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212 C. Hasken et al.
3 Unique Considerations when Managing Pain
for the Critically Ill
Multiple factors contribute to the complexity of managing pain in the critically ill
patient, however at the forefront is a limited ability to effectively identify and assess
pain. ICU patients frequently have communication barriers. Barriers may arise from
intubation and mechanical ventilation, altered mental status, insomnia and exhaus-
tion, or severe immobility and severity of illness altering the perception of pain.
Multiple clinical practice guidelines have highlighted the importance of regular and
standardized pain assessments [1–3, 6].
Family and friends can serve as proxies for patients unable to communicate.
Proxies are valuable s ources of information as resources of pain history, conveying
the patient’s wishes prior to becoming critically ill, and assisting with assessments
of pain in the ICU. Pontillo et al. found that family proxies’ estimated pain scores
were closer predictors of 245 patients’ self-reported pain scores than the nurses or
physicians caring for them [8]. Notably, there was only a moderate level of agreement
between patients and family.
Vitals signs should not be used as indicators of pain in the ICU [3, 6]. Vital sign
alterations are affected by inotropes, vasopressors, catabolic or sepsis states and are
not valid indicators of pain in the critically ill patient. However, vital sign changes
should prompt clinicians to assess for t he driver of the change, including performing
an assessment for pain.
There are three generally accepted and validated tools to assess pain in the critical
care setting that are recommended in the latest clinical practice guidelines [3]. The
Numeric Rating Scale (NRS) is for patients who can communicate, and the Behav-
ioral Pain Score (BPS) or Critical Care Pain Observation Tool (CPOT) is for use
in patients with impaired communication. Self-reported pain is the gold standard
for pain assessment in patients able to effectively communicate [3, 9]. The NRS
can be used visually, orally, written, or with other electronic forms of communica-
tion, making it a useful assessment strategy in a wide variety of patient interactions,
including those requiring mechanical ventilation. The NRS has superior sensitivity,
negative predictive value, and accuracy compared to the verbal descriptor scale (no
pain, mild pain, moderate pain, severe pain, extreme pain), and the visual analog
(faces) scale [3].
For patients who are unable to communicate, for example with altered mental
status or traumatic brain injury, two behavioral assessment tools have been vali-
dated. The Behavioral Pain Scale uses facial expressions, upper limb movements,
and compliance with mechanical ventilation as indicators of pain [ 10]. The Critical
Care Pain Observation Tool(CPOT)is similar, although it differentiates between intu-
bated and non-intubated patients and additionally observes for the degree of muscle
tension [11]. Both scales have been validated for use in critically ill patients who are
unable to self-report pain scales [3, 9–11]. It is important to note that these scales have
not been extensively studied in patients with delirium, although some smaller studies
suggest CPOT may be more reliable in this setting [1, 9]. Rijkenberg et al. compared
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Pain Management Considerations in Critical Care 213
the BPS vs. CPOT in mechanically ventilated patients and found that CPOT was less
likely to score for pain during procedures that were determined as not painful (oral
care), potentially decreasing unnecessary sedation or opioid administration.
Delirium is common in the ICU, with a prevalencebetween 26 and 78% depending
on the subspecialty type of the ICU [1]. Delirium is multifactorial, but may be trig-
gered by untreated pain as well as analgesics, making the balance between these
contradictory goals difficult. Studies validating pain assessment tools have specifi-
cally excluded delirious patients due to the similar symptoms of pain and delirium
(particularly hyperactive delirium) [1, 3, 6], which unfortunately has left a significant
proportion of the critical care population without strong evidence-based guidelines
for pain management. As the importance of light sedation, early mobilization, and
prevention of delirium become more recognized, routine assessment and adequate
treatment of pain is essential and should be an area of focus and future study. Current
guidelines recommend that pain be treated first with an analgesic instead of a sedative
agent and have also introduced the concept of analgosedation, making pain interven-
tion a priority over sedating medications [3]. Care of mechanically ventilated patients
using this method is associated with reduced sedative requirements, decreased dura-
tion of mechanical ventilation, lower pain intensity and shorter length of ICU stay
[3]. Importantly, this method was not associated with increased rates of hypotension,
constipation, or opioid exposure [3].
