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Li Z, Pang M, Zhang J, Mao L, Wang X, Sun P. Effect of ventilation modalities on the early prognosis of patients with poststroke sleep apnea. Ann Clin Transl Neurol 2024; 11:355-367. [PMID: 38010089 PMCID: PMC10863924 DOI: 10.1002/acn3.51956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/09/2023] [Accepted: 11/11/2023] [Indexed: 11/29/2023] Open
Abstract
OBJECTIVE Continuous positive airway pressure (CPAP) is the primary modality for treating sleep apnea after acute ischemic stroke (AIS). However, not all patients are well adherent to CPAP. Finding an alternative modality of ventilation to CPAP is essential. METHODS This prospective randomized clinical trial was conducted from 1 May 2022 to 8 January 2023 at the Department of Neurology, Wuhan Union Hospital. Participants diagnosed with sleep apnea after AIS were grouped according to block randomization principles into the usual care group (nasal cannula and facemask), nasal continuous positive airway pressure (nCPAP) group, and high-flow nasal cannula (HFNC) group. Rates of pulmonary infection and endotracheal intubation within 1 week of hospitalization and 28-day mortality (poststroke) were the primary outcomes (early prognosis). RESULTS In the trial, 178 patients (119 males [66.85%]; mean [SD] age, 61.04 [11.78] years) were eventually enrolled in the usual care group (n = 63), the nCPAP group (n = 55), and the HFNC group (n = 60). After ventilation, the nCPAP and HFNC groups were more effective than the usual care group in reducing the rate of pulmonary infection, endotracheal intubation, and improving neurological function and sleep apnea severity. However, there was no difference in 28-day mortality. Additionally, the improvement in prognosis was consistent between nCPAP and HFNC. In the comparison of comfort, the HFNC group was superior to nCPAP. INTERPRETATION nCPAP and HFNC reduced early pulmonary infection rates and endotracheal intubation rates. For patients with poor compliance with nCPAP, HFNC may be the best alternative.
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Affiliation(s)
- Zhuanyun Li
- Department of Emergency Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Ming Pang
- National Clinical Research Center for Geriatrics, West China HospitalSichuan UniversityChengduChina
| | - Jinnong Zhang
- Department of Emergency Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Ling Mao
- Department of Neurology, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Xiaorong Wang
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Peng Sun
- Department of Emergency Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
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Evans SL, Olney WJ, Bernard AC, Gesin G. Optimal strategies for assessing and managing pain, agitation, and delirium in the critically ill surgical patient: What you need to know. J Trauma Acute Care Surg 2024; 96:166-177. [PMID: 37822025 DOI: 10.1097/ta.0000000000004154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
ABSTRACT Pain, agitation, and delirium (PAD) are primary drivers of outcome in the ICU, and expertise in managing these entities successfully is crucial to the intensivist's toolbox. In addition, there are unique aspects of surgical patients that impact assessment and management of PAD. In this review, we address the continuous spectrum of assessment, and management of critically ill surgical patients, with a focus on limiting PAD, particularly incorporating mobility as an anchor to ICU liberation. Finally, we touch on the impact of PAD in specific populations, including opioid use disorder, traumatic brain injury, pregnancy, obesity, alcohol withdrawal, and geriatric patients. The goal of the review is to provide rapid access to information regarding PAD and tools to assess and manage these important elements of critical care of surgical patients.
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Affiliation(s)
- Susan L Evans
- From the Department of Surgery (S.L.E.), Carolinas Medical Center, Atrium Health, Charlotte, North Carolina; Department of Pharmacy (W.J.O.), Acute Care Surgery, UK HealthCare, Lexington, Kentucky; Department of Surgery (A.C.B.), University of Kentucky, Lexington, Kentucky; and Division of Pharmacy (G.G.), Atrium Health, Charlotte, North Carolina
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3
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Favre E, Rahmaty Z, Ben-Hamouda N, Miroz JP, Abed-Maillard S, Rusca M, Oddo M, Ramelet AS. Nociception assessment with videopupillometry in deeply sedated intensive care patients: Discriminative and criterion validations. Aust Crit Care 2024; 37:84-90. [PMID: 37684156 DOI: 10.1016/j.aucc.2023.07.038] [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: 03/20/2023] [Revised: 07/17/2023] [Accepted: 07/25/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Nociceptive assessment in deeply sedated patients is challenging. Validated instruments are lacking for this unresponsive population. Videopupillometry is a promising tool but has not been established in intensive care settings. AIM/OBJECTIVE To test the discriminate validity of pupillary dilation reflex (PDR) between non-noxious and noxious procedures for assessing nociception in non-neurological intensive care unit (ICU) patients and to test the criterion validity of pupil dilation using recommended PDR cut-off points to determine nociception. METHODS A single-centre prospective observational study was conducted in medical-surgical ICU patients. Two independent investigators performed videopupillometer measurements during a non-noxious and a noxious procedure, once a day (up to 7 days), when the patient remained deeply sedated (Richmond Agitation-Sedation Scale score: -5 or -4). The non-noxious procedures consisted of a gentle touch on each shoulder and the noxious procedures were endotracheal suctioning or turning onto the side. Bivariable and multivariable general linear mixed models were used to account for multiple measurements in same patients. Sensitivity and specificity, and areas under the curve of the receiver operating characteristic curve were calculated. RESULTS Sixty patients were included, and 305 sets of 3 measurements (before, during, and after), were performed. PDR was higher during noxious procedures than before (mean difference between noxious and non-noxious procedures = 31.66%). After testing all variables of patient and stimulation characteristics in bivariable models, age and noxious procedures were kept in the multivariable model. Adjusting for age, noxious procedures (coefficient = -15.14 (95% confidence interval = -20.17 to -15.52, p < 0.001) remained the only predictive factor for higher pupil change. Testing recommended cut-offs, a PDR of >12% showed a sensitivity of 65%, and a specificity of 94% for nociception prediction, with an area under the receiver operating curve of 0.828 (95% confidence interval = 0.779-0.877). CONCLUSIONS In conclusion, PDR is a potentially appropriate measure to assess nociception in deeply sedated ICU patients, and we suggest considering its utility in daily practices. REGISTRATION This study was not preregistered in a clinical registry. TWEETABLE ABSTRACT Pupillometry may help clinicians to assess nociception in deeply sedated ICU patients.
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Affiliation(s)
- Eva Favre
- Department of Intensive Care, Lausanne University Hospital and Lausanne University, Switzerland; Institute of Higher Education and Research in Healthcare, University of Lausanne and Lausanne University Hospital, Switzerland
| | - Zahra Rahmaty
- Institute of Higher Education and Research in Healthcare, University of Lausanne and Lausanne University Hospital, Switzerland
| | - Nawfel Ben-Hamouda
- Department of Intensive Care, Lausanne University Hospital and Lausanne University, Switzerland
| | - John-Paul Miroz
- Department of Intensive Care, Lausanne University Hospital and Lausanne University, Switzerland
| | - Samia Abed-Maillard
- Department of Intensive Care, Lausanne University Hospital and Lausanne University, Switzerland
| | - Marco Rusca
- Department of Intensive Care, Lausanne University Hospital and Lausanne University, Switzerland
| | - Mauro Oddo
- Department of Intensive Care, Lausanne University Hospital and Lausanne University, Switzerland; Medical Directorate for Research, Education and Innovation, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare, University of Lausanne and Lausanne University Hospital, Switzerland.
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Menga LS, Delle Cese L, Rosà T, Cesarano M, Scarascia R, Michi T, Biasucci DG, Ruggiero E, Dell’Anna AM, Cutuli SL, Tanzarella ES, Pintaudi G, De Pascale G, Sandroni C, Maggiore SM, Grieco DL, Antonelli M. Respective Effects of Helmet Pressure Support, Continuous Positive Airway Pressure, and Nasal High-Flow in Hypoxemic Respiratory Failure: A Randomized Crossover Clinical Trial. Am J Respir Crit Care Med 2023; 207:1310-1323. [PMID: 36378814 PMCID: PMC10595442 DOI: 10.1164/rccm.202204-0629oc] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 11/15/2022] [Indexed: 11/16/2022] Open
Abstract
Rationale: The respective effects of positive end-expiratory pressure (PEEP) and pressure support delivered through the helmet interface in patients with hypoxemia need to be better understood. Objectives: To assess the respective effects of helmet pressure support (noninvasive ventilation [NIV]) and continuous positive airway pressure (CPAP) compared with high-flow nasal oxygen (HFNO) on effort to breathe, lung inflation, and gas exchange in patients with hypoxemia (PaO2/FiO2 ⩽ 200). Methods: Fifteen patients underwent 1-hour phases (constant FiO2) of HFNO (60 L/min), helmet NIV (PEEP = 14 cm H2O, pressure support = 12 cm H2O), and CPAP (PEEP = 14 cm H2O) in randomized sequence. Measurements and Main Results: Inspiratory esophageal (ΔPES) and transpulmonary pressure (ΔPL) swings were used as surrogates for inspiratory effort and lung distension, respectively. Tidal Volume (Vt) and end-expiratory lung volume were assessed with electrical impedance tomography. ΔPES was lower during NIV versus CPAP and HFNO (median [interquartile range], 5 [3-9] cm H2O vs. 13 [10-19] cm H2O vs. 10 [8-13] cm H2O; P = 0.001 and P = 0.01). ΔPL was not statistically different between treatments. PaO2/FiO2 ratio was significantly higher during NIV and CPAP versus HFNO (166 [136-215] and 175 [158-281] vs. 120 [107-149]; P = 0.002 and P = 0.001). NIV and CPAP similarly increased Vt versus HFNO (mean change, 70% [95% confidence interval (CI), 17-122%], P = 0.02; 93% [95% CI, 30-155%], P = 0.002) and end-expiratory lung volume (mean change, 198% [95% CI, 67-330%], P = 0.001; 263% [95% CI, 121-407%], P = 0.001), mostly due to increased aeration/ventilation in dorsal lung regions. During HFNO, 14 of 15 patients had pendelluft involving >10% of Vt; pendelluft was mitigated by CPAP and further by NIV. Conclusions: Compared with HFNO, helmet NIV, but not CPAP, reduced ΔPES. CPAP and NIV similarly increased oxygenation, end-expiratory lung volume, and Vt, without affecting ΔPL. NIV, and to a lesser extent CPAP, mitigated pendelluft. Clinical trial registered with clinicaltrials.gov (NCT04241861).
