Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade

Intravenous or oral NSAIDs: Ibuprofen, ketorolac. The PADIS guidelines suggest not routinely

using a COX-1 selective NSAID as an adjunct to opioid therapy for pain management in critically

ill adults. Use with caution in critically ill patients with renal or hepatic dysfunction. May increase

the risk of acute renal failure, bleeding, or GI adverse effects.

population. The PADIS guidelines suggest using low-dose ketamine (1–2 mcg/kg/minute) as

an adjunct to opioid therapy when seeking to reduce opioid consumption in postsurgical adults

admitted to the ICU. Published data for the use of ketamine in adults for analgesia and/or sedation

is limited, and long-term cognitive effects of ketamine are not known. Data from animal studies

suggest a significant decline in cognitive function after continued use of ketamine.

Called a “dissociative anesthetic,” providing analgesic activity at subanesthetic doses. It is a

schedule III controlled substance and works primarily as an N-methyl-d-aspartate receptor

antagonist. Ketamine is void of the constipation, respiratory depression, and hypotensive

effects that plague the opiate class.

ii.

May decrease dose requirements of concurrently administered opioids

iii.

Other uses include rapid sequence intubation, refractory pain syndromes, cancer pain,

neuropathic pain, asthma (bronchodilatory effects), refractory seizure activity, and depression.

iv.

Dosing range is varied; usual starting dose for analgesia or sedation is 0.1 mg/kg/hour. Reviews

of ketamine use in adult ICUs report a dosing range of 0.1–2.5 mg/kg/hour and a range in

duration of 3 hours to 9 days.

Significant adverse effects: Mild to severe emergence reactions (e.g., confusion, excitement,

irrational behavior, hallucinations, delirium) in around 12% of patients, enhanced skeletal

muscle tone, tachycardia, hypertension, hypotension

The PADIS guidelines suggest not offering cybertherapy or hypnosis for pain management in

critically ill adults.

The PADIS guidelines suggest offering massage for pain management in critically ill adults.

The PADIS guidelines suggest offering music therapy to relieve both non-procedural and procedural

pain in critically ill adults.

The PADIS guidelines suggest using a neuropathic pain medication (e.g., gabapentin, carbamazepine,

pregabalin) with opioids for neuropathic pain management in critically ill patients. The PADIS guidelines

recommend using neuropathic pain medications with opioids for pain management in ICU adults

after cardiovascular surgery. There is a potential for significant adverse effects and drug interactions,

requiring close monitoring and follow-up. If the patient is discharged home on an anticonvulsant for

neuropathic pain, follow-up should be documented and the primary care provider notified.

Gabapentin (Neurontin)

Suggested starting dose range: 300–600 mg/day divided two or three times daily; requires

renal adjustment. The target dose is 900–3600 mg/day in three divided doses.

ii.

Pharmacokinetics: Renally excreted, dose adjusted for reduced CrCl

iii.

Adverse effects: May be severe, including CNS depression, delirium, paresthesias, and

asthenias

Carbamazepine (Tegretol)

Suggested starting dose range: 50–100 mg twice daily; use with caution in patients with hepatic

impairment, and adjust for a CrCl less than 10 mL/minute/1.73 m2 or with hemodialysis. The

target dose is 100–200 mg every 4–6 hours; the maximum dose is 1200 mg/day.

ii.

Pharmacokinetics: Strong inducer of many CYP enzymes, substrate of CYP3A4. Closely

monitor for drug interactions.

iii.

Adverse effects: Somnolence, severe skin reactions (e.g., Stevens-Johnson syndrome, toxic

epidermal necrolysis), pancytopenia, syndrome of inappropriate antidiuretic hormone