Critical care clinics
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Safe and successful pain management in pregnant women requires an understanding of the normal physiologic changes of pregnancy. Some hemodynamic changes of labor and delivery are attenuated by effective epidural analgesia. ⋯ The physiologic changes of labor and delivery are reviewed, together with commonly used analgesic techniques. Special emphasis is placed on critically ill obstetric patients with concomitant cardiac disease.
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The often inadequate treatment of acute pain is more often due to improper application of available therapies than to the unavailability of effective drugs and techniques. In our institution, the establishment of an acute pain service has improved the safety and efficacy of postoperative pain control. This has been achieved not simply through the immediate availability of a group of specialist physicians and nurses, but also through staff education. ⋯ Epidurally administered patient-controlled analgesia, on the other hand, appears to provide superior relief of activity pain and earlier resolution of postoperative ileus. The administration of local anesthetic agents, in particular, may reduce reflex diaphragmatic dysfunction following thoracoabdominal surgery and decrease the incidence of graft occlusion following lower extremity vascular procedures. Epidural catheter placement, however, is not without risk, especially in subjects with an established or potential coagulopathy.
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Critical care clinics · Jan 1999
ReviewRegional anesthesia techniques for pain control in the intensive care unit.
The judicious use of regional anesthesia in the intensive care unit should improve patient comfort. Techniques covered include intercostal nerve blocks, interpleural blocks, paravertebral blocks, brachial plexus blocks, and femoral nerve blocks. Rational patient selection for each technique mentioned is also discussed.
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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. ⋯ While at times these techniques have not significantly altered outcome, at other times significant benefits have been observed. More sophisticated techniques and pharmacotherapies are being developed and introduced with increased frequency, but alone they will probably have only minimal impact on overall morbidity and mortality. The integration of a multimodal approach seems logical in the critical care setting, with analgesia as the cornerstone.
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Pain and its treatment are known to have adverse effects on the organism, including deterioration in myocardial, diaphragmatic, and small bowel function. The provision of adequate intravenous analgesia, and the choice of agent, can ameliorate or exacerbate these manifestations of the stress response. The choice of agent, opioid or non-opioid, has in some respects become more difficult as more information has become available regarding the merits and adverse effects of each. ⋯ Ketamine provides intense analgesia at subanesthetic doses. Its centrally mediated sympathomimetic action encourages hemodynamic stability, and it is relatively devoid of respiratory depressant activity. Increasing experience with ketamine outside the operating room has resulted in its successful use in cases of severe bronchospasm and status epilepticus.