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PAIN RELIEF AND SEDATION IN THE INTENSIVE CARE UNIT

PAIN RELIEF AND SEDATION IN THE INTENSIVE CARE UNIT. Prof. Mary Korula Department of Anaesthesia CMC, Vellore. ANY PAIN THERAPY not “One size fits all or Set and forget therapy. Its essentially a maintenance therapy”. Goals of Intensive care Medicine.

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PAIN RELIEF AND SEDATION IN THE INTENSIVE CARE UNIT

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  1. PAIN RELIEF AND SEDATION IN THE INTENSIVE CARE UNIT Prof. Mary Korula Department of Anaesthesia CMC, Vellore.

  2. ANY PAIN THERAPY not “One size fits all or Set and forget therapy. Its essentially amaintenance therapy”

  3. Goals of Intensive care Medicine • Save the salvageable and relieve suffering • Peaceful & dignified death without prolonging life • Curative therapy should not supplant palliation of pain • Use of state-of-the-art interventions • Aggressive & fast paced therapy according to need • Quality pain management mandatory for all patients

  4. Science of pain management in ICU • Physiology of nociception & implication of pain therapy • Evaluation and monitoring of pain in ICU • End - of - life care with sound palliation • Treatment modalities available & their adverse effects • Pain relief within an interdisciplinary holistic model

  5. Truths • Majority ICU patents suffer severe/ moderate pain • 40% are delirious & cannot communicate • 50% are either physically/ emotionally distressed • 10-20% have no hopes of cure --- end-of-life in ICU • Balance between pain relief & maintaining alertness • Multidisciplinary team for multimodal therapies.

  6. Pain in ICU • Repeated episodes of acute pain localised • Surgery / tissue inflammation / immobility • Catheter/ apparatus discomfort / naso & orogastric tubes • Endotracheal intubation/ suctioning/ chest tubes • Phlebotomy / vascular access / physiotherapy • Routine turning & positioning the patient

  7. Types of pain in ICU • Somatic – most common –localised  opiates • Visceral – cramping & colicky  anticholinergics • Neuropathic – burning / shooting  antidepressants • Mixed type  combination therapy • Sustained or chronic pain of varying degrees

  8. Problems • Difficult to differentiate due to lack of communication • Untreated pain affects all body systems • Synergistic effect of pain on anxiety, depression, sleep • Interaction to heighten pain experience • All modalities are unpredictable & have adverse effects • Pain therapy to be tailored to individual needs.

  9. Assessment of pain in ICU • Establishment of pain as 5th vital sign - frequent evaluations • In cognitive impairment /delirium markers - behavioural (facial-FACS) - physiological-BP,HR,RR • Creative assessments - teaching hand movts / blinking • Subjective quantification numeric/graphic scales (W-B faces)

  10. Treatment of Pain • Treatment of perceived & prevention of anticipated pain • Opiates – principal agents in ICU - potent / lack of ceiling effects - mild anxiolytic & sedative - relieves air hunger & suppress cough in resp failure - improved patient – ventilator synchrony - effective antagonist - naloxone • Lack amnesic effects /additional sedatives required • Adjuvant / non-pharmacological / multimodal therapies

  11. Routes of administration • I/V infusions / scheduled doses • S/C when I/v route fails – infusions / bolus • Oral, rectal, sublingual transdermal – unpredictable • Epidural/ intrathecal routes for surgical patients • PCA via any route - PCEA / nerve blocks/ oral/ nasogastric • Basal infusion /short lock-out intervals for added comfort

  12. DISPOSABLE PCA PUMPS

  13. Analgesic Drugs • Morphine & Hydromorphine  accumulation of metabolites • Pethidine - only for shivering/ drug induced rigors • Codeine/oxycodone – oral - not effective • Methadone for c/c pain/ complex pain syndromes • Fentanyl / sufentanil/ remifentanil/ alfentanil  popular • Flexibility of choice essential

  14. Sedation in ICU • In the agitated, ventilated & for procedure discomfort • To avoid self extubation & removal of catheters • NM blockade mandates analgesia & sedation • Control of pain before sedation • All have side effects – dose dependent • Analgesics are not sedatives/ Sedatives are not analgesics

  15. SCCM task force recommendations • Benzodiazepines most popular for sedation • Short term sedation – midazolam<3h (amnesic/ hypotension) - propofol – infusion syndrome/ pancreatitis • Long term – lorazepam<20h /diazepam>96h (not for infusion) • Delirium – haloperidol - neurolept syndrome/torsade pointes • Antagonist- flumazenil 0.2mg-1mg (withdrawal seizures)

  16. Sedation scoring systems • Assess levels to vary according to course of ICU stay • Observational scales - 4 levels – min, mod, deep, GA • Addenbrooke sedation scale 0-7 (vocal, tracheal suction) • Ramsay sedation scale 1-6 (vocal, glabellar tap)--aim for 3-4 • Direct information- ideal to assess analgesia & sedation • BIS – for deep sedated & paralysed

  17. BIS monitor

  18. Sedation protocols • Sedation & amnesia to avoid intense feelings oversedation • Daily sedation interruption with immediate interventions • Lower PTSD symptoms & psychiatric well being • Gradual in sedation  delayed awakening / distress • Both strategies can fail  agitation / oversedation • KEYS – Flexibility & patient/ relatives participation

  19. Delirium in ICU • Environmental - noise, light, sleep deprivation • Fever ,infections, metabolic, electrolyte disturbances, MOF • Sedatives  sleep disturbances –GABA /Ach/ dopamine • Inotropes, vasopressors, steroids, antiarrythmics, dilators • Confusion assessment method for ICU (CAM-ICU) • Richmond agitation sedation scale (RASS)

  20. Newer drugs- dexmedetomidine • Dexmedetomidine- 2 agonist/ GABA sparing effects • Short term analgesia, sedation, anxiolysis • No cardio-respiratory depression/ easily arousable • Continuous infusion in ventilated /prior,during &post- extbn • No amnesia/ crosses placenta/ NREN sleep, REM sleep • Antagonised by atipamezole – combinations useful in ICU

  21. End of life management • Opposing goals - assuring comfort OR communication • Pain, dyspnea, fatigue,anxiety – freq at terminal weaning • Sudden onset distress  unsettling for patients / relatives • Ethical & legal concerns barriers for effective treatment • MYTHS - high dose opioids  hasten death /Euthanasia • Aggressive pain management  delays death - prevents physiological consequences of pain

  22. Future strategies for terminal weaning • ?Aggressive analgesia & sedation when withdrawing care • ? Daily sedative interruption for better communication • ? Target based sedation to improve cognition • ? Changing protocols to target different CNS receptors • ?Gradual reduction of sedatives to prevent abrupt distress • Endpoints Better outcomes /comfort & sleep preservation

  23. “Pain is a more terrible lord of mankind than even death itself”-Albert Schweitzer “Any drug is valueless if it remains in its ampoule, bottle or infusion pump.- Anonymous

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