4 Pharmacological Management of Pain
Both opioid and non-opioid medications are utilized in intensive care units globally
for the management of pain. Some medications such as acetaminophen and non-
steroidal anti-inflammatory drugs (NSAIDs) have been available for decades. Other
medications, including ketamine and long-acting opioids, were more recently devel-
oped and are increasingly used for pain control in critically ill patients. Regional
anesthetic techniques and non-pharmacological methods for pain management may
be useful as adjuncts to decrease opioid use [12]. When assessing pain control in
patients, one must consider the origin of the pain when choosing an analgesic agent
or technique. For acute postoperative or traumatic pain, a regional versus systemic
option for analgesia should be considered [12]. Endotracheal tube irritation or inter-
mittent procedural discomfort may be best treated using short acting opioid medica-
tions or local anesthesia to minimize over-sedation and adequately treat pain [12].
For patients with a history of chronic pain, home regimens consisting of long-acting
opioids and neuropathic pain medications may be most effective.
A group of international experts developed evidence-based guidelines for pain
management in critically ill patients, which were revised and republished in 2018 [3].
Multiple expert groups have contributed to guidelines for analgesia in both pediatric
and adult intensive care patients [3, 6]. However, these recommendations are often
based on weak evidence or “expert consensus” for specific agents utilized in the
ICU. An overview and summary of the current evidence for both pharmacological
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214 C. Hasken et al.
and non-pharmacological management of pain in the adult ICU patient are discussed
below (Table 1).
.
Table 1 Summary of pharmacologic management of pain
Drug Recommended dosing Evidence
Acetaminophen IV,PO,andPR:1g
q6h for maximum of 4
g daily in patients with
normal liver function
Recommended for routine use in ICU for
analgesia; likely similar analgesic effect regardless
of route of administration
NSAIDs Ibuprofen, PO: 600 mg
q6h
Ketoprofen, PO and
IV: 25 mg–50 mg q6–8
hr for maximum of
300 mg daily
Ketorolac, IV and IM:
15–30 mg q6h
PO: 10 mg q4–6h
Only used for short
term use (up to 5 days)
Not recommended for routine use in ICU for
analgesia; additional RCTs needed particularly for
COX-2 inhibitors
Not recommended in patients with renal failure
Neuropathic
medications
Gabapentin, PO:
300–1200 mg TID for
maximum of 3600 mg
daily
Pregabalin, PO:
75–150 mg BID
Carbamazepine, PO:
100 mg TID
Recommended for routine use in ICU for
neuropathic pain; requires enteral access and has
sedating side effects; further RCTs needed; very
limited data regarding carbamazepine use in this
setting
Opioids Sufentanil, IV:
0.23–0.37 mcg/kg/hr
Nalbuphine, IV:
0.15–0.17 mg/kg/hr
Methadone, PO and
IV: 5–15 mg q8h
Evidence from Ji et al. suggests sufentanil and
nalbuphine are safe and effective in ICU patients at
these doses; very limited data for dosing of all
opioid agents in the ICU setting
Ketamine IV: 0.1–0.5 mg/kg
bolus followed by
0.12–0.36 mg/kg/hr
infusion
Recommended as low dose bolus and infusion
combination in conjunction with opioids; further
evidence needed for exact dosing guidelines in
ICU patients
Systemic
lidocaine
IV: +/−1.5 m g/kg
bolus followed by
1–2 mg/min infusion
for up to 24 hours
postoperatively
Strong evidence in postoperative colorectal surgery
patients; no evidence to support its use outside of
this population
Topical lidocaine Patch: 5% lidocaine
with 700 mg applied
for 12 hours on and
12 hours off
Evidence is mixed; may provide benefit for
post-thoracotomy patients as adjunct but additional
evidence is needed
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Pain Management Considerations in Critical Care 215
5 Acetaminophen
Acetaminophen is the most commonly used analgesic medication globally [13]. This
drug acts as a cyclooxygenase inhibitor and additionally exhibits serotonergic effects
[14]. There are numerous routes of administration–oral (PO), intravenous (IV) and
per rectum (PR)—which makes acetaminophen an acceptable option for many crit-
ically ill patients. Randomized controlled trials to date have focused primarily on
IV acetaminophen use in ICU patients, and the evidence suggests acetaminophen
can effectively decrease pain severity[3, 14-16]. Furthermore, this medication may
decrease opioid consumption, decrease mechanical ventilation time, and reduce seda-
tion [3, 14]. Although most studies have evaluated the efficacy of IV acetaminophen,
experts generalize this data to both PO and PR acetaminophen and recommend the
use of acetaminophen as an adjunct for pain management in the ICU [3]. Studies
suggest PO and PR administration are as effective for analgesia as IV administra-
tion and may decreases costs [16]. In critically ill patients, dose adjustment may be
required in patients with liver dysfunction or altered intestinal absorption [3]. As
with all medications in the setting of critical illness, careful assessment and dosing
based on individual patient factors is essential.
