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    Pain Management in Critically Ill Patient: Prof. Dr. Andi Husni Tanra, PHD, SP - An-Kic-Kmn

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    Reza Prakosa Sedyatama
    Pain is commonly experienced by critically ill patients and can have negative physiological effects if not properly managed. It is important to assess for the presence of pain in critically ill patients, even in those with impaired communication, using tools such as the Behavioral Pain Scale or Critical-Care Pain Observation Tool. Once pain is identified, it should be managed following a multimodal approach utilizing opioids, non-opioid analgesics, and other adjunctive medications via various routes of administration. The goal of the multimodal approach is to provide adequate pain relief while minimizing opioid consumption and reducing opioid-related adverse effects. Proper pain management in critically ill patients is an ethical obligation.

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    Pain Management in Critically Ill Patient: Prof. Dr. Andi Husni Tanra, PHD, SP - An-Kic-Kmn

    Uploaded by

    Reza Prakosa Sedyatama
    152 views42 pages
    Pain is commonly experienced by critically ill patients and can have negative physiological effects if not properly managed. It is important to assess for the presence of pain in critically ill patients, even in those with impaired communication, using tools such as the Behavioral Pain Scale or Critical-Care Pain Observation Tool. Once pain is identified, it should be managed following a multimodal approach utilizing opioids, non-opioid analgesics, and other adjunctive medications via various routes of administration. The goal of the multimodal approach is to provide adequate pain relief while minimizing opioid consumption and reducing opioid-related adverse effects. Proper pain management in critically ill patients is an ethical obligation.

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    Pain Management in ICU

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    Pain Management in ICU

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    Pain is commonly experienced by critically ill patients and can have negative physiological effects if not properly managed. It is important to assess for the presence of pain in critically ill patients, even in those with impaired communication, using tools such as the Behavioral Pain Scale or Critical-Care Pain Observation Tool. Once pain is identified, it should be managed following a multimodal approach utilizing opioids, non-opioid analgesics, and other adjunctive medications via various routes of administration. The goal of the multimodal approach is to provide adequate pain relief while minimizing opioid consumption and reducing opioid-related adverse effects. Proper pain management in critically ill patients is an ethical obligation.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    152 views42 pages

    Pain Management in Critically Ill Patient: Prof. Dr. Andi Husni Tanra, PHD, SP - An-Kic-Kmn

    Uploaded by

    Reza Prakosa Sedyatama
    Pain is commonly experienced by critically ill patients and can have negative physiological effects if not properly managed. It is important to assess for the presence of pain in critically ill patients, even in those with impaired communication, using tools such as the Behavioral Pain Scale or Critical-Care Pain Observation Tool. Once pain is identified, it should be managed following a multimodal approach utilizing opioids, non-opioid analgesics, and other adjunctive medications via various routes of administration. The goal of the multimodal approach is to provide adequate pain relief while minimizing opioid consumption and reducing opioid-related adverse effects. Proper pain management in critically ill patients is an ethical obligation.

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    © All Rights Reserved
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    of 42

    Pain Management in

    Critically Ill Patient


    Prof. dr. Andi Husni Tanra, PhD, Sp.An-KIC-KMN
    • An unpleasant sensory and emotional experience
    associated with actual or potential tissue damage, or
    described in terms of such damage
    • Can happen any where in our body

    Pain is..
    Pain is not felt by the brain,
    but by the person

    If the patient complains of pain, then there is pain.


    If the patients said no pain, then there is no pain
    NO MATTER of your examination result

    Sullivan MD et al (2013) What does it mean to call chronic pain a brain disease? J Pain 14:317–322
    80% of patients experience
    different intensities of pain
    during their ICU stay and
    identify it as one of the
    greatest sources of stress
    Adam VN, Matolic M, Ilic KM, Grizelj-Stojcic E, Smiljanic A, Skok I. Pain management in critically ill patients. Periodicum
    Biologorum. Vol. 117, No 2, 225–230, 2015
    Vazquez M et al

    • Analyzed pain intensity during 330 turnings in 96


    medical-surgical patients
    • Significantly increased pain score between rest and
    turning
    • Bolus of analgesic was used in less than 15% of the
    turnings

    Vazquez M, Pardavila M I, Lucia M, Aguado Y, Margall M A, Asiain M C. 2011 Pain assessment in turning procedures for patients
    with invasive mechanical ventilation. Nurs Crit Care 16: 178–185
    Many more pain source..
    Reardon et al

    • Pain stress response release catecholamines, cortisol,


    and glucagon

    Myocardial VO2 +++ Altered Fat and Protein Metabolism


    Insulin Resistance
    Reardon DP, Anger KE, Szumita PM. Pathophysiology, assessment, and management of pain in critically ill adults. Am J Health-Syst
    Pharm—Vol 72 Sep 15, 2015
    Reardon et al

