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Assessment of Procedural Pain in Patients with COVID-19 in the Intensive Care Unit

Published:March 13, 2022DOI:https://doi.org/10.1016/j.pmn.2022.03.002

      Abstract

      Aim

      The purpose of the study was to assess the level of procedural pain in patients treated in the COVID-19 intensive care unit, in a tertiary university hospital.

      Method

      We performed the procedural pain assessment of COVID-19 patients in this study, and 162 (93.6 %) of 173 hospitalized patients assessed during this period. While pain was assessed before, during, and at the 20th minute after endotracheal aspiration, wound care, and position change, which are procedural patient practices, the pain was assessed before, during, and up to the fourth hour after prone positioning, high-flow oxygen therapy (HFOT), and the non-invasive mechanical ventilation (NIMV) procedure. The Numerical Pain Scale was used for conscious patients in pain assessment, while the Behavioral Pain Scale and the Richmond Agitation-Sedation Scale were used for unconscious patients.

      Results

      Patients who underwent endotracheal aspiration, wound care, and positioning had higher pain levels during procedure than other time points. Patients in the prone position with HFOT and NIMV applied had the highest pain scores at fourth hour after procedure; this increase was statistically significant (p = .000, p < .05).

      Conclusions

      The study found that COVID-19 patients in the ICU had pain due to procedural practices and that the level of pain during the procedures was higher because endotracheal aspiration, wound care, and positioning were all short-term procedures. Moreover, prone positioning was found to be associated with pressure-related tissue damage, and patients' pain levels increased with the increasing duration of HFOT and NIMV procedure.
      Invasive mechanical ventilation is required for coronavirus disease 2019 (COVID-19), which progresses from acute hypoxemic respiratory failure to severe acute respiratory failure in some patients (
      • Kebapçı A.
      Current approaches to treatment and care interventions in intensive care units of COVID-19 patients.
      ,
      • Solverson K.
      • Weatherald J.
      • Parhar K.
      Tolerability and safety of awake prone positioning COVID-19 patients with severe hypoxemic respiratory failure.
      ). According to the World Health Organization (WHO), there are about 20 million active cases worldwide, of which about 80,000 (4%) have been classified as requiring intensive care (

      World Health Organization (WHO). (2020a). Coronavirusdisease (COVID-19) Situation Dashboard, Turkey. Retrieved November, 2020 from https://covid19.who.int/region/euro/country/tr (Accessed 14 August 2021)..

      ).
      In the literature, it was determined that approximately 40%-70% of patients hospitalized in the intensive care unit (ICU) due to COVID-19 had pain complaints (
      • Drożdżal S.
      • Rosik J.
      • Lechowicz K.
      • Machaj F.
      • Szostak B.
      • Majewski P.
      • Rotter I.
      • Kotfis K.
      COVID-19: Pain management in patients with SARS-CoV-2 infection-molecular mechanisms, challenges, and perspectives.
      ;
      • Olsen B.F.
      • Rustøen T.
      • Sandvik L.
      • Miaskowski C.
      • Jacobsen M.
      • Valeberg B.T.
      Development of a pain management algorithm for intensive care units.
      ;
      • Rijkenberg S.
      • Stilma W.
      • Bosman R.J.
      • van der Meer N.J.
      • van der Voort P.
      Pain measurement in mechanically ventilated patients after cardiac surgery: Comparison of the Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT).
      ;

      World Health Organization (WHO). (2020b). Report of the WHO-China Joint Mission on coronavirus disease 2019 (COVID-19). Retrieved November, 2020 from https://reliefweb.int/report/china/report-who-china-joint-mission-coronavirus-disease-2019-covid-19?gclid=Cj0KCQiAkZKNBhDiARIsAPsk0Wh2elrOvjIdnJmfabCoxahtWV3JAue-EzBG0HVUTSmtVyvwI9CcYNYaApqpEALw_wcB. (Accessed 06 July 2021).

