Validation of the Critical-Care Pain Observation Tool and Vital Signs in Relation to the Sensory and Affective Components of Pain During Mediastinal Tube Removal in Postoperative Cardiac Surgery Intensive Care Unit Adults

Strategy and Philosophy for Treating Pain and Sleep in Disorders of Consciousness

Despite the evolving practice of brain injury medicine, consciousness remains enigmatic. Most patients with disorders of consciousness have disordered sleep and return of normal sleep architecture is essential to the emergence of consciousness and the healing brain. In this article we lay a framework for understanding the emergence of consciousness in brain-injured patients. We then explore ways to use that framework to evaluate and tailor treatment of sleep and pain in patients with disorders of consciousness. Although more research is needed to empower better treatment in the future, validated tools now exist for evaluation of emergent consciousness, pain, and sleep.

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

OBJECTIVES

Pain assessment in the intensive care unit (ICU) is challenging because many patients are unable to self-report or exhibit pain-related behaviors. In such situations, vital signs (VS) through continuous monitoring are alternative cues for pain assessment. This review aimed to describe the reliability and validity of VS for ICU pain assessment.

DESIGN

Narrative review of the literature.

DATA SOURCES

Medline, Embase, CINAHL, Cochrane.

REVIEW/ANALYSIS METHODS

A narrative review was conducted with a comprehensive search in four databases. Search terms included VS, pain assessment, and ICU.

RESULTS

Out of 1,359 results, 30 studies from 17 countries were included. Heart rate, blood pressure, and respiratory rate were most used for ICU pain assessment. Assessments were performed at rest before procedures, during nociceptive and non-nociceptive procedures, and after procedures. Increases in respiratory rate were clinically significant by more than 25% during nociceptive procedures (e.g., endotracheal suctioning, turning) compared with rest/pre-procedures in five studies. Correlations of VS with self-reported pain (reference standard measure) and behavioral pain scores (alternative measure) were absent or weak.

CONCLUSIONS

VS are not valid indicators for ICU pain assessment. Increases of respiratory rate may be a cue for the detection of pain. However, fluctuations in respiratory rate can be influenced by opioids or controlled ventilation mode. Our results dissuade the use of VS for pain assessment because of the lack of association with ICU pain reference standards. Other physiologic measures of pain in critically ill adults should be explored.

Validation of the Critical-Care Pain Observation Tool (CPOT) in pediatric patients undergoing orthopedic surgery

Background

Postoperative pain cannot be measured accurately among many children with intellectual and developmental disabilities, resulting in underrecognition or delay in recognition of pain. The Critical-Care Pain Observation Tool (CPOT) is a pain assessment tool that has been widely validated in critically ill and postoperative adults.

Aims

The objective of this study was to validate the CPOT for use with pediatric patients able to self-report and undergoing posterior spinal fusion surgery.

Methods

Twenty-four patients (10-18 years old) scheduled to undergo surgery were consented to this repeated-measure, within-subject study. To examine discriminative and criterion validation, CPOT scores and patients' self-reports of pain intensity were collected prospectively by a bedside rater before, during, and after a nonnociceptive and nociceptive procedure on the day following surgery. Patients' behavioral reactions were video recorded at the bedside and retrospectively viewed by two independent video raters to examine interrater and intrarater reliability of CPOT scores.

Results

Discriminative validation was supported with higher CPOT scores during the nociceptive procedure than during the nonnociceptive procedure. Criterion validation was supported with a moderate positive correlation between the CPOT scores and the patients' self-reported pain intensity during the nociceptive procedure. A CPOT cutoff score of ≥2 was associated with the maximum sensitivity (61.3%) and specificity (94.1%). Reliability analyses revealed poor to moderate agreement between bedside and video raters and moderate to excellent consistency within video raters.

Conclusions

These findings suggest that the CPOT may be a valid tool to detect pain in pediatric patients in the acute postoperative inpatient care unit after posterior spinal fusion.

CE: Assessing Movement-Evoked Pain

ABSTRACT

One of the most common and nuanced tasks that nurses perform is pain assessment, particularly in acute postoperative settings where frequent reassessments are needed. Most assessments are limited to obtaining a pain intensity score with little attention paid to the conditions necessitating the assessment or the factors contributing to the pain. Pain is frequently assessed during rest, but seldom during periods of movement or activity, which is a crucial omission given that acute postoperative movement-evoked pain (MEP) is intense and a common barrier to healing and restoration of function. In addition to physical limitations, MEP can impede cognitive, emotional, and social functioning in ways that can contribute to chronic pain, mood disorders, and disability. Professional and regulatory standards are moving away from a focus on pain intensity to an emphasis on its context, impact on function, and associated distress. Thus, there are many driving forces compelling nurses to integrate MEP assessments into practice to expedite the restoration of biopsychosocial functioning in postoperative patients. The authors discuss the clinical significance of a MEP assessment as well as protocols and tools for completing such assessments.

