IC U

MANAGEMENT & PRACTIC E

VOLUME 22
2022

ISSUE 3

Acute Pain
Management

Pain Assessment in Critical Illness, G. Chanques Pain Management in Paediatric Critical Care,
S. Huerta-Calpe, R. Suárez, M. Balaguer, E. Esteban
Sedation, Analgesia and Respiratory Drive in
Mechanically Ventilated Adults, A. Tejpal, S. M. Pereira, Delirium: How Can We Protect Our Patients?
M.C. Sklar Detection and Treatment Strategies, B. Lobo-Valbuena,
R. Molina, L. L. de la Oliva Calvo, F. Gordo
Pain Management Specificities in Critically Ill Patients
With Obesity, A. Cuny, A. De Jong, G. Chanques Ten Overlooked Mistakes During Early Mobilisation in
the Intensive Care Unit, A. Gómez-González,
Analgesia, Sedation and Neuromuscular Blockade M. A. Martínez-Camacho, R. A. Jones-Baro et al.
in Critically Ill Patients: A Practical Approach for
Intensivists, J. Molina-Galeote, G. Patiño-Arreola, Perioperative Haemodynamic Optimisation of the
I. D. Radillo-Santana et al. High-Risk Surgical Patient, F. E. Nacul, N. E. de
Oliveira, J. M. da Silva-Jr et al.

INTENSIVE CARE I EMERGENCY MEDICINE I ANAESTHESIOLOGY icu-management.org @ICU_Management

124 ACUTE PAIN MANAGEMENT

Analgesia, Sedation and

Jhordan Molina-
Galeote
Intensive Care Unit
Hospital General San Juan

Neuromuscular Blockade
del Río
Querétaro, México
[email protected]
@GaleoteMolina

Gabriel Patiño-
in Critically Ill Patients:
A Practical Approach for
Arreola
Intensive Care Unit
Hospital General San Juan
del Río

Intensivists
Querétaro, México
[email protected]
@GabrielPatino15

A practical approach to analgesia, sedation and neuromuscular blockade of

Itzel Donaji Radillo-
Santana critically ill patients and a discussion on potential benefits, adverse effects
Intensive Care Unit
Hospital General San Juan del Río
and current professional international recommendations.
Querétaro, México
[email protected] Introduction Humanisation of Intensive Care Units.
@DonajiSantana Patients hospitalised in the Intensive Care The physiological response to pain
Unit (ICU) are naturally prone to experience commonly presents with tachycardia,
pain. They may require administration of hypertension, tachypnoea, respiratory
sedatives and even neuromuscular block- alkalosis, among others. This response
Ernesto Deloya- ade (NMB) in some cases. At the present is related to haemodynamic instability,
Tomas*
moment, there are several clinical prac- impairment of the immune system and
Intensive Care Unit
Hospital General San Juan tice guidelines in this regard by multiple hyperglycaemia, in addition to the release
del Río
professional associations. However, there of catecholamines, cortisol and vasopressin.
Querétaro, México
[email protected]
are still some discrepancies on the optimal Persistence of pain predisposes to a wide
@E_DeloyaMD clinical approach of these patients, namely variety of detrimental psychological effects
on drug selection alongside monitoring of including agitation, post-traumatic stress
their effects. In this paper, we introduce a disorder, disorientation and depression.
practical approach to the analgesia, sedation The first step of this approach is to
Eder Iván Zamar- and NMB of critically ill patients, whilst accurately identify pain, which may pose
rón-López* a challenge in patients in which verbal
taking into account potential benefits,
Intensive Care Unit
adverse effects and current professional communication is not feasible, for instance,
Hospital Regional IMSS No. 6
Ciudad Madero international recommendations. in patients under IMV or sedatives, as well
Tamaulipas, México as in patients with paralysis, neurological
[email protected] Evaluation and Management of or neuromuscular disorders, among others.
@ederzamarron Pain in the ICU The most widely used scale for pain detec-
More than 50% of critically ill patients expe- tion and assessment is the Critical-Care Pain
rience pain, a situation that is associated with Observation Tool (CPOT) (Table 1), which
Orlando Ruben
Pérez-Nieto* adverse outcomes. These include increasing takes into consideration a handful of clinical
Intensive Care Unit length of ICU stay and in-hospital stay, parameters; of note, this scale can be used
Hospital General San Juan
del Río increasing days under invasive mechanical in patients who can verbally communicate
Querétaro, México ventilation (IMV), and a higher incidence and also in patients who cannot, such as
[email protected] of delirium. Clinicians must implement those under IMV, as it considers facial
@OrlandoRPN expression, upper limb movements and
strategies for the early detection, evaluation
and management of pain, in an attempt compliance with mechanical ventilation.
to maximise patient comfort, since this is Once pain is identified, an adequate
*Members of Sociedad Mecicana de Medicina Crítica y analgesic treatment must be prompted. The
Emergencias and AVENTHO Mechanical Ventilation
considered an essential part of the so-called

