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The following tick boxes represent conclusions based on clinical experience and expert
opinion.
Acute pain in patients with cancer often signals disease progression; sudden severe pain in
patients with cancer should be recognised as a medical emergency and immediately
assessed and treated (U).
Cancer patients receiving controlled‐release opioids need access to immediate‐release
opioids for breakthrough pain; if the response is insufficient after 30 to 60 minutes,
administration should be repeated (U).
Breakthrough analgesia should be one‐sixth of the total regular daily opioid dose in
patients with cancer pain (except when methadone is used, because of its long and
variable half life) (U).
If nausea and vomiting accompany acute cancer pain, parenteral opioids are needed (U).
9.8 ACUTE PAIN MANAGEMENT IN INTENSIVE CARE
The management of pain in the intensive care unit (ICU) requires the application of many
principles detailed elsewhere in these guidelines. Analgesia may be required for a range of
painful conditions, for example after surgery and trauma, in association with invasive devices
and procedures and acute neuropathic pain. There may also be a need for the intensivist to
provide palliative care (Hawryluck et al, 2002).
Consensus guidelines have been published in the United States for the provision of analgesia
and sedation in adult intensive care (Jacobi et al, 2002), but there remains a dearth of sufficient
large‐scale randomised ICU pain studies on which to base evidence‐based guidelines. Some of
the key consensus findings regarding IV analgesia and sedation in the ICU setting were (Jacobi
et al, 2002):
• a therapeutic plan and goal of analgesia should be established and communicated to
caregivers;
CHAPTER 9 • the level of pain reported by the patient is the standard for assessment but subjective
• assessment of pain and response to therapy should be performed regularly;
observation and physiological indicators may be used when the patient cannot
communicate; and
• sedation of agitated critically ill patients should only be started after providing adequate
analgesia and treating reversible physiological causes.
It is difficult to separate pain management from sedation in this context and intensive care
sedation algorithms usually address both aspects. There has been a recent change in emphasis
from sedative‐based sedation (Soliman et al, 2001) to analgesia‐based sedation (Park et al, 2007
Level III‐3; Fraser & Riker, 2007). Although these measures have been widely recommended, they
have not yet been universally incorporated into routine practice. This is despite the fact that
the use of such protocols to preserve consciousness while treating pain appropriately has been
demonstrated to produce a 57.3% decrease in the median duration of mechanical ventilation
in one study (De Jonghe et al, 2005).
Probably the most useful intervention during sedation and analgesia in ICU is the provision of
a daily drug ‘holiday’ (daily interruption of sedation [DIS]) to reassess the need for sedation
and analgesia. This simple step is associated with significantly shorter periods of mechanical
ventilation and shorter stays in the ICU (Kress et al, 2000 Level II), but does not cause adverse
286 Acute Pain Management: Scientific Evidence
