Objective pain management in ICU patients with low consciousness has a variety of challenges. Patients in these high risk categories are often confused by their own responses and may not always be able to provide a detailed account of what happened during an event. Even when a patient can provide details, they may still be unable to describe the exact pain they felt and may be unable to correctly describe the cause of the pain. There is thus a need for using multiple modalities in the management of these patients in ICU.
Pain: Objective pain management in doc patients can be challenging. Objective pain can range from mild to severe and even occasionally deadly, especially for those in a critical or vegetative state. This can make it difficult for even well-trained clinicians to assess the severity and type of pain, which limit the range of treatment options available. While most ICU physicians are able to treat for common, more debilitating, ICU-related pain, more severe and unexpected pain can pose a challenge. The use of objective pain ratings can be an effective way to evaluate and manage pain in these complex patients with low consciousness.
Wakefulness Syndrome: Wakefulness syndrome is defined as the diagnosis of a patient who is in a vegetative state but has responsiveness to direct stimulus. This can include eye movements, reflexes and muscle functions. Because these are typically the properties of the brain, there is the potential for a cognitive process to occur. In the ICU environment, cognitive therapy can be helpful in the management of wakefulness syndrome.
Parietal Response Control: Clinicians treating doc patients in ICU with a wide variety of neurological and cognitive challenges are faced with the challenge of improving functional connectivity between the left and right cerebral hemispheres. This occurs when both hemispheres respond to stimuli in the opposite hemispheres. It is known that functional connectivity exists in a state of rest, known as the resting state. Clinicians have been using resting state assessments to improve alertness and respiratory control in patients diagnosed with a motor neuron paralytic disease (MSV). A promising future application of this method is the assessment of brainstem respiration in patients with a minimally conscious state.
Brainstem respiration: Patients with a motor neuron paralytic disease or those with a primary condition of cerebellar ataxia are likely candidates for this particular assessment. Researchers at the University of Miami have found that theta waves can be detected from brainstem respiration activity which supports the concept of brainstem respiration monitoring. While this test does not directly assess consciousness, it can provide additional information to support researchers' calls for more objective methods in the clinical evaluation of wakefulness and mild vegetative state.
EEG Biofeedback: Several researchers believe that biofeedback, which relies on visual means for identifying brainwaves, can help reduce or eliminate subjective consciousness in wakefulness-dependent conditions. In 2021, James Moody and colleagues at the University of Rochester conducted a preliminary study of biofeedback and found that it was able to decrease theta wave activity and increase alpha wave activity in patients suffering from a motor neuron disease. Other investigators have since performed more conclusive research indicating that biofeedback is an important means of reducing symptoms of multiple sclerosis and chronic pain. During a controlled imagery scan, participants were shown a series of images while their brains were monitored by an EEG machine. When the images and tones matched brainwave patterns, participants indicated how much they thought the images or sounds made them feel.
External Interference: Another technique used to evaluate consciousness involves testing patients for consciousness with a form of external stimuli. Researchers have proposed using a block of sand and asking a patient to push the block toward the center, or push it against a wall, or even drop it onto the floor. Each of these different approaches has been successfully used to measure consciousness. One of the major factors that determine whether a patient is unconscious is whether or not they respond to the different stimuli. Some patients are more sensitive than others to external stimuli, such as music or certain smells. The researchers then took note of each patient's reaction to different stimuli, noting which stimuli led to which feelings of consciousness or lack of consciousness.
A final approach that has been used to examine consciousness is with the patient's own voice. Patients have often been recorded as saying things like, "I can't do it" or "I can't do it." Though the recorded voice will not necessarily reflect the actual condition of the patient, doctors often use this recording as a prognosis for the patient. Because consciousness can be affected by various outside sources, doctors often use recordings of voices to suggest what the patient might be thinking or feeling. This can also help improve the patient's understanding of the situation and lead him/her to a successful recovery.
