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

Does pain optimisation impact delirium outcomes in critically ill patients? A systematic review and meta-analysis protocol

BACKGROUND

Untreated pain is associated with short-term and long-term consequences, including post-traumatic stress disorder and insomnia. Side effects of some analgesic medications include dysphoria, hallucinations and delirium. Therefore, both untreated pain and analgesic medications may be risk factors for delirium. Delirium is associated with longer length of stay or cognitive impairment. Our systematic review and meta-analysis will examine the relationship between pain or analgesic medications with delirium occurrence, duration and severity among critically ill adults.

METHODS AND ANALYSIS

MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of controlled trials and a review of recent conference abstracts will be searched without restriction from inception to 15 May 2023. Study inclusion criteria are: (1) age≥18 years admitted to intensive care; (2) report a measure of pain, analgesic medications and delirium; (3) study design-randomised controlled trial, quasiexperimental designs and observational cohort and case-control studies excluding case reports. Study exclusion criteria are: (1) alcohol withdrawal delirium or delirium tremens; or (2) general anaesthetic emergence delirium; or (3) lab or animal studies. Risk of bias will be assessed with the Risk of Bias V.2 and risk of bias in non-randomised studies tools. There is no language restriction. Occurrence estimates will be transformed using the Freeman-Tukey double arcsine. Point estimates will be pooled using Hartung-Knapp Sidik-Jonkman random effects meta-analysis to estimate a pooled risk ratio. Statistical heterogeneity will be estimated with the I2 statistic. Risk of small study effects will be assessed using funnel plots and Egger test. Studies will be analysed for time-varying and unmeasured confounding using E values.

ETHICS AND DISSEMINATION

Ethical approval is not required as this is an analysis of published aggregated data. We will share our findings at conferences and in peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

The finalised protocol was submitted to the International Prospective Register of Systematic Reviews (PROSPERO ID: CRD42022367715).

Correlation of the Critical Care Pain Observation Tool and Numeric Rating Scale in Intensive Care Unit Patients

PURPOSE

We sought to determine the correlation between the Numeric Rating Scale (NRS) and Critical-Care Pain Observation Tool (CPOT) to determine whether clinical factors modified the relationship between NRS and CPOT assessments.

MATERIALS AND METHODS

We included nonventilated adults admitted to the MICU or SICU who could self-report pain and had at least 3 paired NRS and CPOT assessments. We performed Spearman correlation to assess overall correlation and performed proportional odds logistic regression to evaluate whether the relationship between NRS and CPOT assessments was modified by clinical factors.

RESULTS

Nursing staff performed NRS and CPOT assessments every 4 h in 1302 patients, leading to 61,142 matched assessments. We found that the NRS and CPOT have a Spearman correlation coefficient of 0.56 and an intraclass correlation coefficient of 0.32 in intensive care unit patients. Factors that modified the relationship between the NRS and CPOT included the presence of delirium (P < .001) and lower mean daily Richmond Agitation Sedation Scale (<0.001).

CONCLUSIONS

The correlation coefficient between the NRS and the CPOT was found to be 0.56. The presence of delirium, decreased level of arousal, modified the relationship between the NRS and CPOT. Self-reported and behavioral pain assessments cannot be used interchangeably in critically ill adults.

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.

Relationship Between Pain and Delirium in Critically Ill Adults

OBJECTIVES

Although opioids are frequently used to treat pain, and are an important risk for ICU delirium, the association between ICU pain itself and delirium remains unclear. We sought to evaluate the relationship between ICU pain and delirium.

DESIGN

Prospective cohort study.

SETTING

A 32-bed academic medical-surgical ICU.

PATIENTS

Critically ill adults (n = 4,064) admitted greater than or equal to 24 hours without a condition hampering delirium assessment.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Daily mental status was classified as arousable without delirium, delirium, or unarousable. Pain was assessed six times daily in arousable patients using a 0-10 Numeric Rating Scale (NRS) or the Critical Care Pain Observation Tool (CPOT); daily peak pain score was categorized as no (NRS = 0/CPOT = 0), mild (NRS = 1-3/CPOT = 1-2), moderate (NRS = 4-6/CPOT = 3-4), or severe (NRS = 7-10/CPOT = 5-8) pain. To address missingness, a Multiple Imputation by Chained Equations approach that used available daily pain severity and 19 pain predictors was used to generate 25 complete datasets. Using a first-order Markov model with a multinomial logistic regression analysis, that controlled for 11 baseline/daily delirium risk factors and considered the competing risks of unarousability and ICU discharge/death, the association between peak daily pain and next-day delirium in each complete dataset was evaluated.

RESULTS

Among 14,013 ICU days (contributed by 4,064 adults), delirium occurred on 2,749 (19.6%). After pain severity imputation on 1,818 ICU days, mild, moderate, and severe pain were detected on 2,712 (34.1%), 1,682 (21.1%), and 894 (11.2%) of the no-delirium days, respectively, and 992 (36.1%), 513 (18.6%), and 27 (10.1%) of delirium days (p = 0.01). The presence of any pain (mild, moderate, or severe) was not associated with a transition from awake without delirium to delirium (aOR 0.96; 95% CI, 0.76-1.21). This association was similar when days with only mild, moderate, or severe pain were considered. All results were stable after controlling for daily opioid dose.

CONCLUSIONS

After controlling for multiple delirium risk factors, including daily opioid use, pain may not be a risk factor for delirium in the ICU. Future prospective research is required.

Accuracy of Pain Scales in Predicting Critical Diagnoses in Non-Traumatic Abdominal Pain Cases; a Cross-sectional Study

Introduction

Accurate assessment and management of abdominal pain in the emergency department (ED) is crucial, as it can indicate potentially life-threatening conditions requiring timely treatment. This study aimed to evaluate the ability of pain scales to predict critical diagnoses in patients with non-traumatic abdominal pain.

Methods

This cross-sectional study was conducted at a tertiary university hospital and involved individuals aged 15 years and above who presented to the ED with non-traumatic abdominal pain. Pain severity was evaluated using subjective pain scales, including the Numerical Rating Scale (NRS) and the Face Pain Scale (FPS), as well as objective pain scales, including the Critical Care Pain Observation Tool (CPOT) and the Non-verbal Pain Score (NVPS). The area under the receiver operating characteristic curve (AuROC) was employed to determine the discriminative ability of each pain scale to predict critical diagnosis.

