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Robleda-Font G, López-López C, Latorre-Marco I, Pozas-Peña J, Alonso-Crespo D, Vallés-Fructuoso O, Castanera-Duro A. Appropriateness of behavioural scales in the monitoring of pain in the critically ill patient unable to self-report. ENFERMERIA INTENSIVA 2024; 35:e17-e22. [PMID: 38538437 DOI: 10.1016/j.enfie.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 12/22/2023] [Indexed: 05/25/2024]
Abstract
Appropriateness is a dimension of quality that evaluates the effective use of technologies, resources or interventions in specific situations or populations, assessing whether our interventions do more benefit than harm. The evidence regarding pain monitoring in the critically ill patient points to the periodic assessment of pain using appropriate tools, with the aim of improving pain management and more efficient use of analgesics in the intensive care unit. The first step would be to assess the patient's ability to communicate or self-report and, based on this, to select the most appropriate pain assessment tool. In patients who are unable to self-report, behavioural pain assessment tools are recommended. When we talk about the suitability of behavioural scales for pain monitoring in critically ill patients unable to self-report, we refer to their use with a clear clinical benefit, i.e. using the right tool for pain assessment to be effective, efficient and consistent with bioethical principles. To our knowledge, there are no published data on the suitability of pain assessment tools in unable to self-report critically ill patients, so, in the framework of continuous quality improvement in pain care, new research should incorporate this approach by integrating the best scientific evidence with current clinical practice.
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Affiliation(s)
- G Robleda-Font
- Campus Docent Sant Joan de Déu, Universidad de Barcelona, Sant Boi de Llobregat, Spain; Centro Cochrane Iberoamericano, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), Spain
| | - C López-López
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), Spain; Unidad de Cuidados Intensivos de Trauma y Emergencias, Hospital Universitario 12 de Octubre, Madrid, Spain; Grupo de Investigación en Cuidados (InveCuid), Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain.
| | - I Latorre-Marco
- Unidad de Cuidados Intensivos, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain; Grupo de Investigación en Enfermería y Cuidados de Salud, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - J Pozas-Peña
- Campus Docent Sant Joan de Déu, Universidad de Barcelona, Sant Boi de Llobregat, Spain; Unidad de Cuidados Intensivos, Hospital del Mar, Barcelona, Spain; Grupo de Investigación en Patología Crítica (GREPAC), Instituto de Investigación Hospital del Mar, Barcelona, Spain
| | - D Alonso-Crespo
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), Spain; Unidad de Cuidados Intensivos, Hospital Álvaro Cunqueiro, Vigo, Spain; Grupo de Investigación Traslacional en Cuidados, Hospital Álvaro Cunqueiro, Vigo, Spain
| | - O Vallés-Fructuoso
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), Spain; Unidad de Cuidados Intensivos, Hospital Vall d'Hebrón, Barcelona, Spain; Coordinadora del Grupo de Trabajo Analgesia, Sedación y Delirium de la Sociedad Catalana de Medicina Intensiva, Barcelona, Spain
| | - A Castanera-Duro
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), Spain; Área del Paciente Crítico, Reanimación y Anestesia, Hospital Universitario de Girona Dr. Josep Trueta, Girona, Spain; Departamento de Enfermería Universitat de Girona (UdG), Girona, Spain
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Nguyen V, Richard-Lalonde M, Gélinas C. Interrater Agreement between Bedside and Video Raters Using the CPOT-Neuro for Pain Assessment in Critically Ill Patients with a Brain Injury. NURSING REPORTS 2024; 14:212-219. [PMID: 38391062 PMCID: PMC10885079 DOI: 10.3390/nursrep14010017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 12/15/2023] [Accepted: 01/08/2024] [Indexed: 02/24/2024] Open
Abstract
This study aimed to examine the interrater agreement of Critical-Care Pain Observation Tool-Neuro (CPOT-Neuro) scores as a newly developed tool for pain assessment in patients with critical illness and brain injury between raters using two methods of rating (bedside versus video) during standard care procedures (i.e., non-invasive blood pressure and turning). The bedside raters were research staff, and the two video raters had different backgrounds (health and non-health disciplines). Raters received standardized 45 min training by the principal investigator. Video recordings of 56 patient participants with a brain injury at different levels of consciousness were included. Interrater agreement was supported with an Intraclass Correlation Coefficient (ICC) > 0.65 for all pairs of raters and for each procedure. Interrater agreement was highest during turning in the conscious group, with ICCs ranging from 0.79 to 0.90. The use of video recordings was challenging for the observation of some behaviors (i.e., tearing, face flushing), which were influenced by factors such as lighting and the angle of the camera. Ventilator alarms were also challenging to distinguish from other sources for the video rater from a non-health discipline. Following standardized training, video technology was useful in achieving an acceptable interrater agreement of CPOT-Neuro scores between bedside and video raters for research purposes.
