Analgesia Titration in Critical Care

Topic Progress:

Anaglesia Balances Oxygen Demand and Supply by Reducing Metabolic Demand

Analgesia is primarily used to reduce oxygen demand (grey boxes).

Why Analgesia?

  • Research has found pain is undertreated in critical care1-5
  • Multiple procedures and critical illness can cause pain6
  • If we treat pain then we can usually avoid sedation7-9

Side Effects

  • Hypotension
  • Decreased respiration rate

How to Titrate

  • Start low and go slow10.
  • Wait 15 minutes after each dose of analgesia.
  • It is reasonable to have an infusion of analgesia with IV push breakthrough doses as needed.

A Special Note about COVID-19 and Analgesia

If patients are mechanically ventilated with COVID-19, they are often described as “air hungry.”

This air hunger occurs when they have severely injured lungs. Opioid analgesia can simultaneously provides pain relief and decreases respiratory drive, reducing oxygen demand.

It is common to see fentanyl or hydromorphone infusions for patients with severe COVID-19 air hunger.

Let’s Practice

44 year old patient is in the ICU for respiratory failure secondary to COVID-19. He is intubated and mechanically ventilated. RASS is +1, goal is -1. Behavioural Pain Scale is assessed as 7, the goal is 3. He is currently receiving Propofol 20 mcg/kg/min IV and Fentanyl 25 mcg/min IV.

The physician has written an order for Fentanyl 0-200 mcg/min IV infusion prn, Behavioural Pain Scale goal 3.
  • Does this order seem appropriate?
  • Does the medication ordered seem safe for the patient?
  • Assess the patient to see if the medication is needed.
  • Calculate the Behavioural Pain Scale.
  • Slowly and methodically increase the fentanyl infusion9.
  • Assess the patient 10-15 minutes after each dose to evaluate effectiveness.
  • Titrate the fentanyl infusion to the Behavioural Pain Scale goal.

66 year old is admitted to the ICU with COVID-19 associated respiratory failure. She is on a Propofol infusion at 50 mcg/kg/min IV and Fentanyl infusion at 200 mcg/min IV. Her Behavioural Pain Scale goal is 3 and you assess her as 3.

  • We have met our Behavioural Pain Scale goal.
  • Best practice would be to wean (turn down) the fentanyl infusion while meeting our goal.
  • Calculate Behavioural Pain Scale after each change in dose.
  • Go slow
  • Reassess your patient every 5-15 min.


1. Karamchandani, Kunal, et al. “Critical Care Pain Management in Patients Affected by the Opioid Epidemic: A Review.” Annals of the American Thoracic Society, vol. 15, no. 9, 2018, pp. 1016–1023., doi:10.1513/annalsats.201801-028cme

2. Raub JN, Vettese TE. Acute pain management in hospitalized adult patients with opioid dependence: a narrative review and guide for clinicians. J Hosp Med 2017;12:375–379.

3. Simini B. Patients’ perceptions of intensive care. Lancet 1999;354:571–572.

4. Gan TJ, Habib AS, Miller TE, White W, Apfelbaum JL. Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey. Curr Med Res Opin 2014;30:149–160.

5. Burry LD, Williamson DR, Perreault MM, et al. Analgesic, sedative, antipsychotic, and neuromuscular blocker use in Canadian intensive care units: a prospective, multicentre, observational study. Can J Anaesth. 2014;61(7):619–630. doi:10.1007/s12630-014-0174

6. Puntillo KA, Wild LR, Morris AB, et al. Practices and predictors of analgesic interventions for adults undergoing painful procedures. Am J Crit Care 2002;11(5):415–429.

7. Schweickert, William D, and John P Kress. “Strategies to optimize analgesia and sedation.” Critical care (London, England) vol. 12 Suppl 3,Suppl 3 (2008): S6. doi:10.1186/cc6151

8. Strøm T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet. 2010;375(9713):475–480. doi:10.1016/S0140-6736(09)62072-9

9. Dahaba AA, Grabner T, Rehak PH, List WF, Metzler H. Remifentanil versus morphine analgesia and sedation for mechanically ventilated critically ill patients: a randomized double blind study. Anesthesiology. 2004;101(3):640–646. doi:10.1097/00000542-200409000-00012

10. Payen JF, Bru O, Bosson JL, et al. Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med. 2001;29(12):2258–2263. doi:10.1097/00003246-200112000-00004

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