      ). Treatment of this disease's primary and immediate symptoms, such as infection, moderate-to-severe dyspnea, and heart failure, may cause the pain to be ignored. COVID-19 patients experience localized (e.g., sore throat, pharyngalgia), remote (e.g., headache), and broad body pain (e.g., body aches, muscle and joint pain). In coronavirus, pain can arise due to the body's autoimmune reaction and interventions related to the disease's diagnosis and treatment (
      • Berger J.R.
      COVID-19 and the nervous system.
      ;
      • Bray K.
      • Winkelman C.
      • Bernhofer E.I.
      • Marek J.F.
      Procedural pain in the adult neurological intensive care unit: A retrospective study examining arterial line insertion.
      ). Diagnostic and therapeutic procedures such as high-flow oxygen therapy (HFOT), non-invasive mechanical ventilation (NIMV), and prone positioning, in addition to COVID-19, can induce pain (
      • Phua J.
      • Weng L.
      • Ling L.
      • Egi M.
      • Lim C.M.
      • Divatia J.V.
      • Shrestha B.R.
      • Arabi Y.M.
      • Ng J.
      • Gomersall C.D.
      • Nishimura M.
      • Koh Y.
      • Du B.
      Asian Critical Care Clinical Trials Group
      Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations.
      ;
      • Wang D.
      • Hu B.
      • Hu C.
      • Zhu F.
      • Liu X.
      • Zhang J.
      • Wang B.
      • Xiang H.
      • Cheng Z.
      • Xiong Y.
      • Zhao Y.
      • Li Y.
      • Wang X.
      • Peng Z.
      Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China.
      ;
      • Weatherald J.
      • Solverson K.
      • Zuege D.J.
      • Loroff N.
      • Fiest K.M.
      • Parhar K.
      Awake prone positioning for COVID-19 hypoxemic respiratory failure: A rapid review.
      ;
      • Yang X.
      • Yu Y.
      • Xu J.
      • Shu H.
      • Xia J.
      • Liu H.
      • Wu Y.
      • Zhang L.
      • Yu Z.
      • Fang M.
      • Yu T.
      • Wang Y.
      • Pan S.
      • Zou X.
      • Yuan S.
      • Shang Y.
      Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study.
      ). Pain should be assessed and managed effectively in hemodynamically unstable critical ICU patients since it negatively affects recovery (
      • Olsen B.F.
      • Rustøen T.
      • Sandvik L.
      • Miaskowski C.
      • Jacobsen M.
      • Valeberg B.T.
      Development of a pain management algorithm for intensive care units.
      ;
      • Rijkenberg S.
      • Stilma W.
      • Bosman R.J.
      • van der Meer N.J.
      • van der Voort P.
      Pain measurement in mechanically ventilated patients after cardiac surgery: Comparison of the Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT).
      ;
      • Drożdżal S.
      • Rosik J.
      • Lechowicz K.
      • Machaj F.
      • Szostak B.
      • Majewski P.
      • Rotter I.
      • Kotfis K.
      COVID-19: Pain management in patients with SARS-CoV-2 infection-molecular mechanisms, challenges, and perspectives.
      ,

      World Health Organization (WHO). (2020b). Report of the WHO-China Joint Mission on coronavirus disease 2019 (COVID-19). Retrieved November, 2020 from https://reliefweb.int/report/china/report-who-china-joint-mission-coronavirus-disease-2019-covid-19?gclid=Cj0KCQiAkZKNBhDiARIsAPsk0Wh2elrOvjIdnJmfabCoxahtWV3JAue-EzBG0HVUTSmtVyvwI9CcYNYaApqpEALw_wcB. (Accessed 06 July 2021).

      ).
      Effective pain management requires objective pain assessment. Thus, valid and reliable scales should be used for objective pain assessment in ICU patients. Because assessing pain in unconscious patients on mechanical ventilators can be difficult, pain should be assessed using behavioral scales, and sedation should be assessed using sedation scales (Richmond Agitation Scale-Sedation Scale [RASS] and Ramsey Sedation Scale [RSS]) (
      • Rahu M.A.
      • Grap M.J.
      • Ferguson P.
      • Joseph P.
      • Sherman S.
      • Elswick Jr, R.K.
      Validity and sensitivity of 6 pain scales in critically ill.
      ;
      • Sılay F.
      • Akyol A.
      The role of nurses in pain control in intensive care units.
      ;
      • Sılay F.
      • Akyol A.
      Turkish adaptation of two measurement tools used in the evaluation of sedation-agitation and pain in intensive care units: A validity and reliability study.
      ). Studies have shown that standardized pain assessment reduces pain levels and analgesic consumption (
      • Erden S.
      • Demir S.G.
      • Kanatlı U.
      • Danacı F.
      • Carboğa B.
      The effect of standard pain assessment on pain and analgesic consumption amount in patients undergoing arthroscopic shoulder surgery.
      ;
      • Erden S.
      • Demir N.
      • Ugras G.A.
      • Arslan U.
      • Arslan S.
      Vital signs: Valid indicators to assess pain in intensive care unit patients? An observational, descriptive study.
      ). Although there are many studies in the literature on procedural pain (
      • Czarnecki M.L.
      • Turner H.N.
      • Collins P.M.
      • Doellman D.
      • Wrona S.
      • Reynolds J.
      Procedural pain management: a position statement with clinical practice recommendations.
      ;
      • Sigakis M.J.
      • Bittner E.A.
      Ten myths and misconceptions regarding pain management in the ICU.
      ), no studies were found with COVID-19 ICU patients. In this context, the purpose of this study was to determine the pain levels of patients treated in the COVID-19 ICU regarding painful procedural practices.

