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
- ▪ 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
- ▪ 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).
Patient-controlled device for intravenous and epidural
analgesic regimens. Patients can administer a bolus of the drug
on demand by pushing the button.
Cross-section of the spine, showing the epidural space
distended with infused fluid and adjacent
to nerve roots as they emerge from the cord.
- ▪ 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
- ▪ 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
- ▪ 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 (ie, willingness to ...