Pain is abundant in the intensive care unit (ICU). Successful analgesia demands a comprehensive appreciation for the etiologies of pain, vigilant clinical assessment, and personalized treatments. For the critically ill, frequent threats to mental and bodily integrity magnify the experience of pain, challenging clinicians to respond swiftly and thoughtfully. Because pain is difficult to predict and physiologic correlates are not specific, self-report remains the gold standard assessment. When communication is limited by intubation or cognitive deficits, behavioral pain scales prove useful. Patient-tailored analgesia aspires to mitigate suffering while optimizing alertness and cognitive capacity. Mindfulness of the neuropsychiatric features of pain helps the ICU clinician to clarify limits of traditional analgesia and identify alternative approaches to care. Armed with empirical data and clinical practice recommendations to better conceptualize, identify, and treat pain and its neuropsychiatric comorbidities, the authors (psychiatric consultants, by trade) reinforce holistic approaches to pain management in the ICU. After all, without attempts to understand and relieve suffering on all fronts, pain will remain undertreated.
CrundenE. A reflection from the other side of the bed–an account of what it is like to be a patient and a relative in an intensive care unit. Intensive Crit Care Nurs. 2010;26(1):18–23.
2.
BouckomsAJ. Pain relief in the intensive care unit. J Intensive Care Med. 1988;3(1):32–51.
3.
CrossSA. Pathophysiology of pain. Mayo Clin Proc. 1994;69(4):375–383.
NelsonJEMeierDE. Palliative care in the intensive care unit: part II. J Intensive Care Med. 1999;14(4):189–199.
6.
StevensDSEdwardsWT. Management of pain in the critically ill. J Intensive Care Med. 1990;5(6):258–291.
7.
DesbiensNAWuAWBrosteSK. Pain and satisfaction with pain control in seriously ill hospitalized adults: findings from the SUPPORT research investigations. Crit Care Med. 1996;24(12):1953–1961.
8.
PaseroCPuntilloKLiD. Structured approaches to pain management in the ICU. Chest. 2009;135(6):1665–1672.
9.
ScottEBorateUHeitnerSChaitowitzMTesterWEigerG. Pain management practices by internal medicine residents–a comparison before and after educational and institutional interventions. Am J Hosp Palliat Care. 2009;25(6):431–439.
10.
McCafferyMFerrellBR. Nurses' knowledge of pain assessment and management: how much progress have we made?. J Pain Symptom Manage. 1997;14(3):175–188.
11.
NejadSHAlpayMPain patients. In: SternTAFricchioneGLCassemGLJellinekMSRosenbaumJF (Eds.), Massachusetts General Hospital Handbook of General Hospital Psychiatry.6th ed.2010;Philadelphia, PA: Saunders, 211–236.
12.
MularskiRA. Pain management in the intensive care unit. Crit Care Clin. 2004;20(3):381–401.
13.
PaseroCPaiceJAMcCafferyMBasic mechanisms underlying the causes and effects of pain. In: McCafferyMPaseroC (Eds.), Pain: Clinical Manual.2nd ed.1999;St. Louis, MO: Mosby, 15–34.
14.
VadiveluNWhitneyCJSinatraRSPain pathways and acute pain processing. In: SinatraRSdeLeon-CasasolaOAGinsbergBViscusiER (Eds.), Acute Pain Management.2009;New York, NY: Cambridge University Press, 3–20.
15.
SzokolJWVenderJS. Anxiety, delirium, and pain in the intensive care unit. Crit Care Clin. 2001;17(4):821–842.
16.
OloruntoWAGalandiukS. Managing the spectrum of surgical pain: acute management of the chronic pain patient. J Am Coll Surg. 2006;202(1):169–175.
17.
International Association for the Study of Pain. http://www.iasp-pain.org. Accessed December 11, 2010
18.
ZeilaniRSeymourJE. Muslim women’s experiences of suffering in Jordanian intensive care units: a narrative study. Intensive Crit Care Nurs. 2010;26(3):175–184.
19.