      Methods

      Design and Setting

      This descriptive cross-sectional study was conducted with the participation of patients treated in the COVID-19 ICU of a tertiary university hospital between September 2020 and March 2021. This unit includes nine beds, and around a third of the patients are on a mechanical ventilator. Some procedures (endotracheal aspiration, wound care, position change, prone position, HFOT, NIMV) are used as treatment and care interventions in the clinic, depending on the patient's medical status. Patients with COVID-19 received 4 hours of HFOT and 4 hours of NIMV, in the prone position adjusted to the patient's needs.
      The routine clinical pain management strategy was as-needed analgesia. Nonopioids were given twice daily (BID), and opioids were given in case of severe pain. The analgesic medications were administered by clinical staff based upon the pain levels and not in relationship to procedures.

      Sample

      Patients hospitalized in the COVID-19 ICU of the specified hospital made up the study's population between September 2020 and March 2021. Patients aged ≥18, admitted to the ICU for at least 24 hours, without a history of opioid usage, conscious patients who chose to participate in the study, and unconscious patients with their relatives' permission were all included in the study. During this period, 162 of the 173 patients in the ICU were reached (93.6 %). Eleven patients were excluded from the study because they did not meet the sampling criteria (Fig. 1).

      Data Collection Tools

      The researchers collected data for the study using the “Patient Descriptive Information Form (PDIF)” and the “Pain Assessment Form”, which they created after reviewing the literature (
      • Bayrak-Kahraman B.
      • Özdemir L.
      Evaluation of behavioral and physiological pain indicators of intensive care patients during invasive procedures.
      ;
      • Erden S.
      • Demir N.
      • Ugras G.A.
      • Arslan U.
      • Arslan S.
      Vital signs: Valid indicators to assess pain in intensive care unit patients? An observational, descriptive study.
      ;
      • Sılay F.
      • Akyol A.
      The role of nurses in pain control in intensive care units.
      ;
      • Efe A.K.
      • Çaydam Ö.D.
      Evaluation of pain behaviors due to invasive interventions in patients receiving mechanical ventilation therapy in intensive care unit.
      ).

      Patient Descriptive Information Form (PDIF)

      The PDIF consists of 9 questions with introductory information about the patients enrolled in the study, such as age, gender, Glasgow Coma Score (GCS), day of ICU stay, medical diagnosis, oxygen intake status, mechanical ventilator status, analgesia, and sedation status.

      Pain Assessment Form

      This form includes pain and sedation scores (RASS) over time for endotracheal aspiration, wound care, repositioning (other positions), prone position, HFOT, and painful procedural uses of NIVM. Furthermore, the Numerical Pain Scale (NPS) was used to assess pain in patients who could be contacted, the Behavioral Pain Scale (BPS) was used to assess pain in patients who couldn't be reached, and the RASS was used to assess sedation and agitation in all patients.

      Numerical Pain Scale (NPS)

      In this scale, 0 indicates no pain, and 10 means unbearable pain. It is commonly used to assess pain in conscious patients.

      Behavioral Pain Scale (BPS)

      • Aïssaoui Y.
      • Zeggwagh A.A.
      • Zekraoui A.
      • Abidi K.
      • Abouqal R.
      Validation of a behavioral pain scale in critically ill, sedated, and mechanically ventilated patients.
      developed this scale used to assess pain in ICU patients who are unconscious. There are three items (facial expression, upper extremities, and ventilator compliance) and four variables in this scale, with behavioral responses to pain included in each item. The lowest score on the scale is 3, and the highest score is 12. An increase in score means an increase in pain.

      Richmond Agitation Sedation Scale (RASS)

      • Sessler C.N.
      • Gosnell M.S.
      • Grap M.J.
      • Brophy G.M.
      • O'Neal P.V.
      • Keane K.A.
      • Tesoro E.P.
      • Elswick R.K.
      The Richmond Agitation-Sedation Scale: Validity and reliability in adult intensive care unit patients.
      developed this scale to assess patients' sedation and agitation levels with severe disease, particularly those on mechanical ventilation. Scores on the RASS vary from +4 to -5. Positive RASS scores represent agitated patients; negative RASS scores represent sedated or comatose patients.

      Implementation of the Study

      While pain assessment was performed up to the 20th minute before, during, and after endotracheal aspiration, wound care, and position change, which are procedural patient practices, pain assessment was performed up to the fourth hour before, during, and after prone positioning, HFOT, and NIMV procedures. The patients did not receive any pain relief measures during the procedure.

