A Psychometric Analysis Update of Behavioral Pain Assessment Tools for Noncommunicative, Critically Ill Adults

Impact of implementing the critical-care pain observation tool in the adult intensive care unit: A nonrandomised stepped-wedge trial

BACKGROUND

Approximately 70% of patients in intensive care units (ICUs) experience untreated pain, often due to severe patient conditions and communication barriers.

AIM

The aim of this study was to implement the Critical-Care Pain Observation Tool (CPOT) to improve pain assessment in patients unable to self-report pain in the ICU.

METHOD

A stepped-wedge trial was conducted in six adult ICUs in Saudi Arabia between February and June 2022. The sequential transition of ICU clusters occurred in February 2022, from control to intervention, until all ICUs were exposed to the intervention. The primary outcome was the number of pain assessments, whereas the secondary outcomes were reassessments. Other outcomes were length of stay, mechanical ventilation duration, and administered doses of sedatives and analgesic agents. Statistical analyses were performed using the Statistical Analysis Software v9.4.

RESULTS

A total of 725 patients unable to self-report pain were included; 65% (n = 469) were male with an average age of 55 years. Implementing CPOT showed a significant increase in the number of pain assessments (rate ratio: 1.77, 95% confidence interval: 1.45, 2.16, p < 0.001) and reassessments (rate ratio: 13.99, 95% confidence interval: 8.14, 24.02, p < 0.001) between intervention and control conditions. There was no significant effect on the ICU length of stay, mechanical ventilation duration, and the amount of sedation (midazolam, propofol, and ketamine) and analgesia (fentanyl) administered.

CONCLUSION

The study indicates that the implementation of the CPOT increased the frequency of pain assessment and reassessment. However, the impact on patient outcomes remains inconclusive. Further investigations focussing on CPOT as the primary pain scale are necessary to determine its holistic impact on patient outcomes over the long term.

TRIAL REGISTRATION

NCT05488834.

CLINICAL TRIAL REGISTRATION NUMBER

This study was registered with the U.S. National Library of Medicine (ClinicalTrial.gov, NCT05488834).

Validation of the Nociception Level Index for the Detection of Nociception and Pain in Critically Ill Adults: Protocol for an Observational Study

BACKGROUND

In the intensive care unit (ICU), many patients are unable to communicate their pain through self-reporting or behaviors due to their critical care condition, mechanical ventilation, and medication (eg, heavily sedated or chemically paralyzed). Therefore, alternative pain assessment methods are urgently needed for this vulnerable patient population. The Nociception Level (NOL) index is a multiparameter technology initially developed for the monitoring of nociception and related pain in anesthetized patients, and its use in the ICU is new.

OBJECTIVE

This study aims to validate the NOL for the assessment of nociception and related pain in critically ill adults in the ICU. Specific objectives are to examine the ability of the NOL to: (1) detect pain using standard criteria (ie, self-report and behavioral measures), (2) discriminate between nociceptive and nonnociceptive procedures, and (3) generate consistent values when patients are at rest.

METHODS

The NOL will be monitored in three ICU patient groups: (1) Group A, participants able to self-report their pain (the reference standard criterion using the 0-10 Faces Pain Thermometer) and express behaviors; (2) Group B, participants unable to self-report but able to express behaviors (the alternative standard criterion using the Critical-Care Pain Observation Tool); and (3) Group C, participants unable to self-report and express behaviors. The NOL will be tested before, during, and after two types of standard care procedures: (1) nonnociceptive (eg, cuff inflation to measure blood pressure, soft touch) and (2) nociceptive (eg, tube or drain removal, endotracheal or tracheal suctioning). Receiver operating characteristic curve analysis of the NOL will be performed for Groups A and B using pain standard measures as reference criteria. Mixed linear models for repeated measures will be used to compare time points, procedures, and their interaction in each group (A, B, and C). Based on power analyses and considering an attrition rate of 25%, a total sample size of 146 patients (68 in Group A, 62 in Group B, and 16 in Group C) is targeted.

RESULTS

This study was funded in April 2020 but could not be launched until 2022 due to the COVID-19 pandemic. Recruitment and data collection began at the primary site in July 2022 and has been implemented at the secondary sites in 2023 and 2024 and is planned to continue until 2026.

CONCLUSIONS

The primary strength of this study protocol is that it is based on rigorous validation strategies with the use of pain standard criteria (ie, self-report and behavioral measures). If found to be valid, the NOL could be used as an alternative physiologic measure of pain in critically ill adults for whom no other pain assessment methods are available.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05339737; https://clinicaltrials.gov/study/NCT05339737.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/60672.

Pain Assessment in the Patient Unable to Self- Report: Clinical Practice Recommendations in Support of the ASPMN 2024 Position Statement

Recognizing and managing pain is especially challenging for vulnerable populations who cannot communicate their discomfort. Because there is no valid and reliable objective measure of pain, the American Society for Pain Management Nursing advocates for comprehensive assessment practices articulated in a Hierarchy of Pain Assessment. These practices must gather relevant information to infer the presence of pain and evaluate a patient's response to treatment. Nurses and other healthcare providers must be advocates for those who cannot communicate their pain experience.

Knowledge, attitudes, and perceived barriers regarding pain assessment and management among Thai critical care nurses: A cross-sectional study

BACKGROUND

Pain is a distressing problem which commonly occurs among critically ill patients. Nurses' knowledge of, attitudes, and perceived barriers to pain assessment and management can influence the effectiveness of nursing care.

OBJECTIVE

To explore the current knowledge of, attitudes, and perceived barriers to pain assessment and management among Thai critical care unit nurses.

METHODS

A cross-sectional survey conducted between November 2022 and January 2023 among 158 Thai nurses working in one of eight adult critical care units in a tertiary hospital, evaluated their knowledge of, attitudes, and perceived barriers to pain assessment and management.

RESULTS

Nurses possessed inadequate knowledge and negative attitudes regarding pain assessment and management. The most important barrier to pain assessment and management was "patients are unable to communicate their pain". The results showed a significantly weak positive correlation between nurses' attitudes toward pain assessment and management age (r = 0.26, p = 0.001), year of ICU experience (r = 0.29, p < 0.001), and obtaining a certificate in intensive care nursing (r = 0.37, P < 0.001).

CONCLUSIONS

Thai critical care unit nurses possessed inadequate knowledge and negative attitudes. Further training and education regarding pain assessment and management could include case studies or simulation and immersive virtual reality to improve critical care unit nurses' knowledge and attitudes as well as identifying potential barriers to pain assessment and management in the critical care settings.

IMPLICATIONS FOR CLINICAL PRACTICE

The implications for clinical practice recommend that continued quality assurance procedures should be implemented and maintained to evaluate the effectiveness of current pain assessment practices. Additionally, the perceived barriers to effective pain assessment and management should be considered and managed not only through continued education and training but could include using nursing case review, morbidity and mortality data identifying those patients that experience chronic pain post-ICU discharge.

Assessing pain in paralyzed critically ill patients receiving neuromuscular blocking agents: A monocenter prospective cohort

INTRODUCTION

Given the absence of established recommendations for pain assessment in pharmacologically paralyzed Intensive-Care-Units (ICU) patients under Neuro-Muscular-Blocking Agents (NMBA), this study assessed the validity of various parameters for evaluating pain in this specific population.

