocalization, and muscle
itations to using these visual scales are patients who tension. This scoring system is on a scale from 0 to 8, with
have active delirium, those with vision or hearing scores greater than 2 signifying an unacceptable level of
impairment, or those who otherwise cannot follow pain that requires treatment.7
commands. The adequate assessment of pain should be followed
by appropriate titration of analgesic interventions to
achieve the above-stated positive outcomes. However,
the existing literature suggests that this is not as prevalent
in practice. In one large multicenter prospective cohort
study of medication administration in Canadian ICUs,
over half of the ICUs studied had a standardized assess­
ment and management protocol, but the assessment tool
was used in only 19% and the management protocol in
Figure 1 Numeric pain rating scale – visual component. only 25%.31 In another large multicenter observational

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Item Description Score

Facial Expression Relaxed 1

Partially tightened (e.g. brown lowering) 2

Fully tightened (e.g. eyelid closing) 3

Grimacing 4

Upper Limb Movements No movement 1

Partially bent 2

Fully bent with finger flexion 3

Permanently retracted 4

Compliance with mechanical Tolerating movement 1

ventilation

Coughing but tolerating most of the time 2

Fighting ventilator 3

Unable to control 4

BPS scores range from 3 (no pain) to 12 (maximum pain).

Figure 2 Behavioral pain scale.

trial of over a thousand mechanically ventilated patients, ICU Pain Management

limited to those who had pain assessments and analgesia Appropriate assessment of pain must be partnered with an
administered on Day 2, those assessed for pain had less adequate, multi-modal, and evidence-based management
sedative use and more directed pain treatment surround­ strategy. This multi-modal strategy should incorporate both
ing painful procedures or interventions, and had pharmacologic and non-pharmacologic modalities of pain
improved patient outcomes.8 In this study, standardized control. The recommended approach is to employ an inclu­
protocols were more likely to be used in an academic sive assessment and management protocol, which directs
university-affiliated setting. Thus, although having stan­ recommended pain management strategies based on pain
dardized protocols for the assessment and management of scores.3 In this section, we will discuss currently recom­
pain are critically important, the actual implementation mended pharmacologic and non-pharmacologic pain man­
and adherence to these protocols remains an area for agement strategies.
improvement.
In summary, clinicians should assess critically ill
patients for their level of pain regularly, using self-report Non-Pharmacologic Management
if possible. If the patient cannot communicate, then one There have been several non-pharmacologic methods that
should use validated behavioral pain scales. Vital signs have gained increasing evidence over the last several
should not be used as surrogates for pain assessment. years. The SCCM ICU Liberation Bundle3 recommends
Pain should be reassessed every 2–3 hours and more fre­ four primary non-pharmacologic methods: massage ther­
quently before painful procedures or mobilization. apy, cold therapy, music and sound, and relaxation therapy.

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The goal of non-pharmacologic therapies is to address compared to standard care or even noise reduction showed
both physical sensory pain pathways (massage therapy, a decrease in self-reported pain scores as high as 2.6
cold therapy) as well as the emotional, affective and cog­ points.45 This is another area that is ripe for patient family
nitive elements of pain perception (music and sounds, involvement, as family will likely know what music the
relaxation therapy). A challenge in critically ill patients patient would best enjoy. Familiar voices have not been as
is in many cases they are unable to communicate their wellstudied as music interventions, but from the existing
sensations, perceptions or emotions surrounding their pain. data and anecdotal recounts by ICU survivors, hearing
However, many of these methods have been shown to a familiar voice, especially during procedures, is consid­
decrease both self-reported pain scores and behavioral ered helpful in relieving anxiety symptoms or mental
pain assessments.3 stress,49 and possibly pain.

