It's impossible to get through a single shift in the ICU without encountering several patients experiencing pain. Controlling pain is easy – but controlling pain while limiting collateral side-effects can be a challenge. Anesthesiologists have pioneered the best approaches here, which often involve multimodal combinations of various medications carefully titrated to effect. Although intensivists may be late to the party, we can nonetheless still learn from the practice and evidence of anesthesiologists, to optimize pain management among critically ill patients.
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The IBCC chapter is located here.
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Great post! Some comments: Beware of one major side effect of alpha-2-agonists: Opstipation! This can be a huge problem especially for surgical patients. Caring for gastric and bowel movements is a big part in analgesia and you should add a paragraph or two about it (having a “ladder”-system similar to the analgesic ladder helps, e.g. baseline: macrogol, when to use oral naloxone, naltrexon, laxatives etc.) Don’t you guys have Sufentanil? It has completely replaced fentanyl at our hospital (both for anaesthesia and intensive care). It’s a shame you guys cannot use metamizol. We use it the same ways as you… Read more »
Hi Andreas,
I appreciated this post too. I agree that a issue in ICU is costipation, sometimes severe with prolonged ileus in surgical patients. We use sufentanil too and I think that it has a role in this phenomenon. I’d like to know your opinion about that. Thank you.
Hi Josh,
I thoroughly enjoyed reading this chapter. Do you have any opinions on the use of cannabinoids for pain?
I’m aware there isn’t an awful lot of literature to guide our practice but wondered if yourself or other readers had any experience with this drug class, particularly with chronic pain patients in whom pain may be difficult to control.
Great post!
The dexmedetomidine infusion doses are wrong. Where it says per minute is should say per HOUR.
Also we use Metamizol (Dipirone) in Argentine just like Acetaminophen but i think its banned in the US.
Greetings from South America
Thanks for the great post!
As a sidenote to your article I thought to mention intranasal dexmedetomide. Not a proper analgesic but excellent for short acting light-medium sedation. In the last few years it has become quite popular in ED:s in Finland for procedural or imaging sedation in adults, especially in agitated (alcohol)intoxicated pt:s as well as mentally disabled. Our starting dose is 50-100ug i.n., which rarely causes significant bradycardia. Repeat q15-20mins ad 200ug, where if inadequate sedation move on to another sedative.
https://pubmed.ncbi.nlm.nih.gov/28105598/
Great post!! Small error, though: Dexmedetomidine dose (Table) should be 0-1.4 mcg/kg/HOUR instead of min ?
Great post! Since it is as comprehensive as it is, why not have a section on epidural analgesia and nerve blocks as well especially for the surgical ICU patients?
Wonderful read! So happy to have come across a great summary for multi modal pain management in the ICU.
I noticed there was no mention of transdermal clonidine. Have you used this with any success?
Thanks.