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Pain in the ICU

Pain in the ICU

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Pain in the ICU

  1. 1. Pain in the ICU
  2. 2.  >50% of ICU survivors report severe pain as the most thing they remember from their ICU stay.  Short & long term negative consequences are related to uncontrolled pain in the ICU.  Assessing pain is challenging (esp. if pt is unable to communicate)
  3. 3.  Acute trauma  Injury  Burns  Postoperative pain  Exacerbation of chronic pain  Heart dz  Ischemia  Acute/chronic underlying dz (cancer pain)  Pancreatitis  Abdominal pathology Common causes of pain in the ICU:
  4. 4.  Routine nursing care  Provision of life-sustaining measures  Presence of endotracheal tube & endotracheal tube suctioning  Wound care  Tube or Foley insertion  Immobility  Bed repositioning  Bathing  Medication administration  Physical/ occupational therapy  Other invasive procedures Less noticeable causes:
  5. 5.  Acute pain -> stress response -> hypercatabolic state -> decrease tissue perfusion & impaired wound healing.  Uncontrolled pain-> suppress natural killer cell activity & neutrophil fcn -> decrease in pts immune response to infections. Short-term consequences of pain in ICU
  6. 6.  Health-related quality of life decreased in up to 20% of pts  Chronic pain in up to 4% of pts  Posttraumatic stress d/o in 5-20% of pts. Long-term consequences of pain in ICU (12 months):
  7. 7.  Gold standard for assessing pain: Pts self-report of pain.  The Behavioral Pain Scale (BPS)  The Critical-Care Pain Observation Tool (CPOT)  Should be used routinely in all ICU patients  Most protocols assess pain q4-6h (while pt is awake)  It’s important to re-asses w/in 30-60min after a PRN medication.  PAD guidelines rcd trx w/in 30 mins of a “sig. pain” score.  BPS > 5 or CPOT ≥3 indicate pain.  Vital signs not rcd for pain assessement Assessment of pain:
  8. 8. BPS:
  9. 9. CPOT:
  10. 10.  IV opioids are 1st line for nonneuropathic pain  Non-opioids for mild-moderate pain or w/ opioids to reduce opioid dose. Treatment of pain in ICU:
  11. 11.  Preprocedural pain management with both non-phar & phar therapy.  Examples of nonpharmacologic: relaxation breathing techniques imagery, massage Music thermal measures positioning
  12. 12.  Preemptive analgesia for chest tube removal.  Postoperative thoracic epidural anesthesia/analgesia is recommended for patients undergoing abdominal aortic aneurysm treatment
  13. 13.  IV opioids on an as-needed, scheduled, or continuous infusion basis are recommended to treat pain in the ICU.  Fentanyl is the most commonly used amongst others.  MOA: Bind to mu-opioid receptors in CNS Pharmacotherapy for PAIN:
  14. 14.  Tolerance: May quickly develop to all opiates, particularly when given as a continuous infusion.  there is an equianalgesic dosing for switching between IV & PO opiate, but may be difficult to estimate, and low starting doses should be considered.
  15. 15. Significant adverse effects: o Decreased respiratory drive o Decreased BP and HR. o Constipation o GI intolerance  Altered sensorium
  16. 16. Drug Drug intx Dose Adverse effects Fentanyl 3A4 major substrate 12.5–25 mcg/hr; 0.35–0.5 mcg/kg Respiratory depression, bradycardia, hypotension, CNS depression, constipation, ileus, risk of serotonin syndrome when used with other serotonergic agents, muscle rigidity Morphine Glucuronidation 1–2 mg/hr Hypotension, bradycardia from histamine release, respiratory depression, CNS depression, constipation, ileus. Hydromorph one Glucuronidation 0.25–0.5 mg/hr CNS alterations (e.g., abnormal dreams, aggressive behavior, altered thinking), respiratory depression, hypotension, constipation HIGH potency opiate.