PATIENTS AND METHODS

Four electrophysiological parameters (instant-Analgesia-Nociception-Index (ANI), Bispectral index (BIS), Heart Rate (HR) and Mean Arterial Blood Pressure (ABP)) and one clinical parameter (Behavioural-Pain-Scale (BPS)) were recorded during tracheal-suctioning in all consecutive ICU patients who required a continuous infusion of cisatracurium, before and just after paralysis recovery measured by Train-of-Four ratio. The validity of the five pain-related parameters was assessed by comparing the values recorded during different situations (before/during/after the nociceptive procedure) (discriminant-validity, primary outcome), and the effect of paralysis was assessed by comparing values obtained during and after paralysis (reliability, secondary outcome).

RESULTS

Twenty patients were analyzed. ANI, BIS, and HR significantly changed during the nociceptive procedure in both paralysis and recovery, while BPS changed only post-recovery. ANI and HR were unaffected by paralysis, unlike BIS and BPS (mixed-effect model). ANI exhibited the highest discriminant-validity, with values (min 0/max 100) decreasing from 71 [48-89] at rest to 41 [25-72] during tracheal suctioning in paralyzed patients, and from 71 [53-85] at rest to 40 [31-52] in non-paralyzed patients.

CONCLUSIONS

ANI proves the most discriminant parameter for pain detection in both paralyzed and non-paralyzed sedated ICU patients. Its significant and clinically relevant decrease during tracheal suctioning remains unaltered by NMBA use. Pending further studies on analgesia protocols based on ANI, it could be used to assess pain during nociceptive procedures in ICU patients receiving NMBA.

Person-Centred Pain Measurement in the ICU: A Multicentre Clinimetric Comparison Study of Pain Behaviour Observation Scales in Critically Ill Adult Patients with Burns

Pain in critically ill adults with burns should be assessed using structured pain behavioural observation measures. This study tested the clinimetric qualities and usability of the behaviour pain scale (BPS) and the critical-care pain observation tool (CPOT) in this population. This prospective observational cohort study included 132 nurses who rated pain behaviour in 75 patients. The majority of nurses indicated that BPS and CPOT reflect background and procedural pain-specific features (63-72 and 87-80%, respectively). All BPS and CPOT items loaded on one latent variable (≥0.70), except for compliance ventilator and vocalisation for CPOT (0.69 and 0.64, respectively). Internal consistency also met the criterion of ≥0.70 in ventilated and non-ventilated patients for both scales, except for non-ventilated patients observed by BPS (0.67). Intraclass correlation coefficients (ICCs) of total scores were sufficient (≥0.70), but decreased when patients had facial burns. In general, the scales were fast to administer and easy to understand. Cut-off scores for BPS and CPOT were 4 and 1, respectively. In conclusion, both scales seem valid, reliable, and useful for the measurement of acute pain in ICU patients with burns, including patients with facial burns. Cut-off scores associated with BPS and CPOT for the burn population allow professionals to connect total scores to person-centred treatment protocols.

Appropriateness of behavioural scales in the monitoring of pain in the critically ill patient unable to self-report

Appropriateness is a dimension of quality that evaluates the effective use of technologies, resources or interventions in specific situations or populations, assessing whether our interventions do more benefit than harm. The evidence regarding pain monitoring in the critically ill patient points to the periodic assessment of pain using appropriate tools, with the aim of improving pain management and more efficient use of analgesics in the intensive care unit. The first step would be to assess the patient's ability to communicate or self-report and, based on this, to select the most appropriate pain assessment tool. In patients who are unable to self-report, behavioural pain assessment tools are recommended. When we talk about the suitability of behavioural scales for pain monitoring in critically ill patients unable to self-report, we refer to their use with a clear clinical benefit, i.e. using the right tool for pain assessment to be effective, efficient and consistent with bioethical principles. To our knowledge, there are no published data on the suitability of pain assessment tools in unable to self-report critically ill patients, so, in the framework of continuous quality improvement in pain care, new research should incorporate this approach by integrating the best scientific evidence with current clinical practice.

Pain assessment tools in adults with communication disorders: systematic review and meta-analysis

BACKGROUND

Verbal communication is the "gold standard" for assessing pain. Consequently, individuals with communication disorders are particularly vulnerable to incomplete pain management. This review aims at identifying the current pain assessment instruments for adult patients with communication disorders.

METHODS

A systematic review with meta-analysis was conducted on PubMed, PEDRO, EBSCOhost, VHL and Cochrane databases from 2011 to 2023 using MeSH terms "pain assessment, "nonverbal communication" and "communication disorders" in conjunction with additional inclusion criteria: studies limited to humans, interventions involving adult patients, and empirical investigations.

RESULTS

Fifty articles were included in the review. Seven studies report sufficient data to perform the meta-analysis. Observational scales are the most common instruments to evaluate pain in individuals with communication disorders followed by physiological measures and facial recognition systems. While most pain assessments rely on observational scales, current evidence does not strongly endorse one scale over others for clinical practice. However, specific observational scales appear to be particularly suitable for identifying pain during certain potentially painful procedures, such as suctioning and mobilization, in these populations. Additionally, specific observational scales appear to be well-suited for certain conditions, such as mechanically ventilated patients.

CONCLUSIONS

While observational scales dominate pain assessment, no universal tool exists for adults with communication disorders. Specific scales exhibit promise for distinct populations, yet the diverse landscape of tools hampers a one-size-fits-all solution. Crucially, further high-quality research, offering quantitative data like reliability findings, is needed to identify optimal tools for various contexts. Clinicians should be informed to select tools judiciously, recognizing the nuanced appropriateness of each in diverse clinical situations.

TRIAL REGISTRATION

This systematic review is registered in PROSPERO (International prospective register of systematic reviews) with the ID: CRD42022323655 .

Interrater Agreement between Bedside and Video Raters Using the CPOT-Neuro for Pain Assessment in Critically Ill Patients with a Brain Injury

This study aimed to examine the interrater agreement of Critical-Care Pain Observation Tool-Neuro (CPOT-Neuro) scores as a newly developed tool for pain assessment in patients with critical illness and brain injury between raters using two methods of rating (bedside versus video) during standard care procedures (i.e., non-invasive blood pressure and turning). The bedside raters were research staff, and the two video raters had different backgrounds (health and non-health disciplines). Raters received standardized 45 min training by the principal investigator. Video recordings of 56 patient participants with a brain injury at different levels of consciousness were included. Interrater agreement was supported with an Intraclass Correlation Coefficient (ICC) > 0.65 for all pairs of raters and for each procedure. Interrater agreement was highest during turning in the conscious group, with ICCs ranging from 0.79 to 0.90. The use of video recordings was challenging for the observation of some behaviors (i.e., tearing, face flushing), which were influenced by factors such as lighting and the angle of the camera. Ventilator alarms were also challenging to distinguish from other sources for the video rater from a non-health discipline. Following standardized training, video technology was useful in achieving an acceptable interrater agreement of CPOT-Neuro scores between bedside and video raters for research purposes.

Nociception assessment with videopupillometry in deeply sedated intensive care patients: Discriminative and criterion validations

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.

Correlation of the Critical Care Pain Observation Tool and Numeric Rating Scale in Intensive Care Unit Patients

PURPOSE

We sought to determine the correlation between the Numeric Rating Scale (NRS) and Critical-Care Pain Observation Tool (CPOT) to determine whether clinical factors modified the relationship between NRS and CPOT assessments.

MATERIALS AND METHODS

We included nonventilated adults admitted to the MICU or SICU who could self-report pain and had at least 3 paired NRS and CPOT assessments. We performed Spearman correlation to assess overall correlation and performed proportional odds logistic regression to evaluate whether the relationship between NRS and CPOT assessments was modified by clinical factors.