      Ethical Aspect of Research

      Because the study was done in a university hospital, written permission was received from the university's Faculty of Medicine Non-Interventional Clinical Research Ethics Committee (No: 21/Date:04.09.2020) and the hospital's chief physician (No: 21827/Date:11.09.2020). Moreover, written informed consent was obtained from conscious patients and relatives of unconscious patients in accordance with the Declaration of Helsinki, along with an informed consent form for each patient.

      Statistical Analysis

      SPSS (IBM, IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. [Released 2016]) was used to analyze the obtained data. The descriptive data from COVID-19 patients were analyzed using frequencies and percentages. As descriptive data, the mean, standard deviation, minimum, and maximum values were given. In addition, in repeated measurements for pain assesment done at different time intervals in patients, the analysis of variance (F) test was used, and Fisher's least significant difference test (LSD) test, one of the post-hoc tests, was used to determine from which times the statistically significant statistics came. For all tests, p < .05 was considered significant.

      Results

      Descriptive Characteristics of the Patients

      The mean age of patients included in the study was 63.92 ± 8.97 (45-88) years. The mean day of ICU stay was 3.48 ± 1.14 (2-6) days. Also, 53.7% of the patients were men, 57.4% had acute respiratory distress syndrome (ARDS), 61.7% had GCS 14-15, and 36.4% were treated with a combination of HFOT and NIMV oxygen therapy. Additionally, 88.9% of patients were treated with analgesics, and 55.5% of analgesics used in these patients were non-opioids (Table 1).
      Table 1Descriptive Characteristics of the Patients (N = 162)
      Descriptive CharacteristicsMean ± SDMin-Max
      Age (year)63.92 ±8.9745-88
      ICU admission (day)3.48 ± 1.142-6
      N=162% (100)
      GenderMan8753,7
      Women7546,3
      DiagnosisARDS9357,4
      COVID pneumonia6238,3
      ARDS+LungCa74,3
      Glasgow Coma Score (GCS)14-15 oriented10061,7
      8-13 confused106,2
      8< stupor-coma5232,1
      Received oxygen therapyHFOT+ NIMV5936,4
      Invasive MV5232,1
      HFOT3421,0
      NIMV1710,5
      Analgesic administrationYes14488,9
      No1811,1
      Type of analgesiaOpioid6444,5
      Nonopioid8055,5
      Administering sedationYes
      fentanyl + midazolam; remifentanil. Mean ± SD = Mean Standard deviation; ICU = intensive care unit; ARDS = acute respiratory distress syndrome; LungCa = lung cancer; HFOT = high flow oxygen therapy; MV = mechanical ventilation; NIMV = non-invasive mechanical ventilation,;
      6238,3
      No10061,7
      a fentanyl + midazolam; remifentanil.Mean ± SD = Mean Standard deviation; ICU = intensive care unit; ARDS = acute respiratory distress syndrome; LungCa = lung cancer; HFOT = high flow oxygen therapy; MV = mechanical ventilation; NIMV = non-invasive mechanical ventilation,;

      Introduction of Procedural Practices

      Five hundred fifty (550) procedures were performed on COVID-19 ICU patients during the study. Of these, 162 were position changes other than prone, 144 were prone, 93 were HFOT, 76 were NIMV practice, 52 were endotracheal aspiration, and 23 were wound care procedures. Among these procedures, a change of position was performed in 110 of the conscious patients, of whom 100 were in the prone position, 93 in HFOT, and 76 in NIMV. Repositioning was performed in 52 unconscious patients, prone positioning in 44, endotracheal aspiration in 52, and wound care in 23.

      Pain Levels

      Table 2 displays the patients' pain levels concerning procedural practices and times. There was a significant difference in all procedural pain levels (p < .05). It was found that mean pain scores (T2) were higher during endotracheal aspiration, wound care, and position change than at other times (T1 and T3) and that there was a significant relationship with pain during the procedure (p < .05). Furthermore, when compared with other times, the mean pain scores of all patients in the prone position showed a significant increase at T5 (p < .05). HFOT and NIMV were found to increase pain scores in both T2 and T5, and these increases were significant (p = .000).
      Table 2Pain Levels of the Patients by Procedural Practices and Times
      Procedural practicesTimes
      T1: pre-procedure; T2 = sequence of procedures; T3 = 20 min after the procedure; T4 = 2 hours after the procedure; T5 = 4 hours after the procedure.
      Mean ± SD
      T1T2T3T4T5F/P
      Endotracheal aspiration (N = 52)Conscious (n = 0)