Massage Therapy Relaxation Therapy

Massage therapy for ICU patients typically involves mas­ Relaxation therapy includes techniques such as guided
sage on the back, feet and/or hands. Depending on the imagery, breathing exercises, biofeedback and self-
patient’s clinical status, hands-only massage is also hypnosis, with guided imagery and breathing exercises
acceptable.32 The ICU Liberation Bundle recommends at being the most frequently used in critically ill
least 20 minutes of light pressure massage at least twice in patients.3,10 These therapies have been shown to have an
a 24-hour period.3 Massage therapy, when done consis­ up to a 2.6-point reduction in visual scale pain scores
tently, has been shown to reduce visual numeric pain (0–10), albeit from small sample size and limited study
scores by up to 2 points.33–35 designs.3,10 Guided-image therapy which typically
Massage is typically paired with decreasing sensory involves having the patient imagine a calm and relaxing
stimuli such as dimming lights and either muting alarms location of their choice to take them psychologically out of
or decreasing the volume and providing earplugs or an eye the current painful environment and can sometimes utilize
mask to the patient.3 This is often seen as a barrier to pre-recorded tapes instead of the bedside nurse, has been
implementation of a massage protocol, given frequent dis­ associated with decreased pain scores, less opioid use and
ruptions in an ICU setting. There have been no feasibility shorter length of stay.50,51 In cardiac surgery patients,
studies performed on the implementation of a massage a study of breathing exercises led by a bedside nurse
protocol. The ICU Liberation Bundle recommends demonstrated significantly lower pain scores when com­
engagement of family members to participate in massage bined with opioid therapy compared to opioid therapy
care with guidance from the nursing staff.3,10 alone for chest tube removal.52
We recommended using a combination of these non-
Cold Therapy
pharmacologic therapies in conjunction with pharmacolo­
Cold therapy in ICU patients for pain management has
gic therapy as needed for ICU-related pain.10 These
been described by applying gauze-wrapped ice packs to
strategies can be compiled into a comprehensive pain
procedural areas pre-procedure. This can be done with or
assessment and management protocol that is standardized
without pharmacologic analgesia. In a randomized study
to ensure the highest quality of pain management in
of patients having chest tubes removed, this was done for
the ICU.
a period of 10–20 minutes pre-procedure until the skin
reached 15º C, and was associated with a 1 point drop
on a 0–10 visual scale, with effects diminishing after 15 Pharmacologic Management
minutes.36–40 Pharmacologic management of pain has been the mainstay
of treatment for critically ill patients. However, pharmaco­
Music/Sound Therapy logic agents for pain are not without side effects, and can
Music or sound therapy has been associated with moderate lead to unwanted issues such as opioid tolerance/withdrawal,
decreases in pain scores in ICU patients.10,41–47 This inter­ and delirium. Pharmacologic management should be paired
vention portends no physical risk to the patient so should with protocolized pain assessments, and approached in
be considered. The existing studies recommend at least a gradated fashion in response to pain scores.3,10 SCCM
20–30 minutes,48 taking in the patient’s preferences into guidelines recommend opioids as first-line for non-
account. A randomized study of a music intervention neuropathic pain, being careful to use a protocol based on

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Table 1 Non-Opioid Analgesics for the ICU

Drug Dose Metabolism/ Considerations
Clearance

Acetaminophen <4 g/d Hepatic Dose adjust for cirrhosis: up to 2g/d

Gabapentinoids
Gabapentin 100–1200 mgTID Renal Dose adjust for GFR;
Pregabalin 50–300 mg TID Commonly can cause somnolence, blurry vision

Ketamine Infusion 2–5 mcg/kg/min Hepatic Avoid if history of PTSD/psychosis due to risk of hallucinations

Lidocaine Infusion* 1–2 mg/min Hepatic Avoid if history of seizure disorder, on anti-arrhythmics

NSAIDs* Varies Renal Caution with reduced GFR, peptic ulcers, age >65

SNRIs* Varies Hepatic Analgesic effect is faster onset than anti-depressant effect; helps with anxiety
component
3
Note: *Not recommended for routine use by SCCM.
Abbreviations: TID, three times daily; GFR, glomerular filtration rate; PTSD, post-traumatic stress disorder; NSAIDs, non-steroidal anti-inflammatory drugs; SNRIs,
serotonin/norepinephrine reuptake inhibitors.

