3
Management of Acute Pain in the
Intensive Care Unit
Lauren Coleman, Jin Lee, and Christine Cocanour
INTRODUCTION
Pain management in the critically ill patient is complex. Each patient
brings a unique set of sociodemographic, pharmacokinetic, and phar-
macogenomic variables that are coupled with underlying psychosocial
and medical comorbidities. These not only influence a patient’s re-
sponse to painful stimuli but also to treatment. We know that critically
ill patients experience pain at rest, during routine intensive care unit
(ICU) care, and during procedures.1,2 Pain can originate from multiple
sources, including somatic, visceral, and neuropathic. Pain may be
acute, chronic, or acute on chronic in nature. Comorbidities such as
depression and anxiety can exacerbate pain.3,4 Patients that are younger,
female, and of nonwhite ethnicity are more likely to experience more
intense pain.4–8 Aging patients experience many physiologic changes
that may decrease their perception of pain and increase their vulnera-
bility to the adverse effects of pain medications.9–11
It is imperative to adequately treat pain in the ICU patient. Pain
during a procedure is not only influenced by the type of procedure
(including routine care such as turning) but also by preprocedural
pain intensity.2,5,8,12,13 Adequate assessment of pain and preemptive
analgesia are essential.14 Inadequate pain control contributes to the
development of delirium, and severe pain may lead to cardiac instabil-
ity (tachycardia, bradycardia, hypertension, and/or hypotension), re-
spiratory distress (desaturation, bradypnea, and/or ventilator distress),
and immunosuppression.14,15
To optimize an analgesic regimen, it is important to obtain a thor-
ough past medical history that includes a complete list of medications
and whether alcohol, tobacco, or opioid dependence is present. Man-
aging drug withdrawal in addition to achieving satisfactory analgesia
requires a multimodal approach.
Multimodal analgesia combines two or more drug classes or tech-
niques, employing different mechanisms of action that may target
multiple pain pathways in order to achieve a synergistic or additive
effect. This results in lower opioid consumption with the same or im-
proved level of comfort.16 Multimodal analgesia may include opioids,
nonopioid analgesics such as nonsteroidal antiinflammatory drugs
(NSAIDs) or gabapentinoids, regional or neuraxial blocks, and non-
pharmacologic therapies. Each patient’s medical history, allergies, age,
injuries, and comorbidities will dictate the optimum regimen. Pain
management protocols that mandate the use of validated pain and
sedation scales consistently decrease the consumption of opioids and
sedatives in ICU patients.17,18
ASSESSMENT
An assessment-driven and standardized pain management protocol
improves ICU patient outcomes, but assessment of pain in the critically
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ill patient can be challenging. Many ICU patients are ventilated, cogni-
tively impaired, and/or unable to self-report pain. Consequently, these
patients are at risk for undertreatment of their pain. Valid assessment
tools help guide analgesia while avoiding excess medication administra-
tion in those patients with adequate pain control.16,19–22 A number of
assessment tools are available for use in the ICU patient.14
For those patients able to self-report pain, the Numeric Rating
Scale (NRS) in a visual format had the best sensitivity, negative predic-
tive value, and accuracy in ICU patients.14 More recently, the Defense
and Veterans Pain Rating Scale (DVPRS) has become increasingly
popular.23 It combines a 1–10 pain scale with facial expressions and
colors to express pain intensity. The DVPRS also includes supplemen-
tary questions to measure the degree to which pain interferes with a
patient’s usual activity, sleep, mood, and stress (Fig. 3.1).
The Behavioral Pain Scale (BPS) and the Critical Care Pain Obser-
vation Tool (CPOT) (Fig. 3.2) have the greatest validity and reliability
for monitoring pain in those unable to self-report.14 BPS is a three-
domain assessment tool with four possible scores in each domain.
Scores range from 3 to 12, with scores above 6 indicating an unaccept-
able level of pain.14,24–26 CPOT is similar, with four domains and scores
ranging from 0 to 2 in each domain. The possible score ranges from 0
to 8, with 3 or above indicating the presence of pain.27–32
Vital signs (heart rate, blood pressure, respiratory rate, oxygen satu-
ration, and end tidal carbon dioxide) are not considered valid indicators
for pain in critically ill patients and should only be used as cues to initi-
ate further evaluation using one of the validated assessment measures.14
In unresponsive or paralyzed patients in which the validated scales are
impossible to use, no current assessment methods are available. Promis-
ing technology under development for this patient population includes
measuring heart rate variability (Analgesia Nociception Index), incorpo-
rating several physiologic parameters (Nociception Level Index), and
examining pupillary reflex dilation using video pupillometry.33–38
OPIOIDS
Historically, opioids were considered the mainstay of treatment for
non-neuropathic pain in the critically ill patient population because of
their high potency and efficacy.14,39,40 Opioids act at specific G-protein–
coupled receptors designated delta, kappa, and mu. These exist pre-
dominantly in the central nervous system, but also peripherally and in
certain organs (notably the gastrointestinal tract and heart).41 By acting
at these receptors, opioids decrease the perception of pain without in-
ducing loss of consciousness. All clinically relevant opioids are active at
the mu receptor, and some have additional activity at other receptors.41
The decision regarding which opioid to prescribe is highly depen-
dent on specific patient comorbidities and circumstances. When
titrated appropriately, all intravenous opioids are considered equally
13
14 PART I Common Problems

