Beyond Opioids for Pain Management in Adult Critically Ill Patients

Abstract

Critically ill patients commonly experience pain, and the provision of analgesia is an essential component of intensive care unit (ICU) care. Opioids are the mainstay of pain management in the ICU but are limited by their adverse effects, risk of addiction and abuse, and recent drug shortages of injectable formulations. A multimodal analgesia approach, utilizing nonopioid analgesics as adjuncts to opioid therapy, is recommended since they may modulate the pain response and reduce opioid requirements by acting on multiple pain mediators. Nonopioid analgesics discussed in detail in this article are acetaminophen, α-2 receptor agonists, gabapentinoids, ketamine, lidocaine, and nonsteroidal anti-inflammatory drugs. This literature review describes the clinical pharmacology, supportive ICU and relevant non-ICU data, and practical considerations associated with the administration of nonopioid analgesics in critically ill adult patients.

Therapeutic alternatives and strategies for drug conservation in the intensive care unit during times of drug shortage: a report of the Ontario COVID-19 ICU Drug Task Force

“…19 A multimodal, stepwise approach to pain management employs nonopioid adjunctive therapy (e.g., acetaminophen, pregabalin, non-steroidal anti-inflammatory drugs, methadone, ketamine, lidocaine, and tapentadol) to reduce opioid requirements. 20,21 While many of these strategies may already be employed in Canadian ICUs, reinforcement can still promote conservative opioid prescribing. Interruptions (or empiric dose reductions) in patients receiving continuous infusions of opioid analgesics as well as use of a validated pain assessment scale (e.g., Numerical Pain Rating Scale 22 or Critical Care Pain Observation Tool 23 ) can assist the nurse in titrating infusions to the lowest effective dose.…”

Ketamine — a unique adjuvant drug in pain treatment

“…Ketamine causes a dose-dependent release of endogenous catecholamines through the sympathetic nervous system [58]. Higher doses of ketamine temporarily cause tachycardia and hypertension, which is a problem in patients with cardiovascular diseases [59]. Ketamine also has negative inotropic properties and should be avoided in patients with cardiovascular diseases such as heart failure and in patients at risk of myocardial infarction [60].…”

“…Ketamina powoduje zależne od dawki uwalnianie endogennych katecholamin za pośrednictwem układu nerwowego współczulnego [58]. Większe dawki ketaminy powodują przejściowo tachykardię i nadciśnienie tętnicze, co stanowi problem u pacjentów z chorobą sercowo-naczyniową [59]. Ketamina wykazuje również negatywne właściwości inotropowe i należy jej unikać u pacjentów ze schorzeniami sercowo-naczyniowymi, takimi jak niewydolność serca, i u chorych z ryzykiem wystąpienia zawału serca [60].…”

Opioid and Benzodiazepine Iatrogenic Withdrawal Syndrome in Patients in the Intensive Care Unit

“…The results were inconsistent regarding OP consumption and corresponding reductions in pain score. 24 Nevertheless, the PADIS guidelines conditionally recommend acetaminophen, warning about the hypotensive effect that may preclude the use of intravenous acetaminophen in some patients. 1 Ketamine.-Ketamine is an NMDA receptor antagonist that, in low doses, has an analgesic and antihyperalgesic effect.…”