pain scores for titration.3,10 They also recommend the be avoided for sedation as they are strongly associated
method of “analgosedation,” which treats pain before initiat­ with delirium.3,10,22
ing sedation therapy, and only using sedation if needed.
Multi-modal adjunct therapies are recommended, such as Pain and Delirium
ketamine infusions, acetaminophen, and gabapentinoids Pain has a complex role in the epidemiology of ICU
and in some populations non-steroidal anti-inflammatories delirium. Untreated pain can both perpetuate delirium,
(NSAIDs), lidocaine infusions, and regional anesthesia. See especially in surgical patients, and the pharmacologic
Table 1 for non-opioid pharmacologic treatment options. treatment of pain can also perpetuate it,58 especially opioid
Using a standardized pain assessment and management therapy in older adults. Figure 3 shows the complex inter­
protocol is associated with a more efficient use of pharma­ action between pain, delirium, and agitation.57
cologic pain control, with lower doses of opioids and A common misconception is that sedated patients do
improved self-reported numeric pain scores, although this not feel pain. In studies of patients and anecdotal recounts
association is not always consistent across studies, with of ICU survivors of their ICU experience, this is untrue.68
some showing increased doses in certain populations.21,53,54 These painful experiences tend to become distorted, and
In patients who were adequately assessed for pain, multi- may become incorporated into severe and disturbing delu­
modal adjuvant therapy use such as ketamine, paracetamol sions of patients suffering from ICU delirium. This can be
and nefopam increased, as did the use of dedicated treatment profoundly distressing to patients, even years after their
during procedures.8,55 critical illness, and is a contributing factor to Post-
Unlike many of the non-pharmacologic interventions, Intensive Care Syndrome (PICS),69 which will be dis­
pharmacologic pain management has several adverse effects, cussed in more detail in a later section.
the most concerning being ICU delirium.3,12,15,56–59 As mentioned previously, delirium is an important
There is a complex interplay of pain, pharmacologic balancing risk factor when achieving adequate analgesia
analgesia, and sedation when it comes to delirium, and sedation in the ICU. Delirium has effects on long-term
a needle that must be carefully threaded. Untreated pain cognition, even one to five years after hospital
has been associated with higher rates of delirium;60–64 discharge.4,70–76 Many patients who experience ICU delir­
however, the overuse of opioids and particularly benzo­ ium develop Post-Traumatic Stress Disorder (PTSD) after
diazepines have been associated with increased hospitalization, with many patients reporting flashbacks to
delirium.65–67 This supports the analgosedation approach, particularly painful experiences during their illness.77–82
in which the lowest possible dose to achieve target effect Delirium is also a risk factor for mortality in ICU
is recommended, and benzodiazepines in general should patients,83–85 making it critical to prevent and screen for

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Figure 3 Interaction between pain, delirium, and agitation.

Notes: From The New England Journal of Medicine, Reade MC, Finfer S, Sedation and delirium in the intensive care unit, Volume No. 370(5), Page No. 444–454, Copyright ©
(2014) Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society.57

delirium on a regular basis, and utilize pain management decrease ICU delirium, but did not improve pain
strategies that minimize delirium, by the avoidance of scores.89 Given that the bundle seeks to reduce sedation
benzodiazepines and maintaining the lowest possible and allow patients to communicate, this likely facilitated
dose of pharmacologic agents by employing a multi- patients being able to self-report pain, which is more
modal approach. reliable than behavioral pain assessments and may explain
The utilization of an evidence-based and well-validated why pain scores do not improve with the bundle alone.
ICU Liberation Bundle1 the first portion of which we have
referenced heavily in this article, which was previously
titled the ABCDEF Bundle (Assess, Prevent and Manage Pain-Related Long-Term Outcomes
Pain, Both Spontaneous Awakening Trial (SAT) and in ICU Patients
Spontaneous Breathing Trials (SBT), Choice of Uncontrolled pain in critically ill patients is not just an ethical
Analgesia or Sedation, Delirium: Assess, Prevent, or humanistic concern, but also a medical one. Pain pathways
Manage, Early Mobility and Exercise, Family are intended to relay signals of tissue damage to the brain, in
Engagement86,87 and Empowerment)88 has shown to order to avoid the painful stimulus (by physical withdrawal or