Defense and Veterans Pain Rating Scale

SEVERE
(Red)
MODERATE
(Yellow)

MILD
(Green)

0 1 2 3 4 5 6 7 8 9 10

No pain Hardly Notice Sometimes Distracts Interrupts Hard to Focus of Awful, Can't bear As bad as
notice pain, distracts me, can some ignore, attention, hard to do the pain, it could
pain does not me do usual activities avoid prevents anything unable to be,
interfere activities usual doing do nothing
with activities daily anything else
activities activities matters

DVPRS supplemental questions

For clinicians to evaluate the biopsychosocial impact of pain

1. Circle the one number that describes how, during the past 24 hours, pain has interfered with your usual ACTIVITY:

0 1 2 3 4 5 6 7 8 9 10
Does not interfere Completely interferes

2. Circle the one number that describes how, during the past 24 hours, pain has interfered with your SLEEP:
0 1 2 3 4 5 6 7 8 9 10
Does not interfere Completely interferes

3. Circle the one number that describes how, during the past 24 hours, pain has affected your MOOD:
0 1 2 3 4 5 6 7 8 9 10

Does not affect Completely affects

4. Circle the one number that describes how, during the past 24 hours, pain has contributed to your STRESS:
0 1 2 3 4 5 6 7 8 9 10
Does not contribute Contributes a great deal

Fig. 3.1 The DVPRS is a graphic pain reporting tool for patients that can self-report. (From https://www.
dvcipm.org/site/assets/files/1084/dvprs_single_page.pdf.)

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 CHAPTER 3 Management of Acute Pain in the Intensive Care Unit 15

Critical Care Pain Observation Tool

Indicator Description Score

Facial expression No muscular tension observed Relaxed, neutral 0
Presence of frowning, brow lowering, Tense 1
orbit tightening, and levator contraction
All of the above facial movements plus Grimacing 2
eyelid tightly closed
Body movements Does not move at all Absence of movements 0
Slow, cautious movements, touching or rubbing Protection 1
the pain site, seeking attention through movements
Pulling tube, attempting to sit up, Restlessness 2
moving limbs/thrashing, not following commands,
striking at staff, trying to climb out of bed
Muscle tension No resistance to passive movements Relaxed 0
Evaluation by passive Resistance to passive movements Tense, rigid 1
flexion and extension
of upper extremities Strong resistance to passive movements, Very tense or rigid 2
inability to complete them
Compliance with the Alarms not activated, easy ventilation Tolerating ventilator or 0
ventilator (intubated movement
patients)
Alarms stop spontaneously Coughing but tolerating 1
Asynchrony: blocking ventilation, alarms Fighting ventilator 2
frequently activated
OR Talking in normal tone or no sound Talking in normal tone 0
Vocalization or no sound
(extubated patients) Sighing, moaning Sighing, moaning 1
Crying out, sobbing Crying out, sobbing 2