    • Stress associated pain also lead to coagulopathies and


    reduced activity of the innate and adaptive immune
    systems.
    • Sustained pain result in hyperalgesia and spinal
    sensitization
    • a heightened sensitivity to pain by spinal neurons, which can
    result in an increased response to minimally noxious stimuli or
    the transmission of pain without painful stimuli
    • Acute pain may lead to chronic pain
    Reardon DP, Anger KE, Szumita PM. Pathophysiology, assessment, and management of pain in critically ill adults. Am J Health-Syst
    Pharm—Vol 72 Sep 15, 2015
    Reardon DP, Anger KE, Szumita PM. Pathophysiology, assessment, and management of pain in critically ill adults. Am J Health-Syst
    Pharm—Vol 72 Sep 15, 2015
    Still going to ignore the pain?

    You CAN NOT!


    Declaration of
    Montreal 2010
    Declaration of
    Montreal 2010
    • Obligation of governments and all health care
    institutions to establish laws, policies, and systems
    that will help to promote the access of people in pain
    to fully adequate pain management. Failure to
    establish such laws, policies, and systems is unethical
    and a breach of the human rights of people harmed
    as a result.
    Declaration of
    Montreal 2010
    • Obligation of all health care professionals in a
    treatment relationship with a patient to offer to a
    patient in pain the management that would be
    offered by a reasonably careful and competent health
    care professional in that field of practice. Failure to
    offer such management is a breach of the patient's
    human rights.
    Meaning.. You may face this..
    Furthermore..
    First Step:
    Identification of Presence of Pain
    • Most common choice
    Challenge!!!

    • Critically ill patient with cognitive or communication


    problems due to
    • Stroke
    • Brain injury
    • Dementia
    • Confusion
    • Use of sedatives
    • Difficulty in reporting pain
    Which one is better?

    BPS CPOT
    • Assess 3 domains • Assesses 4 domains
    • Validated in medical, • Validated in medical and surgical
    critically ill adult patients
    surgical, and neurological
    critically ill adult patients • Pre-eliminary phase on
    neurology/neurosurgery patients
    • Simpler • More complex
    Disadvantages

    • Measures the presence of pain but not the pain


    intensity
    • Cannot distinguish between pain types
    PDR
    (Pain Dilatory Reflex)

    Algiscan
    PPI
    (Pain Pupillary Index)
    We identified the presence of pain…

    What next?
    Basic Principle!
    Why Multimodal?
    • Developed analgesic ladder in 1986 for cancer pain
    • Ladder approach extended to the management of acute and
    chronic non-malignant pain
    • 5 Guiding principles
    5 Guiding Principles
    Routes of Administration
    Pharmacotherapy
    Opioids are the primary medications for managing pain
    in critically ill patients because of potency, concomitant
    mild sedative and anxiolytic properties, and their ability
    to be administered by multiple routes.

    Adam VN, Matolic M, Ilic MK, Grizelj-StojcIc E, Smiljanic A, Skok I. Pain management
    in critically ill patients. Periodicum Biologorum. 2015;117(2):225-30.
    Commonly Used Opioids

    Avoid in hemodynamically unstable patients. Active metabolite accumulates in


    renal dysfunction. May cause itching, tachycardia and hypotension due to
    histamine release.
    Fastest onset and shortest duration. Accumulation with hepatic impairment.
    Muscle rigidity.

    No accumulation in hepatic/renal failure. Use IBW if body weight >130%


    IBW. Duration is too short

    Therapeutic option in patients tolerant to morphine/ fentanyl. Accumulation


    with hepatic/renal impairment 5-10x more potent than morphine.

    Elimination may be prolonged in hepatic/renal impairment


    Contraindicated in patients on MAOI or epilepsy.
    Medication or
    Class
    Non Opioid
    Mechanism of Action Medications
    Routes of
    Administration
    Clinical Advantages

    Acetaminophen Reduction of prostaglandin Enteral, i.v., Decreases opioid


    synthesis rectal consumption; provides
    mild analgesia
    Nonsteroidal anti Reduction of prostaglandin Enteral, i.m., i.v. Decrease opioid
    inflammatory drugs synthesis consumption; provide
    mild analgesia
    Local anesthetics Blockade of sodium Regional and Decrease need for opioids
    channels local infiltration for regional pain; decrease
    opioid consumption

    Ketamine Inhibition of NMDA Enteral, i.v. Decreases opioid


    receptors tolerance and opioid-
    related adverse events
    Anticonvulsants Blockade of N-type calcium Enteral May be effective for
    and sodium channels neuropathic pain
    Remember..
    Why reduce Opioid Consumption is
    listed everywhere?

    NSAIDs also possess their own


    risks
    In Conclussion..
    Vigilance is required

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