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Affiliation(s)
- Vivienne Nguyen
- Undergraduate Neuroscience Program, McGill University, Montreal, QC H3A 1R1, Canada
| | - Melissa Richard-Lalonde
- Ingram School of Nursing, McGill University, Montreal, QC H3A 2M7, Canada
- Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital-CIUSSS West-Central-Montreal, Montreal, QC H3T 1E2, Canada
| | - Céline Gélinas
- Ingram School of Nursing, McGill University, Montreal, QC H3A 2M7, Canada
- Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital-CIUSSS West-Central-Montreal, Montreal, QC H3T 1E2, Canada
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Wu TT, Vernooij LM, Duprey MS, Zaal IJ, Gélinas C, Devlin JW, Slooter AJC. Relationship Between Pain and Delirium in Critically Ill Adults. Crit Care Explor 2023; 5:e1012. [PMID: 38053750 PMCID: PMC10695586 DOI: 10.1097/cce.0000000000001012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Abstract
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.
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Affiliation(s)
- Ting Ting Wu
- Bouve College of Health Sciences, Northeastern University, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - Lisette M Vernooij
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Anesthesiology, Intensive Care and Pain Medicine, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Matthew S Duprey
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY
| | - Irene J Zaal
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Intensive Care Medicine, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands
| | - Céline Gélinas
- Ingram School of Nursing, McGill University, Montreal, QC, Canada
- Centre for Nursing Research, Jewish General Hospital, Montreal, QC, Canada
| | - John W Devlin
- Bouve College of Health Sciences, Northeastern University, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - Arjen J C Slooter
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Psychiatry, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
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Kawano T, Ono H, Abe M, Umeshita K. Changes in Physiological Indices Before and After Nursing Care of Postoperative Patients With Esophageal Cancer in the ICU. SAGE Open Nurs 2023; 9:23779608231190144. [PMID: 37528908 PMCID: PMC10387705 DOI: 10.1177/23779608231190144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/17/2023] [Accepted: 06/29/2023] [Indexed: 08/03/2023] Open
Abstract
Introduction Various stressors have been identified in patients in the intensive care unit (ICU), including postoperative pain, ventilatory management, and nursing care. However, sedated patients are less responsive, and nurses have difficulty capturing their stressors. Objective To investigate patient stress caused by nursing care performed in the ICU on sedated patients based on changes in physiological indices. Methods We observed nursing care performed on patients with postoperative esophageal cancer under sedation in the ICU. This included endotracheal suctioning and turning, the time required for the care, and the patients' behavioral responses. Information on arousal levels, autonomic nervous system indices, and vital signs were also obtained. The changes in indicators before and after care were then compared and analyzed. Results There were 14 patients in the study. The mean age of the patients was 68 years. Ninety-nine scenes of nursing care were observed, and in six of these, additional bolus sedation was administered because of the patient's significant body movements. In endotracheal suctioning, no significant changes were observed in all indicators. In turning, vital signs changed significantly, and when both were continued, all indicators changed significantly. Conclusion Our study found that different types and combinations of nursing care may cause different stresses to the patients. Moreover, the autonomic nervous system indices may be more likely to react to stresses in a variety of nursing care, while arousal levels may be more likely to react to burdensome stresses. If the characteristics of these physiological indicators can be understood and effectively utilized during care, it may be possible to better identify and reduce patient stress during sedation management.
