Effect of nursing implemented sedation and pain protocol on the level of sedation, pain and amount of sedative and analgesic drugs use among opium addicted critically ill patients

Hossein Rafiei^{1, 3}, Mehdi Ahmadinejad², Masoud Amiri³, Mohammad EsmaeiliAbdar⁴*

¹Department of Intensive and Critical Care, School of Nursing and Midwifery, Shahrekord University of Medical Sciences, Shahrekord, Iran

²Department of Critical Care, School of Medicine, Kerman Medical University, Kerman, Iran

³Social Health Determinants Research Center and Department of Epidemiology and Biostatistics, School of Health, Shahrekord University of Medical Sciences, Shahrekord, Iran

⁴Department of Critical Care, School of Nursing, Kerman Medical University, Kerman, Iran

*Corresponding Author Email: mesmaeli87@gmail.com

ABSTRACT

Background and Aim: Control of pain and sedation in addicted critically ill patients could be different from other admitted patients to intensive care unit (ICU). This study aimed to assess the effect of nursing implemented sedation and pain protocol on the level of sedation, pain and amount of sedative and analgesic drugs use in opium addicted critically ill patients.

Methods: In a prospective, randomized, controlled trial from September 2011 to June 2012, this study has been conducted in Kerman, Iran. We randomly assigned 37 addicted mechanically ventilated patients who admitted to ICU in two groups; while in intervention group (group I), patients sedated using sedation and pain protocol, in control group (group II), addicted patients received usual, none protocol directed sedation and pain. Using Richmond Agitation Sedation Scale (RASS) and behavioral pain scale (BPS), the level of sedation and pain of patients was assessed in the time of ICU admission and every 4 hours for the first 2 days. Dosage of sedative and analgesic medications used (Morphine and Midazolam) was recorded in special chart every 6 hours by researcher during this period.

Finding: Mean score of the RASS in time of ICU admission was -1.74±1.1 in group I and -1.81±1.1 in group II. During hospitalization in ICU, score of this scale reached up to -1.10±1.0 in group I and -1.63±1.1 in group II. In the time of ICU admission, mean of BPS in patients in group I and II were 7.9±1.3 and 8.0±1.6, respectively. During ICU stay, score of this scale reached to 5.8±1.6 in group I and 6.9±2.1 in group II. In addition, our results showed that group I patients have received less amount of Morphine and Midazolam in comparison with patients in group II.

Conclusion: Our results suggested that using nursing implemented sedation and pain protocol for opium addicted critically ill, could lead to experience better sedation and lower level of pain as well as decreasing amount of sedative and analgesics drugs use with implementation of protocol.

KEY WORDS: Opium addicted patient, Nurse, Protocol, Sedation, Pain, ICU

INTRODUCTION:

The favorable level of sedation and control of pain are two important aspects of nursing care in patients undergoing mechanical ventilation in the Intensive Care Units (ICUs) (Brush, 2009; Walker et al., 2006). Society of Critical Care Medicine suggested that members of medical and nursing teams are better to use sedation and pain guidelines to achieve an ideal sedation and control of pain in critically ill patients (Society of Critical Care Medicine, 2002). Meanwhile, Robinson et al., reported that the use of sedation protocol for critically ill patients in ICU might decrease duration of mechanical ventilation and length of staying in ICU (Robinson et al, 2008). Similarly, Broock et al. studied the effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. They reported that use of sedation protocol by critical care nurses for patients with acute respiratory syndrome may decrease the need of this group of patients to tracheostomy (Broock et al, 1999).

Incidence of substance abuse reported between 5 to 30 percent among critically ill patients admitted to ICU (Suchyta et al, 2006). Furthermore, management of pain and provided ideal sedation in this group of patients could be different from other admitted patients in ICUs. In 2007, De Wit et al. studied the prevalence of alcohol and other drug use disorders among critically ill patients and effect of these problems on sedation and duration of mechanical ventilation (De Wit et al, 2007). They reported that this group of patients in comparison with the patients without substance abuse usually needs more sedative agents for achieving similar level of sedation. The study conducted by Askay et al. showed that the pain was not enough relieved in trauma patients with substance abuse whom referred to the emergency department (Askay et al, 2009). They reported that one of the main causes of insuficient pain control in patients with substance abuse is negative attiude of physicians to control of pain in this group of patients.

Although providing favorable level of sedation and management of pain is different in addicted critically ill patients; however, it seems that previous studies had less attention to this topic. For this reason and also for increasing the quality of nursing care in addicted critically ill patients, present study was designed to explore the effect of nursing implemented sedation and pain protocol on the level of sedation, pain and amount of sedative and analgesic drugs use in opium addicted critically ill patients.