ICU Management & Practice 3 - 2022

 ACUTE PAIN MANAGEMENT 125

Figure 1. Left. CPOT 0: Facial expression relaxed, absence of movements, muscle tension relaxed, tolerating ventilator. RASS -2: Light sedation.
Middle. CPOT 4: Facial expression tense, body movements protection, muscle tension rigid, coughing but tolerating ventilator. RASS +2: Agitated.
Right. CPOT 8: Facial expression grimacing, body movements restlessness, muscle very tense or rigid, fighting. RASS +3: Very agitated.

and magnesium sulfate, may also be used. and codeine, which are associated with a
Critical Care Pain Observation Tool (CPOT) Another strategy to be considered is that higher incidence of adverse effects and a
Facial Relaxed 0 of regional analgesia, more widely used lower analgesic potency.
expression in post-surgical patients, which will not Opioid accumulation is associated with
Tense 1
be addressed in this review. the following side effects: nausea, vomiting,
Grimacing 2
Indications for therapeutic or prophy- ileus, haemodynamic instability and respira-
Body Absence of movements 0 lactic administration of pain medications tory depression. Therefore, their use should
movements
Protection 1 in the ICU include the following: be restricted to short periods of time. It is
Restlessness 2 1. Patients with endotracheal intuba- highly encouraged to use the minimum
tion and IMV effective dose to achieve the desired effect,
Muscle Relaxed 0
tension 2. Polytrauma since higher doses might cause tolerance
Tense, rigid 1 3. Burns and desensitisation of receptors, thereby
Very tense or rigid 2 4. Post-operative period reducing their effect and, in turn, further
Compliance Tolerating ventilator or 0 5. During procedures such as trache- requiring higher doses. To minimise adverse
with the movement ostomy, placement of pleural tubes, effects, a multimodal analgesia with adju-
ventilator dressing and debridement of wounds, vant drugs may be used, with the aim of
Coughing but tolerating 1
drainage of fluid collections, catheter blocking the transmission of pain by other
Fighting 2
placements, etc. mechanisms at the peripheral level and at
Vocalisation Talking in normal tone 0 6. Chronic pain (e.g., cancer) the level of the spinal cord-hypothalamus-
or no sound
7. Neuropathic pain cerebral cortex axis.
Sighing, moaning 1 8. Palliative care Opioid-induced hyperalgesia results from
Crying out, sobbing 2 Opioids are considered first-choice their use for prolonged periods of time
Goal: <3 drugs for analgesia in critically ill patients along with excessive doses (Lee 2011). It
due to their high efficacy. These act on the is originated by an impaired action from
Table1. Critical Care Pain Observation Tool µ, κ and δ receptors of the central nervous N-methyl-D-aspartate (NMDA) glutama-
system (CNS). The most highly recom- tergic receptors and an increase in spinal
drugs most frequently used for pain manage-
mended of them are remifentanil, fentanyl, dynorphin levels, resulting in an excessive
ment in the ICU include acetaminophen,
morphine and hydromorphone given synthesis and a release of excitatory neuro-
non-steroidal anti-inflammatory drugs
their higher analgesic effectiveness. Other peptides, thus shifting the balance between
(NSAIDs) and opioids. Other drugs, such
less advised opioid medications include antinociceptive and pronociceptive systems.
as ketamine, lidocaine, neuromodulators
buprenorphine, oxycodone, nalbuphine For the above reasons, opioids should be

