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Pain: Why treat it?. Humanitarian JCAHO (2001) Blunt autonomic and somatic response to pain - Elevated metabolic rate - Elevated O2 consumption - Hypercoagulability - Altered immune status - Development of chronic pain. Pain: Why Don’t We Treat It Well?. Lack of concern/caring

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pain why treat it
Pain: Why treat it?

Humanitarian

JCAHO (2001)

Blunt autonomic and somatic response to pain

- Elevated metabolic rate

- Elevated O2 consumption

- Hypercoagulability

- Altered immune status

- Development of chronic pain

pain why don t we treat it well
Pain: Why Don’t We Treat It Well?
  • Lack of concern/caring
  • Lack of knowledge
  • Uniform prescribing practices
  • Fear of side effects
  • Fear of addiction
armamentarium
Armamentarium
  • Guided imagery (!)
  • Patient education
  • Narcotics
  • NSAIDs
  • Gaba agonists
  • Local/regional anesthetics
  • “Preemptive” treatment
  • “Procedure specific” – Prospect website
local anesthetics
Local anesthetics

Dose-dependent blockage of sodium channels in neurons

Amides and esters (amides less allergenic)

Amides:Lidocaine, bupivacaine, prilocaine

Esters: Novocaine

Lidocaine dosing: 5 mg/kg without epi

7 mg with epi

nsaids
NSAIDS
  • Conventional Cox inhibitors
  • Cox 2 inhibitors

Decreased incidence of GI bleeding

Didn’t inhibit platelet aggregation

Initial data on side effects was on usage for greater than 1-2 years

Now some data on side effects as analgesics for CABG patients

gabapentin pregabalin
Gabapentin/Pregabalin
  • How do they work?
  • Who knows?
    • Presynaptic binding to calcium channels in brain
    • Decrease excitatory transmission
narcotics
Narcotics
  • Morphine
  • Fentanyl
  • Hydromorphone
  • All work on mu receptors
    • Decrease responsiveness of resp center to CO2
    • Stimulate medullary chemoreceptor trigger zone
    • Increase sphincter tone and decrease peristalsis
opiate analgesic options fentanyl morphine hydromorphone
Opiate Analgesic Options: Fentanyl, Morphine, Hydromorphone

* Offset prolonged after long-term use

** Active metabolite accumulation causes excessive narcosis

rescue bolus doses
Rescue/Bolus Doses
  • MSO4 0.1 mg-0.3 mg/kg IV (70 kg – 7-21 mg IV!!!) – I give 5
  • Fentanyl 25-200 mg IV
  • Dilaudid 0.01-0.03 mg/kg IV (70 kg – .7-2.1 mg IV)
slide11
PCA
  • MSO4
    • Dose 1.5 mg
    • Lockout 7 min
    • 4 hr limit 30
    • How do you adjust?
slide12
PCA
  • Fentanyl
    • Dose 20 mcg
    • Lockout 7 min
    • 4 hour dose 300 mcg
    • When do you use it?
slide13
PCA
  • Dilaudid
    • Dose 0.2 mg
    • Lockout 7 mg
    • 4 hr limit 3 mg
case 1
Case 1

36 y.o morbidly obese woman with RUQ pain at 20 hrs, RUQ tenderness, WBC 13, US with stones, wall 5.0 mm

What’s she got?

How will we manage her pain? What are our Prospects?

case 2
Case 2
  • 65 y.o. man with COPD here for esophageal cancer
  • What operation is he going to get?
epidural anesthesia
Epidural Anesthesia
  • What is good about it?
    • Decreases risk of DVT
    • Increases risk of graft thrombosis
    • Decreases post op ileus in upper abd surgy
    • Decrease ICU days and vent days after abd vasc surgery
flavors of epidurals
Flavors of epidurals
  • Narcotics
  • Narcotics + Local anesthetics
  • Complications:
    • Rostrol migration of morphine with respiratory depression up to 18 hrs after
    • Hypotension from sympathectomy
p o conversion
P.O. Conversion
  • Morphine 10 mg. = oxycodone 20 mg
case 3
Case 3
  • 20 y.o. man MCC intubated in field for combativeness, open femur, SAH and L cerebral contusion, etoh 498
  • What’s going to happen to him tonight?
case 322
Case 3
  • Back from the OR
  • Ex-fix, EVD with ICP 16
  • What meds will you write for? What do you have to treat?
sedation options propofol
Sedation Options: Propofol
  • Pharmacology: GABA agonist
  • Pharmacokinetics/dynamics: onset 1 - 2 minutes, terminal half-life 6 hours, duration 10 minutes, hepatic metabolism
  • Benefits
    • Rapid onset and offset and easily titrated
    • Hypnotic and antiemetic
    • Can be used for intractable seizures and elevated intracranial pressure
  • Risks
    • Not reliably amnestic, especially at low doses
    • NO analgesia!
    • Hypotension
    • Hypertriglyceridemia; lipid source (1.1 kcal/ml)
    • Respiratory depression
    • Propofol Infusion Syndrome

- Cardiac failure, rhabdomyolysis, severe metabolic acidosis, and renal failure

- Caution should be exercised at doses > 80 mcg/kg/min for more than 48 hours

- Particularly problematic when used simultaneously in patient receiving catecholamines and/or steroids

sedation options benzodiazepines midazolam and lorazepam
Sedation Options: Benzodiazepines (Midazolam and Lorazepam)
  • Pharmacokinetics/dynamics
    • Lorazepam: onset 5 - 10 minutes, half-life 10 hours, glucuronidated
    • Midazolam: onset 1 - 2 minutes, half-life 3 hours, metabolized by cytochrome P450, active metabolite (1-OH) accumulates in renal disease
  • Benefits
    • Anxiolytic
    • Amnestic
    • Sedating
  • Risks
    • Delirium
    • NO analgesia
    • Excessive sedation: especially after long-term sustained use
    • Propylene glycol toxicity (parenteral lorazepam): significance uncertain

