Guide to Pain Management in Low-Resource Settings

What to discuss regarding appropriate 
analgesia for Joe
•  Availability of analgesics (both type and form).
•  Appropriate analgesic for this situation, since this 
patient has renal failure and coagulopathy.
•  Opioids (preferably as a continuous infusion).
•  Nerve block and/or epidural may be appropri-
ate once his renal function improves and he is no 
longer coagulopathic.
How and when to use anxiolytics and sedatives
Although these drugs have no analgesic proper-
ties, they may reduce the dose of analgesia required. 
In a survey in 2001 in Western Europe, midazolam 
was most frequently used for sedation in the inten-
sive care situation because it has a shorter duration 
of action than diazepam and is less prone to accumu-
lation. Lorazepam is a cost-effective drug that is lon-
ger acting and can have useful anxiolytic effects for 
prolonged treatment of anxiety; however, it can result 
in oversedation. In the American Society of Critical 
Care Medicine Guidelines, lorazepam was the drug 
recommended for longer-term sedation. Propofol 
infusion is also frequently used in many countries 
in Europe; the advantage being that it can be titrat-
ed easily and the effect will usually diminish quickly 
once the infusion is stopped, allowing for a “seda-
tion vacation” in the ICU. In addition to benzodiaz-
epines and propofol, other drugs with sedative prop-
erties have been used in the past and are considered 
obsolete for sedation: phenothiazines, barbiturates, 
and butyrophenones. Opioids should not be used to 
achieve sedation, and some of their side effects can be 
disturbing in themselves.
Excessive sedation has negative eff ects—re-
duced mobility results in increased risk of deep vein 
thrombosis and pulmonary thromboembolism. Overse-
dation may slow the weaning process or delay extuba-
tion, when the patient is otherwise ready, and so can 
prolong ICU stay, with its attendant risks, and increase 
the cost of care. After several days of continuous ther-
apy with propofol or benzodiazepines, withdrawal phe-
nomena may be precipitated, and reduction in dose 
should be gradual to avoid them.
What adjuncts to pharmacological agents 
should be considered in the intensive care unit?
Th
  e ICU can be a noisy place with regular monitor 
alarms, telephones, and pager calls. Much of the mon-
itor alarm noise is avoidable by setting alarm limits 
around the expected variables of a particular patient 
at that time. Th
  is means that the alarm will still sound 
if there is a change beyond the expected. Although pa-
tients may appear asleep or sedated, their hearing may 
remain, so discussions about the patient may be bet-
ter held out of earshot as the patient may misinterpret 
limited information. Th
  is applies perhaps even more 
to discussion about other patients, because a listening 
patient may mistakenly believe that the conversation 
applies to himself.
Adjustment of the lighting to provide night-
time/daytime levels may help. Even if the patient is 

Pain Management in the Intensive Care Unit
289
tired, it is diffi
  cult to sustain sleep with full daytime 
lighting, and the ICU patient does not have the option 
of hiding beneath the bedclothes. Feeling thirsty, hun-
gry, hot, or cold is a driving force that normally results 
in remedial action, but this is beyond the power of the 
ICU patient.
Good nursing care helps to avoid pressure ar-
eas and prevents the patient from lying on a rumpled 
sheet or tubing, ventilator tubing from dragging on the 
endotracheal tube, ECG leads pulling across the skin on 
the chest, drip tubing pulling on cannulae (in addition, 
dislodgement usually means re-insertion, which may be 
diffi
  cult). Awareness of all such details helps to reduce 
unnecessary discomfort.
Supportive modes of ventilation such as pres-
sure support and other modes on modern ventilators 
are associated with greater patient comfort and require 
less analgesia and sedation compared with full ventila-
tion. Maintaining muscle activity will reduce respiratory 
muscle wasting.
Other symptoms such as nausea, vomiting, 
itch, significant pyrexia, and cramps require their 
own management. Fractures need to be stabilized 
either surgically, when appropriate, or immobilized. 
Causes of agitation such as a full bladder or rectum 
should be excluded.
Are there alternative and psychological 
measures from which my patient could benefi t?
Relaxation techniques require a cooperative patient 
preferably breathing spontaneously to coordinate deep 
breathing with sequential relaxation of muscle groups 
from head to toe. Music can be benefi cial, particularly 
if it is of the patient’s choice and appreciated through 
headphones, rather than being added to background 
noise of ICU.