Results

264 cases with the mean age of 47.2±19.4 years were studied (53.0% male). The most common location of abdominal pain was epigastric pain (43.9%). Most patients presented with dull-aching pain, and those with critical diagnoses had more of this characteristic than those with non-critical diagnoses. (52.5% vs. 28.3%, p = 0.01). The overall median NRS, FPS, CPOT, and NVPS of included participants were 8 (interquartile range (IQR) 7-10), 8 (IQR 6-8), 3 (IQR 1-4), and 3 (IQR 2-4), respectively. Patients with critical diagnoses had a higher NVPS score than patients with non-critical diagnoses (median score of 4 vs. 3, p = 0.02). The AuROC of NRS, FPS, CPOT, and NVPS were 0.53 (95% CI: 0.45-0.62), 0.55 (95% CI: 0.46-0.63), 0.59 (95% CI: 0.50-0.68), and 0.62 (95% CI: 0.53-0.71), respectively. The correlation coefficients among these scales were considered moderately correlated or higher.

Conclusion

In evaluating patients with non-traumatic abdominal pain, the NVPS demonstrated the highest accuracy in predicting critical diagnoses. However, all pain scales, whether subjective or objective, exhibited suboptimal performance in predicting critical diagnoses.

Effects of an interactive handgrip game on surgical patients requiring intensive care: An assessor-blinded randomized controlled trial

OBJECTIVE

To explore the effect of an interactive handgrip game on psychological distress and handgrip strength among critically ill surgical patients.

DESIGN

A randomised controlled trial.

SETTING

A surgical intensive care unit.

INTERVENTION

Participants were enrolled in the program within 48 hours of admission to the intensive care unit. Patients in the intervention group played a 20-minute interactive handgrip game twice daily for a maximum of three days in the intensive care unit in addition to routinely passive physical rehabilitation. Patients in the routine care group had a daily target of 20 min of passive physical rehabilitation as needed.

MEASUREMENT

The primary outcomes included depression, anxiety, and stress measured using the shortened version of the Depression Anxiety Stress Score scale. The secondary outcomes were perceived sleep evaluated using the Richards-Campbell Sleep Questionnaire, delirium assessed using the Intensive Care Delirium Screening Checklist, and handgrip strength measured using handgrip dynamometry within a handgrip device.

RESULTS

Two hundred and twenty-seven patients were eligible and 70 patients were recruited in the intervention (n = 35) and routine care groups (n = 35). The patients in the intervention group had lower scores (median = 6.0, 4.0, and 12.0) for depression, anxiety, and stress compared with those in the routine care group (12.0, 12.0, and 20.0; all p < 0.05). The interactive handgrip game did not significantly improve sleep quality and prevent the occurrence of delirium (both p > 0.05). The patients who received the interactive handgrip game intervention exhibited significantly enhanced handgrip strength in both hands over time (both p < 0.001).

CONCLUSION

An interactive handgrip game may benefit the psychological well-being and handgrip strength of critically ill patients.

IMPLICATIONS FOR CLINICAL PRACTICE

Interactive handgrip games is effective active exercise which should be integrated into routine nursing practice.

Pain Prevalence and Management in a General Hospital Through Repeated Cross-Sectional Surveys in 2011 and 2021

Background

There is great scope for improving the quality of pain management. Although pain prevalence has been investigated in several countries, few studies have comparatively assessed changes in pain prevalence and management over a span of multiple years.

Aim

This work was aimed at determining the pain prevalence and evaluating the condition of pain management in a Chinese general hospital in 2021 and comparing them with corresponding data from 10 years ago.

Methods

Repeated single-center cross-sectional studies were initiated on June 14th, 2011, and September 2nd, 2021, in the same tertiary grade A Chinese general hospital. The same structured questionnaire was used to collect inpatient data on pain intensity and classification and pain management outcomes. We performed statistical analyses to compare categorical variables to assess changes over time.

Results

The sample sizes for the investigations in 2011 and 2021 were 2323 and 4454, respectively. In 2021, 24.34% of patients experienced pain; this percentage was significantly lower than that in 2011. Meanwhile, the prevalence of moderate and severe pain decreased from 14.73% in 2011 to 4.98% in 2021. The other six indicators of pain management outcomes also improved significantly. The percentages of patients using painkillers, opioid analgesics, and multiple analgesics increased from 44.61 to 51.38%, 24.01% to 44.61%, and 6.82% to 14.11%, respectively. Furthermore, the percentages of patients who received pain information and who actively reported pain increased from 27.56% to 96.5% and from 85.54% to 98.71%, respectively. The percentage of patients qualified to accurately use the Numerical Rating Scale increased from 10.5% to 79.98%.

Conclusion

The quality and outcomes of pain management improved greatly after the establishment and implementation of the pain management system. Nonetheless, pain of different intensities is common after major surgeries, and it is recommended that hospitals popularize and implement perioperative multimodal analgesia strategies to reduce the incidence of postoperative pain.

Using AI to Detect Pain through Facial Expressions: A Review

Pain assessment is a complex task largely dependent on the patient's self-report. Artificial intelligence (AI) has emerged as a promising tool for automating and objectifying pain assessment through the identification of pain-related facial expressions. However, the capabilities and potential of AI in clinical settings are still largely unknown to many medical professionals. In this literature review, we present a conceptual understanding of the application of AI to detect pain through facial expressions. We provide an overview of the current state of the art as well as the technical foundations of AI/ML techniques used in pain detection. We highlight the ethical challenges and the limitations associated with the use of AI in pain detection, such as the scarcity of databases, confounding factors, and medical conditions that affect the shape and mobility of the face. The review also highlights the potential impact of AI on pain assessment in clinical practice and lays the groundwork for further study in this area.

Modern Sedation and Analgesia Strategies in Neurocritical Care

PURPOSE OF REVIEW

Patients with acute neurologic injury require a specialized approach to critical care, particularly with regard to sedation and analgesia. This article reviews the most recent advances in methodology, pharmacology, and best practices of sedation and analgesia for the neurocritical care population.