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Affiliation(s)
- Luca S. Menga
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Luca Delle Cese
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Tommaso Rosà
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Melania Cesarano
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Roberta Scarascia
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Teresa Michi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Daniele G. Biasucci
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Ersilia Ruggiero
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Antonio M. Dell’Anna
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Salvatore L. Cutuli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Eloisa S. Tanzarella
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Gabriele Pintaudi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Gennaro De Pascale
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Claudio Sandroni
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Salvatore Maurizio Maggiore
- University Department of Innovative Technologies in Medicine and Dentistry, Gabriele d’Annunzio University of Chieti-Pescara, Chieti, Italy; and
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
| | - Domenico L. Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
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Grieco DL, Russo A, Anzellotti GM, Romanò B, Bongiovanni F, Dell'Anna AM, Mauti L, Cascarano L, Gallotta V, Rosà T, Varone F, Menga LS, Polidori L, D'Indinosante M, Cappuccio S, Galletta C, Tortorella L, Costantini B, Gueli Alletti S, Sollazzi L, Scambia G, Antonelli M. Lung-protective ventilation during Trendelenburg pneumoperitoneum surgery: A randomized clinical trial. J Clin Anesth 2023; 85:111037. [PMID: 36495775 DOI: 10.1016/j.jclinane.2022.111037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/31/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
Study objective To assess the effects of a protective ventilation strategy during Trendelenburg pneumoperitoneum surgery on postoperative oxygenation. DESIGNS Parallel-group, randomized trial. SETTING Operating room of a university hospital, Italy. PATIENTS Morbidly obese patients undergoing Trendelenburg pneumoperitoneum gynaecological surgery. INTERVENTIONS Participants were randomized to standard (SV: tidal volume = 10 ml/kg of predicted body weight, PEEP = 5 cmH2O) or protective (PV: tidal volume = 6 ml/kg of predicted body weight, PEEP = 10 cmH2O, recruitment maneuvers) ventilation during anesthesia. MEASUREMENTS Primary outcome was PaO2/FiO2 one hour after extubation. Secondary outcomes included day-1 PaO2/FiO2, day-2 respiratory function and intraoperative respiratory/lung mechanics, assessed through esophageal manometry, end-expiratory lung volume (EELV) measurement and pressure-volume curves. MAIN RESULTS Sixty patients were analyzed (31 in SV group, 29 in PV group). Median [IqR] tidal volume was 350 ml [300-360] in PV group and 525 [500-575] in SV group. Median PaO2/FiO2 one hour after extubation was 280 mmHg [246-364] in PV group vs. 298 [250-343] in SV group (p = 0.64). Day-1 PaO2/FiO2, day-2 forced vital capacity, FEV-1 and Tiffenau Index were not different between groups (all p > 0.10). Intraoperatively, 59% of patients showed complete airway closure during pneumoperitoneum, without difference between groups: median airway opening pressure was 17 cmH2O. In PV group, airway and transpulmonary driving pressure were lower (12 ± 5 cmH2O vs. 17 ± 7, p < 0.001; 9 ± 4 vs. 13 ± 7, p < 0.001), PaCO2 and respiratory rate were higher (48 ± 8 mmHg vs. 42 ± 12, p < 0.001; 23 ± 5 breaths/min vs. 16 ± 4, p < 0.001). Intraoperative EELV was similar between PV and SV group (1193 ± 258 ml vs. 1207 ± 368, p = 0.80); ratio of tidal volume to EELV was lower in PV group (0.45 ± 0.12 vs. 0.32 ± 0.09, p < 0.001). CONCLUSIONS In obese patients undergoing Trendelenburg pneumoperitoneum surgery, PV did not improve postoperative oxygenation nor day-2 respiratory function. PV was associated with intraoperative respiratory mechanics indicating less injurious ventilation. The high prevalence of complete airway closure may have affected study results. TRIAL REGISTRATION Prospectively registered on http://clinicaltrials.govNCT03157479 on May 17th, 2017.
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Affiliation(s)
- Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Andrea Russo
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gian Marco Anzellotti
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Bruno Romanò
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Filippo Bongiovanni
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio M Dell'Anna
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luigi Mauti
- Department of Internal medicine, Catholic University of The Sacred Heart, Rome, Italy; Respiratory Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Laura Cascarano
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Valerio Gallotta
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Tommaso Rosà
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Varone
- Department of Internal medicine, Catholic University of The Sacred Heart, Rome, Italy; Respiratory Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luca S Menga
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lorenzo Polidori
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marco D'Indinosante
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Serena Cappuccio
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Claudia Galletta
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lucia Tortorella
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Barbara Costantini
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Salvatore Gueli Alletti
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Liliana Sollazzi
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Scambia
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Khan MU, Aziz S, Hirachan N, Joseph C, Li J, Fernandez-Rojas R. Experimental Exploration of Multilevel Human Pain Assessment Using Blood Volume Pulse (BVP) Signals. SENSORS (BASEL, SWITZERLAND) 2023; 23:3980. [PMID: 37112321 PMCID: PMC10143826 DOI: 10.3390/s23083980] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/08/2023] [Accepted: 04/11/2023] [Indexed: 06/19/2023]
Abstract
Critically ill patients often lack cognitive or communicative functions, making it challenging to assess their pain levels using self-reporting mechanisms. There is an urgent need for an accurate system that can assess pain levels without relying on patient-reported information. Blood volume pulse (BVP) is a relatively unexplored physiological measure with the potential to assess pain levels. This study aims to develop an accurate pain intensity classification system based on BVP signals through comprehensive experimental analysis. Twenty-two healthy subjects participated in the study, in which we analyzed the classification performance of BVP signals for various pain intensities using time, frequency, and morphological features through fourteen different machine learning classifiers. Three experiments were conducted using leave-one-subject-out cross-validation to better examine the hidden signatures of BVP signals for pain level classification. The results of the experiments showed that BVP signals combined with machine learning can provide an objective and quantitative evaluation of pain levels in clinical settings. Specifically, no pain and high pain BVP signals were classified with 96.6% accuracy, 100% sensitivity, and 91.6% specificity using a combination of time, frequency, and morphological features with artificial neural networks (ANNs). The classification of no pain and low pain BVP signals yielded 83.3% accuracy using a combination of time and morphological features with the AdaBoost classifier. Finally, the multi-class experiment, which classified no pain, low pain, and high pain, achieved 69% overall accuracy using a combination of time and morphological features with ANN. In conclusion, the experimental results suggest that BVP signals combined with machine learning can offer an objective and reliable assessment of pain levels in clinical settings.
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7
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Wandrey JD, Behnel N, Weidner E, Dummin U, von Dincklage F, Tafelski S. Behaviour-based pain scales: Validity and interrater reliability of BPS-NI and PAINAD-G on general wards. Eur J Pain 2023; 27:201-211. [PMID: 36326568 DOI: 10.1002/ejp.2051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/26/2022] [Accepted: 10/30/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Measuring pain intensity in patients unable to communicate is a challenge on general wards. Observation-based pain scoring tools have been used for patients with dementia or in critically ill intensive care unit (ICU) patients. However, there is no established or validated assessment tool for non-ICU patients without dementia related cognitive deficiencies who cannot communicate. The "Behavioural Pain Scale Non-Intubated" (BPS-NI) and the "Pain Assessment In Advanced Dementia-German" (PAINAD-G) are potential tools to fill this gap. METHODS This study was performed with verbal non-ICU patients on general wards at Charité Berlin. Two assessors independently rated pain intensity using the BPS-NI and the PAINAD-G along with patients' self-ratings on the Numeric Rating Scale (NRS). The interrater-reliability of BPS-NI and PAINAD-G was calculated and ROC-analyses were performed to identify cut-off values for medium and intense pain for each score. Effectiveness was calculated using percentage agreement. In total, 126 patients were included into analysis. RESULTS The BPS-NI showed substantial congruence in interrater-reliability (Cohens-Kappa 0.71), whereas the PAINAD-G showed moderate congruence (Kappa 0.48). Based on ROC-analyses, for medium pain levels a cut-off 4 (BPS-NI) or 2 (PAINAD-G) and for severe pain levels cut-off 5 (BPS-NI) and 3 (PAINAD-G) would result in good accordance with self-reported NRS for pain. CONCLUSION The BPS-NI shows a good validity in measuring pain intensity in patients on general wards and may possibly be used for patients unable to communicate. Using defined cut-off values for BPS-NI and PAINAD-G, clinically relevant pain intensities in patients can reliably be detected. SIGNIFICANCE Measuring the pain intensity in patients unable to communicate is a common challenge on general wards. This study assessed reliability and applicability BPS-NI and the PAINAD-G in a general ward setting. Furthermore, it provides cut-off values in order to estimate pain intensity and support analgesic response.
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Affiliation(s)
- Jan D Wandrey
- Department of Anaesthesiology and Operative Intensive Care, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Niklas Behnel
- Department of Anaesthesiology and Operative Intensive Care, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Elisa Weidner
- Department of Anaesthesiology and Operative Intensive Care, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ulrike Dummin
- Department of Anaesthesiology and Operative Intensive Care, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Falk von Dincklage
- Department of Anaesthesiology and Operative Intensive Care, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Anesthesia, Critical Care, Emergency and Pain Medicine, Ferdinand-Sauerbruch-Strasse, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Sascha Tafelski
- Department of Anaesthesiology and Operative Intensive Care, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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8
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Chuck the Old Compass for a New One: Navigating Palliative Care in the ICU. Crit Care Med 2023; 51:141-143. [PMID: 36519988 DOI: 10.1097/ccm.0000000000005722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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9
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Ghosh A, Umer S, Khan MK, Rout RK, Dhara BC. Smart sentiment analysis system for pain detection using cutting edge techniques in a smart healthcare framework. CLUSTER COMPUTING 2023; 26:119-135. [PMID: 35125934 PMCID: PMC8799976 DOI: 10.1007/s10586-022-03552-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/12/2022] [Accepted: 01/13/2022] [Indexed: 05/04/2023]
Abstract
A sentiment analysis system has been proposed in this paper for pain detection using cutting edge techniques in a smart healthcare framework. This proposed system may be eligible for detecting pain sentiments by analyzing facial expressions on the human face. The implementation of the proposed system has been divided into four components. The first component is about detecting the face region from the input image using a tree-structured part model. Statistical and deep learning-based feature analysis has been performed in the second component to extract more valuable and distinctive patterns from the extracted facial region. In the third component, the prediction models based on statistical and deep feature analysis derive scores for the pain intensities (no-pain, low-pain, and high-pain) on the facial region. The scores due to the statistical and deep feature analysis are fused to enhance the performance of the proposed method in the fourth component. We have employed two benchmark facial pain expression databases during experimentation, such as UNBC-McMaster shoulder pain and 2D Face-set database with Pain-expression. The performance concerning these databases has been compared with some existing state-of-the-art methods. These comparisons show the superiority of the proposed system.
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Affiliation(s)
- Anay Ghosh
- Department of Computer Science & Engineering, University of Engineering & Management, Kolkata, 700156 India
| | - Saiyed Umer
- Department of Computer Science & Engineering, Aliah University, Kolkata, 700156 India
| | - Muhammad Khurram Khan
- Center of Excellence in Information Assurance, College of Computer and Information Sciences, King Saud University, Riyadh, 11451 Saudi Arabia
| | - Ranjeet Kumar Rout
- Department of Computer Science & Engineering, National Institute of Technology, Srinagar, 190006 India
| | - Bibhas Chandra Dhara
- Department of Information Technology, Jadavpur University, Kolkata, 700098 India
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10
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Moran BL, Scott DA, Holliday E, Knowles S, Saxena M, Seppelt I, Hammond N, Myburgh JA. Pain assessment and analgesic management in patients admitted to intensive care: an Australian and New Zealand point prevalence study. CRIT CARE RESUSC 2022; 24:224-232. [PMID: 38046214 PMCID: PMC10692642 DOI: 10.51893/2022.3.oa1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To describe pain assessment and analgesic management practices in patients in intensive care units (ICUs) in Australia and New Zealand. Design, setting and participants: Prospective, observational, multicentre, single-day point prevalence study conducted in Australian and New Zealand ICUs. Observational data were recorded for all adult patients admitted to an ICU without a neurological, neurosurgical or postoperative cardiac diagnosis. Demographic characteristics and data on pain assessment and analgesic management for a 24-hour period were collected. Main outcome measures: Types of pain assessment tools used and frequency of their use, use of opioid analgesia, use of adjuvant analgesia, and differences in pain assessment and analgesic management between postoperative and non-operative patients. Results: From the 499 patients enrolled from 45 ICUs, pain assessment was performed at least every 4 hours in 56% of patients (277/499), most commonly with a numerical rating scale. Overall, 286 patients (57%) received an opioid on the study day. Of the 181 mechanically ventilated patients, 135 (75%) received an intravenous opioid, with the predominant opioid infusion being fentanyl. The median dose of opioid infusion for ventilated patients was 140 mg oral morphine equivalents. Of the 318 non-ventilated patients, 41 (13%) received patient-controlled analgesia and 76 (24%) received an oral opioid, with the predominant opioid being oxycodone. Paracetamol was administered to 63 ventilated patients (35%) and 164 non-ventilated patients (52%), while 2% of all patients (11/499) received a non-steroidal anti-inflammatory drug. Ketamine infusion and regional analgesia were used in 15 patients (3%) and 17 patients (3%), respectively. Antineuropathic agents (predominantly gabapentinoids) were used in 53 patients (11%). Conclusions: Although a majority of ICU patients were frequently assessed for pain with a validated pain assessment tool, cumulative daily doses of opioids were high, and the use of multimodal adjuvant analgesia was low. Our data on current pain assessment and analgesic management practices may inform further research in this area.