Speaking to the patient by name, even though 
the patient appears sedated, and explaining what is 
about to happen is always helpful, both for the patient 
and for visiting relatives or friends. It helps patients to 
reconnect with who they are and with their family. Tell-
ing patients who understand and are recovering that 
they are making good progress assists positive thinking 
and can enhance recovery.
Giving patients the opportunity to express their 
pain or discomforts by some means is helpful so that 
they know staff  are sympathetic and will explain the 
possible remedies. If the patient can write, the fi rst op-
portunity will invariably produce squiggles resembling 
abstract art as opposed to words (reassurance that this 
is very common is needed). Alternatively, pictures dis-
playing the most common complaints and requests can 
be used.
For planned admissions to the ICU, such as af-
ter major surgery, an explanation of tubes, lines, moni-
toring and procedures can be made in advance. In this 
way, common interventions that are not expected by the 
patient will not interpreted by the patient as “something 
has gone wrong.”
While pain perception may be exaggerated by 
additional factors, and ameliorating these factors may 
make pain considerably more tolerable, they will not 
take pain away. Th
  erefore, appropriate doses of analge-
sics will still be required.
Case report (cont.)
Still heavily sedated and ventilated, Joe is started on 
an intravenous infusion of morphine at a rate of 10 mg 
per hour. He starts struggling, and the ventilator alarm 
keeps buzzing. He also becomes very tachycardic and 
hypertensive, causing concern for the staff . A review of 
sedation and analgesia is necessary in the unit. (Th
 ink 
of infection, fat emboli, inadequate sedation/analgesia, 
respiratory distress due to pulmonary contusions, etc.). 
Joe’s white cell count is slightly elevated, temperature is 
on the higher side, platelets are increasing, and coagu-
lation results are encouraging. Th
 ere is no clinical evi-
dence of fat embolization. Th
  ere is a concern that Joe’s 
sedation/analgesia might be inadequate. He is started 
on regular nasogastric paracetamol, his sedation with 
midazolam is increased, and his morphine dose is 
raised to 15 mg per hour, after a bolus dose of 5 mg. 
He settles down, eventually, and there are no immedi-
ate concerns.
What should be considered for weaning and 
preparation for extubation?
Th
 e fi rst rule is to outline your strategies for a success-
ful weaning and extubation, from a pain control point 
of view:
• Continue paracetamol
•  Reduce morphine and midazolam
•  Review full blood count, coagulation parameters, 
and renal function
•  Does the patient still need the intercostal drains?
•  Plan to achieve better analgesic control, such 
as with nerve blocks, or by adding an NSAID 
if renal function has improved and platelets are 

290
Josephine M. Th
  orp and Sabu James
within normal limits (remember gastric muco-
sal protection)
Case report (cont.)
Respiratory parameters support adequate weaning, mor-
phine infusion is ongoing, no epidural or paravertebral 
block has been inserted, and the patient is extubated. He 
manages to survive off  the ventilator for about 2 hours. 
He complains of severe pain in his chest (from the frac-
tured ribs) and in the laparotomy wound. Progressively 
he becomes unable to breathe, his saturation drops, and 
he needs to be re-intubated soon afterward.
Once Joe is settled and stable, inadequate pain 
control is seen to have been a major factor in the failed 
extubation, and he gets a thoracic epidural and a left-
sided paravertebral block. A bolus dose of local anes-
thetic is given into the epidural, and a continuous infu-
sion is set up.
What should be done next? Review his analge-
sia and slowly wind down the morphine infusion, hoping 
that the epidural and paravertebral blocks are working.
Joe is reviewed next day; sedation and morphine 
are minimal, and he is wide awake and wants the endo-
tracheal tube out. When queried about pain, he signals 
that he has none, and is quite comfortable. He is extu-
bated successfully and remains well.
Pearls of wisdom
In general:
•  Talk to the patient by name.
•  Encourage visitors to talk to the patient.
•  Tell recovering patients they are doing well; tell 
those who are less well about some positive as-
pects.
•  Much can be achieved by reducing additional 
sources of discomfort.
•  An adverse ICU experience can be reduced by 
better communication with patients.
•  As ever, “it’s not what you say, but how you say 
it”—use an empathetic tone of voice.
Regarding pain:
•  Ask about pain and irritations at regular intervals.
