PAIN RELIEF AND SEDATION IN THE INTENSIVE CARE UNIT

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PAIN RELIEF AND SEDATION IN THE INTENSIVE CARE
UNIT

• Prof. Mary Korula
• Department of Anaesthesia
• CMC, Vellore.

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ANY PAIN THERAPY not One size fits all or Set
and forget therapy. Its essentially a maintenance
therapy
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Goals of Intensive care Medicine

• Save the salvageable and relieve suffering
• Peaceful dignified death without prolonging
  life
• Curative therapy should not supplant palliation
  of pain
• Use of state-of-the-art interventions
• Aggressive fast paced therapy according to need
• Quality pain management mandatory for all patients

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Science of pain management in ICU

• Physiology of nociception implication of pain
  therapy
• Evaluation and monitoring of pain in ICU
• End - of - life care with sound palliation
• Treatment modalities available their adverse
  effects
• Pain relief within an interdisciplinary holistic
  model

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Truths

• Majority ICU patents suffer severe/ moderate
  pain
• 40 are delirious cannot communicate
• 50 are either physically/ emotionally distressed
• 10-20 have no hopes of cure --- end-of-life in
  ICU
• Balance between pain relief maintaining
  alertness
• Multidisciplinary team for multimodal therapies.

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Pain in ICU

• Repeated episodes of acute pain? localised
• Surgery / tissue inflammation / immobility
• Catheter/ apparatus discomfort / naso
  orogastric tubes
• Endotracheal intubation/ suctioning/ chest tubes
• Phlebotomy / vascular access / physiotherapy
• Routine turning positioning the patient

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Types of pain in ICU

• Somatic most common localised ? opiates
• Visceral cramping colicky ? anticholinergics
• Neuropathic burning / shooting ?
  antidepressants
• Mixed type ? combination therapy
• Sustained or chronic pain of varying degrees

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Problems

• Difficult to differentiate due to lack of
  communication
• Untreated pain affects all body systems
• Synergistic effect of pain on anxiety,
  depression, sleep
• Interaction to heighten pain experience
• All modalities are unpredictable have adverse
  effects
• Pain therapy to be tailored to individual needs.

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Assessment of pain in ICU

• Establishment of pain as 5th vital sign -
  frequent evaluations
• In cognitive impairment /delirium
• markers - behavioural (facial-FACS)
• - physiological-BP,HR,RR
• Creative assessments - teaching hand movts /
  blinking
• Subjective quantification numeric/graphic scales
  (W-B faces)

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Treatment of Pain

• Treatment of perceived prevention of
  anticipated pain
• Opiates principal agents in ICU
• - potent / lack of ceiling effects
• - mild anxiolytic sedative
• - relieves air hunger suppress cough in
  resp failure
• - improved patient ventilator synchrony
• - effective antagonist - naloxone
• Lack amnesic effects /additional sedatives
  required
• Adjuvant / non-pharmacological / multimodal
  therapies

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Routes of administration

• I/V infusions / scheduled doses
• S/C when I/v route fails infusions / bolus
• Oral, rectal, sublingual transdermal
  unpredictable
• Epidural/ intrathecal routes for surgical
  patients
• PCA via any route - PCEA / nerve blocks/ oral/
  nasogastric
• Basal infusion /short lock-out intervals for
  added comfort

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DISPOSABLE PCA PUMPS
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Analgesic Drugs

• Morphine Hydromorphine ? accumulation of
  metabolites
• Pethidine - only for shivering/ drug induced
  rigors
• Codeine/oxycodone oral - not effective
• Methadone ?for c/c pain/ complex pain syndromes
• Fentanyl / sufentanil/ remifentanil/ alfentanil ?
  popular
• Flexibility of choice essential

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Sedation in ICU

• In the agitated, ventilated for procedure
  discomfort
• To avoid self extubation removal of catheters
• NM blockade mandates analgesia sedation
• Control of pain before sedation
• All have side effects dose dependent
• Analgesics are not sedatives/ Sedatives are not
  analgesics

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SCCM task force recommendations

• Benzodiazepines most popular for sedation
• Short term sedation midazolamlt3h (amnesic/
  hypotension)
• - propofol
  infusion syndrome/ pancreatitis
• Long term lorazepamlt20h /diazepamgt96h (not for
  infusion)
• Delirium haloperidol - neurolept
  syndrome/torsade pointes
• Antagonist- flumazenil 0.2mg-1mg (withdrawal
  seizures)

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Sedation scoring systems

• Assess levels to vary according to course of ICU
  stay
• Observational scales - 4 levels min, mod, deep,
  GA
• Addenbrooke sedation scale 0-7 (vocal, tracheal
  suction)
• Ramsay sedation scale 1-6 (vocal, glabellar
  tap)--aim for 3-4
• Direct information- ideal to assess analgesia
  sedation
• BIS for deep sedated paralysed

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BIS monitor
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Sedation protocols

• Sedation amnesia to avoid intense feelings?
  oversedation
• Daily sedation interruption with immediate
  interventions
• Lower PTSD symptoms psychiatric well being
• Gradual in sedation ? delayed awakening /
  distress
• Both strategies can fail ? agitation /
  oversedation
• KEYS Flexibility patient/ relatives
  participation

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Delirium in ICU

• Environmental - noise, light, sleep deprivation
• Fever ,infections, metabolic, electrolyte
  disturbances, MOF
• Sedatives ? sleep disturbances GABA /Ach/
  dopamine
• Inotropes, vasopressors, steroids,
  antiarrythmics, dilators
• Confusion assessment method for ICU (CAM-ICU)
• Richmond agitation sedation scale (RASS)

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Newer drugs- dexmedetomidine

• Dexmedetomidine- ?2 agonist/ GABA sparing effects
• Short term analgesia, sedation, anxiolysis
• No cardio-respiratory depression/ easily
  arousable
• Continuous infusion in ventilated /prior,during
  post- extbn
• No amnesia/ crosses placenta/ NREN sleep, REM
  sleep
• Antagonised by atipamezole combinations useful
  in ICU

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End of life management

• Opposing goals - assuring comfort OR
  communication
• Pain, dyspnea, fatigue,anxiety freq at terminal
  weaning
• Sudden onset distress ? unsettling for patients /
  relatives
• Ethical legal concerns ?barriers for effective
  treatment
• MYTHS - high dose opioids ? hasten death
  /Euthanasia
• Aggressive pain management ? delays death
• - prevents physiological
  consequences of pain

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Future strategies for terminal weaning

• ?Aggressive analgesia sedation when withdrawing
  care
• ? Daily sedative interruption for better
  communication
• ? Target based sedation to improve cognition
• ? Changing protocols to target different CNS
  receptors
• ?Gradual reduction of sedatives to prevent abrupt
  distress
• Endpoints ?Better outcomes /comfort sleep
  preservation

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Pain is a more terrible lord of mankind than
even death itself -Albert Schweitzer
Any drug is valueless if it remains in its
ampoule, bottle or infusion pump. -
Anonymous
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