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      Measuring pain in non-verbal critically ill patients: which pain instrument?

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      Journal: Critical Care
      Publisher: BioMed Central

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          Abstract

          Pain is experienced by many critically ill patients. Although the patient’s self-report represents the gold-standard measure for pain, many patients are unable to communicate in the ICU. In this commentary, we discuss the study findings comparing three objective scales for the assessment of pain in non-verbal patients and the importance of the tool selection process.

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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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            Impact of systematic evaluation of pain and agitation in an intensive care unit.

            Gerald Chanques, Samir Jaber, Eric Barbotte … (2006)
            To measure the impact of implementation of the systematic evaluation of pain and agitation by nurses using the Behavioral Pain Scale (BPS), the Numerical Rating Scale (NRS) for pain, and the Richmond Agitation Sedation Scale (RASS) associated with medical staff education in analgesia and sedation management in intensive care unit (ICU) patients. Two-phase, prospective, controlled study. Twelve-bed medical-surgical ICU in a university hospital. Consecutive patients staying >24 hrs in ICU. BPS, NRS, and RASS were measured twice daily, at rest, by independent observers during 21 wks (control group) and after 4 wks of training, by nurses during 29 wks (intervention group). In the intervention group, the treating physician was alerted in case of pain defined by BPS>5 or NRS>3 or in case of agitation defined by RASS>1. A total of 230 patients were included (control group, n=100; intervention group, n=130). Baseline characteristics were not significantly different. The incidence of pain and agitation decreased significantly in the intervention group: 63% vs. 42% (p=.002) and 29% vs. 12% (p=.002), respectively. Rate of severe pain and agitation events defined by NRS>6 and RASS>2, respectively, also decreased significantly. There were significantly more therapeutic changes in the intervention group in the way of an escalation but also in the way of a de-escalation for analgesic and psychoactive drugs. Compared with the control group, there was a marked decrease in the duration of mechanical ventilation (120 [interquartile range 48-312] vs. 65 (24-192) hrs, p=.01) and nosocomial infections rate (17% vs. 8%, p<.05) in the intervention group. There was no significant difference in median length of stay (9 [4, 15] vs. 7 [4, 13] days) and mortality in ICU (12 vs. 15%). Systematic evaluation of pain and agitation, and analgesics and sedatives need was associated with a decrease in incidence of pain and agitation, duration of mechanical ventilation and nosocomial infections.
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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

                Contributors
                Jean-Francois Payen: jfpayen@ujf-grenoble.fr
                Céline Gélinas: celine.gelinas@mcgill.ca
                Journal
                Journal ID (nlm-ta): Crit Care
                Title: Critical Care
                Publisher: BioMed Central (London )
                ISSN (Print): 1364-8535
                ISSN (Electronic): 1466-609X
                Publication date (Electronic): 15 October 2014
                Publication date (Print): 2014
                Volume: 18
                Issue: 5
                Electronic Location Identifier: 554
                Affiliations
                [ ]Department of Anaesthesia and Critical Care, Michallon Hospital, bd de la Chantourne, Grenoble, F-38000 France
                [ ]Joseph Fourier University, Grenoble Institute of Neurosciences, Chemin Fortuné Ferrini, Grenoble, F-38042 France
                [ ]INSERM, U836, Chemin Fortuné Ferrini, Grenoble, F-38042 France
                [ ]Ingram School of Nursing, McGill University, 3506 University Street, Montréal, QC H3A 2A7 Canada
                [ ]Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, 3755 Cote Sainte Catherine Road, Montréal, QC H3T 1E2 Canada
                Article
                Publisher ID: 554
                DOI: 10.1186/s13054-014-0554-5
                PMC ID: 4281924
                PubMed ID: 25429706
                SO-VID: 650c8bf4-eb58-49c1-9728-8538fc87cfbf
                Copyright © © Payen and Gélinas; licensee BioMed Central Ltd. 2014
                License:

                The licensee has exclusive rights to distribute this article, in any medium, for 12 months following its publication. After this time, the article is available under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. 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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                ScienceOpen disciplines: Emergency medicine & Trauma
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                ScienceOpen disciplines: Emergency medicine & Trauma

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