A 68-year-old woman is evaluated in the surgical intensive care unit for hypertension. She was admitted to the ICU two days ago after undergoing extensive resection and anastomosis for a small bowel infarction. Her abdomen has not been closed due to the possibility of further surgery if additional infarction ensues. She is currently intubated and supported by mechanical ventilation. She is being treated with broad spectrum intravenous antibiotics, fentanyl, and midazolam. She has a history of persistent atrial fibrillation and has been noncompliant with anticoagulation. Her other medical problems include hypertension, congestive heart failure, coronary artery disease, chronic low back pain secondary to osteoporotic spine fractures, and hyperlipidemia. She appears diaphoretic and mildly agitated. Her temperature is 38.3 C (101 F), blood pressure is 200/120 mm Hg, pulse is 120/min, respiratory rate is 35/min, and oxygen saturation is 98%. The ventilator settings are as follows: Arterial blood gas analysis shows a pH of 7.49, a PaCO₂ of 28 mm Hg, and a PaO₂ of 90 mm Hg. Serum creatinine is 1.4 mg/dL and lactate level is 1.2 mg/dL. Which of the following is the most appropriate next step in management?

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Patients in the intensive care unit (ICU) can experience pain from recent surgery, underlying critical illness/injury, or nonsurgical interventions. Nonsurgical interventions include therapeutic devices (e.g., drains, monitors, endotracheal tubes), invasive procedures (e.g., intravenous access), and routine nursing care (e.g., airway suctioning, mobilization, and dressing changes). Alert patients can communicate their pain by pain intensity scales. However, intubated patients (such as this patient) are unable to communicate their pain and require assessment by pain-related behaviors (e.g., grimacing, agitation, writhing) or signs of sympathetic activation (e.g., tachycardia, hypertension). Tachypnea is also caused by pain and anxiety, and can lead to patients overbreathing the ventilator settings (as in this patient). Analgesics reduce pain in ICU patients predominantly by altering CNS pain perception. Current guidelines recommend IV opioids (e.g., fentanyl, hydromorphone, or morphine) to optimize patient comfort (i.e., for pain rating of < 3/10) and diminish physiological responses to pain (e.g., hypermetabolism, increased catabolism, oxygen demand, etc.). Fentanyl is the preferred agent in most patients. < This patient's hypertension, tachycardia, diaphoresis, and ventilator overbreathing with respiratory alkalosis suggest inadequate pain control from her recent abdominal surgery. She also has chronic low back pain and may have used narcotic pain medications at home, resulting in the development of tolerance. The most appropriate next step is to increase the fentanyl dose and monitor her response. (Choice A) Respiratory insufficiency is an important cause of distress that should be identified prior to the use of sedatives and opiates, as these drugs can decrease respiratory drive. However, this patient's ABG shows adequate oxygenation and respiratory alkalosis, reflecting tachypnea that is likely the result of inadequate pain control. (Choice C) Inadequate pain control can lead to sympathetic activation causing hypertension. It is more appropriate to monitor blood pressure while achieving better pain control with an increased fentanyl dose before adding an antihypertensive agent. (Choice D) Neuromuscular blocking agents improve patient-ventilator synchrony, decrease the risk of barotrauma, and enhance gas exchange. Adequate analgesia and sedation should be addressed prior to initiating therapy with neuromuscular blocking agents. (Choice E) Pressure-cycled ventilation as compared to volume-cycled ventilation has not been shown to improve mortality, oxygenation, or work of breathing. The cause of this patient's hyperventilation is most likely pain, which should be addressed and treated. Educational objective: Important causes of distress (e.g., pain, respiratory insufficiency) in intubated patients must be identified and treated prior to the administration of sedatives. Pain should be suspected in critically ill patients if pain-related behaviors (e.g., grimacing, agitation, writhing) or signs of sympathetic activation (e.g., tachycardia, tachypnea, and hypertension) are present. Postoperative hypertension can often be due to inadequate pain control or failure to restart home antihypertensive agents. __________ References: Pain management in the intensive care unit. (http://www.ncbi.nlm.nih.gov/pubmed/15183209)

A 68-Year-Old Woman Is Evaluated in the Surgical Intensive Care