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Affiliation(s)
- Benjamin L. Moran
- Critical Care Program, George Institute for Global Health, Sydney, NSW, Australia
- Department of Intensive Care, Gosford Hospital, Gosford, NSW, Australia
- Department of Anaesthesia and Pain Medicine, Gosford Hospital, Gosford, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - David A. Scott
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Elizabeth Holliday
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
- Clinical Research Design and Statistics Unit, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Serena Knowles
- Critical Care Program, George Institute for Global Health, Sydney, NSW, Australia
| | - Manoj Saxena
- Critical Care Program, George Institute for Global Health, Sydney, NSW, Australia
- Department of Intensive Care Medicine, Bankstown Hospital, Sydney, NSW, Australia
| | - Ian Seppelt
- Critical Care Program, George Institute for Global Health, Sydney, NSW, Australia
- Faculty of Medicine and Health Sciences, University of Sydney, Sydney, NSW, Australia
- Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Naomi Hammond
- Critical Care Program, George Institute for Global Health, Sydney, NSW, Australia
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - John A. Myburgh
- Critical Care Program, George Institute for Global Health, Sydney, NSW, Australia
- Department of Intensive Care Medicine, St George Hospital, Sydney, NSW, Australia
| | - For the George Institute for Global Health, the Australian and New Zealand Intensive Care Society Clinical Trials Group and the Pain in Survivors of Intensive Care Units (PAIN-ICU) Study Investigators
- Critical Care Program, George Institute for Global Health, Sydney, NSW, Australia
- Department of Intensive Care, Gosford Hospital, Gosford, NSW, Australia
- Department of Anaesthesia and Pain Medicine, Gosford Hospital, Gosford, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
- Clinical Research Design and Statistics Unit, Hunter Medical Research Institute, Newcastle, NSW, Australia
- Department of Intensive Care Medicine, Bankstown Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health Sciences, University of Sydney, Sydney, NSW, Australia
- Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Department of Intensive Care Medicine, St George Hospital, Sydney, NSW, Australia
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11
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Pota V, Coppolino F, Barbarisi A, Passavanti MB, Aurilio C, Sansone P, Pace MC. Pain in Intensive Care: A Narrative Review. Pain Ther 2022; 11:359-367. [PMID: 35220551 PMCID: PMC9098741 DOI: 10.1007/s40122-022-00366-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 02/09/2022] [Indexed: 11/26/2022] Open
Affiliation(s)
- Vincenzo Pota
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy.
| | - Francesco Coppolino
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy
| | - Alfonso Barbarisi
- Department of Translational Medical Science, Telematic University Pegaso, Naples, Italy
| | - Maria Beatrice Passavanti
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy
| | - Caterina Aurilio
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy
| | - Pasquale Sansone
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy
| | - Maria Caterina Pace
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy
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12
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Moran BL, Myburgh JA, Scott DA. The complications of opioid use during and post-intensive care admission: A narrative review. Anaesth Intensive Care 2022; 50:108-126. [PMID: 35172616 DOI: 10.1177/0310057x211070008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Opioids are a commonly administered analgesic medication in the intensive care unit, primarily to facilitate invasive mechanical ventilation. Consensus guidelines advocate for an opioid-first strategy for the management of acute pain in ventilated patients. As a result, these patients are potentially exposed to high opioid doses for prolonged periods, increasing the risk of adverse effects. Adverse effects relevant to these critically ill patients include delirium, intensive care unit-acquired infections, acute opioid tolerance, iatrogenic withdrawal syndrome, opioid-induced hyperalgesia, persistent opioid use, and chronic post-intensive care unit pain. Consequently, there is a challenge of optimising analgesia while minimising these adverse effects. This narrative review will discuss the characteristics of opioid use in the intensive care unit, outline the potential short-term and long-term adverse effects of opioid therapy in critically ill patients, and outline a multifaceted strategy for opioid minimisation.
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Affiliation(s)
- Benjamin L Moran
- Critical Care Program, The George Institute of Global Health, Sydney, Australia.,Department of Intensive Care, 90112Gosford Hospital, Gosford Hospital, Gosford, Australia.,Department of Anaesthesia and Pain Medicine, Gosford Hospital, Gosford, Australia.,School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - John A Myburgh
- Critical Care Program, The George Institute of Global Health, Sydney, Australia.,Faculty of Medicine, 7800University of New South Wales, University of New South Wales, Kensington, Australia.,St George Hospital, Kogarah, Australia
| | - David A Scott
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Fitzroy, Australia.,Department of Critical Care, University of Melbourne, Parkville, Australia
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13
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Nurses Knowledge, Attitude, and Practices Toward Pain Assessment and Management of Patients Unable to Communicate Verbally. Crit Care Nurs Q 2021; 44:413-423. [PMID: 34437320 DOI: 10.1097/cnq.0000000000000378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Critically ill patients usually experience a significant level of pain during rest or during routine care such as turning, wound care, and endotracheal suctioning. Pain assessment is the cornerstone of pain management. Adequate pain assessment and management are major responsibilities of critical care nurses. The purpose of this study was to evaluate the nurses' knowledge, attitudes, and practices toward pain assessment and management of the intensive care unit (ICU) patients who are unable to communicate verbally. A descriptive cross-sectional design was used in this study. The study was conducted at ICUs in 5 hospitals from the north, middle, and south areas of Jordan. A self-administered questionnaire developed by Rose was used in this study. The most important finding in this study was that a large number of ICU nurses do not use assessment tools to evaluate the level of pain in patients who are unable to communicate verbally. Moreover, the nurses have inadequate knowledge about pain assessment and management. As perceived by the nurses, "restlessness" was the highest rated routine indicator of pain (25.1%), followed by "not following commands" (24%). Half of the participants (50%) answered that nurses were the persons who provide the most accurate rating of pain intensity. However, the participants showed positive attitude toward pain assessment and management.
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14
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Lafci D, Yildiz E, Pehlivan S. Nurses' views and applications on palliative care. Perspect Psychiatr Care 2021; 57:1340-1346. [PMID: 33283277 DOI: 10.1111/ppc.12695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/30/2020] [Accepted: 11/14/2020] [Indexed: 11/26/2022] Open
Abstract
PURPOSE This study was carried out descriptively to determine the view and applications about pallative care of nurses working in a university hospital. DESIGN AND METHODS The data were collected with the questionnaire form: "Individual Information Form" and "Views and Appllications on Palliative Care," created by the researchers in line with the literature. FINDINGS A total of 96.6% of the nurses evaluated the scope of palliative care as pain relief, and the most common difficulties in care were identified as bad news (88.1%). In all, 22.0% of the nurses talked to the patient and their family about death. PRACTICE IMPLICATIONS It is thought that the majority of nurses are not trained in palliative care and their opinions about palliative care are affected by this situation.
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Affiliation(s)
- Diğdem Lafci
- Faculty of Nursing, Mersin University, Mersin, Turkey
| | - Ebru Yildiz
- Faculty of Nursing, Mersin University, Mersin, Turkey
| | - Seda Pehlivan
- Faculty of Health Sciences, Bursa Uludağ University, Bursa, Turkey
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15
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Naye F, Cachinho C, Tremblay AP, Saint-Germain Lavoie M, Lepage G, Larochelle E, Labrecque L, Tousignant-Laflamme Y. How to objectively assess and observe maladaptive pain behaviors in clinical rehabilitation: a systematic search and review. Arch Physiother 2021; 11:15. [PMID: 34078473 PMCID: PMC8173828 DOI: 10.1186/s40945-021-00109-y] [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] [Received: 12/10/2020] [Accepted: 05/06/2021] [Indexed: 11/11/2022] Open
Abstract
Background Cognitive-affective factors influence the perception of pain and disability. These factors can lead to pain behaviors (PB) that can persist and become maladaptive. These maladaptive PB will further increase the risk of chronicity or persistence of symptoms and disability. Thus, clinicians must be prepared to recognize maladaptive PB in a clinical context. To date, in the context of assessment in a rehabilitation setting, PB in clinical settings are poorly documented. The main objective of this study was to identify direct observation methods and critically appraise them in order to propose recommendations for practice. As a secondary objective, we explored and extracted the different observable PB that patients could exhibit and that clinicians could observe. Methods We conducted a comprehensive review on four databases with a generic search strategy in order to obtain the largest range of PB. For the first objective, a two-step critical appraisal used clinical criteria (from qualitative studies on barriers to implement routine measures) and psychometric criteria (from Brink and Louw critical appraisal tool) to determine which observation methods could be recommended for clinical practice. For the second objective, we extracted PB found in the literature to list potential PB that patients could exhibit, and clinicians could observe. Results From the 3362 retrieved studies, 47 met the inclusion criteria for the first objective. The clinical criteria allowed us to select three observation methods. After the psychometric step, two observation methods were retained and recommended for clinical practice: the Behavioral Avoidance Test-Back Pain (BAT-Back) and the Pain Behaviour Scale (PaBS). For the second objective, 107 studies met the inclusion criteria. The extraction of the PB allowed us to list a large range of PB and classify the data in 7 categories of PB. Conclusion Our results allowed us to recommend two observation methods for clinical practice. However, these methods have limitations and are validated only in chronic low back pain populations. With the extraction of PB presented in the literature, we contribute to better prepare clinicians to recognize PB in all patients who are experiencing pain.
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Affiliation(s)
- Florian Naye
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | | | - Annie-Pier Tremblay
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Maude Saint-Germain Lavoie
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Gabriel Lepage
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Emma Larochelle
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Lorijane Labrecque
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Yannick Tousignant-Laflamme
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada. .,Research Center of the Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada.
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16
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Caron M, Parrot A, Elabbadi A, Dupeyrat S, Turpin M, Baury T, Rozencwajg S, Blayau C, Fulgencio JP, Gibelin A, Blanchard PY, Rodriguez S, Daigné D, Allain MC, Fartoukh M, Pham T. Pain and dyspnea control during awake fiberoptic bronchoscopy in critically ill patients: safety and efficacy of remifentanil target-controlled infusion. Ann Intensive Care 2021; 11:48. [PMID: 33725225 PMCID: PMC7966657 DOI: 10.1186/s13613-021-00832-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 03/02/2021] [Indexed: 12/13/2022] Open
Abstract
Purpose Flexible fiberoptic bronchoscopy is frequently used in intensive care unit, but is a source of discomfort, dyspnea and anxiety for patients. Our objective was to assess the feasibility and tolerance of a sedation using remifentanil target-controlled infusion, to perform fiberoptic bronchoscopy in awake ICU patients. Materials, patients and methods This monocentric, prospective observational study was conducted in awake patients requiring fiberoptic bronchoscopy. In accordance with usual practices in our center, remifentanil target-controlled infusion was used under close monitoring and adapted to the patient’s reactions. The primary objective was the rate of successful procedures without additional analgesia or anesthesia. The secondary objectives were clinical tolerance and the comfort of patients (graded from “very uncomfortable” to “very comfortable”) and operators (numeric scale from 0 to 10) during the procedure. Results From May 2014 to December 2015, 72 patients were included. Most of them (69%) were hypoxemic and admitted for acute respiratory failure. No additional medication was needed in 96% of the patients. No severe side-effects occurred. Seventy-eight percent of patients described the procedure as “comfortable or very comfortable”. Physicians rated their comfort with a median [IQR] score of 9 [8–10]. Conclusion Remifentanil target-controlled infusion administered to perform awake fiberoptic bronchoscopy in critically ill patients is feasible without requirement of additional analgesics or sedative drugs. Clinical tolerance as well as patients’ and operators’ comfort were good to excellent. This technique could benefit patients’ experience. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00832-6.
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Affiliation(s)
- Margot Caron
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Antoine Parrot
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Alexandre Elabbadi
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Sophie Dupeyrat
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Matthieu Turpin
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Thomas Baury
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Sacha Rozencwajg
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Clarisse Blayau
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Jean-Pierre Fulgencio
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Aude Gibelin
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Pierre-Yves Blanchard
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Séverine Rodriguez
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Daisy Daigné
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Marie-Cécile Allain
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France
| | - Muriel Fartoukh
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Paris, France.,Groupe de Recherche Clinique GRC05 CARMAS, Institut Mondor de recherche biomédicale, INSERM, Créteil, France
| | - Tài Pham
- Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de recherche clinique CARMAS, Le Kremlin-Bicêtre, France.