Total, range 0–8

Behavioral Pain Scale

Item Description Score

Facial expression Relaxed 1
Partially tightened (e.g., brow lowering) 2
Fully tightened (e.g. eyelid closing) 3
Grimacing 4
Upper limbs No movement 1
Partially bent 2
Fully bent with finger flexion 3
Permanently retracted 4
Compliance with Tolerating movement 1
ventilation
Coughing but tolerating ventilation for most of the time 2
Fighting ventilator 3

Unable to control ventilation 4

Fig. 3.2 Critical Care Pain Observation Tool (CPOT) and Behavioral Pain Scale (BPS) are two commonly used
tools for monitoring pain in those patients that are unable to self-report. (Adapted from Gelinas C, Fillion L,
Puntillo KA, et al. Validation of the critical-care pain observation tool in adult patients. Am J Crit Care.
2006;15(4):420–427 and Payen JF, Bru O, Bosson JL, et al. Assessing pain in critically ill sedated patients by
using a behavioral pain scale. Crit Care Med. 2001;29(12):2258–2263.)

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16 PART I Common Problems

TABLE 3.1 Opioid Agents and Considerations for Use

Opioid Dosage Forms Onset Pharmacokinetics Considerations
Fentanyl IV, IM, intranasal, trans- 1–2 min • Metabolized by the liver • Very potent (100 times the potency of morphine)
dermal, transmucosal • No active metabolites • Rapid onset and short duration
• Prolonged use leads to accumulation in
peripheral compartments
• Less association with histamine release
Hydromorphone PO, IV, IM, SQ 5–15 min (IV) • Metabolized by the liver into weak • Potent (7–10 times the potency of morphine)
30 min (PO) metabolites • Improved safety profile over morphine in renal
• Excreted renally impairment
• Less association with histamine release
Morphine PO, IV, IM, SQ, transder- 5–10 min (IV) • Metabolized by the liver into potent • Use with extreme caution in renal impairment
mal, transmucosal 15–60 min (PO) metabolites • Use with caution in hepatic impairment
• Excreted renally • High association with histamine release (can
lead to bronchospasm and hypotension)
Oxycodone PO 10–30 min • Metabolized by the liver to multiple • Available in combination or alone
metabolites (oxymorphone)
Hydrocodone PO 15–30 min • Metabolized by the liver to multiple • Only available as a combination currently
metabolites (hydromorphone) • Use with caution in those with severe asthma
Methadone PO 30–60 min • Metabolized by the liver • Plasma levels and risk of death peak 5 days
• No active metabolites after start
• Excreted in feces • Respiratory depressant effect occurs later
than analgesic effect
• Watch for QTc prolongation
• Inhibits serotonin reuptake and can also pro-
duce analgesia via NMDA receptor antagonism
Tramadol* PO 60 min • Metabolized by the liver into • Also modulates serotonin and norepinephrine
O-desmethyl tramadol uptake (can lead to seizures)
• Excreted renally • Less respiratory depression and fewer GI side
effects than pure opioids
*Although not a typical opioid, tramadol is structurally related to morphine and has effects at opioid receptors
GI, Gastrointestinal; IM, intramuscular; IV, intravenous; NMDA, N-methyl-D-aspartate; PO, oral; SQ, subcutaneous.

