Evaluation of Two Observational Pain Assessment Tools in Chinese Critically Ill Patients

Electroencephalogram-based prediction and detection of responsiveness to noxious stimulation in critical care patients: a retrospective single-centre analysis

BACKGROUND

Monitoring of pain and nociception in critical care patients unable to self-report pain remains a challenge, as clinical signs are neither sensitive nor specific. Available technical approaches are limited by various constraints. We investigated the electroencephalogram (EEG) for correlates that precede or coincide with behavioural nociceptive responses to noxious stimulation.

METHODS

In this retrospective study, we analysed frontal EEG recordings of 64 critical care patients who were tracheally intubated and ventilated before, during, and after tracheal suctioning. We investigated EEG power bands for correlates preceding or coinciding with behavioural responses (Behavioural Pain Scale ≥7). We applied the Mann-Whitney U-test to calculate corresponding P-values.

RESULTS

Strong behavioural responses were preceded by higher normalised power in the 2.5-5 Hz band (+17.1%; P<0.001) and lower normalised power in the 0.1-1.5 Hz band (-10.5%; P=0.029). After the intervention, strong behavioural responses were associated with higher normalised EEG power in the 2.5-5 Hz band (+16.6%; P=0.021) and lower normalised power in the 8-12 Hz band (-51.2%; P=0.037) CONCLUSIONS: We observed correlates in EEG band power that precede and coincide with behavioural responses to noxious stimulation. Based on previous findings, some of the power bands could be linked to processing of nociception, arousal, or sedation effects. The power bands more closely related to nociception and arousal could be used to improve monitoring of nociception and to optimise analgesic management in critical care patients.

CLINICAL TRIAL REGISTRATION

DRKS00011206.

Pain Assessment with the BPS and CCPOT Behavioral Pain Scales in Mechanically Ventilated Patients Requiring Analgesia and Sedation

BACKGROUND

Intensive Care Unit (ICU) patients often experience pain, especially during diagnostic, nursing, and therapeutic interventions. Pain assessment using the Behavioral Pain Scale (BPS) and Critical Care Pain Observation Tool (CCPOT) are recommended, but they are difficult to do in patients undergoing deep sedation. This study analyzed the usefulness of the BPS and CCPOT scales in assessing pain among patients with varying degrees of sedation.

METHODS

In 81 mechanically ventilated and sedated ICU patients, 1005 measurements were performed using the BPS and CCPOT scales. The study was conducted by 3 trained observers 3 times a day (each measurement at rest, during painful nursing interventions, and after the intervention). The Richmond Agitation-Sedation Scale (RASS), the Simplified Acute Physiology Score (SAPS II), and the Acute Physiology and Chronic Health Evaluation (APACHE II) were also analyzed from medical records as well as information on the length of hospitalization and treatment.

RESULTS

It was shown that signs of pain increased significantly (p < 0.001) during interventions in patients on both scales (BPS and CCPOT), and then returned to values close to the resting period. RASS results correlated significantly (p < 0.05) and positively with the results of the BPS and CCPOT. A strong correlation was found between the results of both scales at each stage of the study (R = 0.622-0.907).

CONCLUSIONS

Nursing procedures are a source of pain in analgosedated patients. The BPS and CCPOT scales are useful tools for assessing the occurrence of pain in mechanically ventilated patients, including those in deep sedation.

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.

Verification of the critical-care pain observation tool in conscious patients with hemiparesis or cognitive dysfunction

PURPOSE

Altered cognition or hemiparesis can occur in neurocritical but conscious patients, and recognizing pain is challenging. This study aimed to test the reliability and validity of the Critical-Care Pain Observation Tool (CPOT) in this specific group.

MATERIALS AND METHODS

This prospective study included ventilated, conscious patients who had certain neurologic deficits. CPOT scores were assessed before and after nociceptive (turning the patient) and non-nociceptive (measuring body temperature) procedures. The patients' self-reported pain was also recorded using a numerical rating scale (NRS).

RESULTS

Sixty-three patients were enrolled. The intraclass correlation coefficient was r = 0.975-1.000 (p < 0.001) for turning the patient. Discriminant validation indicated that CPOT scores were significantly higher after turning the patient compared with measuring body temperature (p = 0.025). CPOT scores were positively correlated with NRS when turning the patient (r = 0.724, p < 0.001). After turning, the mean increase in CPOT score was lower in the patients with hemiparesis than in those without hemiparesis (p = 0.079), however it was significantly higher in the patients with cognitive dysfunction compared to those without cognitive dysfunction (p = 0.022).