Hamill-RuthRJMarohnML. Evaluation of pain in the critically ill patient. Crit Care Clin. 1999;15(1):35–54.
20.
DrayerRAHendersonJReidenbergM. Barriers to better pain control in hospitalized patients. J Pain Symptom Manage. 1999;17(6):434–440.
21.
CadeCH. Clinical tools for the assessment of pain in sedated critically ill adults. Nurs Crit Care. 2008;13(6):288–297.
22.
DesbiensNAMueller-RiznerN. How well do surrogates assess the pain of seriously ill patients?. Crit Care Med. 2000;28(5):1347–1352.
23.
PunBTDunnJ. The sedation of critically ill adults: part 1: assessment. The first in a two-part series focuses on assessing sedated patients in the ICU. Am J Nurs. 2007;107(7):40–48.
24.
BreivikHBorchgrevinkPCAllenSM. Assessment of pain. Br J Anaesth. 2008;101(1):17–24.
25.
DaoustRBeaulierPManziniCChaunyJMLavigneG. Estimation of pain intensity in emergency medicine: a validation study. Pain. 2008;135(3):565–570.
26.
GaglieseLWeizblitNEllisWChanVW. The measurement of postoperative pain: a comparison of intensity scales in younger and older surgical patients. Pain. 2005;117(3):412–420.
27.
JacobiJFraserGLCoursinDB. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. 2002;30(1):119–141.
28.
ChanquesGVielEConstantinJM. The measurement of pain in intensive care unit: comparison of 5 self-report intensity scales. Pain. 2010;151(3):711–721.
JensenMPMillerLFisherLD. Assessment of pain during medical procedures: a comparison of three scales. Clin J Pain. 1998;14(4):343–349.
31.
ChanquesGJaberSBarbotteE. Impact of systematic evaluation of pain and agitation in an intensive care unit. Crit Care Med. 2006;34(6):1691–1699.
32.
HerrKCoynePJKeyT. Pain assessment in the nonverbal patient: position statement with clinical practice recommendations. Pain Manag Nurs. 2006;7(2):44–52.
33.
PuntilloKAMorrisABThompsonCLStanik-HuttJWhiteCAWildLR. Pain behaviors observed during six common procedures: results from Thunder project II. Crit Care Med. 2004;32(2):421–427.
34.
GélinasCFillionLPuntilloKA. Item selection and content validity of the critical-care pain observation tool for non-verbal adults. J Adv Nurs. 2009;65(1):203–216.
35.
PayenJFBruOBossonJL. Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med. 2001;29(12):2258–2263.
36.
AïssaouiYZeggwaghAAZekraouiAAbidiKAbouqalR. Validation of a behavioral pain scale in critically ill, sedated, and mechanically ventilated patients. Anesth Analg. 2005;101(5):1470–1476.
37.
YoungJSiffleetJNikolettiSShawT. Use of a behavioural pain scale to assess pain in ventilated, unconscious and/or sedated patients. Intensive Crit Care Nurs. 2006;22(1):32–39.
38.
AhlersSJvan der VeenAMvan DijkMTibboelDKnibbeCA. The use of the Behavioral Pain Scale to assess pain in conscious sedated patients. Anesth Analgo. 2010;110(1):127–133.
39.
GélinasCFillionLPuntilloKAViensCFortierM. Validation of the critical-care pain observation tool in adult patients. Am J Crit Care. 2006;15(4):420–427.
40.
MarmoLFowlerS. Pain assessment tool in the critically ill post-open heart surgery patient population. Pain Manag Nurs. 2010;11(3):134–140.
41.
GélinasCJohnstonC. Pain assessment in the critically ill ventilated adult: validation of the critical-care pain observation tool and physiologic indicators. Clin J Pain. 2007;23(6):497–505.
42.
GélinasCArbourC. Behavioral and physiologic indicators during a nociceptive procedure in conscious and unconscious mechanically ventilated adults: similar or different?. J Crit Care. 2009;24(4):628.e7–17.
43.
GélinasCHarelFFillionLPuntilloKAJohnstonCC. Sensitivity and specificity of the critical-care pain observation tool for the detection of pain in intubated adults after cardiac surgery. J Pain Symptom Manage. 2009;37(1):58–67.