ICU Management & Practice 3 - 2022

126 ACUTE PAIN MANAGEMENT

withdrawn as early as possible - as soon a histamine H1 receptor antagonist focused post-operative patients (Wick 2017).
as the cause of the pain is solved. on the inhibition of monoamine uptake in However, NSAIDs are not recommended
As a result of its ultra-short action and synapses, which would lead to an increase for routine use in critically ill patients.
its elimination by plasmatic esterases, in noradrenaline, dopamine and serotonin. In subanaesthetic doses, ketamine exerts
remifentanil is the opioid medication of It is advised as an adjuvant treatment to an analgesic effect comparable to morphine,
choice. This drug is associated with lower opioids and as a treatment alternative. with a similar need for rescue doses. This
days under IMV, lower time to extubation However, it is seldom available worldwide. drug reduces chronic hyperalgesia medi-
and lower length of ICU stay. Its phar- NSAIDs remain an adequate alternative for ated by NMDA receptors, as well as that
macokinetics are not affected by renal or analgesia. Their effect is comparable to low- induced by opioid medications (Hirota
hepatic impairment; therefore, it is safe potency opioids, thereby reducing opioid 2011). Its advantages include the fact that
in patients with liver or kidney diseases. consumption, as well as their side effects. it does not cause respiratory or haemo-
Its major disadvantages include its high There is a wide variety of drugs included dynamic depression, hence it is useful in
cost and lower availability compared to in this group such as COX-1, COX-2 and patients with shock (Eikermann 2012).
other opioid medications (Yang 2021). prostaglandin E2 inhibitors. Among critically Its adverse effects are dose-dependent,
Fentanyl is associated with more days of ill patients, their adverse effects include and they include hypersalivation, nausea
IMV compared to remifentanil. Morphine acute kidney injury and gastrointestinal and vomiting, vivid dreams, blurry vision,
is associated with hypotension due to (GI) bleeding, with even higher risks for hallucinations, nightmares and delirium.
histamine release, pruritus, and a higher patients with pre-existing impaired renal Due to its dissociative effects, ketamine
incidence of nausea and vomiting. Along blood flow, older adults, patients with proves useful in the pain management of
with hydromorphone, these drugs are heart disease, and patients with shock or severely burned patients or in those with
reasonable options for analgesia (Devlin those exposed to other nephrotoxic drugs a large number of invasive devices and
2018). (Thadhani 1996). Other lower incidence procedures. It can also be safely used in
Acetaminophen is recommended as an deleterious effects include cardiovascular patients with intracranial hypertension.
adjuvant analgesic in the opioid therapy of and cerebrovascular complications, fluid Ketamine is metabolised via the liver and
critically ill patients. Dose adjustment should retention, hypertension and thromboem- excreted by the kidneys, nevertheless, no
be considered in chronic liver failure, and bolic events. In particular, ketorolac has significant adverse effects over hepatic
this drug must be avoided in acute liver been associated with a significant increase and renal functions have been noted at
failure and in cases of allergy. Nefopam is in the incidence of anastomotic leaks in subanaesthetic doses.

Mechanism of action Comments Dose Onset; Contraindications/ Adverse effects

half-life cautions
Acetami- Inhibition of cyclooxy- Reduces opioid PO/IV: 1 g Onset: Caution in patients with Associated with hypotension
nophen genases (COX-1, COX-2, consumption. every 6-8 h IV: 5-10 significant liver dysfunc- (IV administration).
and COX-3). Acts upon min tion.
the endocannabinoid First-line treat- Maximum PO: 30-60 Liver failure (high doses).
and serotonergic systems ment for mild to dose: 4 g in min Caution in malnutrition.
and influences transient moderate pain. 24 h
receptor potential channels t½: 4-6 h
(TRP) and voltage-gated Weak anti-
Kv7 potassium channels. inflammatory
Inhibition of Cav3.2 T-type action.
calcium channels. Acts on
L-arginine in the nitric
oxide (NO) synthesis
pathway.
Nefopam Histamine H1 receptor Seldom available 20-30 mg Onset: History of convulsive Blurred vision, xerostomia,
antagonist focused on the worldwide every 6-12 h PO: 15-20 disorders. IM/IV: Urinary constipation, urinary retenti-
inhibition of monoamine min retention linked to on, tachycardia, palpitations,
uptake in synapses, which Maximum IV: 15-20 urinary or prostate disor- angina.
would lead to an increase dose: 120 mg min ders, angle-closure glau-
in noradrenaline, dopa- in 24 h coma. Oral: Concomitant Nausea, vomiting, diarrhoea,
mine and serotonin. t½: 3-8 h use with MAOIs. abdominal pain.

Dizziness, drowsiness,
headache, paraesthesia,
tremor, convulsion,
light-headedness.

Hypotension, syncope.

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 ACUTE PAIN MANAGEMENT 127

Tramadol Acts on the CNS. Binds Partial anta- PO/IV: 50- Onset: Accumulation in renal or Respiratory depression (less
to μ-opioid receptors and gonism by 100 mg every IV: 5-10 liver failure. than other opioids).
blocks noradrenaline and naloxone. 4-6 h min
serotonin reuptake by PO: up to Associated with seizures Nausea/vomiting.
binding to monoaminergic Considered a Maximum 1h in patients with epilepsy.
receptors. mild opioid. dose: 400 mg Ileus.
in 24 h t½: 4-6 h Contraindicated with
concurrent use of mono-
amine oxidase inhibitors
(MAOIs).

Gabapentin Binds to α2δ subunits Useful for neu- Start with Onset: N/A Requires renal dosage Sedation.
of voltage-gated calcium ropathic pain. 100 mg PO t½: 4.8– adjustment.
channels. every 8 h 8.7 h Confusion.
Reduces Absorbed in a relatively
incidence of Maintenance small portion of the Ataxia.
hyperalgesia and dose: 900- duodenum.
central sensiti- 3600 mg/day Dizziness.
sation. Ineffective in patients
under jejunal feeding.
Anticonvulsant.