Exploration of a Multi-Parameter Technology for Pain Assessment in Postoperative Patients After Cardiac Surgery in the Intensive Care Unit: The Nociception Level Index (NOL)TM

Introduction

The aim of this study was to explore the use of a multi-parameter technology, the Nociception Level (NOL) index (Medasense Biometrics Ltd, Ramat Gan, Israel), for pain assessment in postoperative awake patients after cardiac surgery during non-nociceptive and nociceptive procedures in the intensive care unit (ICU).

Materials and Methods

A prospective cohort repeated-measures design was used. Patients were included if they were in the ICU after undergoing cardiac surgery and if they could self-report their pain. A non-invasive probe was placed on the patient’s finger for the continuous monitoring of the NOL index. Patients’ self-reports of pain and anxiety (0–10 Numeric Rating Scale or NRS), and behavioral scores with the Critical-Care Pain Observation Tool (CPOT) were obtained before and during a non-nociceptive procedure (ie, non-invasive blood pressure [NIBP] using cuff inflation), and before, during and after a nociceptive procedure (ie, chest tube removal [CTR]) for a total of five time points. Non-parametric tests were used to compare scores at different time points, and receiver operating characteristic curve analysis was performed.

Results

Fifty-four patients were included in the analysis. The NOL index, pain and anxiety scores were significantly higher during CTR compared to rest and NIBP (p < 0.001). During CTR, the NOL was associated with self-reported pain intensity and unpleasantness but not with anxiety and CPOT scores. The NOL showed a modest performance in detecting pain (NRS ≥1 and ≥5) in this sample with sensitivity and specificity ranging from 61% to 85%.

Conclusion

The NOL index was able to discriminate between a non-nociceptive and a nociceptive procedure and was associated with self-reported pain. Further validation testing of the NOL is necessary in a heterogeneous sample of ICU patients.

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.

Pain assessment of the adult sedated and ventilated patients in the intensive care setting: A scoping review

BACKGROUND

Pain is frequently encountered in the intensive care setting. Given the impact of pain assessment on patient outcomes and length of hospital stay, studies have been conducted to validate tools, establish guidelines and cast light on practices relating to pain assessment.

OBJECTIVE

To examine the extent, range and nature of the evidence around pain assessment practices in adult patients who cannot self-report pain in the intensive care setting and summarise the findings from a heterogenous body of evidence to aid in the planning and the conduct of future research and management of patient care. The specific patient cohort studied was the sedated/ ventilated patient within the intensive care setting.

DESIGN

A scoping review protocol utilised the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping review checklist (PRISMA-ScR).

METHODS

The review comprised of five phases: identifying the research question, identifying relevant studies, study selection, charting the data and collating, summarizing, and reporting the results. Databases were systematically searched from January to April 2020. Databases included were Scopus, Web of Science, Medline via Ovid, CINAHL COMPLETE via EBSCO host, Health Source and PUBMED. Limits were applied on dates (2000 to current), language (English), subject (human) and age (adult). Key words used were "pain", "assessment", "measurement", "tools", "instruments", "practices", "sedated", "ventilated", "adult". A hand search technique was used to search citations within articles. Database alerts were set to apprise the availability of research articles pertaining to pain assessment practices in the intensive care setting.

RESULTS

The review uncovered literature categorised under five general themes: behaviour pain assessment tools, pain assessment guidelines, position statements and quality improvement projects, enablers and barriers to pain assessment, and evidence appertaining to actual practices. Behaviour pain assessment tools are the benchmark for pain assessment of sedated and ventilated patients. The reliability and validity of physiologic parameters to assess pain is yet to be determined. Issues of compliance with pain assessment guidelines and tools exist and impact on practices. In some countries like Australia, there is a dearth of information regarding the prevalence and characteristics of patients receiving analgesia, type of analgesia used, pain assessment practices and the process of recording pain management. In general, pain assessment varies across different intensive care settings and lacks consistency.

CONCLUSION

Research on pain assessment practices requires further investigation to explore the causative mechanisms that contribute to poor compliance with established pain management guidelines. The protocol of this review was registered with Open Science Framework (https://osf.io/25a6) Tweetable abstract: Pain assessment in intensive care settings lacks consistency. New information is needed to understand the causative mechanisms underpinning poor compliance with guidelines.

Validation of the Critical-Care Pain Observation Tool-Neuro in brain-injured adults in the intensive care unit: a prospective cohort study

Background

Pain assessment in brain-injured patients in the intensive care unit (ICU) is challenging and existing scales may not be representative of behavioral reactions expressed by this specific group. This study aimed to validate the French-Canadian and English revised versions of the Critical-Care Pain Observation Tool (CPOT-Neuro) for brain-injured ICU patients.

