9. Providing Analgesia to the Acutely and Critically Ill

Question 1

Overview of pain

Answer 1

-Pain has adverse physiological and psychological effects, including activation of the physiological stress response, depression, and delirium.

-Etiologies of pain in the acutely and critically ill include the obvious sources and the not-so-obvious sources (Table 5-9)

Question 2

Obvious Causes of Pain:

Answer 2

-Incisions
-Invasive Procedures
-Trauma, Fractures
-Prolonged immobility

Question 3

Less Obvious Causes of Pain

Answer 3

-Monitoring and therapeutic devices (catheters, drains, endotracheal tubes, noninvasive ventilating devices)
-Routine nursing care (airway suctioning, dressing changes, physical therapy)

Question 4

Pain Assessment:

Answer 4

-It is recommended that pain be routinely assessed in all adult ICU pts.

-Attempt to obtain the pt’s self-report of pain using the Numerical Rating Scale (NRS), pointing, and head nodding.

-The Behavioral Pain Scale (BPS) is recommended for a pt who is receiving mechanical ventilation and is unable to self-report pain.

-The Crticial-Care Pain Observation Tool (CPOT) is recommended for assessing the pain of a pt who is unable to self-report pain, with or without mechanical ventilation.

-VS alone should not be used for pain assessment in critically ill adults, but they can be used as a cue to assess pain further.

-Consider asking a family member or friend who knows the pt well (a proxy reporter) whether the pt’s behavior may indicate the presence of pain.

Question 5

Pain Management

Answer 5

-Intravenous (IV) opioids are the first-line choice to treat non-neuropathic pain in critically ill pts. All available IV opioids, when titrated to similar pain intensity endpoints, are equally effective (Table 5-10). THE DOSE THAT IS GIVEN MAY VARY DEPENDING UPON UNIT PROTOCOLS.

-PREVENT pain as you are able to by using:
-Preemptive analgesia prior to procedures that are
likely to cause pain.
-Nonpharmacological interventions (distraction,
relaxation therapy)

-*If pt is agitated, treat pain first and then sedate.

Question 6

Fentanyl

Start Dose:

Titration Time/Dose:

Usual Dose Range:

Nursing Implications:

Answer 6

(Sublimate)

Start Dose:
Loading Dose: 25-100 mcg slow IVP over 1-2 min q
10-15 min until pain controlled (using
NRS or BPS).

Continuous Infusion: 25-50 mcg/hr

Titration Time/Dose:
If the goal pain score is not achieved, give 25-50 mcg
IVP and then increase the rate of infusion by 25
mcg/hr; contact the MD if the rate exceeds 200
mcg/hr or if higher doses are needed.

Usual Dose Range:
25-200 mcg/hr

Nursing Implications:
-If a pt is receiving this agent regularly for > 1 week,
do not suddenly stop; taper gradually by ~10-25%
daily in order to prevent withdrawal.

-Weaning is not needed if fentanyl is replaced with an
equianalgesic dose by an alternate route.

-If the pt is not mechanically ventilated, decrease 
dosing requirements for those with sleep apnea, 
those with significant cardiovascular/pulmonary 
disease, those who are elderly, and those who are 
obese (correlates with sleep apnea).

-Consider a sedation vacation, if appropriate.

Question 7

Hydromorphone

Start Dose:

Titration Time/Dose:

Usual Dose Range:

Nursing Implications:

Answer 7

(Dilaudid)

Start Dose:
Loading dose: 0.2 - 0.5 mg q 5 - 15 min until pain is
controlled (using NRS or BPS)

Continuous Infusion: 0.2 - 0.5 mg/hr; Caution: 1 mg of
hydromorphone is equivalent to 7-10 mg of
morphine.

Titration Time/Dose:
If the goal pain score is not achieved, give 0.2 - 0.5mg
IVP and then increase the infusion by 0.2-0.3
mg/hr q 30 min; contact the MD if the rate
exceeds 3 mg/hr or if higher doses are needed.

Usual Dose Range:
0.2 - 3.0 mg/hr

Nursing Implications:
-If a pt is receiving this agent regularly for >1 week, do not suddenly stop; taper gradually by ~10-25% daily in order to prevent withdrawal.

-Weaning is not needed if hydromorphone is replaced with an equianalgesic dose by an alternate route.

-If the pt is not mechanically ventilated, decrease dosing requirements for those with sleep apnea, those with significant cardiovascular/pulmonary disease, those who are elderly, and those who are obese (correlates with sleep apnea).

-Consider a sedation vacation if appropriate.

Question 8

Morphine

Start Dose:

Titration Time/Dose:

Usual Dose Range:

Nursing Implications:

Answer 8

Start Dose:
Loading Dose: 2-4 mg IVP q 5 - 15 min until pain is
controlled (using NRS or BPS)
Continuous Infusion: 1-2 mg/hr

Titration Time/Dose:
If the goal pain score is not achieved, give 2-4 mg
IVP and then increase the rate of infusion by
1-2 mg/hr q 30 min; contact the MD if the rate
exceeds 10 mg/hr or if higher doses are needed.

Usual Dose Range:
1-10 mg/hr

Nursing Implications:
-If a pt is receiving this agent regularly for >1 week, do not suddenly stop; taper gradually by ~10-25% daily in order to prevent withdrawal.

-Weaning is not needed if morphine is replaced with an equianalgesic dose by an alternate route

-If the pt is not mechanically ventilated, decrease dosing requirements for those with sleep apnea, those with significant cardiovascular/pulmonary disease, those who are elderly, and those who are obese (correlates with sleep apnea)

-Consider a sedation vacation, if appropriate.

-If the pt is elderly, active metabolite may accumulate, resulting in renal insufficiency and increased sedation

-Monitor the duration of therapy; possibly consider an alternate opioid.

Question 9

Opioid Reversal with Naloxone

Answer 9

-Give 0.4 to 2 mg IV every 2 minutes until effect to a maximum of 10 mg.

-Duration of naloxone action is 1 to 2 hours; repeated doses may be needed for a long acting opioid.