Managing pain in critically ill

obese
Downloaded from https://journals.lww.com/nursingcriticalcare by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3FJPxKcC74DFhiL3anhtKW9GSA59vtGQJT7YUigwfCaU= on 04/21/2020

patients
By Yvonne D’Arcy, MS, CRNP, CNS

Abstract: Most critical care patients have pain. Significant issues

surround pain management when the patient is obese. Obstacles
include the patient’s physiology, changes in medication utilization,
and the presence of painful comorbidities. This article provides infor-
mation on treating obese patients for pain using practice guidelines.
Keywords: critically ill patients, obesity, pain management, practice
guidelines

Critical care patients arrive at a hospital or trauma center from

a variety of different settings: motor vehicle accidents, homeless
shelters, long-term-care facilities, or postoperative units. They
may or may not be able to provide an accurate health history.
When the patient is obese, treatment options can be limited if
the patient is experiencing significant pain.
This article explores the issue of dealing with obese patients
in a critical care setting when they are in pain. These patients
experience pain differently than nonobese patients, and choos-
ing pain medication can be a difficult process based on the
way obese patients metabolize medications and the high risk
of oversedation. Clinical practice guideline recommenda-
ID-WORK / iSTOCK

tions include interventions for treating pain in obese patients.

Unfortunately, the literature on obese patients in critical care
settings remains underdeveloped with little replication and
focuses on specific patient population, for example, blunt force
trauma patients.

