Pain in intensive care: assessments and patients’ experience

Mapping Intimacies ◽

10.24834/isbn.9789178771424 ◽

2021 ◽

Author(s):

◽

Mia Hylén

Keyword(s):

Intensive Care ◽

Facial Expression ◽

Pain Assessment ◽

Discriminant Validity ◽

Breathing Pattern ◽

Pain Scale ◽

General Linear ◽

Rater Reliability ◽

Behavioral Pain Scale ◽

Patients Experience

The aim of the thesis was to translate, psychometrically test, and further develop the Behavioral Pain Scale for pain assessment in intensive care and to analyze if any other variables (besides the behavioral domains) could affect the pain assessments. Furthermore, the aim was to explore the patients’ experience of pain within the intensive care. The Behavioral Pain Scale (BPS), consisting of the domains “facial expression,” “upper limbs,” and “compliance with ventilator/vocalization,” was translated andculturally adapted into Swedish and psychometrically tested in a sample of 20 patients(study I). The instrument was then further developed within one of the domains and tested for inter-rater reliability, discriminant validity, and criterion validity (study II). The method for analysis in both study I and II was a method specifically developed for paired, ordered, and categorical data. To describe and analyze the process of pain assessment, a General Linear Mixed Model was used to investigate what variables, besides the behaviors, could be associated with the observers’ own assessment of the patients’ pain (study III). Further, the patients’ experiences of pain when being cared for in intensive care were explored (study IV) through interviews with 16 participants post intensive care. Qualitative thematic analysis with an inductive approach was used for the analysis. The first psychometric tests of the BPS (study I) showed inter-rater reliability with agreement of 85%. For the discriminant validity, all domains, except “compliance with ventilator,” indicated discriminant validity. Therefore, in study II, a developed domain of “breathing pattern” was tested alongside the original version. The BPS showed discriminant validity for both the original and the developed version and an inter-rater reliability with agreement of 76-80%. Wheninspecting the respective domains there was a difference in discriminant validity between the original domain of “compliance with ventilation” and the developed domain of “breathing pattern,” showing higher values on the scale for the developed domain during turning. For criterion validity, the BPS showed a higher sensitivity than the observers, who on the contrary had a higher specificity.The General Linear Mix Model (study III) showed that heart rate could be associated with the observers’ assessments of pain. For the behavioral signs, the result indicated that breathing pattern was most associated with the observers’ pain assessment, whilst facial expression did not show any impact on the observers’ assessments. The patients’ experiences of pain (study IV) in intensive care were described as generating a need for control; they experienced a lack of control when pain was present and continuously struggled to regain control. The experience of pain was not only related to the physical sensation but also to psychological and social aspects, along with the balance in the care given, which was important to the participants. In conclusion, the translated and developed version of the Swedish BPS showed promising psychometric results in assessing pain in the adult intensive care patients. Still, other signs, besides behavioral, is possibly used when pain assessing and therefore information about and training in pain assessment are needed to enhance the assessments that are made. Also, the patients’ own experiences highlight the importance of individualizing and adapting pain assessment and treatment to the needs of each patient. Making them a part of the team could enhance their feeling of control, thereby supporting them in facing the experience of pain.

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Evaluation of Pain Assessment Tools in Patients Receiving Mechanical Ventilation

AACN Advanced Critical Care ◽

10.4037/aacnacc2016287 ◽

2016 ◽

Vol 27 (2) ◽

pp. 162-172 ◽

Cited By ~ 11

Author(s):

Zainab Q. Al Darwish ◽

Radwa Hamdi ◽

Summayah Fallatah

Keyword(s):

Mechanical Ventilation ◽

Intensive Care ◽

Pain Assessment ◽

Descriptive Study ◽

Pain Scale ◽

Assessment Tools ◽

Highly Sensitive ◽

Sensitive Tool ◽

P 16 ◽

Behavioral Pain Scale

Pain assessment poses a great challenge for clinicians in intensive care units. This descriptive study aimed to find the most reliable, sensitive, and valid tool for assessing pain. The researcher and a nurse simultaneously assessed 47 nonverbal patients receiving mechanical ventilation in the intensive care unit by using 3 tools: the Behavioral Pain Scale (BPS), the Critical-Care Pain Observation Tool (CPOT), and the adult Nonverbal Pain Scale (NVPS) before, during, and after turning and suctioning. All tools were found to be reliable and valid (Cronbach α = 0.95 for both the BPS and the CPOT, α = 0.86 for the NVPS), and all subscales of both the BPS and CPOT were highly sensitive for assessing pain (P < .001). The NVPS physiology (P = .21) and respiratory (P = .16) subscales were not sensitive for assessing pain. The BPS was the most reliable, valid, and sensitive tool, with the CPOT considered an appropriate alternative tool for assessing pain. The NVPS is not recommended because of its inconsistent psychometric properties.