•  Regular assessment of pain and discontinuing bo-
luses or infusions avoids underdosing and over-
dosing and improves outcome and costs
•  Stabilize fractures with a splint, plaster, or surgi-
cal fi xation as soon as possible.
•  As elsewhere, pain on movement is greater than 
pain at rest.
•  Anticipate painful procedures or maneuvers by 
giving extra analgesia beforehand.
•  Bolus doses of opiate are required before an infu-
sion is started.
•  An infusion rate increase takes time to become 
eff ective; give a bolus fi rst.
•  Multimodal therapy can reduce opioid require-
ments and side eff ects, but beware the hazards of 
nonopioid analgesics in this group of patients.
•  Older persons have lower analgesic requirements; 
young adults have higher ones.
•  Addiction to opioids is not a problem in patients 
surviving critical care.
•  Underprovision of analgesia in general is a greater 
problem than overdosing.
References
[1] Cardno 
N, Kapur D. Measuring pain. BJA CEPD Reviews 2002;2(1):7–10.
[2]  Chong CA, Burchett KR. Pain management in critical care. BJA CEPD 
Reviews 2003;3(6):183–6.
[3]  Dasta JF, Fuhrman TM, McCandles C. Patterns of prescribing and ad-
ministering drugs for agitation and pain in a surgical intensive care unit. 
Crit Care Med 1994;22:974–80.
[4]  Hayden WR. Life and near-death in the intensive care unit. A personal 
experience. Crit Care Clin 1994;10:651–7.
[5]  Intensive Care Society, United Kingdom. Clinical guideline for sedation 
in intensive care units. Available at: www.ics.ac.uk/downloads/sedation.
pdf.
[6]  Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D, Wittbrodt ET, 
Chalfi n DB, Masica MF, Bjerke HS, Coplin WM, Crippen DW, Fuchs 
BD, Kelleher RM, Marik PE, Nasraway SA Jr, Murray MJ, Peruzzi WT, 
Lumb PD; Task Force of the American College of Critical Care Medi-
cine (ACCM) of the Society of Critical Care Medicine (SCCM), Ameri-
can Society of Health-System Pharmacists (ASHP), American College 
of Chest Physicians. Clinical practice guidelines for the use sustained 
use of sedatives and analgesics in the critically ill adult. Crit Care Med 
2002;30:119–41.
[7]  Kehlet H. Multimodal approach to control of postoperative physiology 
and rehabilitation. Br J Anaesth 1997;78:606–17.
[8]  Park GR. Sedation and analgesia—which way is best? Br J Anaesth 
2001;87:183–5.
[9]  Park GR, Ward B. Sedation and analgesia in the critically ill. In: Warrell 
DA, Cox TM, Firth JD, Benz EJ, editors. Oxford textbook of medicine, 
4th edition, vol. 2. Oxford University Press; 2003. p. 1250–3.
[10]  Puntillo KA. Pain experiences of intensive care patients. Heart Lung 
1990;19(5 Pt 1):526–33.
[11]  Shapiro BA, Warren J, Egol AB, Greenbaum DM, Jacobi J, Nasraway 
SA, Schein RM, Spevetz A, Stone JR. Practice parameters for intrave-
nous analgesia and sedation for adult patients in the intensive care unit: 
an executive summary. Society of Critical Care Medicine. Crit Care 
Med 1995;23:1596–600.
[12]  Smith CM, Colvin JR. Control of acute pain in postoperative and post-
traumatic situations. Anaesth Intensive Care Med 2005;6:2–6.
[13]  Soliman HM, Mélot C, Vincent JL. Sedative and analgesic practice in 
the intensive care unit: the results of a European survey. Br J Anaesth 
2001;87:186–92.
[14]  Tonner PH, Weiler N, Paris A, Scholz J. Sedation and analgesia in the 
intensive care unit. Curr Opin Anaesthesiol 2003;16:113–21.