Reduces opioid
consumption
(multimodal
analgesia in the
ICU).
Pregabalin Neuromodulator. With Useful for neu- 50–300 mg Onset: N/A Requires renal dosage Sedation.
potent binding to the α2-δ ropathic pain. PO every t½: 5.5–6.7 adjustment.
subunit, reduces calcium 8-12 h h Confusion.
influx into presynaptic Reduces
nerve terminals, with incidence of Ataxia.
release of excitatory hyperalgesia and
neurotransmitters such as central sensiti- Dizziness.
glutamate, norepinephrine, sation.
and substance P.
Anticonvulsant.

Carbamaze- Blockade of voltage-gated Anticonvulsant. Start with 50- Onset: Caution in AV block. Dizziness
pine sodium channels. 100 mg PO 4-5 h
Reduces opioid every 12 h t½: 5-26 h History of myelo- Ataxia
Potent anticholinergic that consumption suppression and hepatic
acts at the level of muscari- (multimodal Maintenance porphyrias. Drowsiness
nic and nicotinic analgesia in the dose: 100-
receptors. ICU). 200 mg every Caution with concurrent Fatigue
4-6 h use of monoamine oxida-
se inhibitors (MAOIs). Headache
Maximum
dose: 1200 Diplopia
mg/day
Urticaria

Leukopenia

Eosinophilia

Thrombocytopenia

Lidocaine Blockade of voltage-gated Reduces opioid IV bolus: 1.5- Onset: Caution in congestive Dizziness
sodium channels, leading consumption 2 mg/kg immediate heart failure and liver
to a reversible blockade of (when used in (IV) failure. Tinnitus
the propagation of action infusion). Infusion: 1.5- t½: 90-120
potentials. 3 mg/kg min Fasciculations
Shortens durati-
on of periopera- Maximum Visual disturbances
tive ileus. dose: 5 mg/
kg Arrythmias
Decreases the
incidence of
nausea/vomi-
ting.

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128 ACUTE PAIN MANAGEMENT

Morphine Stimulates µ, κ and δ Metabolised by IV bolus: 0.1- Onset: Metabolites accumula- Immunosuppression
receptors distributed in the glucuronidation. 0.2 mg/kg 5-10 min tion in renal failure.
CNS and peripheral tissues. Active metabo- t½: 3-5 h Delirium, sedation, and
lites: M6G and Infusion: Causes histamine release. respiratory depression
M3G. 0.05-0.1 mg/
kg/h Tolerance within 48 h
Releases hista-
mine from mast Withdrawal symptoms after
cells, causing discontinuation
vasodilation. Hyperalgesia and other pain
syndromes with long-term
use
Ileus/constipation/nausea/
vomiting
Urinary retention
Bradycardia

Hydromor- Semi-synthetic opioid Metabolised IV bolus: 0.2- Onset: 10- Decrease dose in older Delirium, euphoria, miosis,
phone agonist. mainly into 0.6 mg 20 min adults. drug dependence, tolerance
dihydroiso- t½: 2-6 h
Stimulates µ receptors morphine Infusion: 0.5- Requires dose adjust- Constipation, nausea,
(and δ receptors to a lesser glucuronide and 5.0 mg/h ment in patients with vomiting
degree) at the supraspinal hydromorpho- morbid obesity, liver/
and spinal levels. ne-3-glucuroni- PO: 2-8 renal failure, COPD, or Pruritus
de (H3G). mg/3-4 h restrictive lung diseases.
Respiratory depression
May require Urinary retention
higher doses in
patients with
history of prior
opioid use
Fentanyl Stimulates µ, κ and δ Synthetic opioid. IV bolus: 0.3- Onset: 1-2 Administration should Sedation, delirium
receptors distributed in the 0.5 mcg/kg min be based on ideal body
CNS and peripheral tissues. Fat-soluble. Up to 2 mcg/ t½: 1-4 h weight in obese patients. Tolerance within 48 h
kg
Causes less Older adults may require Withdrawal symptoms after
hypotension Infusion: lower doses. discontinuation
than morphine. 1-10 mcg/
kg/h Caution in uncontrolled Hyperalgesia and other pain
Hepatic meta- hypothyroidism, lung syndromes with long-term
use
bolism without diseases, decreased
active metabo- respiratory reserve, alco- Respiratory depression
lites holism, functional liver/
renal damage. Ileus, constipation, nausea,
vomiting
Muscle stiffness when
rapidly infused. Urinary retention
Bradycardia

Remifen- μ receptor selective ago- Hydrolysis by IV bolus: 1 Onset: 1-3 No accumulation in Immunosuppression
tanil nist, with rapid onset and plasmatic este- mcg/kg min patients with liver/renal
short duration. rases, without t½: 3-10 failure. Sedation, delirium
active metabo- Infusion: min
lites. 0.05-2 mcg/ Administration should Respiratory depression
kg/h be based on ideal body
Allows for an weight in obese patients. Tolerance within 48 h
early neurologic
assessment in Muscle stiffness may Withdrawal symptoms after
discontinuation
neurointensive occur.
care. Hyperalgesia and other pain
syndromes with long-term
Does not increa- use
se histamine.
Ileus, constipation, nausea,
vomiting
Urinary retention
Bradycardia

