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

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.

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.

IMPACT OF EDUCATIONAL TRAINING ON NEUROLOGICAL ASSESSMENT SKILLS OF FEMALE NURSES IN EVALUATING TRAUMATIC BRAIN INJURY PATIENTS THROUGH GLASGOW COMA SCALE IN LAHORE GENERAL HOSPITAL, LAHORE, PAKISTAN

Background: Traumatic Brain Injury (TBI) is a leading cause of death and disability worldwide. The objective of this study was to determine the impact of educational training on neurological assessment skill of female nurses in evaluating traumatic brain injury patients through Glasgow Coma Scale in Lahore General Hospital, Lahore, Pakistan.Material Methods: This quasi-experimental one group pre-posttest design study was conducted at Lahore School of Nursing, Faculty of Allied Health Sciences, The University of Lahore, Lahore, Pakistan from April 3, 2021 to May 15, 2021. Pre-test neurological assessment skill of 70 nurses was noted by an observer, two weeks educational training was given and four weeks later on, post-test score was noted. For neurological assessment skill, a 20 items observatory checklist was used. Age groups, marital status, job experience, work experience in recent department and work place were four demographic, while neurological assessment skill score was one research variable. Paired sample t test was used for hypothesis testing.Results: Out 70 nurses, 26 (37.1%) were in age group 25-30 years, 18 (25.7%) in 31-35, 16 (22.9%) in 36-40, six (8.6%) in 41-45 and four (5.7%) in 46-50 years. Marital status was; 36 (51.4%) single, 27 (38.6%) married, three (4.3%) divorced and four (5.7%) widow. Job experience was; eight (11.4%) had 2 years, 33 (47.1%) 2-5 years, 25 (35.7%) 6-10 years and four (5.7%) had 10 years. Work experience in recent department was; 16 (22.9%) had 1 year, 39 (55.7%) 1-3 years, 13 (18.6%) 4-5 years and two (2.9%) had 5 years. Work place was Trauma Unit in 12 (17.1%), neurosurgery ICUs in 38 (54.3%) and surgical units in 20 (28.6%) cases. Mean 16.89±2.52 posttest skills score was significantly higher than mean 12.56±2.67 pretest skills score (p=.0001).Conclusion: Our study confirmed that the effect of educational training was significant in improving neurological assessment skills of nurses in evaluating traumatic brain injury patients through Glasgow Coma Scale in Lahore General Hospital, Lahore, Pakistan. Further studies are suggested with increased sample size and multiple research settings.

Occurrence of Delirium during ECMO Therapy in a Critical Care Unit in Poland-A Cross-Sectional Pilot Study

BACKGROUND

The problem of delirium during extracorporeal membrane oxygenation (ECMO) therapy, which has rarely been studied, is an important issue since it is necessary to ensure patient safety during therapy. This study aimed to show the incidence of delirium in patients after extracorporeal membrane oxygenation therapy and factors affecting the occurrence of delirium in this group of patients.

DESIGN

A cross-sectional study was conducted.

METHOD

The study involved a group of patients from an intensive cardiac care unit who received extracorporeal membrane oxygenation therapy. The study lasted for more than two years, in the period from 2018 until 2020. The Nursing Delirium Screening Scale (NuDESC) and the Delirium Observation Screening Scale (DOSS) were applied. Additionally, the patients were examined using Numeric Rating Scale (NRS), the Insomnia Severity Index (ISI), the Richmond Agitation Sedation Scale (RASS), the Ramsay Sedation Scale (RSS), and a thirst intensity scale; ultimately, relationships between these factors and delirium were examined.

RESULTS

In patients who underwent ExtraCorporeal Membrane Oxygenation (ECMO) therapy, delirium was confirmed by the NuDESC in 68.75% of patients in the evening hours, while it was measured by the DOSS scale in 84.38% of patients in the morning. The study found that ECMO delirium was not associated with hyperactivity, sleep disturbance, sedation, pain, or thirst.

CONCLUSION

Delirium in patients undergoing ECMO therapy was confirmed by both the NuDESC and DOSS. Factors such as thirst and sleep disturbance after ECMO therapy were shown to influence the occurrence of delirium. The diagnosis of delirium using standardized scales is possible provided that more tests are carried out. Research should be conducted to determine whether the NuDESC is equivalent to the DOSS.

