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This chapter discusses the importance of pain relief, source of pain, types and severity of pain and modalities of pain relief. Paracetamol is very useful for soft tissue pain and as an opioid sparing drug in more severe pain states. Non-steroidal anti-inflammatory drugs (NSAIDs) are powerful analgesics, particularly useful for bony pain. Tramadol is an atypical analgesic with antagonist actions at morphine receptors and inhibitory effects on the reuptake of serotonin and norepinephrine from the synaptic cleft. Potentiation of serotinergic neurons may be important in activating the descending pain control neuronal pathways. Opioids are the most potent analgesics widely available and form the basis of most critical care pain management treatments. The different opioids discussed in the chapter are: morphine, diamorphine, fentanyl, alfentanil, remifentanil, codeine, ketamine and nitrous oxide. Regional anaesthesia is commonly provided in conditions where the pain intensity is expected to resolve over time.
Critically ill patients are at high risk of malnutrition, due to the nature of their illness and hypermetabolic catabolic state. This chapter presents an assessment of the nutritional status and nutritional requirements by calculating resting energy expenditure for caloric requirements, calculating protein requirements, calculating non-protein (carbohydrates and lipids) components, and by calculating micronutrients including vitamins, electrolytes and trace elements. Nutritional support can be given through one of two routes: enteral feeding (EF) (via the gastrointestinal tract) or parenteral feeding (PN), intravenous (via either peripheral or central vein). Pharmaco/immunonutrition is a relatively new concept in critical care feeding. Some ICUs now have protocols for the use of immunonutrition feeds. The chapter discusses the different complications of nutritional support such as refeeding syndrome, overfeeding, hyperglycaemia, electrolyte imbalances and micronutrient deficiency, and different complications of enteral nutrition, and parenteral nutrition.
There are many clinical scoring systems to provide an assessment of levels of sedation, and commonly used ones include Ramsay and Bloomsbury scales. The other assessment tools are electroencephalograms, bispectral index, and auditory evoked potentials. It takes four half-lives of a drug given by intravenous infusion to achieve steady state. It is therefore necessary to start with a loading dose to minimize delays to achieve adequate sedation. The side effects of sedatives, ideal properties of sedatives, and commonly used sedatives are discussed in this chapter. The chapter reviews intravenous anaesthetic agents, volatile anaesthetic agents, benzodiazepines, opioids, alpha-2 receptor agonists, neuroleptic agents, neuromuscular blockade, and use of protocols and sedation breaks. The recent Awakening and Breathing Control (ABC) trial suggested that a 'wake up and breathe' protocol that pairs daily spontaneous awakening trials with daily spontaneous breathing trials results in better outcomes for mechanically ventilated patients in intensive care.