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Reliability of three linguistically and culturally validated pain assessment tools for sedated ICU patients by ICU nurses in Finland

Scandinavian Journal of Pain ◽

10.1515/sjpain-2017-0139 ◽

2018 ◽

Vol 18 (2) ◽

pp. 165-173 ◽

Cited By ~ 1

Author(s):

Sanna-Mari Pudas-Tähkä ◽

Sanna Salanterä

Keyword(s):

Intensive Care ◽

Internal Consistency ◽

Pain Assessment ◽

Assessment Tools ◽

Endotracheal Suctioning ◽

Icu Patients ◽

Rater Reliability ◽

Intensive Care Patients ◽

Video Recordings ◽

Test Retest Reliability

Abstract Background and aims: Pain assessment in intensive care is challenging, especially when the patients are sedated. Sedated patients who cannot communicate verbally are at risk of suffering from pain that remains unnoticed without careful pain assessment. Some tools have been developed for use with sedated patients. The Behavioral Pain Scale (BPS), the Critical-Care Pain Observation Tool (CPOT) and the Nonverbal Adult Pain Assessment Scale (NVPS) have shown promising psychometric qualities. We translated and culturally adapted these three tools for the Finnish intensive care environment. The objective of this feasibility study was to test the reliability of the three pain assessment tools translated into Finnish for use with sedated intensive care patients. Methods: Six sedated intensive care patients were videorecorded while they underwent two procedures: an endotracheal suctioning was the nociceptive procedure, and the non-nociceptive treatment was creaming of the feet. Eight experts assessed the patients’ pain by observing video recordings. They assessed the pain using four instruments: the BPS, the CPOT and the NVPS, and the Numeric Rating Scale (NRS) served as a control instrument. Each expert assessed the patients’ pain at five measurement points: (1) right before the procedure, (2) during the endotracheal suctioning, (3) during rest (4) during the creaming of the feet, and (5) after 20 min of rest. Internal consistency and inter-rater reliability of the tools were evaluated. After 6 months, the video recordings were evaluated for testing the test-retest reliability. Results: Using the BPS, the CPOT, the NVPS and the NRS, 960 assessments were obtained. Internal consistency with Cronbach’s alpha coefficient varied greatly with all the instruments. The lowest values were seen at those measurement points where the pain scores were 0. The highest scores were achieved after the endotracheal suctioning at rest: for the BPS, the score was 0.86; for the CPOT, 0.96; and for the NVPS, 0.90. The inter-rater reliability using the Shrout-Fleiss intraclass correlation coefficient (ICC) tests showed the best results after the painful procedure and during the creaming. The scores were slightly lower for the BPS compared to the CPOT and the NVPS. The test-retest results using the Bland-Altman plots show that all instruments gave similar results. Conclusions: To our knowledge, this is the first time all three behavioral pain assessment tools have been evaluated in the same study in a language other than English or French. All three tools had good internal consistency, but it was better for the CPOT and the NVPS compared to the BPS. The inter-rater reliability was best for the NVPS. The test-retest reliability was strongest for the CPOT. The three tools proved to be reliable for further testing in clinical use. Implications: There is a need for feasible, valid and reliable pain assessment tools for pain assessment of sedated ICU patients in Finland. This was the first time the psychometric properties of these tools were tested in Finnish use. Based on the results, all three instruments could be tested further in clinical use for sedated ICU patients in Finland.

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Duration of Mechanical Ventilation in an Adult Intensive Care Unit After Introduction of Sedation and Pain Scales

American Journal of Critical Care ◽

10.4037/ajcc2008.17.4.349 ◽

2008 ◽

Vol 17 (4) ◽

pp. 349-356 ◽

Cited By ~ 21

Author(s):

Teresa Ann Williams ◽

Suzanne Martin ◽

Gavin Leslie ◽

Linda Thomas ◽

Timothy Leen ◽

...

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Intensive Care ◽

Pain Scale ◽

Apache Ii ◽

Apache Ii Score ◽

Adult Intensive Care Unit ◽

Before And After ◽

Behavioral Pain Scale ◽

Sedation And Analgesia

Background Sedation and analgesia scales promote a less-distressing experience in the intensive care unit and minimize complications for patients receiving mechanical ventilation. Objectives To evaluate outcomes before and after introduction of scales for sedation and analgesia in a general intensive care unit. Method A before-and-after design was used to evaluate introduction of the Richmond Agitation-Sedation Scale and the Behavioral Pain Scale for patients receiving mechanical ventilation. Data were collected for 6 months before and 6 months after training in and introduction of the scales. Results A total of 769 patients received mechanical ventilation for at least 6 hours (369 patients before and 400 patients after implementation). Age, scores on the Acute Physiology and Chronic Health Evaluation (APACHE) II, and diagnostic groups were similar in the 2 groups, but the after group had more men than did the before group. Duration of mechanical ventilation did not change significantly after the scales were introduced (median, 24 vs 28 hours). For patients who received mechanical ventilation for 96 hours or longer (24%), mechanical ventilation lasted longer after implementation of the scales (P =.03). Length of stay in the intensive care unit was similar in the 2 groups (P = .18), but patients received sedatives for longer after implementation (P=.01). By logistic regression analysis, APACHE II score (P <.001) and diagnostic group (P <.001) were independent predictors of mechanical ventilation lasting 96 hours or longer. Conclusion Sedation and analgesia scales did not reduce duration of ventilation in an Australian intensive care unit.

