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      Clinical Utility of the Behavioral Pain Assessment Tool in Patients Admitted in the Intensive Care Unit

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          A bstract

          Introduction

          Unnoticed and unrelieved pain is one of the main sources of psychological and physiological stress for intensive care unit (ICU) patients. The eight-item behavior pain assessment tool (BPAT) is a multicountry validated tool to assess pain in ICU patients. However, its feasibility and clinical utility for ICU patients in India need further research.

          Aims and objectives

          The Aims and objectives of the study were to assess pain using BPAT and its clinical utility in pain assessment and management in ICU patients.

          Materials and methods

          Following ethical approval, 400 consecutive adult patients admitted in the ICUs in a tertiary care teaching hospital were assessed for pain severity using BPAT at intake, baseline pain and procedural pain. Patients <18 years and in deep coma on the Glasgow coma scale were excluded from the study. The patients with BPAT score ≥4 were given opioid analgesic, and their pain was reassessed after 2–3 hours. A feedback regarding feasibility and clinical utility was filled by the doctors.

          Results

          High interrater agreement for BPAT was observed with excellent kappa coefficients (>0.85) for each item. The BPAT significantly guided the pain management ( p < 0.0001). More than 90% of doctors found BPAT easy to understand and use. In most of the cases (95.5%), doctors agreed that BPAT can improve the clinical management of ICU patients.

          Conclusion

          The BPAT is a reliable, brief, and an easy-to-use pain assessment tool, which clinicians can use for guiding pain assessment and management in the ICU setting on a routine basis.

          Clinical significance

          We recommend implementing BPAT in the clinical practice for better pain assessment and control in ICU patients.

          How to cite this article

          Mitra S, Jain K, Singh J, Saxena P, Nyima T, Selvam SR, et al. Clinical Utility of the Behavioral Pain Assessment Tool in Patients Admitted in the Intensive Care Unit. Indian J Crit Care Med 2020;24(8):695–700.

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          Assessing pain in critically ill sedated patients by using a behavioral pain scale.

          J-L Bosson, J-F Payen, P Lavagne … (2001)
          To establish the validity and reliability of a new behavioral pain scale (BPS) for critically ill sedated adult patients. Prospective evaluation. Ten-bed trauma and surgical intensive care unit in a university teaching hospital. Thirty mechanically ventilated patients who were receiving analgesia and sedation. Assessments with the BPS were completed consecutively at standardized times (morning, afternoon, night) by pairs of evaluators (nurse and nurse's aide). They collected physiologic parameters and BPS results before and during care procedures: non-nociceptive (group 1, compression stockings application and central venous catheter dressing change), nociceptive (group 2, endotracheal suctioning and mobilization), and retested nociceptive (group 3). The BPS score was the sum of three items that had a range score of 1-4: facial expression, movements of upper limbs, and compliance with mechanical ventilation. Two hundred and sixty nine assessments were completed, including 104, 134, and 31 measurements in groups 1, 2 and 3, respectively. There was no difference in Ramsay scale scores between the three groups (Ramsay 4-6). Nociceptive stimulations (group 2) resulted in significantly higher BPS values than non-nociceptive ones (group 1, 4.9 vs. 3.5, p <.01), whereas the two groups had comparable BPS values before stimulation (3.1 vs. 3.0). A trend was found in group 2 between the dosage of sedation/analgesia and BPS: the higher the dosage, the lower BPS values and BPS changes to nociceptive stimulation. Group 3 had BPS values similar to group 2 at rest (3.2 vs. 3.2) and during the procedure (4.4 vs. 4.5), with good interrater correlations (r(2) =.71 and.50, respectively). These results indicate that the expression of pain can be scored validly and reliably by using the BPS in sedated, mechanically ventilated patients. Further studies are warranted regarding the utility of the BPS in making clinical decisions about the use of analgesic drugs in the intensive care unit.
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            Current practices in sedation and analgesia for mechanically ventilated critically ill patients: a prospective multicenter patient-based study.

