Welcome to the SCCM How to Approach Treating Pain in Patients with COVID-19. I'm Paul Zamita, Clinical Pharmacy Practice Manager at Brigham and Women's Hospital in Boston, Massachusetts. I have no disclosures, and the objective of this microlearning is to analyze the management of pain in critically ill patients with COVID-19. Just a brief background, we know that critically ill patients have a high rate of experiencing pain, that that pain experience may increase the morbidity, mortality, and costs, and that pain experience may also increase the risk of chronic pain post-ICU stay. In specific to COVID-19 patients, we've been seeing a large number of patients with ARDS, and so therefore the goal of that individual patient may be the PDF ratio as opposed to maybe just pain specifically, but we need to make sure that we're rotating medications to avoid the adverse effects of one, and rethink that PDF ratio goal once the patient's on us to improve. And of course, we have medication shortages in this COVID-19 crisis timeframe, which comes into play as well. Some nonspecific dose minimization strategies, such as setting that goal, really assessing to make sure we're meeting that goal, using non-pharmacological strategies such as vent adjustments, keeping our patients awake and alert when possible, which may not always be possible, especially when the patient's in acute ARDS, but remember that that's our goal and getting there as soon as possible. Of course, using boluses when possible, opioid rotations when possible, sedation holidays, analgesic-only sedation, or in other words, analogous sedation to decrease the side effects of sedatives, the patient-specific pharmacotherapy depending on the individual needs, and then again, rotating those medications to avoid the accumulation. A couple of key PAD-IS recommendations from the guideline are that the management of pain should be guided by routine pain assessment. We know that a protocol-based, stepwise approach likely is best for our patients and that the patient self-report should be called standard. However, the behavioral pain score can be used in patients who can't self-report. The stepwise approach to pain assessment and management in critically ill patients has been shown to improve many different outcomes. Some of the key concepts of analogous sedation are to take advantage of certain properties, such as the decrease in the need for sedatives and the respiratory depression properties, which we oftentimes don't want, but in ARDS patients we might need. We may have an increase in adverse effects of opioids, so we need to be careful of that, but also analogous sedation may not be appropriate for all, such as patients needing neuromuscular blockade, common in COVID-19 patients. Opioids may have some potential, I put in air quotes, unwanted effects. Of course, the class effects like respiratory depression and sedation actually may be beneficial to patients with ARDS, at least up front, but we need to make sure that those kind of aren't influencing our care moving forward. Of course, there's the other class effects we know with opioids, such as constipation and other bad side effects, but there are the class-specific adverse effects for the individual agents, such as chest wall rigidity with the fentanyl and sufentanol, tachyflaxis, which is seen with really any opioid, but really with fentanyl and sufentanol big. We know we have the QT prolongation with methadone, which potentially is an option for our COVID patients when they're coming off of the higher dose opioid drips. So opioid rotation may be helpful and needed in many of our COVID-19 patients. It's defined as a change in the opioid drug or route of administration for the goal of improving outcomes. The goal of opioid rotation are to establish an opioid regimen that is more effective than the prior one, improves analgesic effects, reduces adverse effects, improves treatment-related outcomes, and can have different, potentially, some routes of administration. So if you're going from continuous infusion to perhaps enteral, for example. There are many different indications, but some of the indications are the occurrence of intolerance of adverse effects of a certain one, poor analgesia effect from one, problematic drug-drug interactions, or a change in patient's clinical status. As I alluded to earlier, a lot of these patients will go from IV infusions, potentially, to enteral medications to get them teed up to get out of the ICU. And methadone is a very reasonable thing to do that to get these patients off the drip and has been shown in a few different analysis that can decrease time to extubation. We know the different mechanisms of pain, and therefore, multimodal analgesia is likely to be effective. Multimodal pain management is endorsed by the 2012 by the 2018 PADS guidelines, in particular, acetaminophen, ketamine, and gabapentin. I don't have time to get into the non-pharmacological strategies, but there are many that have been endorsed by the 2018 PADS guidelines. I recommend that you check those out. Other patient-specific recommendations which aren't necessarily endorsed by the PADS guideline, but perhaps NSAIDs, dexmedetomidine, corticosteroids, or IV lidocaine may be helpful for an individual patient. Just a quick reminder that all these multimodals have their own set of adverse effects, which we all know. We need to think about an individual patient as we're adding these medications. I want to briefly touch on the controversy of NSAIDs and COVID-19. Of course, the suggestion of the NSAIDs may worsen COVID-19. I don't really know that. The FDA suggests there's really no link between this and the evidence. The NIH suggests that for antipyretic effects that acetaminophen or NSAIDs can be used. The Society of Critical Care Medicine's surviving sepsis guidelines suggest that acetaminophen should be preferentially used for the treatment of fever. So in summary, we need to set a patient-specific goal. Critically ill patients are likely to be in pain, but we may be using these medications for other things than just pain, such as ARDS. There may be some unique pain needs for these patients. For some medication pros, medication rotation is key so that we can avoid the adverse effects of one individual. And using the multimodal approach may help patients control pain and decrease the adverse effects of the opioids.

pain management

COVID-19

pain assessment

opioids

multimodal analgesia