A. Pain, discomfort, restlessness, and agitation are major problems for critically ill patients.

B. The ideal strategy aims to manage patient pain and discomfort first, before providing sedative therapy, often resulting in improved patient outcomes.

C. Pain may be under-treated, as a result of avoiding depressing spontaneous ventilation, inducing opioid dependence, and precipitating cardiovascular instability.

D. Appropriate pain resolution facilitates recovery.

E. Pain and anxiety are difficult to measure, because they constitute subjective phenomena. The clinician should not judge the appropriateness of pain, but rather concentrate on managing it appropriately.

A. Identify the etiology of pain.

B. Determine a baseline before starting treatment, and assess the degree of pain in an objective manner with the help of validated scales and instruments.

C. Understand other potential contributing factors such as anxiety, ethnocultural factors, situational meaning, and prior experience.

D. Establish and maintain drug levels for appropriate analgesia and anxiolysis, and determine the end point of treatment.

E. Understand that therapy is an iterative process in which measurements are made, therapeutic actions are taken, effectiveness is reevaluated, and action is repeated until the desired clinical outcome is reached.

A. Pain is an unpleasant sensory and emotional experience that can be associated with actual or potential tissue damage.

B. Pain-related behavior is the only manifestation that can make the observer conclude that pain is being experienced.

C. Acute pain has an identifiable temporal and causal relationship to an injury, in contrast to chronic pain that persists beyond the healing process and may not have an identifiable cause.

D. Nociception is the detection and signaling of the presence of a noxious stimulus.

E. Pathophysiology of pain.

1. Acute pain begins with damage to the skin or other innervated tissues.

2. Locally produced and released mediators (prostaglandins, small peptides) sensitize or stimulate peripheral nociceptors, whose fibers propagate the signal into the dorsal horn of the spinal cord or the sensory nuclei in the brainstem.

3. Before reaching pain-specific areas in deep brain structures or the cortex, the signal is modulated (amplified or attenuated) that can increase or decrease the response to painful stimuli.

A. Location: It should be determined whether the location is consistent with the type of injury sustained or the surgery performed, or whether it is entirely different.

1. Look for unrecognized sources of pain, such as missed or new injuries.

2. Pain can be chronic, neuropathic, or a result of malpositioning during surgery.

3. Medication selection and dosages may be influenced by a history of chronic pain, medication usage, sleep disturbance, fatigue, arthritis, alcohol or other substance abuse, and psychiatric illness.

B. Intensity: Visual or verbal analog scales aid in quantifying a patient’s pain, thereby providing a baseline for the evaluation of the response to treatment.

1. The most widely used scale is the visual analog scale (VAS), where a spectrum of pain from “no pain” to “the worst pain I’ve ever had” is depicted as a scale from 0 to 10.

2. In patients who are unable to communicate (e.g., intubated), markers of sympathetic activity such as restlessness, sweating, tachycardia, lacrimation, pupillary dilation, and hypertension can be graded as signs of pain intensity.

3. It is important to identify reliable and valid tools for evaluating pain in the noncommunicative patient in the ICU. Parameters such as facial expression, upper limb movement, compliance with mechanical ventilation, among others, may be important factors that can help determine if the patient is experiencing pain.

C. Quality of sensation: Pain can be sharp if it is due to direct nociception (e.g., incision), dull or aching if it arises from deeper structures, or pulling or tugging in nature if it is related to the presence of sutures or visceral stimulation.

1. Pain manifested as tingling, stinging, or buzzing sensations is usually related to abnormal neural function, secondary to either recovery from regional anesthesia or reestablishment of neural function after neural compression.

2. Painful dysesthesias may occur in conjunction with peripheral neuropathy.

D. Confounder: Delirium.

1. A transient disorder of attention and cognition resulting in intermittent agitation, hallucinations, disruptive behavior.

2. Common in critically ill patients.

3. Identify the type and potential cause (e.g., induced by sedative or analgesic medications).

E. Assessment and reassessment.

1. Patient-focused sedation and analgesia stress the importance of individual assessment of patients and periodic reevaluation.

2. Identify all therapeutic interventions and measures that may be causing or contributing to pain-related distress (e.g., suctioning, intubation, nasogastric tubes, phlebotomy, or placement of invasive lines).

F. Monitoring the degree of sedation.

1. Successful sedation protocols.

a. Frequently assess pain, anxiety, and agitation using a reproducible scale.

b. Utilize combination therapies coupling opioids and sedatives.

c. Encourage careful communication between team members.

2. Two broad categories of sedation protocols:

a. Patient-targeted sedation protocols rely on structured assessments to carefully guide drug titrations.

b. Daily interruptions of continuous sedative infusions may be employed to focus care providers on the goal of achieving a period of awakening in the earliest phases of critical illness possible.

3. Several numerical scales have been developed to help guide the appropriate dosage of analgesic/sedative medication based on the depth of sedation.

a. The most popular is the 6-point Ramsay Scale (RS)—based on motor responsiveness, ranging from 1 = anxious or restless or both, to 6 = no response to stimulus; demonstrates excellent interrater reliability.

b. Other scales include the Sedation-Agitation Scale (SAS), Richmond Agitation-Sedation Scale (RASS), Glasgow Coma Scale (GCS), and the Motor Activity Assessment Scale.

4. More sophisticated monitoring techniques currently being used in the operating room, like the bispectral index (BIS), provide objective data based on cortical and subcortical interactions, are still being investigated.

A. Peripheral analgesia: nonsteroidal anti-inflammatory drugs (NSAIDs), local anesthetic infiltration, and peripheral nerve blockade.

1. NSAIDs—achieve analgesia through nonselective, competitive inhibition of cyclooxygenase (COX), thereby interfering with the production of prostaglandins and other mediators of the inflammatory cascade.

2.

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