Pain in Covid Era

The COVID19 pandemic has impacted the lives and health of persons worldwide and although majority of COVID19 patients present with respiratory symptoms, pain emerges as an important feature of COVID19 infection. About 15–20% of patients progress to a severe condition that requires hospitalization. Although the disease was initially reported as a respiratory syndrome, other systems such as cardiovascular, renal, and nervous systems may be affected in the acute stages, increasing the need for continuous support to treat multiple sequelae caused by the disease. Due to the severity of the disease, damages found after discharge should also be considered. Providing multidisciplinary interventions promoting physical and psychological recovery in the first stages of hospitalization can minimize these damages. Cognitive, physical and psychological dysfunction reported by COVID19 patients after discharge can have profound effects on quality of life. Pain is usually part of this dysfunction, but it is still poorly understood how it affects survivors of COVID19 infections. There is limited information about the clinical characteristics, treatment and outcome of maintenance of pain in COVID19 patients. The purpose of this narrative review is to provide an overview of the implications of COVID19 on acute and chronic pain states.

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.

Newborn infant parasympathetic evaluation for the assessment of analgosedation adequacy in infants treated by mechanical ventilation - a multicenter pilot study

INTRODUCTION

Adequate analgosedation is important in infants treated in pediatric/neonatal intensive care units (P/NICUs), because both too deep and insufficient analgosedation is disadvantageous. To assess the severity of pain, several behavioral and behavioral-physiological scales are used, but their usefulness is limited. It is therefore justified to search for additional methods to assess the adequacy of analgosedation in these patients. The aim of the present study is to evaluate the usefulness of Newborn Infant Parasympathetic Evaluation (NIPE) in the assessment of analgosedation quality in infants requiring mechanical ventilation, who are treated in P/NICUs.

MATERIAL AND METHODS

We performed simultaneously 180 COMFORT-B assessments and heart rate variability measurements using a NIPE monitor in 30 mechanically ventilated infants receiving analgosedation. A generalized linear mixed model with the logit link function was used in order to perform logistic regression analysis to assess the relationship between NIPEi/NIPEm and deep sedation.

RESULTS

The multivariable logistic regression model showed that NIPEi and NIPEm values were higher when analgosedation was deep as compared to when it was moderate or insufficient (OR (95% CI): NIPEm - 1.065 (1.007-1.126), p = 0.03; NIPEi - 1.068 (1.016-1.123), p = 0.01).

CONCLUSIONS

The NIPE indexes are significantly higher in patients whose assessment on the behavioral scale indicates deep analgosedation as compared to those in whom it indicates moderate or insufficient analgosedation. Allowing continuous monitoring, the NIPE device may be a valuable assisting tool in the assessment of analgosedation quality in mechanically ventilated newborns and infants.

Current Evidence Regarding Biomarkers Used to Aid Postoperative Delirium Diagnosis in the Field of Cardiac Surgery-Review

Postoperative cognitive disorders after cardiac surgery may manifest as postoperative delirium (POD) or later as postoperative cognitive dysfunction (POCD). The incidence of POD after cardiac surgery ranges from 16% to 73%. In contrast to POD, POCD is usually diagnosed after the discharge from hospital, with an incidence of 30 to 70% of cases, very often noticed only by close relative or friends, decreasing after six (20–30%) and twelve (15–25%) months after surgery. Perioperative cognitive disorders are associated with adverse short- and long-term effects, including increased morbidity and mortality. Due to the complexity of delirium pathomechanisms and the difficulties in the diagnosis, researchers have not yet found a clear answer to the question of which patient will be at a higher risk of developing delirium. The risk for POD and POCD in older patients with numerous comorbidities like hypertension, diabetes, and previous ischemic stroke is relatively high, and the predisposing cognitive profile for both conditions is important. The aim of this narrative review was to identify and describe biomarkers used in the diagnosis of delirium after cardiac surgery by presenting a search through studies regarding this subject, which have been published during the last ten years. The authors discussed brain-derived biomarkers, inflammation-related biomarkers, neurotransmitter-based biomarkers, and others. Work based on inflammation-related biomarkers, which are characterized by the low cost of implementation and the effectiveness of delirium diagnosis, seems to be the closest to the goal of discovering an inexpensive and effective marker. Currently, the use of a panel of tests, and not a single biomarker, brings us closer to the discovery of a test, or rather a set of tests ideal for the diagnosis of delirium after cardiac surgery.

