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Pain: Why treat it? Humanitarian JCAHO (2001) Blunt autonomic and somatic response to pain - Elevated metabolic rate - Elevated O2 consumption - Hypercoagulability.

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Presentation on theme: "Pain: Why treat it? Humanitarian JCAHO (2001) Blunt autonomic and somatic response to pain - Elevated metabolic rate - Elevated O2 consumption - Hypercoagulability."— Presentation transcript:

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2 Pain: Why treat it? Humanitarian JCAHO (2001) Blunt autonomic and somatic response to pain - Elevated metabolic rate - Elevated O2 consumption - Hypercoagulability - Altered immune status - Development of chronic pain

3 Pain: Why Don’t We Treat It Well?  Lack of concern/caring  Lack of knowledge  Uniform prescribing practices  Fear of side effects  Fear of addiction

4 Armamentarium  Guided imagery (!)  Patient education  Narcotics  NSAIDs  Gaba agonists  Local/regional anesthetics  “Preemptive” treatment  “Procedure specific” – Prospect website

5 Local anesthetics Dose-dependent blockage of sodium channels in neurons Amides and esters (amides less allergenic) Amides:Lidocaine, bupivacaine, prilocaine Esters: Novocaine Lidocaine dosing: 5 mg/kg without epi 7 mg with epi

6 NSAIDS  Conventional Cox inhibitors  Cox 2 inhibitors Decreased incidence of GI bleeding Didn’t inhibit platelet aggregation Initial data on side effects was on usage for greater than 1-2 years Now some data on side effects as analgesics for CABG patients

7 Gabapentin/Pregabalin  How do they work?  Who knows? Presynaptic binding to calcium channels in brain Presynaptic binding to calcium channels in brain Decrease excitatory transmission Decrease excitatory transmission

8 Narcotics  Morphine  Fentanyl  Hydromorphone  All work on mu receptors Decrease responsiveness of resp center to CO2 Decrease responsiveness of resp center to CO2 Stimulate medullary chemoreceptor trigger zone Stimulate medullary chemoreceptor trigger zone Increase sphincter tone and decrease peristalsis Increase sphincter tone and decrease peristalsis

9 Opiate Analgesic Options: Fentanyl, Morphine, Hydromorphone FentanylHydromorphoneMorphine Rapid onset X Rapid offset X* Avoid in renal disease X** Preload reduction X Avoid in hemodynamic instability X Equivalent doses 100 mcg 1.5 mg 10 mg * Offset prolonged after long-term use ** Active metabolite accumulation causes excessive narcosis

10 Rescue/Bolus Doses  MSO4 0.1 mg-0.3 mg/kg IV (70 kg – 7-21 mg IV!!!) – I give 5  Fentanyl mg IV  Dilaudid mg/kg IV (70 kg – mg IV)

11 PCA  MSO4 Dose 1.5 mg Dose 1.5 mg Lockout 7 min Lockout 7 min 4 hr limit 30 4 hr limit 30 How do you adjust? How do you adjust?

12 PCA  Fentanyl Dose 20 mcg Dose 20 mcg Lockout 7 min Lockout 7 min 4 hour dose 300 mcg 4 hour dose 300 mcg When do you use it? When do you use it?

13 PCA  Dilaudid Dose 0.2 mg Dose 0.2 mg Lockout 7 mg Lockout 7 mg 4 hr limit 3 mg 4 hr limit 3 mg

14 Case 1 36 y.o morbidly obese woman with RUQ pain at 20 hrs, RUQ tenderness, WBC 13, US with stones, wall 5.0 mm What’s she got? How will we manage her pain? What are our Prospects?

15 Case 1

16 Case 2  65 y.o. man with COPD here for esophageal cancer  What operation is he going to get?

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18 Epidural Anesthesia  What is good about it? Decreases risk of DVT Decreases risk of DVT Increases risk of graft thrombosis Increases risk of graft thrombosis Decreases post op ileus in upper abd surgy Decreases post op ileus in upper abd surgy Decrease ICU days and vent days after abd vasc surgery Decrease ICU days and vent days after abd vasc surgery

19 Flavors of epidurals  Narcotics  Narcotics + Local anesthetics  Complications: Rostrol migration of morphine with respiratory depression up to 18 hrs after Rostrol migration of morphine with respiratory depression up to 18 hrs after Hypotension from sympathectomy Hypotension from sympathectomy

20 P.O. Conversion  Morphine 10 mg. = oxycodone 20 mg

21 Case 3  20 y.o. man MCC intubated in field for combativeness, open femur, SAH and L cerebral contusion, etoh 498  What’s going to happen to him tonight?