ICU Management & Practice 3 - 2022

 ACUTE PAIN MANAGEMENT 129

Sufentanil High affinity to the µ re- Synthetic opioid. IV bolus: 0.1- Onset: 1-3 Caution with concurrent Sedation, delirium
ceptor. Slow dissociation. 7 to 10 times 0.3 mcg/kg min use of monoamine oxi-
more potent t½: 0.5-2 h dase inhibitors (MAOIs). Respiratory depression
than fentanyl. Infusion: 0.1-
Accumulation 1 mcg/kg/h Tolerance or withdrawal
unlikely. symptoms

Ileus/constipation

Nausea/vomiting

Urinary retention

Bradycardia

Diclofenac COX-1 and COX-2 inhibi- Analgesic, IV bolus: 75 Onset: 15- Avoid in patients with Acute kidney injury.
tion, which regulate pro- antipyretic, and mg 30 min risk of acute kidney in-
duction of prostaglandins anti-inflamma- t½: 2 h jury: e.g., hypovolaemia GI bleeding.
and thromboxane from tory. Infusion: or inotrope-dependent
arachidonic acid. 0.04 mg/ shock. Hypotension.
kg/h
PO is 100% Avoid in patients with
absorbed. risk of GI bleeding:
burns, platelet abnor-
malities, coagulopathy,
concomitant use of ACE
inhibitors, congestive
heart failure, cirrhosis.

Ibuprofen COX-1 and COX-2 inhibi- Analgesic, PO: 400-600 Onset: 25 Avoid in patients with Acute kidney injury.
tion, which regulate pro- antipyretic, and mg every 4 h min risk of acute kidney in-
duction of prostaglandins anti-inflamma- t½: 1.8- jury: e.g., hypovolaemia GI bleeding.
and thromboxane from tory. Maximum 3.5 h or inotrope-dependent
arachidonic acid. dose: 2.4 g/ shock.
day
Avoid in patients with
risk of GI bleeding:
burns, platelet abnor-
malities, coagulopathy,
concomitant use of ACE
inhibitors, congestive
heart failure, cirrhosis.

Ketorolac COX-1 and COX-2 inhibi- Analgesic, IV: 10-30 mg Onset: 10 Avoid in patients with Acute kidney injury.
tion, which regulate pro- antipyretic, and every 4-6 min risk of acute kidney in-
duction of prostaglandins anti-inflamma- h, in no less jury: e.g., hypovolaemia GI bleeding.
and thromboxane from tory. than 15 s t½: 4-6 h or inotrope-dependent
arachidonic acid. shock. Anastomotic leak.
Infusion: 5
mg/h Avoid in patients with
risk of GI bleeding:
burns, platelet abnor-
malities, coagulopathy,
concomitant use of ACE
inhibitors, congestive
heart failure, cirrhosis.

Table 3. Analgesics
CNS: Central nervous system, MAOIs: Monoamine oxidase inhibitors, COPD: Chronic obstructive pulmonary disease, ACE: Angiotensin converting enzyme, GI: Gastroin-
testinal bleeding.

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130 ACUTE PAIN MANAGEMENT

Sedation If opting for sedation, it is highly recom- Immobility, and Sleep Disruption in Adult
Although maintenance sedation is a mended that the dose of the medications Patients in the ICU (PADIS) guidelines
commonly used approach in critically ill is titrated according to predefined goals endorse propofol and dexmedetomidine
patients, it is intrinsically harmful. This based on the patient’s condition, as well as as first-choice sedatives. Benzodiazepines
intervention is associated with patient continuous monitoring. There are several are not recommended as maintenance
weakness, delirium, increasing days on ways to monitor the sedation state of a sedatives due to their association with
mechanical ventilation and increasing days critically ill patient; the RASS scale is the delirium (Devlin 2018). Ketamine might
of hospitalisation and ICU stay (Nedergaard most widespread tool for this purpose. If also be considered as a sedative for criti-
2022). However, it might be necessary in a given patient has an indication for deep cally ill patients, even showing benefits in
some specific scenarios. Indications for sedation (e.g., ARDS or refractory intra- patients with shock including lower rates
maintenance sedation include the follow- cranial hypertension) it is recommended of hypotension and bradycardia (Umunna
ing (Reade 2014): that they remain at a level <-3. However, 2015).
1. Moderate to severe acute respiratory if only minimal sedation is planned (such The haemodynamic changes associated
distress syndrome (ARDS). as in a patient under a weaning protocol), with propofol may include myocardial
2. Intracranial hypertension (e.g., it is reasonable to remain in levels from 0 depression, bradycardia and hypoten-
severe traumatic brain injury with to -1. It is difficult to find a justification sion. It must be taken into consideration
concurrent mass effect). for maintaining a moderate sedation (RASS that propofol provides up to 1.1 kcal per
3. Status epilepticus (when non- 2 to 3). There are different technological millilitre; therefore, it may cause hypertri-
responsive to first-line or second- sedation monitors such as the unilateral glyceridaemia, pancreatitis or overfeeding.
line therapy). or bilateral bispectral index (BIS), entropy With regard to dexmedetomidine, this drug
4. Consider in abdominal compartment monitoring, among others, although none frequently causes bradycardia, and it may
syndrome, flail chest and patients has been shown superior to the RASS scale also contribute to hypotension in patients
requiring major surgery, or inability (Table 2), and they could indeed prompt with shock; nevertheless, its safety profile
to perform regional anaesthesia. additional expenses. appears to be better than other sedatives
Pain, Agitation/Sedation, Delirium, and it has even been associated with greater
haemodynamic stability in patients with
Richmond Agitation Sedation Scale (RASS) septic shock. Unfortunately, despite many
Combative Overtly combative, immediate danger to staff +4
recommendations discouraging the use of
benzodiazepines, midazolam remains the
Very agitated Pulls on or removes tube (s) or catheter (s) or has aggressive +3 most commonly used sedative in continu-
behaviour toward staff ous sedation among many hospitals (Luz