      Unconscious (n=52)
      3.00±0.00T23.29±0.45T13.15±0.60--6.97

      .002
      p < .01. HFOT = high flow oxygen therapy; NIMV = non-invasive mechanical ventilation; N = number of patients; Mean ± SD = mean standard deviation; F = analysis of variance in repeated measures; T1, T2, T3, T4, T5 = groups with significant difference with LSD tests.
      Wound care (N = 23)Conscious (n = 0)

      Unconscious (n = 23)
      3.26±0.86T23.38±0.89T13.30±087--

      3.94

      .048
      p < .05.
      Position change (N = 162)Conscious (n = 110)0.26±0.55

      T2,T3
      1.74±0.97

      T1,T3
      0.92±1.30

      T1,T2
      --102.89

      .000
      p < .01. HFOT = high flow oxygen therapy; NIMV = non-invasive mechanical ventilation; N = number of patients; Mean ± SD = mean standard deviation; F = analysis of variance in repeated measures; T1, T2, T3, T4, T5 = groups with significant difference with LSD tests.
      Unconscious (n = 52)3.00±0.00

      T2,T3
      3.37± 0.68

      T1,T3
      3.12±0.32 T1,T2--10.86

      .001
      p < .01. HFOT = high flow oxygen therapy; NIMV = non-invasive mechanical ventilation; N = number of patients; Mean ± SD = mean standard deviation; F = analysis of variance in repeated measures; T1, T2, T3, T4, T5 = groups with significant difference with LSD tests.
      Prone position (N = 144)Conscious (n = 100)0.00±0.00

      T2,T3,T4,T5
      0.75±1.26

      T1,T4,T5
      0.79±1.28

      T1, T4,T5
      1.61±1.62

      T1,T2,T3,T5
      2.75±1.21

      T1,T2,T3,T4
      173.91

      .000
      p < .01. HFOT = high flow oxygen therapy; NIMV = non-invasive mechanical ventilation; N = number of patients; Mean ± SD = mean standard deviation; F = analysis of variance in repeated measures; T1, T2, T3, T4, T5 = groups with significant difference with LSD tests.
      Unconscious (n = 44)3.00±0.00

      T2,T3,T4,T5
      3.05±0.21

      T1,T4,T5
      3.00±0.00

      T1, T4,T5
      3.25±0.71

      T1,T2,T3,T5
      3.27± 0.58

      T1,T2,T3,T4
      6.42

      .008
      p < .01. HFOT = high flow oxygen therapy; NIMV = non-invasive mechanical ventilation; N = number of patients; Mean ± SD = mean standard deviation; F = analysis of variance in repeated measures; T1, T2, T3, T4, T5 = groups with significant difference with LSD tests.
      HFOT (N = 105)Conscious (n = 105)

      Unconscious (n = 0)
      0.02±0.19

      T2,T3,T4,T5
      0.65±1.09 T1,T4,T50.05±0.27

      T1, T4,T5
      1.25±1.32 T1,T2,T3,T52.62±1.16 T1,T2,T3,T4164.732

      .000
      p < .01. HFOT = high flow oxygen therapy; NIMV = non-invasive mechanical ventilation; N = number of patients; Mean ± SD = mean standard deviation; F = analysis of variance in repeated measures; T1, T2, T3, T4, T5 = groups with significant difference with LSD tests.
      NIMV (N = 80)Conscious (n = 80)

      Unconscious (n = 0)
      0.05±0.27

      T2,T3,T4,T5
      1.18±1.79 T1,T4,T51.25±1.83 T1, T4,T52.56±1.22 T1,T2,T3,T53.41 ±1.27 T1,T2,T3,T4142.65

      .000
      p < .01. HFOT = high flow oxygen therapy; NIMV = non-invasive mechanical ventilation; N = number of patients; Mean ± SD = mean standard deviation; F = analysis of variance in repeated measures; T1, T2, T3, T4, T5 = groups with significant difference with LSD tests.
      a T1: pre-procedure; T2 = sequence of procedures; T3 = 20 min after the procedure; T4 = 2 hours after the procedure; T5 = 4 hours after the procedure.
      b p < .05.
      c p < .01.HFOT = high flow oxygen therapy; NIMV = non-invasive mechanical ventilation; N = number of patients; Mean ± SD = mean standard deviation; F = analysis of variance in repeated measures; T1, T2, T3, T4, T5 = groups with significant difference with LSD tests.
      The LSD test, one of the post-hoc tests, was performed to determine the times of significance, according to the data in the Table 2. T1 and T2 in endotracheal aspiration and wound care and T1, T2, and T3 in position change were found to be the causes of the differences. These differences were found to be caused by T1-T4-T5 times in the prone position, HFOT, and NIMV procedures.

