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Intensive care specialists have become increasingly more interested in the prevention and treatment of physiologic and psychological stress in critically ill patients1–3 in order to prevent detrimental consequences ranging from systemic inflammatory response syndrome,4 to cardiac complications,5,6 to posttraumatic stress disorder.7–9 Studies have addressed the questions of an optimal sedation regimen and several evidence-based guidelines and strategies have been published.10–14 The analgesic component for sufficient stress relief, however, has not been addressed extensively, and few recommendations, primarily based on individual clinical practices, are currently available.15

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In view of the side effects of opioids, especially respiratory depression, altered mental status, and reduced bowel function, regional analgesia utilizing neuraxial and peripheral nerve blocks offer significant advantages. The lack of a universally reliable pain assessment tool (“analgesiometer”) in the critically ill contributes to the dilemma of adequate analgesia. Many patients in the critical care unit are not able to communicate or use a conventional visual or numeric analog scale to quantify pain. Alternative assessment tools derived from pediatric16–18 or geriatric19 practice that rely on grimacing and other physiologic responses to painful stimuli might be useful, but have been inadequately studied in the intensive care unit (ICU). Changes in heart rate and blood pressure in response to nursing activities, dressing changes, or wound care can also serve as indirect measurements of pain,20 and sedation scores like the Ramsey or Riker and colleagues21,22 scale might be helpful, although not specifically designed for pain assessment.

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The objective of this chapter is to describe the indications, limitations, and practical aspects of continuous regional analgesic techniques in the critically ill based on the available evidence, which at the moment is limited to case reports, cohort studies, expert opinion, and extrapolation from studies looking primarily at intraoperative use of regional anesthesia extending into the postoperative ICU stay. The evidence level of our recommendation is therefore mostly grade C and D according to the “Grades of Recommendation” published by the Oxford University Centre for Evidence Based Medicine (http://www.cebm.net/index.asp).

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Epidural analgesia is probably the most commonly used regional analgesic technique in the ICU setting.23 Some indications, in which epidural analgesia may not improve mortality rates but facilitates management and improves patient comfort in the ICU, include chest trauma,24–27 thoracic28,29 and abdominal surgery,5,30,31 major vascular surgery,32,33 major orthopedic surgery,34 acute pancreatits,35 paralytic ileus,36–39 cardiac surgery,40,41 and intractable angina pain.42,43 Although high-risk patients seem to profit most from epidural analgesia,44,45 the current literature does not address the specific circumstances of the critically ill patient with multiple comorbidity and organ failure. For that reason, an individual approach is necessary when considering application of epidural analgesia in this population.46

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In a survey of 216 general ICUs in England, ...

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