6 Non-steroidal Anti-inflammatory Drugs
In the critical care setting, non-steroidal anti-inflammatory drugs (NSAIDs) also
may be a useful adjunct for acute pain. These medications include cyclo-oxygenase
1 (COX-1) and cyclo-oxygenase 2 (COX-2) inhibitors, both of which inhibit
prostaglandin synthesis [17]. Despite their analgesic effect, NSAIDs are associated
with adverse effects such as platelet dysfunction, renal injury, and gastrointestinal
irritation, which may cause harm to already critically ill patients [17]. However, in
a randomized controlled trial for post-operative cardiac surgery patients, Hynninen
et al. found no difference in change in creatinine from baseline in patients receiving
NSAIDs versus placebo. While this study failed to demonstrate a difference in pain
scores among patients treated with NSAIDs versus placebo, diclofenac and other
NSAIDs may help reduce the need for additional pain medications [17]. In critically
ill patients following major abdominal surgery, Oberhofer et al. found significant
improvements in pain in the NSAID group with reduced nausea and vomiting side
effects compared to the control group [18]. Importantly, there was no significant
difference in bleeding in the NSAID group [18]. With somewhat mixed evidence
and potential adverse effects, one expert task force [3] does not recommend the
routine use of NSAIDs for analgesia in critically ill patients. Additional randomized
controlled trials are needed to better understand the general efficacy and safety of
NSAIDs in the ICU setting.
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216 C. Hasken et al.
7 Neuropathic Pain Medications
In recent years, the use of pregabalin, gabapentin, and carbamazepine as perioperative
and neuropathic pain analgesic agents has garnered significant attention. Both prega-
balin and gabapentin have structures similar to gamma-aminobutyric acid (GABA)
and bind voltage-gated calcium channels within the central nervous system. Their
specific mechanism related to neuropathic pain control is poorly understood, but both
drugs likely reduce glutamatergic activity and minimize the development of hyperal-
gesia [19, 20]. Carbamazepine, an antiepileptic drug, is involved in the inactivation
of sodium channels, which leads to inhibition of high frequency neuronal activity at
epileptic foci [19]. A similar mechanism may explain why carbamazepine demon-
strates an analgesic effect at the site of a painful stimulus. Randomized controlled
trials to date have focused on the use of these medications in Guillain-Barre syndrome
patients in the ICU as well as patients undergoing cardiothoracic surgery. Pandey and
colleagues determined gabapentin to have a superior analgesic effect compared to
carbamazepine in Guillain-Barre patients admitted to the ICU for respiratory support
[19, 21]. Gabapentin also reduced opioid requirements compared to placebo [21].
This reduction in neuropathic pain may be generalizable to other patient popula-
tions but further evidence is needed. In postoperative cardiothoracic surgery patients,
pregabalin is associated with reduced opioid requirements and reduced pain scores
at three months postoperatively in two randomized controlled trials [20, 22]. This
suggests neuropathic pain medications may not only effectively treat acute pain, but
they also may reduce the risk of developing chronic neuropathic pain. An expert
international task force recommends the use of neuropathic pain medications in crit-
ically ill patients but notes enteral administration is required and not always feasible
[3]. These medications are also associated with adverse sedating effects, which may
expose patients to an elevated risk of additional complications [3].
8 Opioids
Nearly all opioids used for analgesia have mu opioid agonist properties with vari-
ability in onset, duration of action, and side effects. Common adverse effects include
respiratory depression, nausea, vomiting, constipation, urinary retention, itching, and
sedation, which can all be detrimental to the recovery of critically ill patients [23].
Opioids with adequate analgesic properties and minimal adverse effects are ideal for
use in the ICU. Sufentanil and nalbuphine may provide an improved safety profile
relative to other commonly used opioids such as fentanyl or morphine. Sufentanil,
a mu agonist, is highly lipophilic with a fast onset and offset following IV adminis-
tration. Nalbuphine produces analgesia through opioid agonist-antagonist effects on
mu and kappa receptors in the central nervous system. Both of these opioids can be
administered as a continuous infusion for analgesia. Nalbuphine has a ceiling effect
on respiratory depression at doses greater than 30 mg per 70 kg [23]. This drug
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Pain Management Considerations in Critical Care 217
may offer a safer alternative to other opioid infusions and achieve adequate pain
control with a lower risk of respiratory complications. An interesting study from
Ji et al. demonstrated the safe and effective use of both nalbuphine and sufentanil
for pain control in patients admitted to the ICU [23]. In their retrospective anal-
ysis, nalbuphine provided superior analgesia for patients age 60 years or younger,
whereas sufentanil provided better analgesia for patients over the age of 60 years [ 23].