22 Case 3  Back from the OR  Ex-fix, EVD with ICP 16  What meds will you write for? What do you have to treat?

23 Sedation Options: Propofol Pharmacology: GABA agonist Pharmacokinetics/dynamics: onset minutes, terminal half- life 6 hours, duration 10 minutes, hepatic metabolism Benefits Rapid onset and offset and easily titrated Rapid onset and offset and easily titrated Hypnotic and antiemetic Hypnotic and antiemetic Can be used for intractable seizures and elevated intracranial pressure Can be used for intractable seizures and elevated intracranial pressureRisks Not reliably amnestic, especially at low doses Not reliably amnestic, especially at low doses NO analgesia! NO analgesia! Hypotension Hypotension Hypertriglyceridemia; lipid source (1.1 kcal/ml) Hypertriglyceridemia; lipid source (1.1 kcal/ml) Respiratory depression Respiratory depression Propofol Infusion Syndrome Propofol Infusion Syndrome -Cardiac failure, rhabdomyolysis, severe metabolic acidosis, and renal failure -Caution should be exercised at doses > 80 mcg/kg/min for more than 48 hours -Particularly problematic when used simultaneously in patient receiving catecholamines and/or steroids

24 Sedation Options: Benzodiazepines (Midazolam and Lorazepam) Pharmacokinetics/dynamics Lorazepam: onset minutes, half-life 10 hours, glucuronidated Lorazepam: onset minutes, half-life 10 hours, glucuronidated Midazolam: onset minutes, half-life 3 hours, metabolized by cytochrome P450, active metabolite (1-OH) accumulates in renal disease Midazolam: onset minutes, half-life 3 hours, metabolized by cytochrome P450, active metabolite (1-OH) accumulates in renal diseaseBenefits Anxiolytic Anxiolytic Amnestic Amnestic Sedating SedatingRisks Delirium Delirium NO analgesia NO analgesia Excessive sedation: especially after long-term sustained use Excessive sedation: especially after long-term sustained use Propylene glycol toxicity (parenteral lorazepam): significance uncertain Propylene glycol toxicity (parenteral lorazepam): significance uncertain -Evaluate when a patient has unexplained acidosis -Particularly problematic in alcoholics (due to doses used) and renal failure Respiratory failure (especially with concurrent opiate use) Respiratory failure (especially with concurrent opiate use) Withdrawal Withdrawal

25 Case 3  Continuous infusion Fentanyl 1 mcg/kg/hr Fentanyl 1 mcg/kg/hr MS mg/hr MS mg/hr Midazolam1-4 mg/hr Midazolam1-4 mg/hr Lorazepam1-4 mg/hr Lorazepam1-4 mg/hr Propofol – mcg/kg/min (packaged at 10mg/cc; approx cc/hr for 70 kg pt) Propofol – mcg/kg/min (packaged at 10mg/cc; approx cc/hr for 70 kg pt)

26 Overview of SCCM Algorithm Jacobi J, Fraser GL, Coursin D, et al. Crit Care Med. 2002;30:

27 Overdose  Nalaxone  flumazenil

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29 Address Pain

30 Atypical Antipsychotics: Quetiapine, Olanzapine, Risperidone, Ziprasidone Mechanism of action unknown Less movement disorders than haloperidol Enhanced effects on both positive (agitation) and negative (quiet) symptoms Efficacy = haloperidol? One prospective randomized study showing equal efficacy of olanzapine to haldol with less EPS One prospective randomized study showing equal efficacy of olanzapine to haldol with less EPSIssues Lack of available IV formulation Lack of available IV formulation Troublesome reports of CVAs, hyperglycemia, NMS Troublesome reports of CVAs, hyperglycemia, NMS Titratability hampered Titratability hampered -QTc prolongation with ziprasidone IM -Hypotension with olanzapine IM

31 Haloperidol No prospective randomized controlled trials in ICU delirium > 700 published reports involving > 2,000 patients The good: Hemodynamic neutrality Hemodynamic neutrality No effect on respiratory drive No effect on respiratory drive The bad: QTc prolongation and torsades de pointes QTc prolongation and torsades de pointes Neuoroleptic malignant syndrome - only three cases with IV haloperidol Neuoroleptic malignant syndrome - only three cases with IV haloperidol Extrapyramidal side effects - less common with IV than oral haloperidol Extrapyramidal side effects - less common with IV than oral haloperidol