CONCLUSIONS

The CPOT is an appropriate instrument to assess pain in conscious patients, particularly those with cognitive dysfunction. The influence of hemiparesis on the CPOT is noteworthy.

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.

Effects of Open and Closed Tracheal Suctioning on Pain in Mechanically Ventilated Patients

Background:

Painful care procedures are the most common cause of stress in patients admitted to Intensive Care Units (ICUs). Tracheal suctioning is the most painful experience for ICU patients. The present study was conducted to compare open and closed endotracheal suctioning in terms of their effect in pain in mechanically ventilated patients.

Materials and Methods:

The present clinical trial recruited 70 mechanically ventilated patients with tracheostomy in 2019. The eligible patients were randomly divided into open and closed suctioning groups. The pain was measured in the patients using the Critical Pain Observational Tool (CPOT) before and during suctioning as well as 10 and 30 min later. The data were analyzed using the repeated measures Analysis Of Variance (ANOVA), paired t-test, and Chi-squared test.

Results:

The pain score was significantly higher in the open suctioning group during (t = 2.59, p = 0.01) and 10 min after suctioning (t = 3.02, p = 0.004). No significant differences were observed in the pain score between the two groups 30 min after suctioning (t = 0.32, p = 0.75). The post hoc Least Significant Difference (LSD) test showed that the CPOT scores 10 min after suctioning was significantly higher than that before suctioning and significantly lower than that during suctioning (p = 0.001). The CPOT score 30 min after suctioning was also significantly lower than that 10 min after suctioning (p < 0.001).

Conclusions:

The present findings suggested a lower pain in the patients with closed suctioning compared to those with open suctioning.

Behavioral Pain Scale and Critical Care Pain Observation Tool for pain evaluation in orotracheally tubed critical patients. A systematic review of the literature

Objective:

To describe the appropriateness of two behavioral scales, the Behavioral Pain Scale and the Critical Care Pain Observation Tool, for pain assessment in orotracheally intubated patients admitted to intensive care units.

Method:

Using the methodology recommended by the Cochrane Center, a systematic literature review was performed in the electronic database EBSCO Host (CINAHL Complete; MEDLINE® Complete; Nursing & Allied Health Collection: Comprehensive; Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews; Cochrane Methodology Register; Library, Information Science & Technology Abstracts; MedicLatina). Two searches were conducted using the following English terms in the search field: “behavioral pain scale” AND “critical care pain observation tool” AND “behavioral pain scale” OR “critical care pain observation tool”. Two independent reviewers performed the critical evaluation and data extraction and synthesis.

Results:

Fifteen studies were included that showed that the Behavioral Pain Scale and the Critical Care Pain Observation Tool are valid and reliable scales for pain assessment in orotracheally intubated patients admitted to the intensive care unit. The scales showed similar psychometric properties and good reliability.

Conclusion:

Both scales are adequate for assessing pain in orotracheally intubated patients admitted to intensive care units; however, they exhibit limitations in specific populations, such as trauma, burn and neurosurgical patients. Further studies on the subject and in specific populations are suggested.

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.

Translation into Spanish and Cultural Adaptation of the Critical-Care Pain Observation Tool

BACKGROUND

The Critical-Care Pain Observation Tool (CPOT) is recommended for evaluating pain behaviors in patients in the intensive care unit who are unable to report pain. The source of the only published Spanish version of the CPOT does not verify that it underwent a formal translation process.

OBJECTIVE

To describe the translation into Spanish and cultural adaptation of the original French version of the CPOT.

METHODS

Key persons in the translation process included one with a master's degree in translation, a critical care physician, nurse faculty members with vast experience in intensive care units, and the instrument's developer. This team followed the Principles of Good Practice for the Translation and Cultural Adaptation Process for Patient-Reported Outcomes Measures as a guide to translate and culturally adapt the CPOT.

RESULTS

The first Spanish-language version was back translated to French and was also compared with the English version. Revisions necessitated a second version, which was submitted to experts in critical care. Their modifications required a third version, which was back translated to French and discussed with the CPOT developer, after which a fourth version was created. Finally, a linguistic expert proofread the tool, and the translation leaders incorporated the recommendations, thereby obtaining a final Spanish version.

CONCLUSION

The Spanish version is ready to undergo validation with patients in the intensive care unit, which is the next step toward its use in assessing pain behaviors among patients in intensive care units where Spanish is spoken.

Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

OBJECTIVE

To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU.

DESIGN

Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017.

METHODS

Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified.

RESULTS

The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation.

CONCLUSIONS

We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.

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.

Reliability and Validity of the Critical-Care Pain Observation Tool: A Rapid Synthesis of Evidence

Staff in a tertiary hospital critical care unit in Doha, Qatar, suggested that the Critical-Care Pain Observation Tool (CPOT) would be a better tool for assessing pain in ventilated and sedated patients than current local practice. We undertook a rapid synthesis of evidence to establish whether current research supports use of CPOT for assessing pain in ventilated and sedated patients in a critical care setting. CPOT has been shown in reviews and more recent primary studies to be reliable and valid for most patients unable to self-report in critical care settings. This finding is supported by several guidelines. Studies also suggest that CPOT is feasible for use in research and clinical practice though training of observers is important. Further research may be warranted to strengthen current evidence, particularly in patients with neurological trauma.

Reliability of three linguistically and culturally validated pain assessment tools for sedated ICU patients by ICU nurses in Finland

Background and aims:

Pain assessment in intensive care is challenging, especially when the patients are sedated. Sedated patients who cannot communicate verbally are at risk of suffering from pain that remains unnoticed without careful pain assessment. Some tools have been developed for use with sedated patients. The Behavioral Pain Scale (BPS), the Critical-Care Pain Observation Tool (CPOT) and the Nonverbal Adult Pain Assessment Scale (NVPS) have shown promising psychometric qualities. We translated and culturally adapted these three tools for the Finnish intensive care environment. The objective of this feasibility study was to test the reliability of the three pain assessment tools translated into Finnish for use with sedated intensive care patients.

Methods:

Six sedated intensive care patients were videorecorded while they underwent two procedures: an endotracheal suctioning was the nociceptive procedure, and the non-nociceptive treatment was creaming of the feet. Eight experts assessed the patients’ pain by observing video recordings. They assessed the pain using four instruments: the BPS, the CPOT and the NVPS, and the Numeric Rating Scale (NRS) served as a control instrument. Each expert assessed the patients’ pain at five measurement points: (1) right before the procedure, (2) during the endotracheal suctioning, (3) during rest (4) during the creaming of the feet, and (5) after 20 min of rest. Internal consistency and inter-rater reliability of the tools were evaluated. After 6 months, the video recordings were evaluated for testing the test-retest reliability.

Results:

Using the BPS, the CPOT, the NVPS and the NRS, 960 assessments were obtained. Internal consistency with Cronbach’s alpha coefficient varied greatly with all the instruments. The lowest values were seen at those measurement points where the pain scores were 0. The highest scores were achieved after the endotracheal suctioning at rest: for the BPS, the score was 0.86; for the CPOT, 0.96; and for the NVPS, 0.90. The inter-rater reliability using the Shrout-Fleiss intraclass correlation coefficient (ICC) tests showed the best results after the painful procedure and during the creaming. The scores were slightly lower for the BPS compared to the CPOT and the NVPS. The test-retest results using the Bland-Altman plots show that all instruments gave similar results.

Conclusions:

To our knowledge, this is the first time all three behavioral pain assessment tools have been evaluated in the same study in a language other than English or French. All three tools had good internal consistency, but it was better for the CPOT and the NVPS compared to the BPS. The inter-rater reliability was best for the NVPS. The test-retest reliability was strongest for the CPOT. The three tools proved to be reliable for further testing in clinical use.

Implications:

There is a need for feasible, valid and reliable pain assessment tools for pain assessment of sedated ICU patients in Finland. This was the first time the psychometric properties of these tools were tested in Finnish use. Based on the results, all three instruments could be tested further in clinical use for sedated ICU patients in Finland.

The Critical care Pain Observation Tool is reliable in non-agitated but not in agitated intubated patients

OBJECTIVE

The Critical-Care Pain.

OBSERVATION

Tool is one of the instruments developed to assess pain in patients who are unable to communicate verbally. The study aimed to survey the psychometric properties of Critical-Care Pain.

OBSERVATION

Tool in four groups of non-verbal patients according to their Richmond Agitation Sedation Score (RASS).

STUDY DESIGN AND METHODOLOGY

65 critically ill patients (medical, surgical, trauma) were assessed using the critical care pain observation tool on six occasions (before, during and after nociceptive and non-nociceptive procedures). Patients were divided into four groups according to their RASS score: 1. All patients (RASS -3 to +2), 2. Sedated patients (RASS -3 to -1), 3. Restless patients (RASS +1), 4. Agitated patients (RASS +2).