44.
Tousignant-LaflammeYBourgaultPGélinasCMarchandS. Assessing pain behaviors in healthy subjects using the Critical-Care Pain Observation Tool (CPOT): a pilot study. J Pain. 2010;11(10):983–987.
45.
WibbenmeyerLSevierALiaoJ. Evaluation of the usefulness of two established pain assessment tools in a burn population. J Burn Care Res. 2011;32(1):52–60.
46.
ChanquesGPayenJFMercierG. Assessing pain in non-intubated critically ill patients unable to self report: an adaptation of the behavioral pain scale. Intensive Care Med. 2009;35(12):2060–2067.
47.
HuRJiangXZengYChenXZhangY. Effects of earplugs and eye masks on nocturnal sleep, melatonin and cortisol in a simulated intensive care unit environment. Crit Care. 2010;14(2):R66.
48.
BourneRSMillsGHMinelliC. Melatonin therapy to improve nocturnal sleep in critically ill patients: encouraging results from a small randomised controlled trial. Crit Care. 2008;12(2):R52.
49.
MistralettiGSabbatiniGTavernaM. Pharmacokinetics of orally administered melatonin in critically ill patients. J Pineal Res. 2010;48(2):142–147.
50.
SultanSS. Assessment of role of perioperative melatonin in prevention and treatment of postoperative delirium after hip arthroplasty under spinal anesthesia in the elderly. Saudi J Aneasth. 2010;4(3):169–173.
51.
Al-AamaTBrymerCGutmanisIWoolmore-GoodwinSMEsbaughJDasguptaM. Melatonin decreases delirium in elderly patients: a randomized placebo-controlled trial. Int J Geriatr Psychiatry. 2010;26(7):687–694.
52.
ErstadBLPuntilloKGilbertHC. Pain management principles in the critically ill. Chest. 2009;135(4):1075–1086.
KochMEKainZNAyoubCRosenbaumSH. The sedative and analgesic sparing effect of music. Anesthesiology. 1998;89(2):300–306.
55.
GoodMAndersonGCStanton-HicksMGrassJAMakiiM. Relaxation and music reduce pain after gynecologic surgery. Pain Manag Nurs. 2002;3(2):61–70.
56.
GoodMAndersonGCAhnSCongXStanton-HicksM. Relaxation and music reduce pain following intestinal surgery. Res Nurs Health. 2005;28(3):240–251.
57.
SullivanMJLThornBHaythornthwaiteJA. Theoretical perspectives on the relation between catastrophizing and pain. Clin J Pain. 2001;17(1):52–64.
58.
SesslerCNVarneyK. Patient-focused sedation and analgesia in the ICU. Chest. 2008;133(2):552–565.
59.
DevlinJWRobertsRJ. Pharmacology of commonly used analgesics and sedatives in the ICU: benzodiazepines, propofol, and opioids. Crit Care Clin. 2009;25(3):431–449.
60.
BurchardiH. Aims of sedation/analgesia. Minerva Anestesiol. 2004;70(4):137–143.
61.
MacLarenRPlamondonJMRamsayKBRockerGMPatrickWDHallRI. A prospective evaluation of empiric versus protocol-based sedation and analgesia. Pharmacotherapy. 2000;20(6):662–672.
SunEASnapeWJJrCohenSRennyA. The role of opiate receptors and cholinergic neurons in the gastrocolonic response. Gastroenterology. 1982;82(4):689–693.
64.
HallJB. Creating the animated intensive care unit. Crit Care Med. 2010;38(10 suppl):S668–S675.
65.
MossJRosowCE. Development of peripheral opioid antagonists: new insights into opioid effects. Mayo Clin Proc. 2008;83(10):1116–1130.
66.
SlatkinNThomasJLipmanAG. Methylnaltrexone for treatment of opioid-induced constipation in advanced illness patients. J Support Oncol. 2009;7(1):39–46.
67.
