2. What’s pain got to do with it? Disclosures None

3. Toxicologic Antidotes Outline 1.Case based review of the assessment and treatment of pain in the adult ICU 2.Review the presentation and management of excited delirium What’s pain got to do with it?

4. Toxicologic Antidotes Outline What’s pain got to do with it?

5. Mr. VE 37M, multiple gun shot wounds History of Polysubstance abuse Chronic opioid use Injuries Brachial artery laceration Right rib/lung/diaphragm injuries Penetrating liver and bowel injury Toxicologic AntidotesWhat’s pain got to do with it?

6. Mr. VE Multiple (?8) trips to operating room Multiple complications Severe sepsis Rhabomyolysis (PRIS?) Acute kidney injury requiring dialysis High narcotic and sedative requirements Toxicologic AntidotesWhat’s pain got to do with it?

7. Mr. VE (3 weeks later) Acute issues resolved Escalating analgesic requirements Hydromorphone 7 mg po q4h scheduled Hydromorphone 1-2 mg IV q1h PRN “Switched-on” – Tachy/HTN/Febrile Reports of poor affect/motivation Severe, unremitting “10/10” abdominal pain Toxicologic AntidotesWhat’s pain got to do with it?

8. Questions on rounds 1.How can we reliably assess this patient’s pain? 2.Can we use his vital signs as an indication? 3.Are there other therapeutic options? 4.What about his mood? Toxicologic AntidotesWhat’s pain got to do with it?

11. Pain in the ICU

13. Nurse!! My back hurts!!!!

14. 1.Jones et al., Intensive care medicine, 1979; 5:89-92 2.Gelinas, C. Crit Care Nurs, 2007; 23:298-303 Pain in the ICU

19. Pain the ICU

20. Pain in the ICU

21. Back to Case 1 37M, multiple gun shot wounds Persistent 10/10 abdominal pain “Unresponsive” to narcotics What worked for him? Scaled back regular hydromorphone to 2 mg q4h Stopped routine bowel care Aggressive mobilization Dramatic response to trial of methylphenidate (Ritalin®) Pain in the ICU

22. Toxicologic Antidotes Outline What’s pain got to do with it?

23. Mr. WF 41M, suicide attempt after romantic crisis Voluntary ingestion of 6500 mg bupropion XL, and self-injection of 3 epi-pens Acutely agitated, disoriented, aggressive Midazolam x 50 mg in ER and infusion in ICU Remained extremely agitated Physically restrained Toxicologic AntidotesWhat’s pain got to do with it?

25. Mr. WF Received bolus doses of propofol Settled in am after MDZ turned off Severe rhabdomyolysis CK > 45,000 Started isotonic fluid hyper-hydration Consequence? Complication? Toxicologic AntidotesWhat’s pain got to do with it?

26. Excited Delirium (ExDS)

35. Two sources Aggressive Chemical Sedadddtion

36. Excited Delirium (ExDS) Benzodiazpines Diazepam Midazolam Lorazepam Propofol (IMV) Failure of BDZ Extreme agitation Safer to put down Antipsychotics (Caution) QT prolongation NaC-blockade Anticholinergic Other Ketamine Dexmed

37. Toxicologic Antidotes Take home points 1.Pain assessment is far from objective 2.Protocolized use of pain scales is an effective trigger for pain assessment 3.Agitated delirium is a rare though lethal entity 4.All ICUs need to comfortable with the aggressive treatment required What’s pain got to do with it?