MATERIAL AND METHODS:

This study is a randomized controlled trial conducted from September 2011 to June 2012 in three ICUs at the Shahid Bahonar hospital, Kerman, Iran. This hospital has 33 mixed ICU beds that admitted 1104 patients in 2010 (Ahmadinejad et al, 2011). This study has received permissions from deputy of research and also the ethics' board of the Kerman University of Medical Sciences. Inclusion criteria were being on mechanical ventilation, having an endotracheal tube, staying in the ICU for at least two days, addiction, age between 15 to 45 years, haemodynamically stable, not receiving resuscitative therapies and not receiving neuromuscular blockade drugs. Patients with previous history of heart, lung, kidney and liver diseases were excluded. Each patient or his/her relative (if patient was not able to respond) was asked to fill in a written consent form (previously approved by ethics committees). After finding eligible patients, if they have already intubated, patients were randomly assigned to protocol (I) or control (II) sedation regimens by the supervisors of ICUs, who chose the next serially numbered sealed opaque envelope containing a simple 1:1 randomization sequence. In Shahid Bahonar ICUs, usual care was the sedative and analgesic drugs which were ordered by physicians; therefore, the nurses would have administration responsibility of medications to the patients, when patients had pain and needed to these prescriptions.

Patients after admission to the ICUs were randomly assigned to intervention (group I) or control group (group II). In group I, control of pain and sedation was performed using the pain and sedation protocol implemented by critical care nurses. The flow-diagram from our sedation and pain protocol is shown in Figure 1. The aim of the protocol was to maintain the level of patients' sedation between +1 to -2 with regards to RASS and level of patients' pain between 3 to 6 with regards to BPS (Payen et al, 2001; Sessleret al al, 2002). In this group before administration of drugs, nurses could assess the potential reasons of patients’ agitation and pain. In group II, control of pain and sedation was performed according to routine prescription which may use in ICUs. For data collection, one of researchers assessed the level of sedation and pain in the time of patients' admission in ICUs and six times per 24-hour. The researcher did not know which patients were in which groups (control or intervention). Dosage of sedative and analgesic medications (Morphine and Midazolam) was recorded in mg in special chart every 6 hours by researcher during first 48-hour. Before beginning of study, a one-day workshop was conducted for nurses in order to be familiar with the protocol by the researchers. At all stages of research, intensivist was supervising it. The data analysis was performed using SPSS (Statistical Package for the Social Sciences) version 17. A P value of < 0.05 was considered as statistically significant. Descriptive statistics (expressed as mean and SD) and independent T- test for comparing the means of normally distributed independent-samples were used.

RESULTS:

Thirty seven addicted patients admitted to the ICUs. Of them, 18 patients were allocated in group I and 19 patients were assigned to group II. Of these patients, 33 participants were men (16 in group I and 17 in group II). Of four women patients, 2 were in group I and 2 were in group II. The mean age of patients was 34±7.4 years. Mean age of patients in both groups was similar. Of total, 97% of patients ventilated through endotracheal tube and 3% through tracheostomy tube. Most common causes of patient’s admission to ICU were multiple traumas and subdural hemorrhagic in group I (38%) and group II (42%) respectively (Table 1).

All patients in both groups were addicted to a special form of opium that named "Taryak" in Iran. Mean score of the RASS in time of ICU admission was not statistically significant different between groups (P > 0.05). After study, mean of RASS score decreased in group I patients more than patients in group II (was statistically significant (P < 0.05)) (Table 2). Results of independent t-test did not show any significant difference in mean of BPS score between groups in the time of ICU admission (P > 0.05). However, after starting of study, mean of BPS score were decreased more in patients of group I than in patients of group II. This difference was statistically significant (P < 0.05) (Table 2).

Our results has also showed that addicted critically ill patients in group I had received less dose of Morphine and Midazolam compared to the patients in group II; mean doses of Mmorphine were 3.5±0.4 mg in group I and 4.6±0.3mg in group II in each work shift. Mean dose of Midazolam was 2.7±0.5 mg in group I and 4.0±0.8mg in group II in each work shift.

