Factors impacting nonopioid selection in critically ill patients with pain

Condition	Suitable nonopioid	Comments
Fever or mild pain	Acetaminophen Nonsteroidal anti-inflammatory agent is an alternative	Acetaminophen can be administered as an oral, intravenous, or rectal agent.
Burns or significant postoperative pain not controlled with opioids	Intravenous ketamine (low-dose infusion)	May provide pain relief and reduce the opioid needs.
Tolerance, withdrawal, or hyperalgesia after opioid therapy	Intravenous ketamine or dexmedetomidine	May provide pain relief and reduce the opioid needs.
Moderate pain	Nonsteroidal anti-inflammatory agent	Use with caution in patients with: Renal dysfunction Active gastrointestinal bleeding Surgical bleeding Platelet abnormality Congestive heart failure Cirrhosis Asthma Concomitant angiotensin-converting enzyme inhibitor therapy Recent cardiac or vascular surgery
Neuropathic pain	Oral gabapentinoids or carbamazepine	Gabapentinoids are generally first-line agents.
Risk for developing chronic pain syndromes	Ketamine or gabapentinoids

Nonopioids are often used in combination with opioids for moderate to severe pain while nonopioids are used alone in those with mild pain.

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