IBCC Episode 96 - Analgesia for the critically ill patient | The Internet Book of Critical Care Podcast

The podcast addresses the pervasive issue of pain management in critical care, advocating for a shift towards multimodal analgesia to minimize reliance on opioids. It highlights the difficulty of diagnosing pain versus agitation in critically ill patients and the limited evidentiary basis for many common practices. The discussion emphasizes the importance of a tiered approach, starting with acetaminophen and progressing cautiously through options like ketamine and alpha-2 agonists before resorting to opioid infusions. The hosts caution against the overuse of opioid infusions due to rapid tolerance, dependence, and potential for hyperalgesia, advocating instead for bolus-only strategies and aggressive weaning protocols. They also explore the judicious use of NSAIDs, lidocaine, and gabapentinoids, while underscoring the value of non-pharmacological interventions like early mobility and physical therapy.

Outlines

Part 1: Fundamentals of Pain Management

Part 2: Non-Opioid Foundations

Part 3: Opioid Management and Risks

Part 4: Specialized Delivery and Infusions

Part 5: Neuropathic and Adjunctive Therapies

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IBCC Episode 96 - Analgesia for the critically ill patient

The Internet Book of Critical Care Podcast

Part 1: Fundamentals of Pain Management

Analgesia in Critical Illness: The Importance of Pain Management

Rethinking Analgesia: From Sedation to Multimodal Approaches

Multimodal Analgesia: Evidence, the WHO Ladder, and Avoiding Opioid Infusions

Part 2: Non-Opioid Foundations

Acetaminophen (Tylenol): Efficacy, Dosing, and Contraindications

Pain Dose Ketamine Infusion: NMDA Dissociation and Synergistic Effects

Dexmedetomidine and Clonidine: Synergistic Analgesia and Sedation

Alpha-2 Agonists: Weaning, Interactions with Ketamine, and Hemodynamic Effects

Part 3: Opioid Management and Risks

Opioids: How They Work and Avoiding Overuse

Opioid Selection, Context-Specific Half-Life, and Common Complications

Avoiding the Opioid Vortex: Respiratory Suppression, GI Failure, and Dependence

Strategies to Avoid Opioid Infusion Problems: Bolus-Only, Multimodal, and Ketamine

Part 4: Specialized Delivery and Infusions

Opioid Infusions in Specific Cases: Severe ARDS and Chronic Opioid Patients

Patient-Controlled Analgesia (PCA): Setup, Common Mistakes, and Limitations

NSAIDs: General Use, Mechanisms, and Optimal Candidates

Lidocaine Infusions: Mechanism, Pharmacokinetics, and Cautions

Lidocaine: Systemic Toxicity, Patient Selection, and Dosage

Part 5: Neuropathic and Adjunctive Therapies

Gabapentinoids: Neuropathic Pain and Potential Multimodal Role

Other Measures: Nerve Blocks, Early Mobility, and Physical Therapy

IBCC Episode 96 - Analgesia for the critically ill patient

The Internet Book of Critical Care Podcast

Part 1: Fundamentals of Pain Management

00:05Analgesia in Critical Illness: The Importance of Pain Management

Analgesia in Critical Illness: The Importance of Pain Management

01:11Rethinking Analgesia: From Sedation to Multimodal Approaches

Rethinking Analgesia: From Sedation to Multimodal Approaches

03:04Multimodal Analgesia: Evidence, the WHO Ladder, and Avoiding Opioid Infusions

Multimodal Analgesia: Evidence, the WHO Ladder, and Avoiding Opioid Infusions

Part 2: Non-Opioid Foundations

04:42Acetaminophen (Tylenol): Efficacy, Dosing, and Contraindications

Acetaminophen (Tylenol): Efficacy, Dosing, and Contraindications

07:16Pain Dose Ketamine Infusion: NMDA Dissociation and Synergistic Effects

Pain Dose Ketamine Infusion: NMDA Dissociation and Synergistic Effects

09:39Dexmedetomidine and Clonidine: Synergistic Analgesia and Sedation

Dexmedetomidine and Clonidine: Synergistic Analgesia and Sedation

12:31Alpha-2 Agonists: Weaning, Interactions with Ketamine, and Hemodynamic Effects

Alpha-2 Agonists: Weaning, Interactions with Ketamine, and Hemodynamic Effects

Part 3: Opioid Management and Risks

14:24Opioids: How They Work and Avoiding Overuse

Opioids: How They Work and Avoiding Overuse

15:56Opioid Selection, Context-Specific Half-Life, and Common Complications

Opioid Selection, Context-Specific Half-Life, and Common Complications

18:21Avoiding the Opioid Vortex: Respiratory Suppression, GI Failure, and Dependence

Avoiding the Opioid Vortex: Respiratory Suppression, GI Failure, and Dependence

21:31Strategies to Avoid Opioid Infusion Problems: Bolus-Only, Multimodal, and Ketamine

Strategies to Avoid Opioid Infusion Problems: Bolus-Only, Multimodal, and Ketamine

Part 4: Specialized Delivery and Infusions

23:51Opioid Infusions in Specific Cases: Severe ARDS and Chronic Opioid Patients

Opioid Infusions in Specific Cases: Severe ARDS and Chronic Opioid Patients

25:34Patient-Controlled Analgesia (PCA): Setup, Common Mistakes, and Limitations

Patient-Controlled Analgesia (PCA): Setup, Common Mistakes, and Limitations

27:27NSAIDs: General Use, Mechanisms, and Optimal Candidates

NSAIDs: General Use, Mechanisms, and Optimal Candidates

29:46Lidocaine Infusions: Mechanism, Pharmacokinetics, and Cautions

Lidocaine Infusions: Mechanism, Pharmacokinetics, and Cautions

32:31Lidocaine: Systemic Toxicity, Patient Selection, and Dosage

Lidocaine: Systemic Toxicity, Patient Selection, and Dosage

Part 5: Neuropathic and Adjunctive Therapies

34:46Gabapentinoids: Neuropathic Pain and Potential Multimodal Role

Gabapentinoids: Neuropathic Pain and Potential Multimodal Role

36:40Other Measures: Nerve Blocks, Early Mobility, and Physical Therapy

Other Measures: Nerve Blocks, Early Mobility, and Physical Therapy