effective with regard to analgesic efficacy and clinical outcomes.39 How-

ever, studies have shown patients may demonstrate variability in opioid
pharmacodynamics and pharmacokinetics, resulting in more favorable
reactions to one opioid over another.42 Thus providers must be com-
fortable with many different opioids, depending on the patient’s reac-
tion and clinical course. Common parenteral and oral opioids are
summarized in Table 3.1.
Though opioids remain a cornerstone of pain management, con-
siderable attention is now focused on limiting the opioids required
through the use of multimodal therapy. This is primarily because of
the many side effects of opioid-centered analgesia. Short term, these
can include physical dependence, ileus, constipation, nausea and vom-
iting, respiratory depression, sedation, pruritus, and urinary reten-
tion.43 Opioids may increase ICU length of stay and worsen post-ICU
patient outcomes. Long-term sequelae of opioid use include addiction,
immunosuppression, and opioid-induced hyperalgesia. These compli-
cations are prevalent, regardless of the specific opioid used or the route
of administration.
Particular attention should be paid to bowel dysfunction associated
with opioids secondary to binding of mu receptors in the enteric ner-
vous system.44 Opioids often induce constipation or worsen preexist-
ing constipation; prevalence of these conditions with opioid use vary
in the literature from 22% to 81% of patients.44 Thus prevention via a
robust bowel regimen that includes laxatives and/or bulking agents is
an essential consideration when prescribing opioids.
ACETAMINOPHEN
Despite being a commonly used analgesic and antipyretic, acetamino-
phen’s exact mechanism of action remains unknown. It has consistently
been shown to reduce opioid requirements when used as an adjunct;
furthermore, acetaminophen has minimal side effects. For the critically
ill patient, acetaminophen offers an advantage in that it can be admin-
istered via multiple routes of administration (intravenous [IV], orally
[PO], nasogastric [NG], per rectum [PR]). Although the IV formula-
tion has a slightly faster onset when used as a first dose, there is minimal
difference between the IV and enteral/rectal formulations when admin-
istered in a scheduled manner.45 Acetaminophen carries a risk of hepa-
totoxicity, though this is more commonly noted when high doses are
used for chronic pain rather than short-term acute pain. In 2011, the
Food and Drug Administration (FDA) released a recommendation to
reduce the maximum daily dose of acetaminophen from 4000 mg/day
to 3000 mg/day; however, it is important to note that this recommenda-
tion was aimed at consumers exposed to numerous over-the-counter
acetaminophen-containing combination products. In the inpatient set-
ting, the maximum daily dose should remain 4000 mg/day.46
NSAIDs
NSAIDs work as analgesics and antipyretics by inhibiting cyclooxygen-
ase (COX) enzymes, thereby reducing the formation of prostaglandins.