- Evaluate when a patient has unexplained acidosis

- Particularly problematic in alcoholics (due to doses used) and renal failure

    • Respiratory failure (especially with concurrent opiate use)
    • Withdrawal
case 325
Case 3
  • Continuous infusion
    • Fentanyl 1 mcg/kg/hr
    • MS04 1-5 mg/hr
    • Midazolam 1-4 mg/hr
    • Lorazepam 1-4 mg/hr
    • Propofol – 30-120 mcg/kg/min (packaged at 10mg/cc; approx 10-40 cc/hr for 70 kg pt)
overview of sccm algorithm
Overview of SCCM Algorithm

1

2

3

4

Jacobi J, Fraser GL, Coursin D, et al. Crit Care Med. 2002;30:119-141.

overdose
Overdose
  • Nalaxone
  • flumazenil
atypical antipsychotics quetiapine olanzapine risperidone ziprasidone
Atypical Antipsychotics: Quetiapine, Olanzapine, Risperidone, Ziprasidone
  • Mechanism of action unknown
  • Less movement disorders than haloperidol
  • Enhanced effects on both positive (agitation) and negative (quiet) symptoms
  • Efficacy = haloperidol?
    • One prospective randomized study showing equal efficacy of olanzapine to haldol with less EPS
  • Issues
    • Lack of available IV formulation
    • Troublesome reports of CVAs, hyperglycemia, NMS
    • Titratability hampered

- QTc prolongation with ziprasidone IM

- Hypotension with olanzapine IM

haloperidol
Haloperidol
  • No prospective randomized controlled trials in ICU delirium
  • > 700 published reports involving > 2,000 patients
  • The good:
    • Hemodynamic neutrality
    • No effect on respiratory drive
  • The bad:
    • QTc prolongation and torsades de pointes
    • Neuoroleptic malignant syndrome - only three cases with IV haloperidol
    • Extrapyramidal side effects - less common with IV than oral haloperidol
opiate and benzodiazepine withdrawal
Opiate and Benzodiazepine Withdrawal
  • Frequency related to dose and duration
    • 32% if receiving high doses for longer than a week
  • Onset depends on the half-lives of the parent drug and its active metabolites
  • Clinical signs and symptoms are common among agents
    • CNS activation: seizures, hallucinations,
    • GI disturbances: nausea, vomiting, diarrhea
    • Sympathetic hyperactivity: tachycardia, hypertension, tachypnea, sweating, fever
  • No prospectively evaluated weaning protocols available
    • 10 - 20% daily decrease in dose
    • 20 - 40% initial decrease in dose with additional daily reductions of 10 - 20%
  • Consider conversion to longer acting agent or transdermal delivery form
protocols and assessment tools
Protocols and Assessment Tools
  • SCCM practice guidelines can be used as a template for institution-specific protocols.
  • Titration of sedatives and analgesics guided by assessment tools:
    • Validated sedation assessment tools (Ramsay Sedation Scale [RSS], Sedation-Agitation Scale [SAS], Richmond Sedation-agitation Scale [RSAS], etc.)

- No evidence that one is preferred over another

    • Pain assessment tools - none validated in ICU (numeric rating scale [NRS], visual analogue scale [VAS], etc.)
daily goal is arousable comfortable sedation
Daily Goal is Arousable, Comfortable Sedation
  • Sedation needs to be protocolized and titrated to goal:
    • Lighten sedation to appropriate wakefulness daily.
  • Effect of this strategy on outcomes:
    • One- to seven-day reduction in length of sedation and mechanical ventilation needs
    • 50% reduction in tracheostomies
    • Three-fold reduction in the need for diagnostic evaluation of CNS
appropriate recall may be important
Appropriate Recall May be Important
  • Factual memories (even unpleasant ones) help to put ICU experience into perspective
  • Delusional memories risk panic attacks and PTSD
  • The optimal level of sedation for most patients is that which offers comfort while allowing for interaction with the environment.
recall in the icu
Recall in the ICU
  • Some degree of recall occurs in up to 70% of ICU patients.
    • Anxiety, fear, pain, panic, agony, or nightmares reported in 90% of those who did have recall.
  • Potentially cruel:
    • Up to 36% recalled some aspect of paralysis.
  • Associated with PTSD in ARDS?
    • 41% risk of recall of two or more traumatic experiences.
  • Associated with PTSD in cardiac surgery
what we know about icu agitation discomfort
What We Know About ICU Agitation/Discomfort
  • Prevalence
    • 50% incidence in those with length of stay > 24 hours
  • Primary causes: unrelieved pain, delirium, anxiety, sleep deprivation, etc.
  • Immediate sequelae:
    • Patient-ventilator dyssynchrony
    • Increased oxygen consumption
    • Self (and health care provider) injury
    • Family anxiety
  • Long-term sequelae: chronic anxiety disorders and post-traumatic stress disorder (PTSD)
opiates
Opiates
  • Benefits
    • Relieve pain or the sensibility to noxious stimuli
    • Sedation trending toward a change in sensorium, especially with more lipid soluble forms including morphine and hydromorphone.
  • Risks
    • Respiratory depression
    • NO amnesia
    • Pruritus
    • Ileus
    • Urinary retention
    • Histamine release causing venodilation predominantly from morphine
    • Morphine metabolites which accumulate in renal failure can be analgesic and anti-analgesic.
    • Meperidine should be avoided due to neurotoxic metabolites which accumulate, especially in renal failure, but also produces more sensorium changes and less analgesia than other opioids.