RECENT FINDINGS

In addition to established agents such as propofol and midazolam, dexmedetomidine and ketamine are two sedative agents that play an increasingly central role, as they have a favorable side effect profile on cerebral hemodynamics and rapid offset can facilitate repeated neurologic exams. Recent evidence suggests that dexmedetomidine is also an effective component when managing delirium. Combined analgo-sedation with low doses of short-acting opiates is a preferred sedation strategy to facilitate neurologic exams as well as patient-ventilator synchrony. Optimal care for patients in the neurocritical care population requires an adaptation of general ICU strategies that incorporates understanding of neurophysiology and the need for close neuromonitoring. Recent data continues to improve care tailored to this population.

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.

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.

Clinical Assessment of Chronic Musculoskeletal Pain-A Framework Proposal Based on a Narrative Review of the Literature

The assessment of chronic musculoskeletal pain (CMP) is a challenge shared by several health professionals. Fragmented or incomplete assessment can cause deleterious consequences for the patient's function. The objective of this paper was to propose a framework for clinical assessment of CMP based on the current literature and following the conceptual model of the International Classification of Functioning and Health (ICF). We propose that the ICF rationale may help to guide the processes, acting as a moderator of the clinical assessment, since it changes the perspective used to obtain and interpret findings during anamnesis and physical examination. Additionally, updated specific knowledge about pain, including that of pain domains and mechanisms, along with effective patient-clinician communication may act as a mediator of CMP assessment. We conduct the readers through the steps of the clinical assessment of CMP using both the proposed moderator and mediators and present a clinical example of application. We suggest that the proposed framework may help clinicians to implement a CMP assessment based on the biopsychosocial model using a critical and updated rationale, potentially improving assessment outcomes, i.e., clinical diagnosis.

Rationale for integration of palliative care in the medical intensive care: A narrative literature review

Despite the remarkable technological advancement in the arena of critical care expertise, the mortality of critically ill patients remains high. When the organ functions deteriorate, goals of care are not fulfilled and life-sustaining treatment becomes a burden on the patient and caregivers, then it is the responsibility of the physician to provide a dignified end to life, control the symptoms of the patient and provide psychological support to the family members. Palliative care is the best way forward for these patients. It is a multidimensional specialty which emphasizes patient and family-based care and aims to improve the quality of life of patients and their caregivers. Although intensive care and palliative care may seem to be at two opposite ends of the spectrum, it is necessary to amalgamate the postulates of palliative care in intensive care units to provide holistic care and best benefit patients admitted to intensive care units. This review aims to highlight the need for an alliance of palliative care with intensive care in the present era, the barriers to it, and models proposed for their integration and various ethical issues.

Risk factors of self-extubation in intensive care. Retrospective cohort study

Introduction: Acute respiratory failure remains one of the three leading causes of admission to the intensive care unit (ICU). Self-extubation is an adverse outcome requiring reintubation in 50% of cases. Objective: To assess for determinants (risk factors) of self-extubation and mortality in the ICU by using a generalized estimation equation model (GEE). Methods: The data was collected from a retrospective cohort study from 2017-2020 including all patients admitted to the ICU with mechanical ventilation. Univariate and bivariate analyses were performed. Then, a GEE model was conducted to predict the risk of self-extubation and mortality. Results: A total of 857 subjects were included, with a mean age of 60.5 +/- 17 years-old. Most of the subjects were males (55.2%). An 8.99-fold risk (95%CI 3.83-21.1, p<0.01) of self-extubation was identified in patients with agitation. Exposure to infusion of neuromuscular blockade was also found to increase the risk of self-extubation 3.37 times (95%CI 1.31-8.68, p=0.01). No associations were identified between immobilization and self-extubation (OR 1.38 95%CI 0.76-2.51, p=0.29). Finally, light sedation according to the Richmond Sedation Scale (RASS) between 0 to -2 rather than moderate (RASS-3) reduces the risk of mortality (OR 0.57, 95%CI 0.38-0.83, p<0.01). Conclusions: The main factors resulting in self-extubation were: agitation, delirium, and infusion of neuromuscular blocking agents. An association was found between light sedation and a lower risk of mortality. No association was found between the use of physical restraint and the desired outcome.

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.

Analgesia in the Neurosurgical Intensive Care Unit

Acute pain in neurosurgical patients is an important issue. Opioids are the most used for pain treatment in the neurosurgical ICU. Potential side effects of opioid use such as oversedation, respiratory depression, hypercapnia, worsening intracranial pressure, nausea, and vomiting may be problems and could interfere with neurologic assessment. Consequently, reducing opioids and use of non-opioid analgesics and adjuvants (N-methyl-D-aspartate antagonists, α2 -adrenergic agonists, anticonvulsants, corticosteroids), as well as non-pharmacological therapies were introduced as a part of a multimodal regimen. Local and regional anesthesia is effective in opioid reduction during the early postoperative period. Among non-opioid agents, acetaminophen and non-steroidal anti-inflammatory drugs are used frequently. Adverse events associated with opioid use in neurosurgical patients are discussed. Larger controlled studies are needed to find optimal pain management tailored to neurologically impaired neurosurgical patients.

Intensive care therapy during the pandemic in 2020 and beyond: Mnemonics can help

In a busy working environment, with a shortage of healthcare workers and increased workloads since the beginning of the COVID-19 pandemic, the implementation of an easy-to-remember mnemonic can significantly help anesthesiologists and clinicians in conducting intensive therapy. One of the first mnemonics in critical care therapy was implemented by Jean-Louis Vincent in 2005. FAST HUG concept reminds clinicians of crucial moments in therapy - nutritional support(F-feeding), analgesia and sedation (A - analgesia, S - sedation), thrombosis prophylaxis (T - thrombolytic prophylaxis), head elevation in bed (H - head of the elevated bed), antiulcer therapy (U - stress ulcer prevention) and glycemic control (G - glucose control). This acronym has been modified and tested in several studies over the years for the treatment of different patient types. This concept is widely utilized in intensive care units, it is characterized with easy implementation, and proved to be useful in ventilator-associated pneumonia prevention. Therapy of critically ill patients with COVID-19 is based on elements of general intensive care therapy with some specific therapeutic guidelines. With the intention to ease and improve therapy of patients with COVID-19 in intensive care units, a new and comprehensive acronym is proposed: One Fast Hug Bids COVID.