No patients experienced hypoxemia, hypotension, or bradycardia related to opioid
administration. Use of these agents in the ICU setting is uncommon, and randomized
controlled trials are needed to determine if nalbuphine and sufentanil are superior in
efficacy or safety compared to other opioid agents.
The use of methadone in critically ill patients is growing, but evidence remains
limited regarding appropriate patient selection, dosing, and duration of use.
Methadone primarily acts as a mu opioid receptor agonist, N-methyl-D-aspartate
(NMDA) receptor antagonist, and inhibitor of serotonin and norepinephrine reuptake
[24]. This drug may assist with analgesia, as well as decrease mechanical ventilation
time, reduce opioid withdrawal after prolonged sedation from a continuous opioid
infusion, and improve delirium [24]. However, adverse effects including respiratory
depression are still a risk with methadone. Additional studies are needed to guide
the appropriate use of methadone for analgesia in critically ill patients.
Many ICU patients have baseline chronic pain conditions that make adequate pain
control challenging during a critical illness or in the postoperative period. Patients
with substantial baseline opioid tolerance require higher opioid dosing to achieve an
appropriate comfort level when subjected to noxious stimuli. Unfortunately, these
patients are often undertreated with opioids during hospital admission. This may be
due to provider unfamiliarity or discomfort prescribing high dose opioid regimens,
as well as difficulty quantifying baseline opioid requirements. The baseline opioid
calculations can be particularly difficult for patients who abuse opioids and for whom
baseline administration data is inconsistent [25]. Regardless of the etiology, opioid
underdosing in these patients can lead to an increased hospital l ength of stay and
worsened patient outcomes. Patients on chronic opioid therapy require their baseline
morphine milligram equivalents in addition to additional short acting opioids for
acute pain control [25]. Dosing of medications may need adjustments based on
changes in hepatic and renal function from baseline, volume status, and mental status
alterations in critically ill patients.
9Ketamine
The use of ketamine as an analgesic alternative to opioids in critically ill patients
is rapidly expanding. Ketamine acts primarily as an analgesic via NMDA receptor
antagonism [26]. Potentially beneficial effects of ketamine in ICU patients include
preservation of airway reflexes, increases in lung compliance, minimal respiratory
depression, and reduction in respiratory complications [26]. However, ketamine
may cause hallucinations or worsen delirium in critically ill patients [26]. One
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218 C. Hasken et al.
randomized controlled trial suggested a higher dose ketamine infusion (2 mg/kg/hr)
can actually decrease the incidence of delirium in mechanically ventilated patients
but may not improve outcomes such as opioid consumption, ventilator free days,
ICU length of stay, or mortality [27]. Other studies have shown a reduction in opioid
requirements for patients treated with ketamine [28, 29]. For analgesia, lower doses
of ketamine as an IV bolus (0.1–0.3 mg/kg) or as an IV infusion (0.12–0.36 mg/
kg/hr) have improved pain control with minimal adverse psychogenic effects [29].
The optimal dosing regimen is typically an IV bolus followed by an IV infusion for
up to 48 hours [29]. The KAPT trial is a large randomized controlled trial currently
underway aiming to evaluate the impact of ketamine on trauma patients in stepdown
units and ICUs [30]. Results of this study may provide some clarity regarding appro-
priate patient selection, ketamine dosing, and duration of treatment for critically
ill trauma patients. Current clinical practice guidelines recommend using low dose
ketamine as a 0.5 mg/kg IV bolus followed by a 0.06-0.12 mg/kg/hr IV infusion in
conjunction with opioids for postoperative ICU patients [3].
There are several studies that evaluated the use of ketamine in combination with
local anesthetic for wound infiltration and regional blocks perioperatively [31, 32].
The evidence is mixed, but small randomized controlled trials have shown improved
analgesia with ketamine plus local anesthetic infiltration compared to only local
anesthetic infiltration for patients undergoing abdominal surgery [31, 32]. Further
trials specific to critically ill patients are needed to assess the utility of ketamine for
wound infiltration in the ICU setting.
