The Validity of Vital Signs for Pain Assessment in critically Ill Adults: A Narrative Review

Behavioral pain scales, vital signs, and pupilometry to pain assessment in the critically ill patient: A cross sectional study

BACKGROUND

Detecting pain in sedated critically ill patients requires utmost attention.

AIM

To assess the pain in mechanically ventilated critically ill patients with the Behavioral Pain Scale (BPS), Behavioral Indicators Pain Scale (ESCID), the pupillary dilation response (PDR), and vital signs.

DESIGN

Cross-sectional study METHODS: The study was conducted between March and December 2019, involving patients with a baseline BPS of 3, ESCID of 0, and RASS between -1 and -4. Patients with mobility limitations or altered pupillary reflexes were excluded. We measured before and after non-painful stimulation (NP) followed by 10-20-30-40 mA stimuli and endotracheal aspirate (ETA). The primary outcome was the pain measured with BPS and ESCID scales and PDR with AlgiScan® pupilometer defined as BPS≥4, ESCID≥1, and PDR≥11,5 %. We performed a descriptive study and analyzed the agreement between pain detection methods.

RESULTS

Thirty-one patients were included, and 183 measurements were recorded. The scales showed minimal changes. Approximately 30 % of patients reported pain at a 30 mA stimulus, increasing to over 70 % after ETA. The PDR ranged from 2 % to 6-33% on the ETA, even in pain-free patients, with pain incidence between 70 % and 100 % for the 40 mA and ETA stimuli. Vital signs did not show relevant changes. The PDR had over 90 % agreement with scales for no pain. For higher-intensity stimuli, agreement ranged from 60 % to 80 %. Disagreement occurred when there was no pain by scales (BPS<4; ESCID<1) and pain with PDR (PDR≥11.5).

CONCLUSIONS

Pain behavioral scores and vital signs were low in critically ill patients. PDR detected a nociceptive pain response in no-pain patients.

Pain Assessment in the Patient Unable to Self- Report: Clinical Practice Recommendations in Support of the ASPMN 2024 Position Statement

Recognizing and managing pain is especially challenging for vulnerable populations who cannot communicate their discomfort. Because there is no valid and reliable objective measure of pain, the American Society for Pain Management Nursing advocates for comprehensive assessment practices articulated in a Hierarchy of Pain Assessment. These practices must gather relevant information to infer the presence of pain and evaluate a patient's response to treatment. Nurses and other healthcare providers must be advocates for those who cannot communicate their pain experience.

Knowledge, attitudes, and perceived barriers regarding pain assessment and management among Thai critical care nurses: A cross-sectional study

BACKGROUND

Pain is a distressing problem which commonly occurs among critically ill patients. Nurses' knowledge of, attitudes, and perceived barriers to pain assessment and management can influence the effectiveness of nursing care.

OBJECTIVE

To explore the current knowledge of, attitudes, and perceived barriers to pain assessment and management among Thai critical care unit nurses.

METHODS

A cross-sectional survey conducted between November 2022 and January 2023 among 158 Thai nurses working in one of eight adult critical care units in a tertiary hospital, evaluated their knowledge of, attitudes, and perceived barriers to pain assessment and management.

RESULTS

Nurses possessed inadequate knowledge and negative attitudes regarding pain assessment and management. The most important barrier to pain assessment and management was "patients are unable to communicate their pain". The results showed a significantly weak positive correlation between nurses' attitudes toward pain assessment and management age (r = 0.26, p = 0.001), year of ICU experience (r = 0.29, p < 0.001), and obtaining a certificate in intensive care nursing (r = 0.37, P < 0.001).

CONCLUSIONS

Thai critical care unit nurses possessed inadequate knowledge and negative attitudes. Further training and education regarding pain assessment and management could include case studies or simulation and immersive virtual reality to improve critical care unit nurses' knowledge and attitudes as well as identifying potential barriers to pain assessment and management in the critical care settings.