DISCUSSION:

For many patients, the critical care environment could provide a frightening and stressful environment. Analgesics and sedatives are used to improve the comfort and safety of critically ill patients (Smith, 2010). Opium addicted patients as well as other patients in ICU, need to be receiving sedative and pain management. Opium addiction in these patients should not be a barrier to adequate attention compared to other patients. The results of present study showed that the mean score of the RASS in the intervention group compared with the control group was closer to the desired sedation score. Based on our knowledge, there was no other study to assess the effects of sedation protocol on the level of sedation of addicted patients in ICU. However, previous studies reported that the use of nursing implemented sedation protocols among non addicted patients in ICU is beneficial (Egerod et al, 2010; Riverea et al, 2008; Quenot et al, 2007]. For example, Aduardo et al. in a study on 40 non-addicted critically ill patients reported that the use of sedation protocol in ICU might lead to better sedation in patients undergoing mechanical ventilation (Eduardo et al, 2008). Therefore, it seems that the use of the sedation protocol to achieve the appropriate level of sedation in addicted patients is helpful. By using protocol for sedation before administering sedative in ICU, nurses could assess the potential reasons of patients’ agitation. In fact, many causes of patients' agitation in ICU don not need any medication therapy. For example, unfamiliar noises in ICU can cause patients' agitation. So the patients do not receive unnecessary sedative drugs and risk of oversedation would decrease.

Ideally, patients should not suffer any pain in an ICU (Hillman, 2004). Control of pain in hospitalized opium addicted patients could be very challenging. Previous studies reported that the pain in addicted patients was not well controlled by medical and nursing team members (Askay et al, 2009; De Wit et al, 2007). De Wit et al reported that addicted patients may be tending to more pain during the hospital stay compared to non-addicted patients (De Wit et al, 2007). Our study has shown that patients receiving protocolzed pain care suffered less pain. Moreover, many causes of pain in critically ill patients cannot be eliminated with medication therapy. For example, inappropriate bone traction can result in severe pain even if the patients have been received a high dose of analgesic drugs. Nurses, who assessed cause of pain before medication administration following a protocol, can identify actual and potential causes of pain. So, the use of the protocol by critical care nurses who are caring critically addicted patients could help to improve the control of pain in this group of patients. Control of pain in opium addicted critically ill patients is very important. These patients in addition to their pain due to current illness, may also experience more pain related to not receiving opiate for their usual needs.

Table 1: Admission diagnosis of patients

Diagnosis	Group I(N=18)	Group II(N=19)
Multiple trauma	7 (38.8%)	4 (21%)
Subdural hemorrhagic	4 (21%)	8 (42.1%)
Diffuse axonal injury	2 (10.6%)	3 (15.7%)
Brain tumor	2 (10.6%)	2 (10.6%)
Others	3 (15.7%)	2 (10.6%)

On the other hand, negative attitude of physicians and nurses related to pain control in this population is a contributing factor in the exacerbation of pain in these patients. Meanwhile, use of high dose of analgesics and sedative could cause many problems in critically ill patients such as deep sedation, failure to weaning from mechanical ventilation, increase time of ICU stay, drug interactions and pneumonia (Smith et al, 2010; Urden, 2010; Keller et al, 2002; Iranmanesh et al,2012]. Results of our study showed that the use of pain and sedation protocol for control of pain and sedation in addicted critically ill patients could significantly reduce the use of morphine and midazolam. Similarly, De Wit et al. in 2007 reported that addicted patients in comparison to non-addicted patients need increasing dosages of sedative drugs to achieve some levels of sedation (De Wit et al, 2007). Many causes of pain and agitation in critically ill patients can be treated successfully with non pharmacologic interventions, such as massage and relive of pressure. By using the protocol, critical care nurses could assess their patients before administering medications which might decrease need to medications.

CONCLUSION:

We found that the use of nursing implemented sedation and pain protocol for opium addicted critically ill patients in ICUs is helpful. Opium addicted patients whom were under sedation and pain protocol have had lower levels of pain and were better sedated; therefore, the need for sedative and analgesics drugs may also decrease. Lack of proper planning for sedation and pain control for patients in ICUs can cause many complications such as delay in weaning from the ventilator, increasing the risk of infections, thromboemboli, gastric ileuses, pressure ulcers, drug interactions and the increase length of ICU stay (Urden, 2010; Keller et al, 2002; Iranmanesh et al, 2012; Rafiei et al, 2012; Scemons et al, 2009). These complications could be more severe in opium addicted patients, because they have more clinical problems compared to the other patients.

LIMITATIONS:

Our study has small sample size. We did not examine the effects of sedation on sedation related outcomes, such as rate of self-extubation, length of ICU stay, length of hospital stay, delirium, and ventilator associated pneumonia.

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Received on 18.01.2013 Modified on 10.02.2013

Asian J. Nur. Edu. and Research 3(1): Jan.-March 2013; Page 37-41

Groups	RASS score		P value	BPS score		P value
Groups	Group I	Group II	P value	Group I	Group II	P value
Baseline	-1.81±0.9	-1.74±1.1	(P > 0.05)	7.9±1.3	8.0±1.6	(P > 0.05).
After intervention	-1.10±1.0	-1.63±1.1	(P < 0.05).	5.8±1.6	6.9±2.1	(P < 0.05).