RESULTS

Nursing staff performed NRS and CPOT assessments every 4 h in 1302 patients, leading to 61,142 matched assessments. We found that the NRS and CPOT have a Spearman correlation coefficient of 0.56 and an intraclass correlation coefficient of 0.32 in intensive care unit patients. Factors that modified the relationship between the NRS and CPOT included the presence of delirium (P < .001) and lower mean daily Richmond Agitation Sedation Scale (<0.001).

CONCLUSIONS

The correlation coefficient between the NRS and the CPOT was found to be 0.56. The presence of delirium, decreased level of arousal, modified the relationship between the NRS and CPOT. Self-reported and behavioral pain assessments cannot be used interchangeably in critically ill adults.

Cross-cultural adaptation and validation of the Indonesian version of the Critical-care Pain Observation Tool

Objective

The Critical-care Pain Observation Tool (CPOT) is one of the most accurate methods for assessing pain in ICU patients with critical illness and/or a decreased level of consciousness (LOC). This study aimed to determine the validity and reliability of the Indonesian version of the CPOT.

Methods

The English version of CPOT was translated into the Indonesian version following five steps: initial translation, synthesis of instrument translation results, back translation, validation of the instrument by an expert committee, and testing of the Indonesian instrument. Between September and December 2022, a total of 52 ICU patients from four hospitals in Indonesia were evaluated for pain at rest, during body-turning procedure, and 15 minutes after the procedure using the CPOT. The researcher used the verbal Faces Pain Thermometer (FPT) instrument as a gold standard to assess the CPOT's criteria validity. Validity assessments included content and criterion validity. Reliability was evaluated using Cronbach's α coefficient and interrater reliability.

Results

Higher CPOT scores were found during the body-turning procedure than at rest and after the procedure. The instrument's item-content validity index (I-CVI) ranged from 0.75 to 1.00, and the overall instrument's average scale-level content validity index (S-CVI/Ave) was 0.93. The statistical analysis revealed a positive correlation (r) between the CPOT and the patient's FPT scores (0.877-0.983, P < 0.01). The significant agreement amongst raters (κ) revealed the inter-rater reliability of the CPOT (0.739-0.834, P < 0.01).

Conclusion

The Indonesian version of the CPOT has been proven valid and reliable in assessing pain in patients with critical illness and/or decreased LOC.

Relationship Between Pain and Delirium in Critically Ill Adults

OBJECTIVES

Although opioids are frequently used to treat pain, and are an important risk for ICU delirium, the association between ICU pain itself and delirium remains unclear. We sought to evaluate the relationship between ICU pain and delirium.

DESIGN

Prospective cohort study.

SETTING

A 32-bed academic medical-surgical ICU.

PATIENTS

Critically ill adults (n = 4,064) admitted greater than or equal to 24 hours without a condition hampering delirium assessment.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Daily mental status was classified as arousable without delirium, delirium, or unarousable. Pain was assessed six times daily in arousable patients using a 0-10 Numeric Rating Scale (NRS) or the Critical Care Pain Observation Tool (CPOT); daily peak pain score was categorized as no (NRS = 0/CPOT = 0), mild (NRS = 1-3/CPOT = 1-2), moderate (NRS = 4-6/CPOT = 3-4), or severe (NRS = 7-10/CPOT = 5-8) pain. To address missingness, a Multiple Imputation by Chained Equations approach that used available daily pain severity and 19 pain predictors was used to generate 25 complete datasets. Using a first-order Markov model with a multinomial logistic regression analysis, that controlled for 11 baseline/daily delirium risk factors and considered the competing risks of unarousability and ICU discharge/death, the association between peak daily pain and next-day delirium in each complete dataset was evaluated.

RESULTS

Among 14,013 ICU days (contributed by 4,064 adults), delirium occurred on 2,749 (19.6%). After pain severity imputation on 1,818 ICU days, mild, moderate, and severe pain were detected on 2,712 (34.1%), 1,682 (21.1%), and 894 (11.2%) of the no-delirium days, respectively, and 992 (36.1%), 513 (18.6%), and 27 (10.1%) of delirium days (p = 0.01). The presence of any pain (mild, moderate, or severe) was not associated with a transition from awake without delirium to delirium (aOR 0.96; 95% CI, 0.76-1.21). This association was similar when days with only mild, moderate, or severe pain were considered. All results were stable after controlling for daily opioid dose.

CONCLUSIONS

After controlling for multiple delirium risk factors, including daily opioid use, pain may not be a risk factor for delirium in the ICU. Future prospective research is required.

Continuous visualization and validation of pain in critically ill patients using artificial intelligence: a retrospective observational study

Machine learning tools have demonstrated viability in visualizing pain accurately using vital sign data; however, it remains uncertain whether incorporating individual patient baselines could enhance accuracy. This study aimed to investigate improving the accuracy by incorporating deviations from baseline patient vital signs and the concurrence of the predicted artificial intelligence values with the probability of critical care pain observation tool (CPOT) ≥ 3 after fentanyl administration. The study included adult patients in intensive care who underwent multiple pain-related assessments. We employed a random forest model, utilizing arterial pressure, heart rate, respiratory rate, gender, age, and Richmond Agitation-Sedation Scale score as explanatory variables. Pain was measured as the probability of CPOT scores of ≥ 3, and subsequently adjusted based on each patient's baseline. The study included 10,299 patients with 117,190 CPOT assessments. Of these, 3.3% had CPOT scores of ≥ 3. The random forest model demonstrated strong accuracy with an area under the receiver operating characteristic curve of 0.903. Patients treated with fentanyl were grouped based on CPOT score improvement. Those with ≥ 1-h of improvement after fentanyl administration had a significantly lower pain index (P = 0.020). Therefore, incorporating deviations from baseline patient vital signs improved the accuracy of pain visualization using machine learning techniques.

Preliminary clinical testing to inform development of the Critical Care Pain Observation Tool for Families (CPOT-Fam)

Introduction

Many patients in the intensive care unit (ICU) cannot communicate. For these patients, family caregivers (family members/close friends) could assist in pain assessment. We previously adapted the Critical Care Pain Observation Tool (CPOT) for family caregiver use (CPOT-Fam). In this study, we conducted preliminary clinical evaluation of the CPOT-Fam to inform further tool development.

Methods

For preliminary testing, we collected (1) pain assessments of patients in the ICU from family caregivers (CPOT-Fam) and nurses (CPOT) and determined the degree of agreement (kappa coefficient, κ) and (2) collected openended feedback on the CPOT-Fam from family caregivers. For refinement, we used preliminary testing data to refine the CPOT-Fam with a multidisciplinary working group.

Results

We assessed agreement between family caregiver and nurse pain scores for 29 patients. Binary agreement (κ) between CPOT-Fam and CPOT item scores (scores ≥2 considered indicative of significant pain) was fair, κ = 0.43 (95% confidence interval [CI] 0.18-0.69). Agreement was highest for the CPOT-Fam items ventilator compliance/vocalization (weighted κ = 0.48, 95% CI 0.15-0.80) and lowest for muscle tension (weighted κ = 0.10, 95% [CI] -0.17 to 0.20). Most participants (n = 19; 69.0%) reported a very positive experience using the CPOT-Fam, describing it as "good" and "easy-to-use/clear/straightforward." We iteratively refined the CPOT-Fam over five cycles using the data collected until no further revisions were suggested.

Conclusion

Our preliminary clinical testing suggests that family involvement in pain assessment in the ICU is well perceived. The CPOT-Fam has been further refined and is now ready for clinical pilot testing to determine its feasibility and acceptability.