Methods

A prospective cohort study was conducted in three Canadian and one American sites. Patients with a traumatic or a non-traumatic brain injury were assessed with the CPOT-Neuro by trained raters (i.e., research staff and ICU nurses) before, during, and after nociceptive procedures (i.e., turning and other) and non-nociceptive procedures (i.e., non-invasive blood pressure, soft touch). Patients who were conscious and delirium-free were asked to provide their self-report of pain intensity (0–10). A first data set was completed for all participants (n = 226), and a second data set (n = 87) was obtained when a change in the level of consciousness (LOC) was observed after study enrollment. Three LOC groups were included: (a) unconscious (Glasgow Coma Scale or GCS 4–8); (b) altered LOC (GCS 9–12); and (c) conscious (GCS 13–15).

Results

Higher CPOT-Neuro scores were found during nociceptive procedures compared to rest and non-nociceptive procedures in both data sets (p < 0.001). CPOT-Neuro scores were not different across LOC groups. Moderate correlations between CPOT-Neuro and self-reported pain intensity scores were found at rest and during nociceptive procedures (Spearman rho > 0.40 and > 0.60, respectively). CPOT-Neuro cut-off scores ≥ 2 and ≥ 3 were found to adequately classify mild to severe self-reported pain ≥ 1 and moderate to severe self-reported pain ≥ 5, respectively. Interrater reliability of raters’ CPOT-Neuro scores was supported with intraclass correlation coefficients > 0.69.

Conclusions

The CPOT-Neuro was found to be valid in this multi-site sample of brain-injured ICU patients at various LOC. Implementation studies are necessary to evaluate the tool’s performance in clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03561-1.

Parametric study of transcranial alternating current stimulation for brain alpha power modulation

Transcranial alternating current stimulation, a non-invasive brain stimulation technique, has been used to increase alpha (8-12 Hz) power, the latter being associated with various brain functions and states. Heterogeneity among stimulation parameters across studies makes it difficult to implement reliable transcranial alternating current stimulation protocols, explaining the absence of consensus on optimal stimulation parameters to modulate the alpha rhythm. This project documents the differential impact of controlling for key transcranial alternating current stimulation parameters, namely the intensity, the frequency and the stimulation site (anterior versus posterior). Phase 1:20 healthy participants underwent 4 different stimulation conditions. In each experimental condition, stimulation via 2 electrodes was delivered for 20 min. Stimulation conditions were administered at PO7-PO8 or F3-F4 at individual's alpha frequency, or at individual's theta frequency or sham. Stimulation intensity was set according to each participant's comfort following a standardized unpleasantness scale (≤ 40 out of 100) and could not exceed 6 mA. All conditions were counterbalanced. Phase 2: participants who tolerated higher intensity of stimulation (4-6 mA) underwent alpha-frequency stimulation applied over PO7-PO8 at 1 mA to investigate within-subject modulation of stimulation response according to stimulation intensity. Whether set over posterior or anterior cortical sites, alpha-frequency stimulation showed greater increase in alpha power relative to stimulation at theta frequency and sham stimulation. Posterior alpha-frequency stimulation showed a greater increase in alpha power relative to the adjacent frequency bands over frontal and occipito-parietal brain areas. Low intensity (1 mA) posterior alpha stimulation showed a similar increase in alpha power than at high (4-6 mA) intensity when measured immediately after stimulation. However, when tested at 60 min or 120 min, low intensity stimulation was associated with significantly superior alpha power increase relative to high intensity stimulation. This study shows that posterior individual's alpha frequency stimulation at higher intensities is well tolerated but fails to increase stimulation aftereffects recorded within 2 h of stimulation on brain oscillations of the corresponding frequency band. In sharp contrast, stimulating at 1 mA (regardless of phosphene generation or sensory perception) effectively and selectively modulates alpha power within that 2-h time window, thus validating that it as a reliable stimulus intensity for future studies. This study also shows that posterior alpha-frequency stimulation preferentially modulates endogenous brain oscillations of the corresponding frequency band. Moreover, our data suggest that posterior alpha-frequency transcranial alternating current stimulation is a reliable and precise non-invasive brain stimulation technique for persistent modulation of both frontal and occipito-parietal alpha power.

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.

Comparison of the Zurich Observation Pain Assessment with the Behavioural Pain Scale and the Critical Care Pain Observation Tool in nonverbal patients in the intensive care unit: A prospective observational study

OBJECTIVES

To determine the concordance of Zurich Observation Pain Assessment (ZOPA) with the behavioural Pain Scale (BPS) and the Critical Care Pain Observation Tool (CPOT) to detect pain in nonverbal ICU patients.

