Adult ICU patient: assess pain
Adults only. Assess regularly (for example every 4 h), before and after procedures, and when agitated.
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Critical CareManagement
ICU Pain Assessment and Management
ICU Pain Assessment and Management: Adult ICU patient: assess pain → Can the patient self-report pain reliably? → Can self-report: use the 0-10 Numeric ...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Decision Can the patient self-report pain reliably?
Self-report is the reference standard when the patient can communicate reliably.
- If Yes
03Action Can self-report: use the 0-10 Numeric Rating Scale
Visual NRS works best in ICU. NRS 4 or more = significant pain.
- 0 = no pain; 10 = worst pain
- NRS 4 or more = significant pain: treat
- Agree a comfort goal with the patient (usually NRS 3 or less)
04Decision Significant pain present?
NRS 4 or more, CPOT 3 or more, or BPS 6 or more.
- If Yes
05Action Significant pain: treat pain before sedation
Analgesia first. Use an assessment-driven, protocol-based, stepwise approach.
- Treat pain before you start or increase a sedative for agitation
- Look for a treatable cause of new or worse pain
- Opioid-based sedation may not suit alcohol or drug withdrawal, neuromuscular blockade, raised ICP or status epilepticus
06Warning Before opioids: check the risk of respiratory depression
Not intubated, older, frail, renal or hepatic impairment, sleep apnoea: start low and titrate slowly.
- Not intubated: monitor sedation score and respiratory rate; rising sedation is the early warning sign
- Hard to rouse or slow breathing: stop the opioid, support breathing, give naloxone
- Naloxone (adult): 100-200 micrograms IV every 2-3 min, titrate to breathing, not full reversal. Opioid dependent: smaller doses (risk of severe withdrawal)
07Action Give an IV opioid at the lowest effective dose
Opioids are first line for non-neuropathic pain. Adult bolus doses; titrate to the pain score.
- Fentanyl: 0.35-0.5 mcg/kg IV (about 25-35 mcg at 70 kg) every 30-60 min as needed
- Morphine: 2-4 mg IV every 1-2 h as needed
- Hydromorphone: 0.2-0.6 mg IV every 1-2 h as needed; use 2 mg/mL. HP 10 mg/mL is for opioid-tolerant patients only
- Renal impairment: prefer fentanyl; avoid morphine (active metabolites accumulate)
- On regular opioids, methadone or buprenorphine: continue the usual dose, expect higher needs, ask the acute pain service
- Infusion (ventilated adults): fentanyl 0.7-10 mcg/kg/h or morphine 2-30 mg/h; start at the low end
08Action Add non-opioid and non-drug measures to reduce opioid use
Paracetamol as a routine adjunct. Under 50 kg or at liver risk: lower paracetamol dose. Other adjuncts by indication.
- Paracetamol (IV or oral), over 50 kg: 1 g every 4-6 h, max 4 g/day
- Paracetamol, under 50 kg, liver disease, chronic alcohol use, malnutrition or dehydration: 15 mg/kg per dose, max 60 mg/kg/day and max 2 g/day (AU IV PI)
- Paracetamol: renal or hepatic impairment, at least 6 h between doses; do not use in liver failure
- Neuropathic pain: add gabapentin, pregabalin or carbamazepine; adjust gabapentinoids for renal function
- After surgery, to cut opioid use: ketamine 0.5 mg/kg IV once, then 1-2 mcg/kg/min infusion. Can cause delirium and raise blood pressure; avoid where a rise in blood pressure is dangerous
- NSAIDs: not routine; avoid in AKI, bleeding risk, GI bleeding or heart failure
- Non-drug: massage and music
09Decision Pain controlled on reassessment?
Reassess with the same scale 15-30 min after an IV dose, and regularly after that.
- If Yes
10Action Controlled: continue the regimen and keep assessing
Use the lowest dose that keeps pain at goal. Plan for procedures.