Changes in Physiological Indices Before and After Nursing Care of Postoperative Patients With Esophageal Cancer in the ICU

Introduction

Various stressors have been identified in patients in the intensive care unit (ICU), including postoperative pain, ventilatory management, and nursing care. However, sedated patients are less responsive, and nurses have difficulty capturing their stressors.

Objective

To investigate patient stress caused by nursing care performed in the ICU on sedated patients based on changes in physiological indices.

Methods

We observed nursing care performed on patients with postoperative esophageal cancer under sedation in the ICU. This included endotracheal suctioning and turning, the time required for the care, and the patients' behavioral responses. Information on arousal levels, autonomic nervous system indices, and vital signs were also obtained. The changes in indicators before and after care were then compared and analyzed.

Results

There were 14 patients in the study. The mean age of the patients was 68 years. Ninety-nine scenes of nursing care were observed, and in six of these, additional bolus sedation was administered because of the patient's significant body movements. In endotracheal suctioning, no significant changes were observed in all indicators. In turning, vital signs changed significantly, and when both were continued, all indicators changed significantly.

Conclusion

Our study found that different types and combinations of nursing care may cause different stresses to the patients. Moreover, the autonomic nervous system indices may be more likely to react to stresses in a variety of nursing care, while arousal levels may be more likely to react to burdensome stresses. If the characteristics of these physiological indicators can be understood and effectively utilized during care, it may be possible to better identify and reduce patient stress during sedation management.

Validation of the Critical-Care Pain Observation Tool (CPOT) in pediatric patients undergoing orthopedic surgery

Background

Postoperative pain cannot be measured accurately among many children with intellectual and developmental disabilities, resulting in underrecognition or delay in recognition of pain. The Critical-Care Pain Observation Tool (CPOT) is a pain assessment tool that has been widely validated in critically ill and postoperative adults.

Aims

The objective of this study was to validate the CPOT for use with pediatric patients able to self-report and undergoing posterior spinal fusion surgery.

Methods

Twenty-four patients (10-18 years old) scheduled to undergo surgery were consented to this repeated-measure, within-subject study. To examine discriminative and criterion validation, CPOT scores and patients' self-reports of pain intensity were collected prospectively by a bedside rater before, during, and after a nonnociceptive and nociceptive procedure on the day following surgery. Patients' behavioral reactions were video recorded at the bedside and retrospectively viewed by two independent video raters to examine interrater and intrarater reliability of CPOT scores.

Results

Discriminative validation was supported with higher CPOT scores during the nociceptive procedure than during the nonnociceptive procedure. Criterion validation was supported with a moderate positive correlation between the CPOT scores and the patients' self-reported pain intensity during the nociceptive procedure. A CPOT cutoff score of ≥2 was associated with the maximum sensitivity (61.3%) and specificity (94.1%). Reliability analyses revealed poor to moderate agreement between bedside and video raters and moderate to excellent consistency within video raters.

Conclusions

These findings suggest that the CPOT may be a valid tool to detect pain in pediatric patients in the acute postoperative inpatient care unit after posterior spinal fusion.

Development and preclinical testing of the critical care pain observation tool for family caregiver use (CPOT-Fam)

Background and Aims

Pain assessment in noncommunicative intensive care unit (ICU) patients is challenging. For these patients, family caregivers (i.e., family members, friends) may be able to assist in pain assessment by identifying individualistic signs of pain due to their intimate patient knowledge. This study adapted the critical care pain observation tool (CPOT) to facilitate pain assessment in adult ICU patients by family caregivers.

Methods

This study was conducted through three distinct phases: (1)CPOT adaptation for family caregiver use (to create the CPOT-Fam): A working group met monthly to adapt the CPOT and develop educational material and sample cases for practice scoring until consensus was reached.(2)CPOT-Fam preclinical testing: Family caregiver study participants viewed educational materials and scored four randomly selected sample cases using the CPOT-Fam. Scores were compared to reference scores to assess agreement and identify CPOT-Fam sections requiring revision. Open-ended feedback on the CPOT-Fam was collected.(3)CPOT-Fam revision: the CPOT-Fam was revised by the working group considering score agreement and feedback received from study participants.

Results

Of the n = 30 participants, n = 14 (47.0%) had experience with an ICU patient. Agreement between CPOT-Fam participant scores and reference scores were highest for the vocalization dimension (Is the patient making any sounds?; Intraclass correlation coefficient; ICC = 1.0) and lowest for the body movements dimension (What are the patient's body movements like?; ICC = 0.85. Participants indicated they found the CPOT-Fam to be "informative" and "easy-to-use" but "not graphic enough"; participants also indicated that descriptors like "lack of breath" and "struggling to move" are helpful with identifying individualistic behaviors of pain exhibited by their loved ones.

Conclusion

The CPOT-Fam shows ease of use and may be of value in involving family caregivers in ICU care. Clinical pilot testing is needed to determine feasibility and acceptability and identify further areas for refinement.

Discomfort improvement for critically ill patients using electronic relaxation devices: results of the cross-over randomized controlled trial E-CHOISIR (Electronic-CHOIce of a System for Intensive care Relaxation)

Purpose

To assess the impact of different electronic relaxation devices on common stressful patient symptoms experienced in intensive care unit (ICU).

Methods

Sixty critically ill patients were enrolled in four relaxation sessions using a randomized cross-over design: standard relaxation (TV/radio), music therapy (MUSIC-CARE©), and two virtual reality systems using either real motion pictures (DEEPSEN©) or synthetic motion pictures (HEALTHY-MIND©). The goal was to determine which device was the best to reduce overall patient discomfort intensity (0–10 Numeric Rating Scale (NRS); primary endpoint). Secondary endpoints were specific stressful symptoms (pain, anxiety, dyspnea, thirst, and lack of rest feeling) and stress response measured by Analgesia/Nociception Index (ANI). Multivariate mixed-effect analysis was used, taking into account patient characteristics and multiple measurements.

Results

Fifty patients followed the full research protocol, and ten patients did at least one research planned session of relaxation. HEALTHY-MIND© was associated with a significant decrease in overall discomfort, the primary endpoint (median NRS = 4[2–6] vs. 2[0–5]; p = 0.01, mixed-effect model), accompanied by a significant decrease in stress response (increase in ANI, secondary endpoint; p < 0.01). Regarding other secondary endpoints, each of the two virtual reality systems was associated with a decrease in anxiety (p < 0.01), while HEALTHY-MIND© was associated also with a decrease in pain (p = 0.001) and DEEPSEN© with a decrease in lack of rest (p = 0.01). Three incidents (claustrophobia/dyspnea/agitation) were reported among 109 virtual reality sessions. Cybersickness was rare (NRS = 0[0–0]).

Conclusion

Electronic relaxation therapy is a promising, safe, and effective non-pharmacological solution that can be used to improve overall discomfort in alert and non-delirious ICU patients. Its effectiveness depends on technical characteristics (virtual reality using a synthetic imagined world versus a real world or music therapy alone without virtual reality), as well as the type of symptoms.

Electronic relaxation therapies are effective supportive care tools for improving stressful symptoms in ICU patients.

Effectiveness depends on the type of symptom and the characteristics of the devices.

Overall discomfort and adrenergic stress response are more significantly improved by virtual reality using a synthetic imagined world than using a real world or music therapy alone.