RESULTS

Discriminant and criterion validity, confirmatory factor analysis and internal reliability showed good validity and reliability in the critical care pain observation tool in all groups except agitated patients. The results showed that, in general, the CPOT has good version of the critical care pain observation tool has good psychometric properties to evaluate pain in non-verbal patients admitted to intensive care units who have a RASS score ranging from -3 to +1, but it is not a good tool to evaluate pain in patients who are agitated according to RASS.

A Study on the Psychometric Properties of Revised-nonverbal Pain Scale and Original-nonverbal Pain Scale in Iranian Nonverbal-ventilated Patients

Background and Aims:

The nonverbal pain scale is one of the instruments which study pain in nonverbal-ventilated patients with regard to the changes of behavioral and physiological indices. The purpose of the study is to survey the psychometric properties of revised-nonverbal pain scale (R-NVPS) and original-nonverbal pain scale (O-NVPS) in ventilated patients hospitalized in critical care units.

Materials and Methods:

Four nurses studied pain in sixty patients hospitalized in trauma, medical, neurology, and surgical critical care units using R-NVPS and O-NVPS at six times (before, during, and after nociceptive and nonnociceptive procedures). The test was repeated in 37 patients after 8–12 h.

Results:

Cronbach's alpha coefficient for R-NVPS and O-NVPS was 0.8 and 0.76, respectively. The inter-rater correlation coefficient during different times was r = 0.89–0.96 for R-NVPS and r = 0.80–0.87 for O-NVPS. Test-retest correlation coefficient for R-NVPS and O-NVPS was r = 0.55–0.86 and r = 0.51–0.75, respectively. The meaningful difference in pain score between nociceptive and nonnociceptive procedures (P < 0.001) and a higher pain score in patients who confirmed pain (P < 0.001) showed a discriminant and criterion validity for both scales of NVPS, respectively.

Conclusions:

R-NVPS and O-NVPS can both be used as valid and reliable scales in studying pain in ventilated patient. However, in comparing the items, “respiration” (R-NVPS) had a higher sensitivity than “physiology II” (O-NVPS) in assessing pain.

Accuracy of Critical Care Pain Observation Tool and Behavioral Pain Scale to assess pain in critically ill conscious and unconscious patients: prospective, observational study

Background

Critically ill patients admitted to intensive care unit (ICU) may suffer from different painful stimuli, but the assessment of pain is difficult because most of them are almost sedated and unable to self-report. Thus, it is important to optimize evaluation of pain in these patients. The main aim of this study was to compare two commonly used scales for pain evaluation: Critical Care Pain Observation Tool (CPOT) and Behavioral Pain Scale (BPS), in both conscious and unconscious patients. Secondary aims were (1) to identifying the most relevant parameters to determine pain scales changes during nursing procedures, (2) to compare both pain scales with visual analog scale (VAS), and (3) to identify the best combination of scales for evaluation of pain in patients unable to communicate.

Methods

In this observational study, 101 patients were evaluated for a total of 303 consecutive observations during 3 days after ICU admission. Measurements with both scales were obtained 1 min before, during, and 20 min after nursing procedures in both conscious (n.41) and unconscious (n.60) patients; furthermore, VAS was recorded when possible in conscious patients only. We calculated criterion and discriminant validity to both scales (Wilcoxon, Spearman rank correlation coefficients). The accuracy of individual scales was evaluated. The sensitivity and the specificity of CPOT and BPS scores were assessed. Kappa coefficients with the quadratic weight were used to reflect agreement between the two scales, and we calculated the effect size to identify the strength of a phenomenon.

Results

CPOT and BPS showed a good criterion and discriminant validity (p < 0.0001). BPS was found to be more specific (91.7 %) than CPOT (70.8 %), but less sensitive (BPS 62.7 %, CPOT 76.5 %). COPT and BPS scores were significantly correlated with VAS (p < 0.0001). The combination of BPS and CPOT resulted in better sensitivity 80.4 %. Facial expression was the main parameter to determine pain scales changes effect size = 1.4.

Conclusions

In critically ill mechanically ventilated patients, both CPOT and BPS can be used for assessment of pain intensity with different sensitivity and specificity. The combination of both BPS and CPOT might result in improved accuracy to detect pain compared to scales alone.

Trial registration

NCT01669486