Assessing pain in paralyzed critically ill patients receiving neuromuscular blocking agents: A monocenter prospective cohort

Jules Voeltzel; Océane Garnier; Albert Prades; Julie Carr; Audrey De Jong; Nicolas Molinari; Samir Jaber; Gerald Chanques

doi:10.1016/j.accpm.2024.101384

Assessing pain in paralyzed critically ill patients receiving neuromuscular blocking agents: A monocenter prospective cohort

Anaesth Crit Care Pain Med. 2024 May 4:101384. doi: 10.1016/j.accpm.2024.101384. Online ahead of print.

Authors

Jules Voeltzel¹, Océane Garnier¹, Albert Prades¹, Julie Carr¹, Audrey De Jong¹, Nicolas Molinari², Samir Jaber¹, Gerald Chanques³

Affiliations

¹ Department of Anaesthesia & Critical Care Medicine, Saint Eloi Montpellier University Hospital, and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France.
² Department of Statistics, University of Montpellier La Colombière Hospital, and Institut Montpelliérain Alexander Grothendieck (IMAG), University of Montpellier, CNRS, Montpellier, France.
³ Department of Anaesthesia & Critical Care Medicine, Saint Eloi Montpellier University Hospital, and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France. Electronic address: gerald.chanques@umontpellier.fr.

PMID: 38710326
DOI: 10.1016/j.accpm.2024.101384

Abstract

Introduction: Given the absence of established recommendations for pain assessment in pharmacologically paralyzed Intensive-Care-Units (ICU) patients under Neuro-Muscular-Blocking Agents (NMBA), this study assessed the validity of various parameters for evaluating pain in this specific population.

Patients and methods: Four electrophysiological parameters (instant-Analgesia-Nociception-Index (ANI), Bispectral index (BIS), Heart Rate (HR) and Mean Arterial Blood Pressure (ABP)) and one clinical parameter (Behavioural-Pain-Scale (BPS)) were recorded during tracheal-suctioning in all consecutive ICU patients who required a continuous infusion of cisatracurium, before and just after paralysis recovery measured by Train-of-Four ratio. The validity of the five pain-related parameters was assessed by comparing the values recorded during different situations (before/during/after the nociceptive procedure) (discriminant-validity, primary outcome), and the effect of paralysis was assessed by comparing values obtained during and after paralysis (reliability, secondary outcome).

Results: Twenty patients were analyzed. ANI, BIS, and HR significantly changed during the nociceptive procedure in both paralysis and recovery, while BPS changed only post-recovery. ANI and HR were unaffected by paralysis, unlike BIS and BPS (mixed-effect model). ANI exhibited the highest discriminant-validity, with values (min 0/max 100) decreasing from 71 [48-89] at rest to 41 [25-72] during tracheal suctioning in paralyzed patients, and from 71 [53-85] at rest to 40 [31-52] in non-paralyzed patients.

Conclusions: ANI proves the most discriminant parameter for pain detection in both paralyzed and non-paralyzed sedated ICU patients. Its significant and clinically relevant decrease during tracheal suctioning remains unaltered by NMBA use. Pending further studies on analgesia protocols based on ANI, it could be used to assess pain during nociceptive procedures in ICU patients receiving NMBA.

Keywords: analgesia; intensive care unit; neuromuscular blocking agents; pain; paralysis; sedation.