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Affiliation(s)
| | - Hiroshi Ono
- College of Nursing Art and Science, University of Hyogo, Akashi, Japan
| | - Masaki Abe
- Faculty of Nursing Science, Osaka Seikei University, Osaka, Japan
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Wojnar-Gruszka K, Sega A, Płaszewska-Żywko L, Wojtan S, Potocka M, Kózka M. Pain Assessment with the BPS and CCPOT Behavioral Pain Scales in Mechanically Ventilated Patients Requiring Analgesia and Sedation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10894. [PMID: 36078609 PMCID: PMC9517797 DOI: 10.3390/ijerph191710894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/19/2022] [Accepted: 08/30/2022] [Indexed: 06/15/2023]
Abstract
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.
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Affiliation(s)
- Katarzyna Wojnar-Gruszka
- Department of Clinical Nursing, Faculty of Health Sciences, Collegium Medicum, Jagiellonian University, 31-501 Kraków, Poland
| | - Aurelia Sega
- Department of Clinical Nursing, Faculty of Health Sciences, Collegium Medicum, Jagiellonian University, 31-501 Kraków, Poland
| | - Lucyna Płaszewska-Żywko
- Department of Clinical Nursing, Faculty of Health Sciences, Collegium Medicum, Jagiellonian University, 31-501 Kraków, Poland
| | - Stanisław Wojtan
- Department of Clinical Nursing, Faculty of Health Sciences, Collegium Medicum, Jagiellonian University, 31-501 Kraków, Poland
- Department of Anaesthesiology and Intensive Therapy, University Hospital in Kraków, 30-688 Kraków, Poland
| | - Marcelina Potocka
- Department of Clinical Nursing, Faculty of Health Sciences, Collegium Medicum, Jagiellonian University, 31-501 Kraków, Poland
| | - Maria Kózka
- Department of Clinical Nursing, Faculty of Health Sciences, Collegium Medicum, Jagiellonian University, 31-501 Kraków, Poland
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Altıntop ÇG, Latifoğlu F, Akın AK. Can patients in deep coma hear us? Examination of coma depth using physiological signals. Biomed Signal Process Control 2022. [DOI: 10.1016/j.bspc.2022.103756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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López-López C, Arranz-Esteban A, Sánchez-Sánchez MM, Pérez-Pérez T, Arias-Rivera S, Solís-Muñoz M, Latorre-Marco I. Pain Behaviors Analyzed by Videorecording in Brain-Injured Patients Admitted to the Intensive Care Unit. Pain Manag Nurs 2022; 24:113-122. [PMID: 36057509 DOI: 10.1016/j.pmn.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/06/2022] [Accepted: 07/20/2022] [Indexed: 10/14/2022]
Abstract
AIM To describe and classify pain behaviors (facial and body) in brain-injured patients with a low level of consciousness before, during, and after the performance of painful and non-painful care procedures. METHODS Facial behaviors and body movements in brain-injured patients were videotaped at rest, during the application of three care procedures (two painful and one non-painful), and 15 minutes after completion of these procedures. Each video recording was evaluated by expert evaluators blinded to each other. For each of the behaviors observed, all possible combinations between the three procedures and/or time were compared using the McNemar test. Effect size was measured by the difference in proportions using the Wilson score 95% confidence intervals. RESULTS Twenty-seven patients were included. The mean (standard deviation) Glasgow Coma Score was 5.4 (1.9). A total of 33 behaviors (29 active, four neutral) were registered. Expression of behaviors was more common during the painful procedures compared with the other time points (non-painful procedures, baseline, and final evaluation). Inter-evaluator agreement was substantial (Kappa index >0.7) in more than 50% of the observed behaviors. CONCLUSIONS In this study involving brain-injured patients with a low level of consciousness, facial, body, and ventilation-related behaviors were more common during painful procedures. Agreement between evaluators to detect the presence or absence of these behaviors was substantial. These findings underscore the need to develop pain assessment measures specific to this patient population.