DESIGN

Prospective observational study [BASEC-Nr. PB_2016-02324].

SETTING

A total of 49 ICU patients from cardiovascular, visceral and thoracic surgery and neurology and neurosurgery were recruited. Data from 24 patients were analyzed.

MAIN OUTCOME MEASUREMENTS

Three independent observers assessed pain with the BPS, the CPOT or ZOPA prior, during and after a potential painful nursing intervention. Tools were randomized concerning the pain management after each pain assessment. Frequency of nine additional pain indicating items from a previous qualitative, explorative study was calculated.

RESULTS

ZOPA was positive in 32 of 33 measuring cycles (97.0%; 95%CI: 84.2-99.9%), followed by the CPOT (28/33 cycles, 84.8%; 95%CI: 68.1-94.9%) and the BPS (23/33 cycles, 67.0%; 95%CI: 51.3-84.4%). In 22/33 cycles all tools were concordant (66.7%; 95%CI: 48.2-82.0%). Analgesics were provided in 29 out of 33 cycles (87.9%; 95%CI: 71.8-96.6%). Additional pain indicating items were inconsistently reported.

CONCLUSION

ZOPA is concordant with the BPS and the CPOT to indicate pain but detects pain earlier due to the low threshold value. Inclusion of further items does not improve pain assessment.

Exploration of the Nociception Level (NOL™) Index for Pain Assessment during Endotracheal Suctioning in Mechanically Ventilated Patients in the Intensive Care Unit: An Observational and Feasibility Study

BACKGROUND

Many patients in the intensive care unit (ICU) suffer from pain and are non-communicative. Therefore, alternative pain measures are necessary. Although behavioral pain measures are available, physiological measures are lacking. The Nociception Level index (NOL™) provides a value from combination of multiple physiological parameters to measure pain and its use in the ICU is new.

AIM

To explore the use of a multiple physiological parameter measure for pain assessment, the NOL™ index, in mechanically ventilated patients able to self-report pain in the ICU.

METHODS

A prospective cohort study was performed. Data were collected before, during, and 15 minutes after a non-nociceptive procedure (noninvasive blood pressure using cuff inflation) and a nociceptive procedure (endotracheal suctioning). NOL index, 0 to 10 pain intensity, and Critical-Care Pain Observation Tool (CPOT) scores were also obtained. Data were analyzed using Friedman and Mann-Whitney tests. Feasibility of study procedures was described.

RESULTS

Out of 28 patients who consented, 17 remained eligible and data were analyzed for 15. Technical issues prevented obtaining a NOL signal in 2 patients. NOL values were higher during endotracheal suctioning (median = 41.6) compared with before (median = 11.2) and after the procedure (median = 11.8) and compared with cuff inflation (median = 15.1; Friedman test, p < .001). NOL values were associated with pain intensity and CPOT scores (Mann-Whitney tests, p < .05).

CONCLUSIONS

The study procedures with the NOL were found feasible; NOL values could discriminate between nociceptive and non-nociceptive procedures, and values were associated with reference pain measures. Further NOL testing is required in other ICU patient groups and procedures.

Effects of Massage in Reducing the Pain and Anxiety of the Cardiac Surgery Critically Ill-a Randomized Controlled Trial

Objective

To evaluate the effectiveness of hand massage on the pain and anxiety of the cardiac surgery critically ill.

Design

A three-arm randomized controlled trial.

Setting

This study was conducted in a medical-surgical intensive care unit in Canada.

Subjects

Adult patients who underwent elective cardiac surgery, who were able to speak French/English and to self-report symptoms, without a high risk of postoperative complications were eligible.

Methods

Patients were randomly allocated to standard care plus either two 20-minute hand massages (experimental), two 20-minute hand holdings (active control), or two 20-minute rest periods (passive control/standard care). Pain intensity, pain unpleasantness, anxiety, muscle tension, and vital signs were evaluated before, after, and 30 minutes later for each intervention.

Results

From the 83 patients recruited, 60 were randomized (20 massage, 19 hand holding, 21 standard care). After controlling for baseline scores, the massage group reported significantly lower pain intensity, pain unpleasantness, and anxiety for the first data collection set compared with both hand holding and standard care (analysis of covariance, P < 0.02), with an average decrease of two points on a 0-10 scale. No statistically significant differences were noted between hand holding and standard care for any of the symptoms. Similar results were observed for the second data collection set (N = 43). Patients had decreased muscle tension post massage. Vital signs did not differ significantly between groups.

Conclusions

Findings suggest that a 20-minute hand massage in addition to routine postoperative pain management can concomitantly reduce pain intensity, pain unpleasantness, and anxiety by two points on average on a 0-10 scale.