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 CHAPTER 3 Management of Acute Pain in the Intensive Care Unit
A wide variety of NSAIDs are available with numerous routes of ad-
ministration (IV, PO, NG, PR, topical) and varying degrees of selectiv-
ity to COX-1 and COX-2.
Historically, there has been a reluctance to use NSAIDs in the acute
pain setting because of their adverse effects, including increased risk of
gastrointestinal bleeding, nephrotoxicity, impaired platelet function,
and impaired wound healing. NSAIDs have long been avoided in the
setting of fractures because of the risk of nonunion; however, more
recent literature reviews have shown that this does not appear to be a
long-term issue, particularly with early postinjury or postoperative
administration.47–49 Thus the most recent guidelines support their use
in this setting.50
Platelet inhibition is primarily associated with inhibition of COX-1
and can be avoided with the use of COX-2 selective agents such as ce-
lecoxib. Unfortunately, COX-2 selective agents are not without risk—
they are contraindicated after coronary artery bypass graft surgery and
carry a risk of cardiovascular thrombotic events, such as myocardial
infarction and stroke. Despite their known risks, NSAIDs can be ben-
eficial in mitigating opioid exposure in select patient populations.
GABAPENTINOIDS
Opioids and other medications that often work well for nociceptive
pain offer minimal benefit for neuropathic pain. For patients who suf-
fer from diabetic neuropathy, spinal cord injury, burn pain, phantom
limb, post-stroke central pain, postherpetic neuralgia, or other forms
of neuropathic pain, gabapentinoids should be considered.51–53 Gaba-
pentin and its prodrug, pregabalin, work by inhibiting presynaptic
calcium channels. Originally developed as antiepileptic medications,
these agents have shown to be effective in the management of chronic
neuropathic pain.54 Although less data are available regarding their use
for acute pain, gabapentinoids should be considered when a source of
neuropathic pain is suspected. Caution should be exercised when ini-
tiating gabapentin or pregabalin in the elderly, as these agents are
known to cause somnolence and dizziness. In patients with renal dys-
function, doses should be adjusted accordingly.
MUSCLE RELAXANTS
Patients who experience pain secondary to muscle spasm may find
benefit from antispasmodic agents such as methocarbamol, cyclo-
benzaprine, baclofen, or diazepam. However, literature regarding
their efficacy is scant, particularly in the acute pain setting. Careful
consideration must be given before using these agents, given the as-
sociated risk of sedation. This is especially a concern in the older
adult patient.
KETAMINE
Ketamine is a phencyclidine derivative that acts as an N-methyl-D-
aspartate (NMDA) antagonist and has been used in the perioperative
and procedural setting for its anesthetic and analgesic effects. More
recently, subanesthetic doses of ketamine have been used in a continu-
ous fashion to provide analgesia without eliciting hallucinations or
other psychomimetic effects. Benefits of ketamine in the critically ill
setting include its neutral hemodynamic effects and its lack of respira-
tory suppression. Traditionally, ketamine has been avoided in patients
with cardiovascular comorbidities and patients with elevated intracra-
nial pressure (ICP); however, recent literature suggests that ketamine
may be used safely in patients with ICP concerns.55
At higher steady-state levels, magnesium has been shown to exhibit
similar anti-NMDA activity in the perioperative setting.56 Although
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17
this effect has not yet been demonstrated in the ICU setting, studies are
currently ongoing.
LIDOCAINE
Topical lidocaine patches can be used for localized pain to avoid sys-
temic effects, but their efficacy remains unclear, and caution should be
exercised near open wounds. Lidocaine drips have been used in the
perioperative setting to reduce opioid requirements and ileus recovery
time, but its role in the critical care setting remains largely un-
known.57,58
2 AGONISTS
Centrally acting a2 agonists, such as dexmedetomidine and clonidine,
may offer analgesic effects while avoiding respiratory depression. How-
ever, data regarding their use for acute pain in the critically ill popula-
tion are minimal, and cardiovascular effects such as hypotension and
bradycardia limit their use in hemodynamically unstable patients.
A summary of the previously discussed nonopioid analgesics can
be found in Table 3.2.
REGIONAL ANESTHESIA
Regional anesthesia techniques include neuraxial blocks (such as spi-
nal and epidural catheters), paravertebral blocks, intercostal nerve
blocks, transversus abdominis plane blocks, and peripheral nerve
blocks of the extremities. The use of regional anesthesia is associated
with improved analgesia in many patient populations, including post-
operative and polytrauma patients. Many studies have also shown that
the use of regional anesthesia leads to decreases in opioid-related side
effects.43 Of special interest within the critically ill population is the
association between epidural analgesia and improved global pulmo-
nary outcomes.59
Despite the many benefits of regional anesthesia documented in
the literature, it remains generally underused in the critically ill popu-
lation for a multitude of reasons. Hemodynamic instability and sepsis
are considered relative contraindications to neuraxial techniques.60
Critically ill patients may also require anticoagulation or develop co-
agulopathy, both of which may limit the ability of providers to per-
form neuraxial techniques safely. Finally, caution must be exercised in
patients at risk for developing compartment syndrome because of the
potential masking of symptoms. Of note, however, this can also be a
concern with systemic analgesia.
MUSIC MODALITIES
Music modalities for pain management can broadly be separated
into music medicine and music therapy. Music medicine uses music
to promote relaxation, provide distraction, and/or alleviate ten-
sion.61 Music therapy is instead a holistic approach involving a
music therapist that focuses on the healing process of music via
personal interaction.
Within the critically ill population, three small studies have found
minimal to moderate improvements in self-reported and assumed
pain scores through various forms of music medicine.62–64 Two of these
studies even found temporary improvement in pain scores for me-
chanically ventilated patients undergoing music medicine.63,64 In post-
operative patients, a recent meta-analysis of 97 studies found that
music medicine had a small to moderate effect on reducing opioid us-
age, and music therapy was found to decrease patient perception of
pain intensity.61 Music interventions generally had a stronger impact
18 PART I Common Problems