Impact of the 2018 Society of Critical Care Medicine Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Guidelines on Nonopioid Analgesic Use and Related Outcomes in Critically Ill Adults After Major Surgery

We compared ICU nonopioid analgesic use, opioid use, and pain before and after Pain, Agitation/Sedation, Delirium, Immobility, and Sleep guideline publication at one academic center among critically ill adults receiving an opioid infusion and greater than or equal to 24 hours of mechanical ventilation after major surgery. The 2017 (n = 77) and 2019 (n = 57) groups were similar at baseline. The 2019 (vs 2017) patients were more likely to receive scheduled IV/oral acetaminophen (84% vs 69%; p = 0.05), less likely to receive a lidocaine patch (33% vs 50%; p = 0.05), and just as likely to receive ketamine (4% vs 3%; p = 1.0), an nonsteroidal anti-inflammatory drug (7% vs 3%; p = 0.26), or gabapentin/pregabalin (16% vs 9%; p = 0.23). Daily average opioid exposure (in IV morphine milligram equivalent) was not different (70 [42–99] [2017] vs 78 mg [49–109 mg]; p = 0.94). The 2019 (vs 2017) group spent more ICU days with severe pain (p = 0.04). At our center, Pain, Agitation/Sedation, Delirium, Immobility, and Sleep guideline publication had little effect on nonopioid analgesic or opioid prescribing practices in critically ill surgical adults.

Opioid Use Increases the Risk of Delirium in Critically Ill Adults Independently of Pain

Rationale: It is unclear whether opioid use increases the risk of ICU delirium. Prior studies have not accounted for confounding, including daily severity of illness, pain, and competing events that may preclude delirium detection.Objectives: To evaluate the association between ICU opioid exposure, opioid dose, and delirium occurrence.Methods: In consecutive adults admitted for more than 24 hours to the ICU, daily mental status was classified as awake without delirium, delirium, or unarousable. A first-order Markov model with multinomial logistic regression analysis considered four possible next-day outcomes (i.e., awake without delirium, delirium, unarousable, and ICU discharge or death) and 11 delirium-related covariables (baseline: admission type, age, sex, Acute Physiology and Chronic Health Evaluation IV score, and Charlson comorbidity score; daily: ICU day, modified Sequential Organ Failure Assessment, ventilation use, benzodiazepine use, and severe pain). This model was used to quantify the association between opioid use, opioid dose, and delirium occurrence the next day.Measurements and Main Results: The 4,075 adults had 26,250 ICU days; an opioid was administered on 57.0% (n = 14,975), severe pain occurred on 7.0% (n = 1,829), and delirium occurred on 23.5% (n = 6,176). Severe pain was inversely associated with a transition to delirium (odds ratio [OR] 0.72; 95% confidence interval [CI], 0.53-0.97). Any opioid administration in awake patients without delirium was associated with an increased risk for delirium the next day [OR, 1.45; 95% CI, 1.24-1.69]. Each daily 10-mg intravenous morphine-equivalent dose was associated with a 2.4% increased risk for delirium the next day.Conclusions: The receipt of an opioid in the ICU increases the odds of transitioning to delirium in a dose-dependent fashion.

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.

Effectiveness of the ABCDEF bundle on delirium, functional outcomes and quality of life in intensive care patients: a study protocol for a randomised controlled trial with embedded process evaluation

INTRODUCTION

Hospital mortality for critically ill patients has decreased significantly throughout the developed world over the past two decades, attributable to improvements in the quality of intensive care, advances in critical care medicine and technologies that provide long-term multiorgan support. However, the long-term outcomes of intensive care unit (ICU) survivors is emerging as a real issue. Cognitive and physical impairments suffered by ICU survivors are common including profound weakness, pain and delirium which are inextricably linked. This study aims to determine the effectiveness of the Assess, prevent and manage pain; Both spontaneous awakening and spontaneous breathing trials; Choice of sedation and analgesia; Delirium: assess, prevent and manage; Early mobility and exercise; Family engagement and empowerment (ABCDEF) bundle in reducing ICU-related short-term and long-term consequences of critical illness through a randomised controlled trial (RCT).

METHODS AND ANALYSIS

The study will be a single-centre, prospective RCT. A total of 150 participants will be recruited and randomised to either receive the ABCDEF bundle protocol or non-protocolised standard care for the duration of the participant's admission in the ICU. The primary outcome is delirium status measured using the Confusion Assessment Measure for ICU (CAM-ICU). Secondary outcomes include physical function measured by the Functional Independence Measure and quality of life measured by the European Quality of Life five dimensions, five-level questionnaire. A mixed-method process evaluation will contribute to understanding the experience of health teams who implement the ABCDEF bundle into practice.

ETHICS AND DISSEMINATION

Ethics approval was provided by the Metro South Health Human Research Ethics Committee (HREC) (EC00167) and the Griffith University's HREC prior to study commencement.Study results will be disseminated by presentations at conferences and via publications to peer-review journals.

TRIAL REGISTRATION NUMBER

ACTRN12620000736943; Pre-results.

Short- and long-term opioid use in survivors of subarachnoid hemorrhage

OBJECTIVES

Opioids are frequently used for analgesia in patients with acute subarachnoid hemorrhage (SAH) due to a high prevalence of headache and neck pain. However, it is unclear if this practice may pose a risk for opioid dependence, as long-term opioid use in this population remains unknown. We sought to determine the prevalence of opioid use in SAH survivors, and to identify potential risk factors for opioid utilization.

METHODS

We analyzed a cohort of consecutive patients admitted with non-traumatic and suspected aneurysmal SAH to an academic referral center. We included patients who survived hospitalization and excluded those who were not opioid-naïve. Potential risk factors for opioid prescription at discharge, 3 and 12 months post-discharge were assessed.