- Reassess regularly and after each change
- Reduce opioid doses as pain settles
- Document score, drug, dose and response
11Action Before painful procedures: give pre-emptive analgesia
Time the analgesic so its peak effect matches the procedure.
- IV opioid at the lowest effective dose, timed to peak at the procedure
- Discrete, infrequent procedure: IV, oral or rectal NSAID is an alternative if no AKI, bleeding risk, GI bleeding or heart failure
- Cold packs or relaxation techniques can help
- Chest drain removal: PADIS suggests not using local anaesthetic or nitrous oxide; use an opioid
- Do not use NSAID gel or inhaled volatile anaesthetics for procedural pain
12Outcome Pain controlled
NRS 3 or less, CPOT less than 3 or BPS less than 6, patient comfortable. Keep assessing.
If No13Action Not controlled: titrate and escalate
Titrate the opioid and add adjuncts. Look again for a new cause.
- Check for a new cause (for example a surgical complication)
- Ask the acute pain service or anaesthesia for review
- Consider regional analgesia (for example epidural or nerve block); check anticoagulants and clotting first
14Outcome Pain refractory: specialist review
Acute pain service or anaesthesia review; consider regional analgesia.
If No15Action No significant pain: keep assessing
Reassess regularly and after any change. Paralysed (neuromuscular blocker): a low score does not exclude pain; keep analgesia and sedation.
- Reassess regularly, before and after procedures, and when agitated
- Path rejoins step 11Shared downstream outcome
If No16Action Cannot self-report: use CPOT or BPS (not valid if paralysed)
Use only when behaviours can be seen. CPOT 3 or more, or BPS 6 or more = significant pain.
- Neuromuscular blocker (paralysed): scores read falsely low. Give analgesia and deep sedation before and during paralysis
- CPOT (0-8): 3 or more = significant pain
- BPS (3-12; BPS-NI if not intubated): 6 or more = significant pain
- Vital signs are not valid pain measures; use a change only as a cue to assess
- Family can help with the assessment when appropriate
- Path rejoins step 04Shared downstream outcome
Guideline Source
Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS 2018; pain recommendations unchanged in the 2025 focused update)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only. Not for children.
- Opioid doses are adult starting ranges (PAD 2013 table); titrate to effect and follow your ICU protocol. Reduce doses in older, frail, opioid-naive, renal or hepatic impairment.
- Pain scales need training; BPS and CPOT are not validated in all groups (for example some brain-injured patients).
- Does not cover chronic pain, opioid-tolerant patients, PCA or epidural management.
- Availability of IV paracetamol, ketamine and regional techniques varies.
Contraindicated Populations
pediatric
Applicable Regions
AUUSEUGlobal
AU: Hydromorphone injection: Dilaudid 2 mg/mL; Dilaudid-HP 10 mg/mL and 50 mg/mL are for opioid-tolerant patients only. IV paracetamol PI (Paracetamol Kabi) caps at-risk adults at 60 mg/kg/day, not over 2 g/day.
Global: SCCM PADIS 2018; the 2025 focused update made no changes to the pain recommendations.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the ICU Pain Assessment and Management?
The ICU Pain Assessment and Management is a management clinical algorithm for Critical Care. It provides a structured decision tree to guide clinical decision-making, based on Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS 2018; pain recommendations unchanged in the 2025 focused update).
What guideline is the ICU Pain Assessment and Management based on?
This algorithm is based on Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS 2018; pain recommendations unchanged in the 2025 focused update) (DOI: 10.1097/CCM.0000000000003299).
What are the limitations of the ICU Pain Assessment and Management?
Known limitations include: Adults only. Not for children.; Opioid doses are adult starting ranges (PAD 2013 table); titrate to effect and follow your ICU protocol. Reduce doses in older, frail, opioid-naive, renal or hepatic impairment.; Pain scales need training; BPS and CPOT are not validated in all groups (for example some brain-injured patients).; Does not cover chronic pain, opioid-tolerant patients, PCA or epidural management.; Availability of IV paracetamol, ketamine and regional techniques varies.. Individual patient factors may require deviation from these recommendations.
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