  17. 17. Drug Drug intx Dose Adverse effects Methadone 3A4 and 2B6 major substrates Dose-dependent QTc prolongation, serotonin syndrome, altered mental status, respiratory depression, confusion, dizziness, arrhythmias, constipation, risk of serotonin syndrome when used with other serotonergic agents Remifentanil Blood and tissue esterases Loading dose: 1.5 mcg/kg CI: 0.5–15 mcg/ kg/hr Chest wall rigidity; rebound pain on discontinuation, Respiratory depression, hypotension, bradycardia, constipation
  18. 18. o Hepatic metabolism o CYP450 3A4 substrate o Quick onset and short duration of action o No active metabolites o Highly lipophilic o High Vd and protien binding o 3-compartment model o Continuous infusion -> prolonged & unpredictable clearance  Dosage forms: injectable, transdermal, transmucosal and nasal spray. Fentanyl:
  19. 19. o Two active metabolites: morphine-3-glucuronide (no analgesic effect) & morphine-6-glucuronide o Renally eliminated Dosage forms: injectable and oral. Morphine:
  20. 20.  Hepatic metabolism o Inactive but neurotoxic metabolite o Low Vd o Highly water soluble o Low protein binding Dosage forms: injectable and oral Hydromorphone
  21. 21.  Pharmacokinetics: Clearance by blood and tissue esterase  clearance not dependent on organ function. o Fast onset and duration of action o High Vd o High protien binding  Rebound pain.  Benefit in adult ICUs: decreased time on mechanical ventilation with short-term use.  Dosage forms: injectable only. Remifentanil
  22. 22. o Inactive metabolites o Many drug interactions o Variable duration of action (12-48hr) o Marketed as a racemic mixture Dosage forms: injectable and oral Methadone
  23. 23.  Clinically stable patients may tolerate a conversion from opiates to non-opiate medications.  Local and regional anesthetics such as bupivacaine Non-opioid adjunctive meds:
  24. 24.  Maximum daily dose: 4g  Decreased total daily dose in liver dysfcn pt  IV acetaminophen: dose should be reduced if CrCl ≤ 30ml/min/1.73m2 OR w/ continuous renal replacement therapy(q8h)  C/I in severe hepatic dz.  PO or rectal is cheaper than IV. Acetaminophen
  25. 25.  Ibuprofen, Ketorolac  For critically ill pts. w/ renal or hepatic dysfcn.  May increase risk of AKI, bleeding, or GI SE. IV or PO NSAID meds:
  26. 26.  Used for analgesia and sedation in the ICU, primarily in the pediatric population.  N-methyl-d-aspartate receptor antagonist.  A “dissociative anesthetic,” providing analgesic activity at subanesthetic doses  S.E: Mild - severe emergence reactions (e.g., confusion, excitement, irrational behavior, hallucinations, delirium), enhanced skeletal muscle tone, tachycardia, hypertension, hypotension Ketamine
  27. 27.  Dose analgesia or sedation initial: 0.1mg/kg/hr. for adult ICU pts: 0.1-2.5mg/kg/hour. duration: 3-9hours.
  28. 28.  Gabapentin: 300-600mg/d divided 2-3/d & requires renal adjustment.  S.E: CNS depression, paresthesias, and asthenias  Carbamazepine: 50-100mg BID  Use w/caution in pt w/ hepatic impairment and adjust for CrCl <10ml/min/1.73m2 or hemodialysis  PK: strong CYP inducer, monitor intx.  S.E : Somnolence, severe skin reactions (e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis), pancytopenia, syndrome of inappropriate antidiuretic hormone Anticonvulsants: rcd w/opioids for confirmed neuropathic pain.
  29. 29.  It advices the use of opiate medications before prescribing an anxiolytic/hypnotic medication to provide patient comfort in the ICU unless anxiolytics are otherwise indicated.  Early pain relief in ICU -> decrease agitation &/or general discomfort.  Minimize the use of alternative meds (for agitation) like benzodiazepine. Analgosedation Method in the ICU

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