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291
Websites
Bandolier—evidence based web site incorporating the Oxford Pain Internet 
Site is a free resource
http://www.jr2.ox.ac.uk/Bandolier/booth/painpag/index2.html
Lothian Joint Formulary is freely accessible on the internet. Th
  ere are both 
adult and paediatric formularies. Two choices are provided for each group 
of drugs. Analgesics are under Central Nervous System section 4.7. Detailed 
drug information is not given
http://www.ljf.scot.nhs.uk/
Lothian Joint Formulary can be downloaded and saved
http://www.ljf.scot.nhs.uk/downloads/ljf_adult_20060524.pdf
Update in Anaesthesia. An educational journal aimed at providing practi-
cal advice for those working in isolated or diffi
  cult environments. Extremely 
valuable resource; all twenty-fi ve issues accessible on-line.
http://www.nda.ox.ac.uk/wfsa/index.htm
AnaesthesiaUK is an educational resource for postgraduate exams. As well as 
instructive material, it provides access to a weekly tutorial
http://www.frca.co.uk/default.aspx
A selection of articles on acute pain topics
http://www.frca.co.uk/SectionContents.aspx?sectionid=148
A selection of articles on chronic pain topics
http://www.frca.co.uk/SectionContents.aspx?sectionid=183

293
Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. All rights reserved. Th
  is material may be used for educational 
and training purposes with proper citation of the source. Not for sale or commercial use. No responsibility is assumed by IASP for any injury and/or damage to persons or property 
as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material herein. Because of the rapid advances in the 
medical sciences, the publisher recommends that there should be independent verifi cation of diagnoses and drug dosages. Th
  e mention of specifi c pharmaceutical products and any 
medical procedure does not imply endorsement or recommendation by the editors, authors, or IASP in favor of other medical products or procedures that are not covered in the text.
Guide to Pain Management in Low-Resource Settings
Steven D. Waldman
Chapter 38
Diagnostic and Prognostic Nerve Blocks
What are the assumptions 
underlying the use of nerve     
blocks in pain management?
Th
  e cornerstone of successful treatment of the patient 
with pain is a correct diagnosis. As straightforward as 
this statement is in theory, success may become diffi
  cult 
to achieve in the individual patient. Th
  e reason for this 
diffi
  culty is due to four disparate, but interrelated issues:
Pain is a subjective response that is diffi
  cult  if  not 
impossible to quantify;
Th
  e pain response in humans is made up of a variety 
of obvious and not-so-obvious factors that may serve to 
modulate the patient’s clinical expression of pain either 
upward or downward;
Our current understanding of neurophysiological, 
neuroanatomical, and behavioral components of pain is 
incomplete and imprecise; and
Th
  ere is ongoing debate by pain management spe-
cialists as to whether pain is best treated as a symptom 
or as a disease.
Th
  e uncertainty introduced by these factors can 
often make accurate diagnosis very problematic and 
limit the utility of neural blockade as a prognosticator 
of the success or failure of subsequent neurodestructive 
procedures. Given the diffi
  culty in establishing a correct 
diagnosis of a patient’s pain, the clinician often is forced 
to look for external means to quantify or fi rm up a shaky 
clinical impression. Laboratory and radiological testing 
are often the next place the clinician seeks reassurance, 
although the lack of readily available diagnostic testing in 
the low-resource setting may preclude their use.
Fortunately, diagnostic nerve block requires 
limited resources, and when done properly, it can pro-
vide the clinician with useful information to aid in in-
creasing the comfort level of the patient with a tentative 
diagnosis. However, it cannot be emphasized enough 
that overreliance on the results of even a properly per-
formed diagnostic nerve block can set in motion a se-
ries of events that will, at the very least, provide the pa-
tient with little or no pain relief, and at the very worst, 
result in permanent complications from invasive surger-
ies or neurodestructive procedures that were justifi ed 
solely on the basis of a diagnostic nerve block.
What would be a roadmap for      
the appropriate use of diagnostic 
nerve blocks?
It must be said at the outset of this discussion, that even 
the perfectly performed diagnostic nerve block is not 
without limitations. Table 1 provides the reader with a 
list of do’s and don’ts when performing and interpreting 
diagnostic nerve blocks.
 First and foremost, the clinician should use 
the information gleaned from diagnostic nerve blocks 

294
Steven D. Waldman
with caution and only as one piece of the overall di-
agnostic workup of the patient in pain. Results of a 
diagnostic nerve block that contradicts the clinical 
impression that the pain management specialist has 
formed, as a result of the performance of a targeted 
history and physical examination and consideration of 
available confi rmatory laboratory radiographic, neu-
rophysiological, and radiographic testing, should be 
viewed with great skepticism. Such disparate results, 
when the nerve block is used in a prognostic manner, 
should never serve as the sole basis for moving ahead 
with neurodestructive or invasive surgical procedures, 
which in this situation have little or no hope of helping 
to alleviate a patient’s pain.
