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Dear Editor, The problem of analgosedation in Intensive Care Units is as old as the Intensive Care Unit itself, but it is only in recent years that the importance of the "fifth vital parameter" in terms of association has been recognized not only as immediate complications such as agitation and delirium but also in the long term with post-traumatic stress disorder, chronic pain, and reduced quality of life after discharge, so much so as to recognize the need to adopt pain and agitation control scales even in non-communicating patients or patients with altered mental status.1[...]

Ribs are frequently affected after a blunt or penetrating thoracic trauma. Acute key complications associated with rib fractures include pain, hemo-pneumothorax, extrapleural hematoma, pulmonary contusion and laceration, and vascular injury. In high energy traumas, injuries to abdominal solid organs may also coexist. A later complication that can limit the weaning of patients from sedation and ventilation is neuropathic pain, which is frequently associated with rib fractures and that is often poorly responsive to oral and topical medications. The benefit of interventional nerve block procedures is still controversial. Ultrasound-guided erector spinae plane (ESP) block is a relatively new technique for thoracic analgesia that can be both a simpler and safer alternative to more complex and invasive neural blocking techniques, especially in intensive care unit patients whereas major contraindications (i.e. coagulation alteration, infection etc.) might limit the feasibility of more invasive methods, such as central blocks.

Adult patients in the intensive care unit (ICU) often experience pain resulting from acute and chronic illness, as well as from standard positioning and maneuverers in the ICU. In recent years, the need for effective pain control in intensive care has emerged strongly. Partial or ineffective control is associated with multiple complications, such as agitation, delirium, inability to adapt to mechanical ventilation, increased length of stay, and post-traumatic stress disorder. Recent guidelines and studies suggest multimodal strategies for effective pain control, also re-evaluating the use of locoregional anesthesiological techniques. Oncological pain in critically ill patients represents a particular challenge for medical staff, being closely linked to the concept of palliative care. We present a case of refractory pain and agitation in an oncologic patient following an emergency exploratory laparotomy. Through the use of an intrathecal catheter, we provided effective analgesia to control pain and agitation, allowing weaning from mechanical ventilation before, and once the terminal state of the tumor was established, providing palliative care to ensure dignity and satisfaction of the patient.