Pain Measurement in Mechanically Ventilated Patients After Cardiac Surgery: Comparison of the Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT)

Cross-cultural adaptation and validation of the Indonesian version of the Critical-care Pain Observation Tool

Objective

The Critical-care Pain Observation Tool (CPOT) is one of the most accurate methods for assessing pain in ICU patients with critical illness and/or a decreased level of consciousness (LOC). This study aimed to determine the validity and reliability of the Indonesian version of the CPOT.

Methods

The English version of CPOT was translated into the Indonesian version following five steps: initial translation, synthesis of instrument translation results, back translation, validation of the instrument by an expert committee, and testing of the Indonesian instrument. Between September and December 2022, a total of 52 ICU patients from four hospitals in Indonesia were evaluated for pain at rest, during body-turning procedure, and 15 minutes after the procedure using the CPOT. The researcher used the verbal Faces Pain Thermometer (FPT) instrument as a gold standard to assess the CPOT's criteria validity. Validity assessments included content and criterion validity. Reliability was evaluated using Cronbach's α coefficient and interrater reliability.

Results

Higher CPOT scores were found during the body-turning procedure than at rest and after the procedure. The instrument's item-content validity index (I-CVI) ranged from 0.75 to 1.00, and the overall instrument's average scale-level content validity index (S-CVI/Ave) was 0.93. The statistical analysis revealed a positive correlation (r) between the CPOT and the patient's FPT scores (0.877-0.983, P < 0.01). The significant agreement amongst raters (κ) revealed the inter-rater reliability of the CPOT (0.739-0.834, P < 0.01).

Conclusion

The Indonesian version of the CPOT has been proven valid and reliable in assessing pain in patients with critical illness and/or decreased LOC.

Evaluation of Pain Scales and Outcome in Critically Ill Patients of a Greek ICU

The purpose of the study was to evaluate painful procedures in ICU patients and to investigate their effect as well as the role of analgesia in the outcome. We measured pain level and vital signs before, during and after potentially painful procedures by using the Behavioral Pain Scale (BPS) and the Critical Care Pain Observation Tool (CPOT). We analyzed the correlation of these measurements and of analgesia with the outcome. Twenty-eight patients were subjected to 160 stimuli. There were statistically significant differences in pain scores and most vital signs between the different timepoints (before-during, during-after). Most of them were significantly correlated with each other. Physiotherapy proved to be the most painful procedure. Regarding the outcome, the administration of extra analgesia predicted less days of mechanical ventilation (p = 0.015) and of ICU stay (p = 0.016). The higher change in BPS was correlated with more days of mechanical ventilation [B (95% CI) = 3.640 (1.001-6.280), p = 0.007] and of ICU stay [B (95% CI) = 3.645 (1.035-6.254), p = 0.006]. The higher change in CPOT and the nonuse of extra analgesia were related to increased mortality [OR (95% CI) = 1.492 (1.107-2.011), p = 0.009 and OR (95% CI) = 2.626 (1.013-6.806), p = 0.047]. Increased pain in ICU patients was successfully assessed by the BPS and CPOT and correlated to worse outcomes, which the administration of extra analgesia might improve.

Behaviour-based pain scales: Validity and interrater reliability of BPS-NI and PAINAD-G on general wards

BACKGROUND

Measuring pain intensity in patients unable to communicate is a challenge on general wards. Observation-based pain scoring tools have been used for patients with dementia or in critically ill intensive care unit (ICU) patients. However, there is no established or validated assessment tool for non-ICU patients without dementia related cognitive deficiencies who cannot communicate. The "Behavioural Pain Scale Non-Intubated" (BPS-NI) and the "Pain Assessment In Advanced Dementia-German" (PAINAD-G) are potential tools to fill this gap.

METHODS

This study was performed with verbal non-ICU patients on general wards at Charité Berlin. Two assessors independently rated pain intensity using the BPS-NI and the PAINAD-G along with patients' self-ratings on the Numeric Rating Scale (NRS). The interrater-reliability of BPS-NI and PAINAD-G was calculated and ROC-analyses were performed to identify cut-off values for medium and intense pain for each score. Effectiveness was calculated using percentage agreement. In total, 126 patients were included into analysis.

