Elsevier

Critical Care Clinics

Volume 15, Issue 1, 1 January 1999, Pages 1-16
Critical Care Clinics

PAIN: A Prelude

https://doi.org/10.1016/S0749-0704(05)70036-1Get rights and content

We must all die. But that I can save him from daysof torture, that is what I feel as my great and evernew privilege. Pain is a more terrible lord ofmankind than even death itself.
ALBERT SCHWEITZER

Pain has long been feared. The quotation from Albert Schweitzer is probably representative of the feelings of most patients and physicians alike. Management of pain in the critically ill patient demands extreme dedication to the provision of analgesia that is appropriate for the specific clinical situation. An intensivist's challenge is vast, and lies in understanding the mechanisms of nociception, understanding the influences of stress responses evoked during surgery or non-surgical critical illness, understanding pharmacokinetics and pharmacodynamics, understanding the influences of drugs on changes in volume of distribution or organ dysfunction, possessing a mastery of techniques which may be indicated under certain clinical circumstances and finally trying to ensure the appropriate level of analgesia many times under conditions when direct patient feedback is unattainable. As one might expect, the challenges are many and complex.

The causation of pain is generally multifactorial in the critical care unit. Depending on the setting, patients may possess immense surgical wounds or experience pain emanating from nonsurgical sources. Most patients will have catheters of some classification inserted, for example Foley catheters, pulmonary artery catheters, central venous catheters, or arterial catheters, and a vast array of drains. Tubes inserted may include endotracheal, nasogastric, Dobhoff, and thoracostomy tubes. In addition to surgical trauma, pain may originate as a result of nonsurgical etiologies and may include myocardial ischemia and/or infarction, pancreatitis, a sickle cell anemia crisis, subarachnoid hemorrhage, nephrolithiasis, or cholecystitis, all of which require medical attention and, if deemed serious, could mandate admission to the critical care unit.

This article will attempt to review briefly what is understood and what is not understood about pain and its management. Topics include pain assessment, knowledge of analgesia administration, the physiologic influences of pain (both surgical and non-surgical), and the impact of pain on patient outcome.

Section snippets

A RETROSPECTIVE OF PAIN ASSESSMENT AND TREATMENT

Physicians' deficiency in pain assessment skills and apprehension of inducing overdose with the use of narcotics have been fairly well documented. In 1979 a survey of 100 patients admitted and treated in the intensive care unit revealed that 32 of these patients ranked pain as their greatest “worry.”9 Sixty-six of these patients stated that pain was a factor in both preventing and disturbing their sleep. In 1996, the study to understand prognoses and preferences for outcomes and risks of

Psychophysiology

Factors influencing pain in a particular patient tend to be multifactorial in origin. Elements that are most instrumental include a triad of psychology, physiology, and sociology.24 Two levels of pain threshold are generally described, low and high. The low pain threshold refers to the moment of a response to a painful stimulus. Upper pain thresholds are attained when absolute tolerance to the painful stimulus is achieved. These thresholds can be manipulated with the use of various

ANALGESIC INFLUENCES ON THE STRESS RESPONSE

Evidence has accrued demonstrating attenuation of the numerous physiologic alterations brought about by the stress response. As previously stated, while not problematic in some patients, a stress response may be of concern if exaggerated (e.g., a critical injury) or experienced by a patient with comorbid illness. Therefore, modifying the response may be appropriate. An abundance of literature supports the use of neural blockade of varied types to modify neuroendocrine responses, specifically in

OUTCOMES AND ANALGESIA

Attention to the administration of analgesics is a quintessential component of any comprehensive patient care plan. However, patients can be plagued by an abundance of undesired complications from the physiologic perturbations that occur during the stress of surgery. Therefore, a question of considerable relevance that must be examined is the effect of analgesia via neural blockade on clinical outcome (i.e., on pulmonary complications, duration of ICU stay, or mortality). The preponderance of

SUMMARY

Although pain is a common fear to most, our overall ability to recognize pain, and assess and intervene with appropriate therapies is mediocre at best. However, if made a priority, substantial gains can be made in improving patient satisfaction with pain control and in rectifying deficits in the knowledge of health-care professionals. This goal is not easily obtained and generally requires time, patience, and a multidisciplinary team approach.

Pain can induce numerous metabolic and

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    Address reprint requests to John D. Lang, Jr, MD, Department of Anesthesiology, The University of Alabama at Birmingham, 845M Jefferson Tower, 619 South 19th Street, Birmingham, AL 35233–6810

    *

    Department of Anesthesiology, The University of Alabama at Birmingham, Birmingham, Alabama

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