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17
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Kia Z, Allahbakhshian M, Ilkhani M, Nasiri M, Allahbakhshian A. Nurses' use of non-pharmacological pain management methods in intensive care units: A descriptive cross-sectional study. Complement Ther Med 2021; 58:102705. [PMID: 33677019 DOI: 10.1016/j.ctim.2021.102705] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Pain is a common and unpleasant feeling among patients in intensive care units. Therefore, the use of proper pain management methods, such as non-pharmacological interventions, is a priority in intensive care units. OBJECTIVE This study aimed to ascertain the extent of the use of non-pharmacological pain management methods by intensive care unit nurses in Iran and to identify the obstacles that hindered the use of these methods. MATERIAL AND METHODS This study used a descriptive cross-sectional design which involved a convenience sample of 224 nurses who worked in 16 intensive care units across northern Iran. Data were collected using the non-pharmacological pain management questionnaire and a researcher-developed checklist of the obstacles that hindered the use of non-pharmacological pain management methods. RESULTS A moderate number of ICU nurses used non-pharmacological pain management methods (55.8 %). The most common method used by nurses was repositioning (M = 2.72), while methods such as acupuncture and reflexology were used less frequently. Furthermore, the most common obstacles to the use of non-pharmacological pain management methods were nurses' fatigue (M = 2.92) and multiple responsibilities (M = 2.91). Demographic variables such as age, gender, educational level, and work experience were not significantly associated with the use of non-pharmacological pain management methods. CONCLUSIONS Due to factors such as fatigue, multiple responsibilities, a heavy workload, and an insufficient number of nurses per shift, the rate of utilization of non-pharmacological pain management methods among intensive care unit nurses in Iran was low. Furthermore, most of the participants in this study had not attended courses on non-pharmacological pain management.
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Affiliation(s)
- Zeinab Kia
- School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Maryam Allahbakhshian
- School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Mahnaz Ilkhani
- School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Malihe Nasiri
- School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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18
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Gilder E, Jull A, Slark J, Parke RL. Patient's experiences of endotracheal tubes and suction following cardiac surgery. Nurs Crit Care 2021; 27:187-194. [PMID: 33586305 DOI: 10.1111/nicc.12604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 12/27/2020] [Accepted: 01/28/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND There is a growing body of evidence addressing the patient experience of intensive care, including patient reports that the presence of an endotracheal tube is bothersome and distressing, and that endotracheal suction is moderately to extremely painful. Yet there remains little information about the patient experience of the endotracheal tube and suction in those patients receiving planned short-term mechanical ventilation. AIMS AND OBJECTIVES This study aimed to describe the patient experience of the endotracheal tube and suction, following mechanical ventilation in post-operative cardiac surgical patients. DESIGN This qualitative study used inductive thematic analysis. Participants having planned cardiac surgery, anticipated to receive less than 12-hours mechanical ventilation, were approached pre-operatively and written consent provided. METHODS Ten participants were recruited using purposive sampling. Semi-structured interviews were conducted between days four and six post-operatively. One researcher interviewed all participants; two researchers independently read, coded, and agreed themes. FINDINGS None of the participants recalled endotracheal suction, while half had no recollection of the endotracheal tube. Three themes were identified; the experience of the endotracheal tube and extubation, the experience of emerging from sedation, and participants concerns about the future. The presence of the endotracheal tube was described as bothersome, whilst breathing through the tube and extubation were described as 'weird' and 'strange' but not painful. CONCLUSIONS Knowledge of the patient experience can help inform nursing practice by improving pre and post-operative care planning. RELEVANCE TO CLINICAL PRACTICE This study adds to the body of knowledge about the patient experience of the endotracheal tube and extubation. TRIAL REGISTRATION Prospective registration with the Australian New Zealand Clinical Trials Registry. www.anzctr.org.au (ACTRN12616001515482).
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Affiliation(s)
- Eileen Gilder
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand.,School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Andrew Jull
- School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Julia Slark
- School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Rachael L Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand.,School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.,Australian and New Zealand Intensive Care Research Centre, Melbourne, Victoria, Australia
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Helmer LM, Weijenberg RA, de Vries R, Achterberg WP, Lautenbacher S, Sampson EL, Lobbezoo F. Crying out in pain-A systematic review into the validity of vocalization as an indicator for pain. Eur J Pain 2020; 24:1703-1715. [PMID: 32573041 PMCID: PMC7587015 DOI: 10.1002/ejp.1623] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 06/14/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Vocalization is often used to assess pain, sometimes combined with other behaviours such as facial expressions. Contrary to facial expressions, however, for vocalization, there is little evidence available on the association with pain. The aim of this systematic review was to critically analyse the association between vocalization and pain, to explore if vocalizations can be used as a "stand-alone" indicator for pain. METHODS The search was performed according to the Prisma Guidelines for systematic reviews and meta-analysis. The following terms were used: "Pain Measurement," "Vocalization" and "Verbalization." The study population included verbal and non-verbal individuals, including older people and children. The search was performed in three different databases: PubMed, Embase and CINAHL. A total of 35 studies were selected for detailed investigation. Quality assessments were made using two grading systems: Grading of Recommendations Assessment Development and Evaluation system and the Newcastle-Ottawa scale. RESULTS An association between vocalization and pain was found in most studies, particularly when different types of vocalizations were included in the investigation. Different types of vocalization, but also different types of pain, shape this association. The association is observed within all groups of individuals, although age, amongst others, may have an influence on preferred type of vocalization. CONCLUSIONS There is an association between vocalization and pain. However, vocalization as a "stand-alone" indicator for pain indicates only a limited aspect of this multifactorial phenomenon. Using vocalization as an indicator for pain may be more reliable if other pain indicators are also taken into account. SIGNIFICANCE Vocalizations are frequently used in pain scales, although not yet thoroughly investigated as a "single indicator" for pain, like, e.g. facial expression. This review confirms the role of vocalizations in pain scales, and stresses that vocalizations might be more reliable if used in combination with other pain indicators.
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Affiliation(s)
- Loreine M.L. Helmer
- Department of Orofacial Pain and DysfunctionAcademic Centre for Dentistry Amsterdam (ACTA)University of Amsterdam and Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Roxane A.F. Weijenberg
- Department of Orofacial Pain and DysfunctionAcademic Centre for Dentistry Amsterdam (ACTA)University of Amsterdam and Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Ralph de Vries
- Medical LibraryVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Wilco P. Achterberg
- Department of Public Health and Primary careLeiden University Medical CentreLeidenThe Netherlands
| | | | - Elizabeth L. Sampson
- Marie Curie Palliative Care Research DepartmentDivision of PsychiatryUniversity College LondonLondonUK
| | - Frank Lobbezoo
- Department of Orofacial Pain and DysfunctionAcademic Centre for Dentistry Amsterdam (ACTA)University of Amsterdam and Vrije Universiteit AmsterdamAmsterdamThe Netherlands
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20
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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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21
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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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22
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Bray K, Winkelman C, Bernhofer EI, Marek JF. Procedural Pain in the Adult Neurological Intensive Care Unit: A Retrospective Study Examining Arterial Line Insertion. Pain Manag Nurs 2019; 21:323-330. [PMID: 31753605 DOI: 10.1016/j.pmn.2019.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 09/12/2019] [Accepted: 09/14/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND This was a retrospective chart review of procedural pain assessments and interventions during arterial catheter insertion in an adult neurological intensive care unit where patients with impaired consciousness are common. Overall, pain assessment was well documented (100%) by Registered Nurses, but not specific to arterial line insertion. Nurse practitioners commonly placed arterial lines and used local analgesia in over 75% of the documented procedures. AIMS The purpose of this study was to examine healthcare providers' pain-related practices documented during arterial catheter insertion, one of the most painful procedures in a neurological intensive care unit. Secondary purposes were determining whether patient characteristics, procedure-related factors, or provider licensure were associated with pain assessment or procedural pain interventions. DESIGN A retrospective records review design was used. METHODS 120 electronic patient medical records were reviewed during a one-year period. RESULTS 100 charts met inclusion criteria. Nurses assessed all pain within 4 hours following the procedure in all charts but procedure-specific pain assessments were documented in 4% of charts. Pain-related interventions for arterial line insertion were local analgesic (76% of charts) and other procedure-specific interventions (10%). Significant associations occurred between procedure specific pain assessments and decreased number of insertion attempts (p = .006) and between pain interventions and number of insertion attempts (p = .003). No provider documented procedural pain assessment regarding arterial line insertion. Associations between patient characteristics and pain interventions were significant for patient ethnicity (F = 8.967, p = .007). CONCLUSIONS Overall pain assessment was documented (100%) but not specific to arterial line insertion. Although arterial line insertion can be extremely painful, patients were rarely assessed for such pain by any clinician; 14% did not receive any preprocedural analgesia. CLINICAL IMPLICATIONS The lack of procedural pain assessment in this vulnerable population indicates a need for increased pain management education for clinicians and further investigations to determine whether sufficient analgesia is provided to reduce procedural pain during arterial line insertion.
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Affiliation(s)
- Kaylee Bray
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio.
| | | | | | - Jane F Marek
- Frances Payne Bolton School of Nursing, Cleveland, Ohio
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23
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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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Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med 2019; 46:e825-e873. [PMID: 30113379 DOI: 10.1097/ccm.0000000000003299] [Citation(s) in RCA: 1732] [Impact Index Per Article: 346.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU. DESIGN Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017. METHODS Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified. RESULTS The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation. CONCLUSIONS We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.
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25
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Gélinas C, Boitor M, Puntillo KA, Arbour C, Topolovec-Vranic J, Cusimano MD, Choinière M, Streiner DL. Behaviors Indicative of Pain in Brain-Injured Adult Patients With Different Levels of Consciousness in the Intensive Care Unit. J Pain Symptom Manage 2019; 57:761-773. [PMID: 30593909 DOI: 10.1016/j.jpainsymman.2018.12.333] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 12/18/2018] [Accepted: 12/18/2018] [Indexed: 11/25/2022]
Abstract
CONTEXT Many brain-injured patients are unable to self-report their pain during their hospitalization in the intensive care unit (ICU), and existing behavioral pain scales may not be well suited. OBJECTIVES The objectives of this study were to describe and compare behaviors in brain-injured patients with different levels of consciousness during nociceptive and nonnociceptive care procedures in the ICU and to examine interrater agreement of individual behaviors as well as discriminative and criterion validation of putative pain behaviors. METHODS Brain-injured ICU patients were observed using a 40-item behavioral checklist before and during soft touch (i.e., nonnociceptive procedure), turning, and other care procedures (nociceptive) by pairs of trained raters. When possible, patients self-reported their pain on a 0-10 visual thermometer. Patients were classified into unconscious (Glasgow Coma Scale, 3<GCS≤8), altered consciousness (9≤GCS≤12), or conscious (13≤GCS≤15). RESULTS A sample of 147 patients participated (65 conscious, 56 altered consciousness, and 26 unconscious). Active behaviors (e.g., face expressions and body movements) were more frequent in conscious patients. High-percentage interrater agreement (80%-98%) was obtained for most behaviors. The total number of active behaviors was significantly higher during turning and other nociceptive procedures compared with rest (Wilcoxon = 9.873, P < 0.001) and soft touch (Wilcoxon = 9.486, P < 0.001) regardless of levels of consciousness. The strongest predictors of pain intensity (n = 33) were grimace, mouth opening, orbit tightening, eye weeping, and eyes tightly closed; these behaviors were moderately correlated with self-reported pain intensity (Spearman rho = 0.47). CONCLUSION These findings may guide the revision of existing pain scales to make their content more suited for this population.