RESULTS

The BPS-NI showed substantial congruence in interrater-reliability (Cohens-Kappa 0.71), whereas the PAINAD-G showed moderate congruence (Kappa 0.48). Based on ROC-analyses, for medium pain levels a cut-off 4 (BPS-NI) or 2 (PAINAD-G) and for severe pain levels cut-off 5 (BPS-NI) and 3 (PAINAD-G) would result in good accordance with self-reported NRS for pain.

CONCLUSION

The BPS-NI shows a good validity in measuring pain intensity in patients on general wards and may possibly be used for patients unable to communicate. Using defined cut-off values for BPS-NI and PAINAD-G, clinically relevant pain intensities in patients can reliably be detected.

SIGNIFICANCE

Measuring the pain intensity in patients unable to communicate is a common challenge on general wards. This study assessed reliability and applicability BPS-NI and the PAINAD-G in a general ward setting. Furthermore, it provides cut-off values in order to estimate pain intensity and support analgesic response.

Validation Testing of the European Portuguese Critical-Care Pain Observation Tool

Aim. The study aim was to validate the Portuguese version of the Critical-Care Pain Observation Tool (CPOT) in the critically ill adult population of Portugal. Methods. A prospective, observational cohort study was conducted to evaluate the CPOT in mechanically ventilated patients who were admitted to an intensive care unit. A consecutive sample of 110 patients was observed at rest pre-procedure, during a nociceptive procedure (NP) which includes turning/positioning and endotracheal or tracheal suctioning and 20 min post-procedure. Two raters participated in the data collection. The discriminative validity, criterion validity, convergent validity and inter-rater reliability of the CPOT were examined. Results. The inter-rater reliability was excellent (0.93 ≤ α ≤ 1.00) at rest and fair to moderate (0.39 ≤ α ≤ 0.60) during the NP. The CPOT could discriminate between conditions with higher scores during the NP when compared to CPOT scores at rest (p < 0.001). The optimal CPOT cut-off score was >2, with a sensitivity of 71% and a specificity of 80%, and self-reported pain was the gold standard criterion. Significant correlations (<0.40) were found between CPOT scores, the heart rate and the respiratory rate during the nociceptive procedure. Conclusions. The CPOT appears to be a valid alternative for both ventilated and non-ventilated patients who are unable to communicate.

A Comparative Study of the Diagnostic Value of the Critical Care Pain Observation Tool and the Behavioral Pain Scale for Pain Assessment among Unconscious Patients

Background

Pain assessment in unconscious patients is a major challenge for healthcare providers. This study aims to compare the diagnostic value of the critical-care pain observation tool (CPOT) and the behavioral pain scale (BPS) for pain assessment among unconscious patients.

Materials and methods

This cross-sectional study was conducted in 2019. Forty-five unconscious patients were selected randomly from four general intensive care units (ICUs) in the north of Iran. The discriminant validity of CPOT and BPS were evaluated for pain during a nociceptive and a nonnociceptive procedure. For reliability assessment, interrater agreement was obtained using Lin's concordance correlation coefficient and weighted kappa coefficient.

Results

Patients who had been hospitalized in ICU due to surgery or trauma (57.70%) or medical problems (42.30%) were studied. During the nociceptive procedure, the mean scores of CPOT and BPS and all their dimensions, except for the compliance with ventilator dimension, were significantly greater than the nonnociceptive procedure (p <0.05) although the effect size of both instruments was small (0.32 vs 0.18). The Lin's concordance correlation coefficient in nonnociceptive and nociceptive procedures was respectively 0.67 and 0.62 for CPOT and 0.74 and 0.88 for BPS.

Conclusion

CPOT and BPS have acceptable discriminant validity in differentiating nonnociceptive and nociceptive procedural pain although the effect size of CPOT is larger than that of BPS. Although both instruments have low reliability, the reliability of BPS is better.

How to cite this article

Nazari R, Froelicher ES, Nia HS, Hajihosseini F, Mousazadeh N. Diagnostic Values of the Critical Care Pain Observation Tool and the Behavioral Pain Scale for Pain Assessment among Unconscious Patients: A Comparative Study. Indian J Crit Care Med 2022;26(4):472–476.

ASSESSMENT OF PROCEDURAL PAIN IN PATIENTS WITH COVID-19 IN THE INTENSIVE CARE UNIT

Aim

The purpose of the study was to assess the level of procedural pain in patients treated in the COVID-19 intensive care unit, in a tertiary university hospital.