RESULTS

Of 240 SAH patients who met our inclusion criteria (mean age 58.4 years [SD 14.8], 58% women), 233 (97%) received opioids during hospitalization and 152 (63%) received opioid prescription at discharge. Twenty-eight patients (12%) still continued to use opioids at 3 months post-discharge, and 13 patients (6%) at 12-month follow up. Although patients with poor Hunt and Hess grades (odds ratio 0.19, 95% CI 0.06-0.57) and those with intraventricular hemorrhage (odds ratio 0.38, 95% CI 0.18-0.87) were less likely to receive opioid prescriptions at discharge, we did not find significant differences between patients who had long-term opioid use and those who did not.

CONCLUSION

Opioids are regularly used in both the acute SAH setting and immediately after discharge. A considerable number of patients also continue to use opioids in the long-term. Opioid-sparing pain control strategies should be explored in the future.

Authorized Agent-Controlled Analgesia for Pain Management in Critically Ill Adult Patients

BACKGROUND

Patient-controlled analgesia is commonly used for adult patients requiring parenteral opioid analgesia in the postoperative setting. However, many patients are unable to use patient-controlled analgesia because of physical or cognitive limitations. Authorized agent-controlled analgesia, in which a nurse or family member activates the patient-controlled analgesia device, has been studied in the pediatric population but has received little attention in adults.

OBJECTIVE

To evaluate the efficacy of authorized agent-controlled analgesia in critically ill adult patients.

METHODS

A retrospective pilot study was conducted involving 46 patients who were placed on an authorized agent-controlled analgesia protocol in a mixed medical/surgical adult intensive care unit. Critical-Care Pain Observation Tool scores were abstracted for the 24 hours before and after initiation of authorized agent-controlled analgesia. Authorized agent-controlled analgesia was administered by nurses only.

RESULTS

The mean (SD) change in pain score was -3.4 (2.0) (95% CI, -4.0 to -2.7), representing a 69% decrease in the mean (SD) pain score from before to after initiation of authorized agent-controlled analgesia (4.8 [1.8] vs 1.5 [1.6]; P < .001). When the results were controlled for time, sedative administration, and opioid medication administration, the effect of authorized agent-controlled analgesia initiation on pain scores remained significant (P < .001).

CONCLUSIONS

Use of authorized agent-controlled analgesia is associated with a reduction in pain in critically ill patients. Larger studies are warranted to confirm these findings.

Current Perspectives on the Assessment and Management of Pain in the Intensive Care Unit

Critical illness is often painful, both from the underlying source of illness, as well as necessary procedures performed for the monitoring and care of these patients. Pain is often under-recognized in the critically ill, especially among those who cannot self-report, so accurate assessment and management continue to be major consideration in their care. Pain management in the intensive care unit (ICU) is an evolving practice, with a focus on accurate and frequent pain assessment, and targeted pharmacologic and non-pharmacologic treatment methods to maximize analgesia and minimize sedation. In this review, we will evaluate several validated methods of pain assessment in the ICU and present management options. We will review the evidence-based recommendations put forth by the largest critical care societies and several high-quality studies related to both the in-hospital approach to pain, as well as the short- and long-term consequences of untreated pain in ICU patients. We conclude with future directions.

Patient's experiences of endotracheal tubes and suction following cardiac surgery

BACKGROUND

There is a growing body of evidence addressing the patient experience of intensive care, including patient reports that the presence of an endotracheal tube is bothersome and distressing, and that endotracheal suction is moderately to extremely painful. Yet there remains little information about the patient experience of the endotracheal tube and suction in those patients receiving planned short-term mechanical ventilation.

AIMS AND OBJECTIVES

This study aimed to describe the patient experience of the endotracheal tube and suction, following mechanical ventilation in post-operative cardiac surgical patients.

DESIGN

This qualitative study used inductive thematic analysis. Participants having planned cardiac surgery, anticipated to receive less than 12-hours mechanical ventilation, were approached pre-operatively and written consent provided.

METHODS

Ten participants were recruited using purposive sampling. Semi-structured interviews were conducted between days four and six post-operatively. One researcher interviewed all participants; two researchers independently read, coded, and agreed themes.

FINDINGS

None of the participants recalled endotracheal suction, while half had no recollection of the endotracheal tube. Three themes were identified; the experience of the endotracheal tube and extubation, the experience of emerging from sedation, and participants concerns about the future. The presence of the endotracheal tube was described as bothersome, whilst breathing through the tube and extubation were described as 'weird' and 'strange' but not painful.

CONCLUSIONS

Knowledge of the patient experience can help inform nursing practice by improving pre and post-operative care planning.

RELEVANCE TO CLINICAL PRACTICE

This study adds to the body of knowledge about the patient experience of the endotracheal tube and extubation.

TRIAL REGISTRATION

Prospective registration with the Australian New Zealand Clinical Trials Registry. www.anzctr.org.au (ACTRN12616001515482).

An Objective Pain Score for Chronic Pain Clinic Patients

Objectives

Although numerous studies have looked at the numeric rating scale (NRS) in chronic pain patients and several studies have evaluated objective pain scales, no known studies have assessed an objective pain scale for use in the evaluation of adult chronic pain patients in the outpatient setting. Subjective scales require patients to convert a subjective feeling into a quantitative number. Meanwhile, objective pain scales utilize, for the most part, the patient's behavioral component as observed by the provider in addition to the patient's subjective perception of pain. This study aims to examine the reliability and validity of an objective Chronic Pain Behavioral Pain Scale for Adults (CBPS) as compared to the traditional NRS.

Methods

In this cross-sectional study, patients were assessed before and after an interventional pain procedure by a researcher and a nurse using the CBPS and the NRS. Interrater reliability, concurrent validity, and construct validity were analyzed.

Results

Interrater reliability revealed a fair-good agreement between the nurse's and researcher's CBPS scores, weighted kappa values of 0.59 and 0.65, preprocedure and postprocedure, respectively. Concurrent validity showed low positive correlation for the preprocedure measurements, 0.34 (95% CI 0.16-0.50) and 0.47 (95% CI 0.31-0.61), and moderate positive correlation for the postprocedure measurements, 0.68 (95% CI 0.56-0.77) and 0.67 (95% CI 0.55-0.77), for the nurses and researchers, respectively. Construct validity demonstrated an equally average significant reduction in pain from preprocedure to postprocedure, CBPS and NRS median (IQR) scores preprocedure (4 (2-6) and 6 (4-8)) and postprocedure (1 (0-2) and 3 (0-5)), p < 0.001. Discussion. The CBPS has been shown to have interrater reliability, concurrent validity, and construct validity. However, further testing is needed to show its potential benefits over other pain scales and its effectiveness in treating patients with chronic pain over a long-term. This study was registered with ClinicalTrial.gov with National Clinical Trial Number NCT02882971.

