Patients admitted to the intensive care unit (ICU) and receiving invasive mechanical ventilation (IMV) frequently require sedation and analgesia to ensure their comfort, prevent pain associated with invasive procedures, and minimize complications related to agitation. Appropriate analgesia management is essential to ensure patient comfort while minimizing the consequences of excessive opioid exposure, including delirium, prolonged mechanical ventilation, extended ICU stays, and the risk of post-ICU syndrome (PICS). While sedation assessment relies on validated tools such as the RASS score, pain assessment in non-communicative patients remains more complex. In practice, it relies primarily on behavioral scales such as the Behavioral Pain Scale (BPS), the only internationally validated scale that has been translated into French and is recommended for use in intensive care. However, these scales have certain limitations, particularly in deeply sedated patients or when motor expression is impaired. Thus, over the past few years, automated pupillometry has been developed to assess pain through the pupillary dilation reflex (PDR), which is an autonomic physiological response to nociception. Indeed, pupillometry allows for the quantitative measurement of the PDR induced by standardized, noninvasive nociceptive stimulation. This measurement yields the Pupillary Pain Index (PPI), which serves as an objective, reproducible, and observer-independent indicator of nociception. Measuring the PPI could enable earlier and more individualized adjustment of analgesia, leading to a reduction in painful episodes and opioid exposure.
In this context, this randomized study aims to compare, in patients on mechanical ventilation with deep sedation and analgesia (RASS -4/-5), a pain monitoring strategy guided by pupillometry with standard care based on the BPS. The objective is to evaluate the impact of this strategy on the frequency of pain event detection and on complications associated with opioid use in the intensive care unit
On mechanical ventilation
And requiring sedation and analgesia
With a RASS score between -4 and -5
And a BPS
- A family member who refuses the patient's participation
Patients under 18 years of age
Patients who are not enrolled in or eligible for a social security program
Individuals subject to legal protective measures (guardianship, conservatorship)
Parallel
PPI Measurement (Pupillary Pain Index)
Other interventionPain management will follow the protocol for adjusting daily doses of sufentanil or remifentanil to best tailor the doses to patients' needs, based on the results of pupillometry: • A PPI \< 4 allows for a reduction in sufentanil doses by 2.5 gamma/h or remifentanil doses by 0.02 µg/kg/min • A PPI between 4 and 6 does not require any changes to sufentanil or remifentanil doses • And a PPI \> 6 indicates the need to prescribe, in addition to sufentanil or remifentanil, a Step I or II analgesic, with a subsequent reassessment of the level of nociception (based on the duration and peak effect of the administered medications).
BPS Measurement (Behavioral Pain Scale)
Other interventionThe BPS scale used to assess pain involves observing three criteria rated on a scale of 1 to 4: facial expression, upper limb tone, and adaptation to the ventilator. Thus, the BPS ranges from 3 (minimum score) to 12 (maximum pain score measurable with this tool). This measurement is simple to perform and is now fully mastered by healthcare teams working in intensive care units.
Average percentage of daily painful events during the period in which the patient is on VMI with RASS-4/-5, defined as the ratio of the daily number of painful events to the number of potentially painful procedures performed.
Average percentage of daily painful events during the period in which the patient is on VMI with RASS-4/-5, defined as the ratio of the daily number of painful events to the number of potentially painful procedures performed.
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