Analgesia in the Neurosurgical Intensive Care Unit

Abstract

Acute pain in neurosurgical patients is an important issue. Opioids are the most used for pain treatment in the neurosurgical ICU. Potential side effects of opioid use such as oversedation, respiratory depression, hypercapnia, worsening intracranial pressure, nausea, and vomiting may be problems and could interfere with neurologic assessment. Consequently, reducing opioids and use of non-opioid analgesics and adjuvants (N-methyl-D-aspartate antagonists, α2 -adrenergic agonists, anticonvulsants, corticosteroids), as well as non-pharmacological therapies were introduced as a part of a multimodal regimen. Local and regional anesthesia is effective in opioid reduction during the early postoperative period. Among non-opioid agents, acetaminophen and non-steroidal anti-inflammatory drugs are used frequently. Adverse events associated with opioid use in neurosurgical patients are discussed. Larger controlled studies are needed to find optimal pain management tailored to neurologically impaired neurosurgical patients.

Headache persisting after aneurysmal subarachnoid hemorrhage: A narrative review of pathophysiology and therapeutic strategies

“…Concern for side‐effects with deleterious consequences in SAH including vasospasm and re‐bleeding should be considered in treating post‐SAH headache. Opioids in particular are heavily prescribed in the setting of post‐SAH pain; 3,6 however, these medications carry the serious risk of tolerance and addiction, 78 are limited by side‐effects including induced hypercapnia, 79,80 and are not uniformly effective for headache relief in this setting 3,4,6,11,13 . Aspirin and other NSAIDs that inhibit cyclooxygenase (COX)‐1 could potentially increase risk of aneurysm re‐bleeding 81 .…”

Efektivitas Rotasi Opioid Dibandingkan Kombinasi Opioid untuk Mengobati Nyeri Kanker: Laporan Kasus Berbasis Bukti

“…Fentanyl transdermal memiliki waktu aksi kerja awal (onset of action) yang lebih lambat, yaitu 12-24 jam, sehingga untuk modifikasi dosis dapat lebih cepat tercapai apabila dikombinasikan dengan opioid kerja cepat seperti morfin atau tramadol oral. 15,16 Namun, hingga saat ini praktik penggunaan dua jenis opioid kuat dalam waktu bersamaan dan dalam jangka waktu panjang sekaligus (bukan sebagai transisi) belum direkomendasikan. Rasionalisasi penggunaan kombinasi dua macam opioid kuat secara bersamaan belum cukup bukti dan berpotensi menimbulkan efek samping yang berat.…”

“…14 Efek samping lainnya yang dapat terjadi yaitu sedation berlebihan, depresi napas, hiperkapnia, perburukan tekanan intrakranial, nausea, dan vomitus. 15 Hanya 30% nyeri kanker dan diberi opioid kuat masih belum mengalami perbaikan, timbul efek samping opioid, atau terjadi keduanya. 16 Opioid itu sendiri merupakan pilihan analgesik yang paling baik dan paling sering digunakan pada nyeri kanker.…”

Regional anesthesia in the intensive care unit: a single center’s experience and a narrative literature review

“…Ongoing and continuing focus on the topic has led researchers to investigate the possible role of LRA and multimodal analgesia in the neurocritical patient as well [ 37 ].…”