      Discussion

      In ICU patients with COVID-19, both the disease itself and the procedural diagnostic and treatment interventions cause pain. In this particular patient group, treatment of the illness precedes pain treatment (
      • Drożdżal S.
      • Rosik J.
      • Lechowicz K.
      • Machaj F.
      • Szostak B.
      • Majewski P.
      • Rotter I.
      • Kotfis K.
      COVID-19: Pain management in patients with SARS-CoV-2 infection-molecular mechanisms, challenges, and perspectives.
      ;
      • Meyer-Frießem C.H.
      • Gierthmühlen J.
      • Baron R.
      • Sommer C.
      • Üçeyler N.
      • Enax-Krumova E.K.
      Pain during and after COVID-19 in Germany and worldwide: A narrative review of current knowledge.
      ). Diagnosis of pain is critical to pain control. The pain levels caused by procedural practices specific to COVID-19 patients were examined in this study.
      Endotracheal aspiration is one of the most painful procedures in intensive care. According to our findings, patients with COVID-19 who underwent endotracheal aspiration had a higher (T2) pain level (3.29±0.45) during the procedure than at other times. Other studies conducted in the intensive care unit found that the level of pain in patients increased during endotracheal aspiration, similar to our findings (
      • Aïssaoui Y.
      • Zeggwagh A.A.
      • Zekraoui A.
      • Abidi K.
      • Abouqal R.
      Validation of a behavioral pain scale in critically ill, sedated, and mechanically ventilated patients.
      ;
      • Arroyo-Novoa C.M.
      • Figueroa-Ramos M.I.
      • Puntillo K.A.
      • Stanik-Hutt J.
      • Thompson C.L.
      • White C.
      • Wild L.R.
      Pain related to tracheal suctioning in awake acutely and critically ill adults: a descriptive study.
      ,
      • Yaman Aktaş Y.
      • Karabulut N
      The effects of music therapy in endotracheal suctioning of mechanically ventilated patients.
      ;
      • Czarnecki M.L.
      • Turner H.N.
      • Collins P.M.
      • Doellman D.
      • Wrona S.
      • Reynolds J.
      Procedural pain management: a position statement with clinical practice recommendations.
      ;
      • Erden S.
      • Demir N.
      • Ugras G.A.
      • Arslan U.
      • Arslan S.
      Vital signs: Valid indicators to assess pain in intensive care unit patients? An observational, descriptive study.
      ;
      • Esen H.
      • Öntürk Z.K.
      • Badır A.
      • Aslan F.E.
      Pain behaviours of intubated and sedated intensive care patients during positioning and aspiration.
      ;
      • Lee K.
      • Oh H.
      • Suh Y.
      • Seo W.
      Patterns and clinical correlates of pain among brain injury patients in critical care assessed with the critical care pain observation tool.
      ;
      • Puntillo K.A.
      • Max A.
      • Timsit J.F.
      • Vignoud L.
      • Chanques G.
      • Robleda G.
      • Roche-Campo F.
      • Mancebo J.
      • Divatia J.V.
      • Soares M.
      • Ionescu D.C.
      • Grintescu I.M.
      • Vasiliu I.L.
      • Maggiore S.M.
      • Rusinova K.
      • Owczuk R.
      • Egerod I.
      • Papathanassoglou E.D.
      • Kyranou M.
      • Joynt G.M.
      • Azoulay E.
      Determinants of procedural pain intensity in the intensive care unit. The Europain® study.
      ). In this context, it may be recommended not to routinely perform endotracheal aspiration in patients with COVID-19 unless there is an indication for it and to use analgesics before the procedure if it is to be performed after all.
      Our study found that the pain level during procedure (T2) was higher in patients undergoing wound care than at other times. Studies conducted with intensive care patients have found that patient pain levels increase during wound care (
      • Erden S.
      • Demir N.
      • Ugras G.A.
      • Arslan U.
      • Arslan S.
      Vital signs: Valid indicators to assess pain in intensive care unit patients? An observational, descriptive study.
      ;
      • Puntillo K.A.
      • Max A.
      • Timsit J.F.
      • Vignoud L.
      • Chanques G.
      • Robleda G.
      • Roche-Campo F.
      • Mancebo J.
      • Divatia J.V.
      • Soares M.
      • Ionescu D.C.
      • Grintescu I.M.
      • Vasiliu I.L.
      • Maggiore S.M.
      • Rusinova K.
      • Owczuk R.
      • Egerod I.
      • Papathanassoglou E.D.
      • Kyranou M.
      • Joynt G.M.
      • Azoulay E.
      Determinants of procedural pain intensity in the intensive care unit. The Europain® study.
