Critical care clinics
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Epidural opioid analgesia has become an important therapeutic technique in the management of acute pain and has been demonstrated to be superior or equal to other parenteral opioid techniques (intramuscular, intravenous, PCA) with less associated sedation and significantly smaller doses of drugs. Beneficial therapeutic effects of epidural opioids as a result of improved analgesia include improvement in pulmonary function, modification of the endocrine-metabolic stress response, improvement in time to ambulation, decreased morbidity, and shorter hospital stay. ⋯ These potential problems either occur rarely, or are controllable or preventable with appropriate patient selection and management. The potential benefits to the critical care patient as a result of the superior analgesia and reduced systemic effects associated with epidural opioid analgesia represent distinct medical and economic advantages, compared to conventional analgesic techniques.
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The possible options for the management of acute pain are quite numerous and continue to expand as our understanding of the mechanisms of pain becomes increasing sophisticated. Many of the options discussed have been available for years, and their present underutilization may be a reflection of the lack of emphasis on the importance of management of acute pain. An illustration of this would be our present ritual of prescribing narcotics postoperatively, a longstanding, but unfortunately inadequate practice. ⋯ Certain techniques, such as continuous local anesthetic infusions, may warrant an escalated level of monitoring and ancillary care. Other techniques, such as the infiltration of a wound with local anesthetic or the addition of a nonsteroidal anti-inflammatory agent to a regimen of mild oral narcotics are so simple that excluding them from patient care is almost callous and inconsiderate. Attention to the mechanisms of pain that may be present in a given situation, whether it be muscle spasm, ischemia, inflammation, edema, or nerve injury, may guide the clinician toward a more rational approach in managing that pain.
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In summary, there are now available very potent narcotics, with small side effect liability. Critical care physicians should be experts in administration of intravenous narcotics and should understand the concepts behind different methods of administration. ⋯ Intravenous administration allows rapid and almost complete control of desired effect. Intravenous access is universally available in the ICU population, and we should take every advantage of it.
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Pain is a common experience of the ICU patient, with a diverse clinical manifestation. To manage pain we must understand its anatomic pathways and physiology. This article reviews the development of our understanding of the theory of pain from Descartes to the gate theory of Melzack and Wall. We will review the anatomy of the pathways of pain and the interrelationship of "A" and "C" fibers and the unique nature of the opiate receptor.
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This article discusses the roles of the critical care team in providing pain relief. The attitudes of the staff concerning pain relief impact on the delivery of care. ⋯ Nurses have a role in use of epidural administration of narcotics, and provide relief with the use of patient-controlled analgesia and general pain relief measures. Pain as a nursing diagnosis, substance abuse in the medical profession, and control of narcotics are also issues discussed.