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Mat B, Sanz L, Arzi A, Boly M, Laureys S, Gosseries O. New behavioral signs of consciousness in patients with severe brain injuries. Semin Neurol 2022; 42:259-272. [PMID: 35738292 DOI: 10.1055/a-1883-0861] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Beril Mat
- Neurology, University of Wisconsin-Madison, Madison, United States.,Coma Science Group, University of Liege, Liege, Belgium
| | - Leandro Sanz
- Coma Science Group, University of Liege, Liege, Belgium
| | - Anat Arzi
- The Hebrew University of Jerusalem Department of Cognitive and Brain Sciences, Jerusalem, Israel
| | - Melanie Boly
- Neurology, University of Wisconsin-Madison, Madison, United States.,Psychiatry, University of Wisconsin-Madison, Madison, United States
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Gélinas C, Bérubé M, Puntillo KA, Boitor M, Richard-Lalonde M, Bernard F, Williams V, Joffe AM, Steiner C, Marsh R, Rose L, Dale CM, Tsoller DM, Choinière M, Streiner DL. Validation of the Critical-Care Pain Observation Tool-Neuro in brain-injured adults in the intensive care unit: a prospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:142. [PMID: 33849619 PMCID: PMC8042624 DOI: 10.1186/s13054-021-03561-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/31/2021] [Indexed: 11/10/2022]
Abstract
Background Pain assessment in brain-injured patients in the intensive care unit (ICU) is challenging and existing scales may not be representative of behavioral reactions expressed by this specific group. This study aimed to validate the French-Canadian and English revised versions of the Critical-Care Pain Observation Tool (CPOT-Neuro) for brain-injured ICU patients. Methods A prospective cohort study was conducted in three Canadian and one American sites. Patients with a traumatic or a non-traumatic brain injury were assessed with the CPOT-Neuro by trained raters (i.e., research staff and ICU nurses) before, during, and after nociceptive procedures (i.e., turning and other) and non-nociceptive procedures (i.e., non-invasive blood pressure, soft touch). Patients who were conscious and delirium-free were asked to provide their self-report of pain intensity (0–10). A first data set was completed for all participants (n = 226), and a second data set (n = 87) was obtained when a change in the level of consciousness (LOC) was observed after study enrollment. Three LOC groups were included: (a) unconscious (Glasgow Coma Scale or GCS 4–8); (b) altered LOC (GCS 9–12); and (c) conscious (GCS 13–15). Results Higher CPOT-Neuro scores were found during nociceptive procedures compared to rest and non-nociceptive procedures in both data sets (p < 0.001). CPOT-Neuro scores were not different across LOC groups. Moderate correlations between CPOT-Neuro and self-reported pain intensity scores were found at rest and during nociceptive procedures (Spearman rho > 0.40 and > 0.60, respectively). CPOT-Neuro cut-off scores ≥ 2 and ≥ 3 were found to adequately classify mild to severe self-reported pain ≥ 1 and moderate to severe self-reported pain ≥ 5, respectively. Interrater reliability of raters’ CPOT-Neuro scores was supported with intraclass correlation coefficients > 0.69. Conclusions The CPOT-Neuro was found to be valid in this multi-site sample of brain-injured ICU patients at various LOC. Implementation studies are necessary to evaluate the tool’s performance in clinical practice. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03561-1.
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Affiliation(s)
- Céline Gélinas
- Ingram School of Nursing, McGill University, 680 Sherbrooke West St., Suite 1800, Montreal, QC, H3A 2M7, Canada. .,Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, CIUSSS West-Central Montreal, 3755 Côte-Sainte-Catherine Road, Montreal, QC, H3T 1E2, Canada.
