1. Pain Management in Critically Ill Patients:
   • Critically ill patients experience pain at rest, during routine ICU care, and during procedures.
   • Pain can originate from multiple sources and may be acute, chronic, or acute on chronic in nature.
   • Patients that are younger, female, and of nonwhite ethnicity are more likely to experience more intense pain.
   • Inadequate pain control contributes to the development of delirium, cardiac instability, respiratory distress, and immunosuppression.
2. Multimodal Analgesia:
   • Multimodal analgesia combines two or more drug classes or techniques to achieve a synergistic or additive effect.
   • It may include opioids, nonopioid analgesics, regional or neuraxial blocks, and nonpharmacologic therapies.
   • Each patient’s medical history, allergies, age, injuries, and comorbidities will dictate the optimum regimen.
   • Pain management protocols that mandate the use of validated pain and sedation scales consistently decrease the consumption of opioids and sedatives in ICU patients.
3. Assessment of Pain:
   • Assessment-driven and standardized pain management protocol improves ICU patient outcomes.
   • Valid assessment tools help guide analgesia while avoiding excess medication administration in those patients with adequate pain control.
   • A number of assessment tools are available for use in the ICU patient.
   • For those patients able to self-report pain, the Numeric Rating Scale (NRS) in a visual format had the best sensitivity, negative predictive value, and accuracy in ICU patients.
   • The Behavioral Pain Scale (BPS) and the Critical Care Pain Observation Tool (CPOT) have the greatest validity and reliability for monitoring pain in those unable to self-report.
4. Opioids:
   • Opioids were considered the mainstay of treatment for non-neuropathic pain in the critically ill patient population because of their high potency and efficacy.
   • The decision regarding which opioid to prescribe is highly dependent on specific patient comorbidities and circumstances.
   • When titrated appropriately, all intravenous opioids are considered equally effective with regard to analgesic efficacy and clinical outcomes.
   • However, studies have shown patients may demonstrate variability in opioid pharmacodynamics and pharmacokinetics, resulting in more favorable reactions to one opioid over another.
5. Multimodal therapy is preferred over opioid-centered analgesia:
   • Opioids have many side effects, including physical dependence, ileus, constipation, nausea and vomiting, respiratory depression, sedation, pruritus, and urinary retention.
   • ICU length of stay and post-ICU patient outcomes can be worsened by opioids.
   • Long-term complications of opioid use include addiction, immunosuppression, and opioid-induced hyperalgesia.
6. Bowel dysfunction is a common side effect of opioids:
   • Opioids often induce constipation or worsen preexisting constipation.
   • Prevention via a robust bowel regimen that includes laxatives and/or bulking agents is essential when prescribing opioids.
7. Acetaminophen is a commonly used analgesic with minimal side effects:
   • Acetaminophen reduces opioid requirements when used as an adjunct.
   • Acetaminophen can be administered via multiple routes of administration.
   • Acetaminophen carries a risk of hepatotoxicity, but the maximum daily dose in the inpatient setting should remain 4000 mg/day.
8. NSAIDs can be beneficial in mitigating opioid exposure:
   • NSAIDs work as analgesics and antipyretics by inhibiting COX enzymes.
   • NSAIDs have adverse effects, including increased risk of gastrointestinal bleeding, nephrotoxicity, impaired platelet function, and impaired wound healing.
   • Recent guidelines support their use in the acute pain setting.
   • COX-2 selective agents such as celecoxib carry a risk of cardiovascular thrombotic events.
9. Gabapentinoids are effective for neuropathic pain:
   • Gabapentin and pregabalin inhibit presynaptic calcium channels.
   • Gabapentinoids should be considered when a source of neuropathic pain is suspected.
   • Caution should be exercised when initiating gabapentin or pregabalin in the elderly or in patients with renal dysfunction.
10. Muscle relaxants may benefit patients with pain secondary to muscle spasm:
    • Antispasmodic agents such as methocarbamol, cyclobenzaprine, baclofen, or diazepam may be effective.
    • Their efficacy is scant, particularly in the acute pain setting.
    • Careful consideration must be given before using these agents, given the associated risk of sedation.
11. Ketamine can provide analgesia without respiratory suppression:
    • Ketamine acts as an NMDA antagonist.
    • Subanesthetic doses of ketamine can be used in a continuous fashion to provide analgesia.
    • Ketamine has neutral hemodynamic effects and can be used safely in patients with ICP concerns.
    • Magnesium has been shown to exhibit similar anti-NMDA activity in the perioperative setting.
12. Centrally acting α-agonists may offer analgesic effects:
    • Dexmedetomidine and clonidine may be effective.
    • Their use for acute pain in the critically ill population is minimal.
    • Cardiovascular effects such as hypotension and bradycardia limit their use in hemodynamically unstable patients.
13. Regional anesthesia:
    • Regional anesthesia techniques, such as neuraxial blocks and peripheral nerve blocks, are associated with improved analgesia and decreased opioid-related side effects in many patient populations.
    • Epidural analgesia has been associated with improved global pulmonary outcomes in critically ill patients, but it remains generally underused due to relative contraindications and other concerns.
14. Music modalities:
    • Music modalities, including music medicine and music therapy, have been found to have small to moderate effects on reducing pain and opioid usage in postoperative patients and mechanically ventilated patients.
    • Consideration should be given to employing these modalities in the ICU, pending availability and institutional logistics.
15. Cognitive behavioral modalities:
    • Cognitive behavioral modalities, such as hypnosis and guided imagery, have been extensively studied as an adjunct for both acute and chronic pain management, but there is a paucity of evidence within the critically ill population.
    • Clinical practice guidelines recommend cognitive behavioral therapy as adjunctive treatments in the postoperative patient, and the critical care provider may consider incorporating these techniques into pain management.
16. Aromatherapy:
    • Aromatherapy has been found to reduce anxiety and improve sleep in critically ill patients, including the mechanically ventilated subpopulation.
    • Although evidence examining aromatherapy for pain management in the ICU is lacking, it may have a role in a well-rounded regimen for pain management.
17. Physical modalities:
    • Physical modalities, such as acupuncture and massage, are generally safe and inexpensive, but there is scant scientific literature in the critically ill population.
    • Clinical practice guidelines neither recommend nor discourage the use of these techniques for postoperative pain management, and whether the critically ill patient would benefit from these physical modalities is currently unknown.
18. Valid pain assessment tools:
    • Valid pain assessment tools are important in guiding analgesia while avoiding excess medication administration in those patients with adequately controlled pain.
19. Multimodal analgesia regimens:
    • Multimodal analgesia regimens are highly recommended because of their improved efficacy and an associated decrease in opioid consumption, with resultant reduction in opioid-related side effects.
20. Costs of inadequate pain control:
    • The costs of inadequate pain control are high and include the development of delirium, cardiac instability, respiratory distress, and immunosuppression.