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.

Family Members' Experiences with Observing Pain Behaviors Using the Critical-Care Pain Observation Tool

BACKGROUND

Current guidelines support family members' participation in care, but little is known regarding their potential contribution to pain assessment using validated behavioral pain scales.

AIMS

This study aimed to describe family members' observations of pain behaviors with the Critical-Care Pain Observation Tool and their evaluation of the tool and its use, and to understand their experience and perceptions of their potential role in pain management in the intensive care unit.

DESIGN

A mixed methods cross-sectional explanatory design was used.

SETTING

A medical-surgical intensive care unit in Canada.

PARTICIPANTS/SUBJECTS

Family members were eligible if they had a loved one admitted in the intensive care unit who was unable to self-report.

METHODS

Family members identified pain behaviors using the Critical-Care Pain Observation Tool after a brief training, completed a self-administered questionnaire, and participated in a follow-up individual interview regarding their experience and perceived potential role in pain management when their loved one is unable to self-report.

RESULTS

Ten family members participated. A 15-minute training appeared sufficient for family members to be comfortable with observing pain behaviors included in the Critical-Care Pain Observation Tool. The tool allowed them to confirm their observations of pain behaviors, to focus more on the patient, and to advocate for better pain management.

CONCLUSIONS

Future research is needed to explore the views of more family members and to compare their Critical-Care Pain Observation Tool scores to the ones of nurses' for interrater reliability testing.

Associations between respiratory nursing diagnoses and nursing interventions in patients submitted to thoracic or upper abdominal surgery

OBJECTIVE

To determine associations between respiratory nursing diagnoses and nursing interventions in patients submitted to thoracic or upper abdominal surgery.

METHOD

Cross sectional quantitative study. Participants were 312 adult patients within the first 48 hours after thoracic or upper abdominal surgery. Patients were examined by the research team using an instrument with variables related to the respiratory function. The research team established the presence/absence of three nursing diagnoses and proposed interventions using the NANDA-I classification and the Nursing Interventions Classification. Correlations were tested using the chi-square or Fisher's test.

RESULTS

From the total 312 examinations, ineffective airway clearance was present in 185 (59.3%) assessments, ineffective breathing pattern in 123 (39.4%), and impaired gas exchange in 141 (45.4%). Significant correlations showed that patients with ineffective airway clearance were more likely to require pain management (or: 2.27), chest physiotherapy (or: 2.96), and positioning (or:1.8), while patients with impaired gas exchange were less likely to require airway management (or: 0.13) and chest physiotherapy (or: 0.28).

CONCLUSIONS

Patients with ineffective airway clearance had more chances of requiring pain management, chest physiotherapy, and positioning, while the nursing diagnosis impaired gas exchange was related with airway management and chest physiotherapy. The findings provide basis for nurses to develop effective care plans and to minimize postoperative respiratory complications.

Comparison of Two Pain Scales: Behavioral Pain Scale and Critical-care Pain Observation Tool During Invasive and Noninvasive Procedures in Intensive Care Unit-admitted Patients

Background:

Critically ill patients admitted to intensive care units (ICUs) frequently experience pain, but the severity of pain in this group of patients is underestimated by the treatment team due to barriers to verbal communication. The aim of the present study was comparing the severity of pain measured by two scales: behavioral pain scale (BPS) and critical-care pain observation tool (CPOT) in ICU-admitted patients during routine daily procedures.

Materials and Methods:

Ninety patients were enrolled in the study. The severity of pain was measured during resting, invasive (suctioning) and noninvasive (mouthwash and body position change) procedures, and respiratory physiotherapy with two scales: BPS and CPOT. Wilcoxon and Friedman statistical tests were used to compare the score of pain in different situations, and Spearman correlation coefficient was also used to measure the correlation of pain score measured by two scales.

Results:

Patients experienced no pain during resting, mild pain during changing position, and respiratory physiotherapy, mild-to-moderate pain during mouthwash and moderate pain during secretion suctioning. Wilcoxon test used for pairwise comparisons between pain score in different situations showed a significant difference in both scales (p < 0.05). There were positive and strong correlations (r > 0.80, p < 0.05) between the pain score measured by BPS and CPOT from ICU-admitted patients in all procedures.

Conclusions:

Critically ill patients in ICU experience a different range of pain in routine daily care. BPS and CPOT scales could be used successfully for monitoring of pain in this group of patients.

Psychometric Properties of the Behavioral Pain Scale in Traumatic Brain Injury

BACKGROUND

Pain assessment of patients with traumatic brain injury is a challenge because they are unable to self-report their pain experience.

AIMS

To investigate the psychometric properties of validity, reliability, and responsiveness of the Brazilian version of the Behavioral Pain Scale (BPS-Br) in patients with traumatic brain injury.

