Spécificités diagnostiques et thérapeutiques de la douleur en réanimation

Diseases associated with a patient's admission to an intensive care unit (ICU) (trauma, surgery, acute pancreatitis, etc.) and the ICU itself (catheters, mechanical ventilation, etc.) are numerous causes of pain. Every patient hospitalized in a medical or surgical ICU can develop a pain event. In addition to pain caused by a lesion process (trauma, pancreatitis), pain related to back and limbs (muscles, joints) are the main causes of pain, whatever the type of patient (medical or surgical). This could be determined by the strict immobilization of the patient in the ICU bed, the inflammatory response and sepsis. ICU patient's pain is a model of acute/subacute pain. Its evolution is going based on a basal pain with acute events associated with care procedures or evolution of the underlying disease. A pain event should be considered first as a major diagnosis symptom, which could be determinant in the patient's course. Systematic research of any pain symptom should be optimal using assessing tools adapted to the ICU patients. Patient's self-report intensity pain scales should be recommended in ICU as elsewhere. The visually enlarged laminated 0-10 Numeric Rating Scale is an interesting help to assess pain in fatigable ICU patients whose communication is worsen by the endotracheal tube, the oxygen face mask or the strict immobilization to bed. Regarding delirious or sedated patients, behavioral pain scores have been constructed and validated either with intubated patients (Behavioral Pain Scale [BPS]) or non-intubated patients (BPS-NI). On the other hand, pain treatment should be included in a global therapeutic strategy because pain is part of the stress response with hemodynamic, respiratory, neurologic, behavioral, immunitary and homeostatic consequences. A better management of pain in the ICU setting is associated with improved outcomes. The management of pain should be multidisciplinary, global and rationalized included (1) a systematic evaluation of pain by bedside nurses, (2) taking pain into account as a major diagnosis symptom, (3) optimal evaluation of the benefit-risk ratio to use each analgesic, according to each clinical situation, taking into account multiple organ dysfunctions and analgesics' side effects, (4) adaptation of analgesics' regimen to patients needs and systematic research of side effects. In the same way, non pharmacological treatments, such as music therapy for example, could be a relevant alternative to drugs.