Agitated Frequent non-purposeful movement or patient-ventilator +2 2022). It is recommended to consider
dyssynchrony
the use of anti-psychotic agents, volatile
Restless Anxious or apprehensive but movements not aggressive or +1 anaesthetics or intermittent benzodiaz-
vigorous
epines in patients with ARDS who do not
Alert and calm Spontaneously pays attention to caregiver 0 achieve deep sedation with propofol and

dexmedetomidine.
Drowsy Not fully alert, but has sustained (more than 10 seconds) -1
awakening, with eye contact to voice It is important to emphasise that the
condition that leads the patient to require
Light sedation Briefly (less than 10 seconds) awakens with eye contact to -2
voice sedation must be solved as soon as possible,
Moderate sedation Any movement (but no eye contact) to voice -3 and a wake-up test must be performed
early in the course to prompt a timely
Deep sedation No response to voice, but any movement to physical stimula- -4 ICU discharge, which should be repeated
tion every day until the patient can be safely
Unarousable No response to voice or physical stimulation -5 withdrawn from mechanical ventilation.
This procedure is associated with fewer
Table 2. Richmond Agitation Sedation Scale days on IMV, and fewer days of ICU stay.

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 ACUTE PAIN MANAGEMENT 131

Mechanism of action Comments Dose Onset; Contraindications/ Adverse effects

half-life cautions
Propofol Potentiates activation Sedative-hypno- IV bolus: 1-2 Onset: 15- Hepatic metabolism. Respiratory depression
of GABA-mediated ion tic, anxiolytic. mg/kg 30 s
channels. t½: 5-10 Renal excretion. Metabolic acidosis
Antiemetic. Infusion: min
Inhibition of NMDA 20-50 mcg/ Avoid with triglycerides Immunosuppression
receptors. kg/min ≥800 mg/dl.
Pancreatitis
≥60 mcg/
kg/min Hypotension
associated QT prolongation
with propofol
infusion Myocardial depression
syndrome
Green urine
Dexmedeto- αα2 receptor agonist. α2 Conscious IV bolus: no Onset: Caution with concurrent Hypotension
midine selectivity over α1 recep- sedation, 15-20 min use of esmolol.
tors (1600:1). sympatholytic, Infusion: t½: 3-4 h Bradycardia
anxiolytic, 0.2-0.7 mcg/ Consider dose reduction
Induces sleep by de- analgesic. kg/h in patients with liver Dry mouth
creasing the firing of disease.
noradrenergic neurons of Decreases risk of >1.5 mcg/ Nausea
the locus coeruleus in the delirium. Regu- kg/h associa-
brainstem, and by activa- lates sleep. ted with risk
ting endogenous pathways of cardioto-
that promote non-rapid eye Reduces opioid xicity.
movement (NREM) sleep. consumption
(multimodal
analgesia).
Ketamine NMDA antagonist. Dissociative IV bolus: Onset: Porphyria Sialorrhea
anaesthesia, 0.2-4.5 mg/kg 30-40 s
Acts upon opioid receptors sedation, and t½: 10-15 Thyroid diseases Laryngospasm
and monoaminergic analgesia. IM: 6.5-13 min
receptors. mg/kg Drug dependence
Prevents neuro-
Inhibition of muscarinic pathic pain. Infusion: Dysuria
receptors. 2.5-5 mcg/
Confers haemo- kg/min Urinary incontinence
Promotes GABAergic trans- dynamic sta- Hallucinations
mission. bility (positive > 20 mg/
chronotropism, kg associ-
increases blood ated with
pressure). myocardial
depression
Bronchodilation.

