ICU Pain Assessment and Management

Algorithm Steps

1. ▶

   Start

   ICU Patient - Pain Assessment

   Routine pain assessment for all ICU patients

   1. ◆

      Decision

      Patient Can Self-Report Pain?

      Self-report is gold standard

      1. ●

         Action

         Use Numeric Rating Scale (NRS)

         0-10 scale for verbal patients

         • 0 = No pain
         • 1-3 = Mild pain
         • 4-6 = Moderate pain
         • 7-10 = Severe pain
         • Target: NRS ≤3
         1. ◆

            Decision

            Significant Pain Present?

            NRS ≥4 or CPOT ≥3 or BPS ≥5

            1. ●

               Action

               Continue Monitoring

               Reassess regularly

               • Routine assessment q4h
               • Before/after procedures
               • Anticipate pain with procedures
               • Preemptive analgesia for procedures
               1. ✓

                  Outcome

                  Pain Controlled

                  NRS ≤3, CPOT <3, patient comfortable

            2. ●

               Action

               Analgesia-First Approach

               Treat pain before sedation

               • Pain is primary driver of agitation
               • Treat pain → may reduce sedation needs
               • PADIS: Analgesia-first, analgesia-based sedation
               1. ●

                  Action

                  Select Opioid Analgesic

                  IV opioids first-line for ICU pain

                  • Fentanyl: 25-100 mcg IV q1-2h PRN
                  • - Preferred: hemodynamic instability, renal failure
                  • - Continuous: 25-200 mcg/hr
                  • Hydromorphone: 0.2-0.6 mg IV q2-3h
                  • - Less histamine release than morphine
                  • Morphine: 2-4 mg IV q2-4h
                  • - Caution: renal failure (M6G accumulation)
                  1. ●

                     Action

                     Consider Multimodal Analgesia

                     Opioid-sparing strategies

                     • Acetaminophen: 650-1000mg q6h (IV or PO)
                     • - Max 3-4g/day, caution hepatic disease
                     • NSAIDs: Short-term only if no CI
                     • - Caution: AKI, bleeding, cardiac
                     • Ketamine: Low-dose 0.1-0.5 mg/kg/hr
                     • - Adjunct for refractory pain
                     • Gabapentin/Pregabalin: neuropathic pain
                     1. ●

                        Action

                        Reassess Pain Response

                        15-30 min after intervention

                        • Reassess using same scale
                        • Titrate to target (NRS ≤3, CPOT <3)
                        • Document response
                        • Adjust regimen as needed
                        1. ✓

                           Outcome

                           Pain Refractory

                           Consider pain consult, regional techniques

                  2. ●

                     Action

                     Procedural Pain Management

                     Anticipate and prevent procedure pain

                     • Pre-procedure bolus (fentanyl 50-100 mcg)
                     • Increase sedation temporarily
                     • Local anesthesia when possible
                     • Non-pharm: positioning, distraction
      2. ●

         Action

         Use Behavioral Pain Scale

         For patients who cannot self-report

         • CPOT (Critical-Care Pain Observation Tool)
         • BPS (Behavioral Pain Scale)
         • CPOT ≥3 or BPS ≥5 = significant pain
         • Assess q4h and PRN
         • Before/after painful procedures