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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

Monitoring for pain: as per SCCM 2013 guidelines, monitor pain routinely in all adult ICU patients.
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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)
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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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More topics in this section

  • 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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More topics in this section

  • Music therapy

  • Cold therapy

  • Relaxation techniques

  • Cybertherapy and hypnosis

Therapeutic procedures

Neuraxial analgesia: as per SCCM 2013 guidelines, consider administering thoracic epidural analgesia in patients with traumatic rib fractures.
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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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More topics in this section

  • 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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More topics in this section

  • 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)

Follow-up and surveillance

Post-ICU care: as per AAFP 2021 guidelines, screen patients for weakness after ICU discharge and refer for physical rehabilitation when appropriate.
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