TABLE 3.2 Nonopioid Agents and Considerations for Use

Class Medication Dosage Forms Considerations
Acetaminophen Acetaminophen PO, IV, rectal • Caution in hepatic dysfunction
• IV formulation associated with hypotension
NSAIDs Nonselective PO, IV, topical, rectal • Caution in patients with gastrointestinal bleeding, acute kidney
Ibuprofen injury, and cardiovascular events
(COX-1 selective) • Ketorolac carries a black box warning cautioning against more than
Ketorolac 5 days of use to mitigate these risks
Naproxen
(COX-2 selective) PO
Celecoxib
Gabapentinoids Gabapentin PO • Consider for neuropathic pain
Pregabalin • Caution in elderly patients and renal
Venlafaxine dysfunction
• Monitor for dizziness and drowsiness
Muscle relaxants Baclofen PO • Caution in elderly patients and renal dysfunction
Methocarbamol • Tolerance/dependence may develop with prolonged use of baclofen
Cyclobenzaprine
Diazepam PO, IV • Associated with sedation and respiratory depression
NMDA antagonists Ketamine IV, IM, PO • Contraindicated in history of CVA, severe cardiac decompensation,
or conditions in which an increase in blood pressure may be harmful
• Increased risk of laryngospasm (procedural doses)
• Potential for tolerance with long-term use
• Monitor for emergence reactions
Magnesium (high dose) IV, PO • Contraindicated in patients with bradycardia
• IV bolus can be associated with hypotension
• Caution in patients with renal dysfunction and neuromuscular
disease
Sodium channel blockers Lidocaine IV, topical • IV product contraindicated in heart block
• Monitor for neurologic and cardiac toxicity
a2 agonists Dexmedetomidine IV • Associated bradycardia and hypotension
• Potential for tachyphylaxis to develop with long-term use
Clonidine PO • Associated hypotension and sedation

COX, Cyclooxygenase; CVA, cerebrovascular accident; IM, intramuscular; IV, intravenous; NSAID, nonsteroidal antiinflammatory drug; PO, oral.
Data from Erstad BL. Attempts to limit opioid prescribing in critically ill patients: Not so easy, not so fast. Ann Pharmacother. 2019;53:716–725;
O’Connor A, Dworkin R. Treatment of neuropathic pain: An overview of recent guidelines. Am J Med. 2009;122, S22-–S32; See S, Ginzburg R.
Skeletal muscle relaxants. Pharmacotherapy. 2008;28(2):207–213.

on acute or procedural pain versus chronic or cancer pain. Given these

results, and the fact that music modalities are inexpensive and safe,
consideration should be given to employing these modalities in the
ICU, pending availability and institutional logistics.
COGNITIVE BEHAVIORAL MODALITIES
Cognitive behavioral modalities include hypnosis, guided imagery, and
relaxation methods. Although these modalities have been extensively
studied as an adjunct for both acute and chronic pain management,
there is unfortunately a paucity of evidence within the critically ill
population. Examining the postoperative literature, cognitive behav-
ioral modalities frequently are found to improve postoperative pain
and analgesic use.65 Thus clinical practice guidelines from several
prominent medical societies recommend cognitive behavioral therapy
as adjunctive treatments in the postoperative patient.65 As these mo-
dalities are noninvasive and associated with minimal harm, the critical
care provider may consider incorporating these techniques into pain
management.
AROMATHERAPY
Aromatherapy involves the inhalation, topical application, or injection
of plant oils with pleasant smells. Common fragrances include berga-
mot, rose, orange, and mint, though lavender essential oil is one of the
most frequently discussed in the literature. Although evidence examin-
ing aromatherapy for pain management in the ICU is lacking, a system-
atic review of randomized controlled trials found that aromatherapy
reduces anxiety and improves sleep in critically ill patients.66 This effect
has also been noted in the mechanically ventilated subpopulation.67
PHYSICAL MODALITIES
Physical modalities include techniques such as acupuncture, cold or
heat therapy, and massage. Although these interventions are generally
safe and inexpensive, there is scant scientific literature in the critically
ill population. One small study found acupuncture in the ICU to be
feasible and safe, but effectiveness of the technique in this setting has
not been studied.68 Furthermore, the impact of physical modalities for

