0
Postgraduate Education Corner: CONTEMPORARY REVIEWS IN CRITICAL CARE MEDICINE |

Pain Management Principles in the Critically Ill

Brian L. Erstad, PharmD; Kathleen Puntillo, RN, CNS, DNSc; Hugh C. Gilbert, MD; Mary Jo Grap, PhD, RN; Denise Li, PhD, RN, CNS; Justine Medina, RN, MS; Richard A. Mularski, MD, MSHS, MCR, FCCP; Chris Pasero, MS, RN-BC; Basil Varkey, MD, FCCP; Curtis N. Sessler, MD, FCCP
Author and Funding Information

*From the Department of Pharmacy Practice & Science (Dr. Erstad), University of Arizona College of Pharmacy, Tucson, AZ; the Department of Physiological Nursing (Dr. Puntillo), University of California, San Francisco, CA; the Department of Anesthesiology (Dr. Gilbert), Feinberg School of Medicine, Northwestern University, Chicago, IL; Adult Health and Nursing Systems Department (Dr. Grap), Virginia Commonwealth University, Richmond, VA; the Department of Nursing & Health Sciences (Dr. Li), College of Science, California State University, East Bay, Hayward, CA; Professional Practice and Programs, American Association of Critical Care Nurses (Ms. Medina), Aliso Viejo, CA; the Department of Pulmonary & Critical Care Medicine (Dr. Mularski), Oregon Health & Science University, Portland, OR; Pain Management Educator and Clinical Consultant (Ms. Pasero), El Dorado Hills, CA; the Department of Medicine (Dr. Varkey), Medical College of Wisconsin, Milwaukee, WI; and Virginia Commonwealth University Health System (Dr. Sessler), Richmond, VA.

Correspondence to: Brian L. Erstad, PharmD, University of Arizona College of Pharmacy, Department of Pharmacy Practice & Science, 1295 N Martin–Pulido, PO Box 210202, Tucson, AZ 85721; e-mail: erstad@pharmacy.arizona.edu


Ms. Puntillo has no relationships with industry but does make formal presentations at professional societies that are, at times, sponsored by industry. She has no personal contact with industry personnel or others that make those arrangements. Ms. Pasero discloses that her lectures, which cover general pain management, do not promote any products or equipment and are occasionally supported by industry (Baxter Healthcare Corporation, Ortho McNeil, and Johnson & Johnson). She has been paid as a consultant to critique pain management products in development (eg, Alpharma and Johnson & Johnson). She answers general pain management questions of industry customers, such as nurses, pharmacists, and physicians (Baxter Healthcare Corporation and Cardinal Health) and develops patient education materials (Endo Pharmaceutical). Dr. Varkey served as a speaker and in an advisory board meeting for Astra Zeneca in August 2008. Dr. Sessler received a grant from Physiometrix, and has served as a consultant and on the advisory committee for Hospira. Drs. Erstad, Gilbert, Grap, Li, and Mularski, and Ms. Medina have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

For editorial comment see page 894

For related article see page 1069


Chest. 2009;135(4):1075-1086. doi:10.1378/chest.08-2264
Text Size: A A A
Published online

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 body's 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.


Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Figures

Tables

References

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543