Analgesia and Sedation emergency medicine

1. Analgesia and sedation are two
closely related concepts that are
used to manage pain and anxiety in
various medical settings. Here's a
breakdown of each:
Analgesia refers to the absence or
relief of pain. It can be achieved
through various methods,
including:
•Medications: These can be
opioids, non-opioids, or other
drugs that act on different pain
pathways.
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2. on-opioid analgesics are increasingly emphasized in a variety of clinical
settings as a preferred, safe, and effective first-line therapy for mild to
moderate acute and chronic pain.
Examples of Non-Opioid Analgesics
Non-opioid analgesics include a variety of agents, indicated for a
number of pain conditions, and carry related potential side effects and
risks (see Figure 1). The most commonly used agents include:
•Acetaminophen (paracetamol)
•Anticonvulsants (including gabapentin and pregabalin)
•Antidepressants (including amitriptyline and duloxetine)
•Aspirin (acetylsalicylic acid)
•Other NSAIDs (including ibuprofen, diclofenac, naproxen, and COX-2
inhibitors)
•Topical agents (including lidocaine and capsaicin)
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3. Differences Among Non-Opioid Analgesics
Acetaminophen. The analgesic and fever-reducing effects of acetaminophen are well-
known, but its mechanism of action is not. Nevertheless, it is widely considered to be
the safest analgesic available, although liver injury is a concern with overdose.
Aspirin and other NSAIDs. Aspirin and other NSAIDs alleviate pain and reduce fever
and inflammation by decreasing the synthesis and release of prostaglandins, which are
pro-inflammatory molecules. Cyclooxygenase-2 (COX-2) inhibitors also inhibit
prostaglandin synthesis and release, but unlike aspirin and non-selective NSAIDs, COX-2
inhibitors do not inhibit platelet aggregation.
Antidepressants. Tricyclic antidepressants (amitriptyline) and serotonin-
norepinephrine (noradrenaline) reuptake inhibitors (SNRIs, e.g., duloxetine) have
unknown mechanisms for their pain-relieving properties. However, studies suggest that
their analgesic effects may be related in part to presynaptic inhibition of the reuptake
of serotonin and norepinephrine in pain inhibitory pathways, as well as a peripheral
mechanism involving β2-adrenergic receptors.
Anticonvulsants. Anticonvulsive drugs (including gabapentin and pregabalin) provide
analgesic properties by lowering neurotransmitter release or reducing neuronal firing.
Topical treatments. Topical non-opioid medications such as lidocaine and capsaicin are
applied to the skin and thus act locally. Lidocaine works by blocking nerve signals that
send the feeling of pain from the site of injury to the brain. It causes a temporary loss
of feeling in the area to which it is applied. Capsaicin appears to deplete local neurons
of substance P, which is required in the transmission of nociceptive input.
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4. Are Non-Opioid Analgesics Appropriate for Severe Pain?
The short-term use of low-dose opioids may be necessary to treat the moderate-to-
severe acute pain that occurs after surgery or traumatic injury. However, risks
associated with opioid use, including the potential for dependence and overdose,
have led prescribers to consider non-opioid analgesics — as well as non-
pharmacologic alternatives such as cognitive behavioral therapy, exercise therapy,
and complementary medicine — to treat mild or moderate acute and chronic
pain. CDC guidelines support this practice, noting that nonopioid medications are
generally not associated with the development of substance use disorder and
recommending “non-opioid medications and nonpharmacologic treatments as the
preferred therapies for chronic pain outside of active cancer and palliative or end-of-
life care.”
Clinical trials also support this strategy. One study of patients with moderate to
severe chronic back pain or hip or knee osteoarthritis pain found that the use of
opioid versus non-opioid medication therapy did not result in significantly better
pain-related function over 12 months. Moreover, those receiving opioids during the
study had significantly more medication-related symptoms over 12 months than
those receiving non-opioid analgesics.
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5. Non-Opioid Analgesics in Clinical Settings
Non-opioid analgesics can play an important role in the emergency
department and intensive care unit (ICU). For example, a double-blind clinical
trial found that for emergency department patients with acute extremity pain,
combinations of non-opioid analgesics may be as effective in reducing pain as
opioids. And a meta-analysis of 12 randomized clinical trials demonstrated
that non-opioid analgesics, used as adjuvants to opioids, reduced the
consumption and the side effects of opioids in ICU patients with Guillain-Barré
syndrome while decreasing patient pain scores.
Researchers also suggest that non-opioid NSAIDs should become the standard
of care for surgical patients to minimize the use of perioperative opioids and
to decrease postoperative opioid-related adverse effects such as nausea,
vomiting, sedation, ileus, pruritus, and respiratory depression. This finding
aligns with the enhanced recovery after surgery pathway (ERAS) strategy,
which calls for multimodal pain management. The study’s authors state,
“multimodal analgesia is based on the premise that the concurrent use of
primarily non-opioid analgesics has additive, if not synergistic, effects that
produce superior analgesia while decreasing opioid use and opioid-related
side effects.” However, they also encouraged clinicians to seek continuing
medical education on multimodal analgesia drug-drug interactions and
adverse effects to limit unanticipated consequences of the practice.
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6. Pain Treatment Strategies
Today’s clinicians have a variety of pharmacological
and non-pharmacological options for treating pain.
For some patients with acute severe pain, a short
course of opioids aids in healing and recovery. For
other patients with chronic severe pain, opioids
provide relief an d allow patients to function in their
daily lives.
As the medical community increases its focus on
safer, more judicious opioid prescribing and reducing
the misuse of opioids, health care providers are
carefully evaluating all available alternatives — from
opioids and non-opioid analgesics to mind-body
therapies — weighing their potential benefits against
their risks. As new studies and trials of non-opioid
analgesics are undertaken, clinicians will have
additional evidence for their effective use.
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7. Non-pharmacological
interventions: These include
physical
therapy, massage, acupuncture, an
d heat or cold therapy. Analgesia and Sedation 7

8. Regional anesthesia: This involves
numbing a specific area of the
body with a local anesthetic.
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9. Sedation refers to a state of reduced consciousness or arousal. It can be
used to:
1. Manage anxiety: This can be helpful for patients undergoing
stressful procedures or who are experiencing pain.
2. Facilitate medical procedures: Sedation can make it easier for
patients to tolerate uncomfortable procedures.
3. Promote mechanical ventilation: In some cases, patients may need
to be sedated to tolerate being on a ventilator.
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10. Sedation can be achieved through
various methods, including:
•Medications: These can be
benzodiazepines, propofol, or
other drugs that depress the
central nervous system.
Inhalational agents: These are
gases that are inhaled through a
mask or breathing tube, such as
nitrous oxide.
Nitrous oxide
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11. It's important to note that analgesia and sedation are a continuum, and
the level of each can be adjusted to meet the individual needs of the
patient. For example,
a patient may need moderate analgesia to manage pain, but only
minimal sedation to remain comfortable and cooperative during a
procedure.
Both analgesia and sedation
can have side effects
so it's important to carefully monitor patients who are receiving these
treatments.
Some common side effects include
1. drowsiness
2. Nausea
3. vomiting, and respiratory depression.
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