38 l Nursing2016Critical Care l Volume 11, Number 3 www.nursingcriticalcare.com

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

www.nursingcriticalcare.com May l Nursing2016Critical Care l 39

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Managing pain in critically ill obese patients
The obese patient
The obese patient can be found in almost any
area of critical care from pediatric ICUs to medi-
cal ICUs. Issues of concern when caring for obese
patients who are critically ill involve not only the
obvious body habitus, concerns for safe transfers,
and skin integrity, but also the changed physiology
of an obese patient, higher pain levels, and altered
responses to the usual opioid pain medications.
The World Health Organization (WHO) reports
that over 1.4 billion adults worldwide meet the cri-
teria to be classed as overweight, with 500 million
meeting the criteria for obesity.1 Further estimates
indicate that if the current trend continues by 2030,
58% of the world’s population is expected to be
overweight or obese.2 The two major contributing
factors for obesity identified by WHO are diet and
lack of exercise. No concrete data are available
on prevalence for the critically ill patient popula-
tion, but estimates indicate it may reach as high as
one in four patients.3 In a study of blunt trauma
patients, Neville and colleagues found that 26% of
242 patients in the study were classified as obese.4
The classification system for obesity is based on the
patients’ body mass index (BMI; see BMI classifica-
tion in adults).
Along with increased weight, obese patients
tend to have multiple comorbidities that can
make treating their pain more difficult and limit
treatment choices such as opioids or nonsteroi-
dal anti-inflammatory drugs (NSAIDs). Common
comorbidities for obese patients include diabetes
mellitus, hypertension, and dyslipidemia. These
conditions may not only limit treatment options
but also create additional underlying pain issues
BMI classification in adults
Classification BMI
Underweight Less than 18.5
Normal weight 18.5–24.9
Overweight 25.0–29.9
Obese Class I 30.0–34.9
Obese Class II 35.0–39.9
Obese Class III (morbid obesity) 40.00 or greater
Source: World Health Organization. BMI classification. 2016.
http://apps.who.int/bmi/index.jsp?introPage=intro_3.html.
40 l Nursing2016Critical Care l Volume 11, Number 3
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
such as neuropathic pain from diabetic neuropa-
thy or low back pain from weight burden on the
spinal structures. In many cases the pain will be
a mixed presentation, such as neuropathic pain
with nociceptive pain from trauma or spinal nerve
compression.
Pain in general is a physiologic response to injury
or tissue damage. Nociceptive pain has a source
in the viscera, muscles, or skin. This type of pain
can be postoperative or due to trauma or injury.
Neuropathic pain, on the other hand, is a result
of damage to nerves, either in the peripheral or
central nervous system. Many obese patients are
diabetic and may have underlying neuropathic pain
conditions such as painful diabetic neuropathy in
their hands or feet.
How these patients gain and retain excess weight
is a “who came first, the chicken or the egg?” sce-
nario. Does the sedentary lifestyle that many obese
patients adopt cause the weight gain, or does the
chronic pain they feel limit their ability to move?
In reality, the excess weight is probably a result of
both causes. Sedentary lifestyle and pain both limit
a patient’s ability to be physically active. McVinnie
reports that pleasure eating is in some way linked to
the sense of pain relief, adding to a patient’s weight.5
Differences in pain for obese patients
The obese patient has a different physiology that
may increase the effect of a painful stimulus.
Obesity seems to increase pain intensities, with the
heaviest patients having the highest levels of pain.2
In a Gallup survey taken from 2008 to 2010 with
one million individuals in the United States, only
19.2% could be classified as having a low, normal
BMI.6 When the respondents were questioned
about pain, the overweight group reported 20%
more pain than the normal-weight respondents.
However, in the highest weight group, the obese
respondents reported daily pain at 254% higher
rates than the normal-weight group.6 The findings
were similar for both genders, and the correlation
between weight and pain increased with age.
What makes heavier patients experience more
pain? It can partially be explained by the high pro-
portion of comorbidities associated with pain condi-
tions, such as diabetes mellitus with painful diabetic
neuropathies. The increased pain can also be associ-
ated with metabolic changes that increase the levels
www.nursingcriticalcare.com
of inflammation in obese individuals, which subse-