Preserves airway
reflexes.
Etomidate Modulates and activates Anaesthetic, IV bolus: Onset: Hepatic metabolism. Inhibition of adrenocortical
GABA A receptors that con- hypnotic. 0.2-0.6 mg/ 30-60 s axis
tain β2 and β3 subunits. kg t½: 2.5- Renal excretion.
Haemodynamic 5.5 h Myoclonus
stability (atte- Infusion: no Interaction with metami-
nuates responses zole (dipyrone). Nausea/vomiting
to ACO and
bradykinin). Injection site pain

34% decrease in Nystagmus

cerebral blood
flow and 45% Hiccups
decrease in ce-
rebral metabolic
rate of oxygen
(CMRO2)
without mean
arterial pressure
(MAP) being
affected.

Anticonvulsant.

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132 ACUTE PAIN MANAGEMENT

Midazolam GABA agonist. Hypnotic, seda- IV bolus: Onset: 2-3 Clearance depends on he- Hypotension
tive, anxiolytic, 0.01-0.05 min patic and renal function.
Increases the opening and amnesic mg/kg t½: 3-72 h Bradycardia
frequency of chloride activity.
channels. Infusion: Thrombosis
Anticonvul- 0.02-0.1 mg/
sant (first-line kg/h Respiratory depression
therapy in status
epilepticus). Delirium

Tachyphylaxis

Immunosuppression

Ataxia

Polyneuropathy/Critical
illness myopathy
Lorazepam GABA agonist. Anterograde PO: 2-3 mg Onset: 1-3 Myasthenia gravis, acute Hypotension
amnesia. every 8-12 h min (IV), angle-closure glaucoma.
Increases the opening 15-30 min Respiratory depression
frequency of chloride Sedative. IM: 0.05 mg/ (IM) Caution in obstructive
channels. This change kg t½: 14 h sleep apnoea and severe Diarrhoea
results in hyperpolarisati- Anxiolysis. Peak plas- respiratory failure.
on and stabilisation of cell IV bolus: ma time: 2 Delirium
plasma membrane. Anticonvulsant. 0.02-0.04 h (PO)
mg/kg Tachyphylaxis

Infusion:
0.01-0.1 mg/
kg/h
Diazepam GABA agonist. Anterograde IV bolus: 0.1- Onset: 2-5 Diazepam and desmet- Hypotension
amnesia, seda- 0.2 mg/kg min hyldiazepam (active
Increases the opening tion. t½: 20- metabolite) accumulate Respiratory depression
frequency (but not ope- Infusion: no 120 h with repeated dosing.
ning duration) of chloride Highly fat-so- Phlebitis
channels. luble. Biphasic Accumulation occurs
half-life mostly in newborns, ol- Delirium
Crosses the with a der adults and in patients
blood-brain rapid with liver diseases. Tachyphylaxis
barrier. initial dis-
tribution
phase and a
prolonged
terminal
elimination
phase of 1
to 2 days.

Table 4. Sedatives
NMDA: N-methyl-D-aspartate, GABA: Gamma-aminobutiryc acid.

Neuromuscular Blockade 2. Moderate to severe ARDS only non-depolarising drug indicated for
Neuromuscular blockade (NMB) can be 3. Consider in intracranial hyperten- induction and intubation during RSI.
common among critically ill patients, sion, refractory status asthmaticus, Regarding the management of moder-
especially in the course of ARDS treat- failed sedation, and to temporarily ate to severe ARDS in patients under IMV,
ment. Its indications are limited, and this reduce intra-abdominal pressure meta-analyses have shown a reduction in
modality is associated with several adverse in patients with intra-abdominal mortality in the ICU when using an infusion
effects such as venous thromboembolism, hypertension (IAH), among others of cisatracurium (Ho 2020), and recently,
critical illness myopathy, patient awareness (De Laet 2007). it has shown greater utility if maintained
during paralysis, autonomic interactions, The American Society of Anesthesi- under continuous infusion for more than
pressure ulcers, corneal ulcers and residual ologists (ASA) recommends the use of 48 hours in patients with respiratory failure
paralysis (Renew 2020). NMB to reduce the number of intubation under IMV due to COVID-19 (Li 2021). The
Indications of NMB in the ICU include: attempts, thereby decreasing the risk of major advantage of cisatracurium relies on
1. Rapid sequence intubation (RSI) airway injuries during direct laryngoscopy its metabolism by Hofmann elimination,
(Apfelbaum 2013). Rocuronium is the which confers a rapid elimination of its