| | - Mélanie Bérubé
- Faculty of Nursing, Université Laval, 1050 Avenue de la Médecine, Room 3486, Quebec City, QC, G1V 0A6, Canada.,Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval, 1401, 18e rue, Room Z-243, Quebec City, QC, G1J 1Z4, Canada
| | - Kathleen A Puntillo
- Physiological Nursing, University of California San Francisco, 2 Koret Way, San Francisco, CA, 94143, USA
| | - Madalina Boitor
- Faculty of Dentistry, McGill University, 3640 University St., Montreal, QC, H3A 0C7, Canada
| | - Melissa Richard-Lalonde
- Ingram School of Nursing, McGill University, 680 Sherbrooke West St., Suite 1800, Montreal, QC, H3A 2M7, Canada.,Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, CIUSSS West-Central Montreal, 3755 Côte-Sainte-Catherine Road, Montreal, QC, H3T 1E2, Canada
| | - Francis Bernard
- Équipe de Recherche en Soins Intensifs (ERESI), Research centre, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Coeur-de-Montréal, 5400 boulevard Gouin Ouest, K-3000, Montreal, QC, H4J 1C4, Canada.,Department of Medicine, Université de Montréal, Succursale Centre-Ville, C.P. 6128, Montreal, QC, H3C 3J7, Canada
| | - Virginie Williams
- Équipe de Recherche en Soins Intensifs (ERESI), Research centre, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Coeur-de-Montréal, 5400 boulevard Gouin Ouest, K-3000, Montreal, QC, H4J 1C4, Canada
| | - Aaron M Joffe
- School of Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA.,Harborview Medical Center, University of Washington Medicine, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Craig Steiner
- School of Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Rebekah Marsh
- Harborview Medical Center, University of Washington Medicine, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, 57 Waterloo Rd, London, SE1 8WA, UK.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada
| | - Craig M Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada.,Tory Trauma Program, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, M4N 3M5, Canada
| | - Darina M Tsoller
- Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, CIUSSS West-Central Montreal, 3755 Côte-Sainte-Catherine Road, Montreal, QC, H3T 1E2, Canada
| | - Manon Choinière
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Succursale Centre-Ville, C.P. 6128, Montreal, QC, H3C 3J7, Canada.,Research Center, Centre Hospitalier de l'Université de Montréal, Saint Antoine Building, Room S01-126, 850 Saint Denis St, Montreal, QC, H2X 0A9, Canada
| | - David L Streiner
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, St. Joseph's Healthcare, 100 West 5th Street, Box 585, Hamilton, ON, L8N 3K7, Canada
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10
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Cho Y, Hong GRS. Behavioral and Physiological Pain Responses in Brain-Injured Patients Who Are Unable to Communicate in the Intensive Care Unit. Pain Manag Nurs 2020; 22:80-85. [PMID: 33097416 DOI: 10.1016/j.pmn.2020.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/15/2020] [Accepted: 08/23/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Assessing pain of critically ill patients with brain injuries who are unable to communicate is a challenge. Current behavioral scales are limited in accurate pain assessments for this population. AIMS This study sought to investigate the behavioral and physiological responses induced by routine painful procedures in patients with brain injuries who are unable to communicate. METHODS Using a repeated-measure within-subject observational study design, 12 participants admitted to an intensive care unit were observed before, during, and 15 minutes after a nonnociceptive (noninvasive blood pressure measurement) procedure and three nociceptive (suctioning, turning, and trapezius pinch) procedures. During each assessment, patients' behavioral and physiological responses were observed using video cameras and bedside monitors. RESULTS In the overall behavioral responses to the nociceptive procedures, clenched teeth with tense jaw, frowning, orbit tightening, closing of eyes, eye movement, fixation-staring, flushing, flexion withdrawal of arm, flexion withdrawal of leg, muscle rigidity, twitching, and coughing were more frequently observed during procedures than before and after procedures (p < .01). Regarding physiological responses, significant increases in systolic blood pressure, diastolic blood pressure, mean arterial pressure, heart rate, and respiratory rate were identified across assessments (p < .001). CONCLUSIONS The findings can be used as a basis for pain assessment and the development of pain assessment tools for brain-injured patients who are unable to communicate. However, since physiological responses may be influenced by various factors besides pain, physiological changes may be used as a sign of the need for pain assessment rather than being used alone as a basis for pain assessment.
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Affiliation(s)
- Youngmin Cho
- School of Nursing, University of North Carolina at Chapel Hill, NC, USA.
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Assessing pain in critically ill brain-injured patients: a psychometric comparison of 3 pain scales and videopupillometry. Pain 2020; 160:2535-2543. [PMID: 31188267 DOI: 10.1097/j.pain.0000000000001637] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Gélinas C, Joffe AM, Szumita PM, Payen JF, Bérubé M, Shahiri T S, Boitor M, Chanques G, Puntillo KA. A Psychometric Analysis Update of Behavioral Pain Assessment Tools for Noncommunicative, Critically Ill Adults. AACN Adv Crit Care 2020; 30:365-387. [PMID: 31951666 DOI: 10.4037/aacnacc2019952] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
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.