Method

We performed the procedural pain assessment of COVID-19 patients in this study, and 162 (93.6 %) of 173 hospitalized patients assessed during this period. While pain was assessed before, during, and at the 20th minute after endotracheal aspiration, wound care, and position change, which are procedural patient practices, the pain was assessed before, during, and up to the fourth hour after prone positioning, high-flow oxygen therapy (HFOT), and the non-invasive mechanical ventilation (NIMV) procedure. The Numerical Pain Scale was used for conscious patients in pain assessment, while the Behavioral Pain Scale and the Richmond Agitation-Sedation Scale were used for unconscious patients.

Results

Patients who underwent endotracheal aspiration, wound care, and positioning had higher pain levels during procedure than other time points. Patients in the prone position with HFOT and NIMV applied had the highest pain scores at fourth hour after procedure; this increase was statistically significant (p = .000, p < .05).

Conclusions

The study found that COVID-19 patients in the ICU had pain due to procedural practices and that the level of pain during the procedures was higher because endotracheal aspiration, wound care, and positioning were all short-term procedures. Moreover, prone positioning was found to be associated with pressure-related tissue damage, and patients' pain levels increased with the increasing duration of HFOT and NIMV procedure.

Tools Are Needed to Promote Sedation Practices for Mechanically Ventilated Patients

Suboptimal sedation practices continue to be frequent, although the updated guidelines for management of pain, agitation, and delirium in mechanically ventilated (MV) patients have been published for several years. Causes of low adherence to the recommended minimal sedation protocol are multifactorial. However, the barriers to translation of these protocols into standard care for MV patients have yet to be analyzed. In our view, it is necessary to develop fresh insights into the interaction between the patients' responses to nociceptive stimuli and individualized regulation of patients' tolerance when using analgesics and sedatives. By better understanding this interaction, development of novel tools to assess patient pain tolerance and to define and predict oversedation or delirium may promote better sedation practices in the future.

Evaluation of pain severity in critically ill patients on mechanical ventilation

OBJECTIVES

To elucidate how patients' illness severity, respiratory status, or haemodynamics are associated with the pain score of critically ill patients.

METHODS

This was an observational study of patients on mechanical ventilation after surgeries. At rest and on turning, patient pain was evaluated using the Behavioural Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT). Related factors were collected from medical records and analysed.

FINDINGS

Multiple logistic regression analysis was performed using data on 127 scenarios. An increase of >2 in BPS score on turning was affected by the Acute Physiology and Chronic Health Evaluation (APACHE) II score (odds ratio [OR] = 0.864), systolic blood pressure at rest (OR = 1.032), BPS at rest (OR = 0.638), heart rate difference (OR = 1.124), and tidal volume difference (OR = 0.548). An increase of >2 in CPOT on turning score was associated with the APACHE II score (OR = 0.894), Sequential Organ Failure Assessment score (OR = 1.248), systolic blood pressure at rest (OR = 1.025), heart rate difference (OR = 1.096), and tidal volume difference (OR = 0.578).

CONCLUSION

The Behavioural Pain Scale and the Critical-Care Pain Observation Tools were associated with illness severity and haemodynamics. A reduction in tidal volume may be useful in assessing pain.

Delirium Prevention in Postcardiac Surgical Critical Care

This review provides an overview for health care teams involved in the perioperative care of cardiac surgery patients. The intention is to summarize key determinants of delirium, its impact on short- and long-term outcomes as well as to discuss effective management strategies. The first component of this review examines the prevalence and the factors associated with an increased risk of postoperative delirium. A multitude of predisposing (eg, baseline vulnerability and comorbidities) and precipitating (eg, type of cardiac surgery and postoperative care) factors that contribute to the occurrence of delirium are discussed.

Pain in intensive care unit patients-A longitudinal study

Aim

To assess occurrence of pain during the first 6 days of intensive care unit (ICU) stay and evaluate associations between occurrence of pain and selected patient-related variables.

Design

A longitudinal study.

Methods

Adult ICU patients from three units were included. Patients' pain was assessed with valid pain assessment tools every 8 hr during their first 6 days in ICU. Possible associations between occurrence of pain and selected patient-related variables were modelled using multiple logistic regression.

Results

When pain was assessed regularly with pain assessment tools, 10% of patients were in pain at rest and 27% were in pain during turning. The proportions of patients who were in pain were significantly higher for patients able to self-report pain, compared with patients not able to self-report (p < .001). Several predictors were associated with being in pain. It is important to be aware of these predictors in order to improve pain management.

