Page 302 Guide to Pain Management in Low-Resource Settings

290 Josephine M. Th orp and Sabu James

within normal limits (remember gastric muco- • Stabilize fractures with a splint, plaster, or surgi-
sal protection) cal fi xation as soon as possible.
• As elsewhere, pain on movement is greater than
Case report (cont.) pain at rest.

Respiratory parameters support adequate weaning, mor- • Anticipate painful procedures or maneuvers by
phine infusion is ongoing, no epidural or paravertebral giving extra analgesia beforehand.
block has been inserted, and the patient is extubated. He • Bolus doses of opiate are required before an infu-
manages to survive off the ventilator for about 2 hours. sion is started.
He complains of severe pain in his chest (from the frac- • An infusion rate increase takes time to become
tured ribs) and in the laparotomy wound. Progressively eff ective; give a bolus fi rst.
he becomes unable to breathe, his saturation drops, and • Multimodal therapy can reduce opioid require-
he needs to be re-intubated soon afterward. ments and side eff ects, but beware the hazards of
Once Joe is settled and stable, inadequate pain nonopioid analgesics in this group of patients.
control is seen to have been a major factor in the failed • Older persons have lower analgesic requirements;
extubation, and he gets a thoracic epidural and a left- young adults have higher ones.
sided paravertebral block. A bolus dose of local anes- • Addiction to opioids is not a problem in patients
thetic is given into the epidural, and a continuous infu- surviving critical care.
sion is set up. • Underprovision of analgesia in general is a greater
What should be done next? Review his analge- problem than overdosing.
sia and slowly wind down the morphine infusion, hoping
that the epidural and paravertebral blocks are working. References
Joe is reviewed next day; sedation and morphine
are minimal, and he is wide awake and wants the endo- [1] Cardno N, Kapur D. Measuring pain. BJA CEPD Reviews 2002;2(1):7–10.
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Lumb PD; Task Force of the American College of Critical Care Medi-
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traumatic situations. Anaesth Intensive Care Med 2005;6:2–6.
• Regular assessment of pain and discontinuing bo- [13] Soliman HM, Mélot C, Vincent JL. Sedative and analgesic practice in
the intensive care unit: the results of a European survey. Br J Anaesth
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