quently increase pain levels. The increased level of
inflammation is due to higher fat stores that induce
the body to produce pain-producing cytokines.5,7
The higher the patient weight and the longer the
patient has been obese directly correlates with high-
er amounts of body fat, causing increased insulin
resistance, leading to the development of metabolic
syndrome (MetS). This syndrome includes the syn-
dromes of hypertension, central adiposity, elevated
fasting blood glucose, and dyslipidemia with high
triglycerides and low high-density lipoprotein cho-
lesterol.5 MetS increases the risk of cardiovascular
disease and diabetes.
Additionally, MetS and increased systemic
inflammation have a positive correlation, creating
higher rates of inflammation that is fed by adipose
tissue.5,7 Unfortunately, adipose tissue is consid-
ered a major source of cytokine production, par-
ticularly those cytokines that have a proinflamma-
tory function.8 Other pain-producing factors asso-
ciated with adipose tissue include tumor necrosis
factor, interleukin-6, and C-reactive protein, which
are associated with insulin resistance leading to
higher rates of joint inflammation and the devel-
opment of osteoarthritis (OA). The more obese a
patient is, the higher the levels of pain-producing
substances.
In a study of obese patients undergoing lap
banding for weight reduction, the subsequent
postoperative weight loss decreased the levels of
proinflammatory cytokines while increasing the
production of anti-inflammatory cytokines such as
adiponectin.8 Women who are diagnosed with OA,
a condition with high inflammation, have on aver-
age a BMI that is 24% higher than women with an
average BMI.9 In a study of 677 patients with total
knee replacements and 547 patients with total hip
replacements and one MetS factor, the findings
demonstrated that surgical outcomes were nega-
tively affected by metabolic abnormalities.9
Although the research is incomplete, a growing
body of evidence shows that MetS can increase the
production of pain-producing cytokines, and high
levels of adipose tissue produce larger amounts
of pain-producing cytokines. These findings tend
to correlate with the Gallup findings that heavier
patients had higher levels of pain than their normal-
weight counterparts.
www.nursingcriticalcare.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Assessing pain in critical care
Assessing pain in critical care patients can be dif-
ficult because many are so ill that carrying out an
assessment may result in an inconsistent result.
Most patients who are ill enough to be in critical
care are taking numerous medications, can have
delirium or agitation, or need intubation. Asking
family members or caregivers who are familiar with
the patient to help identify pain behaviors can be
helpful when the patient is unable to communicate.
For critical care patients who can provide a self-
report of pain, the numeric intensity pain scale, the
0-to-10 pain intensity rating scale can be used. This
applies to all adult patients and those in pediatric
ICUs who are old enough to understand the use of
numbers for a pain rating.
For patients who have dementia or are nonver-
bal, intubated, or too young to use numbers, behav-
ioral pain scales are appropriate. For children, the
Wong-Baker FACES scale can provide an indica-
tion of how the pain is affecting the patient. The
scale uses a set of six faces that range from happy
and smiling to sad and crying. The patient is asked
to pick the example that best represents how the
pain makes them feel. For patients unable to use a
simple picture or who are too young (usually ages
2 months to 7 years), the Face, Legs, Activity, Cry,
Consolability (FLACC) scales can give an idea of the
patient’s pain using facial expressions, leg move-
ment, and crying indicators.
For nonverbal adults, intubated patients, or
patients with dementia, critical care guidelines
recommend the use of the Behavioral Pain Scale
(BPS) or the Critical Care Pain Observation Tool
(CPOT).10,11
Behavioral tools rely on observation of the
patients when they are experiencing pain. The tools
are not as refined or complete as other more formal
tools, but they can provide the nurse with some
indication that pain is present. Some tools with
numeric conversions can be converted to electronic
medical records, making documentation easier.
The BPS is used for patients who have dementia,
are nonverbal, or have aphasia from a stroke. It is
comprised of a set of five indicators: face, vocaliza-
tions, restlessness, muscle tone, and consolability.10
The nurse observes the patient and uses a 0,1,2
rating to document the severity of the symptoms.
These numbers are added together to get a rating
May l Nursing2016Critical Care l 41
Managing pain in critically ill obese patients