Comparison of two behavioural pain scales for the assessment of procedural pain: A systematic review

AIM

To examine the clinical utility and measurement properties of the Critical-Care Pain Observation Tool and the Behavioural Pain Scale when used to assess pain during procedures in the intensive care unit.

DESIGN

A systematic review was conducted, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist.

METHODS

A systematic search was conducted in CINAHL, MEDLINE, EMBASE and PsychINFO (01 October 2019). Study selection, data extraction and assessment of methodological quality were performed by a pair of authors working independently. Different psychometric properties were addressed: inter-rater reliability, internal consistency, test-retest reliability, discriminant validity and criterion validity.

RESULTS

Eleven studies were included. Both Critical-Care Pain Observation Tool and the Behavioural Pain Scale showed good reliability and validity and were good options for assessing pain during painful procedures with intensive care unit patients unable to self-report on pain. The Critical-Care Pain Observation Tool is to be preferred since this tool was shown to have particularly good reliability and validity in assessing pain during procedures, but the Behavioural Pain Scale is an appropriate alternative.

A Psychometric Analysis Update of Behavioral Pain Assessment Tools for Noncommunicative, Critically Ill Adults

This is an updated, comprehensive review of the psychometric properties of behavioral pain assessment tools for use with noncommunicative, critically ill adults. Articles were searched in 5 health databases. A total of 106 articles were analyzed, including 54 recently published papers. Nine behavioral pain assessment tools developed for noncommunicative critically ill adults and 4 tools developed for other non-communicative populations were included. The scale development process, reliability, validity, feasibility, and clinical utility were analyzed using a 0 to 20 scoring system, and quality of evidence was also evaluated. The Behavioral Pain Scale, the Behavioral Pain Scale-Nonintubated, and the Critical-Care Pain Observation Tool remain the tools with the strongest psychometric properties, with validation testing having been conducted in multiple countries and various languages. Other tools may be good alternatives, but additional research on them is necessary.

Back Pain-Inducing Test, a Novel and Sensitive Screening Test for Painful Osteoporotic Vertebral Fractures: A Prospective Clinical Study

To detect painful vertebral fractures (VFs) in back pain populations at risk of osteoporosis, we designed a physical examination test (the Back Pain-Inducing Test [BPIT]) that included three movements: lying supine, rolling over, and sitting up. If back pain is induced during any of these movements, the result is defined as positive, thereby establishing a presumptive diagnosis of painful VFs. Pain severity is quantified using a self-reported numerical rating scale (NRS). The presence or absence of painful VFs is verified by whole-spine magnetic resonance imaging (MRI), the gold standard for final diagnosis. According to the standards for reporting diagnostic accuracy, a real-world, prospective, and observational study was performed on 510 back pain patients (enrolled from a single institute) at risk of osteoporosis. The sensitivity, specificity, and accuracy of the BPIT for identifying painful VFs were 99.1% (95% CI, 97.5% to 99.8%), 67.9% (95% CI, 60.4% to 74.5%), and 89.0%, respectively. The positive and negative predictive values were 86.6% (95% CI, 82.9% to 89.6%) and 97.4% (95% CI, 92.6% to 99.3%), respectively. Cutoff NRS scores for lying supine, rolling over, and sitting up were 3, 0, and 2, respectively. The corresponding area under the receiver operating characteristic curves (AUROCs) of each movement was 0.898 (95% CI, 0.868 to 0.922), 0.884 (95% CI, 0.854 to 0.911), and 0.910 (95% CI, 0.882 to 0.933), respectively. Although the high prevalence of VFs in the enrolled cohort partially limits the external validity of the predictive value in the general population, we conclude that the BPIT is potentially effective for detecting painful VFs in back pain populations at risk of osteoporosis. This test may be used as a stratification tool in decision-making on subsequent imaging procedures: a negative BPIT rules out painful VFs and indicates that an MRI should be spared, whereas a positive BPIT means that an MRI is necessary and is likely to identify painful VFs. © 2019 American Society for Bone and Mineral Research.

Assessment of Pain Management During Interfacility Air Medical Transport of Intubated Patients

OBJECTIVE

The management of pain is an important component of care in the prehospital and transport setting. However, recent evidence suggests that pain control is infrequently achieved in these settings. The objective of the current study was to determine the proportion and frequency of opioid analgesia provided to intubated patients during interfacility transport by an air medical transport system.