Evidence-Based Guideline for Adult Sedation, Pain Assessment, and Analgesia in a Low Resource Setting Intensive Care Unit: Review Article

Background

Agitation and anxiety occur frequently in ICU and affect about 30–80% of patients in ICU present with delirium worldwide, and it is associated with adverse clinical outcomes. This review aimed to systematically review articles and finally draw an evidence-based guideline for an area with limited resources.

Methods

The review was reported based on preferred reporting items for systemic and meta-analysis (PRISMA) protocol. We searched literature from PubMed, Google Scholar, and Medline database using keywords like the level of sedation, sedation score, pain assessment in ICU, and sedative drugs in ICU from an article published in English. After extraction with a patient population and exclusion, five randomized clinical trials, four systemic reviews and meta-analysis, four observation cohort study, and two practical guidelines were used for the review.

Conclusion

In addition to high validity and reliability, RASS has the advantage of easiness to remember for nurses making it a preferred sedation assessment tool in an adult ICU setting. Light sedation with daily interruption was recommended with an aim of an awake and alert patient ready for the weaning trial. Propofol was preferred when sedation is for a short duration and when intermittent awakening is required. Ketamine is the preferred induction for asthmatic hypotensive and patient requiring prolonged continuous sedation. With a similar time for sedation, diazepam shows a shorter time for intubation compared to midazolam. Besides diazepam has shown a cheaper cost of sedation than midazolam. This makes it a drug of preference in a low resource setting.

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.

Pain Management Interventions for Drug-addicted Patients Admitted in Intensive Care Units: An Integrative Review

Background:

Pain management interventions among critically ill drug-addicted patients admitted to ICUs are still the major challenge faced by healthcare practitioners.

Objective:

Therefore, this study aimed to identify and appraise the pain management approaches of patients with drug addiction (substance use disorder) admitted in ICUs.

Methods:

An integrative review of the literature was performed; narrative data synthesis was used for data extraction. The search was performed using scientific databases, including Google Scholar, PubMed, Scopus, Web of Science, Ovid Medline and EMBASE from January 2000 to September 2019. All studies that assessed pain management interventions for drug-addicted patients (substance use disorder) admitted in ICUs were included in the review.

Results:

Initially, four studies were included in this review. All these studies were Randomized Controlled Trials. The settings were intensive care units in the United States and Iran. The evidence identified from all studies included administration of intravenous paracetamol and midazolam, implementation of Buprenorphine-Naloxone therapy, adjuvant therapy and proper utilization of nursing sedation and pain management interventions for addicted patients admitted in ICUs.

Conclusion:

Management of pain in drug-addicted patients admitted in ICUs is relevant to healthcare practitioners, especially critical care nurses, as these patients’ subpopulation is at risk of underestimation of pain levels and not getting appropriate treatment.

Incidence of Inadequate Pain Treatment among Ventilated, Critically Ill Surgical Patients in a Thai Population

BACKGROUND

Inadequate pain treatment during intensive care unit stays causes many unfavorable outcomes. Pain assessment in mechanically ventilated patients is challenging because most cannot self-report pain. The incidence of pain among Thai surgical intensive care unit (SICU) patients has never been reported.

AIMS

To determine the inadequate pain control incidence among ventilated, critically ill, surgical patients.

DESIGN

Prospective, observational study.

SETTING

SICU of a university-based hospital during November 2017-January 2019.

PARTICIPANTS

Patients aged > 18 years, admitted to the SICU for a foreseeable duration of mechanical ventilation > 24 hours were included.

METHODS

On post-admission Day 2, each was assessed for pain at rest (every 4 hours) and during bed-bathing using the Critical Care Pain Observation Tool (CPOT; Thai version) or the 0-10 numeric rating scale (NRS). CPOT scores > 2 or NRS scores > 3 signified inadequate pain control, while a RASS score ≤ -3 was defined as overtreatment.

RESULTS

118 were included. The inadequate-pain-management incidence was 34% (n = 40) at rest and 29% (n = 34) during bed-bathing. The severe-pain incidence (NRS > 6, or CPOT > 5) was 5.9% (n = 7). Our incidence of overtreatment was 1.7%. The demographic data and ICU complication-rates of patients with adequate and inadequate pain treatment were similar.

CONCLUSIONS

Pain assessment tools in critically ill patients should be developed and validated to the language of the tool users in order to determine the incidence of pain accurately. The inadequate-pain-treatment incidence in ventilated critically ill, Thai surgical patients was lower than previously reported from other countries.

Assessing pain in critically ill brain-injured patients: a psychometric comparison of 3 pain scales and videopupillometry

Three clinical scales (the Nociception Coma Scale adapted for Intubated patients [NCS-I], its Revised version [NCS-R-I], and the Behavioral Pain Scale [BPS]) and videopupillometry were compared for measuring pain in intubated, noncommunicating, critically ill, brain-injured patients. Pain assessment was performed before, during, just after, and 5 minutes after 3 procedures: the reference non-nociceptive procedure (assessment of the Richmond Agitation Sedation Scale) and 2 nociceptive procedures (turning and tracheal suctioning). The primary endpoint was construct validity (discriminant and criterion validation), determined by comparing pain measurements between different times/procedures. Secondary endpoints were internal consistency, inter-rater reliability, and feasibility. Fifty patients (54% women, median age 63 years [56-68]) were included 13 [7-24] days after brain injury (76% hemorrhagic or ischemic strokes). All tools increased significantly more (P < 0.001) during the nociceptive procedures vs the non-nociceptive procedure. The BPS was the only pain tool that did not increase significantly during the non-nociceptive procedure (P = 0.41), suggesting that it was the most discriminant tool. The BPS, NCS-I, and NCS-R-I were good predictors of nociception with areas under the curves ≥0.96, contrary to videopupillometry (area under the curve = 0.67). The BPS, NCS-I, and NCS-I-R had high inter-rater reliabilities (weighted kappa = 0.86, 0.82 and 0.84, respectively). Internal consistency was moderate (>0.60) for all pain scales. Factor analysis represented a majority of information on a first dimension, with motor domains represented on a second dimension. Scale feasibility was better for the NCS-I and NCS-R-I than for the BPS. In conclusion, the BPS, NCS-I, and NCS-R-I are valid, reliable, and acceptable pain scales for use in intubated critically ill, brain-injured patients, unlike videopupillometry. Future research requires tool design centered on domains of observation adapted to this very specific population.