METHODS

This was an observational, cross-sectional, repeated-measure and analytical study. This study was developed at the medical and surgical ICUs in a high-complexity public hospital at Aracaju, Sergipe, Brazil. Thirty-seven adult patients with moderate or severe TBI were included. This study was completed with 444 independent observations, a pairwise comparison, and was performed simultaneously before, during, and after eye cleaning and endotracheal suctioning of 37 adult patients with moderate to severe traumatic brain injury.

RESULTS

The BPS-Br had good internal consistency (.7 ≤ α ≤ .9), good discriminant validity (p < .001), moderate to excellent reliability based on inter-rater agreement (intraclass correlation coefficient = 0.66-1.00; κ = 0.5-1.0), and high responsiveness (0.7-1.7). The upper limbs subscale had the highest score during the nociceptive procedure (1.8 ± 0.9). Deep sedation affected the increase of grading during painful procedures (p < .001).

CONCLUSIONS

Our results suggest the BPS-Br is a useful tool for clinical practice to evaluate the pain experienced by patients with traumatic brain injury. Further studies of different samples are needed to evaluate the benefits of systematic pain assessment of critically ill 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.

Pain assessment of traumatic brain injury victims using the Brazilian version of the Behavioral Pain Scale

Objective

To evaluate the validity and reliability of the Brazilian version of the Behavioral Pain Scale (BPS-Br) in victims of traumatic brain injury.

Methods

Observational prospective study with paired and repeated measures conducted at two intensive care units (clinical and surgical) of a large general hospital. The convenience sample consisted of adult victims of moderate or severe penetrating or blunt craniocerebral trauma who were sedated and mechanically ventilated. A total of 432 paired observations were performed by independent evaluators simultaneously, prior to eye cleaning, during eye cleaning, during tracheal aspiration and after tracheal aspiration. Sociodemographic, clinical, trauma-related, sedoanalgesia and physiological parameter data (heart rate, systolic and diastolic blood pressure) were collected. The discriminant validity was tested using the Friedman and Wilcoxon paired tests. The intraclass correlation coefficient and Cohen's Kappa coefficient were used to evaluate the reliability. The Spearman correlation test was used to test the association between clinical variables and BPS-Br scores during tracheal aspiration.

Results

There was a significant increase in the physiological parameters during tracheal aspiration, but without correlation with the BPS-Br scores. Pain was significantly more intense during tracheal aspiration (p < 0.005). Satisfactory interobserver agreement was found, with an intraclass correlation coefficient of 0.95 (0.90 - 0.98) and Kappa coefficient of 0.70.

Conclusion

Brazilian version of the Behavioral Pain Scale scores increased during tracheal aspiration. The Brazilian version of the scale was valid and reliable for pain assessment of traumatic brain injury victims undergoing tracheal aspiration.

Validation of the Polish version of the Critical Care Pain Observation Tool (CPOT) to assess pain intensity in adult, intubated intensive care unit patients: the POL-CPOT study

INTRODUCTION

Pain in the critically ill affects nearly 50% of patients. In patients unable to self-report pain, behavioural scales are used. The aim of this study was to validate the Polish version of the Critical Care Pain Observation Tool (CPOT).

MATERIAL AND METHODS

The prospective observational cohort study included patients observed during non-nociceptive and nociceptive procedures, at rest, during the intervention, and 15 min after each intervention. Assessments included self-report by patients and CPOT assessment carried out by two blinded observers.

RESULTS

A total of 71 patients were included in the study (mean age: 66 years), predominantly males (50/71, 70%), mean APACHE II score 26.04 ±10.56. Results showed an excellent inter-rater correlation (ICC) between raters (ICC scores > 0.97). Self-report NRS (numeric rating scale) scores were available from 58/71 patients (82%). Patients' self-reported pain and CPOT showed a very strong correlation (Spearman's R > 0.85, p < 0.0001). The CPOT has high diagnostic value for detection of presence of patients' self-reported pain (ROC AUC = 0.938 for rater A and 0.951 for rater B, p < 0.0001). CPOT score ≥ 2 is an optimal cut-off to detect pain during a nociceptive procedure. A significantly higher mean CPOT score during a nociceptive procedure as compared to a non-nociceptive procedure or at rest was found (p < 0.0001).

CONCLUSIONS

This study shows that the Polish version of the CPOT can be used to assess pain in critically ill patients with no hypnotic, opioid-based analgo-sedation. Polish CPOT scores correlated well with patients' self-reported presence of pain and showed excellent inter-rater reliability. This makes the Polish version of the CPOT a reliable pain assessment tool.