Investigation of behavioral pain scale, critical care pain observation tool, nociceptive flexion reflex and pupillary dilatation reflex as predictors of behavioral reactions to nociceptive procedures in critically ill patients unable to self-report pain

BACKGROUND

Procedural pain is a common burden in critical care treatment and the prediction of nociceptive reactions remains challenging. Thus, we investigated the behavioral pain scale (BPS), the critical pain observational Tool (CPOT), the nociceptive flexion reflex (NFR), the pupillary dilation reflex (PDR), the Richmond agitation-sedation scale (RASS) as predictors of behavioral reactions to nociceptive procedures.

METHODS

In this monocentric, prospective, observational study we analyzed data of 128 critically ill adults unable to self-report pain to investigate the predictability of behavioral reactions to two procedures: endotracheal suctioning and turning. Next to routine clinical data, CPOT, BPS, PDR, NFR, RASS, propofol and sufentanil doses were recorded before the procedures.

RESULTS

For endotracheal suctioning, NFR, BPS, CPOT, RASS showed predictive performances significantly better than chance, but none of them performed significantly better than the sufentanil dose rate. For turning, BPS, CPOT, RASS showed predictive performances significantly better than chance, but only the RASS performed significantly better than the propofol dose rate.

CONCLUSIONS

Behavioral reactions to both investigated clinical procedures can be predicted by observational scales or nociceptive reflexes. For endotracheal suctioning, none of the predictors performed superior to using the sufentanil dose rate as a predictor. As using sufentanil as a predictor requires no extra effort in contrast to the other predictors, none of the here investigated tools seem advisable for predicting behavioral reactions to endotracheal suctioning. For patient turning, the RASS predicts reactions better than any other tool.

Study protocol: development and pilot testing of the Critical Care Pain Observation Tool for families (CPOT-Fam)

Background

Patients in the intensive care unit (ICU) often have limited ability to communicate making it more difficult to identify and effectively treat their pain. Family caregivers or close friends of critically ill patients may be able to identify signs of pain before the clinical care team and could potentially assist in routine pain assessments. This study will adapt the Critical Care Pain Observation Tool (CPOT) for use by family members to create the CPOT-Fam and compare family CPOT-Fam assessments with nurse-provided CPOT assessments for a given patient.

Methods

This study will be executed in two phases:

1) Development of the CPOT-Fam — A working group of patient partners, ICU clinicians, and researchers will adapt the CPOT for use by family caregivers (creating the CPOT-Fam) and produce an accompanying educational module to deliver information on pain and how to use the tool. The CPOT-Fam will undergo preclinical testing with participants (i.e., members of the public and family caregivers of critically ill adults), who will complete the educational module and provide CPOT-Fam scores on sample cases. Feedback on the CPOT-Fam will be collected.

2) Pilot testing the CPOT — Fam family caregivers of critically ill adults will complete the educational module and provide information on the following: (1) demographics, (2) anxiety, (3) caregiving self-efficacy, and (4) satisfaction with care in the ICU. Family caregivers will then provide a proxy assessment of their critically ill loved one’s pain through the CPOT-Fam and also provide a subjective (i.e., questionnaire-based including open-ended responses) account of their loved one’s pain status. A comparison (i.e., agreement) will be made between family caregiver provided CPOT-Fam scores and ICU nurse-provided CPOT scores (collected from the provincial health information system), calculated independently and blinded to one another. Feasibility and acceptability of the CPOT-Fam will be determined.

Discussion

The results of this work will produce a family caregiver CPOT (i.e., CPOT-Fam), determine feasibility and acceptability of the CPOT-Fam, and compare pain assessments conducted by family caregivers and ICU nurses. The results will inform whether a larger study to determine a role for family caregivers in ICU pain assessment using the CPOT-Fam is warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01102-3.

Acceptability and Feasibility of a Patient-Oriented Music Intervention to Reduce Pain in the Intensive Care: Protocol for a Randomized Crossover Pilot Trial (Preprint)

BACKGROUND

Many patients experience pain in the intensive care unit (ICU) despite receiving pain medication. Research has shown that music can help reduce pain. Music interventions studied so far have not used music streaming to generate playlists based on patient preferences while incorporating recommended tempo and duration. Previous research has focused on postoperative ICU patients able to self-report, which is underrepresentative of the ICU population that might benefit from a music intervention for pain management. We developed a new patient-oriented music intervention (POMI) that incorporates features based on theoretical, empirical, and experiential data intended to be used in the ICU. Such a music intervention should consider the expertise of ICU patients, family members, and nursing staff, as well as the practicality of the intervention when used in practice.

OBJECTIVE

The primary objectives of this study are to (1) evaluate the acceptability and feasibility of the POMI to reduce pain in ICU patients and (2) evaluate the feasibility of conducting a crossover pilot randomized controlled trial (RCT) for intervention testing in the ICU. A secondary objective is to examine the preliminary efficacy of the POMI to reduce pain in ICU patients.

METHODS

A single-blind 2×2 crossover pilot RCT will be conducted. Patients will undergo 1 sequence of 2 interventions: the POMI which delivers music based on patients' preferences via headphones or music pillow for 20-30 minutes and the control intervention (headphones or pillow without music). The sequence of the interventions will be inverted with a 4-hour washout period. Timing of the interventions will be before a planned bed turning procedure. Each patient will undergo 1 session of music. Twenty-four patients will be recruited. Patients able to self-report (n=12), family members of patients unable to self-report (n=12), and nursing staff (n=12) involved in the bed turning procedure will be invited to complete a short questionnaire on the POMI acceptability. Data will be collected on the feasibility of the intervention delivery (ie, time spent creating a playlist, any issue related to headphones/pillow or music delivery, environmental noises, and intervention interruptions) and research methods (ie, number of patients screened, recruited, randomized, and included in the analysis). Pain scores will be obtained before and after intervention delivery.

RESULTS

Recruitment and data collection began in March 2022. As of July 5, 2022, in total, 22 patients, 12 family members, and 11 nurses were recruited.

CONCLUSIONS

Methodological limitations and strengths are discussed. Study limitations include the lack of blinding for patients able to self-report. Strengths include collecting data from various sources, getting a comprehensive evaluation of the intervention, and using a crossover pilot RCT design, where participants act as their own control, thus reducing confounding factors.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05320224; https://clinicaltrials.gov/ct2/show/NCT05320224.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40760.

Validation Testing of the European Portuguese Critical-Care Pain Observation Tool

Aim. The study aim was to validate the Portuguese version of the Critical-Care Pain Observation Tool (CPOT) in the critically ill adult population of Portugal. Methods. A prospective, observational cohort study was conducted to evaluate the CPOT in mechanically ventilated patients who were admitted to an intensive care unit. A consecutive sample of 110 patients was observed at rest pre-procedure, during a nociceptive procedure (NP) which includes turning/positioning and endotracheal or tracheal suctioning and 20 min post-procedure. Two raters participated in the data collection. The discriminative validity, criterion validity, convergent validity and inter-rater reliability of the CPOT were examined. Results. The inter-rater reliability was excellent (0.93 ≤ α ≤ 1.00) at rest and fair to moderate (0.39 ≤ α ≤ 0.60) during the NP. The CPOT could discriminate between conditions with higher scores during the NP when compared to CPOT scores at rest (p < 0.001). The optimal CPOT cut-off score was >2, with a sensitivity of 71% and a specificity of 80%, and self-reported pain was the gold standard criterion. Significant correlations (<0.40) were found between CPOT scores, the heart rate and the respiratory rate during the nociceptive procedure. Conclusions. The CPOT appears to be a valid alternative for both ventilated and non-ventilated patients who are unable to communicate.