10 Systemic Lidocaine
Most studies assessing systemic lidocaine use for perioperative analgesia are among
colorectal patients and not specific to ICU patients. In multiple randomized controlled
trials, systemic lidocaine decreased the duration of postoperative ileus, decreased
hospital length of stay, and possibly reduced pain scores compared to alterna-
tive analgesic options for colorectal surgery patients[33–35]. One small random-
ized controlled trial demonstrated equivalent pain scores, postoperative return of
bowel function, and hospital length of stay among patients receiving systemic lido-
caine versus thoracic epidural analgesia following open colorectal surgery [36]. This
suggests IV lidocaine administration is a reasonable analgesic alternative for patients
unable to receive an epidural catheter for open colorectal surgeries. Regarding dosing
of systemic lidocaine, the data is variable. Some studies included a bolus of IV lido-
caine prior to starting the IV infusion, and others did not. Dosing ranged from 1 to
2 mg/min and duration ranged from only intraoperatively versus up to 24 hours post-
operatively in these studies [33–35]. Outside of colorectal surgery patients, minimal
evidence exists to support the use of systemic lidocaine for analgesia. In postoperative
cardiac surgery patients, one randomized trial found no benefit in time to extubation,
ICU length of stay, or hospital length of stay among patients receiving systemic lido-
caine versus placebo infusion [37]. Although systemic lidocaine may be beneficial
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Pain Management Considerations in Critical Care 219
in certain ICU patients, few studies have specifically evaluated its use in critically
ill patients. Additional large investigations are needed, but current evidence recom-
mends the use of systemic lidocaine for up to 24 hours postoperatively in colorectal
surgery patients admitted to the ICU.
11 Dexmedetomidine
With potential benefits as both a sedative and analgesic agent, dexmedetomidine has
become a popular tool for analgosedation, typically administered as an infusion for
patients in the intensive care unit. The primary focus of the literature in critically ill
patients is in reducing or preventing delirium with the use of dexmedetomidine [38].
The use of dexmedetomidine for pain control in ICU patients remains sparse. As a
centrally acting alpha-2 receptor agonist, dexmedetomidine reduces norepinephrine
release and can lead to bradycardia, hypotension, and decreased cardiac output [38].
For critically ill patients with cardiovascular instability, the risks may outweigh the
benefits for use as an analgesic. In the peripheral nervous system, dexmedetomidine
also inhibits C-fibers and A alpha-fibers which can decrease pain[39]. Postoperative
analgesic benefit has been shown via multiple routes of administration including
intravenous,epidural, intrathecal, intra-articular, and as an adjunct to local anesthetics
in nerve blocks [39]. Despite the promising data to date in the perioperative period,
additional evidence in critically ill patients is needed to safely and effectively use
dexmedetomidine as an analgesic.
12 Other Adjuncts
Evidence is variable regarding the use of lidocaine patches for analgesia in post-
operative cardiothoracic surgery ICU patients [40, 41]. Fiorelli et al. found that
lidocaine patches may reduce pain both at rest and with coughing, as well as reduce
opioid requirements in these patients. However, Liu et al. found no difference in pain
scores, ICU length of stay, or hospital length of stay for patients who received lido-
caine patches. Perhaps in certain patient populations, such as those with chronic pain
or with limited options for analgesia, utilizing a lidocaine patch may provide benefit
as an adjunct to other therapies with minimal risk. However, additional evidence is
needed to recommend routine use.
Cannabinoids have the potential to provide analgesia in conjunction with other
methods. Narang et al. suggest cannabinoids can reduce pain scores and improve
patient satisfaction in the outpatient chronic pain population but this has not been
studied in ICU patients [42]. More evidence is needed prior to recommending their
use in critically ill patients for analgesic purposes.
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220 C. Hasken et al.
13 Regional Anesthesia Techniques
For critically ill patients, delirium and other complications can result from complex
medication regimens and polypharmacy. Regional anesthesia including neuraxial
blocks, peripheral nerve blocks, and truncal blocks can reduce the amount of systemic
pain medications required for adequate pain control. Regional anesthetic tech-
niques may reduce sedation requirements, thereby facilitating early mobilization,
normal sleep and wake cycles, and meaningful interactions with family members
and providers [12]. However, due to difficulty with positioning patients who require
mechanical ventilation, with multiple lines and drains, skin edema, skin infections,
hemodynamic instability, and coagulopathy, regional anesthesia techniques may
be difficult to perform or even contraindicated in some critically ill patients [43].
Evidence supporting the use of regional anesthesia for analgesia in ICU patients is
discussed below.