HolzerP. Opioid antagonists for prevention and treatment of opioid-induced gastrointestinal effects. Curr Opin Anaesthesiol. 2010;23(5):616–622.
68.
WooMO’ConnorMYuanCSMossJ. Reversal of opioid-induced gastric dysfunction in a critically ill burn patient after methylnaltrexone. Anesth Analg. 2008;107(6):1965–1967.
69.
PereiraJBrueraE. Emerging neuropsychiatric toxicities of opioids. J Pharmaceut Care Pain Symptom Contr. 1997;5(4):3–29.
70.
DaeninckPJBrueraE. Opioid use in cancer pain. Is a more liberal approach enhancing toxicity?. Acta Anaesthesiol Scand. 1999;43(9):924–938.
71.
HeitHA. Addiction, physical dependence, and tolerance: precise definitions to help clinicians evaluate and treat chronic pain patients. J Pain Palliat Care Pharmacother. 2003;17(1):15–29.
72.
CammaranoWBPittetJFWeitzSSchlobohmRMMarksJD. Acute withdrawal syndrome related to the administration of analgesic and sedative medications in adult intensive care unit patients. Crit Care Med. 1998;26(4):676–684.
73.
JonesCBäckmanCCapuzzoMFlaattenHRylanderCGriffithsRD. Precipitants of post-traumatic stress disorder following intensive care: a hypothesis generating study of diversity in care. Intensive Care Med. 2007;33(6):978–985.
74.
MackAHFranklinJEFrancesRJSubstance use disorders. In: HalesREYudovskySC (Eds.), The American Psychiatric Publishing Textbook of Clinical Psychiatry.4th ed.2003;Washington, DC: American Psychiatric Publishing, Inc, 309–377.
75.
KressJPPohlmanASHallJB. Sedation and analgesia in the intensive care unit. Am J Respir Care Med. 2002;166(8):1024–1028.
76.
ReadyLBBrownCRStahlgrenLH. Evaluation of intravenous ketorolac administered by bolus or infusion for treatment of postoperative pain. Anesthesiology. 1994;80(6):1337–1286.
77.
MarretKKurdiOZuffereyPBonnetF. Effects of nonsteroidal anti-inflammatory drugs on patient-controlled analgesia morphine side effects: meta-analysis of randomized controlled trials. Anesthesiology. 2005;102(6):1249–1260.
78.
GilronI. Gabapentin and pregabalin for chronic neuropathic and early postsurgical pain: current evidence and future directions. Curr Opin Anaesthesiol. 2007;20(5):456–472.
79.
HicksRD. Pain management in the chemically dependent patient. Hawaii Med J. 1989;48(11):494–495.
80.
IocolanoCF. Perioperative pain management in the chemically dependent patient. J Perianesth Nurs. 2000;15(5):329–344.
81.
AlfordDPComptonPSametJH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med. 2006;144(2):127–134.
82.
ChuLFClarkDJAngstMS. Opioid tolerance and hyperalgesia in chronic pain patients after one month of oral morphine therapy: a preliminary prospective study. J Pain. 2006;7(1):43–48.
83.
DovertyMWhiteJMSomogyiAABochnerFAliRLingW. Hyperalgesic responses in methadone maintenance patients. Pain. 2001;90(1-2):91–96.
84.
DovertyMSomogyiAAWhiteJM. Methadone maintenance patients are cross-tolerant to the antinociceptive effects of morphine. Pain. 2001;93(2):155–163.
85.
ComptonPCharuvastraVCLingW. Pain intolerance in opioid-maintained former opiate addicts: effects of long-acting maintenance agent. Drug Alcohol Depend. 2001;63(2):139–146.
86.
PollackMHOttoMWWittmannCWRosenbaumJFAnxious patients. In: SternTAFricchioneGLCassemGLJellinekMSRosenbaumJF (Eds.), Massachusetts General Hospital Handbook of General Hospital Psychiatry.6th ed.2010;Philadelphia, PA: Saunders, 133–152.
87.
RinconHGGranadosMUnutzerJ. Prevalence, detection, and treatment of anxiety, depression, and delirium in the adult critical care unit. Psychosomatics. 2001;42(5):391–396.
