Analgesia in the surgical intensive care unit

Abstract

Critically ill patients are a heterogeneous group with diverse comorbidities and physiological derangements. The management of pain in the critically ill population is emerging as a standard of care in the intensive care unit (ICU). Pain control of critically ill patients in the ICU presents numerous challenges to intensivists. Inconsistencies in pain assessment, analgesic prescription and variation in monitoring sedation and analgesia result in suboptimal pain management. Inadequate pain control can have deleterious effects on several organ systems in critically ill patients. Therefore, it becomes incumbent on physicians and nurses caring for these patients to carefully evaluate their practice on pain management and adopt an optimal pain management strategy that includes a reduction in noxious stimuli, adequate analgesia and promoting education regarding sedation and analgesia to the ICU staff. Mechanistic approaches and multimodal analgesic techniques have been clearly demonstrated to be the most effective pain management strategy to improve outcomes. For example, recent evidence suggests that the use of short acting analgesics and analgesic adjuncts for sedation is superior to hypnotic based sedation in intubated patients. This review will address analgesia in the ICU, including opioid therapy, adjuncts, regional anaesthesia and non-pharmacological options that can provide a multimodal approach to treating pain.

A deadly trend in fentanyl fatalities (England, 1998–2017)

“…Pharmaceutical fentanyls are key in the delivery of modern medicine, [6][7][8][9][10][11][12][13] with their use most widespread in the delivery of general anaesthesia: more than 3.5 million patients are treated in NHS hospitals by anaesthetists every year. 32 A UK-wide survey indicates general anaesthetics are associated with a low mortality rate of 1 in 100,000, with elderly or infirm patients, or those undergoing emergency surgery at greatest risk.…”

A review of compliance with pain assessments within a UK ICU

“…This highlights that significant improvements need to be made with pain assessment and the management of pain. As well as a reduction in length of stay, adequate pain control can promote quality of sleep, ventilator compliance, reduced oxygen demand and reduced risk of atelectasis (Ehieli et al, 2017;Whitehouse et al, 2014). By providing too much analgesia ventilator weaning could be delayed, assessment of neurological status impaired and result in cardiovascular instability (Barr et al, 2013).…”

“…Due to extensive benefits of adequate pain management it is essential that pain assessment occurs frequently to ensure effective pain management (Barr et al, 2013). Pain should be acted on to promote high quality nursing care with benefits to patients physical and psychological health (Sacco and LaRiccia, 2016;Malchow and Black, 2008;Ehieli et al, 2017). The importance of adequately assessing a patients pain to ensure that this is a controlled is a rationale for this audit to be completed.…”

Management of Pain in the Intensive Care Unit

“…Opioids which include fentanyl, methadone, morphine, hydromorphone, and remifentanil, are the principal medications for treatment of pain in the critically ill patients residing in ICU [20] . The ideal selection of opioid and the dosing schedule which is used for an individual patient of ICU relies on many elements, together with the drug's pharmacodynamics and pharmacokinetic properties.…”