14 Neuraxial Anesthesia
Neuraxial techniques are commonly used in the ICU for pain control. For esophagec-
tomy patients, thoracic epidural anesthesia (TEA) has been shown to reduce anas-
tomotic leak rates and increase blood flow to the gastric conduit [44, 45]. TEA may
also reduce mechanical ventilation time, reduce ICU length of stay, and decrease
opioid requirements in esophagectomy patients [46]. For patients undergoing open
nephrectomy, Capdevila et al. found that TEA significantly improved pain control
and reduced opioid requirements compared to patients randomized to the morphine
patient-controlled analgesia group [47]. Among patients undergoing elective abdom-
inal aortic aneurysm repair, those who received general anesthesia with an epidural
compared to general anesthesia without an epidural were less likely to require a
surgical re-intervention at 30 days and less likely to develop bowel ischemia, respi-
ratory complications, or renal failure requiring dialysis in a large retrospective anal-
ysis [48]. Among patients undergoing lung resection, TEA may reduce mortality
and the risk of pulmonary complications [49]. For elective liver surgeries in the
setting of cirrhosis, there may be increased risk of epidural hematoma even with
normal coagulation profile due to thrombocytopenia and distended epidural veins
[43]. Appropriate evaluation of risks and benefits of TEA in these patients is critical.
There is emerging evidence that patients undergoing cardiac surgery requiring full
anticoagulation and cardiopulmonary bypass may also benefit from TEA. Landoni
et al. performed a meta-analysis of 88,820 patients undergoing cardiac surgery with
TEA in place. The group found a 1 in 3,552 incidence of epidural hematoma, which
is approximately triple the risk in a non-cardiac surgery patient. However, they also
determined the number needed to save a life was 70 cardiac surgery patients, which
they suggest outweighs the risk of bleeding complications [50]. The meta-analysis
further signaled a reduction in mechanical ventilation requirement and decreased
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Pain Management Considerations in Critical Care 221
incidence of myocardial infarction among patients with TEA. Although full antico-
agulation on cardiopulmonary bypass has previously been considered a contraindi-
cation for neuraxial anesthesia, perhaps the benefits of analgesia and reduction in
other morbidities should encourage anesthesiologists to reconsider this as an option
for cardiac surgery patients.
Among patients with acute pancreatitis, there is strong evidence that TEA can
improve patient analgesia and other recovery parameters [51, 52]. In animal models,
TEA improves microcirculation to the pancreas due to splanchnic vasodilation from
local sympathectomy [51, 52]. In these studies, TEA was associated with a decreased
severity of pancreatitis on tissue exam and reduced mortality. In human patients, Al-
Leswas et al. performed a meta-analysis of 726 patients with acute pancreatitis who
received TEA [53]. Their analysis showed improvements in pain control, pancreatic
perfusion, mechanical ventilation requirements, and mortality [53]. The patients who
benefited most were those who received TEA early on in their hospital course. There
were no major neurological complications related to TEA in this meta-analysis,
suggesting TEA may not only provide significant analgesic benefit to patients with
acute pancreatitis but is also safe and associated with reductions in morbidity and
mortality.
Overall, neuraxial anesthesia is associated with additional benefits including
improved coronary perfusion, reduced inflammation, improved intestinal perfusion
and motility, and reduced respiratory complications [49]. Rodgers et al. performed
a meta-analysis of randomized trials involving neuraxial versus non-neuraxial anes-
thesia and reported a reduction in thromboembolic events and transfusion require-
ments [54]. These implications may reduce ICU and hospital length of stay as patients
are able to better mobilize and participate in rehabilitation postoperatively.
15 Other Regional Techniques
For patients in whom neuraxial anesthesia is contraindicated or for patients with
localized extremity pain, alternative regional anesthesia techniques can assist with
pain control in critically ill patients. Similar concerns including patient positioning,
tissue edema, skin infection, hemodynamic instability, and safety of performing a
block for a sedated patient should be carefully considered for truncal and peripheral
blocks [43]. Assessments of neurovascular function during and after block placement
may quickly identify or reduce complications such as nerve injury [43]. However, the
benefits of decreased mechanical ventilation and sedation must be weighed against
the potential consequences of undetected neurovascular injury. Conversations with
the patient’s family and multidisciplinary care team are essential to weigh these risks
and benefits.
Thoracic surgery causes significant pain if not managed appropriately [55]. In
addition to TEA, other regional techniques may provide similar analgesic benefits.
A meta-analysis by Joshi et al. evaluated randomized controlled trials to compare
the use of TEA, paravertebral blocks (PVB), intrathecal opioids, intercostal block,
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