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Affiliation(s)
- Céline Gélinas
- Ingram School of Nursing, McGill University, Montréal, Québec, Canada; Centre for Nursing Research and Lady Davis Institute, CIUSSS Centre-Ouest-Ile-de-Montréal - Jewish General Hospital, Montréal, Québec, Canada.
| | - Madalina Boitor
- Faculty of Dentistry, McGill University, Montréal, Québec, Canada; Centre for Nursing Research and Lady Davis Institute, CIUSSS Centre-Ouest-Ile-de-Montréal - Jewish General Hospital, Montréal, Québec, Canada
| | - Kathleen A Puntillo
- Physiological Nursing, University of California San Francisco, San Francisco, California, USA
| | - Caroline Arbour
- Faculty of Nursing, Université de Montréal, Montréal, Québec, Canada; Centre de recherche Hôpital du Sacré-Cœur de Montréal, CIUSSS du Nord-de-l'Île-de-Montréal, Montreal, Québec, Canada
| | | | - Michael D Cusimano
- Injury Prevention Research Office and Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Manon Choinière
- Centre de recherche du Centre hospitalier de l'Université de Montréal, Montréal, Quebec, Canada; Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - David L Streiner
- St. Joseph's Healthcare, Mountain Site, Hamilton, Ontario, Canada; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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Leonard H. Live Music Therapy During Rehabilitation After Total Knee Arthroplasty: A Randomized Controlled Trial. J Music Ther 2019; 56:61-89. [DOI: 10.1093/jmt/thy022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Sulla F, La Chimia M, Barbieri L, Gigantiello A, Iraci C, Virgili G, Artioli G, Sarli L. A first contribution to the validation of the Italian version of the Behavioral Pain Scale in sedated, intubated, and mechanically ventilated paediatric patients. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:19-24. [PMID: 30539934 PMCID: PMC6502142 DOI: 10.23750/abm.v89i7-s.7945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 12/06/2018] [Indexed: 12/01/2022]
Abstract
Background and aim of the work: Numerous negative outcomes of inadequate pain management among children have been cited in the literature. Inadequate pain management may be particularly detrimental to children and adolescents facing life-threatening injury or illness on a Paediatric Intensive Care Unit (PICU). It is therefore absolutely necessary that professionals utilize effective and efficient tools in order to evaluate a person’s sensations of pain in the most objective way possible. The COMFORT-B scale is recognised as the gold standard in such patients. However, the use of this instrument in the clinical PICU setting is disputed. It requires long periods of observation to ensure an adequate utilization. Boerlage et al. noted that nurses are often impatient and do not always observe the patient for the recommended 2 minutes period. The Behavioral Pain Scale (BPS), instead, is considered to be the gold standard for pain assessment in deeply sedated, mechanically ventilated adult patients. This observational pain scale requires shorter observation time compared to the COMFORT-B. Moreover, BPS three subscales are included in other observational pain scales for paediatric patients. Therefore, the objective of this study was to assess the applicability of the BPS for use with paediatric patients. Methods: Firstly, a questionnaire was administered to physicians and nursing staff that work in the units where the study was conducted in order to investigate the actual use of observational pain scales in their units. A second questionnaire was administered to a group of experts regarding the BPS, to assess both face validity and content validity, and to gain opinions on the relative appropriateness of each item. A descriptive, comparative design was used. A convenience sample of non-verbal, sedated and mechanically ventilated critical care paediatric patients was included. 39 observations were collected from 9 patients, all in their first year of age. Patient pain was assessed concurrently with the three observational scales, before, during and after routine procedures that are considered painful and non-painful. Results: The data collected through questionnaires for professionals gave a useful insight into pain assessment in the investigated units: only 46% of respondents stated that they assessed patients’ pain levels, with an average of 2.8 times per shift; 60% of respondents declared to be unhappy with the observational scales that they utilise. Regarding the observations, internal consistency was α = .865. Correlations between BPS and the other instruments were high, demonstrating a good concurrent validity of the test. T test and ROC curves demonstrated a good discriminant validity as well. Conclusions: Although the current study is based on a small sample of participants, these first results encourage us to continue working in the validation of the BPS in paediatric patients.
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Affiliation(s)
- Francesco Sulla
- Department of Medicine and Surgery, Parma University, Italy.
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Psychometric Properties of the Behavioral Pain Scale in Traumatic Brain Injury. Pain Manag Nurs 2018; 20:152-157. [PMID: 30528364 DOI: 10.1016/j.pmn.2018.09.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 07/24/2018] [Accepted: 09/02/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Pain assessment of patients with traumatic brain injury is a challenge because they are unable to self-report their pain experience. AIMS To investigate the psychometric properties of validity, reliability, and responsiveness of the Brazilian version of the Behavioral Pain Scale (BPS-Br) in patients with traumatic brain injury. METHODS This was an observational, cross-sectional, repeated-measure and analytical study. This study was developed at the medical and surgical ICUs in a high-complexity public hospital at Aracaju, Sergipe, Brazil. Thirty-seven adult patients with moderate or severe TBI were included. This study was completed with 444 independent observations, a pairwise comparison, and was performed simultaneously before, during, and after eye cleaning and endotracheal suctioning of 37 adult patients with moderate to severe traumatic brain injury. RESULTS The BPS-Br had good internal consistency (.7 ≤ α ≤ .9), good discriminant validity (p < .001), moderate to excellent reliability based on inter-rater agreement (intraclass correlation coefficient = 0.66-1.00; κ = 0.5-1.0), and high responsiveness (0.7-1.7). The upper limbs subscale had the highest score during the nociceptive procedure (1.8 ± 0.9). Deep sedation affected the increase of grading during painful procedures (p < .001). CONCLUSIONS Our results suggest the BPS-Br is a useful tool for clinical practice to evaluate the pain experienced by patients with traumatic brain injury. Further studies of different samples are needed to evaluate the benefits of systematic pain assessment of critically ill patients.
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Nazari R, Pahlevan Sharif S, Allen KA, Sharif Nia H, Yee BL, Yaghoobzadeh A. Behavioral Pain Indicators in Patients with Traumatic Brain Injury Admitted to an Intensive Care Unit. J Caring Sci 2018; 7:197-203. [PMID: 30607360 PMCID: PMC6311629 DOI: 10.15171/jcs.2018.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 06/12/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction: A consistent approach to pain assessment for patients admitted to intensive care unit (ICU) is a major difficulty for health practitioners due to some patients' inability, to express their pain verbally. This study aimed to assess pain behaviors (PBs) in traumatic brain injury (TBI) patients at different levels of consciousness. Methods: This study used a repeated-measure, within-subject design with 35 patients admitted to an ICU. The data were collected through observations of nociceptive and non-nociceptive procedures, which were recorded through a 47-item behavior-rating checklist. The analyses were performed by SPSS ver.13 software. Results: The most frequently observed PBs during nociceptive procedures were facial expression levator contractions (65.7%), sudden eye openings (34.3%), frowning (31.4%), lip changes (31.4%), clear movement of extremities (57.1%), neck stiffness (42.9%), sighing (31.4%), and moaning (31.4%). The number of PBs exhibited by participants during nociceptive procedures was significantly higher than those observed before and 15 minutes after the procedures. Also, the number of exhibited PBs in patients during nociceptive procedures was significantly greater than that of exhibited PBs during the non-nociceptive procedure. The results showed a significant difference between different levels of consciousness and also between the numbers of exhibited PBs in participants with different levels of traumatic brain injury severity. Conclusion: The present study showed that most of the behaviors that have been observed during painful stimulation in patients with traumatic brain injury included facial expressions, sudden eye opening, frowning, lip changes, clear movements of extremities, neck stiffness, and sighing or moaning.
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Affiliation(s)
- Roghieh Nazari
- Department of Nursing, Amol Faculty of Nursing and Midwifery, Mazandaran
University of Medical Sciences, Sari, Iran
| | - Saeed Pahlevan Sharif
- Department, Taylor’s Business School, Taylor’s University Malaysia, Subang Jaya,
Malaysia
| | - Kelly A Allen
- Melbourne Graduate School of Education, University of Melbourne, Melbourne,
Australia
| | - Hamid Sharif Nia
- Department of Nursing, Amol Faculty of Nursing and Midwifery, Mazandaran
University of Medical Sciences, Sari, Iran
| | - Bit-Lian Yee
- Department of Nursing, Open University Malaysia, Kuala Lumpur, Malaysia
| | - Ameneh Yaghoobzadeh
- Department of Geriatric Nursing, School of Nursing and Midwifery, Tehran
University of Medical Sciences, Tehran, Iran
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Jacq G, Melot K, Bezou M, Foucault L, Courau-Courtois J, Cavelot S, Lang A, Bedos JP, Le-Boeuf D, Boussard JM, Legriel S. Music for pain relief during bed bathing of mechanically ventilated patients: A pilot study. PLoS One 2018; 13:e0207174. [PMID: 30427906 DOI: 10.1371/journal.pone.0207174] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 10/26/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Pain is a universal issue and is of particular concern in mechanically ventilated patients, as they require intensive nursing care and multiple invasive procedures, while being unable to communicate verbally. The aim of this study was to assess the effect of music on pain experienced by mechanically ventilated patients during morning bed bathing. METHODS Of the 60 mechanically ventilated patients enrolled in this single-center pilot study between March 2013 and October 2015, the first 30 received no music and the next 30 the music intervention, during the morning bed bath. The Behavioral Pain Scale (BPS) score was determined during and at the end of the bath then 30, 60, and 120 minutes after the bath. BPS score changes over time were assessed and the proportions of bath times spent with a BPS score ≥5 and with the maximal BPS score were determined. RESULTS At baseline, no patient had pain (defined as a BPS score <5) and the median BPS score was 3 [IQR, 3;3] in both groups (P = 0.43). After bed bath initiation, 88% of patients experienced pain. The maximum BPS value during the bath was lower in the music group (5 [5;6.7] vs. 7 [5;7]). Proportions of total bath time spent with BPS≥5 and with the maximum BPS were significantly lower in the music group than in the control group (2.0 [0.3;4.0] vs. 10 [4.3;18.0]; P < .0001 and 1.5 [0;3.0] vs. 3.5 [2.0;6.0]; P = .005; respectively). Two hours after the end of the bath, the BPS values had returned to baseline in both groups. CONCLUSION In our population, music significantly decreased pain intensity and duration during the morning bed bath in mechanically ventilated patients. These results warrant further assessment in a large multicenter randomized controlled trial. TRIAL REGISTRATION ClinicalTrials.gov NCT02883959.
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Affiliation(s)
- Gwenaëlle Jacq
- Intensive Care Department, GHT Sud Yvelines, Centre Hospitalier de Versailles-Site André Mignot, Le Chesnay Cedex, FRANCE
| | - Karine Melot
- Intensive Care Department, GHT Sud Yvelines, Centre Hospitalier de Versailles-Site André Mignot, Le Chesnay Cedex, FRANCE
| | - Mathilde Bezou
- Intensive Care Department, GHT Sud Yvelines, Centre Hospitalier de Versailles-Site André Mignot, Le Chesnay Cedex, FRANCE
| | - Laura Foucault
- Intensive Care Department, GHT Sud Yvelines, Centre Hospitalier de Versailles-Site André Mignot, Le Chesnay Cedex, FRANCE
| | - Josette Courau-Courtois
- Intensive Care Department, GHT Sud Yvelines, Centre Hospitalier de Versailles-Site André Mignot, Le Chesnay Cedex, FRANCE
| | - Sebastien Cavelot
- Intensive Care Department, GHT Sud Yvelines, Centre Hospitalier de Versailles-Site André Mignot, Le Chesnay Cedex, FRANCE
| | - Annie Lang
- Intensive Care Department, GHT Sud Yvelines, Centre Hospitalier de Versailles-Site André Mignot, Le Chesnay Cedex, FRANCE
| | - Jean-Pierre Bedos
- Intensive Care Department, GHT Sud Yvelines, Centre Hospitalier de Versailles-Site André Mignot, Le Chesnay Cedex, FRANCE
| | - Dominique Le-Boeuf
- Intensive Care Department, GHT Sud Yvelines, Centre Hospitalier de Versailles-Site André Mignot, Le Chesnay Cedex, FRANCE
| | - Jean-Marc Boussard
- Direction des soins, GHT Sud Yvelines, Centre hospitalier de Rambouillet, Rambouillet, FRANCE
| | - Stephane Legriel
- Intensive Care Department, GHT Sud Yvelines, Centre Hospitalier de Versailles-Site André Mignot, Le Chesnay Cedex, FRANCE
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Ribeiro CJN, Araújo ACSD, Brito SB, Dantas DV, Nunes MDS, Alves JAB, Ribeiro MDCDO. Pain assessment of traumatic brain injury victims using the Brazilian version of the Behavioral Pain Scale. Rev Bras Ter Intensiva 2018; 30:42-49. [PMID: 29742216 PMCID: PMC5885230 DOI: 10.5935/0103-507x.20180009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 12/01/2017] [Indexed: 01/08/2023] Open
Abstract
Objective To evaluate the validity and reliability of the Brazilian version of the
Behavioral Pain Scale (BPS-Br) in victims of traumatic brain injury. Methods Observational prospective study with paired and repeated measures conducted
at two intensive care units (clinical and surgical) of a large general
hospital. The convenience sample consisted of adult victims of moderate or
severe penetrating or blunt craniocerebral trauma who were sedated and
mechanically ventilated. A total of 432 paired observations were performed
by independent evaluators simultaneously, prior to eye cleaning, during eye
cleaning, during tracheal aspiration and after tracheal aspiration.