METHODS

This was a health records review examining electronic records of intubated patients transported by Ornge from July 2015 to November 2015. Cases were identified using Ornge database, and intubated patients were selected based on the inclusion criteria. A standardized data extraction form was piloted and used by a single trained data extractor. The primary outcome was whether analgesia was provided. Secondary outcomes included the frequency of administration and dose adequacy of an opioid analgesia; the analgesic used; adverse events; and the impact of age, sex, past medical history of chronic pain, or reason for transfer on pain management.

RESULTS

Of the 500 potential patient transports, 448 met our inclusion criteria. Among the 448 patients, 295 (65.8%) were men, 327 (73.0%) received analgesia, and 211 (64.3%) received more than 1 dose during transport (median frequency of 2 doses, interquartile range = 1 to 3). The average transport time was 135 minutes, and repeated dosing (> 1 repeat dose) occurred primarily (45.5%) in transports of over 180 minutes. Fentanyl was the most commonly used analgesic (97.9%), and the most common dose was 50 µg (51.8%). Adverse events occurred in 8 patients (2.5%), most commonly new hypotension (mean arterial pressure < 65 mm Hg, n = 5). There was no significant difference in the administration of analgesia based on the patient's age or sex (68.0% of female patients and 75.6% of male patients received analgesia). Interestingly, only 30.8% of patients repatriated to their originating hospital received analgesia compared with 72.3% of patients undergoing their initial transfer to a higher level of care.

CONCLUSION

Seventy-three percent of intubated patients transported by Ornge received an opioid analgesic, most commonly fentanyl. We found no clinically relevant difference in the administration of analgesics based on age, sex, past medical history of chronic pain, or reason for transfer other than repatriation to the originating hospital.

The German version of the Critical-Care Pain Observation Tool for critically ill adults : A prospective validation study

BACKGROUND

The implementation of the Critical-Care Pain Observation tool (CPOT) in intensive care units (ICU) has been associated with more frequent pain assessments, a reduced number of complications, and improved administration of analgesics and sedatives. So far no German translation exists. Translating this tool into foreign languages requires further validation testing.

OBJECTIVE

The aim of this prospective observational validation study was to translate the original version of the CPOT according to scientific principles for translation and to establish the validity and reliability of the German translation of CPOT for critically ill adult patients.

MATERIAL AND METHODS

A total of 292 cardiac surgery patients from 2 ICUs of 2 German university teaching hospitals were included (114 patients at center 1 and 178 patients at center 2). Of the included patients 22.6% were female and 76.4% were male with a mean age of 68.5 years ±9.3 SD. Pain was evaluated with the CPOT, the Bhavioral Pain Scale (BPS) and with the Numeric Rating scale (NRS) at three time points (1. intubated + sedated, 2. intubated + awake, 3. extubated + awake) at rest and during nociceptive stimulus (positioning). Assessments were made separately by trained physicians and nursing staff.

RESULTS

Good results for interrater reliability and internal consistency could be demonstrated (weighted Cohen's kappa of 0.73, Cronbach's coefficient alpha of 0.8). Spearman correlation between CPOT and NRS was moderate but significant. The receiver operating characteristic (ROC) analysis to obtain optimal thresholds of CPOT to detect pain revealed different results during rest and stimulus and in intubated and extubated patients.

CONCLUSION

The validated German CPOT translation is a reliable tool for pain assessment in cardiac ICU patients in the absence of patients' ability for self-reporting. The use of this German version of CPOT now allows a better international comparability of corresponding data in future studies.

Validating a pain assessment tool in heterogeneous ICU patients: Is it possible?

BACKGROUND

Non-communicative adult ICU patients are vulnerable to inadequate pain management with potentially severe consequences. In German-speaking countries, there is limited availability of a validated pain assessment tool for this population.

AIM

The aim of this observational study was to test the German version of the Critical-Care Pain Observation Tool (CPOT) in a heterogeneous adult ICU population.

METHODS

The CPOT's feasibility for clinical use was evaluated via a questionnaire. For validity and reliability testing, the CPOT was compared with the Behavioural Pain Scale (BPS) and patient's self-report in 60 patients during 480 observations simultaneously performed by two raters.