Validation of the Italian version of the Critical Pain Observation Tool in brain-injured critically ill adults

Background and aim: Pain in intensive care units (ICUs) is a frequent and often undermanaged problem. Brain-injured patients are often unable to reliably self-report their pain, calling forth the need to use behavioural scales such as the Critical-Care Pain Observation Tool (CPOT). This study aimed to test the reliability and validity of the Italian CPOT use with brain-injured ICU adults. Method: A sample of 50 adults critical care patients was included. Each patient was assessed by two independent observers at three predefined times – at rest; during mobilization for hygiene; 20 minutes later – using the CPOT, PAINAD, and NRS. Results: A good correlation was found between independent observers scores during painful procedure, establishing interrater reliability of CPOT. Criterion validation was supported by a strong correlation between CPOT and PAINAD scores, and a moderate relation between CPOT and NRS scores. The CPOT was able to discriminate between patients undergoing painful versus non-painful procedures. However, PAINAD performed better in this sample, as revealed by the comparison between the two AUC of ROC curves. Conclusions: The Italian CPOT use was found reliable and valid in this patient group.

Patients with limited communication in end-of-life situations: Initial psychometric properties of a discomfort observation scale

This work presents an observational scale which takes into account different observable indicators of discomfort of patients in end-of-life situations with difficulties in communicating due to cognitive impairment, fatigue or sedation and provides details of its validation. In all, 71 adults participated. Model fit was adequate (χ²(27) = 43.28, p = .024, comparative fit index = .975, root mean square error of approximation = .092 and confidence interval 90% (.033-.140)). Alpha coefficient was .70 and composite reliability index was .90. Our study provides data regarding the properties of a discomfort assessment scale. Such a scale is needed and could be very useful for the evaluation of such patients and thus to attend to their needs.

Symptom assessment in non-vocal or cognitively impaired ICU patients: Implications for practice and future research

BACKGROUND

Symptom assessment in critically ill patients is challenging because many cannot provide a self-report.

OBJECTIVES

To describe the state of the science on symptom communication and the assessment of selected physical symptoms in non-vocal ICU patients.

METHODS

This paper summarizes a 2014 American Thoracic Society Annual International Conference symposium presenting current evidence on symptom communication, delirium, and the assessment of common physical symptoms (i.e., dyspnea, pain, weakness, and fatigue) experienced by non-vocal ICU patients.

RESULTS

Symptom assessment begins with accurate assessment, which includes an evaluation of delirium, and assistance in symptom communication. Simple self-report measures (e.g., 0-10 numeric rating scale), observational measures (e.g., Respiratory Distress Observation Scale and Critical-Care Pain Observation Tool), or objective measures (e.g., manual muscle testing and hand dynamometry) have demonstrated utility among this population.

CONCLUSION

Optimizing symptom assessment with valid and reliable instruments with minimum patient burden is necessary to advance clinical practice and research in this field.

The Behavior Pain Assessment Tool for critically ill adults: a validation study in 28 countries

Many critically ill adults are unable to communicate their pain through self-report. The study purpose was to validate the use of the 8-item Behavior Pain Assessment Tool (BPAT) in patients hospitalized in 192 intensive care units from 28 countries. A total of 4812 procedures in 3851 patients were included in data analysis. Patients were assessed with the BPAT before and during procedures by 2 different raters (mostly nurses and physicians). Those who were able to self-report were asked to rate their pain intensity and pain distress on 0 to 10 numeric rating scales. Interrater reliability of behavioral observations was supported by moderate (0.43-0.60) to excellent (>0.60) kappa coefficients. Mixed effects multilevel logistic regression models showed that most behaviors were more likely to be present during the procedure than before and in less sedated patients, demonstrating discriminant validation of the tool use. Regarding criterion validation, moderate positive correlations were found during procedures between the mean BPAT scores and the mean pain intensity (r = 0.54) and pain distress (r = 0.49) scores (P < 0.001). Regression models showed that all behaviors were significant predictors of pain intensity and pain distress, accounting for 35% and 29% of their total variance, respectively. A BPAT cut-point score >3.5 could classify patients with or without severe levels (≥8) of pain intensity and distress with sensitivity and specificity findings ranging from 61.8% to 75.1%. The BPAT was found to be reliable and valid. Its feasibility for use in practice and the effect of its clinical implementation on patient pain and intensive care unit outcomes need further research.

The Effectiveness of Hand Massage on Pain in Critically Ill Patients After Cardiac Surgery: A Randomized Controlled Trial Protocol

Background

Postoperative pain is common in the intensive care unit despite the administration of analgesia. Some trials suggest that massage can be effective at reducing postoperative pain in acute care units; however, its effects on pain relief in the intensive care unit and when pain severity is highest remain unknown.

Objective

The objective is to evaluate the effectiveness of hand massage on the pain intensity (primary outcome), unpleasantness and interference, muscle tension, anxiety, and vital signs of critically ill patients after cardiac surgery.

