Multimodal analgesia in trauma patients in ICU

Abstract

Treatment of the trauma patient has evolved rapidly in the past decade. Nevertheless, the treatment of pain as part of overall trauma management has been relatively neglected. Although recent publications suggest that the assessment and treatment of pain in trauma have improved, most studies still document inadequate analgesia..Following the initial resuscitation of trauma patients, the pain experienced may be divided into a ‘background’ pain and a ‘breakthrough’ pain associated with painful procedures in ICU (e.g. tracheal suctioning, chest tube positioning, staple removal and wound-dressing, bathing in major burn patients.) Background pain may be treated with intravenous opioids via continuous infusion or patient-controlled analgesia (PCA) and/ or less potent oral opioids, epidural analgesia or with continuous regional blocks, The aim is to reduce patient anxiety, improve analgesia and ensure immobilization when required. Untreated pain and improper sedation may result in psychological distress such as post-traumatic stress disorder, major depression or delirium and activation of inflammatory response During painful procedures the most reliable way to administer drugs is intravenously. Fast-acting opioids can be combined with propofol or benzodiazepines. Adjuvant drugs such as clonidine, low dose ketamine, magnesium and paracetamol (acetaminophen) have also been used to realize a multimodal drugs approach both in the treatment of background pain as well as during procedural pain. Patients in spontaneous breathing may only receive ketamine will usually maintain spontaneous breathing. This is an important feature in patients with heat trauma (major burn) who are continuously turned during wound dressing procedures and where analgo-sedation is often performed by practitioners who are not specialists in anaesthesiology. However, it must bear in mind that trauma patients often show an altered pharmacokinetic and pharmacodynamic response to drugs as a result of altered haemodynamics, protein binding and/or increased extracellular fluid volume, and possible changes in glomerular filtration. Educating the staff to perform early routine assessment of pain and to be familiar with the administration of analgesia are key elements to improved pain management in trauma.. Further developments are needed in order to provide safer and more effective analgesia to the trauma patient.