Sociodemographic, clinical, trauma-related, sedoanalgesia and physiological
parameter data (heart rate, systolic and diastolic blood pressure) were
collected. The discriminant validity was tested using the Friedman and
Wilcoxon paired tests. The intraclass correlation coefficient and Cohen's
Kappa coefficient were used to evaluate the reliability. The Spearman
correlation test was used to test the association between clinical variables
and BPS-Br scores during tracheal aspiration. Results There was a significant increase in the physiological parameters during
tracheal aspiration, but without correlation with the BPS-Br scores. Pain
was significantly more intense during tracheal aspiration (p < 0.005).
Satisfactory interobserver agreement was found, with an intraclass
correlation coefficient of 0.95 (0.90 - 0.98) and Kappa coefficient of
0.70. Conclusion Brazilian version of the Behavioral Pain Scale scores increased during
tracheal aspiration. The Brazilian version of the scale was valid and
reliable for pain assessment of traumatic brain injury victims undergoing
tracheal aspiration.
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Affiliation(s)
| | | | - Saulo Barreto Brito
- Departamento de Enfermagem, Universidade Federal de Sergipe, Aracaju, SE, Brazil
| | - Daniele Vieira Dantas
- Programa de Pós-Graduação em Enfermagem, Universidade Federal de Sergipe, Aracaju, SE, Brazil
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Andersson M, Wilde-Larsson B, Persenius M. Intensive care nurses fail to translate knowledge and skills into practice - A mixed-methods study on perceptions of oral care. Intensive Crit Care Nurs 2018; 52:51-60. [PMID: 30297151 DOI: 10.1016/j.iccn.2018.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/05/2018] [Accepted: 09/18/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To identify intensive care nurses' perceptions of oral care according to Coker et al.'s (2013) conceptual framework and to contribute to the knowledge base of oral care in intensive care. DESIGN/METHODS This was a concurrent embedded mixed-methods design, with more weight given to the quantitative part. Participants responded to the Nursing Care related to Oral Health questionnaire, including perceptions of oral care antecedents (18 items), defining attributes (17 items), and consequences (6 items) and two open-ended questions. The data were analysed with descriptive and correlation statistics and qualitative content analysis. SETTING Intensive care nurses (n = 88) in six general intensive care units. RESULTS Intensive care nurses perceived that an important part of nursing care was oral care, especially to intubated patients. They perceived that the nursing staff was competent in oral care skills and had access to different kinds of equipment and supplies to provide oral care. The oral cavity was inspected on a daily basis, mostly without the use of any assessment instruments. Oral care seemed to be task-oriented, and documentation of the patients' experiences of the oral care process was rare. CONCLUSIONS The antecedents, knowledge and skills are available to provide quality oral care, but intensive care nurses seem to have difficulties translating these components into practice. Thus they might have to shift their task-oriented approach towards oral care to a more person-centred approach in order to be able to meet patients' needs.
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Affiliation(s)
- Maria Andersson
- Department of Health Science, Karlstad University, Faculty of Health, Science and Technology, Karlstad, Sweden.
| | - Bodil Wilde-Larsson
- Department of Health Science, Karlstad University, Faculty of Health, Science and Technology, Karlstad, Sweden; Faculty of Public Health Studies, Inland Norway University of Applied Sciences, Elverum, Norway
| | - Mona Persenius
- Department of Health Science, Karlstad University, Faculty of Health, Science and Technology, Karlstad, Sweden
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Birnie KA, Noel M, Chambers CT, Uman LS, Parker JA. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev 2018; 10:CD005179. [PMID: 30284240 PMCID: PMC6517234 DOI: 10.1002/14651858.cd005179.pub4] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND This is the second update of a Cochrane Review (Issue 4, 2006). Pain and distress from needle-related procedures are common during childhood and can be reduced through use of psychological interventions (cognitive or behavioral strategies, or both). Our first review update (Issue 10, 2013) showed efficacy of distraction and hypnosis for needle-related pain and distress in children and adolescents. OBJECTIVES To assess the efficacy of psychological interventions for needle-related procedural pain and distress in children and adolescents. SEARCH METHODS We searched six electronic databases for relevant trials: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; PsycINFO; Embase; Web of Science (ISI Web of Knowledge); and Cumulative Index to Nursing and Allied Health Literature (CINAHL). We sent requests for additional studies to pediatric pain and child health electronic listservs. We also searched registries for relevant completed trials: clinicaltrials.gov; and World Health Organization International Clinical Trials Registry Platform (www.who.int.trialsearch). We conducted searches up to September 2017 to identify records published since the last review update in 2013. SELECTION CRITERIA We included peer-reviewed published randomized controlled trials (RCTs) with at least five participants per study arm, comparing a psychological intervention with a control or comparison group. Trials involved children aged two to 19 years undergoing any needle-related medical procedure. DATA COLLECTION AND ANALYSIS Two review authors extracted data and assessed risks of bias using the Cochrane 'Risk of bias' tool. We examined pain and distress assessed by child self-report, observer global report, and behavioral measurement (primary outcomes). We also examined any reported physiological outcomes and adverse events (secondary outcomes). We used meta-analysis to assess the efficacy of identified psychological interventions relative to a comparator (i.e. no treatment, other active treatment, treatment as usual, or waitlist) for each outcome separately. We used Review Manager 5 software to compute standardized mean differences (SMDs) with 95% confidence intervals (CIs), and GRADE to assess the quality of the evidence. MAIN RESULTS We included 59 trials (20 new for this update) with 5550 participants. Needle procedures primarily included venipuncture, intravenous insertion, and vaccine injections. Studies included children aged two to 19 years, with few trials focused on adolescents. The most common psychological interventions were distraction (n = 32), combined cognitive behavioral therapy (CBT; n = 18), and hypnosis (n = 8). Preparation/information (n = 4), breathing (n = 4), suggestion (n = 3), and memory alteration (n = 1) were also included. Control groups were often 'standard care', which varied across studies. Across all studies, 'Risk of bias' scores indicated several domains at high or unclear risk, most notably allocation concealment, blinding of participants and outcome assessment, and selective reporting. We downgraded the quality of evidence largely due to serious study limitations, inconsistency, and imprecision.Very low- to low-quality evidence supported the efficacy of distraction for self-reported pain (n = 30, 2802 participants; SMD -0.56, 95% CI -0.78 to -0.33) and distress (n = 4, 426 participants; SMD -0.82, 95% CI -1.45 to -0.18), observer-reported pain (n = 11, 1512 participants; SMD -0.62, 95% CI -1.00 to -0.23) and distress (n = 5, 1067 participants; SMD -0.72, 95% CI -1.41 to -0.03), and behavioral distress (n = 7, 500 participants; SMD -0.44, 95% CI -0.84 to -0.04). Distraction was not efficacious for behavioral pain (n = 4, 309 participants; SMD -0.33, 95% CI -0.69 to 0.03). Very low-quality evidence indicated hypnosis was efficacious for reducing self-reported pain (n = 5, 176 participants; SMD -1.40, 95% CI -2.32 to -0.48) and distress (n = 5, 176 participants; SMD -2.53, 95% CI -3.93 to -1.12), and behavioral distress (n = 6, 193 participants; SMD -1.15, 95% CI -1.76 to -0.53), but not behavioral pain (n = 2, 69 participants; SMD -0.38, 95% CI -1.57 to 0.81). No studies assessed hypnosis for observer-reported pain and only one study assessed observer-reported distress. Very low- to low-quality evidence supported the efficacy of combined CBT for observer-reported pain (n = 4, 385 participants; SMD -0.52, 95% CI -0.73 to -0.30) and behavioral distress (n = 11, 1105 participants; SMD -0.40, 95% CI -0.67 to -0.14), but not self-reported pain (n = 14, 1359 participants; SMD -0.27, 95% CI -0.58 to 0.03), self-reported distress (n = 6, 234 participants; SMD -0.26, 95% CI -0.56 to 0.04), observer-reported distress (n = 6, 765 participants; SMD 0.08, 95% CI -0.34 to 0.50), or behavioral pain (n = 2, 95 participants; SMD -0.65, 95% CI -2.36 to 1.06). Very low-quality evidence showed efficacy of breathing interventions for self-reported pain (n = 4, 298 participants; SMD -1.04, 95% CI -1.86 to -0.22), but there were too few studies for meta-analysis of other outcomes. Very low-quality evidence revealed no effect for preparation/information (n = 4, 313 participants) or suggestion (n = 3, 218 participants) for any pain or distress outcome. Given only a single trial, we could draw no conclusions about memory alteration. Adverse events of respiratory difficulties were only reported in one breathing intervention. AUTHORS' CONCLUSIONS We identified evidence supporting the efficacy of distraction, hypnosis, combined CBT, and breathing interventions for reducing children's needle-related pain or distress, or both. Support for the efficacy of combined CBT and breathing interventions is new from our last review update due to the availability of new evidence. The quality of trials and overall evidence remains low to very low, underscoring the need for improved methodological rigor and trial reporting. Despite low-quality evidence, the potential benefits of reduced pain or distress or both support the evidence in favor of using these interventions in clinical practice.
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Affiliation(s)
- Kathryn A Birnie
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
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Carrillo-Torres O, Mendiola-Roa M, Ramirez-Torres M. Pain in patients in critical condition and its environment. REVISTA MÉDICA DEL HOSPITAL GENERAL DE MÉXICO 2018. [DOI: 10.1016/j.hgmx.2016.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Dale CM, Prendergast V, Gélinas C, Rose L. Validation of The Critical-care Pain Observation Tool (CPOT) for the detection of oral-pharyngeal pain in critically ill adults. J Crit Care 2018; 48:334-338. [PMID: 30286403 DOI: 10.1016/j.jcrc.2018.09.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 08/28/2018] [Accepted: 09/21/2018] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Mechanically ventilated patients experience pain at rest and during daily care procedures. Our objective was to test the reliability and validity of the Critical-Care Pain Observation Tool (CPOT) to detect oral-pharyngeal pain in intubated and tracheostomised adults during routine oral care procedures. MATERIALS AND METHODS Two trained research team members independently observed patients during two non-painful (rest and gentle touch) and three potentially painful (oral suctioning, tooth brushing, and swabbing with a sponge toothette) procedures. Conscious patients were asked if they experienced pain during each procedure (yes/no) and to rate their pain intensity on a 0 to 10 numeric rating scale. RESULTS A total of 98 patients, primarily intubated (92.9%) and male (63.3%) participated. Criterion validation was supported by patient self-report of pain during tooth brushing (AUC=.80; P<0.5) and oral suction (AUC=.72; P<0.3) but not for oral swabbing (AUC=.68; P=0.16). Discriminative validation was demonstrated for all oral care procedures compared to rest (P<.001). Intra-class correlation coefficients between raters ranged from .78 to .91 (P<.001) for total CPOT scores, indicating excellent inter-rater reliability. CONCLUSIONS The CPOT is reliable and valid for the detection of oral-pharyngeal pain during oral care procedures indicated as painful by critically ill adults.
