Guidelines for pain management and sedation in critically ill patients

Guidelines for pain management and sedation in critically ill patients – In Consultation

Dougles B. Coursin

What tips can you suggest for the delicate balancing of analgesia and sedation in the ICU?

Analgesia and sedation in critically ill patients are increasingly recognized as important topics and recently have been addressed in various prospective studies. (1-5) In addition, an updated, evidenced-based set of guidelines on the optimal use of sedative, analgesic, and paralyzing drugs in, the ICU has been generated by a multidisciplinary group of critical care experts and published in the respective journals of the Society of Critical Care Medicine (6,7) and the American Society of Health-System Pharmacists.

Several principles deserve emphasis (Table). (1) Talk to patients routinely about their needs for sedation or analgesia; reassure them that you will address their needs. Patients frequently require both analgesia and sedation, particularly intubated, agitated, or delirious critically ill patients. A large number of ICU patients require judicious drug administration, while some may benefit from pain management using nonpharmacologic means, such as biofeedback or massage therapy. Pharmacologic strategies may include classic oral, intramuscular, or intravenous administration of narcotic or anti-inflammatory drugs as needed or timed bolus injection or continuous infusion. Local anesthetic delivered with or without narcotics in regional blocks or by epidural or subarachnoid administration may be necessary also.

It is paramount that pain, the “fifth vital sign,” be identified, alleviated, and even eliminated. Combine inquiry with the use of subjective scoring criteria, such as visual analog scales, to evaluate pain in critically ill patients. Do not overlook the need for pain management in unconscious, intubated, and noncommunicative patients. Analgesic medications may provide some sedation, but sedative agents are not analgesics and may heighten the sense of pain while adding to an altered sensorium.

The use of an objective device to monitor levels of consciousness and patient comfort currently is under evaluation. Appropriate indications for and application of modified electroencephalography (with electromygrphic filtering) or evoked potentials appear to be evolving. (8) The need for practitioner education and experience with such devices is being assessed.

Various groups have reported the benefits of standardizing sedative, analgesic, and paralytic protocols. (1-4) Recent data suggest that a daily discontinuation of all sedative/analgesic medications may be effective in decreasing the duration of ventilation and ICU stay without untoward effects, such as unplanned extubation or hemodynamic instability. (4) Subjective systems that are easy to apply and valid between observers should be used universally.

Neuromuscular blocking agents (NMBs), such as succinylcholine, atracurium, rocuronium, and pancuronium, are combined with anesthetic and analgesic drugs to facilitate airway establishment and selected procedures in critically ill patients. On a case-by-case basis (approximately 1% or fewer of mechanically ventilated patients), NMBs are administered for hours to days as intermittent boluses or continuous infusions. (7)

Nondepolarizing NMBs have no sedative, hypnotic, analgesic, or amnestic effects. Ventilation must be provided for patients during the use of these potent paralyzing agents. Induce the minimal degree of paralysis needed to allow adequate ventilation: use a handheld peripheral nerve stimulator to monitor the degree of paralysis every 4 to 8 hours while NMBs are administered. (7,8) Although the exact adjustment of the train-of four ratio has not been identified, it should be as little as possible (try to maintain at least 2 of 4 twitches with train-of-four monitoring). The use of peripheral nerve stimulation has been shown to limit but not eliminate significant side effects, such as postparalysis weakness. (7-10)

Sedatives and analgesics are some of the most commonly used medications in the ICU. These drugs have potent side effects and potential for significant direct and indirect costs. Optimal use of these agents requires individualized dosing, subjective or objective determination of drug effects, and continuous reappraisal of need for therapy. Experts advise discontinuing these agents routinely–often daily–to reassess patient responsiveness and the need for continued therapy.

Table — General principles for sedation and analgesia

* Anticipate, recognize, quantify, and treat–then reassess

* Consider nanpharmacologic therapies

* Always titrate medications to desired effect (use a scale when

possible)

* Talk to the patient and provide reassurance to reduce the need

for medication

* Use the smallest effective dose

* Anticipate that medication needs will change with time and effects

will vary depending on:

External stimuli

Age

Pharmacokinetic variability

Severity of illness

Renal and liver function

Tolerance

Accumulation

Concomitant medications

Adapted from Park Get al. Crit Care Clin. 2001. (1)

(1.) Park G, Coursin D, Ely EW, et al. Commentary: balancing sedation and analgesia in the critically ill. Crit Care Clin. 2001;17:1015-1027.

(2.) Kollef MH, Levy NT, Ahrens TS, et al. The use of continuous IV sedation is associated with prolongation of mechanical ventilation. Chest. 1998;114:541-548.

(3.) Brook AD, Ahrens TS, Schaiff R, et al. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med. 1999;27:2609-2615.

(4.) Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engi I Med. 2000;342:1471-1477.

(5.) Ely EW. lnouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA. 2001;286:2703-2710.

(6.) Jacobi J, Fraser GL, Coursin DB, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. 2002;30:119-141.

(7.) Murray MJ, Cowan J, DaBlock H, et al. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Crit Care Med. 2002;30:142-156.

(8.) Riker RR, Fraser GL. Monitoring sedation, agitation, analgesia, and neuromuscular blockade. Samin Respir Crit Care Mad. 2001;22:189-198.

(9.) Rudis MI, Sikora CA, Angus E, et al. A prospective, randomized, controlled evaluation of peripheral nerve stimulation versus standard clinical dosing of neuromuscular blocking agents in critically ill patients. Crit Care Mad. 1997;25:575-583.

(10.) de Letter MA, Schmitz PI, Visser LH, et al. Risk factors for the development of polyneuropathy and myopathy in critically ill patients. Crit Care Med. 2001;29:2281-2286.

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DOUGLAS B. COURSIN, MD

Professor of anesthesiology and internal medicine and associate director of the Trauma & Life Support Center, University of Wisconsin Medical School, Madison.

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