regional analagesia in ICU

1. Regional Analgesia in Pain
Management for ICU patients
Mohammed Abdelmon`em El Besh
M.B.B.CH (2010)

2. ACKNOWLEGEMENT

3. Pain in ICU
Pain has been defined as ‘‘. . . an unpleasant sensory and emotional
experience associated with actual or potential tissue damage
Approximately 50% of all critically ill patients experience moderate to
severe pain during an ICU stay
Unfortunately, around 20% of critically ill patients are unable to
identify the site of their pain

4. Consequences of Pain in ICU
• Physiological consequences
Acute pain is one of the activators of the complex neurohumoral and immune
response to injury
• Psychological consequences
anxiety and depression nightmares and feelings of demoralisation,
helplessness and loss of autonomy
• Ethical consequences

5. The Injury Response

6. Metabolic and endocrinal response to injury

7. Detection of Pain in ICU
According to American Society for Pain Management ,Five strategies were
recommended:
1. Obtain a self-report of pain if at all possible
2. Search for potential causes of pain, including pathologic conditions and
common procedures known to cause pain
3. Observe behaviors that may indicate pain
4. solicit surrogate reporting from significant others familiar with the
patient’s response to pain
5. Use analgesics to evaluate if pain management reduces behaviors
believed to be related to pain.

8. Methodsof Assessment of pain in ICU
• Self-Report :
1. Numeric rating scale (NRS) :The most commonly used 0-to-10 numeric rating scale (NRS)
should be offered to patients who seem able to communicate.
2. Visual analogue scales (VAS
• Objective tools in measures of pain
when patients are not able to communicate with ICU clinicians
1. Pain assessment, intervention, and notation (PAIN)
2. Behavioral pain scale (BPS) : 3 (no pain) to 12 (maximal pain) 5 is accepted
3. Critical-Care Pain Observation Tool (CPOT): 0 (indicating no pain) to 8 (indicating
the most pain)

9. Visual analogue scales (VAS) Wong-Baker
FACES Pain Rating Scale.
The patient is asked to mark the line and the ‘score’ is the distance in millimeters from
the left side of the scale to the mark.

10. Critical-Care Pain Observation Tool CPOT

11. Behavioral Pain Scale

12. Pain management
• The cornerstone of pain management is multimodal analgesia
(MA). It classically refers to the use of multiple pharmacological
interventions in combination, with the aim of decreasing dose
requirements especially of strong opioids and subsequent side
effects
1. Pharmacological management
2. NonPharmacological management

13. Pharmacological management
Systemic
Opoids
Non-opoids
Regional
Neuroaxial
Nerve blocks

14. Properties of Opioids Commonly Used in
Intensive Care Unit

15. Non-Pharmacological management.
• meditation,
• music therapy,
• palliative radiation or chemotherapy,
• distraction therapies,
• acupuncture or acupressure and massage

16. Regional Analgesia in ICU
Regional anesthesia and analgesia refers to techniques that use
needles, catheters, and infusion devices to deliver medications in
close proximity to peripheral nerves, plexuses, nerve roots, ganglia,
or directly into spinal fluid.

17. Advantages and disadvantages of Regional
Analgesia
Advantages Disadvantages
1. Excellent pain relief
2. Reduction in stress response
3. Reduction in use of opioids and their
side-effects
4. Reduced sedation, delirium, and ileus
5. Ability to better assess neurology in the
absence of opioids (especially poly-trauma)
6. Possible reduced duration of mechanical
ventilation and early ambulation
7. Minimizes progression to chronic pain
(e.g. in amputations)
8. Promotes gut motility and splanchnic
perfusion
9. Reduces sympathetic tone, useful in
promoting blood flow in critical ischaemia
1. Need for expertise and high-resolution
ultrasound machines
2. Variable failure rate
3. Difficulty in obtaining consent
4. Possible, but unproven higher incidence
of rare and serious complications
(e.g. epidural haematoma)
5. Difficulty in monitoring for side-effects
in sedated patients (e.g. nerve
injury)
6. Repeated position change leading to
dislodgement and disconnection
7. Potential for errors—route and drug

18. Indications of Regional Analgesia in critically ill
Patients
1. Surgical and Post-surgical Analgesia in the Critically Ill
2. Nonsurgical Analgesia, Sympatholysis, and Other
Indications
3. Painful Procedures in the ICU

20. Regional Analgesia in ICU: controversies
• There are many clinical dilemmas, which clinicians often face when deciding to
perform RA in ICU as there is no specific guidance on the suitability of RA in
these circumstances, but the generic recommendations in these areas of
controversy are:
1. To perform a risk–benefit analysis on an individual basis and clearly
document the reasons. For continuous techniques, the risk–benefit analysis
must be reviewed on a daily basis
2. To minimize the risk of RA by:
• Availing best local expertise;
• Avoiding multiple needle passes;
• Using advanced technology like ultrasound;
• Appropriate case selection;
• Consideration of available alternatives;
• Meticulous monitoring for complications.

21. Techniques of Regional analgesia in critically ill
patients
Single-shot regional anesthesia
•Skin infiltration with local
anesthetics
•for the placement of invasive
lines such as arterial lines or
central venous catheters,
lumbar drains,
ventriculostomies,
• placement of chest tubes or
abscess drains
•and the performance of
tracheostomies
NEURAXIAL ANALGESIA
•Epidural Analgesia
•ThoracicEpiduralAnalgesia(TEA).
•LumbarEpiduralAnalgesia
•Intrathecal (Subarachnoid)
Analgesia
PERPHERAL NERVE BLOCKS
•Thoracic Paravertebral
Block(TPVB)
•Intercostal Nerve Block (ICNB)
•Interpleural Blockade
•Brachial Blexus Blocks
•Interscalene
•Infra-clavicular
•Subclavianperivascular
• Axillaryapproach
•Femoral Nerve Block (FNB)
•Transversus Abdominis Plane
Block(TAP)

22. DRUGS USED IN REGIONAL ANALGESIA
1. Local Anaesthetic drugs
2. Opioids
3. Combinations of local anesthetics and opioids
4. α-adrenergic agonists: Dexmedetomidine and Clonidine
5. Epinephrine
6. Others:
A. Sodium bicarbonate
B. Magnesium sulfate
C. Dexamethasone
D. Ketorolac
E. Midazolam

23. Properties of commonly used local anaesthetics

24. RA in the ICU setting poses uniquechallenges
Drug factors;
• pharmacokinetics and pharmacodynamics of the local anaesthetics (LAs) may be
altered due to the derangements in physiological
• Impaired ability to clear LA due to factors discussed above predisposes to LA
toxicity
patient factors;
Difficult discover complication , sedated,neurological insult
Difficult lamdmarking , edema
Organ failure ,predisposes to toxicity
Difficult positioning
Human and environmental factors
Infrequent use of RA in ICU, lack of experience and good trainer

25. Common complication of RA

26. Conclusion
• RA is highly effective tool in pain management in ICU .
• RA reduce adverse effects of systemic analgesia
• Performing RA in ICU should be done under a risk–benefit analysis on an
individual basis.
• Once indicated and after appropriate risk-benefit analysis, RA
techniques are preferable, because (as compared to intravenous opioid-
treatment) they result in improved peri-operative analgesia, a
reduction of pulmonary complications, an improvement of intestinal
motility and mobilization and reduced ICU length of stay LOS
• Expertise hand has a major role in successful RA .
• Sepsis , vasopressor therapy , coagulopathy and sedation were cited as
the most common contraindications for the performance of RA.

27. THANK YOU