Progressive active mobilization with dose control and training load in critically ill patients (PROMOB): Protocol for a randomized controlled trial

The dose of progressive active mobilization is still uncertain. The purpose of this study is to identify if the addition of a protocol of progressive active mobilization with dose and training load control to usual care is effective in reducing the length of stay in intensive care unit (ICU) and the improvement of the functioning, incidence of ICU-acquired weakness (ICUAW), mechanical ventilation duration and mortality rate in patients hospitalized in ICU. It is Double-blind randomised clinical trial. The setting for this trial will be medical and surgical ICU of a university hospital. The study participants will be 118 patients aged> 18 years admitted to ICU for less than 72 hours. Participants will be randomized to either an experimental or control group. The experimental group will undertake addition of a protocol of progressive active mobilization with dose and training load control to usual care, while the control group will undertake only usual care. The primary outcome will be length of ICU stay. The secondary outcomes will be Cross-sectional area and muscle thickness of the rectus femoris and biceps brachii, Change in muscle strength from the baseline, Functional Status, incidence of ICUAW, Days with mechanical ventilation and Mortality. All statistical analyses will be conducted following intention-to-treat principles. It has a detailed description of the dose of exercise, was designed with the strictest methodological criteria. These characteristics allow to investigate with greater certainty the results progressive active mobilization in critical patients, allowing replication and future combinations in meta-analyzes.

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.

Developing a pain intensity prediction model using facial expression: A feasibility study with electromyography

The automatic detection of facial expressions of pain is needed to ensure accurate pain assessment of patients who are unable to self-report pain. To overcome the challenges of automatic systems for determining pain levels based on facial expressions in clinical patient monitoring, a surface electromyography method was tested for feasibility in healthy volunteers. In the current study, two types of experimental gradually increasing pain stimuli were induced in thirty-one healthy volunteers who attended the study. We used a surface electromyography method to measure the activity of five facial muscles to detect facial expressions during pain induction. Statistical tests were used to analyze the continuous electromyography data, and a supervised machine learning was applied for pain intensity prediction model. Muscle activation of corrugator supercilii was most strongly associated with self-reported pain, and the levator labii superioris and orbicularis oculi showed a statistically significant increase in muscle activation when the pain stimulus reached subjects' self -reported pain thresholds. The two strongest features associated with pain, the waveform length of the corrugator supercilii and levator labii superioris, were selected for a prediction model. The performance of the pain prediction model resulted in a c-index of 0.64. In the study results, the most detectable difference in muscle activity during the pain experience was connected to eyebrow lowering, nose wrinkling and upper lip raising. As the performance of the prediction model remains modest, yet with a statistically significant ordinal classification, we suggest testing with a larger sample size to further explore the variables that affect variation in expressiveness and subjective pain experience.

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.

The effectiveness of systematic pain assessment on critically ill patient outcomes: A randomised controlled trial

BACKGROUND

Evidence suggests that critically ill patients' pain may still be underestimated. Systematic approaches to pain assessment are of paramount importance for improving patients' outcomes.

OBJECTIVES

To investigate the effectiveness of a systematic approach to pain assessment on the incidence and intensity of pain and related clinical outcomes in critically ill patients.

METHODS

Randomized controlled study with consecutive critically ill patients allocated to either a standard care only or a systematic pain assessment group. The Behavioral Pain Scale (BPS) and the Critical Pain Observation Tool (C-POT) were completed twice daily for all participants. In the intervention group, clinicians were notified of pain scores. Linear Mixed Models (LMM) for the longitudinal effect of the intervention were employed.

RESULTS

A total of 117 patients were included (control: n=61; intervention: n2=56). The incidence of pain (C-POT >2) in the intervention group was significantly lower compared to the control group (p < .001). The intervention had a statistically significant effect on pain intensity (BPS, p = 0.01). The average total morphine equivalent dose in the intervention group was higher than in the control group (p = 0.045), as well as the average total dose of propofol (p = 0.027). There were no statistically significant differences in ICU mortality (23.4% vs 19.3%, p=0.38, odds ratio 0.82 [0.337-1.997]) and length of ICU stay (13.5, SD 11.1 vs 13.9, SD 9.5 days, p= 0.47).

CONCLUSION

Systematic pain assessment may be associated with a decrease in the intensity and incidence of pain and influence the pharmacological management of pain and sedation of critically ill patients.

Pain Assessment in the Patient Unable to Self-Report: Clinical Practice Recommendations in Support of the ASPMN 2019 Position Statement

Pain is a subjective experience, unfortunately, some patients cannot provide a self-report of pain verbally, in writing, or by other means. In patients who are unable to self-report pain, other strategies must be used to infer pain and evaluate interventions. In support of the ASPMN position statement "Pain Assessment in the Patient Unable to Self-Report", this paper provides clinical practice recommendations for five populations in which difficulty communicating pain often exists: neonates, toddlers and young children, persons with intellectual disabilities, critically ill/unconscious patients, older adults with advanced dementia, and patients at the end of life. Nurses are integral to ensuring assessment and treatment of these vulnerable populations.

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.

Validation of a Chinese version critical-care pain observation tool in nonintubated and intubated critically ill patients: Two cross-sectional studies

AIMS AND OBJECTIVES

To validate the Chinese version of the Critical-Care Pain Observation Tool (CPOT) in nonintubated and intubated ICU patients.