            Michèle Binhas, C Genty, J Leguillou … (2007)
            The authors conducted a patient-based survey of practices to fully describe the assessment and the management of pain and sedation of a large cohort of mechanically ventilated patients during their first week of intensive care unit (ICU) stay. A total of 1,381 adult patients were included in a prospective, observational study in 44 ICUs in France. Pain and sedation assessment, analgesic and sedative use, and analgesic management during procedural pain were collected on days 2, 4, and 6 of the ICU stay. The observed rates of assessment on day 2 for sedation (43%) and analgesia (42%) were significantly smaller than that of use of sedatives (72%) and opioids (90%), also noted on days 4 and 6. The use of protocols/guidelines for sedation/analgesia in the ICU reduced the proportion of patients who were treated, although not evaluated. A large proportion of assessed patients were in a deep state of sedation (40-50%). Minor changes in the dosages of the main prescribed agents for sedation (midazolam, propofol) and analgesia (sufentanil, fentanyl, morphine, remifentanil) were found across 6 days of the patient's ICU stay. Procedural pain was specifically managed for less than 25% of patients; during those procedures, the proportion of patients with pain significantly increased from the baseline pain evaluation. Excessively deep states of sedation and a lack of analgesia during painful procedures must be prevented. To facilitate systematic pain and sedation assessment and to adjust daily drug dosages accordingly, it seems crucial to promote educational programs and elaboration of protocols/guidelines in the ICU.
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              Validation of the critical-care pain observation tool in adult patients.

              Julie Fortier, K Puntillo, C Viens-Bitker … (2006)
              Little research has been conducted to validate pain assessment tools in critical care, especially for patients who cannot communicate verbally. To validate the Critical-Care Pain Observation Tool. A total of 105 cardiac surgery patients in the intensive care unit, recruited in a cardiology health center in Quebec, Canada, participated in the study. Following surgery, 33 of the 105 were evaluated while unconscious and intubated and 99 while conscious and intubated; all 105 were evaluated after extubation. For each of the 3 testing periods, patients were evaluated by using the Critical-Care Pain Observation Tool at rest, during a nociceptive procedure (positioning), and 20 minutes after the procedure, for a total of 9 assessments. Each patient's self-report of pain was obtained while the patient was conscious and intubated and after extubation. The reliability and validity of the Critical-Care Pain Observation Tool were acceptable. Interrater reliability was supported by moderate to high weighted kappa coefficients. For criterion validity, significant associations were found between the patients' self-reports of pain and the scores on the Critical-Care Pain Observation Tool. Discriminant validity was supported by higher scores during positioning (a nociceptive procedure) versus at rest. The Critical-Care Pain Observation Tool showed that no matter their level of consciousness, critically ill adult patients react to a noxious stimulus by expressing different behaviors that may be associated with pain. Therefore, the tool could be used to assess the effect of various measures for the management of pain.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Indian J Crit Care Med
                Journal ID (iso-abbrev): Indian J Crit Care Med
                Journal ID (publisher-id): IJCCM
                Title: Indian Journal of Critical Care Medicine : Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine
                Publisher: Jaypee Brothers Medical Publishers
                ISSN (Print): 0972-5229
                ISSN (Electronic): 1998-359X
                Publication date (Print): August 2020
                Volume: 24
                Issue: 8
                Pages: 695-700
                Affiliations
                [1–7 ]Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
                Author notes
                Sukanya Mitra, Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India, Phone: +91172-2665253, e-mail: drsmitra12@ 123456yahoo.com
                Article
                DOI: 10.5005/jp-journals-10071-23521
                PMC ID: 7519617
                PubMed ID: 33024377
                SO-VID: 33081c2f-dec4-4a07-a31f-3c9f1ab688e9
                Copyright © Copyright © 2020; Jaypee Brothers Medical Publishers (P) Ltd.
                License:

                © The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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                Categories
                Subject: Original Research

                ScienceOpen disciplines: Emergency medicine & Trauma
                Keywords: assessment,intensive care unit,management,pain,scale,utility
                Data availability:
                ScienceOpen disciplines: Emergency medicine & Trauma
                Keywords: assessment, intensive care unit, management, pain, scale, utility

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