Page 301 Guide to Pain Management in Low-Resource Settings

Pain Management in the Intensive Care Unit 289

tired, it is diffi cult to sustain sleep with full daytime abstract art as opposed to words (reassurance that this
lighting, and the ICU patient does not have the option is very common is needed). Alternatively, pictures dis-
of hiding beneath the bedclothes. Feeling thirsty, hun- playing the most common complaints and requests can
gry, hot, or cold is a driving force that normally results be used.
in remedial action, but this is beyond the power of the For planned admissions to the ICU, such as af-
ICU patient. ter major surgery, an explanation of tubes, lines, moni-
Good nursing care helps to avoid pressure ar- toring and procedures can be made in advance. In this
eas and prevents the patient from lying on a rumpled way, common interventions that are not expected by the
sheet or tubing, ventilator tubing from dragging on the patient will not interpreted by the patient as “something
endotracheal tube, ECG leads pulling across the skin on has gone wrong.”
the chest, drip tubing pulling on cannulae (in addition, While pain perception may be exaggerated by
dislodgement usually means re-insertion, which may be additional factors, and ameliorating these factors may
diffi cult). Awareness of all such details helps to reduce make pain considerably more tolerable, they will not
unnecessary discomfort. take pain away. Th erefore, appropriate doses of analge-
Supportive modes of ventilation such as pres- sics will still be required.
sure support and other modes on modern ventilators
are associated with greater patient comfort and require Case report (cont.)
less analgesia and sedation compared with full ventila- Still heavily sedated and ventilated, Joe is started on
tion. Maintaining muscle activity will reduce respiratory an intravenous infusion of morphine at a rate of 10 mg
muscle wasting. per hour. He starts struggling, and the ventilator alarm
Other symptoms such as nausea, vomiting, keeps buzzing. He also becomes very tachycardic and
itch, significant pyrexia, and cramps require their hypertensive, causing concern for the staff . A review of
own management. Fractures need to be stabilized sedation and analgesia is necessary in the unit. (Th ink
either surgically, when appropriate, or immobilized. of infection, fat emboli, inadequate sedation/analgesia,
Causes of agitation such as a full bladder or rectum respiratory distress due to pulmonary contusions, etc.).
should be excluded. Joe’s white cell count is slightly elevated, temperature is
on the higher side, platelets are increasing, and coagu-
Are there alternative and psychological lation results are encouraging. Th ere is no clinical evi-
measures from which my patient could benefi t?
dence of fat embolization. Th ere is a concern that Joe’s
Relaxation techniques require a cooperative patient sedation/analgesia might be inadequate. He is started
preferably breathing spontaneously to coordinate deep on regular nasogastric paracetamol, his sedation with
breathing with sequential relaxation of muscle groups midazolam is increased, and his morphine dose is
from head to toe. Music can be benefi cial, particularly raised to 15 mg per hour, after a bolus dose of 5 mg.
if it is of the patient’s choice and appreciated through He settles down, eventually, and there are no immedi-
headphones, rather than being added to background ate concerns.
noise of ICU.
Speaking to the patient by name, even though What should be considered for weaning and
preparation for extubation?
the patient appears sedated, and explaining what is
about to happen is always helpful, both for the patient Th e fi rst rule is to outline your strategies for a success-
and for visiting relatives or friends. It helps patients to ful weaning and extubation, from a pain control point
reconnect with who they are and with their family. Tell- of view:
ing patients who understand and are recovering that • Continue paracetamol
they are making good progress assists positive thinking • Reduce morphine and midazolam
and can enhance recovery. • Review full blood count, coagulation parameters,
Giving patients the opportunity to express their and renal function
pain or discomforts by some means is helpful so that • Does the patient still need the intercostal drains?
they know staff are sympathetic and will explain the • Plan to achieve better analgesic control, such
possible remedies. If the patient can write, the fi rst op- as with nerve blocks, or by adding an NSAID
portunity will invariably produce squiggles resembling if renal function has improved and platelets are