Strategies for postoperative pain relief in neurosurgical intensive care unit.

Despite advances in neurosurgical and neuroanesthesiological practice, postoperative pain continues to be undertreated. There are many modalities that may provide safe and effective postoperative analgesia. We discuss mainly systemic (e.g. opioids, nonsteroidal antiinflammatory agents) analgesic options. They still remain the most widely used method for providing pain relief in acute surgical situations. The exact choice or combination of analgesics utilized for a particular patient will depend on the risk benefit profile and patient preferences. Especially is crucial to promptly involve the analgesics when an opioid tolerant patient requires aggressive pain treatment. But, opioid analgesia alone may not fully relieve all aspects of acute postoperative pain. Combinations of drugs acting on different mechanisms of nociceptive modulation will decrease the incidence of adverse effects and offer additive and/or sinergistic effects. Analgesic concentrations of ketamine infusions remain a valuable addition to opioid administration. Complementary medicine techniques used as adjuvant therapies have the potential to improve pain management and improve postoperative distress. Neuromuscular blocking agents (NMB) in the intensive care unit (ICU) patient facilitate intubation and ventilatory support, decrease oxygen consumption, facilitate bedside procedures and diagnostics, and potentially decrease intracranial pressure. Ideally, analgesics, sedatives and/or muscle relaxants should be combined into a multimodal approach to facilitate patient recovery after surgery. Although a great deal is known about specific drugs and dosage requirements, further research is needed that clearly examines optimal scheduling regimens if we are to maximize patient care. The most important rule of pain management is that pain is what the patient says it is.