Analgesia

Pain treatment has the priority over the use of sedatives and antipsychotics. Good pain control is essential for the high risk patient adaptation to acute illness and intensive care environment.
Nevertheless, we must not forget the side effects of analgesics, in particular for opioid: respiratory depression, hypotension, bradycardia, nausea and vomiting, slowing of peristalsis, pruritus, urinary retention are dose-dependent effects, which lead us to limit the amount of opiates at the minimum necessary to control pain.
Recently, analgesia-based sedation has been responsible for increase the intensivists' sensitivity to the problem of pain control in ventilated patients and allowed to test the possibility of keeping awake even critically ill patients at high risk; unfortunately it resulted in an excessive use of opioid analgesics, exposing to the risk of probably avoidable side effects ...
The multimodal analgesia (intravenous acetaminophen, NSAIDs, use of adjuvants such as gabapentin or clonidine, locoregional analgesia where possible) could lead to a reduction of side effects with the same analgesic efficacy.
The international literature shows that the winning approach to decrease morbidity and mortality is to control the pain through the minimum effective dose of analgesics and control anxiety and agitation with other methods (pharmacological and non pharmacological) that have fewer side effects.

A&A 2006 Vaurio - Pain management & Post operative delirium

A&A 2010 Ahlers - Behavioral Pain Scale in conscious sedate ICU patients

AJRCCM 2002 Kress - Sedation and analgesia in the Intensive Care Unit

Anaesthesia 2009 Tan - Use of Remifentanil as a sedative agent in critically ill patients

CC 2005 Breen - Decreased ventilation with Remifentanil

CC 2008 Sessler - Analgesia and sedation in ICU

CCM 2001 Payen - Behavioral Pain Scale

CCM 2002 Jacobi - Clinical practice guidelines for anaglesic and sedatives in ICU

CurrOpAnesth 2007 Fraser - Sedation and analgesia practices

German guidelines on analgesia-sedation 2010

ICM 2006 Martin - Sedation and analgesia in a German Intensive Care Unit: a patient-based survey

ICM 2009 Chanques - Behavioral Pain Scale for non-intubated critically ill patient inable to self report

ICM 2011 Spies - Fentanyl = Remifentanil

LANCET 2007 Strøm - A protocol of non sedation for ventilated ICU patients

Pharmacotherapy 2005 Riker - Adverse events associated with sedatives and analgesics

Review 2008 Meurant - Sedation or analgo-sedation in the ICU multimodality approach