Page 297 Guide to Pain Management in Low-Resource Settings

Pain Management in the Intensive Care Unit 285

Pain is exacerbated by movement, which may care.
evoke pain of a quite diff erent character. Moving, turn- 3) Patients should be calm, cooperative, and able to
ing the patient, and the eff ects of endotracheal tube suc- sleep when undisturbed. Th is does not mean that they
tion and physiotherapy give valuable information about must be asleep at all times.
the eff ectiveness of analgesia. 4) Patients must be able to tolerate appropriate or-
For children, scales have been developed spe- gan system support. Th us, patients with very poor gas
cifi cally for neonatal and pediatric use, e.g., the Riley In- exchange, particularly those requiring inverse I:E ra-
fant Pain Scale: tios or the initial stages of permissive hypercapnia, may

Score Facial Expression Sleep Movements Cry Touch
0 - Neutral - Sleeping quietly - Moves easily - None -
- Smiling, calm
1 - Frowning - Restless - Restless body - Whimpering - Winces with touch
- Grimaces movements
2 - Clenched teeth - Intermittent - Moderate agita- - Crying - Cries with touch
tion - Diffi cult to console
3 - Crying expression - Prolonged, with - Th rashing, - Screaming, - Screams when touched
periods of jerking fl ailing high-pitched - Inconsolable
or no sleep

Whatever method of assessment is selected, it need neuromuscular blockade. Th e use of a nerve stim-
should be regular. Both the patient and the response to ulator to monitor the extent of neuromuscular blockade
drugs are constantly changing, so drugs and doses need may be useful in some situations.
regular adjustment. 5) Patients must never be paralysed and awake.

What are the main problems for Joe in the Pain management in
intensive care unit?
the intensive care unit
• Being heavily sedated and ventilated, and thus
unable to communicate What techniques of pain management
• Being critically ill, with multiple injuries includ- are available?
ing lung contusions and possible head injury Most intensive care patients will require analgesia. In
• Experiencing massive blood loss, massive trans- 1995, the Society of Critical Care Medicine published
fusion, and coagulopathy practice parameters for intravenous analgesia and seda-
• Having hypothermia tion in the ICU. Morphine and fentanyl were the pre-
• Having anuria ferred analgesic agents, and midazolam or propofol were
• Experiencing multiple sources of pain: intercostal recommended for short-term sedation, with propofol
drains, fractured ribs, elbow and knee wounds, being the agent of choice for rapid awakening. More re-
and a laparotomy wound cently, sedative and analgesic practice in ICUs in Europe
has been surveyed; opioids are the drugs most common-
What are the aims of therapy?
ly used for pain relief, usually by infusion, with morphine
Th e objective should be a cooperative, pain-free patient, being the most widely used. Shorter-acting fentanyl and
which implies that the patient is not unduly sedated. alfentanil, as well as ultra-short-acting remifentanil, are
Th e United Kingdom Intensive Care Society also used, but they are more expensive. Propofol and
guidelines on sedation state the following: benzodiazepines are used for sedation, with diazepam,
1) All patients must be comfortable and pain free: lorazepam, and midazolam all being widely used.
Analgesia is thus the fi rst aim.
2) Anxiety should be minimized. Th is is diffi cult as What are the available application routes for
anxiety is an appropriate emotion. Th e most important pharmacological agents?
way to reduce anxiety is to provide compassionate and Th e ideal route is intravenous, which is more reliable
considerate care; communication is an essential part of than the alternatives. Small frequent intravenous bolus