A Comparative Study of the Diagnostic Value of the Critical Care Pain Observation Tool and the Behavioral Pain Scale for Pain Assessment among Unconscious Patients

Background

Pain assessment in unconscious patients is a major challenge for healthcare providers. This study aims to compare the diagnostic value of the critical-care pain observation tool (CPOT) and the behavioral pain scale (BPS) for pain assessment among unconscious patients.

Materials and methods

This cross-sectional study was conducted in 2019. Forty-five unconscious patients were selected randomly from four general intensive care units (ICUs) in the north of Iran. The discriminant validity of CPOT and BPS were evaluated for pain during a nociceptive and a nonnociceptive procedure. For reliability assessment, interrater agreement was obtained using Lin's concordance correlation coefficient and weighted kappa coefficient.

Results

Patients who had been hospitalized in ICU due to surgery or trauma (57.70%) or medical problems (42.30%) were studied. During the nociceptive procedure, the mean scores of CPOT and BPS and all their dimensions, except for the compliance with ventilator dimension, were significantly greater than the nonnociceptive procedure (p <0.05) although the effect size of both instruments was small (0.32 vs 0.18). The Lin's concordance correlation coefficient in nonnociceptive and nociceptive procedures was respectively 0.67 and 0.62 for CPOT and 0.74 and 0.88 for BPS.

Conclusion

CPOT and BPS have acceptable discriminant validity in differentiating nonnociceptive and nociceptive procedural pain although the effect size of CPOT is larger than that of BPS. Although both instruments have low reliability, the reliability of BPS is better.

How to cite this article

Nazari R, Froelicher ES, Nia HS, Hajihosseini F, Mousazadeh N. Diagnostic Values of the Critical Care Pain Observation Tool and the Behavioral Pain Scale for Pain Assessment among Unconscious Patients: A Comparative Study. Indian J Crit Care Med 2022;26(4):472–476.

Exploration of a Multi-Parameter Technology for Pain Assessment in Postoperative Patients After Cardiac Surgery in the Intensive Care Unit: The Nociception Level Index (NOL)TM

Introduction

The aim of this study was to explore the use of a multi-parameter technology, the Nociception Level (NOL) index (Medasense Biometrics Ltd, Ramat Gan, Israel), for pain assessment in postoperative awake patients after cardiac surgery during non-nociceptive and nociceptive procedures in the intensive care unit (ICU).

Materials and Methods

A prospective cohort repeated-measures design was used. Patients were included if they were in the ICU after undergoing cardiac surgery and if they could self-report their pain. A non-invasive probe was placed on the patient’s finger for the continuous monitoring of the NOL index. Patients’ self-reports of pain and anxiety (0–10 Numeric Rating Scale or NRS), and behavioral scores with the Critical-Care Pain Observation Tool (CPOT) were obtained before and during a non-nociceptive procedure (ie, non-invasive blood pressure [NIBP] using cuff inflation), and before, during and after a nociceptive procedure (ie, chest tube removal [CTR]) for a total of five time points. Non-parametric tests were used to compare scores at different time points, and receiver operating characteristic curve analysis was performed.

Results

Fifty-four patients were included in the analysis. The NOL index, pain and anxiety scores were significantly higher during CTR compared to rest and NIBP (p < 0.001). During CTR, the NOL was associated with self-reported pain intensity and unpleasantness but not with anxiety and CPOT scores. The NOL showed a modest performance in detecting pain (NRS ≥1 and ≥5) in this sample with sensitivity and specificity ranging from 61% to 85%.

Conclusion

The NOL index was able to discriminate between a non-nociceptive and a nociceptive procedure and was associated with self-reported pain. Further validation testing of the NOL is necessary in a heterogeneous sample of ICU patients.

Validity of Pulse Oximetry-derived Peripheral Perfusion Index in Pain Assessment in Critically Ill Intubated Patients

OBJECTIVES

Evaluation of pain in critically ill intubated patients is difficult and subjective. This study aimed to evaluate the accuracy of oximetry-derived peripheral perfusion index (PPI) in pain assessment in critically ill intubated patients using the behavioral pain scale (BPS) as a reference.

MATERIALS AND METHODS

This prospective observational study included 35 adult mechanically ventilated surgical patients during their first 2 postoperative days in the intensive care unit. Values of PPI, BPS, Richmond Agitation Sedation Scale (RASS), heart rate, and blood pressure were obtained before and after a standard painful stimulus (changing the patient position) and the ratio between the second and the first reading was calculated to determine the change (Δ) in all variables. The outcomes were the correlation between ΔBPS and ΔPPI as well as other hemodynamic parameters. The ability of the PPI to detect pain (defined as BPS ≥6) was analyzed using the area under receiver operating characteristic curve.

RESULTS

Paired readings were obtained from 35 patients. After the standard painful stimulus, the PPI decreased while the BPS and the Richmond agitation sedation scale increased. The Spearman correlation coefficient (95% confidence interval) between Δ PPI and Δ BPS was 0.41 (0.09-0.65). PPI values showed poor accuracy in detecting pain with area under receiver operating characteristic curve (95% confidence interval): 0.65 (0.53-0.76), with best cutoff value of ≤2.7.

CONCLUSION

The PPI decreased after application of a standard painful stimulus in critically ill intubated patients. ∆PPI showed a low correlation with ∆BPS, and a PPI of ≤2.7 showed a low ability to detect BPS ≥6. Therefore, PPI should not be used for pain evaluation in critically ill intubated surgical patients.

Description of the validity of the Analgesia Nociception Index (ANI) and Nociception Level Index (NOL) for nociception assessment in anesthetized patients undergoing surgery: a systematized review

Maintaining optimum analgesia in anesthetized patients is challenging due to the inability to self-report pain or exhibit pain-related behaviours. The Analgesia Nociception Index (ANI) (based on heart rate variability [HRV]) and the Nociception Level Index (NOL) (based on HRV, photoplethysmography, skin conductance, and temperature) both include HRV and provide continuous index monitoring for nociception assessment. The research question was: "What are the validation strategies of the NOL and ANI for nociception assessment in anesthetized patients?". The objectives were to describe and analyze the validation strategies and results. A systematized review was conducted using a comprehensive search with keywords under three concepts (nociception/pain, ANI/NOL, and validity) in four databases. A quality assessment using an adapted GRADE approach for measurement tools, and a risk of bias assessment using QUADAS-2 tool were performed by two reviewers. Out of 525 results, 15 validation studies were included. Strategies included hypothesis testing, discriminative, and criterion validation. Significant changes in ANI/NOL values were found in response to nociceptive stimuli at different opioid concentrations (hypothesis testing). Higher ANI/NOL values were observed during nociceptive stimuli (discriminative). AUCs ranging from 0.83 to 0.99 were obtained to detect nociceptive stimuli (criterion). Both technologies performed superiorly in detecting nociceptive stimuli compared to individual monitoring of HR and blood pressure. Although the aforementioned validation strategies are deemed appropriate, in the absence of a gold standard, criterion validation findings should be interpreted with caution. Moreover, reliability could be examined using test-retest with consistent ANI/NOL values during a stable time-interval.

Determinants of pain assessment documentation in intensive care units

PURPOSE

The underassessment of pain is a major barrier to effective pain management, and the lack of pain assessment documentation has been associated with negative patient outcomes. This study aimed to 1) describe the contextual factors related to pain assessment and management in five Québec intensive care units (ICUs); 2) describe their pain assessment documentation practices; and 3) identify sociodemographic and clinical determinants related to pain assessment documentation.