In addition to the above admonitions, it must 
be recognized that the clinical utility of the diagnostic 
nerve block can be aff ected by technical limitations. In 
general, the reliability of data gleaned from a diagnos-
tic nerve block is in direct proportion to the clinician’s 
familiarity with the functional anatomy of the area in 
which the nerve block resides and the clinician’s expe-
rience in performing the block being attempted. Even 
in the best of hands, some nerve blocks are technically 
more demanding than others, which increases the like-
lihood of a less-than-perfect result. Furthermore, the 
proximity of other neural structures to the nerve, gan-
glion, or plexus being blocked may lead to the inadver-
tent and often unrecognized block of adjacent nerves, 
invalidating the results that the clinician sees, e.g., the 
proximity of the lower cervical nerve roots, phrenic 
nerve, and brachial plexus to the stellate ganglion. It 
should also be remembered that the possibility of un-
detected anatomical abnormality always exists, which 
may further confuse the results of the diagnostic nerve 
block, e.g., conjoined nerve roots, the Martin Gruber 
anastomosis (a median to ulnar nerve connection), etc.
Since each pain experience is unique to the in-
dividual patient and the clinician really has no way to 
quantify it, special care must be taken to be sure that 
everybody is on the same page regarding what pain the 
diagnostic block is intended to diagnose. Many patients 
have more than one type of pain. A patient may have 
both radicular pain and the pain of diabetic neuropathy. 
A given diagnostic block may relieve one source of the 
patient’s pain while leaving the other untouched.
Furthermore, if the patient is having incident 
pain, e.g., pain when walking or sitting, the performance 
of a diagnostic block in a setting other than one that will 
provoke the incident pain is of little or no value. Th
 is 
often means that the clinician must tailor the type of 
nerve block that he or she is to perform to allow the pa-
tient to be able to safely perform the activity that incites 
the pain. Finally, a diagnostic nerve block should never 
be performed if the patient is not having, or is unable to 
provoke the pain that the pain management specialist is 
trying to diagnosis as there will be nothing to quantify.
Th
  e accuracy of diagnostic nerve block can be 
enhanced by assessing the duration of nerve relief rela-
tive to the expected pharmacological duration of the 
agent being used to block the pain. If there is discor-
dance between the duration of pain relief relative to 
duration of the local anesthetic or opioid being used, 
extreme caution should be exercised before relying 
solely on the results of that diagnostic nerve block. 
Such discordance can be due to technical shortcom-
ings in the performance of the block, anatomical varia-
tions, and most commonly, behavioral components of 
the patient’s pain.
 Table 1
Th
  e do’s and don’ts of diagnostic nerve blocks                                                          
Do analyze the information obtained from diagnostic nerve blocks in the context of the patient’s history, physical, laboratory, 
neurophysiological, and radiographic testing
Don’t over-rely on information obtained from diagnostic nerve blocks
Do view contradictory information obtained from diagnostic nerve blocks with skepticism
Don’t rely on information obtained from diagnostic nerve block as the sole justifi cation to proceed with invasive treatments
Do consider the possibility of technical limitations that limit the ability to perform an accurate diagnostic nerve block
Do consider the possibility of patient anatomical variations that may infl uence the results
Do consider the presence of incidence pain when analyzing the results of diagnostic nerve blocks
Don’t perform diagnostic blocks in patients currently not having the pain you are trying to diagnose
Do consider behavioral factors that may infl uence the results of diagnostic nerve blocks
Do consider that patients may premedicate themselves prior to diagnostic nerve blocks

Diagnostic and Prognostic Nerve Blocks 
295
Finally, it must be remembered that the pain 
and anxiety caused by the diagnostic nerve block it-
self may confuse the results of an otherwise technically 
perfect block. Th
  e clinician should be alert to the fact 
that many pain patients may premedicate themselves 
with alcohol or opioids because of the fear of procedur-
al pain. Th
  is situation also has the potential to confuse 
the observed results. Obviously, the use of sedation or 
anxiolysis prior to the performance of diagnostic nerve 
block will further cloud the very issues the nerve block 
is in fact supposed to clarify.