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 ACUTE PAIN MANAGEMENT 133

effects when withdrawn. Moreover, it does by relaxation of the abdominal muscles fixed-dose of cisatracurium; titration based
not depend on hepatic or renal depuration. A (Malbrain 2005). Nonetheless, conclusive solely on TOF and a ventilator synchrony
strategy that combines the use of NMB with evidence in this regard is lacking. protocol), it was shown that a protocol
cisatracurium and low tidal volume could There are other neuromuscular block- using ventilator synchrony for cisatracu-
reduce mortality, most likely due to a reduc- ing agents (NMBA) not currently recom- rium titration required significantly less
tion of asynchrony events and improvement mended as first-choice drugs; however, drug compared to TOF-based titration and
of pulmonary compliance and functional their use in specific scenarios may be a fixed dosing regimen (DiBridge 2021).
residual capacity, which would translate justified when the latter are not available. Several factors affect the duration of
into an increase in oxygenation (Murray In patients with ARDS that require NMB, NMBA activity: for instance, the concomitant
2016; Battaglini 2021; Chang 2020). vecuronium, atracurium or pancuronium use of diuretics, antiarrhythmics, amino-
Among neurocritical patients with acute may also be used, although with the risk glycosides, magnesium, lithium, as well
brain injury, the use of NMB has been of prolonging neuromuscular relaxation, as some conditions such as hypokalaemia,
suggested in order to reduce the number thereby increasing side effects. In addition, hypothermia and acidosis, all increase the
of episodes of intracranial hypertension; when rocuronium is not available for RSI, potency of non-depolarising NMBA. NMBA
however, the level of evidence for this succinylcholine can also be considered, potency is inversely related to its speed of
recommendation is low (Renew 2020). which is a depolarising NMB of ultra-short onset (that is, the lower the potency of the
Its main effect relies on the reduction of action, although with the risk of hyperka- drug, the faster the onset of neuromuscular
asynchrony events with the ventilator, cough laemia and even malignant hyperthermia blockade after its administration). Patients
limitation and any other condition that (Zamarrón-López 2019). with myasthenia gravis and glaucoma are
may cause Valsalva manoeuvre (Steingrub Train-of-four nerve stimulation (TOF) is especially sensitive to the effects of NMB.
2014). In patients with intra-abdominal a tool for the monitoring of NMB. A value On the other hand, patients with burns are
hypertension and abdominal compartment <0.7 is considered an adequate paralysis resistant to the effects of NMBA due to the
syndrome, NMB has also been suggested (Murphy 2010). In a recent study that proliferation (upregulation) of nicotinic
in order to increase abdominal compliance compared three strategies for using NMB (a receptors in the sarcolemma (Murray 2016).

Figure 5. Analgesia, sedation and neuromuscular blockade in critically ill patients

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134 ACUTE PAIN MANAGEMENT

NMBA Mechanism of action Comments Dose Onset; Contraindications/cau- Adverse effects

half-life tions
Atracurium nNMBs. Intermediate Histamine IV bolus: 0.4- Onset: 3-5 Does not require dose Hypotension
action. release. 0.5 mg/kg min adjustment in liver/renal
t½: 2-20 failure. Seizures
Metabolite: Infusion: min
laudanosine (de- 5-20 mcg/ Skin flush
creases seizure kg/min
threshold). Green urine

Cisatracu- nNMBs. First-line in IV bolus: 0.1- Onset: 2-3 Does not require dose Histamine release in high
rium continuous 0.2 mg/kg min adjustment in liver/renal doses
Elimination by plasmatic infusion. t½: 22-29 failure.
esterases. Infusion: 1-4 min
mcg/kg/min

Pancuro- nNMBs. Prolonged action. Vagal blockade, IV bolus: Onset: 2-3 Significant accumulation, Hypotension
nium sympathetic 0.05-0.1 mg/ min prone to residual blocka-
stimulation. kg t½: 89-161 ge (3-OH metabolite). Tachycardia
min
Infusion: Vagal blockade
0.8-1.7 mcg/
kg/min Catecholamine release

Rocuronium nNMBs. Intermediate Second-line IV bolus: 0.6- Onset: 1-2 Preferable over vecuro- Unpredictable in recurring
action. in continuous 1.2 mg/kg min nium in renal dysfunc- doses
infusion. t½: 1-2 h tion.
Infusion:
8-12 mcg/kg/
min

Vecuronium nNMBs. Intermediate Does not cause IV bolus: 0.1 Onset: 3-4 Preferable over rocuro- Vagal blockade with higher
action. fasciculations. mg/kg min nium in liver dysfunc- doses
t½: 4 min tion.
Infusion: Arrhythmia
0.8-1.7 mcg/
kg/min Urinary retention

Table 5. Neuromuscular blocking agents

nNMBs: Non-depolarising neuromuscular blockers.

Conclusions care involves knowledge of their indications, Conflict of Interest

Analgesics, sedatives and neuromuscular adverse effects, their correct use and the None.
blocking agents are commonly used medi- selection of the most appropriate agent,
cations in the ICU. An adequate protocol of with the aim of reducing morbimortality
in critically ill patients.

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