METHODS

A descriptive-correlational retrospective design was used. Sociodemographic data (i.e., age, sex), clinical data (i.e., diagnosis, mechanical ventilation, level of consciousness, severity of illness, opioids, sedatives), and pain assessments were extracted from 345 medical charts of ICU admissions from five teaching hospitals between 2017 and 2019. Descriptive statistics and multiple linear regression were performed.

RESULTS

All sites reported using the 0-10 numeric rating scale, but the implementation of a behavioural pain scale was variable across sites. A median of three documented pain assessments were performed per 24 hr, which is below the minimal recommendation of eight to 12 pain assessments per 24 hr. Overall, pain assessment was present in 70% of charts, but only 20% of opioid doses were followed by documented pain reassessment within one hour post-administration. Higher level of consciousness (β = 0.37), using only breakthrough doses (β = 0.24), and lower opioid doses (β = -0.21) were significant determinants of pain assessment documentation (adjusted R2 = 0.25).

CONCLUSION

Pain assessment documentation is suboptimal in ICUs, especially for patients unable to self-report or those receiving higher opioid doses. Study findings highlight the need to implement tools to optimize pain assessment and documentation.

Current Perspectives on the Assessment and Management of Pain in the Intensive Care Unit

Critical illness is often painful, both from the underlying source of illness, as well as necessary procedures performed for the monitoring and care of these patients. Pain is often under-recognized in the critically ill, especially among those who cannot self-report, so accurate assessment and management continue to be major consideration in their care. Pain management in the intensive care unit (ICU) is an evolving practice, with a focus on accurate and frequent pain assessment, and targeted pharmacologic and non-pharmacologic treatment methods to maximize analgesia and minimize sedation. In this review, we will evaluate several validated methods of pain assessment in the ICU and present management options. We will review the evidence-based recommendations put forth by the largest critical care societies and several high-quality studies related to both the in-hospital approach to pain, as well as the short- and long-term consequences of untreated pain in ICU patients. We conclude with future directions.

A Pilot Study on Pain Assessment Using the Japanese Version of the Critical-Care Pain Observation Tool

BACKGROUND

Critically ill patients experience various types of pain that are difficult to assess because patients cannot communicate verbally due to artificial airways and sustained sedation. The Critical-Care Pain Observation Tool (CPOT) objectively evaluates patients' pain.

AIMS

This study aimed to re-assess the reliability and validity of the Japanese version (CPOT-J) and to reveal limitations of behaviors specific to mechanically ventilated patients.

DESIGN

Secondary analysis of observational pilot study and case report.

PARTICIPANTS

  METHODS: We obtained consent preoperatively from 40 cardiovascular surgery patients. CPOT-J scores were evaluated immediately before, immediately after, and 20 minutes after painful stimulation. Inter-rater reliability was determined by the researcher and 18 ICU nurses (minimum one-year ICU experience). Validity was examined by comparing CPOT-J with vital sign values and patients' self-reports of pain. Two cases revealed the tool's characteristics: one score was consistent with patient reports while the other was not.

RESULTS

We evaluated pain in 34 patients (26 men, 8 women; mean age = 66.8 years). Weighted kappa scores ranged from 0.48 to 0.94. The tool only correlated with changes in systolic blood pressure and pulse pressure. Case studies indicated that the tool effectively evaluated mid-sternum-wound pain, but not back pain at rest.

CONCLUSIONS

The CPOT-J can assess pain in mechanically ventilated patients, but being immobile results in a score of 0 for body movement (e.g., being immobile while feeling back pain) and is a limitation of the scoring.

Validation of the Critical-Care Pain Observation Tool-Neuro in brain-injured adults in the intensive care unit: a prospective cohort study

Background

Pain assessment in brain-injured patients in the intensive care unit (ICU) is challenging and existing scales may not be representative of behavioral reactions expressed by this specific group. This study aimed to validate the French-Canadian and English revised versions of the Critical-Care Pain Observation Tool (CPOT-Neuro) for brain-injured ICU patients.

Methods

A prospective cohort study was conducted in three Canadian and one American sites. Patients with a traumatic or a non-traumatic brain injury were assessed with the CPOT-Neuro by trained raters (i.e., research staff and ICU nurses) before, during, and after nociceptive procedures (i.e., turning and other) and non-nociceptive procedures (i.e., non-invasive blood pressure, soft touch). Patients who were conscious and delirium-free were asked to provide their self-report of pain intensity (0–10). A first data set was completed for all participants (n = 226), and a second data set (n = 87) was obtained when a change in the level of consciousness (LOC) was observed after study enrollment. Three LOC groups were included: (a) unconscious (Glasgow Coma Scale or GCS 4–8); (b) altered LOC (GCS 9–12); and (c) conscious (GCS 13–15).

Results

Higher CPOT-Neuro scores were found during nociceptive procedures compared to rest and non-nociceptive procedures in both data sets (p < 0.001). CPOT-Neuro scores were not different across LOC groups. Moderate correlations between CPOT-Neuro and self-reported pain intensity scores were found at rest and during nociceptive procedures (Spearman rho > 0.40 and > 0.60, respectively). CPOT-Neuro cut-off scores ≥ 2 and ≥ 3 were found to adequately classify mild to severe self-reported pain ≥ 1 and moderate to severe self-reported pain ≥ 5, respectively. Interrater reliability of raters’ CPOT-Neuro scores was supported with intraclass correlation coefficients > 0.69.

Conclusions

The CPOT-Neuro was found to be valid in this multi-site sample of brain-injured ICU patients at various LOC. Implementation studies are necessary to evaluate the tool’s performance in clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03561-1.

Analgesia and Sedation in Critically Ill Adult Patients Admitted to a COVID-19 Intensive Care Unit

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing the COVID-19 has spread globally, prompting world health organization (WHO) to declare COVID-19 a pandemic. As of January 2, 2021, about 82,579,768 laboratory-confirmed COVID-19 cases had been reported to the WHO with 1,818,849 deaths (https://covid19.who.int). The pandemic has severely impacted health care systems around the world, resulting in a vast number of surgical procedures being cancelled or postponed and an unprecedented burden on intensive care units (ICU). A critical component of the perioperative or ICU services delivery is the provision of analgesia and sedation. Volatile inhalational anesthetics combined with opioids are widely used in an operating room, whereas in ICUs, intravenous drugs are used for this purpose. Although target-controlled infusions are not routinely used in ICUs, in the context of the thematic series on total intravenous anesthesia during COVID-19 pandemic, this article will focus on key aspects of intravenous sedation and analgesia in the management of critically ill patients admitted to an ICU following positive swab test for SARS-CoV-2 RNA.