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Affiliation(s)
- Céline Gélinas
- Céline Gélinas is Associate Professor, Ingram School of Nursing, McGill University, 680 Sherbrooke West, Room 1838, Montréal, Québec, Canada, H3A 2M7; and Researcher, Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, Montréal, Québec, Canada
| | - Aaron M Joffe
- Aaron M. Joffe is Professor, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Paul M Szumita
- Paul M. Szumita is Clinical Pharmacy Practice Manager and Program Director - PGY2 Critical Care Pharmacy Practice Residency, Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jean-Francois Payen
- Jean-Francois Payen is Professor, Department of Anesthesiology and Critical Care, and Researcher, Inserm, U1216, Grenoble Institut Neurosciences, Grenoble Alpes University Hospital, Grenoble, France
| | - Mélanie Bérubé
- Mélanie Bérubé is Assistant Professor, Faculty of Nursing, Université Laval; and Researcher, CHU de Québec, Université Laval Research Center (Hôpital de l'Enfant-Jésus), Québec City, Québec, Canada
| | - Shiva Shahiri T
- Shiva Shahiri T is a PhD Student, Ingram School of Nursing, McGill University
| | - Madalina Boitor
- Madalina Boitor is a Student, Faculty of Dentistry, McGill University
| | - Gerald Chanques
- Gerald Chanques is Professor, Department of Anesthesia & Critical Care Medicine, Montpellier University Hospital Saint Eloi, and PhyMedExp, University of Montpellier, INSERM, CNRS, 34295 Montpellier cedex 5, France
| | - Kathleen A Puntillo
- Kathleen A. Puntillo is Professor of Nursing Emeritus, University of California San Francisco School of Nursing, San Francisco, California
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13
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López-López C, Arranz-Esteban A, Arias-Rivera S, Solís-Muñoz M, Pérez-Pérez T, Latorre-Marco I. Application of the Behavioural Indicators of Pain Scale in patients with traumatic brain injury. J Adv Nurs 2020; 76:1862-1870. [PMID: 32338391 DOI: 10.1111/jan.14400] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 02/03/2020] [Accepted: 03/17/2020] [Indexed: 11/28/2022]
Abstract
AIM To develop and psychometrically test the Behavioural Indicators of Pain Scale (ESCID) in patients with traumatic brain injury (TBI). DESIGN A prospective observational study to test the psychometric properties of the Behavioural Indicators of Pain Scale in patients with TBI. METHOD A convenience sample of patients with TBI, who were non-communicative and using invasive mechanical ventilation was selected. Pain was evaluated by two observers who were blinded from each other. Assessments were performed at baseline via the performance of a painful procedure (aspiration of secretions) and a non-painful procedure (rubbing with a gauze). Assessments were repeated after application of procedures on days 1 and 6 of hospitalization in an intensive care unit. Data were collected between January-December 2016. RESULTS About 134 patients were included in the study. Of these, 76.1% were men. The mean age of participants was 45.2 (SD 17.5) years. The pain score significantly increased during the painful procedure when compared with the baseline measure and non-painful procedure (p < .001). Patients displayed a greater number of pain-indicating behaviours during the painful procedure on day 6, compared with day 1 (p < .05). This finding coincided with a reduced level of sedation and a greater level of consciousness. CONCLUSION The ESCID scale detects pain behaviours and discriminates among the different types of stimulation in patients with brain injury, who are uncommunicative and with mechanical ventilation, with good reliability. The ability for patients with brain injury to express behaviours is limited because of the low level of consciousness and the deep level of sedation. IMPACT This research will have an impact on the practice of pain assessment in patients with brain injury, representing a first step to adapt the content of the ESCID.