IMPLICATIONS FOR CLINICAL PRACTICE

The implications for clinical practice recommend that continued quality assurance procedures should be implemented and maintained to evaluate the effectiveness of current pain assessment practices. Additionally, the perceived barriers to effective pain assessment and management should be considered and managed not only through continued education and training but could include using nursing case review, morbidity and mortality data identifying those patients that experience chronic pain post-ICU discharge.

Calibration trial of an innovative medical device (NEVVA© ) for the evaluation of pain in non-communicating patients in the intensive care unit

Background

Pain management is an essential and complex issue for non-communicative patients undergoing sedation in the intensive care unit (ICU). The Behavioral Pain Scale (BPS), although not perfect for assessing behavioral pain, is the gold standard based partly on clinical facial expression. NEVVA© , an automatic pain assessment tool based on facial expressions in critically ill patients, is a much-needed innovative medical device.

Methods

In this prospective pilot study, we recorded the facial expressions of critically ill patients in the medical ICU of Caen University Hospital using the iPhone and Smart Motion Tracking System (SMTS) software with the Facial Action Coding System (FACS) to measure human facial expressions metrically during sedation weaning. Analyses were recorded continuously, and BPS scores were collected hourly over two 8 h periods per day for 3 consecutive days. For this first stage, calibration of the innovative NEVVA© medical device algorithm was obtained by comparison with the reference pain scale (BPS).

Results

Thirty participants were enrolled between March and July 2022. To assess the acute severity of illness, the Sequential Organ Failure Assessment (SOFA) and the Simplified Acute Physiology Score (SAPS II) were recorded on ICU admission and were 9 and 47, respectively. All participants had deep sedation, assessed by a Richmond Agitation and Sedation scale (RASS) score of less than or equal to -4 at the time of inclusion. One thousand and six BPS recordings were obtained, and 130 recordings were retained for final calibration: 108 BPS recordings corresponding to the absence of pain and 22 BPS recordings corresponding to the presence of pain. Due to the small size of the dataset, a leave-one-subject-out cross-validation (LOSO-CV) strategy was performed, and the training results obtained the receiver operating characteristic (ROC) curve with an area under the curve (AUC) of 0.792. This model has a sensitivity of 81.8% and a specificity of 72.2%.

Conclusion

This pilot study calibrated the NEVVA© medical device and showed the feasibility of continuous facial expression analysis for pain monitoring in ICU patients. The next step will be to correlate this device with the BPS scale.

Three patterns of symptom communication between patients and clinicians in the intensive care unit: A fieldwork study

AIM

To describe different patterns of communication aimed at preventing, identifying and managing symptoms between mechanically ventilated patients and clinicians in the intensive care unit.

DESIGN

We conducted a fieldwork study with triangulation of participant observation and individual interviews.

METHODS

Participant observation of nine patients and 50 clinicians: nurses, physiotherapists and physicians. Subsequent individual face-to-face interviews with nine of the clinicians, and six of the patients after they had regained their ability to speak and breathe spontaneously, were fully alert and felt well enough to sit through the interview.

FINDINGS

Symptom communication was found to be an integral part of patient care. We identified three communication patterns: (1) proactive symptom communication, (2) reactive symptom communication and (3) lack of symptom communication. The three patterns co-existed in the cases and the first two complemented each other. The third pattern represents inadequate management of symptom distress.

CONCLUSION

Recognition of symptoms in non-speaking intensive care patients is an important skill for clinicians. Our study uncovered three patterns of symptom communication, two of which promoted symptom management. The third pattern suggested that clinicians did not always acknowledge the symptom distress.

IMPLICATIONS FOR PATIENT CARE

Proactive and reactive symptom assessment of non-speaking patients require patient verification when possible. Improved symptom prevention, identification and management require a combination of sound clinical judgement and attentiveness towards symptoms, implementation and use of relevant assessment tools, and implementation and skill building in augmentative and alternative communication.

IMPACT

This study addressed the challenges of symptom communication between mechanically ventilated patients and clinicians in the intensive care unit. Our findings may have an impact on patients and clinicians concerned with symptom management in intensive care units.

REPORTING METHOD

We used the consolidated criteria for reporting qualitative research.

PATIENT CONTRIBUTION

A user representative was involved in the design of the study.