Pain in the Critically Ill Patient

The intensive care unit (ICU) presents a unique environment for the assessment and treatment of pain, given the potential compromise of both the patients' physiologic stability and communication skills secondary to underlying disease processes. These present special challenges to clinicians that may not be seen in other arenas of pain control. The typical patient in the ICU may not be able to communicate with the nursing or physician staff his/her discomfort due to the level of discomfort caused by either the severity of the disease or impediments to communication. The problem of pain control in those patients in the ICU has been clearly documented. This may be partially due to the difficulty in assessing how much pain a critically ill patient, who may be obtunded secondary to the underlying disease process or physiologically compromised by a process, such as sepsis or shock, is having. Thus, patients who cannot verbalize pain may need more creative techniques of pain assessment, as well as an increased vigilance by both the physician and nursing staff to maintain an awareness of pain issues. Patients in the ICU, who typically may be intubated or are at higher risk for pulmonary complications, may especially be vulnerable to increased levels of pain after surgery. There are many options for pain control in these patients, including epidural analgesia, intrapleural analgesia, intravenous patient-controlled analgesia, and intercostal nerve blockade. In addition, organizational changes may improve pain control in the ICU.