Hugh C. Gilbert

Pain Management Principles in the Critically Ill

This article addresses conventional pharmacologic and nonpharmacologic treatment of pain in patients in ICUs. For the critically ill patient, opioids have been the mainstay of pain control. The optimal choice of opioid and dosing regimen for a specific patient varies depending on factors such as the pharmacokinetics and physicochemical characteristics of an opioid and the bodys handling of the opioid, concomitant sedative regimen, potential or actual adverse drug events, and development of tolerance. The clinician must appreciate that favorable pharmacokinetic properties such as a short-elimination half-life do not necessarily translate into clinical advantages in the ICU setting. A variety of medications have been proposed as alternatives or adjuncts to the opioids for pain control that have unique considerations when contemplated for use in the critically ill patient. Most have been relatively unstudied in the ICU setting, and many have limitations with respect to availability of the GI route of administration in patients with questionable GI absorptive function. Nonpharmacologic, complementary therapies are low cost, easy to provide, and safe, and many clinicians can implement them with little difficulty or resources. However, the evidence base for their effectiveness is limited. At present, insufficient research evidence is available to support a broad implementation of nonpharmacologic therapies in ICUs.

A multicenter evaluation of a new continuous cardiac output pulmonary artery catheter system.

OBJECTIVE To validate a new system of continuous cardiac output monitoring. DESIGN Multicenter, prospective, nonrandomized clinical study. SETTING Four university hospitals. PATIENTS Forty-seven adult intensive care unit patients. INTERVENTIONS Pulmonary artery catheterization. MEASUREMENTS AND MAIN RESULTS Continuous and bolus cardiac output measurements were obtained over 72 hrs. The 327 continuous cardiac output measurements compared favorably with bolus cardiac output measurements (bias = 0.12 L/min, precision = +/-0.84). The continuous cardiac measurement was not adversely affected by temperatures of <37 degrees C or >38 degrees C, high (>7.5 L/min) or low (<4.5 L/min) cardiac output values, or duration (72 hrs) of the study. CONCLUSIONS This continuous cardiac output system provides a reliable estimate of cardiac output for clinical use if applied in conditions similar to this study. The combination of a continuous measure of cardiac output with other continuous physiologic monitoring (arterial and mixed venous oxygen saturation, oxygen consumption, etc.) may provide important information that no single parameter could achieve.

Structured Approaches to Pain Management in the ICU

Pain in patients who are critically ill remains undertreated despite decades of research, guideline development and distribution, and intense educational efforts. By nature of their complex medical conditions, these patients present unique challenges to the delivery of optimal pain treatment. Outdated clinical practices and faulty systems, such as a formulary that allows dangerous prescriptions, present additional obstacles. A multidisciplinary and patient-centered continuous quality improvement process is essential to identifying barriers and implementing evidence-based solutions to the problem of undertreated pain in hospital ICUs. This article addresses barriers common to the ICU setting and presents a number of structured approaches that have been shown to be successful in improving pain treatment in patients who are critically ill.

Pain Management Within the Palliative and End-of-Life Care Experience in the ICU*

In the ICU where critically ill patients receive aggressive life-sustaining interventions, suffering is common and death can be expected in up to 20% of patients. High-quality pain management is a part of optimal therapy and requires knowledge and skill in pharmacologic, behavioral, social, and communication strategies grounded in the holistic palliative care approach. This contemporary review article focuses on pain management within comprehensive palliative and end-of-life care. These key points emerge from the transdisciplinary review: (1) all ICU patients experience opportunities for discomfort and suffering regardless of prognosis or goals, thus palliative therapy is a requisite approach for every patient, of which pain management is a principal component; (2) for those dying in the ICU, an explicit shift in management to comfort-oriented care is often warranted and may be the most beneficial treatment the health-care team can offer; (3) communication and cultural sensitivity with the patient-family unit is a principal approach for optimizing palliative and pain management as part of comprehensive ICU care; (4) ethical and legal misconceptions about the escalation of opiates and other palliative therapies should not be barriers to appropriate care, provided the intention of treatment is alleviation of pain and suffering; (5) standardized instruments, performance measurement, and care delivery aids are effective strategies for decreasing variability and improving palliative care in the complex ICU setting; and (6) comprehensive palliative care should addresses family and caregiver stress associated with caring for critically ill patients and anticipated suffering and loss.

Point of care technologies.

Laboratory analysis is an essential aspect of the practice of anesthesiology and critical care medicine. Over the past several decades, new technologies have advanced the capability for obtaining laboratory and monitoring data at the bedside. Bedside analysis is often termed point-of-care analysis. This chapter examines how point-of-care analysis can impact on clinical decisions in acute care settings. The clinical laboratory remains an essential component of an acute care hospital. Physicians use laboratory data to confirm clinical impressions, to make a diagnosis, or to guide therapy. Clinical laboratories have been designed to provide results of an analysis or test with a reasonable turnaround time and with a documented degree of precision and accuracy. There have been dramatic increases in the demand by physicians for the testing and monitoring of biochemical, biologic, and physiological parameters in both the hospitalized and outpatient settings. This demand has been a driving force for developing laboratory instrumentation and policies and procedures, which shorten the time from request for testing and the availability of the result of testing. Historically, the development of multichannel semiautomatic analyzers facilitated the centralization of clinical laboratories. Hospitals determined the battery of tests it needed automated, procured the necessary equipment, trained operators, and devised methods for collection of samples and the distribution of results. Specialized technology such as polyacrylamide gel electrophoresis for protein analysis, high-performance liquid chromatography for therapeutic drug monitoring, and immunoas-

Regional analgesia in the intensive care unit. Principles and practice.

Nociception is a complicated process, and only in recent years have the neural pathways and mediators of pain transmission been unraveled. Several regional anesthetic interventions, most notably epidural drug delivery, can interrupt nociception and provide safe and effective pain control in critically ill patients while substantially reducing the need for systemic medications. This article discusses the possibilities for regional control of the neurobiology of nociception and describes the arsenal of regional anesthetic techniques available to the intensivist. Used wisely, regional techniques can provide excellent pain control and may have a significant role in improving overall patient outcome. Regional analgesia offers the best opportunity to provide substantial analgesia without significant central opioid effects. Well-conducted regional analgesia can reduce many of the unpleasant or potentially problematic side effects observed when traditional intravenous medications are used exclusively for pain control.

Methods for Evaluating Myocardial Contractility

A brief review of theory and indices for discerning changes in the contractile state of the heart is presented. A reliable bedside technique for determining myocardial contractility has yet to be found. The complexity involved in validating such a technique insures continued investigation in this area for a long time to come.

Physiologic Effects of Endotoxemia

Since the recognition of the specific shock syndrome associated with gram negative septicemia, the pathophysiology of endotoxemia has received world-wide attention. Numerous investigators have contributed to the understanding of the pathophysiologic interplay felt to be a part of the endotoxic syndrome. This effort has spanned the spectrum of the life sciences and has resulted in a wealth of information focusing on various possible pathophysiologic mechanisms.