from 0 to 10. Although the tool Recommended

relies on observation, it provides treatment options
an indication of how severe the The critical care practice guide-
pain may be. One advantage of lines remind practitioners that
this tool is the ability to convert the vast majority of patients in
the tool into an electronic medi- critical care have pain. Routine
cal record and allow for consis- ICU care can cause pain, and the
tent pain documentation.12 procedures that are performed,
The Payen BPS is designed to such as placing chest tubes or
be used for ventilated and intu- central lines, produce pain as
bated patients. It is based on the well. When the critical care
sum score of three indicators: patient is obese, it is reasonable
facial expression, movement of to expect high levels of pain
the upper limbs, and adherence based on the body’s lipid con-
with mechanical ventilation. Obese patients tent; managing that pain will be
Each indicator is scored from 1 tend to have multiple difficult based on the presence
(no response) to 4 (full response). comorbidities that can of comorbidities and increased
The tool has established reliabil- make treating their risk for respiratory compromise.
ity and validity and has been rep- The critical care guidelines for
pain more difficult and
licated. It has excellent interrater pain and agitation have some
reliability and provides a score limit treatment choices. basic recommendations for adult
that can be ascertained even with patients who are critically ill:
heavy sedation levels.12 • Do not use routine vital signs to
The CPOT is designed to be used for both intu- diagnose pain. Variations in vital signs may be caused
bated and nonverbal nonintubated patients in criti- by something other than pain, such as anxiety.
cal care. It is based on four behavioral dimensions: • When removing a chest tube, use preemp-
facial expression, body movements, muscle tension, tive analgesia, premedicate, and help the patient
and ventilator adherence for ventilated patients or use relaxation techniques prior to removal.
vocalization for nonintubated patients.13 The tool Premedication prior to procedures is a good idea for
is reliable and valid, and the original study used a all patients.
turn-in bed (where the patient is turned in bed from • Use I.V. opioids as a first-line drug class for non-
one side to the other) as a pain stimulus, which in neuropathic pain.
past research has been found to be rated by patients • Add in nonopioids when possible.
at a 5 on the 0-to-10 pain intensity scale.11 • Consider gabapentin or carbamazepine for neu-
Using specialized tools for critical care can help pro- ropathic pain (drugs used FDA-off label for neuro-
vide a method of assessing pain in patients who are pathic pain).
not able to self-report their pain. An advantage of the • Consider thoracic epidural catheters for aortic
CPOT is that it instructs nurses to provide pain inter- aneurysm repair and rib fractures.
ventions for patients who score above 2 overall. • Regional analgesia is not recommended over sys-
As always, the patient type, source of pain, and temic analgesics in medical ICU patients.10
underlying comorbidities need to be considered Although these are general recommendations
when converting a pain scale rating to a treatment not specific to obese patients, most can apply to all
option. Respiratory and cardiovascular diseases are patients who are critically ill. There are some spe-
common in obese patients, and choosing the correct cific considerations for pain management when the
medication and dose is critical. A 7/10 pain rating (on patient is obese.
a scale of 0 to 10, with zero indicating no pain and The metabolism of medication can be affected
10 indicating the worst pain) in an obese patient may by the ratio of adipose tissue to lean body tissue.
require lower doses with more frequent administra- In the obese patient, a disproportion in the ratio
tion added to careful monitoring of medication effect. of lean to adipose tissue exists, with higher levels