      ). Although tissue perfusion and care of a damaged wound may cause pain due to nerve damage, widespread muscle pain, especially in COVID-19 patients, may increase tissue tenderness. The study found that the patients' pain level significantly increased during the change of position (T2) and decreased at the 20th minute (T3) after positioning. Examining the literature, we find that patients' pain levels are higher during position change (
      • Erden S.
      • Demir N.
      • Ugras G.A.
      • Arslan U.
      • Arslan S.
      Vital signs: Valid indicators to assess pain in intensive care unit patients? An observational, descriptive study.
      ,
      • Olsen B.F.
      • Valeberg B.T.
      • Jacobsen M.
      • Småstuen M.C.
      • Puntillo K.
      • Rustøen T.
      Pain in intensive care unit patients-A longitudinal study.
      ;
      • Robleda G.
      • Roche-Campo F.
      • Sendra M.À.
      • Navarro M.
      • Castillo A.
      • Rodríguez-Arias A.
      • Juanes-Borrego E.
      • Gich I.
      • Urrutia G.
      • Nicolás-Arfelis J.M.
      • Puntillo K.
      • Mancebo J.
      • Baños J.E.
      Fentanyl as pre-emptive treatment of pain associated with turning mechanically ventilated patients: A randomized controlled feasibility study.
      ), parallel to our study, and patients' pain decreases significantly in the hours after position change (
      • Ibdah R.K.
      • Ta'an W.F.
      • Shatnawi R.M.
      • Suliman M.M.
      • Rababah J.A.
      • Rawashdeh S.I.
      The effectiveness of early position change postcardiac catheterization on patient's outcomes: A randomized controlled trial.
      ). Pharmacologic/non-pharmacologic analgesia should be administered before treatment and care procedures such as wound care and change of position.
      Prone positioning is widely used in COVID-19 patients with moderate to severe ARDS because it improves oxygenation and minimizes the need for mechanical ventilators (
      • Navas-Blanco J.R.
      • Dudaryk R.
      Management of respiratory distress syndrome due to COVID-19 infection.
      ,
      • Solverson K.
      • Weatherald J.
      • Parhar K.
      Tolerability and safety of awake prone positioning COVID-19 patients with severe hypoxemic respiratory failure.
      ). Peripheral nerve damage and musculoskeletal (back and shoulder) pain result from prolonged prone positions (
      • Ghelichkhani P.
      • Esmaeili M.
      Prone position in management of COVID-19 patients; a Commentary.
      ;
      • Meyer-Frießem C.H.
      • Gierthmühlen J.
      • Baron R.
      • Sommer C.
      • Üçeyler N.
      • Enax-Krumova E.K.
      Pain during and after COVID-19 in Germany and worldwide: A narrative review of current knowledge.
      ;
      • Ogawa K.
      • Asano K.
      • Ikeda J.
      • Fujii T.
      Non-invasive oxygenation strategies for respiratory failure with COVID-19: A concise narrative review of literature in pre and mid-COVID-19 era.
      ;
      • Tavernier E.
      • McNicholas B.
      • Pavlov I.
      • Roca O.
      • Perez Y.
      • Laffey J.
      • Mirza S.
      • Cosgrave D.
      • Vines D.
      • Frat J.P.
      • Ehrmann S.
      • Li J.
      Awake prone positioning of hypoxaemic patients with COVID-19: protocol for a randomised controlled open-label superiority meta-trial.
      ). This study found that pain levels increased over time in patients in the prone position, reaching the highest pain level in the fourth hour (T5) after positioning. The literature also indicates that the duration of remaining in the prone position and the level of pain in patients with severe acute respiratory failure increase in direct proportion with COVID-19 (
      • Bamford P.
      • Bentley A.
      • Dean J.
      • Whitmore D.
      • Wilson-Baid N
      ICS guidance for prone positioning of theconscious COVID patient 2020.
      ;
      • Elharrar X.
      • Trigui Y.
      • Dols A.M.
      • Touchon F.
      • Martinez S.
      • Prud’homme E.
      • Papazian L.
      Use of Prone Positioning in Nonintubated Patients With COVID-19 and Hypoxemic Acute Respiratory Failure.
      ,
      • Slessarev M.
      • Cheng J.
      • Ondrejicka M.
      • Arntfield R.
      • Critical Care Western Research Group
      Patient self-proning with high-flow nasal cannula improves oxygenation in COVID-19 pneumonia.
      ,
      • Solverson K.
      • Weatherald J.
      • Parhar K.
      Tolerability and safety of awake prone positioning COVID-19 patients with severe hypoxemic respiratory failure.
      ,
      • Telias I.
      • Katira B.H.
      • Brochard L.
      Is the prone position helpful during spontaneous breathing in patients with COVID-19?.
      ;
      • Weatherald J.
      • Solverson K.
      • Zuege D.J.
      • Loroff N.
      • Fiest K.M.
      • Parhar K.
