Indian Journal of Pain

: 2019  |  Volume : 33  |  Issue : 3  |  Page : 119--120

Pain management in neurocritical care: Challenges and the road ahead

Obaid Ahmad Siddiqui 
 Department of Anaesthesiology, JN Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Correspondence Address:
Dr. Obaid Ahmad Siddiqui
Department of Anaesthesiology, JN Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh

How to cite this article:
Siddiqui OA. Pain management in neurocritical care: Challenges and the road ahead.Indian J Pain 2019;33:119-120

How to cite this URL:
Siddiqui OA. Pain management in neurocritical care: Challenges and the road ahead. Indian J Pain [serial online] 2019 [cited 2020 Oct 20 ];33:119-120
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Full Text

The International Association for the study of pain defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage.

With the evolution of neurocritical care as a subspecialty of critical care, the quantum and case mix of patients admitted in the neurocritical care units (NCCUs) has also increased. Patients with traumatic brain injury, subarachnoid hemorrhage, acute stroke, neuromuscular disorders (Guillain–Barre syndrome, myasthenia gravis), and encephalopathies, etc., are now being increasingly admitted in the NCCU. These patients experience neurogenic, neuropathic, and central pain either alone or in combination. The development of central pain is of particular importance since it is most difficult to treat.

The management of pain therefore is an integral component of neurocritical care. Recent data suggest that quite often, neurocritically ill patients suffer from inadequate pain management, thereby increasing the morbidity and tissue damage. The aim is to keep the patient comfortable without causing any neurological deterioration since neurological assessment is an important component of basic neurocritical care.[1] The options therefore become limited.

Parenteral opioids, for example, morphine, fentanyl, and hydromorphone, remain the most commonly utilized drugs for providing analgesia and because of their additive effect with benzodiazepines, a combination of the sedative-analgesic regime is a general rule in the NCCU. However, opioid use with the exception of ultrashort-acting drugs such as remifentanil is associated with marked sedation and respiratory depression which hampers neurological assessment and causes raised intracranial pressure.[2] The concern of the general neurophysician community regarding the clouding of consciousness therefore becomes valid. Ultrashort-acting drugs, for example, remifentanil because of their unique pharmacokinetic profile, are a suitable alternative to conventionally used opioids; however, whether routine administration of these drugs will be of advantage in the NCCU remains to be seen.

The issue with opioids has led to an increased possibility of exploring nonopioid analgesics, for example, acetaminophen, gabapentinoids, alpha 2 agonists, and N-Methyl-D-aspartic acid (NMDA) receptor antagonists. Of particular interest in recent years is the use of dexmedetomidine, an alpha 2 agonist, which causes dose-dependent sedation, anxiolysis, and analgesia with the relative advantage of preserving cognitive function.[3]

Ketamine, an NMDA receptor antagonist, produces profound analgesia and amnesia by inhibiting central sensitization to painful stimuli.[4] The concern regarding the stimulating properties of ketamine on brain was negated by many recent studies which found no significant effect on cerebral hemodynamics.

The management of pain in critically ill neurological patients is an area of concern, and management decisions are mainly based on the choice of treating physicians. Moreover, the relative scarcity of literature on this subject leads to the provision of suboptimal care of neurocritical patients. The effort is lacking in devising a standard protocol-based management of pain in neurocritical care. Although guidelines for the management of pain in the critically ill patients exist, there is no such guideline for pain management in neurocritical care. Adherence to guidelines will lead to improved outcomes and cost reduction. A multimodal approach to manage pain is the most prudent approach to provide optimal care. However, since the data are lacking, there remains a need to conduct randomized controlled studies to determine the best combination of analgesics for treating pain in such patients.

The effective utilization of nonopioids, for example, dexmedetomidine and ketamine as an analgesic in the NCCU, is a relatively unexplored domain, and future research with these nonopioid and promising class of drugs to assess the adequacy of pain control is needed. The current opinion is to explore the possibilities of combining these drugs in the sedative analgesic protocol of the NCCUs.


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2Morad A, Farrokh S, Papangelou A. Pain management in neurocritical care; An update. Curr Opin Crit Care 2018;24:72-9.
3Gertler R, Brown HC, Mitchell DH, Silvius EN. Dexmedetomidine: A novel sedative-analgesic agent. Proc (Bayl Univ Med Cent) 2001;14:13-21.
4Umunna BP, Tekwani K, Barounis D, Kettaneh N, Kulstad E. Ketamine for continuous sedation of mechanically ventilated patients. J Emerg Trauma Shock 2015;8:11-5.