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Affiliation(s)
- Candelas López-López
- Department of Intensive Care, 12 de Octubre University Hospital (H12O), Madrid, Spain.,Care Research Group (Invecuid), Instituto de Investigación Sanitaria, 12 de Octubre University Hospital (imas12), Madrid, Spain.,Nursery, Physiotherapy and Podiatry Facultie, Complutense University of Madrid, Madrid, Spain
| | - Antonio Arranz-Esteban
- Emergency and Trauma Intensive Care Unit, 12 de Octubre University Hospital (H12O), Madrid, Spain
| | - Susana Arias-Rivera
- Hospital Nurse and Health Care Research, Getafe University Hospital (HUG), Madrid, Spain.,CIBER Respiratory Diseases, Carlos III Health Institute, Madrid, Spain
| | - Montserrat Solís-Muñoz
- Nursing Department, Puerta de Hierro Majadahonda University Hospital (HUPHM), Madrid, Spain.,Nursing and Health Care Research Group, Puerta de Hierro-Segovia de Arana Health Research Institute, Madrid, Spain
| | - Teresa Pérez-Pérez
- Department of Statistics and OR III, Complutense University of Madrid, Madrid, Spain.,Department of Statistics and Data Science, Madrid, Spain
| | - Ignacio Latorre-Marco
- Nursing and Health Care Research Group, Puerta de Hierro-Segovia de Arana Health Research Institute, Madrid, Spain.,Intensive Care Unit, Puerta de Hierro Majadahonda University Hospital (HUPHM), Madrid, Spain
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14
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Bonin EA, Lejeune N, Thibaut A, Cassol H, Antonopoulos G, Wannez S, Martial C, Schnakers C, Laureys S, Chatelle C. Nociception Coma Scale-Revised Allows to Identify Patients With Preserved Neural Basis for Pain Experience. THE JOURNAL OF PAIN 2020; 21:742-750. [DOI: 10.1016/j.jpain.2019.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 09/05/2019] [Accepted: 11/11/2019] [Indexed: 01/18/2023]
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15
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Vital signs fluctuations and their relationship with pain in the brain-injured adult critically ill - A repeated-measures descriptive-correlational study. Intensive Crit Care Nurs 2019; 55:102743. [PMID: 31677850 DOI: 10.1016/j.iccn.2019.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 06/26/2019] [Accepted: 07/03/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To evaluate the use of vital signs for pain detection in brain-injured patients in the intensive care unit. DESIGN A repeated-measures descriptive-correlational study. SETTING Two neurological intensive care units in Montréal, Canada. A total of 101 brain-injured patients were included. MAIN OUTCOME MEASURES This study examined the fluctuations in systolic and diastolic blood pressure, heart and respiratory rates, and oxygen saturation in brain-injured critically ill patients before, during, and 15 minutes after turning and soft touch using a data collection computer. When possible, patients' pain self-reports were obtained using a 0-10 Faces Pain Thermometer. RESULTS The heart and respiratory rates were higher during turning than soft touch and higher during the procedure compared to prior (p < 0.05), but their fluctuation was modest. The systolic blood pressure increased during both turning and soft touch by 2 mmHg, but was 26.6 mmHg higher for those who reported pain versus no pain (Mann-Whitney = 25.00, p = 0.008, n = 28). A moderate correlation was observed between the systolic blood pressure (Spearman's rho = 0.617, p = 0.004, n = 24) and self-reported pain intensity during turning. No significant effects were observed for diastolic blood pressure and oxygen saturation. CONCLUSION Only increases in systolic blood pressure were positively associated with pain in this sample and replication studies with larger samples is needed.
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Herr K, Coyne PJ, Ely E, Gélinas C, Manworren RCB. Pain Assessment in the Patient Unable to Self-Report: Clinical Practice Recommendations in Support of the ASPMN 2019 Position Statement. Pain Manag Nurs 2019; 20:404-417. [PMID: 31610992 DOI: 10.1016/j.pmn.2019.07.005] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 06/25/2019] [Accepted: 07/21/2019] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Keela Herr
- College of Nursing, University of Iowa, Iowa City, Iowa.
| | - Patrick J Coyne
- Palliative Care Department, Medical University of South Carolina, Charleston, South Carolina
| | - Elizabeth Ely
- Department of Nursing Research, University of Chicago Hospitals, Chicago, Illinois
| | - Céline Gélinas
- Ingram School of Nursing, McGill University, Montréal, Québec, Canada; Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital - CIUSSS, Centre-West-Montréal, Montréal, Québec, Canada
| | - Renee C B Manworren
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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