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Affiliation(s)
- Craig M Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada.
| | | | - Céline Gélinas
- Ingram School of Nursing, McGill University, Montréal, Canada; Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, CIUSSS Centre-Ouest-Ile-Montréal, Montréal, Canada
| | - Louise Rose
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada; Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
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Raad S, Chaftari AM, Hachem RY, Shah P, Natividad E, Cleeland CS, Rosenblatt J. Removal and insertion of central venous catheters in cancer patients is associated with high symptom burden. Expert Rev Med Devices 2018; 15:591-596. [PMID: 30067125 DOI: 10.1080/17434440.2018.1500892] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To assess the symptom burden associated with CVC removal and insertion in cancer patients. METHODS We collected patient-reported symptom-burden outcomes for 60 consecutive cancer patients: 30 undergoing CVC removal and 30 undergoing CVC insertion. Cancer patients self-administered the MD Anderson Symptom Inventory to rate the severity of 21 different symptoms immediately after the procedure Results: Symptoms were present in up to 57% to 67% of patients undergoing CVC insertion and removal respectively. Nineteen patients (32%) were moderately symptomatic with a symptom burden of four or more: ten insertion and nine removal patients. Symptoms with a score of 4 or more clustered around physical symptoms (pain, pressure or burning) or more generalized symptoms (fatigue, sleep, distress, dry mouth, and drowsiness). Nine (15%) patients rated at least one symptom as eight or more, five (17%) being insertion patients. CONCLUSIONS CVCs are essential for the management of cancer patients. However, they can become infected and may need to be removed. Catheter removal and insertion produced moderate to severe symptom burden in cancer patients. Safe interventions that would salvage the vascular access without worsening the infectious outcome should be explored to alleviate morbidity associated with the symptom burden of removal and re-insertion.
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Affiliation(s)
- Sammy Raad
- a Department of Infectious Diseases, Infection Control and Employee Health , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Anne Marie Chaftari
- a Department of Infectious Diseases, Infection Control and Employee Health , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Ray Y Hachem
- a Department of Infectious Diseases, Infection Control and Employee Health , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Pankil Shah
- a Department of Infectious Diseases, Infection Control and Employee Health , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Elizabeth Natividad
- b Department of Infusion Therapy , The University of Texas MD Anderson Cancer Center , Houston , USA
| | - Charles S Cleeland
- c Department of Symptom Research , The University of Texas MD Anderson Cancer Center , Houston , USA
| | - Joel Rosenblatt
- a Department of Infectious Diseases, Infection Control and Employee Health , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
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Erden S, Demir N, Ugras GA, Arslan U, Arslan S. Vital signs: Valid indicators to assess pain in intensive care unit patients? An observational, descriptive study. Nurs Health Sci 2018; 20:502-508. [DOI: 10.1111/nhs.12543] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 05/02/2018] [Accepted: 05/20/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Sevilay Erden
- Department of Nursing; Çukurova University; Adana Turkey
| | - Nevra Demir
- Department of Nursing; Gazi University; Ankara Turkey
| | | | - Umut Arslan
- Department of Public Health; Hacettepe University School of Medicine; Ankara Turkey
| | - Sevban Arslan
- Department of Nursing; Çukurova University; Adana Turkey
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Shan K, Cao W, Yuan Y, Hao JJ, Sun XM, He X, Li GY, Wang YM, Zhou JX. Use of the critical-care pain observation tool and the bispectral index for the detection of pain in brain-injured patients undergoing mechanical ventilation: A STROBE-compliant observational study. Medicine (Baltimore) 2018; 97:e10985. [PMID: 29851854 PMCID: PMC6392730 DOI: 10.1097/md.0000000000010985] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The assessment of pain in patients with brain injury is challenging due to impaired ability to communicate. We aimed to test the reliability and validity of the critical-care pain observation tool (CPOT) and the bispectral index (BIS) for pain detection in critically brain-injured patients.This prospective observational study was conducted in a neurosurgical intensive care unit in a University-Affiliated Hospital. Adult brain-injured patients undergoing mechanical ventilation were enrolled. Nociceptive (endotracheal suctioning) and non-nociceptive (gentle touching) procedures were performed in a random crossover fashion. Before and immediately after the procedure, CPOT was evaluated by 2 residents and 2 chief nurses, and BIS was documented. The ability to self-report pain was also assessed. The inter-observer reliability of CPOT was analyzed. The criterion and discriminant validities of the CPOT and the BIS were tested.During the study, we enrolled 400 brain-injured patients. The ability to self-report pain was maintained in 214 (54%) and 218 (55%) patients during suctioning and gentle touching, respectively. The intraclass correlation coefficients (95% confidence interval) for inter-observer reliability of CPOT ranged from 0.86 (0.83-0.89) to 0.93 (0.91-0.94). Using self-reported pain as the reference, the area under the receiver operating characteristic curve (95% confidence interval) was 0.84 (0.80-0.88) for CPOT and 0.76 (0.72-0.81) for BIS. When the 2 instruments were combined as either CPOT ≥2 or BIS ≥88 after the procedure, the sensitivity and specificity were 0.90 (0.85-0.93) and 0.59 (0.52-0.66), respectively; and when the 2 instruments were combined as both CPOT ≥2 and BIS ≥88, the sensitivity and specificity were 0.62 (0.55-0.68) and 0.89 (0.83-0.93). Both CPOT and BIS increased significantly after suctioning (all P < .001) but remained unchanged after gentle touching (P ranging from .06 to .14).Our criterion and discriminant validity results supported the use of CPOT and BIS to detect pain in critically brain-injured patients. Combining use of CPOT and BIS in different ways might provide comprehensive pain assessment for different purposes.
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Affiliation(s)
| | - Wei Cao
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuan Yuan
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing-Jing Hao
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiu-Mei Sun
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuan He
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gui-Yun Li
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yu-Mei Wang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Comparison of effect of dexmedetomidine and lidocaine on intracranial and systemic hemodynamic response to chest physiotherapy and tracheal suctioning in patients with severe traumatic brain injury. J Anesth 2018; 32:518-523. [PMID: 29725828 DOI: 10.1007/s00540-018-2505-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Accepted: 04/28/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE Chest physiotherapy and tracheal suction cause sympathetic stimulation and increase heart rate (HR), mean arterial pressure (MAP) and intracranial pressure (ICP) which may have deleterious effect in the head injured. We planned to compare the effect of intravenous dexmedetomidine and lidocaine on intracerebral and systemic hemodynamic response to chest physiotherapy (CP) and tracheal suctioning (TS) in patients with severe traumatic brain injury (sTBI). METHODS Prospective, randomized study in patients with sTBI, 18-60 years of age, undergoing mechanical ventilation and intraparenchymal ICP monitoring. Patients were randomized to receive either iv dexmedetomidine 0.5 mcg/kg (group I; n = 30) or iv lidocaine 2 mg/kg (group II; n = 30) over 10 min. After infusion of test drug, CP with vibrator and manual compression was performed for 2 min and TS was done over next 15-20 s. The hemodynamic response was recorded before, during and at interval of 1 min for 10 min after CP and TS. A 20% change in hemodynamic parameters was considered significant. RESULTS The baseline hemodynamic (HR, MAP), intracranial (ICP, CPP) and respiratory (SPO2, AWPpeak) parameters were normal and comparable in both the groups. After dexmedetomidine infusion, MAP and CPP decreased significantly from baseline value. In group II, there was no significant change in HR, MAP, ICP and CPP. At end of CP and TS, HR, MAP and CPP in group I was lower as compared to group II. During the 10-min observation period following CP and TS, MAP and CPP in group I remained significantly lower as compared to baseline and group II. There was no significant change in value of other measured parameters. CONCLUSIONS Both dexmedetomidine and lidocaine were effective to blunt rise in HR, MAP and ICP in response to CP and TS in patients with sTBI. However, intravenous dexmedetomidine caused significant decrease in MAP and CPP as compared to the baseline and lidocaine.
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The Prophylactic Use of Remifentanil for Delayed Extubation After Elective Intracranial Operations: a Prospective, Randomized, Double-Blinded Trial. J Neurosurg Anesthesiol 2018; 29:281-290. [PMID: 27152427 DOI: 10.1097/ana.0000000000000311] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Endotracheal extubation is a painful and stressful procedure. The authors hypothesized that the prophylactic use of remifentanil would attenuate the pain intensity and stress responses resulting from extubation in neurosurgical patients. MATERIALS AND METHODS In this prospective, randomized, double-blinded, controlled trial, 160 patients with planned delay extubation after elective intracranial operation were randomized 1:1 to receive either remifentanil or normal saline (control) before their extubation. The dose regime of remifentanil was a bolus of 0.5 μg/kg over 1 minute, followed by a continuous infusion of 0.05 μg/kg/min for 20 minutes. The primary outcome was the incidence of severe pain during the periextubation period. Secondary outcomes included changes in the pain intensity and vital signs, failing to pass an extubation evaluation after the study drug infusion, severe adverse events, postextubation complications, and clinical outcomes. RESULTS Two patients in the remifentanil group did not pass the extubation evaluation. The incidence of severe pain during the periextubation period was significantly lower in the remifentanil group compared with the control group (25.0% vs. 41.3%, P=0.029). Compared with the control group, the visual analog scale in the remifentanil group was significantly lower after the bolus of remifentanil (12±18 vs. 25±27, P=0.001) and immediately after extubation (19±25 vs. 34±30, P=0.001). There were no significant differences in the vital signs immediately after extubation between the 2 groups (P>0.05). CONCLUSIONS The prophylactic use of remifentanil decreases the incidence of severe pain. Our preliminary findings merit a larger trial to clarify the effect of the prophylactic use of remifentanil on clinical outcomes and adverse events.
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Wiegand DL, Wilson T, Pannullo D, Russo MM, Kaiser KS, Soeken K, McGuire DB. Measuring Acute Pain Over Time in the Critically Ill Using the Multidimensional Objective Pain Assessment Tool (MOPAT). Pain Manag Nurs 2018; 19:277-287. [PMID: 29398346 DOI: 10.1016/j.pmn.2017.10.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 10/07/2017] [Accepted: 10/11/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND A valid and reliable instrument is needed to assess acute pain in critically ill patients unable to self-report and who may be transitioning between critical care and other settings. AIM To examine the reliability, validity, and clinical utility of the Multidimensional Objective Pain Assessment Tool (MOPAT) when used over time by critical care nurses to assess acute pain in non-communicative critically ill patients. METHODS Twenty-seven patients had pain assessed at two time points (T1 and T2) surrounding a painful event for up to 3 days. Twenty-one ICU nurses participated in pain assessments and completed the Clinical Utility Questionnaire. RESULTS Internal consistency reliability coefficient alphas for the MOPAT were .68 at T1 and .72 at T2. Inter-rater agreement during painful procedures or turning was 68% for the behavioral dimension and 80% for the physiologic dimension. Validity was evidenced by decreases (p < .001) in the MOPAT total and behavioral and physiologic dimension scores when comparing T1 and T2. Nurses found the tool clinically useful. CONCLUSION The MOPAT can be used in the critical care setting as a helpful tool to assess pain in non-communicative patients. The MOPAT is unique in that the instrument can be used over time and across settings.