Methods

A 3-arm randomized controlled trial will be conducted. A total of 79 patients who are 18 years or older, able to speak French or English and self-report symptoms, have undergone elective cardiac surgery, and do not have a high risk of postoperative complications and contraindications to hand massage will be recruited. They will be randomly allocated (1:1:1) to standard care plus either 3 20-minute hand massages (experimental), 3 20-minute hand holdings (active control), or 3 20-minute rest periods (passive control). Pain intensity, unpleasantness, anxiety, muscle tension, and vital signs will be evaluated before, immediately after, and 30 minutes later for each intervention administered within 24 hours postoperatively. Peer-reviewed competitive funding was received from the Quebec Nursing Intervention Research Network and McGill University in December 2015, and research ethics approval was obtained February 2016.

Results

Recruitment started in April 2016, and data collection is expected to be complete by January 2017. To date, 24 patients were randomized and had data collection done.

Conclusions

This study will be one of the first randomized controlled trials to examine the effect of hand massage on the pain levels of critically ill patients after cardiac surgery and to provide empirical evidence for the use of massage among this population.

ClinicalTrial

ClinicalTrials.gov NCT02679534; https://clinicaltrials.gov/ct2/show/NCT02679534 (Archived by WebCite at http://www.webcitation.org/6l8Ly5eHS)

Validation of the Danish version of the Critical Care Pain Observation Tool

BACKGROUND

Assessing pain in critically ill patients is a challenge even in an intensive care unit (ICU) with a no sedation protocol. The aim of this study was to validate the Danish version of the pain assessment method; Critical Care Pain Observation Tool (CPOT) in an ICU with a no sedation protocol.

METHODS

Seventy patients were included in this study. The patients were observed during a non-nociceptive procedure (wash of an arm) and a nociceptive procedure (turning). Patients were observed before, during, and 15 min after the two interventions (six assessments). Two observers participated in the data collection and CPOT scores were blinded to each other. Calculations of interrater reliability, criterion validity and discriminant validity were performed to validate the Danish version of CPOT.

RESULTS

The results indicated a good correlation between the two raters (all scores > 0.9 and P < 0.05). About 48 (68.6%) of the included patients were able to self-report pain. We found a significantly higher mean CPOT score at the nociceptive procedure than at rest or the non-nociceptive procedure (P < 0.05). No correlation was found between CPOT scores and physiological indicators. Patients self-reported pain and CPOT showed a significant correlation (P < 0.05). A CPOT score of ≥ 3 correlated with patients' self-reported pain (ROC AUC 0.83).

CONCLUSION

The Danish version of CPOT can be used to assess pain in critically ill patients, also when the ICU has a no sedation protocol. CPOT scores showed a good interrater reliability and correlates well with patient's self-reported pain.

Comparison of Two Pain Assessment Tools, "Facial Expression" and "Critical Care Pain Observation Tool" in Intubated Patients After Cardiac Surgery

BACKGROUND

Critical-care patients are at higher risk of untreated pain, because they are often unable to communicate owing to altered mental status, tracheal intubation and sedation.

OBJECTIVES

This study compared two pain assessment tools on tracheal intubated critically ill patients in a cardiac post-anesthesia care unit, who were unable to communicate verbally. The studied tools were "critical-care pain observation tool (CPOT)" and "facial expression (FE)".

PATIENTS AND METHODS

This was a prospective study based on diagnostic test evaluation. A sample of 91 intubated patients was selected from cardiac post-anesthesia care unit. Collected data were demographic characteristics, vital signs, FE and CPOT tools' scale. Pain was assessed with CPOT and FE scores five times. The first assessment was performed in at least 3 hours after admission of patients to ICU. Then, the pain intensity was reassessed every 30 minutes. In addition, blood pressure, heart rate, respiratory rate and oxygen saturation were measured simultaneously.

RESULTS

At the first period, the frequency of "severe" pain intensity using the CPOT was 58.2% and with the FE tool was 67% (P = 0.001). Both tools demonstrated reduction in severity of pain on second and third assessment times. Significantly increasing level of pain and blood pressure due to nursing painful procedures (endo-tracheal suctioning, changing patient's position, etc.), were obtained by CPOT in fourth assessment. FE was not able to detect such important findings (κ = 0.249). In the fifth step, pain intensity was reduced. The most agreement between the two tools was observed when the reported pain was "severe" (κ = 0.787, P < 0.001) and "mild" (κ = 0.851, P < 0.001).

CONCLUSIONS

The sensitivity of CPOT was higher for detection and evaluation of pain in intubated postoperative patients compared with "Facial Expression". Best agreement between these tools was observed in two extremes of pain intensity.