88.
McKinleySStein-ParburyJChehelnabiALovasJ. Assessment of anxiety in intensive care patients by using the faces anxiety scale. Am J Crit Care. 2004;13(2):146–152.
89.
McKinleySMadronioC. Validity of the faces anxiety scale for the assessment of state anxiety in intensive care patients not receiving mechanical ventilation. J Psychosom Res. 2008;64(5):503–507.
90.
MarangellLBSilverJMGoffDCYudofskySCPsychopharmacology and electroconvulsive therapy. In: HalesREYudovskySC (Eds.), The American Psychiatric Publishing Textbook of Clinical Psychiatry.4th ed.2003;Washington, DC: American Psychiatric Publishing, Inc., 1047–1149.
91.
CawleyMJ. Short-term lorazepam infusion and concern for propylene glycol toxicity: case report and review. Pharmacotherapy. 2001;21(9):1140–1144.
92.
TsurutaRNakaharaTMiyauchiT. Prevalence and associated factors for delirium in critically ill patients at a Japanese intensive care unit. Gen Hosp Psychiatry. 2010;32(6):607–611.
93.
AgarwalVO’NeillPJCottonBA. Prevalence and risk factors for development of delirium in burn intensive care unit patients. J Burn Care Res. 2010;31(5):706–715.
94.
SalluhJISoaresMTelesJM. Delirium Epidemiology in Critical Care (DECCA): an international study. Crit Care. 2010;14(6):R210.
95.
van den BoogaardMPetersSAvan der HoevenJG. The impact of delirium on the prediction of in-hospital mortality in intensive care patients. Crit Care. 2010;14(4):R146.
96.
American Psychiatric Association (APA).Delirium, dementia, amnestic and other cognitive disorders. In: APA, (Ed.), Quick Reference to the Diagnostic Criteria from DSM-IV-TR. 2000;Washington, DC: APA, 83–98.
97.
CaplanJPCassemEHMurrayGBParkJMSternTADelirious patients. In: SternTAFricchioneGLCassemGLJellinekMSRosenbaumJF (Eds.), Massachusetts General Hospital Handbook of General Hospital Psychiatry. 2010; 6th ed. Philadelphia, PA: Saunders, 93–104.
98.
MorandiAJacksonJCElyEW. Delirium in the intensive care unit. Int Rev Psychiatry. 2009;21(1):43–58.
99.
FricchioneGLNejadSHEssesJA. Postoperative delirium. Am J Psychiatry. 2008;165(7):803–812.
100.
PisaniMAMurphyTEAraujoKLVan NessPH. Factors associated with persistent delirium after intensive care unit admission in an older medical patient population. J Crit Care. 2010;25(3):540.e1–e7.
101.
MorrisonRSMagazinerJGlibertM. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci. 2003;58(1):76–81.
102.
van den BoogaardMPickkersPvan der HoevenH. Implementation of a delirium assessment tool in the ICU can influence haloperidol use. Crit Care. 2009;13(4):R131.
103.
GuentherUPoppJKoecherL. Validity and reliability of the CAM-ICU Flowsheet to diagnose delirium in surgical ICU patients. J Crit Care. 2010;25(1):144–151.
104.
RiekerkBPenEJHofhuisJGRommesJHSchultzMJSpronkPE. Limitations and practicalities of CAM-ICU implementation, a delirium scoring system, in a Dutch intensive care unit. Intensive Crit Care Nurs. 2009;25(5):242–249.
105.
Al-KhatibSMLaPointeNMKramerJMCaliffRM. What clinicians should know about the QT interval. JAMA. 2003;289(16):2120–2127.
106.
MacLarenRPlamondonJMRamsayKBRockerGMPatrickWDHallRI. A prospective evaluation of empiric versus protocol-based sedation and analgesia. Pharmacotherapy. 2000;20(6):662–672.
107.
ErdekMAPronovostPJ. Improving assessment and treatment of pain in the critically ill. Int J Qual Health Care. 2004;16(1):59–64.