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Affiliation(s)
- Debra L Wiegand
- University of Maryland School of Nursing, Baltimore, Maryland.
| | - Tracey Wilson
- Medical Intensive Care Unit, University of Maryland Medical Center, Baltimore, Maryland
| | - Diane Pannullo
- Surgical Intensive Care Unit, University of Maryland Medical Center, Baltimore, Maryland
| | - Marguerite M Russo
- Palliative Care, University of Maryland Medical Center, Baltimore, Maryland; University of Maryland Baltimore Graduate School, Baltimore, Maryland
| | | | - Karen Soeken
- University of Maryland School of Nursing, Baltimore, Maryland
| | - Deborah B McGuire
- Virginia Commonwealth University School of Nursing, Richmond, Virginia
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Khanna P, Pandey RK, Chandralekha C, Sharma A, Pangasa N. Comparison between Critical-Care Pain Observation Tool and physiologic indicators for pain assessment in the critically ill, mechanically ventilated adult patients. Saudi J Anaesth 2018; 12:384-388. [PMID: 30100835 PMCID: PMC6044155 DOI: 10.4103/sja.sja_642_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background and Objectives: Pain assessment of nonverbal, critically ill patients continues to present a challenge in Intensive Care Unit (ICU). The Critical-Care Pain Observation Tool (CPOT) rates critically ill patients’ pain based on clinical observation. In the present study, the accuracy of CPOT was compared with physiological indicators of pain in mechanically ventilated, critically ill patients. Methods: This quantitative prospective observational study was conducted to assess pain in the critically ill, mechanically ventilated patients in comparison to physiologic indicators such as blood pressure and heart rate. A repeated measures design was chosen, and a sample size of 180 was taken from 60 patients with sepsis, acute exacerbations of chronic obstructive pulmonary disease, community-acquired pneumonia, and postsurgical patients in the ICU. The two painful procedures chosen were tracheal suction and patient positioning. The data were collected at rest, at tracheal suctioning, 20 min later at positioning of the patient, and final reading 20 min later. Three testing periods, each including 4 assessments for a total of 12 pain assessments with sixty patients, were completed during each patient's ICU course. A total of six assessments were done with the patient at rest and three each with pain stimulus of tracheal suctioning and patient positioning. Results: There was a significant increase in both hemodynamic variables (systolic blood pressure and diastolic blood pressure) during painful procedures except for the heart rate during positioning. The correlation between the CPOT and Ramsay scale was negative and significant. Conclusions: The present study provides evidence that the CPOT has good psychometric properties. It might prove useful for pain assessment in uncommunicative critically ill patients.
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Affiliation(s)
- Puneet Khanna
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Ravinder Kumar Pandey
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Chandralekha Chandralekha
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Ankur Sharma
- Department of Anaesthesiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Neha Pangasa
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Prevalence and predictors of difficulty accessing the mouths of intubated critically ill adults to deliver oral care: An observational study. Int J Nurs Stud 2017; 80:36-40. [PMID: 29353710 DOI: 10.1016/j.ijnurstu.2017.12.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 12/21/2017] [Accepted: 12/23/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Oral care of intubated patients is essential to the prevention of infection and patient discomfort. However, barriers to oral access and delivery of oral care have received little attention. OBJECTIVE To determine prevalence and predictors of oral access difficulty. DESIGN A prospective, observational, multi-center study. SETTINGS Four intensive care units in Toronto, Canada. PARTICIPANTS Adult patients orally intubated for ≥48 h. METHODS We screened consecutive admissions once a week to identify eligible participants. We observed each patient and asked the patient's nurse about presence or absence of difficulty accessing the mouth to deliver oral care across three categories: (1) visualizing inside the mouth; (2) obtaining patient cooperation, or (3) inserting instruments for delivery of oral care. We asked nurses to identify presence of patient behaviors contributing to oral access difficulty and perceived level of difficulty on a Likert response scale. We examined patient and treatment characteristics associated with extreme difficulty (i.e., difficulty in all 3 categories) using a generalized estimating equation regression model. RESULTS A total of 428 patients were observed, 58% admitted with a medical diagnosis. More than half (57%) had ≥2 oral devices up to maximum of 4. Oral care difficulty was identified in 83% of patients and rated as moderate to high for 217 (51%). Difficulty concerned visibility (74%), patient cooperation (55%), and space to insert instruments (53%). Patient behaviors contributing difficulty included coughing/gagging (60%), mouth closing (49%), biting (45%) and localizing (27%) during care. Variables associated with extreme difficulty included neurological (OR 1.92, 95% CI 1.42-2.60) or trauma admission (OR 1.83, 95% CI 1.16-2.89), lack of pain assessment or treatment in the 4 h prior to oral care (OR 1.43, 95% CI 1.14-1.80), more oral devices (OR 1.40, 95% CI 1.05-1.87), and duration of intubation (OR 1.05, 95% CI 1.01-1.10). Absence of documented agitation in the 4 h prior to oral care was associated with less difficulty (OR 0.68, 95% CI 0.54-0.86). CONCLUSIONS Oral care is complex and difficulties are experienced in a vast majority of intubated patients. Some difficulties are amenable to correction such as pain management.
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Content validation of behaviours and autonomic responses for the assessment of pain in critically ill adults with a brain injury. Aust Crit Care 2017; 31:145-151. [PMID: 29146105 DOI: 10.1016/j.aucc.2017.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 09/12/2017] [Accepted: 10/05/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The evidence shows that brain-injured patients express behaviours that are related to their level of consciousness (LOC), and different from other patients in the intensive care unit (ICU). Therefore, existing behavioural scales should be revised to enhance their content and validity for use in these patients. OBJECTIVES The aim was to evaluate the content relevance of behaviours and autonomic responses for pain assessment of brain-injured ICU patients from the perspective of critical care clinicians. METHODS A total of 77 clinicians from four adult neuroscience ICUs (three from Canada and one from the United States) participated in this descriptive study. A physician/nurse ratio of 21% (13/61) was reached in this quota sample, and three physiotherapists also participated. They completed a content validation questionnaire of 19 items rated on clarity and relevance based on the patient's LOC. Item Content Validity Index (I-CVI), and modified kappa (κ*) were calculated. Values higher than 0.78 and 0.75 respectively were considered excellent. RESULTS Regardless of the patient's LOC, brow lowering, grimacing, and trying to reach the pain site were rated as the most relevant behaviours by clinicians, with excellent values of I-CVI>0.78 and κ*>0.75. Eyes tightly closed, moaning and verbal complaints of pain also obtained excellent values in altered LOC and conscious patients. Eye weeping obtained excellent values only in conscious patients. Other items showed fair (0.40-0.59) to good (0.60-0.74) values, while blinking and coughing showed poor values (<0.40) at various LOC. CONCLUSIONS Facial expressions, movements towards the pain site, and vocalisation of pain were the most relevant pain-related behaviours rated by critical care clinicians. The relevance of some behaviours (e.g., moaning and verbal complaints of pain) varied across LOCs, thereby calling forth adaptations of behavioural pain scales to allow for interpretation in the context of a patient's LOC and ability to express specific behaviours.
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Rijkenberg S, Stilma W, Bosman RJ, van der Meer NJ, van der Voort PH. Pain Measurement in Mechanically Ventilated Patients After Cardiac Surgery: Comparison of the Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT). J Cardiothorac Vasc Anesth 2017; 31:1227-1234. [DOI: 10.1053/j.jvca.2017.03.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Indexed: 11/11/2022]
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Family Perspectives of Traumatically Brain-Injured Patient Pain Behaviors in the Intensive Care Unit. Pain Manag Nurs 2017; 18:202-213. [DOI: 10.1016/j.pmn.2017.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 04/07/2017] [Accepted: 04/07/2017] [Indexed: 11/22/2022]
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Chu Y, Zhao X, Han J, Su Y. Physiological Signal-Based Method for Measurement of Pain Intensity. Front Neurosci 2017; 11:279. [PMID: 28603478 PMCID: PMC5445136 DOI: 10.3389/fnins.2017.00279] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Accepted: 05/01/2017] [Indexed: 12/25/2022] Open
Abstract
The standard method for prediction of the absence and presence of pain has long been self-report. However, for patients with major cognitive or communicative impairments, it would be better if clinicians could quantify pain without having to rely on the patient's self-description. Here, we present a newly pain intensity measurement method based on multiple physiological signals, including blood volume pulse (BVP), electrocardiogram (ECG), and skin conductance level (SCL), all of which are induced by external electrical stimulation. The proposed pain prediction system consists of signal acquisition and preprocessing, feature extraction, feature selection and feature reduction, and three types of pattern classifiers. Feature extraction phase is devised to extract pain-related characteristics from short-segment signals. A hybrid procedure of genetic algorithm-based feature selection and principal component analysis-based feature reduction was established to obtain high-quality features combination with significant discriminatory information. Three types of classification algorithms-linear discriminant analysis, k-nearest neighbor algorithm, and support vector machine-are adopted during various scenarios, including multi-signal scenario, multi-subject and between-subject scenario, and multi-day scenario. The classifiers gave correct classification ratios much higher than chance probability, with the overall average accuracy of 75% above for four pain intensity. Our experimental results demonstrate that the proposed method can provide an objective and quantitative evaluation of pain intensity. The method might be used to develop a wearable device that is suitable for daily use in clinical settings.
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Affiliation(s)
- Yaqi Chu
- State Key Laboratory of Robotics, Shenyang Institute of Automation, Chinese Academy of SciencesShenyang, China
| | - Xingang Zhao
- State Key Laboratory of Robotics, Shenyang Institute of Automation, Chinese Academy of SciencesShenyang, China
| | - Jianda Han
- State Key Laboratory of Robotics, Shenyang Institute of Automation, Chinese Academy of SciencesShenyang, China
| | - Yang Su
- Shengjing Hospital of China Medical UniversityShenyang, China
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Abstract
Many critically ill adults are unable to communicate their pain through self-report. The study purpose was to validate the use of the 8-item Behavior Pain Assessment Tool (BPAT) in patients hospitalized in 192 intensive care units from 28 countries. A total of 4812 procedures in 3851 patients were included in data analysis. Patients were assessed with the BPAT before and during procedures by 2 different raters (mostly nurses and physicians). Those who were able to self-report were asked to rate their pain intensity and pain distress on 0 to 10 numeric rating scales. Interrater reliability of behavioral observations was supported by moderate (0.43-0.60) to excellent (>0.60) kappa coefficients. Mixed effects multilevel logistic regression models showed that most behaviors were more likely to be present during the procedure than before and in less sedated patients, demonstrating discriminant validation of the tool use. Regarding criterion validation, moderate positive correlations were found during procedures between the mean BPAT scores and the mean pain intensity (r = 0.54) and pain distress (r = 0.49) scores (P < 0.001). Regression models showed that all behaviors were significant predictors of pain intensity and pain distress, accounting for 35% and 29% of their total variance, respectively. A BPAT cut-point score >3.5 could classify patients with or without severe levels (≥8) of pain intensity and distress with sensitivity and specificity findings ranging from 61.8% to 75.1%. The BPAT was found to be reliable and valid. Its feasibility for use in practice and the effect of its clinical implementation on patient pain and intensive care unit outcomes need further research.
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Association Between Behavioral Responses and Burn Pain Intensity. Trauma Mon 2017. [DOI: 10.5812/traumamon.39442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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[Validation of the Brazilian version of Behavioral Pain Scale in adult sedated and mechanically ventilated patients]. Rev Bras Anestesiol 2017; 67:271-277. [PMID: 28258734 DOI: 10.1016/j.bjan.2015.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 11/23/2015] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The Behavioral Pain Scale is a pain assessment tool for uncommunicative and sedated Intensive Care Unit patients. The lack of a Brazilian scale for pain assessment in adults mechanically ventilated justifies the relevance of this study that aimed to validate the Brazilian version of Behavioral Pain Scale as well as to correlate its scores with the records of physiological parameters, sedation level and severity of disease. METHODS Twenty-five Intensive Care Unit adult patients were included in this study. The Brazilian Behavioral Pain Scale version (previously translated and culturally adapted) and the recording of physiological parameters were performed by two investigators simultaneously during rest, during eye cleaning (non-painful stimulus) and during endotracheal suctioning (painful stimulus). RESULTS High values of responsiveness coefficient (coefficient=3.22) were observed. The Cronbach's alpha of total Behavioral Pain Scale score at eye cleaning and endotracheal suctioning was 0.8. The intraclass correlation coefficient of total Behavioral Pain Scale score was ≥ 0.8 at eye cleaning and endotracheal suctioning. There was a significant highest Behavioral Pain Scale score during application of painful procedure when compared with rest period (p≤0.0001). However, no correlations were observed between pain and hemodynamic parameters, sedation level, and severity of disease. CONCLUSIONS This pioneer validation study of Brazilian Behavioral Pain Scale exhibits satisfactory index of internal consistency, interrater reliability, responsiveness and validity. Therefore, the Brazilian Behavioral Pain Scale version was considered a valid instrument for being used in adult sedated and mechanically ventilated patients in Brazil.
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