Pain

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  Greater than 50% of intensive care unit (ICU) survivors report significant pain during their ICU stay

  
  
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  Common causes of pain in the ICU: acute trauma, injury or burns, postoperative pain, cancer pain, invasive procedures, and routine nursing care such as endotracheal tube suctioning, wound care, and tube insertion

  
  
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  Short-term consequences of unrelieved pain: catabolic hypermetabolism, increased circulating catecholamines, impaired tissue perfusion, and decreased immune function

  
  
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  Long-term consequences of unrelieved pain: chronic pain, lower health-related quality of life, neuropathic pain, and posttraumatic stress disorder

  
  
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  Analgosedation: analgesia-first or analgesia-based sedation (treat with an opioid before a sedative)

  
  
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  Assessment: assess pain q4–6h using either the Behavioral Pain Scale or Critical-Care Pain Observation Tool ( Tables 22.1 and 22.2 )

  
  
  
  

  Table 22.1

  
  

  Behavioral Pain Scale (BPS) ^a

  
  

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

  ITEM	DESCRIPTION	SCORE
  Facial expression	Relaxed	1
  	Party tightened (e.g., brow lowering)	2
  	Fully tightened (e.g., eyelid closing)	3
  	Grimacing	4
  Upper limbs	No movement	1
  	Partly bent	2
  	Fully bent with finger flexion	3
  	Permanently retracted	4
  Compliance with ventilation	Tolerating movement	1
  	Coughing but tolerating ventilation most of the time	2
  	Fighting ventilator	3
  	Unable to control ventilation	4

   
  

  a A BPS score >5 indicates significant pain

  
  
  
  

  Table 22.2

  
  

  Critical-Care Pain Observation Tool (CPOT) ^a

  
  

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

  INDICATOR	DESCRIPTION	SCORE
  Facial expression	Relaxed	0
  	Tense	1
  	Grimacing	2
  Body movements	Absence	0
  	Protection	1
  	Restlessness	2
  Muscle tension	Relaxed	0
  	Tense, rigid	1
  	Very tense, rigid	2
  Vent compliance or vocalization	Tolerating	0
  	Coughing	1
  	Fighting	2
  	Talking normally	0
  	Sighing, moaning	1
  	Crying out, sobbing	2

   
  

  a A CPOT score ≥3 indicates significant pain

  
  
  
  
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  Pharmacologic management ( Tables 22.3 and 22.4 )

  
  
  
  

  Table 22.3

  
  

  Opiates Commonly Used in the ICU

  
  

  Drugs without brand names are denoted by generic name only

  
  

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

  DRUG	USUAL DOSE	PD/PK (IV)	METABOLISM	COMMENTS
  Fentanyl (Sublimaze)	Start at 0.5 mcg/kg/h Titrate by 0.25 mcg/kg/h q15min to CPOT <3 or BPS ≤5 Usual maximum: 5 mcg/kg/h	Onset: 1–2 min Duration: 0.5–1 h Half-life: 2–4 h	Hepatic CYP3A4 major substrate	Accumulates in hepatic failure Prolonged half-life with infusion duration Muscle rigidity <1%
  Morphine	Start at 2 mg/h Titrate by 2 mg/h Q15min to CPOT <3 or BPS ≤5 Usual maximum: 20 mg/h	Onset: 5–15 min Duration: 3–5 h Half-life: 3–4 h	Glucuronidation	Hypotension and bradycardia from histamine release Active metabolites, morphine-3-glucuronide (45–55%) and morphine-6 glucuronide (10–15%), accumulate in renal failure
  Hydromorphone (Dilaudid)	Start at 0.25 mg/h Titrate by 0.25 mg/h q15min to CPOT <3 or BPS ≤5 Usual maximum: 2 mg/h	Onset: 5–15 min Duration: 3–4 h Half-life: 2–3 h	Glucuronidation	Accumulates in hepatic failure
  Remifentanil (Ultiva)	LD 1.5 mcg/kg; followed by 0.5 mcg/kg/h Titrate by 0.5 mcg/kg/h q5min to CPOT <3 or BPS ≤5 Usual maximum: 15 mcg/kg/h	Onset: 1–3 min Duration: 3–10 min Half-life: 10–20 min	Blood and tissue esterases	Muscle rigidity >10% Rebound pain and withdrawal symptoms due to quick offset

   
  

  BPS , Behavioral Pain Scale; CPOT , Critical-Care Pain Observation Tool; ICU , Intensive care unit; IV : Intravenously; LD : Loading dose; PD/PK : Pharmacodynamics/pharmacokinetics
  
  
  
  

  Table 22.4

  
  

  Non-Opioid Adjunctive Pain Medications

  
  

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

  DRUG	USUAL DOSE	PD/PK	METABOLISM	COMMENTS
  Acetaminophen (Ofirmev)	IV: 650 mg q4h–1 g q6h	Onset: 5–10 min Half-life: 10–20 min	Glucuronidation, sulfonation	CI in severe hepatic disease
  Ketorolac (Toradol)	IM/IV: 30 mg then 15–30 mg q6h up to 5 days	Onset: 10 min Half-life: 2.4–8.6 h	Hydroxylation, conjugation/renal excretion	Use with caution in renal/hepatic dysfunction May increase risk of ARF, bleeding, or GI ADR
  Gabapentin (Neuronton)	PO: 300–600 mg/day÷2–3 doses	Onset: N/A Half-life: 5–7 h	Renal excretion	Renally adjust For neuropathic pain
  Carbamazepine (Tegretol)	PO: 50–100 mg BID	Onset: 1–3 min Half-life: 25–65 h then 12–17 h	Oxidation	For neuropathic pain Caution in hepatic impairment Strong inducer of CYP enzymes, substrate of CYP3A4 ADR: SJS, TEN, pancytopenia, SIADH
  Pregabalin	PO: 75–200 mg BID	Onset: days Half-life: 6 h	Urine (90% unchanged drug)	For neuropathic pain
  Ketamine (Ketalar)	IV: 0.5 mg/kg ×1 LD then 1–2 mcg/kg/min	Onset: 30 s Half-life: alpha: 10–15 min beta: 2.5 h	N-dealkylation, hydroxylation, conjugation	ADR >10%: confusion, irrational behavior, excitement, delirium, hallucinations For postsurgical patients to reduce opioid consumption
  Notes: • Non-opioid adjunctive pain medications to be used in combination with opioids to reduce opioid use and optimize analgesia

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