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144 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

pharmacological treatment of pain, non-pharmacological
strategies can prove effective as an adjunct to drug therapy TABLE 7.7 Non-pharmacological treatment for pain
or as an alternative.
Pain relief may be required for preexisting injuries or prior Comfort measures Diversional measures
to specific procedures to prevent its occurrence. Being ● Repositioning 34 ● Relaxation
turned is often cited as the most painful procedure, ● Oral and endotracheal suctioning ● Breathing exercises
however wounds, drain removal, tracheal suction, femoral ● Mouth, oral and/or wound care ● Visual imagery 107
catheter removal, placement of central-line catheter and ● Reassurance and information ● Music therapy
● Massage
non-burn wound dressings, and coughing may also cause ● Heat or cold therapy 34
considerable discomfort. 90,103 Guidelines and written pro-
tocols for procedures such as femoral sheath removal and
insertion of central-line catheter, can significantly reduce Non-Pharmacological Treatment for Pain
pain intensity as they often contain reminders to provide
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analgesia. Some procedures, such as insertion of a Non-pharmacological strategies to reduce pain are linked
central-line catheter, require additional pain management to some key strategies to reduce stress. Excessive pain may
considerations such as administration of local anaes- lead to stress as the body attempts to maintain homeo-
thetic. This highlights the potential need for additional stasis and stress can exacerbate pain. Strategies to reduce
pain protocols linked to key standard procedures (e.g. stress and pain include both comfort measures and diver-
patient turning) to reduce patients’ pain experience. sional interventions, which require the critical care nurse
to individualise and adapt strategies to match the patient’s
Pain relieving medication can be given by a number of needs and preferences. Diversional methods may include
routes, including oral, enteral feeding tube, intravenous, strategies to distract the patient, and aim to refocus the
rectal, topical, subcutaneous, intramuscular, epidural and patient’s thinking away from the pain and on to other
intrathecal. For all routes of administration, assessment more pleasant thoughts or activities. Table 7.7 lists some
of the patient’s suitability and contraindications for use interventions that may prove effective.
is an essential part of the decision-making process.
Patient-controlled analgesia for intravenous and, more Non-pharmacological interventions have the benefit of
recently, epidural analgesia is commonly part of critical being nurse-initiated, non-invasive and able to be person-
care nursing. alised for each patient. These strategies alone may not
achieve a pain-free experience but they have the capacity
Epidural pain management requires additional evalua- to enhance the effects of analgesic medication and huma-
tion, including sensory and functional assessment, due nise the critically ill patient’s experience.
to the use of local anaesthetic agents in addition to opioid
drugs. Sensory function should be regularly checked Pharmacological Treatment for Pain
using a dermatome chart to gauge segments that are Pharmacological treatment for pain in critically ill patients
blocked by the local anaesthetic agent. In addition to centres on opioid drugs which act as opioid agonists
sensory blockade, regular assessment for lower limb binding to the µ-receptors in the brain, central nervous
motor deficit is required to detect changes in motor system and other tissues. Opioid drugs have a rapid
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response, which may impair ability to mobilise safely. action, are readily titrated and their metabolites, if
Sudden or subtle changes may also indicate a complica- present, are less likely to accumulate. Morphine sulphate
tion such as epidural haematoma. The Bromage Assess- and fentanyl are routinely used in critical care, and their
ment Scale is often used for assessing motor response. properties, side effects and nursing implications are out-
Regular checks of the catheter site are essential to identify lined in Table 7.8. For ischaemic chest pain, nitrates will
complications such as bleeding, haematoma and infec- be used together with morphine sulphate as first-line
tion early but also to ensure catheter patency. Intrathecal pain measures (see Chapter 10).
administration of analgesic medications has similar con-
traindications and complications to epidural analgesia Other medications such as non-steroidal anti-
and requires similar precautions. It is important to note inflammatory drugs (NSAIDs) act by inhibition of an
that intrathecal (as compared to intravenous) administra- enzyme within the inflammatory cascade, and may
tion does not eliminate all of the side effects of opioids produce analgesia (especially when combined with
(see Further reading). opioids) for bone and soft tissue injuries. As with all
medication, side effects and contraindications for use can
be serious and, in the case of NSAIDs, include gastroin-
Practice tip testinal bleeding, renal insufficiency and exacerbation of
asthma. Paracetamol is another medication that may be
Epidural administration of medication does not preclude
mobilisation. However certain safety measures should be highly effective for mild pain and when combined with
taken. Ensure that the epidural catheter is well secured: view opioid medications provides analgesia for bone and soft
the site before mobilising and apply extra tape. Monitor blood tissue injuries.
pressure and heart rate before and during the initial stages of An alternative to opioid medication for procedural pain
mobilising. Two health care personnel should assist during the is ketamine. 108,109 Single doses of the medication are effec-
first attempt to mobilise. tive in achieving analgesia during severely painful inter-
ventions such as deep wound care (for example, a burn