Sedation and pain management for the critically ill

Critically ill cancer patients may present special problems. Often these patients are terminally ill and mortality in a critical care unit devoted to cancer patients is higher than in other units. Sedation becomes paramount in the treatment of these patients. Some techniques may be inappropriate, such as epidural narcotics in a patient who is thrombocytopenic from chemotherapy. Drug pharmacokinetics are ill defined in these patients who often have liver and renal failure either resulting from tumor or chemotherapy. As the number of available drugs increases, interactions among these drugs become more important. Very little investigations has been done with the drugs we used everyday in the ICU. One should carefully titrate medication to effect--not rely on standard dosage regimens that have been primarily determined in relatively healthy patients. Combinations of techniques are being used, such as PCA with epidural narcotic administration with short acting, lipid soluble narcotics. Nerve blocks, primarily intercostal for chest trauma, were used in the past, but the requirement for frequent reinjection has made them less desirable. Recently thoracic paravertebral block has been used successfully for 9 to 10 hour pain relief with chest trauma. With this armamentarium of techniques and drugs, the critical care physicians should be able to go a long way to relieve pain and suffering of patients in the ICU.