Examining Post-Intensive Care Syndrome

Possible risk factors for chronic ICU-related pain include preexisting pain conditions, older age, opioid exposure, and psychological features of post-intensive care syndrome, including depression, anxiety, and posttraumatic stress disorder.1

Substantial research is needed to explore the etiology, mechanisms, risk factors, and interventions for chronic ICU-related pain. “Methods for identifying those at risk [for] developing chronic pain and stratifying this heterogeneity could lead to clinically relevant tools to improve pain management during acute and chronic phases of the patient pathway,” concluded the authors.1 “It is anticipated that, as our understanding of the pathological mechanisms and risk factors improves…interventions can be designed and integrated into rehabilitation programs.”

To learn more about chronic ICU-related pain, Clinical Pain Advisor interviewed Christina Hayhurst, MD, assistant professor of anesthesiology in the critical care division at Vanderbilt University Medical Center in Tennessee. Dr Hayhurst conducts research on this topic.3

Clinical Pain Advisor: What do we known about chronic pain in survivors of critical illness?

Dr Hayhurst: We know that chronic pain after critical illness is more common than many of us would predict. In studies, between 33% and 77% of patients have reported persistent pain several months after discharge from the ICU.1,9 In one study, 57% of surgical patients reported having pain up to 6 to 11 years after their acute illness.10 Even more significantly, several studies examining the impact of this chronic pain on patients’ ability to return to a normal life have shown that a significant percentage of critical illness survivors have pain that interferes with their ability to return to work, enjoy life, and interact with their families.

There seem to be similar rates of pain in medical and surgical admissions, but with different etiologies in the acute setting. Severity of illness, length of stay, and pre-admission pain syndromes seem to be the strongest risk factors for post-ICU chronic pain. The most commonly reported sites of chronic pain are the shoulder and ankle.

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Clinical Pain Advisor: How should chronic ICU-related pain be addressed in clinical practice?

Dr Hayhurst: It is difficult to clearly guide management to help prevent chronic pain in critically ill patients because many of the risk factors are nonmodifiable, and we still have much to identify unknown risk factors. However, a good place to start would be to minimize acute pain during critical illness. This is best accomplished by standardized and routine evaluations of pain using a numeric rating scale or nonverbal score such as the Critical Care Pain Observation Tool. A multimodal analgesic approach is recommended by the Society of Critical Care Medicine, which includes acetaminophen, gabapentinoids, ketamine, and the lowest effective dose of opioids. 

Clinical Pain Advisor: What are other key considerations for clinicians treating these patients? 

Dr Hayhurst: I don’t take care of patients outside of the ICU setting, but I would recommend that patients be seen in a post-ICU specific clinic, of which there are a few around the country. They are staffed by people who understand the practice patterns of the ICU and can go over the medication lists to reduce unnecessary medications that were started during critical illness but are now no longer needed — for example, antipsychotics for sleep. These clinics can help set patients up with durable medical equipment, rehabilitation programs, and mental health and spiritual counseling.

Clinical Pain Advisor: What are some of the remaining needs in this area?

Dr Hayhurst: We still have much to learn about chronic pain after critical illness. Pain is a subjective experience, so a patient’s coping mechanisms, level of depression, and social support will all contribute to their experience of pain, in addition to the actual physical injury they might have incurred during their illness. A couple areas of research that will be interesting to follow are early mobilization and physical therapy to help prevent chronic pain, as well as minimization of opioids. Patients need to be educated on expectations, and physicians need to be diligent about assessing pain in critically ill patients.

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1. Kemp HI, Laycock H, Costello A, Brett SJ. Chronic pain in critical care survivors: a narrative review. Br J Anaesth. 2019;123(2):e372-e384.

2. Baumbach P, Götz T, Günther A, Weiss T, Meissner W. Prevalence and characteristics of chronic intensive care-related pain: the role of severe sepsis and septic shock. Crit Care Med. 2016;44(6):1129-1137.

3. Hayhurst CJ, Jackson JC, Archer KR, Thompson JL, Chandrasekhar R, Hughes CG. Pain and its long-term interference of daily life after critical illness. Anesth Analg. 2018;127(3):690-697.

4. Marx G, Zimmer A, Rothaug J, Mescha S, Reinhart K, Meissner W. Chronic pain after surviving sepsis. Crit Care. 2006;10(Suppl 1):P421.

5. Granja C, Dias C, Costa-Pereira A, Sarmento A. Quality of life of survivors from severe sepsis and septic shock may be similar to that of others who survive critical illness. Crit Care. 2004;8(2):R91-R98.

6. Dowdy DW, Eid MP, Sedrakyan A, et al. Quality of life in adult survivors of critical illness: a systematic review of the literature. Intensive Care Med. 2005;31(5):611-620.

7. Choinière M, Watt-Watson J, Victor JC, et al. Prevalence of and risk factors for persistent postoperative nonanginal pain after cardiac surgery: a 2-year prospective multicentre study. CMAJ. 2014;186(7):E213-E223.

8. Baumbach P, Götz T, Günther A, Weiss T, Meissner W. Somatosensory functions in survivors of critical illness. Crit Care Med. 2017;45:e567-e574.

9. Stamenkovic DM, Laycock H, Karanikolas M, Ladjevic NG, Neskovic V, Bantel C. Chronic pain and chronic opioid use after intensive care discharge – Is it time to change practice? Front Pharmacol. 2019;10:23.

10. Timmers T, Verhofstad MJ, Leenen LP, Moons KG, Van Beeck EF. Long-term (>6 years) quality of life after surgical intensive care admission. Crit Care. 2010;14(Suppl 1):P437.