RESULTS

The feasibility evaluation demonstrated high satisfaction with clinical usability (85% of responses 4 or 5 on a 5-point Likert scale). The CPOT revealed excellent criterion validity [agreement between CPOT and BPS 94.0%, correlation of CPOT and BPS sum scores r = 0.91 (P < .05), agreement of CPOT with patient self-report 81.4%], good discriminant validity [mean difference of CPOT scores between at rest and non-painful stimulus 0.33 (P < .029), mean difference of CPOT scores between at rest, and painful stimulus 2.19 (P < .001)], for a CPOT cut-off score of >2 a high sensitivity and specificity (93% and 84%), high positive predictive value (85%), and a high negative predictive value (93%). The CPOT showed acceptable internal consistency (Cronbach's α 0.79) and high inter-rater reliability [90% agreement, no differences in CPOT sum scores in 64.2% of observations, and correlation for CPOT sum scores r = 0.72 (P < .05)]. Self-report obtained in patients with delirium did not correlate with the CPOT rating in 62% of patients.

CONCLUSION

This is the first validation study of the CPOT evaluating all of the described validity dimensions, including feasibility, at once. The results are congruent with previous validations of the CPOT with homogeneous samples and show that it is possible to validate a tool with a heterogeneous sample. Further research should be done to improve pain assessment and treatment in ICU patients with delirium.

RELEVANCE TO CLINICAL PRACTICE

The German CPOT version can be recommended for ICUs in German-speaking countries.

Evaluation of Observational and Behavioural Pain Assessment Tools in Nonverbal Intubated Critically Adult Patients after Open - Heart Surgery: A Systematic Review

BACKGROUND

Over 70% of patients hospitalised in an intensive care unit (ICU) often experience moderate to severe pain due to pre-existing diseases, trauma, surgery, aggressive procedures, and routine ICU care. Many patients hospitalised in ICU are not able to speak and express their pain due to various causes, including mechanical ventilation, reduced consciousness, and administration of sedative drugs. Therefore, the use of observational and behavioural pain tools is recommended in this group of patients given their inability to express pain.

AIM

To examine the existing observational and behavioural tools for assessment of in Nonverbal Intubated Critically Adult Patients after Open-Heart Surgery.

METHODS

A systematic review of available observational and behavioural tools for assessment of pain was undertaken using the COSMIN checklist. A literature search was conducted using the following databases: Ovid, Science Direct, Scopus, PubMed, and CINHAL databases, Google Scholar search engine as well as Persian resources Sid, Magiran, Iran doc, and IranMedex up to the end of 2017 were reviewed.

RESULTS

A total of 47 studies that had examined five tools used in intensive care units after cardiac surgery in patients under mechanical ventilation were reviewed. Each of the five tools included behavioural and observational items, and only one tool had physiological items. All the tools had been evaluated regarding validity and reliability. In the three tools, sensitivity, specificity, responsiveness, and satisfaction were considered.

CONCLUSION

Based on available evidence and investigations, CPOT and BPS tools have good validity and reliability to be used in pain assessment in Nonverbal Intubated Critically Adult Patients after Open-Heart Surgery. The NVPS tool requires more studies to be further confirmed before the assessment of pain in this group of patients.

Pain measurement techniques: spotlight on mechanically ventilated patients

Background

Procedural pain is a frequent problem in intensive care units (ICUs). For that, pain assessment has been increasingly introduced to the ICU professional’s routine, and studies have been developed to show the relevance of measuring pain in critically ill patients.

Objective

This review aimed to describe pain measurement techniques for mechanically ventilated adult patients based on evidence and already published.

Method

Systematic literature search was performed on PubMed and Google Scholar. Keywords “pain”, “pain measurement”, “intensive care units” and “respiration, artificial” were combined to the Boolean operator AND. No language or publication year was limited in this search. The purpose and method of all papers were analyzed and only studies which described pain assessment in mechanically ventilated patients were included in this review.

Results

Objective methods were found in the literature to assess pain in mechanically ventilated adults. Behavioral scales were the most used method for pain measurement in noncommunicative patients. Vital signs were used, but the reliability of this method was questioned. Pupillometry, bispectral index and skin conductance were found and described as pain assessment methods.

Conclusion

This review showed that objective measures, as behavioral scales, are the gold standard tools to measure pain intensity in noncommunicative subjects. These data contribute to professionals’ knowledge about ICU pain measurement and emphasize its importance and consequences for adequate pain management.

Validation of The Critical-care Pain Observation Tool (CPOT) for the detection of oral-pharyngeal pain in critically ill adults

OBJECTIVE

Mechanically ventilated patients experience pain at rest and during daily care procedures. Our objective was to test the reliability and validity of the Critical-Care Pain Observation Tool (CPOT) to detect oral-pharyngeal pain in intubated and tracheostomised adults during routine oral care procedures.

