American Society of Regional Anesthesia and Pain Medicine November 2017 - 34

Figure 1: Risk factors for the development of chronic post-ICU pain.a
Severe sepsis
Acute respiratory distress syndrome (ARDS)
Surgery
Presence of preoperative pain

safe; unfortunately, there is a lack of evidence to make a strong
recommendation for use.
Palliative and end-of-life pain management is also an important
concern for physicians in intensive care units because 20% of
patients who die in the hospital report pain and 50% of hospice
patients report daily pain. Alleviation of dyspnea and pain should be
the goal of drug therapies.11
In summary, critically ill patients routinely experience pain and
are often not able to communicate this to their healthcare team.
Undertreated pain can contribute negatively to both short- and
long-term outcomes. Pain should be routinely assessed and treated
in critically ill patients using validated assessment tools such as
CPOT and BPS.

Prolonged ICU stay
Prolonged hospitalization
Prolonged mechanical ventilation
Post ICU depression or anxiety

REFERENCES

Posttraumatic stress disorder (PTSD)

Payen J-F, Chanques G, Mantz J, et al. Current practices in sedation and
analgesia for mechanically ventilated critically ill patients: a prospective
multicenter patient-based study. Anesthesiology 2007;106(4):687-695. doi:
10.1097/01.anes.0000264747.09017.da

Burry LD, Williamson DR, Perreault MM, et al. Analgesic, sedative, antipsychotic,
and neuromuscular blocker use in Canadian intensive care units: a
prospective, multicentre, observational study. Canadian Journal of Anesthesia
2014;61(7):619-630. doi: 10.1007/s12630-014-0174-1

Kumar AB, Brennan TJ. Pain assessment, sedation, and analgesic administration
in the intensive care unit. Anesthesiology 2009;111(6):1187-1188. doi:
10.1097/ALN.0b013e3181c0d1b5

Siffleet J, Young J, Nikoletti S, Shaw T. Patients' self-report of procedural
pain in the intensive care unit. J Clin Nurs 2007;16(11):2142-2148. doi:
10.1111/j.1365-2702.2006.01840.x

Chanques G, Sebbane M, Barbotte E, Viel E, Eledjam JJ, Jaber S. A
prospective study of pain at rest: incidence and characteristics of an
unrecognized symptom in surgical and trauma versus medical intensive
care unit patients. Anesthesiology 2007;107:858-860. doi: 10.1097/01.
anes.0000287211.98642.51

Desbiens NA, Wu AW, Broste SK, et al. Study to Understand Prognoses and
Preferences for Outcomes and Risks of Treatment. Pain and satisfaction with
pain control in seriously ill hospitalized adults: findings from the SUPPORT
research investigations. Crit Care Med 1996;24:1953-1961.

Puntillo KA, Wild LR, Morris AB, et al. Practices and predictors of analgesic
interventions for adults undergoing painful procedures. Am J Crit Care
2002;11(5):415-429.

Brennan F, Carr DB, Cousins M. Pain management: a fundamental human right.
Anesth Analg 2007;105:205-221. doi: 10.1213/01.ane.0000268145.52345.55

Faber-Langendoen K, Chao T. Pain control. In: 20 Common Problems: Ethics in
Primary Care. Sugarman J (ed.). New York, New York: McGraw-Hill; 2000:199-210.

Use of corticosteroids
Use of nondepolarizing neuromuscular blockers
Source: U.S. Pharmacist, 2016. https://www.uspharmacist.com/article/
chronic-posticu-pain-and-postintensive-care-syndrome

of the intensive care population because of underlying disease
processes and the systemic effects it may have on cognition.24
It is now recognized that long-term survivors of medical and ICUs
are at high risk for developing chronic pain syndromes.25 Risk
factors for development of chronic post-ICU pain are described in
Figure 1.26
Patients at high risk for neuropathic pain-for example, GuillainBarre syndrome, burns, amputations, and spinal cord injury-
should be considered for early administration of gabapentin and
carbamazepine; however, these medications have not been shown
to be consistently effective.20,27 Burn patients receiving dressing
changes should be treated with fast-acting opioids, anxiolytics,
and ketamine to decrease anticipatory anxiety and development of
post-traumatic stress disorder and chronic pain.28
Although opioids are considered first-line therapy for nonneuropathic pain, a multimodal approach to pain management
may help decrease opioid requirements and thus the side effects
of opioid use. Nonsteroidal anti-inflammatory drugs are effective
but may be contraindicated because of the risks of gastric ulcers,
bleeding, and renal dysfunction. Nonpharmacologic interventions
for pain management (music therapy, relaxation) should be
considered because they are generally low risk, low cost, and

10. Payen JF, Bosson JL, Chanques G, Mantz J, Labarere J. Pain assessment
is associated with decreased duration of mechanical ventilation in the
intensive care unit: a post hoc analysis of the DOLOREA study. Anesthesiology
2009;111(6):1308-1316. doi: 10.1097/ALN.0b013e3181c0d4f0
11. Chanques G, Jaber S, Barbotte E, et al. Impact of systematic evaluation of pain
and agitation in an intensive care unit. Crit Care Med 2006;34(6):1691-1699.
doi: 10.1097/01.CCM.0000218416.62457.56
12. Morris PE, Griffin L, Berry M, et al. Receiving early mobility during an
intensive care unit admission is a predictor of improved outcomes in

American Society of Regional Anesthesia and Pain Medicine
2017

https://www.uspharmacist.com/article/chronic-posticu-pain-and-postintensive-care-syndrome https://www.uspharmacist.com/article/chronic-posticu-pain-and-postintensive-care-syndrome

Table of Contents for the Digital Edition of American Society of Regional Anesthesia and Pain Medicine November 2017