Analgesia and sedation in patients with ARDS

Acute Respiratory Distress Syndrome (ARDS) is one of the most demanding conditions in an Intensive Care Unit (ICU). Management of analgesia and sedation in ARDS is particularly challenging. An expert panel was convened to produce a "state-of-the-art" article to support clinicians in the optimal management of analgesia/sedation in mechanically ventilated adults with ARDS, including those with COVID-19. Current ICU analgesia/sedation guidelines promote analgesia first and minimization of sedation, wakefulness, delirium prevention and early rehabilitation to facilitate ventilator and ICU liberation. However, these strategies cannot always be applied to patients with ARDS who sometimes require deep sedation and/or paralysis. Patients with severe ARDS may be under-represented in analgesia/sedation studies and currently recommended strategies may not be feasible. With lightened sedation, distress-related symptoms (e.g., pain and discomfort, anxiety, dyspnea) and patient-ventilator asynchrony should be systematically assessed and managed through interprofessional collaboration, prioritizing analgesia and anxiolysis. Adaptation of ventilator settings (e.g., use of a pressure-set mode, spontaneous breathing, sensitive inspiratory trigger) should be systematically considered before additional medications are administered. Managing the mechanical ventilator is of paramount importance to avoid the unnecessary use of deep sedation and/or paralysis. Therefore, applying an "ABCDEF-R" bundle (R = Respiratory-drive-control) may be beneficial in ARDS patients. Further studies are needed, especially regarding the use and long-term effects of fast-offset drugs (e.g., remifentanil, volatile anesthetics) and the electrophysiological assessment of analgesia/sedation (e.g., electroencephalogram devices, heart-rate variability, and video pupillometry). This review is particularly relevant during the COVID-19 pandemic given drug shortages and limited ICU-bed capacity.

Incidence of Inadequate Pain Treatment among Ventilated, Critically Ill Surgical Patients in a Thai Population

BACKGROUND

Inadequate pain treatment during intensive care unit stays causes many unfavorable outcomes. Pain assessment in mechanically ventilated patients is challenging because most cannot self-report pain. The incidence of pain among Thai surgical intensive care unit (SICU) patients has never been reported.

AIMS

To determine the inadequate pain control incidence among ventilated, critically ill, surgical patients.

DESIGN

Prospective, observational study.

SETTING

SICU of a university-based hospital during November 2017-January 2019.

PARTICIPANTS

Patients aged > 18 years, admitted to the SICU for a foreseeable duration of mechanical ventilation > 24 hours were included.

METHODS

On post-admission Day 2, each was assessed for pain at rest (every 4 hours) and during bed-bathing using the Critical Care Pain Observation Tool (CPOT; Thai version) or the 0-10 numeric rating scale (NRS). CPOT scores > 2 or NRS scores > 3 signified inadequate pain control, while a RASS score ≤ -3 was defined as overtreatment.

RESULTS

118 were included. The inadequate-pain-management incidence was 34% (n = 40) at rest and 29% (n = 34) during bed-bathing. The severe-pain incidence (NRS > 6, or CPOT > 5) was 5.9% (n = 7). Our incidence of overtreatment was 1.7%. The demographic data and ICU complication-rates of patients with adequate and inadequate pain treatment were similar.

CONCLUSIONS

Pain assessment tools in critically ill patients should be developed and validated to the language of the tool users in order to determine the incidence of pain accurately. The inadequate-pain-treatment incidence in ventilated critically ill, Thai surgical patients was lower than previously reported from other countries.

The Diagnostic Accuracy of Critical Care Pain Observation Tool (CPOT) in ICU Patients: A Systematic Review and Meta-Analysis

BACKGROUND

The critical care pain observation tool (CPOT) has been widely used to assess pain in ICU patients, and its validity and reliability have been tested in various contexts.

OBJECTIVE

To determine the diagnostic accuracy of the CPOT in critically ill patients, a systematic review of diagnostic studies was performed.

METHODS

A database search (PubMed, Medline, CINAHL, ProQuest, EMBASE, Cochrane Library, CNKI, Wanfang, COVIP, CBM) was conducted, as was the manual identification of eligible papers from citations. Eligible studies were published between 2006 and February 2020. Quality appraisal of the studies was carried out with the QUADAS-2 checklist, and data extraction was performed in alignment with STARD 2015. Open Meta Analyst was used for the statistical analysis.

RESULTS

In total, 25 articles involving 1920 subjects with 3493 experimental results were included. Most of the studies were of fair quality. A high degree of heterogeneity (I² = 57.2%, P < 0.001) was discovered. The Youden index values were 1.56 and 1.55 when the CPOT threshold was set at two and three, respectively. The diagnostic performance of the CPOT was affected by the reference standard. The CPOT had a higher diagnostic odds ratio of 11.52 (95% CI: 7.42-17.87) during nociceptive procedures compared with 9.14 (95% CI: 5.38-15.53) at rest or during non-nociceptive procedures.

CONCLUSION

CPOT has moderate diagnostic parameters with a threshold of two or three, suggesting that it is a fair but not excellent tool. More research on the validity of the CPOT in specific subgroups is needed to broaden its applicability in critical care.

Translation into Spanish and Cultural Adaptation of the Critical-Care Pain Observation Tool

BACKGROUND

The Critical-Care Pain Observation Tool (CPOT) is recommended for evaluating pain behaviors in patients in the intensive care unit who are unable to report pain. The source of the only published Spanish version of the CPOT does not verify that it underwent a formal translation process.

OBJECTIVE

To describe the translation into Spanish and cultural adaptation of the original French version of the CPOT.

METHODS

Key persons in the translation process included one with a master's degree in translation, a critical care physician, nurse faculty members with vast experience in intensive care units, and the instrument's developer. This team followed the Principles of Good Practice for the Translation and Cultural Adaptation Process for Patient-Reported Outcomes Measures as a guide to translate and culturally adapt the CPOT.

RESULTS

The first Spanish-language version was back translated to French and was also compared with the English version. Revisions necessitated a second version, which was submitted to experts in critical care. Their modifications required a third version, which was back translated to French and discussed with the CPOT developer, after which a fourth version was created. Finally, a linguistic expert proofread the tool, and the translation leaders incorporated the recommendations, thereby obtaining a final Spanish version.

CONCLUSION

The Spanish version is ready to undergo validation with patients in the intensive care unit, which is the next step toward its use in assessing pain behaviors among patients in intensive care units where Spanish is spoken.

Exploration of the Nociception Level (NOL™) Index for Pain Assessment during Endotracheal Suctioning in Mechanically Ventilated Patients in the Intensive Care Unit: An Observational and Feasibility Study

BACKGROUND

Many patients in the intensive care unit (ICU) suffer from pain and are non-communicative. Therefore, alternative pain measures are necessary. Although behavioral pain measures are available, physiological measures are lacking. The Nociception Level index (NOL™) provides a value from combination of multiple physiological parameters to measure pain and its use in the ICU is new.

AIM

To explore the use of a multiple physiological parameter measure for pain assessment, the NOL™ index, in mechanically ventilated patients able to self-report pain in the ICU.

METHODS

A prospective cohort study was performed. Data were collected before, during, and 15 minutes after a non-nociceptive procedure (noninvasive blood pressure using cuff inflation) and a nociceptive procedure (endotracheal suctioning). NOL index, 0 to 10 pain intensity, and Critical-Care Pain Observation Tool (CPOT) scores were also obtained. Data were analyzed using Friedman and Mann-Whitney tests. Feasibility of study procedures was described.

RESULTS

Out of 28 patients who consented, 17 remained eligible and data were analyzed for 15. Technical issues prevented obtaining a NOL signal in 2 patients. NOL values were higher during endotracheal suctioning (median = 41.6) compared with before (median = 11.2) and after the procedure (median = 11.8) and compared with cuff inflation (median = 15.1; Friedman test, p < .001). NOL values were associated with pain intensity and CPOT scores (Mann-Whitney tests, p < .05).

CONCLUSIONS

The study procedures with the NOL were found feasible; NOL values could discriminate between nociceptive and non-nociceptive procedures, and values were associated with reference pain measures. Further NOL testing is required in other ICU patient groups and procedures.

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

Introduction

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

Aims and objectives

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

Materials and methods

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

Results

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

Conclusion

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

Clinical significance

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

How to cite this article

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