COVID-19: Pain Management in Patients with SARS-CoV-2 Infection-Molecular Mechanisms, Challenges, and Perspectives

Since the end of 2019, the whole world has been struggling with the pandemic of the new Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2). Available evidence suggests that pain is a common symptom during Coronavirus Disease 2019 (COVID-19). According to the World Health Organization, many patients suffer from muscle pain (myalgia) and/or joint pain (arthralgia), sore throat and headache. The exact mechanisms of headache and myalgia during viral infection are still unknown. Moreover, many patients with respiratory failure get admitted to the intensive care unit (ICU) for ventilatory support. Pain in ICU patients can be associated with viral disease itself (myalgia, arthralgia, peripheral neuropathies), may be caused by continuous pain and discomfort associated with ICU treatment, intermittent procedural pain and chronic pain present before admission to the ICU. Undertreatment of pain, especially when sedation and neuromuscular blocking agents are used, prone positioning during mechanical ventilation or extracorporeal membrane oxygenation (ECMO) may trigger delirium and cause peripheral neuropathies. This narrative review summarizes current knowledge regarding challenges associated with pain assessment and management in COVID-19 patients. A structured prospective evaluation should be undertaken to analyze the probability, severity, sources and adequate treatment of pain in patients with COVID-19 infection.

Postoperative Delirium in Patients with Chronic Obstructive Pulmonary Disease after Coronary Artery Bypass Grafting

Background and Objectives: The incidence of postoperative delirium (POD) in patients with chronic obstructive pulmonary disease (COPD) is unclear. It seems that postoperative respiratory problems that may occur in COPD patients, including prolonged mechanical ventilation or respiratory-tract infections, may contribute to the development of delirium. The aim of the study was to identify a relationship between COPD and the occurrence of delirium after cardiac surgery and the impact of these combined disorders on postoperative mortality. Materials and Methods: We performed an analysis of data collected from 4151 patients undergoing isolated coronary artery bypass grafting (CABG) in a tertiary cardiac-surgery center between 2012 and 2018. We included patients with a clinical diagnosis of COPD according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. The primary endpoint was postoperative delirium; Confusion Assessment Method in the Intensive Care Unit (CAM-ICU) was used for delirium assessment. Results: Final analysis included 283 patients with COPD, out of which 65 (22.97%) were diagnosed with POD. Delirious COPD patients had longer intubation time (p = 0.007), more often required reintubation (p = 0.019), had significantly higher levels of C-reactive protein (CRP) three days after surgery (p = 0.009) and were more often diagnosed with pneumonia (p < 0.001). The CRP rise on day three correlated positively with the occurrence of postoperative pneumonia (r = 0.335, p = 0.005). The probability of survival after CABG was significantly lower in COPD patients with delirium (p < 0.001). Conclusions: The results of this study confirmed the relationship between chronic obstructive pulmonary disease and the incidence of delirium after cardiac surgery. The probability of survival in COPD patients undergoing CABG who developed postoperative delirium was significantly decreased.

The impact of pain and opioids use on survival in cancer patients: Results from a population-based cohort study and a meta-analysis

The study aimed to explore whether cancer-related pain and opioids use are associated with the survival of cancer patients, and perform a cohort study and a meta-analysis to quantify the magnitude of any association.A retrospective cohort study was performed to analyze the impact of pain level, and opioids use on cancer-specific survival (CSS) in advanced cancer patients. Patients and relevant medical records were selected from the registry of the Radiation and chemotherapy division of Ningbo First Hospital between June 2013 and October 2017. Hazard ratios (HRs) and 95% confidential intervals (CIs) for CSS by opioids use were calculated by univariate and multivariate Cox regression analyses. The systematic review included relevant studies published before October 2018. The combined HRs and 95% CIs for overall survival (OS) and progression-free survival (PFS) were calculated using random-effect models.A total of consecutive 203 cancer patients were included in the cohort study. Kaplan-Meier curves indicate a negative association between CSS and cancer-related pain or opioids requirement, but less evidence of an association with the dose of opioids use. Multivariate models revealed that the pain level and opioids requirement were associated with shorter CSS, after adjusting for significant covariates. The results of the meta-analysis indicated that postoperative opioids use had a poor effect on PFS, and opioids use for cancer-related pain was associated with poor OS in cancer patients, while intraoperative opioids use was not associated with cancer survival.We concluded that cancer-related pain and opioids requirements are associated with poor survival in advanced cancer patients, and postoperative opioids use and opioids use for cancer-related pain may have an adverse effect on the survival of cancer patients.

COVID-19: What do we need to know about ICU delirium during the SARS-CoV-2 pandemic?