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 CHAPTER 3 Management of Acute Pain in the Intensive Care Unit
pain management in other patient populations is highly variable. As
such, clinical practice guidelines neither recommend nor discourage
the use of these techniques for postoperative pain management.65
Whether the critically ill patient would benefit from these physical
modalities is currently unknown.
KEY POINTS
• Pain management in the ICU patient is complex because of unique sociode-
mographic, pharmacokinetic, and pharmacogenomic variables that are
coupled with underlying psychosocial and medical comorbidities.
• The costs of inadequate pain control are high and include the development
of delirium, cardiac instability, respiratory distress, and immunosuppression.
• Valid pain assessment tools are important, as they help guide analgesia
while avoiding excess medication administration in those patients with
adequately controlled pain.
• Multimodal analgesia regimens are highly recommended because of their
improved efficacy and an associated decrease in opioid consumption, with
resultant reduction in opioid-related side effects.
• Nonpharmacologic modalities for pain control should not be underestimated
and may have a role in a well-rounded regimen for pain management.
References for this chapter can be found at expertconsult.com.
ANNOTATED REFERENCES
Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, Bickler S, Brennan T,
et al. Management of postoperative pain: a clinical practice guideline from
the American Pain Society, the American Society of Regional Anesthesia and
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19
Pain Medicine, and the American Society of Anesthesiologists’ Committee on
Regional Anesthesia, Executive Committee, and Administrative Council.
Journal of Pain. 2016;17(2):131–157.
This clinical practice guideline was developed by an interdisciplinary expert
panel after incorporating a systemic review of postoperative pain manage-
ment. Special focus is given to tailoring pain management to the individual
patient and the surgical procedure involved.
Devlin JW, Srobik Y, Gélinas C, Needham DM, Slooter AJC, Pandharipande PP,
et al. Clinical practice guidelines for the prevention and management of
pain, agitation/sedation, delirium, immobility, and sleep disruption in adult
patients in the ICU. Critical Care Medicine, 2018;46(9):e825–e873.
These guidelines represent the most recent recommendations from the Society
of Critical Care Medicine as a collaborative effort by a large interdisciplinary
cohort of international experts. An emphasis is placed on the evidence behind
various multimodal agents.
Hsu JR, Mir H, Wally M, & Seymour RB. Clinical practice guidelines for pain
management in acute musculoskeletal injury. Journal of Orthopaedic
Trauma. 2019;33(5):e158–e182.
Released by the Orthopaedic Trauma Association Musculoskeletal Pain Task
Force, this recent guideline uses the GRADE method to provide evidence-
based recommendations to improve the management of acute pain after
musculoskeletal injury.
Kaye AD, Baluch A, & Scott JT. Pain management in the elderly population:
a review. The Ochsner Journal. 2010;10:179–187.
A review of pain management in the elderly, including physiologic changes
associated with aging and how it affects pain management.
Skrobik Y, Ahern S, Leblanc M, Marquis F, Awissi DK, & Kavanagh BP. Protocolized
intensive care unit management of analgesia, sedation, and delirium improves
analgesia and subsyndromal delirium rates. Anesthesia and Analgesia. 2010;
111:451–463.
A pre-post study showing that systematic management protocols with
individualized titration of sedation, analgesia, and delirium therapies
are associated with better outcomes in the ICU patient.

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