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Hallucinations and emergence phenomena can be attenu- stimulation (TENS), acupuncture, aromatherapy, etc., should
ated by the co-administration of benzodiazepines. not be withheld. Anecdotal evidence suggests a benefit
There is furthermore some evidence, that ketamine can be from acupuncture in neuropathic pain, and reduced seda-
useful in chronic pain states such as central pain, complex tive and analgesic requirements following aromatherapy.
regional pain syndrome, fibromyalgia and neuropathic pain. Summary
Either alone or in combination with opioids it provides
Opioids are the most commonly used analgesic agents,
rapid, effective and prolonged analgesia .
often giving in combination with sedative drugs. There is no
Neuropathic pain agents doubt that this method is effective and cheap, and staff have
Some patients may be suffering from or develop neuro- a wealth of experience in its use. However, such regimes do
pathic pain. This sort of pain may be difficult to manage not provide satisfactory pain relief in all patients.
with standard analgesics, and consideration should be given What is needed to avoid patients experiencing pain while
to adding in specific drugs for neuropathic pain as outlined in Ithe CU is individualized, goal-directed analgesic regimes
in Table 13.1.2. Patients may also have pre-existing neuro- in their own right, not as a side effect of sedation. In con-
pathic pain problems; medication should be continued cert with analgesia, anxiety, the physical environment and
where possible. the patient’s sleeping pattern need to be considered.
Adherence to a clear protocol may be as important as
Table 13.1.2 Adjuvant therapies for pain in critical care. choice of medication.
Further reading
Drug Dose mg Neuropathic Sleep PTSD Barr J, Donner A. Optimal intravenous dosing strategies for seda-
pain tives and analgesics in the intensive care unit. Crit Care Clin 1995;
11: 827–47.
Tricyclic 20–100 nocte + ++ +
antidepressants Breen D, Karabinis A, Malbrain M, et al. Decreased duration of
mechanical ventilation when comparing analgesia-based sedation
Gabapentin 100–900 ++ + +? using remifentanil with standard hypnotic-based sedation for up
Pregabalin 25–300 ++ + +? to 10 days in intensive care unit patients: a randomised trial. Crit
Care. 2005; 9: R200–10.
PTSD = post-traumatic stress disorder. Curtis SP, Ng J, Yu Q, et al. Renal effects of etoricoxib and comparator
nonsteroidal anti-inflammatory drugs in controlled clinical trials.
Clin Ther 2004; 26: 70–83.
Adjuvant therapies Kuhlen R, Putensen C. Remifentanil for analgesia-based sedation in
Especially in patients with features of chronic pain or the intensive care unit. Crit Care 2004; 8: 13–4.
altered sleep patterns, tricyclic antidepressants have been Muellejans B, Matthey T, Scholpp J, et al. Sedation in the intensive
used extensively. There might be a rationale for using these care unit with remifentanil/propofol versus midazolam/fentanyl:
drugs in the medium- to long-stay patient where a constel- a randomised, open-label, pharmacoeconomic trial. Crit Care
lation of pain, anxiety and depression co-exists, possibly 2006; 10: R91.
along with a disturbed sleep pattern. There is evidence that Roemsing J, Moeniche S. A systematic review of COX-2 inhibitors
the usage of tricyclics, and possibly some of the drugs used compared with traditional NSAIDs, or different COX-2 inhibitors
to treat neuropathic pain, may reduce the development of for post-opereative pain. Acta Anaesthesiol Scand 2004; 48: 525–46.
post-traumatic stress disorder (PTSD) in ICU survivors. Wilson W, Smedira N, Fink C, et al. Ordering and administration of
sedatives and analgesics during the withholding and withdrawal of
Alternative therapies life support from critically ill patients. JAMA 1992; 267: 949–53.
No evidence exits to support the use of alternative thera- http://www.anzca.edu.au/publications/acutepain.
pies in the critically ill. In the absence of any untoward htm
effects, however, the use of transcutaneous electrical nerve