The evolution of pain management in the critically ill trauma patient: Emerging concepts from the global war on terrorism.
BACKGROUND
The evolution of military medical care to manage polytrauma, critically ill-wounded warriors from the greater war on terrorism has been accompanied by significant changes in the diagnosis, management, and modulation of acute and chronic trauma-related pain. A paradigm shift in pain management includes early treatment of pain at the point of injury and throughout the continuum of care with a combination of standard and novel therapeutic interventions. These concepts are important for all critical care providers because they translate to most critically ill patients, including those resulting from natural disasters. Previous authors have reported a high incidence of moderate to severe pain and poor analgesia in intensive care units associated with sleep disturbances, tachycardia, pulmonary complications, increased stress response with thromboembolic incidents, and immunosuppression, increased intensive care unit and hospital stays, and needless suffering. Although opioids have traditionally been the cornerstone of acute pain management, they have potential negative effects ranging from sedation, confusion, respiratory depression, nausea, ileus, constipation, tolerance, opioid-induced hyperalgesia as well as potential for immunosuppression. Alternatively, multimodal therapy is increasingly recognized as a critical pain management approach, especially when combined with early nutrition and ambulation, designed to improve functional recovery and decrease chronic pain conditions.


CONCLUSIONS
Multimodal therapy encompasses a wide range of procedures and medications, including regional analgesia with continuous epidural or peripheral nerve block infusions, judicious opioids, acetaminophen, anti-inflammatory agents, anticonvulsants, ketamine, clonidine, mexiletine, antidepressants, and anxiolytics as options to treat or modulate pain at various sites of action.


CONCLUSIONS
With a more aggressive acute pain management strategy, the military has decreased acute and chronic pain conditions, which may have application in the civilian sector as well.
Malchow
Randall J
RJ
Department of Anesthesiology, Brooke Army Medical Center, San Antonio, TX, USA. randallmalchow@earthlink.net
Black
Ian H
IH
D000698:Analgesia / Q000379:methods* / Q000639:trends; D000700:Analgesics / Q000009:adverse effects / Q000627:therapeutic use; D000701:Analgesics, Opioid / Q000627:therapeutic use; D000765:Anesthesia, Conduction / Q000009:adverse effects / Q000379:methods / Q000639:trends; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D000927:Anticonvulsants / Q000627:therapeutic use; D000929:Antidepressive Agents, Tricyclic / Q000627:therapeutic use; D001569:Benzodiazepines / Q000627:therapeutic use; D003000:Clonidine / Q000627:therapeutic use; D003422:Critical Care / Q000458:organization & administration*; D016638:Critical Illness / Q000628:therapy; D004359:Drug Therapy, Combination; D014943:Global Health; D006801:Humans; D007649:Ketamine / Q000627:therapeutic use; D008887:Military Medicine / Q000458:organization & administration*; D009104:Multiple Trauma / Q000150:complications*; D010146:Pain / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology; D059408:Pain Management; D010147:Pain Measurement; D017410:Practice Guidelines as Topic; D012307:Risk Factors; D023481:Terrorism / Q000639:trends; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
D000700:Analgesics; D000701:Analgesics, Opioid; D000894:Anti-Inflammatory Agents, Non-Steroidal; D000927:Anticonvulsants; D000929:Antidepressive Agents, Tricyclic; D001569:Benzodiazepines; D007649:Ketamine; D003000:Clonidine