Adjuvant Analgesic Use in the Critically Ill: A Systematic Review and Meta-Analysis

Abstract

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Analgesia and sedation in patients with ARDS

“…However, they are not without adverse effects: (1) immunosuppression, (2) drug accumulation resulting in prolonged sedation and respiratory depression that may affect ventilator liberation, (3) tolerance within 48 h, (4) withdrawal signs after discontinuation [47], (5) hyperalgesia and chronic pain syndromes with prolonged use, and (6) ileus potentially resulting in increased abdominal pressure and subsequent worsening of respiratory mechanics. Although not rigorously evaluated in ARDS, non-opioid analgesics (e.g., paracetamol, ketamine, and nefopam) used in a multimodal fashion, may reduce opioid use and their Time to offset can be prolonged for hour-days in patients receiving high-dose infusions for > 3 days, particularly in the face of obesity, end-stage renal disease, and/or end-stage liver disease Risk of hypokalemia, hypernatremia, hypochloremic metabolic alkalosis side effects, but also improve pain control in critically ill adults [2,48]. Ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, induces potent analgesia without affecting respiratory drive, making it a potentially useful addition to opioids in ARDS patients ready for mechanical ventilation liberation [49].…”

“…The most commonly used intravenous opioids include hydromorphone, fentanyl, sufentanil, remifentanil, and morphine, with caution for the latter in the setting of renal impairment. Opioid sparing agents (e.g., gabapentin, paracetamol, nefopam, lidocaine, carbamazepine, clonidine, dexmedetomidine, and low-dose ketamine) can be employed in a multimodal analgesia approach with the additional benefit that some of these drugs have sedative properties [48].…”

Consensus for the management of analgesia, sedation and delirium in adults with COVID-19-associated acute respiratory distress syndrome

“…( 42 ) However, the use of multimodal analgesia has been limited to managing postoperative pain and cancer; thus far, there is no good quality evidence for its routine use in ICUs. ( 15 , 42 , 49 ) Table 2 shows the most commonly used nonopioid drugs in the ICU in case this strategy is implemented.…”

Efficacy and Safety Considerations With Second-Generation Antipsychotics as Adjunctive Analgesics: A Review of Literature

“…Analgesic medications, such as opioids, are drugs designed to provide relief from pain. 1 The apprehension by prescribers to furnish prescriptions for opioids is well founded, as historic use of opioids for both acute and chronic pain have been linked to the development of misuse, abuse, adverse drug effects, and addiction in patients. Serious adverse effects of opioids can include respiratory depression, constipation, immunosuppression, and other gastrointestinal disturbances.…”

“…Serious adverse effects of opioids can include respiratory depression, constipation, immunosuppression, and other gastrointestinal disturbances. 1,2 Opioids produce their pharmacological actions by acting on the mu, delta, and kappa receptors located on neuronal cell membranes. Activation of these receptors leads to supraspinal analgesia and potential opioid adverse effects.…”