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avoidance) and further injury. Pain pathways are closely inter­ untreated pain, or amount of opioid received in the ICU is
connected to the sympathetic nervous system. Many of our directly associated with chronic pain conditions after dis­
physiologic signs of pain are sympathetic in nature, such as charge, there is enough literature to signal there exists a link,
tachycardia, hypertension, and diaphoresis. Uncontrolled pain and further work is necessary in this space to better identify
can leave a critically ill patient in a state of persistent adrenergic modifiable risk factors or interventions to prevent the devel­
activation, which can lead to additional stress to an already opment of chronic pain conditions in these patients.
ailing cardiovascular system.90–92 Critically ill patients are
typically in catabolism, and uncontrolled pain leads to even Summary and Future Directions
higher levels of metabolic energy expenditure,57,93 which may Recognition of pain as a prevalent problem in the criti­
worsen an already precarious metabolic state. Uncontrolled cally ill, including those who are sedated and non-
pain can even have unwanted immunomodulatory effects in communicative is essential. The approach to assessment
cancer.94,95 and treatment of pain in the ICU should be well-
Post-Intensive Care Syndrome (PICS) is a constellation protocolized and multi-modal, with a focus on adequate
of symptoms related to physical, cognitive and psycholo­ and frequent assessment of pain both at rest and during
gical ailments that persist months to years after discharge procedures, with specific guidelines for addressing pain
from the ICU.69 Chronic pain is an aspect of PICS with scores that are out of an acceptable range. Incorporating
between 33% and 77% of ICU survivors reporting persis­ non-pharmacologic methods is important and may allow
tent pain after discharge from the ICU that can last for for less of a need for pharmacologic interventions. These
years, with a third to three-quarters of patients still report­ efforts may be time-consuming, so engagement of the
ing pain at 1 year after ICU discharge.96–99 patient’s family and loved ones is paramount for success­
In a large prospective cohort study of almost 300 ICU ful pain management in these patients. Although opioid
survivors that sought more granular detail of chronic pain therapy remains the mainstay of pharmacologic pain
after the ICU, Hayhurst et al. found that at one year post- management in the ICU, there are several multi-modal
discharge, 74% of patients reported any pain, with 35% of adjuncts that should be used in addition to non-
patients rating this pain as moderate to severe.97 In a study by pharmacologic methods when possible in the appropriate
Baumbach et al., 33% of patients reported chronic pain at 6 patient populations, as this may allow the minimization
months post-discharge with half (16%) reporting this pain as of opioid therapy, which has several undesired side
resulting directly from their ICU stay, without a pre-existing effects, one of which is ICU delirium, especially when
history of pain symptoms.96 In another smaller study, Devine benzodiazepine-based sedation is utilized.
et al. found that 66% a mixed medical/surgical ICU cohort A major area in need of further research is identifying
reported a new pain disorder associated with their critical modifiable risk factors or interventions that can help pre­
illness.100 There has been at least one study that this chronic vent the development of chronic pain syndromes in ICU
pain may persist long after the one-year mark, with 57% of survivors. Over a third of ICU survivors report functional
patients reporting pain at 6 to 11 years after discharge.101 or physical limitations even at one-year post-ICU dis­
Mental health disorders such as depression and anxiety charge, and a third suffer from depression.80 Many
are a large component of PICS, with one-third of ICU patients report pain as a contributing factor to their phy­
survivors suffering from depression, which is highly comor­ sical limitations, which has a profound impact on these
bid with pain conditions.80,101 This syndrome, including patients from a quality of life and economic standpoint,
chronic pain, has a significant impact of quality of life and with one-third unable return to work at one year, and for
the ability of ICU survivors to return to work and other those who return to work, a third experience job loss and
normal daily activities, even years after their illness. up to two-thirds require an occupation change, with up to
Chronic pain after critical illness affects patients’ ability to 84% reporting a worsening employment status.103
sleep, enjoy life, time with their families and/or return to Rigorous prospective studies identifying pain-related
work.96,97,100 At 5 years after ICU discharge, three-quarters interventions either in-hospital, such as locoregional
of scores related to physical functioning on a quality of life therapies or strictly protocolized analgesia regimens, or
assessment were below the population mean.102 shortly after discharge, such as early referral to pain man­
Although there has yet to be an adequately powered or agement and/or physical therapy, that could prevent this
rigorously conducted study to test the hypothesis that tremendous economic and public health issue of chronic

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pain and debilitation of ICU survivors are desperately 15. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines
for the management of pain, agitation, and delirium in adult
needed.
patients in the intensive care unit. Crit Care Med. 2013;41
(1):263–306.
16. Merskey HAFD, Bonica JJ, Carmon A, et al. Pain terms: a list
Disclosure with definitions and notes on usage. Recommended by the IASP
Dr Mina Nordness reports grants from NIH-NIA, during subcommittee on taxonomy. Pain. 1979;6(3):249.
the conduct of the study. Dr Pratik Pandharipande reports 17. Puntillo KA, Miaskowski C, Kehrle K, Stannard D, Gleeson S,
Nye P. Relationship between behavioral and physiological indi­
grants from Pfizer, outside the submitted work. The author cators of pain, critical care patients’ self-reports of pain, and
report no other conflicts of interest in this work. opioid administration. Crit Care Med. 1997;25(7):1159–1166.
doi:10.1097/00003246-199707000-00017
18. Puntillo KA, Max A, Timsit JF, et al. Pain distress: the negative
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