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33 Opiate and Benzodiazepine Withdrawal Frequency related to dose and duration 32% if receiving high doses for longer than a week 32% if receiving high doses for longer than a week Onset depends on the half-lives of the parent drug and its active metabolites Clinical signs and symptoms are common among agents CNS activation: seizures, hallucinations, CNS activation: seizures, hallucinations, GI disturbances: nausea, vomiting, diarrhea GI disturbances: nausea, vomiting, diarrhea Sympathetic hyperactivity: tachycardia, hypertension, tachypnea, sweating, fever Sympathetic hyperactivity: tachycardia, hypertension, tachypnea, sweating, fever No prospectively evaluated weaning protocols available % daily decrease in dose % daily decrease in dose % initial decrease in dose with additional daily reductions of % % initial decrease in dose with additional daily reductions of % Consider conversion to longer acting agent or transdermal delivery form

34 Protocols and Assessment Tools SCCM practice guidelines can be used as a template for institution-specific protocols. Titration of sedatives and analgesics guided by assessment tools: Validated sedation assessment tools (Ramsay Sedation Scale [RSS], Sedation-Agitation Scale [SAS], Richmond Sedation-agitation Scale [RSAS], etc.) Validated sedation assessment tools (Ramsay Sedation Scale [RSS], Sedation-Agitation Scale [SAS], Richmond Sedation-agitation Scale [RSAS], etc.) -No evidence that one is preferred over another Pain assessment tools - none validated in ICU (numeric rating scale [NRS], visual analogue scale [VAS], etc.) Pain assessment tools - none validated in ICU (numeric rating scale [NRS], visual analogue scale [VAS], etc.)

35 Daily Goal is Arousable, Comfortable Sedation Sedation needs to be protocolized and titrated to goal: Lighten sedation to appropriate wakefulness daily. Lighten sedation to appropriate wakefulness daily. Effect of this strategy on outcomes: One- to seven-day reduction in length of sedation and mechanical ventilation needs One- to seven-day reduction in length of sedation and mechanical ventilation needs 50% reduction in tracheostomies 50% reduction in tracheostomies Three-fold reduction in the need for diagnostic evaluation of CNS Three-fold reduction in the need for diagnostic evaluation of CNS

36 Appropriate Recall May be Important Factual memories (even unpleasant ones) help to put ICU experience into perspective Delusional memories risk panic attacks and PTSD The optimal level of sedation for most patients is that which offers comfort while allowing for interaction with the environment.

37 Recall in the ICU Some degree of recall occurs in up to 70% of ICU patients. Anxiety, fear, pain, panic, agony, or nightmares reported in 90% of those who did have recall. Anxiety, fear, pain, panic, agony, or nightmares reported in 90% of those who did have recall. Potentially cruel: Up to 36% recalled some aspect of paralysis. Up to 36% recalled some aspect of paralysis. Associated with PTSD in ARDS? 41% risk of recall of two or more traumatic experiences. 41% risk of recall of two or more traumatic experiences. Associated with PTSD in cardiac surgery

38 What We Know About ICU Agitation/Discomfort Prevalence 50% incidence in those with length of stay > 24 hours 50% incidence in those with length of stay > 24 hours Primary causes: unrelieved pain, delirium, anxiety, sleep deprivation, etc. Immediate sequelae: Patient-ventilator dyssynchrony Patient-ventilator dyssynchrony Increased oxygen consumption Increased oxygen consumption Self (and health care provider) injury Self (and health care provider) injury Family anxiety Family anxiety Long-term sequelae: chronic anxiety disorders and post- traumatic stress disorder (PTSD)

39 Opiates Benefits Relieve pain or the sensibility to noxious stimuli Relieve pain or the sensibility to noxious stimuli Sedation trending toward a change in sensorium, especially with more lipid soluble forms including morphine and hydromorphone. Sedation trending toward a change in sensorium, especially with more lipid soluble forms including morphine and hydromorphone.Risks Respiratory depression Respiratory depression NO amnesia NO amnesia Pruritus Pruritus Ileus Ileus Urinary retention Urinary retention Histamine release causing venodilation predominantly from morphine Histamine release causing venodilation predominantly from morphine Morphine metabolites which accumulate in renal failure can be analgesic and anti-analgesic. Morphine metabolites which accumulate in renal failure can be analgesic and anti-analgesic. Meperidine should be avoided due to neurotoxic metabolites which accumulate, especially in renal failure, but also produces more sensorium changes and less analgesia than other opioids. Meperidine should be avoided due to neurotoxic metabolites which accumulate, especially in renal failure, but also produces more sensorium changes and less analgesia than other opioids.


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