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Pain distress: the negative emotion associated with procedures in ICU patients



The intensity of procedural pain in intensive care unit (ICU) patients is well documented. However, little is known about procedural pain distress, the psychological response to pain.


Post hoc analysis of a multicenter, multinational study of procedural pain. Pain distress was measured before and during procedures (0–10 numeric rating scale). Factors that influenced procedural pain distress were identified by multivariable analyses using a hierarchical model with ICU and country as random effects.


A total of 4812 procedures were recorded (3851 patients, 192 ICUs, 28 countries). Pain distress scores were highest for endotracheal suctioning (ETS) and tracheal suctioning, chest tube removal (CTR), and wound drain removal (median [IQRs] = 4 [1.6, 1.7]). Significant relative risks (RR) for a higher degree of pain distress included certain procedures: turning (RR = 1.18), ETS (RR = 1.45), tracheal suctioning (RR = 1.38), CTR (RR = 1.39), wound drain removal (RR = 1.56), and arterial line insertion (RR = 1.41); certain pain behaviors (RR = 1.19–1.28); pre-procedural pain intensity (RR = 1.15); and use of opioids (RR = 1.15–1.22). Patient-related variables that significantly increased the odds of patients having higher procedural pain distress than pain intensity were pre-procedural pain intensity (odds ratio [OR] = 1.05); pre-hospital anxiety (OR = 1.76); receiving pethidine/meperidine (OR = 4.11); or receiving haloperidol (OR = 1.77) prior to the procedure.


Procedural pain has both sensory and emotional dimensions. We found that, although procedural pain intensity (the sensory dimension) and distress (the emotional dimension) may closely covary, there are certain factors than can preferentially influence each of the dimensions. Clinicians are encouraged to appreciate the multidimensionality of pain when they perform procedures and use this knowledge to minimize the patient’s pain experience.

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Contributors: We recognize and thank patients and clinicians from the following ICUs who were involved in the Europain® study. (1) Medical Intensive Care Unit, University of Paris-Diderot, Saint Louis Hospital, Paris, France; (2) Medical Intensive Care Unit, Bichat University Hospital, France; (3) Institut Albert Bonniot, INSERM U823, Grenoble, France; (4) Département d’Anesthésie-Réanimation, Hôpital Saint Eloi, France; (5) Unite U1046 de l’Institut National de la Sante et de la Recherche, University of Montpellier, Montpellier, France; (6) Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Spain; (7) Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Mumbai, India; (8) D’Or Institute for Research Education, Postgraduate Program, Instituto Nacional de Cancer, Rio de Janeiro, Brazil; (9) Department of Anesthesia and Intensive Care I, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania; (10) Anesthesia and Intensive Care Department, Clinical Emergency Hospital, Bucharest, Romania; (11) Department of Anesthesiology and Intensive Care, Policlinico A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy; (12) Department of Anaesthesiology and Intensive Care, General University Hospital, First Faculty of Medicine of Charles University, Prague, Czech Republic; (13) Department of Anaesthesiology and Intensive Therapy, Medical University of Gdansk, Gdansk, Poland; (14) Trauma Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; (15) Department of Nursing, Cyprus University of Technology, Nicosia, Cyprus; (16) Nursing Department, Papageorgiou Hospital, Thessaloniki, Greece; (17) The Chinese University of Hong Kong, Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Shatin, Hong Kong; (18) Intensive Care Unit, Hospital Maciel, Santorio Americano and Sanatorio Hospital in Montevideo, Montevideo, Uruguay; (19) Intensive Care Services, Hawke’s Bay Hospital, Hastings, New Zealand; (20) Department of Intensive Care Medicine and School of Population Health, Royal Perth Hospital and University of Western Australia, Perth, Australia; (21) Trauma ICU and CCU of Helsinki University Hospital, Helsinki, Finland; ICU of Kuopio University Hospital, Finland; ICU of Oulu University Hospital, Finland; (22) Department of Intensive Care, Medical Centre Leeuwarden, Netherlands; (23) Department of Intensive Care Medicine, University Medical Center, Utrecht, Netherlands; (24) Clinic of Anesthesiology and Intensive Medicine, Jessenius Faculty of Medicine in Martin-Comenius University in Bratislava, University Hospital Martin, Martin, Slovakia; (25) Intensive Care Unit Department, Erasme Hospital, Belgium; (26) Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium; (27) ICU Maennedorf, Spital Maennedorf, Maennedorf, Switzerland; (28) ICU Department, Khoula Hospital, Muscat, Sultanate of Oman; (29) Intensive Care Unit of Clinica Las Americas, Medellin, Columbia; (30) ICU, Neurosurgery, Medical ICU, Hadassah Hebrew University Hospital, Jerusalem, Israel; (31) Intensive Care Unit, CHU F. Bourguiba, Monastir, Tunisia; (32) Department of Anaesthesia and Intensive Care, Mater Dei Hospital, Msida, Malta; (33) Servico Cuidados Intensivos, Hospital Santo Antonio, Centro Hospitalar do Porto, Porto, Portugal; and (34) Department of Critical Care Medicine, Peking University People’s Hospital, Beijing, China.


Supported by a grant from the European Society of Intensive Care Medicine/European Critical Care Research Network Award (ECCRN Established Investigator Award, 2009) and by an academic grant from AP-HP, Hôpital Saint-Louis, Paris, France.

Author information

KAP, EA, AM, study concept and design. KAP, AM, EA, training materials. KAP, EA, JFT, SR, data analysis and interpretation. KAP, EA, JFT, SR, manuscript preparation and drafting. KAP, EA, JFT, SR, statistical methods, statistical data analysis. AM, GC, GR, JM, FRC, JVD, MS, DCI, IMG, SMM, KR, RO, IE, EDEP, MK, GMJ, GB, RCF, KMH, AK, RTG, JK, MMSS, MN, DDB, MSGS, AH, FJP, JSB, FA, AA, JRCM, YA, acquisition of the data and manuscript critique and review. All authors approved the manuscript submitted.

Correspondence to Kathleen A. Puntillo.

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Puntillo, K.A., Max, A., Timsit, J. et al. Pain distress: the negative emotion associated with procedures in ICU patients. Intensive Care Med 44, 1493–1501 (2018).

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  • ICU
  • Procedures
  • Pain distress