BACKGROUND

While CPOT was found to have the best psychometric properties among objective pain assessment scales, there is no Chinese version CPOT for nonintubated patients.

DESIGN

Cross-sectional design was used in these two observational studies.

METHODS

Seventy-six nonintubated patients and 53 intubated patients were assessed to examine internal consistency, criterion-related and discriminative validity of CPOT in the first study. Pain assessment during low pain condition as well as increased pain condition was performed by Numeric Rating Scale (NRS) and the Chinese version COPT. Forty nonintubated patients and 43 intubated patients were assessed to examine inter-rater reliability in the second study. A bedside nurse and a researcher independently executed paired pain assessments with CPOT in the same conditions. The STROBE Statement was followed to guide these studies.

RESULTS

The Cronbach's α in nonintubated patients and intubated patients was 0.903-0.930 and 0.868-0.870. The intraclass correlation coefficients (ICCs) in nonintubated patients ranged from 0.959-0.982, and the ICC in intubated patients ranged from 0.947-0.959, confirming the inter-rater reliability. The moderately positive Pearson's correlations between CPOT and NRS scores (r = 0.757-0.838 in nonintubated patients, r = 0.574-0.705 in intubated patients) indicated the criterion-related validity. A significant increase in CPOT scores in the increased pain condition compared with those acquired in the low pain condition verified the discriminative validity.

CONCLUSIONS

The Chinese version of CPOT was presented to be valid and reliable for both nonintubated and intubated critically ill adults, which could be applicable for pain assessment in patients in ICU.

RELEVANCE TO CLINICAL PRACTICE

This study provides an applicable pain assessment tool for both nonintubated patients and intubated patients in ICU.

Cross-Correlation Among Visual Analog, Observational, and Behavioral Pain Scales of Oncological Patients Undergoing Major Abdominal Surgery

PURPOSE

To determine the perception of postoperative pain intensity between nurses and oncology patients undergoing major abdominal surgery.

DESIGN

A prospective cross-correlation study with 173 oncology patients undergoing major abdominal surgery, such as hepatectomy or pancreatectomy.

METHODS

Postoperative pain intensity was evaluated by clinical pain assessment tools such as critical-care pain observation tool (CPOT) and behavioral pain scale (BPS) recorded by the researcher, whereas the visual analog scale was completed by patients. Demographic and clinical data were recorded.

FINDINGS

The Cronbach's α for CPOT and BPS was α = 0.738 for each. There was a significant correlation between CPOT and BPS (ρ = 0.796, P < .001), whereas the visual analog scale was correlated with CPOT and BPS (ρ = 0.351, P < .001 and ρ = 0.352, P < .001, respectively), showing that nurses did not underestimate patients' pain levels.

CONCLUSIONS

The management of postoperative pain intensity after major abdominal surgery requires clinical comprehension by nurses to achieve the reduction or suppression of pain.

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.

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.

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.

Transition From Continuous Infusion Fentanyl to Hydromorphone in Critically Ill Patients

BACKGROUND

The 2013 Society of Critical Care Medicine guidelines for the management of pain, agitation, and delirium in adult intensive care unit (ICU) patients recommend intravenous opioids as first-line therapy to treat nonneuropathic pain. There is a paucity of literature describing possible benefits of utilizing specific opioids over others in ICU patients.

OBJECTIVE

The objective was to identify rationales for the transition from continuous infusion fentanyl to continuous infusion hydromorphone in critically ill patients.

METHODS

This was a single-center, prospective, observational analysis of adult ICU patients who were transitioned from fentanyl to hydromorphone. The major end point was to characterize the primary reason for transition. Minor end points included secondary reason(s) for transition, transition dosing, changes in continuous sedative requirements, and level of sedation.

RESULTS

Forty-six patients were included in the analysis. The primary rationale for transition was ventilator compliance (28.3%), followed by tachyphylaxis or better pain control (19.6%), and reduction in sedatives (13.0%). The most common secondary reason(s) for transition included reduction in sedatives (47.8%), opioid rotation (32.6%), and obesity (30.4). Median fentanyl rate of 100 µg/h was transitioned to 1 mg/h of hydromorphone. The percentage of patients requiring the use of continuous sedatives was decreased in the 24 hours following transition (P = .005); however, patients were more deeply sedated (P = .02).

CONCLUSION

Rationales for transition were to improve ventilator compliance, optimize patient-specific pharmacokinetics, and limit overall sedative exposure.

Comparison of Self-Reported and Behavioral Pain Assessment Tools in Critically Ill Patients

BACKGROUND

Self-reported and behavioral pain assessment scales are often used interchangeably in critically ill patients due to fluctuations in mental status. The correlation between scales is not well elucidated. The purpose of this study was to describe the correlation between self-reported and behavioral pain scores in critically ill patients.

METHODS

Pain was assessed using behavioral and self-reported pain assessment tools. Behavioral pain tools included Critical Care Pain Observation Tool (CPOT) and Behavioral Pain Scale (BPS). Self-reported pain tools included Numeric Rating Scale (NRS) and Wong-Baker Faces Pain Scales. Delirium was assessed using the confusion assessment method for the intensive care unit. Patient preference regarding pain assessment method was queried. Correlation between scores was evaluated.

RESULTS

A total of 115 patients were included: 67 patients were nondelirious and 48 patients were delirious. The overall correlation between self-reported (NRS) and behavioral (CPOT) pain scales was poor (0.30, P = .018). In patients without delirium, a strong correlation was found between the 2 behavioral pain scales (0.94, P < .0001) and 2 self-reported pain scales (0.77, P < .0001). Self-reported pain scale (NRS) and behavioral pain scale (CPOT) were poorly correlated with each other (0.28, P = .021). In patients with delirium, there was a strong correlation between behavioral pain scales (0.86, P < .0001) and a moderate correlation between self-reported pain scales (0.69, P < .0001). There was no apparent correlation between self-reported (NRS) and behavioral pain scales (CPOT) in patients with delirium (0.23, P = .12). Most participants preferred self-reported pain assessment.

CONCLUSION

Self-reported pain scales and behavioral pain scales cannot be used interchangeably. Current validated behavioral pain scales may not accurately reflect self-reported pain in critically ill patients.