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Pain in the ICU
Guidelines
Key sources
The following summarized guidelines for the evaluation and management of pain in the ICU are prepared by our editorial team based on guidelines from the World Society of Emergency Surgery (WSES 2024), the Korean Society of Critical Care Medicine (KSCCM 2022), the Society of Critical Care Medicine (SCCM 2022,2018,2013), and the American Academy of Family Physicians (AAFP 2021).
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Screening and diagnosis
Diagnostic investigations
Pain assessment: as per KSCCM 2022 guidelines, obtain routine and reproducible pain assessments and evaluate responses to pain treatment using the patient's self-report or Behavioral Pain Scale.
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Behavioral Pain Scale for pain assessment in intubated patients (BPS)
Calculator
When to use
Facial expression
Relaxed
Partially tightened
Fully tightened
Grimacing
Upper limb movements
No movement
Partially bent
Fully bent with finger flexion
Permanently retracted
Compliance with mechanical ventilation
Tolerating movement
Coughing but tolerating ventilation for most of the time
Fighting ventilator
Unable to control ventilation
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Medical management
General principles
As per KSCCM 2022 guidelines:
Individualize and personalize the treatment plan and the goal of optimal pain management, shared among all participating clinicians for consistent analgesic therapy.
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Prefer continuous IV infusion or an intermittent scheduled-administration strategy of analgesics over on-demand administration to maintain consistent analgesic action.
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Opioid analgesics
Non-opioid analgesics
Ketamine
Intravenous lidocaine
Management of neuropathic pain
Nonpharmacologic interventions
Manual therapy: as per SCCM 2018 guidelines, consider offering massage for pain management in critically ill adult patients.
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Music therapy
Cold therapy
Relaxation techniques
Cybertherapy and hypnosis
Therapeutic procedures
Perioperative care
Periprocedural analgesia: as per SCCM 2018 guidelines, consider administering an opioid at the lowest effective dose for procedural pain management in critically ill adult patients.
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Perioperative analgesia
Specific circumstances
Pediatric patients: as per SCCM 2022 guidelines, consider obtaining routine pain assessment via self-report using the VAS, NRS, Oucher Scale, or Wong-Baker Faces pain scale in critically ill pediatric patients aged ≥ 6 years capable of communicating.
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Elderly trauma patients (general principles)
Elderly trauma patients (opioid analgesics)
Elderly trauma patients (non-opioid analgesics)
Elderly trauma patients (nonpharmacologic interventions)
Elderly trauma patients (neuraxial analgesia)
Elderly trauma patients (peripheral nerve block)