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Introduction

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Intensive care patients experience pain to varying degrees and for a variety of reasons during their intensive care unit (ICU) stay. The evolution of the discipline of pain management as well as increasingly precise knowledge about the pharmacology and physiology of pain has led to significant advances in its evaluation and treatment. Intensive care providers have a growing arsenal of tools with which to treat pain including pain management consultants, patient- controlled analgesia (PCA), epidural analgesia, opioids, and new nonsteroidal agents.

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Definitions and Terms

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  • ▪  Pain: The sensation of discomfort or distress, which may be localized or diffuse, resulting from stimulation of pain receptors (or nociceptors), and which results in the initiation of a variety of protective and potentially deleterious physiologic consequences.
  • ▪  Pain scale: A variety of visual analogs, indexes, and questionnaires designed to help a patient characterize the intensity, location, and quality of pain.
  • ▪  Visual analog scale: Probably the most common approach to pain assessment in intensive care patients (Figure 9-1).
  • ▪  PCA: See Figure 9-2.
  • ▪  PCEA: Patient-controlled epidural analgesia (Figure 9-3).

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Figure 9-2.
Graphic Jump Location

Patient-controlled device for intravenous and epidural analgesic regimens. Patients can administer a bolus of the drug on demand by pushing the button.

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Figure 9-3.
Graphic Jump Location

Cross-section of the spine, showing the epidural space distended with infused fluid and adjacent to nerve roots as they emerge from the cord.

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Techniques

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  • ▪  Intensive care patients experience pain due to the underlying illness, injury, or therapy (ie, surgery), which may be augmented by sleeplessness or anxiety.
  • ▪  Pain evaluation is a routine and required part of intensive care nursing assessment, and assessment may take the form of direct questioning, the use of scales and charts or empiric/clinical evaluation when the patient is unable to participate directly in the assessment.
  • ▪  Pain may result in adverse secondary clinical consequences such as splinting (and consequent atelectasis), tachycardia, sleeplessness, and delirium that may guide the choice of the primary treatment and require the use of complementary treatments to ameliorate the secondary problem (ie, β-blockade, sleeping medication)
  • ▪  Narcotic agents are typically used as first-line interventions in the ICU and can be administered intravenously by bolus, continuous infusion, patient-controlled continuous infusion, or as components of epidural analgesia
  • ▪  Nonsteroidal anti-inflammatory agents can be used to supplement narcotics
  • ▪  Initial assessment on admission to the intensive care should include consideration of the admission diagnosis, the likelihood that the patient will experience pain during the ICU stay, preadmission narcotic use that may necessitate modification of the analgesic regiment (ie, patient’s long-term narcotics use at home), cultural factors ...

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