In March 2020, the World Health Organisation announced the COVID-19 pandemic caused by the SARS-CoV-2 virus. As well as respiratory failure, the SARS-CoV-2 may cause central nervous system (CNS) involvement, including delirium occurring in critically ill patients (ICU delirium). Due attention must be paid to this subject in the face of the COVID-19 pandemic. Delirium, the detection of which takes less than two minutes, is frequently underestimated during daily routine ICU care, but it may be a prodromal symptom of infection or hypoxia associated with severe respiratory failure. During the COVID-19 pandemic, systematic delirium monitoring using validated tests (CAM-ICU or ICDSC) may be sacrificed. This is likely to be due to the fact that the main emphasis is placed on organisational issues, i.e. the lack of ventilators, setting priorities for limited mechanical ventilation options, and a shortage of personal protective equipment. Early identification of patients with delirium is critical in patients with COVID-19 because the occurrence of delirium may be an early symptom of worsening respiratory failure or of infectious spread to the CNS mediated by potential neuroinvasive mechanisms of the coronavirus. The purpose of this review is to identify problems related to the development of delirium during the COVID-19 epidemic, which are presented in three areas: i) factors contributing to delirium in COVID-19, ii) potential pathophysiological factors of delirium in COVID-19, and iii) long-term consequences of delirium in COVID-19. This article discusses how healthcare workers can reduce the burden of delirium by identifying potential risk factors and difficulties during challenges associated with SARS-CoV-2 infection.

Ultrasound-guided fascia iliaca compartment block combined with general anesthesia for amputation in an acute myocardial infarction patient after percutaneous coronary intervention: A case report

BACKGROUND

Fascia iliaca compartment block is a technique that blocks three nerves, similar to a 3-in-1 nerve block. This block provides analgesia for patients undergoing lower limb surgery, and is a simple technique that is easy to implement. Here, we report a case of fascia iliaca compartment block in a patient with myocardial infarction who underwent emergency middle thigh amputation.

CASE SUMMARY

A 78-year-old female patient weighing 38 kg with gangrene and occlusive peripheral atherosclerosis of the right leg underwent an emergency middle thigh amputation. The patient had a history of hypertension, coronary heart disease, cerebral infarction, anterior wall myocardial infarction, and had recently undergone percutaneous coronary intervention consisting of coronary angiography and right coronary artery stent implantation. Considering the patient's condition, an ultrasound-guided fascia iliaca compartment block combined with general anesthesia was implemented for amputation. The fascia iliaca compartment block provided analgesia for the operation, and reduced the dosage of general anesthetics. It also alleviated adverse cardiovascular effects caused by pain stress, and ensured the safety of the patient during the perioperative period. This block also provided postoperative analgesia. The patient had a good prognosis, and was subsequently discharged from hospital.

CONCLUSION

Fascia iliaca compartment block provides surgical analgesia. It also alleviates adverse cardiovascular effects, and ensures patient safety during the perioperative period.

Acute and Chronic Pain Learning and Teaching in Medical School-An Observational Cross-Sectional Study Regarding Preparation and Self-Confidence of Clinical and Pre-Clinical Medical Students

Background and objectives: Adequate pain management is a major challenge of public health. The majority of students graduating from medical schools has insufficient education and experience with patients suffering pain. Not enough is being taught regarding pain in non-verbal patients (children, critically ill in the intensive care unit, demented). Chronic pain is the most difficult to optimize and requires appropriate preparation at the level of medical school. Our aim was to evaluate attitudes, expectations and the actual knowledge of medical students at different levels of their career path regarding the assessment and treatment of acute and chronic pain. Materials and Methods: We performed an observational cross-sectional study that was based on a survey distributed among medical students of pre-clinical and post-clinical years at the Pomeranian Medical University in Szczecin, Poland. The survey included: demographic data, number of hours of formal pain teaching, actual knowledge of pain assessment, and pain treatment options in adults and children. Results: We received responses from 77/364 (21.15%) students and 79.2% of them rated the need to obtain knowledge regarding pain as very important (10/10 points). Post-clinical group declared having on average 11.51 h of acute pain teaching as compared to the 7.4 h reported by the pre-clinical group (p = 0.012). Graduating students also reported having significantly more classes regarding the treatment of chronic pain (6.08 h vs. 3.79 h, p = 0.007). The average level of comfort in the post-clinical group regarding treatment of acute pain was higher than in the pre-clinical group (6.05 vs. 4.26, p = 0.006), similarly with chronic pain treatment in adults (4.33 vs. 2.97, p = 0.021) and with pain treatment in children (3.14 vs. 1.97, p = 0.026). Conclusions: This study shows that education about pain management is a priority to medical students. Despite this, there continues to be a discrepancy between students’ expectations and the actual teaching and knowledge regarding effective pain management, including the vulnerable groups: chronic pain patients, children, and critically ill people.

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.