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The pain response, an evolutionary adaptation which promotes tissue integrity and survival, is prevalent in patients with critical illness or injury. However, pain in the intensive care unit (ICU) can be maladaptive by increasing suffering and contributing to physiologic perturbations, agitation, ventilator dyssynchrony, and impaired mobility. The accurate assessment of pain and precise targeting of analgesic therapy is therefore a fundamental goal of intensive care medicine. Here, we review pain assessment tools which have been developed and/or validated for use in the ICU. Direct pain evaluation in critically ill patients is challenged by barriers to assessment such as intubation, sedation, brain dysfunction or injury, and, more recently, paralysis for management of severe ARDS due to COVID-19. In these instances, pain assessment is relegated to indirect measurement tools whose validity and reliability are not well established. Protocol-based pain surveys in the ICU have been associated with reductions in pain scores, opioid requirements, duration of mechanical ventilation, and ICU length of stay. Research aiming to test and validate specific and sensitive pain biomarkers could lay the foundation for more precise, effective, and safe treatment of pain in the ICU.

Objective The purpose of this study was to determine the duration, intensity, location, and usual treatment of pain throughout hospitalization following subarachnoid hemorrhage. Background Headache following subarachnoid hemorrhage can be sudden and severe. Little is known about the longitudinal course of headache or its analgesic therapy following the initial diagnosis of subarachnoid hemorrhage. Methods A prospectively maintained database of 564 patients diagnosed with cerebral aneurysms collected from 10/2009 to 2/2013 was searched for conscious patients with subarachnoid hemorrhage. Available electronic records were queried for pain scores (0-10/10), location, and analgesic consumption. Results Forty-six adults with subarachnoid hemorrhage met eligibility criteria for inclusion. Mean [CI 95] daily pain was 3.8 [3.2, 4.4] and maximal daily pain was 5.8 [5.1, 6.6]. Eighty-nine percent of patients reported severe pain of 7-10/10, and 63% of patients reported 10/10 pain at some point during hospitalization. While mean [CI 95] pain declined over the course of hospital stay at a rate of 0.06 [0.04, 0.07] units/day (P

Purpose of review Pain management in neurocritical care is a subject often avoided because of concerns over the side-effects of analgesics and the potential to cause additional neurological injury with treatment. The sedation and hypercapnia caused by opioids have been feared to mask the neurological examination and contribute to elevations in intracranial pressure. Nevertheless, increasing attention to patient satisfaction has sparked a resurgence in pain management. As opioids have remained at the core of analgesic therapy, the increasing attention to pain has contributed to a growing epidemic of opioid dependence. In this review, we summarize the most recent literature regarding opioids and their alternatives in the treatment of acute pain in patients receiving neurocritical care. Recent findings Studies on pain management in neurocritical care continue to explore nonopioid analgesics as part of a multimodal strategy aimed at decreasing overall opioid consumption. Agents including local anesthetics, acetaminophen, ketamine, gabapentinoids, and dexmedetomidine continue to demonstrate efficacy. In addition, the prolonged longitudinal course of many recent trials has also revealed more about the transition from acute to chronic pain following hospitalization. Summary In an era of increasing attention to patient satisfaction mitigated by growing concerns over the harms imposed by opioids, alternative analgesic therapies are being investigated with promising results.

Object Opioid administration following major intracranial surgery is often limited by a presumed lack of need and a concern that opioids will adversely affect postoperative outcome and interfere with the neurological examination. Nevertheless, evidence is accumulating that these patients suffer moderate to severe postoperative pain and that this pain is often undertreated. The authors hypothesized that intravenous patient-controlled analgesia (PCA) would safely and more effectively treat postoperative supratentorial craniotomy pain than conventional as needed (PRN) therapy. Methods Following a standardized course of general anesthesia, adult patients who underwent elective supratentorial intracranial surgery were randomized in the neurosciences intensive care unit to receive either PRN intravenous fentanyl 25–50 μg every 30 minutes or PCA intravenous fentanyl 0.5 μg/kg every 15 minutes (maximum 4 doses/hour). The authors measured pain (self-reported scale score [0–10]), sedation (Ramsay Sedation Scale score), Glasgow Coma Scale score, fentanyl use, and major adverse events (excessive sedation, respiratory depression, pruritus, nausea, or vomiting) hourly. Results Sixty-four patients with a mean age of 48 years (range 22–77 years) were randomized to intravenous PCA (29 patients) or PRN fentanyl (35 patients) groups. There were no statistically significant demographic differences between the 2 groups. Patients receiving intravenous PCA had significantly lower pain scores than those receiving intravenous PRN fentanyl (2.53 ± 1.96 vs 3.62 ± 2.11 [p = 0.039]) and received significantly more fentanyl than the PRN group (44.1 ± 34.5 vs 23.6 ± 23.7 μg/hour [p = 0.007]). There were no differences between the 2 groups regarding the number of patients with adverse events. Conclusions Intravenous PCA more effectively treats the pain of supratentorial intracranial surgery than PRN fentanyl, and patients in the former group did not experience any untoward events related to the self-administration of opioids.

Surgery of the posterior fossa often produces intense postoperative pain. However, this pain is infrequently treated because of concern that opioid administration may mask the postoperative neurologic examination and/or produce hypercarbia. In this prospective, randomized controlled trial, we sought to determine whether IV patient-controlled analgesia (PCA) would lead to reductions in postoperative pain after neurosurgical procedures of the posterior fossa compared with conventional IV nurse-administered as-needed (PRN) therapy.Eighty patients (age range, 18-82 years) undergoing elective posterior fossa surgery were randomized to receive postoperative IV fentanyl PRN 25 to 50 μg every 30 minutes or via PCA 0.5 μg/kg/dose, with a maximal dose limit of 50 μg, and 15-minute lockout (4 doses/hour). We measured pain (Numerical Rating Scale, 0-10), analgesic use, sedation (Ramsay Sedation Scale and Glasgow Coma Scale), respiration, hemodynamics, and adverse events hourly.Sixty-five patients completed the study. Thirty-one patients received IV PCA and 34 received PRN analgesia. Patient demographics did not differ between groups. Patients in the PCA group reported less pain at rest (mean [95% confidence interval]: 3.7 [3.0, 4.4] vs 5.2 [4.5, 5.8], P = 0.003) and received more fentanyl (mean [95% confidence interval]: 54.8 [42.1, 67.6] vs 29.9 [24.2, 35.7] μg/h, P = 0.002) than those in the PRN group. There were no differences in side effects and no adverse events related to analgesic therapy.IV PCA use resulted in reduction in postoperative pain compared with PRN analgesic therapy after surgery of the posterior fossa. Larger studies will be required to determine the safety of IV PCA in this patient population.