MATERIALS AND METHODS

Two trained research team members independently observed patients during two non-painful (rest and gentle touch) and three potentially painful (oral suctioning, tooth brushing, and swabbing with a sponge toothette) procedures. Conscious patients were asked if they experienced pain during each procedure (yes/no) and to rate their pain intensity on a 0 to 10 numeric rating scale.

RESULTS

A total of 98 patients, primarily intubated (92.9%) and male (63.3%) participated. Criterion validation was supported by patient self-report of pain during tooth brushing (AUC=.80; P<0.5) and oral suction (AUC=.72; P<0.3) but not for oral swabbing (AUC=.68; P=0.16). Discriminative validation was demonstrated for all oral care procedures compared to rest (P<.001). Intra-class correlation coefficients between raters ranged from .78 to .91 (P<.001) for total CPOT scores, indicating excellent inter-rater reliability.

CONCLUSIONS

The CPOT is reliable and valid for the detection of oral-pharyngeal pain during oral care procedures indicated as painful by critically ill adults.

Validation of the behavioral pain scale to assess pain intensity in adult, intubated postcardiac surgery patients: A cohort observational study - POL-BPS

Patients after cardiac surgery experience significant pain, but cannot communicate effectively due to opioid analgesia and sedation. Identification of pain with validated behavioral observation tool in patients with limited abilities to self-report pain improves quality of care and prevents suffering. Aim of this study was to validate Polish version of behavioral pain scale (BPS) in intubated, mechanically ventilated patients sedated with dexmedetomidine and morphine after cardiac surgery.Prospective observational cohort study included postoperative cardiac surgery patients, both sedated with dexmedetomidine and unsedated, observed at rest, during a nociceptive procedure (position change) and 10 minutes after intervention. Pain control was achieved using morphine infusion and nonopioid coanalgesia. Pain intensity evaluation included self-report by patient using numeric rating scale (NRS) and BPS assessments carried out by 2 blinded observers.A total of 708 assessments were performed in 59 patients (mean age 68 years), predominantly men (44/59, 75%). Results showed very good interrater correlation between raters (interrater correlation scores >0.87). Self-report NRS scores were obtained from all patients. Correlation between NRS and BPS was relatively strong during nociceptive procedures in all patients for rater A and rater B (Spearman R > 0.65, P < .001). Both mean NRS and BPS scores were significantly higher during nociceptive procedures as compared to assessments at rest, in both sedated and unsedated patients (P < .001).The results of this observational study show that the Polish translation of BPS can be regarded as a useful and validated tool for pain assessment in adult intubated patients. This instrument can be used in both unsedated and sedated cardiac surgery patients with limited communication abilities.

Comparison between Critical-Care Pain Observation Tool and physiologic indicators for pain assessment in the critically ill, mechanically ventilated adult patients

Background and Objectives:

Pain assessment of nonverbal, critically ill patients continues to present a challenge in Intensive Care Unit (ICU). The Critical-Care Pain Observation Tool (CPOT) rates critically ill patients’ pain based on clinical observation. In the present study, the accuracy of CPOT was compared with physiological indicators of pain in mechanically ventilated, critically ill patients.

Methods:

This quantitative prospective observational study was conducted to assess pain in the critically ill, mechanically ventilated patients in comparison to physiologic indicators such as blood pressure and heart rate. A repeated measures design was chosen, and a sample size of 180 was taken from 60 patients with sepsis, acute exacerbations of chronic obstructive pulmonary disease, community-acquired pneumonia, and postsurgical patients in the ICU. The two painful procedures chosen were tracheal suction and patient positioning. The data were collected at rest, at tracheal suctioning, 20 min later at positioning of the patient, and final reading 20 min later. Three testing periods, each including 4 assessments for a total of 12 pain assessments with sixty patients, were completed during each patient's ICU course. A total of six assessments were done with the patient at rest and three each with pain stimulus of tracheal suctioning and patient positioning.

Results:

There was a significant increase in both hemodynamic variables (systolic blood pressure and diastolic blood pressure) during painful procedures except for the heart rate during positioning. The correlation between the CPOT and Ramsay scale was negative and significant.

Conclusions:

The present study provides evidence that the CPOT has good psychometric properties. It might prove useful for pain assessment in uncommunicative critically ill patients.