**5. Few final recommending points**

#### **5.1. Hospital pain team**

Consider referring complex ICU patients to the hospital pain team. It helps the patients on multimodal therapy but if still experiencing severe pain. Referral to the pain team can often lead to an increased level of support that would benefit the suffering patients, and once patients are discharged from the critical care unit, the pain team follows them to the ward [26].

#### **5.2. Alternative therapy**

The alternative medicine modalities of pain management like transcutaneous electrical nerve stimulation (TENS), acupuncture and aromatherapy have a very weak evidence base pain management in intensive care, but should be considered as the adverse-effect profile is low [25].

#### **5.3. Reassessment**

α2-Agonists are used to improve the quality of analgesia and aid opioid rotation in opioidtolerant individuals. The side-effect profile of both α2-agonists includes bradycardia, cardiac asystole and hypotension. Although rare, it can cause rebound hypertension and can cause

It is an N-methyl-aspartate antagonist, commonly used as analgosedative agent. Its use in combination with the opioid PCA reduces the opioid consumption and side effects. In combination with midazolam, ketamine provides effective analgesia in sickle cell crisis patients. Ketamine has an opioid-sparing effect and commonly used in lower dosage in burns patients. The main side effects of ketamine are tachycardia, hallucination, delirium ketotonia and

It acts through the NMDA receptors and acts as adjunct by reducing analgesic requirements without any major adverse effects, but there is no evidence that magnesium has any opioid-

The Gabapentin and Pregabalin work by binding to the α2δ subunits of voltage-dependent calcium ion channels. They reduce the development of hyperalgesia and central sensitization

Gabapentin compared with Carbamazepine or placebo reduces pain intensity in patients with GBS (Gillian Barrie syndrome) without increasing side effects. Gabapentinoids are used mainly in neuropathic and post-burn debridement pain. The extra advantage is that these medications are available in the enteric form and get absorbed in the duodenum; hence, one has to be careful when the patient is fed through a jeujenostomy tube. The major side effects

Consider referring complex ICU patients to the hospital pain team. It helps the patients on multimodal therapy but if still experiencing severe pain. Referral to the pain team can often lead to an increased level of support that would benefit the suffering patients, and once patients are discharged from the critical care unit, the pain team follows them to the ward [26].

The alternative medicine modalities of pain management like transcutaneous electrical nerve stimulation (TENS), acupuncture and aromatherapy have a very weak evidence base pain management in intensive care, but should be considered as the adverse-effect profile is low [25].

withdrawal syndrome.

68 Pain Management in Special Circumstances

increase intracranial pressure [25].

sparing effects in the critically ill patients [25].

**5. Few final recommending points**

**5.1. Hospital pain team**

**5.2. Alternative therapy**

and are useful adjuncts in the treatment of neuropathic pain.

of these medications are confusion, dizziness, ataxia and convulsions [25].

*4.2.5. Ketamine*

*4.2.6. Magnesium*

*4.2.7. Gabapentinoids*

Patients must be evaluated hourly to ensure appropriate response to therapeutic interventions so that health-care providers can proactively act to relieve pain. If reassessment reveals inadequate pain control despite the initiation of therapeutic interventions, we should consider titration of medications, rotation of medications or changes in the route of administration [26].

#### **5.4. Guidelines and protocols**

These guidelines should be developed that combine a scientific basis and expert opinion. Wellness model from the World Health Organization's treatment of pain after cardiac surgery, we can see that guidelines and protocols lead to the effective management of post-cardiac surgery pain. If we look at the complexity of ICU pain, we need to have organized protocols to help us care for these patients. The examination of published literature reviews and evidencebased guidelines can facilitate the development of institution-specific guidelines.

#### **5.5. Clinical pathways**

It provides a consistent and repeatable time line for planning individualized patient care. The pathway details the precise course of the patient, including multidisciplinary elements. It includes history, examination, diagnostics and treatment and incorporates pre-emptive treatment for procedures as well as management of chronic pain issues [26].

#### **5.6. Checklists**

It is a way to verify that clinical pathways or tasks are completed and it is a good way to ensure that pathways or tasks are followed. It helps in errors prevention [26].

#### **5.7. Daily goals**

Daily goals highlighting by white board, electronic reminders to all members of the multidisciplinary team can access the plan and ensure that the patient is being treated from all perspectives [26].