42 l Nursing2016Critical Care l Volume 11, Number 3 www.nursingcriticalcare.com

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

of adipose tissue that interfere with the protein
binding of drugs. This allows for an increased
concentration of drug in the free plasma con-
centration. A greater negative effect is seen in
the patient as obesity increases, creating a larger
disparity between lean and adipose tissues. When
this effect is studied in both obese and nonobese
patients of the same age, height, and gender,
a greater negative effect with a higher risk for
adverse reactions due to plasma drug concentra-
tions is seen in obese patients.14 As a result of
this physiologic difference, medication needs to
be dosed appropriately and individually for obese
patients.
Additional factors that influence medication utili-
zation, efficacy, and safety include:
• A high prevalence of sleep apnea in obese patients
can preclude combining medications, especially
those with sedative effects; this means closer
monitoring for sedation and respiratory changes is
needed if opioids are used.
• Changes in hepatic and renal function can be
affected by the fatty degeneration of the liver, while
renal clearance may be increased.
• For obese patients with kidney dysfunction, the
usual creatinine clearance calculations will be inac-
curate, requiring an alternative method for obtaining
accurate measurement for determining the correct
dose of medication such as using measurement tech-
niques that account for the effect of the muscle to
adipose tissue effect and the patient’s overall higher
weight.
• Reductions in cardiac performance may reduce
tissue perfusion, although less than 5% of cardiac
function is directly affected by cardiac perfusion.13
Depending on the comorbidities present (for
examples, diabetes and any kidney or liver impair-
ment), nonopioid medications may not be a good
choice for obese patients. Many obese patients have
impaired kidney function, making them poor can-
didates for NSAIDs. If joint pain is an issue, topical
formulations of NSAIDs can provide some pain
relief when used appropriately. If the patient has
a normal liver function, medications such as acet-
aminophen, both oral and I.V., are a good options
for added pain relief.10
Although multimodal analgesic regimens are
recommended, when combining opioids and nono-
pioids, sedation is always a major concern. Most
www.nursingcriticalcare.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
obese patients can tolerate opioids in usual doses
but it is extremely important to provide careful
monitoring for sedation and respiratory depres-
sion. The critical care setting is designed to provide
monitoring techniques such as capnography, pulse
oximetry, and respiratory monitors that can alert
the nurse to early changes in respiratory status.
When the obese patient has had surgery, general
recommendations for pain management include:
• use of multimodal analgesia using regional and
opioid-sparing techniques
• avoidance of sedatives, especially when combined
with opioids
• noninvasive ventilation with oxygen
• early mobilization
• elevating the head of the bed to 30 degrees
• low threshold for the use of capnography and
pulse oximetry
• arterial BP management
• placement in a high monitoring area such as ICU
or step-down unit with continuous monitoring
in the postoperative time period until the oxygen
saturation is greater than 90% while asleep without
supplemental oxygen.15
For the surgical patient who is obese with
patient-controlled analgesia, continuous infusions
are not contraindicated. Remember that opioid
requirements are not related to body surface
area.15 Additionally, the use of nonpharmacologic
techniques is encouraged with relaxation, aroma-
therapy, therapeutic touch, or Reiki, all of which
can be helpful for pain relief.
Understanding the patient’s pain
Caring for obese patients with pain in critical
care can be difficult, but given the high use of
monitors to detect early signs of sedation, it is a
better setting than open surgical or medical units.
Understanding why a patient has high levels of
pain can help the nurse make better choices for
medications and using multimodal therapies is
encouraged. Using the critical care guidelines for
pain management can give the nurse a sense of
confidence in medication choices and treatment
options. ❖
REFERENCES
1. World Health Organization. Global strategy on diet, physical
activity and health. 2014. www.who.int/dietphysicalactivity.
May l Nursing2016Critical Care l 43
Managing pain in critically ill obese patients
2. Kelly T, Yang W, Chen CS, Reynolds K, He J. Global burden of
obesity in 2005 and projections to 2030. Int J Obes (Lond). 2008;32
(9):1431-1437.
3. Marmo L, D’Arcy Y. A Compact Clinical Guide to Critical Care,
Trauma, and Emergency Pain Management. New York: Springer Pub-
lishing; 2013:320.
4. Neville AL, Brown CV, Weng J, Demetriades D, Velmahos GC.
Obesity is an independent risk factor of mortality in severely in-
jured blunt trauma patients. Arch Surg. 2004;139(9):983-987.
5. McVinnie DS. Obesity and pain. Br J Pain. 2013;7(4):163-170.
6. Stone AA, Broderick JE. Obesity and pain are associated in the
United States. Obesity (Silver Spring). 2012;20(7):1491-1495.
7. Gandhi R, Razak F, Davey JR, Mahomed NN. Metabolic syn-
drome and the functional outcomes of hip and knee arthroplasty.
J Rheumatol. 2010;37(9):1917-1922.
8. Moschen AR, Molnar C, Enrich B. Geiger S. Ebenbichler CF,
Tilig H. Adipose and liver expression of Interleukin (IL) 1 family
members in morbid obesity and effects of weight loss. Mol Med.
2011;17(7-8):840-845.
9. Sowers MF, Yosef M, Jamadar D, Jacobson J, Karvonen-Gutier-
rez C, Jaffe M. BMI vs. body composition and radiographically de-
fined osteoarthritis of the knee in women: a 4-year follow-up study.
Osteoarthritis Cartilage. 2008;16(3):367-372.
44 l Nursing2016Critical Care l Volume 11, Number 3
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
10. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines
for the management of pain, agitation, and delirium in adult pa-
tients in the intensive care unit. Crit Care Med. 2013;41(1):263-306.
11. Puntillo KA, White C, Morris AB, et al. Patients’ perceptions
and responses to procedural pain: results from Thunder Project II.
Am J Crit Care. 2001;10(4):238-251.
12. Payen JF, Bru O, Bosson JL, et al. Assessing pain in critically
ill sedated patients using a behavioral pain scale. Crit Care Med.
2001;29(12):2256-2263.
13. Gélinas C, Fillion L, Puntillo KA, Viens C, Fortier M. Valida-
tion of the critical-care pain observation tool in adult patients. Am J
Crit Care. 2006;15(4):420-427.
14. Leykin Y, Miotto L, Pellis T. Pharmacokinetic considerations in
the obese. Best Pract Res Clin Anaesthesiol. 2011;25(1):27-36.
15. Schug SA, Raymann A. Postoperative pain management of the
obese patient. Best Pract Res Clin Anaesthesiol. 2011;25(1):73-81.
Yvonne D’Arcy is a pain management nurse practitioner and pain manage-
ment consultant and educator in Ponte Vedra Beach, Fla.
The author has disclosed that she has no financial relationships related to
this article.
DOI-10.1097/01.CCN.0000482511.74669.38
www.nursingcriticalcare.com