      Awake prone positioning for COVID-19 hypoxemic respiratory failure: A rapid review.
      ). This finding may be related to patients with COVID-19 who remain in the prone position for long periods for oxygen therapy and experience back and shoulder pain due to pressure-induced tissue damage in the skin and subcutaneous tissues.
      In COVID-19 patients, HFOT and NIMV are combined for various reasons, including the treatment of acute respiratory failure, acute pulmonary edema, and the maintenance of oxygenation (
      • Agarwal A.
      • Basmaji J.
      • Muttalib F.
      • Granton D.
      • Chaudhuri D.
      • Chetan D.
      • Hu M.
      • Fernando S.M.
      • Honarmand K.
      • Bakaa L.
      • Brar S.
      • Rochwerg B.
      • Adhikari N.K.
      • Lamontagne F.
      • Murthy S.
      • Hui D.
      • Gomersall C.
      • Mubareka S.
      • Diaz J.V.
      • Burns K.
      • Vandvik P.O.
      High-flow nasal cannula for acute hypoxemic respiratory failure in patients with COVID-19: systematic reviews of effectiveness and its risks of aerosolization, dispersion, and infection transmission.
      ;
      • Ogawa K.
      • Asano K.
      • Ikeda J.
      • Fujii T.
      Non-invasive oxygenation strategies for respiratory failure with COVID-19: A concise narrative review of literature in pre and mid-COVID-19 era.
      ). Although the location of the pain was not specified in the tables, conscious patients were asked about the location of the pain in addition to the level of the pain. Patients reported the location of the pain as the face and nose for HFOT and NIMV procedures and the shoulder and back for the prone position. The patients' shoulder and back pain was found to be highest at the fourth hour (T5) of the prone position in our study (p = .000). While no study in the literature has examined nasal and facial pain in patients with COVID-19 who have undergone HFOT, some studies indicate that pain was more severe during the procedure in patients who underwent NIMV (
      • Aïssaoui Y.
      • Zeggwagh A.A.
      • Zekraoui A.
      • Abidi K.
      • Abouqal R.
      Validation of a behavioral pain scale in critically ill, sedated, and mechanically ventilated patients.
      ;
      • Olsen B.F.
      • Rustøen T.
      • Sandvik L.
      • Miaskowski C.
      • Jacobsen M.
      • Valeberg B.T.
      Development of a pain management algorithm for intensive care units.
      • Robleda G.
      • Roche-Campo F.
      • Sendra M.À.
      • Navarro M.
      • Castillo A.
      • Rodríguez-Arias A.
      • Juanes-Borrego E.
      • Gich I.
      • Urrutia G.
      • Nicolás-Arfelis J.M.
      • Puntillo K.
      • Mancebo J.
      • Baños J.E.
      Fentanyl as pre-emptive treatment of pain associated with turning mechanically ventilated patients: A randomized controlled feasibility study.
      ). Because the change of position, endotracheal aspiration, and wound care are short-term procedural practices, patients experience more pain during the procedure, whereas other procedural practices (Prone position, HFOT, and NIMV) increase pain levels with increasing duration due to the pressure associated with the medical device.

      Limitations of the Study

      This study is single-center and is limited to COVID- 19 patients treated only in the intensive care unit.

      Conclusions

      In conclusion, it was found that procedural practices performed on conscious and unconscious patients with COVID-19 in the ICU caused pain, and because endotracheal aspiration, wound care, and position change were short-term procedures, patients had more severe pain during those procedures. Moreover, patients' pain levels were found to increase with increasing duration of prone positioning, HFOT, and NIMV procedures related to pressure-induced tissue damage. In light of this, it is recommended that no painful procedural practices be performed unless: (1) pharmacologic or non-pharmacologic analgesia methods are used before the procedures; (2) supportive surface procedures are used; (3) pain assessment and management in COVID-19 be done effectively.

      Implications for Nursing

      Symptom management to prevent the severity of the disease in patients with COVID 19 causes pain to be ignored. Pain should be controlled in order to reduce the complications related to pain in patients with COVID 19 who have hemodynamic instability. Therefore, pharmacologic and non-pharmacologic analgesic methods should be used before procedural procedures.

      Declaration of Competing Interest

      The authors declare that they have no conflict of interest.

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