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Validity and Reliability of Neonatal Infant Pain Scale (NIPS) in Neonatal Intensive Care Unit in Vietnam

MedPharmRes ◽

10.32895/ump.mpr.3.2.1 ◽

2019 ◽

Vol 3 (2) ◽

pp. 1-7

Author(s):

Hai Thanh Ngo ◽

Kathleen Fitzsimmons ◽

Kien Gia To

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Neonatal Intensive Care Unit ◽

Registered Nurses ◽

Neonatal Intensive Care ◽

Pain Scale ◽

Rater Reliability ◽

Neonatal Pain ◽

Clinical Procedures ◽

Infant Pain

Background: The study aimed to culturally adapt and validate Neonatal Infant Pain Scale (NIPS) for use in Vietnamese settings. Methods: The original NIPS was translated into Vietnamese using a standard protocol. Registered nurses of Neonatal Intensive Care Unit (NICU), Tien Giang General Hospital, Vietnam used the Vietnamese NIPS for assessing neonatal pain and then provided feedback on acceptability of the scale. Five registered nurses of NICU were randomly selected and used NIPS for assessing neonatal pain while watching thirty videos at two times, two weeks apart from each other. Pulse rates per minute and oxygen saturation (SpO2) were also recorded for validity evaluation. Intraclass correlation coefficients (ICC) with two-way random effects were applied to assess intra-rater and inter-rater reliability. Multilevel linear regression was applied to assess the association between NIPS score with pulse rates and SpO2 adjusting for raters, three periods and two assessments. Results: The Vietnamese NIPS was accepted and valued by nurses at the NICU. ICCs between the first and second assessments were from 0.53 to 1.00 for five raters before, during and after clinical procedures showing moderate to excellent intra-rater reliability. ICCs among five raters were moderate to good before and after, but poor (ICC<0.4) during clinical procedures. NIPS score was not associated with SpO2, but with pulse rates per minute. Conclusions: The preliminary results showed that the Vietnamese version of NIPS is reliable and should be used. However, it is recommended that further research should be conducted to confirm its reliability and validity.

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Pain assessment using a Polish version of the Behavioral Pain Assessment Scale in sedated and mechanically ventilated patients

Ból ◽

10.5604/01.3001.0009.5271 ◽

2016 ◽

Vol 17 (3) ◽

pp. 27-35

Author(s):

Aleksandra Gutysz-Wojnicka ◽

Dorota Ozga ◽

Ewa Mayzner-Zawadzka

Keyword(s):

Critical Care ◽

Clinical Practice ◽

Pain Assessment ◽

Pain Scale ◽

Adult Patients ◽

Mechanically Ventilated ◽

Mechanically Ventilated Patients ◽

Polish Version ◽

Behavioral Pain Scale ◽

Ventilated Patients

“Gold standard” in the assessment of pain is patient’s subjective assessment by means of standardized numerical, analog-visual or verbal scales. Unconscious, sedated, mechanically ventilated patients are able to subjectively assess pain in this way. Clinical practice guidelines for the management of pain, agitation and delirium in adult patients in the intensive care unit developed by a working group of the American College of Critical Care Medicine (ACCCM) state that adult patients treated in the ICU routinely experience pain at rest and during routine care. The guidelines recommend routine monitoring of pain in all adult patients in the ICU using the Behavioral Pain Scale (BPS) or Critical-Care Pain Observation Tool (CPOT). Cultural adaptation was conducted in Poland, psychometric properties of Polish version of Behavioral Pain Scale (BPS) were evaluated. Internal consistency determined by Cronbach’s alpha amounted to 0.6883. The correlation coefficients between items of the scale and the sum score in the pain phase were in the range 0.27-0.28. The analysis of principal components confirmed that all the components of the scale respectively, the face, the upper limbs, synchronization with the respirator are one factor and explain 63.9% of the rating variation, while discriminatory accuracy of the scale was unconfirmed. The value of pain assessment using the Polish version of BPS increased significantly, also in the case of routine painless procedures, most likely due to other factors. That prevented the unambiguous interpretation of the results of the pain assessment and enforced additional data from other sources in the assessment of pain. The reason for the lack of discriminant accuracy can be vague operationalization of the scale indicators especially in the category: Face and Synchronization with the ventilator and the lack of adequate training for personnel in scale application. The aim of the study was to prepare the Polish version of Behavioral Pain Scale (BPS) with more favorable psychometric properties. Based on the analysis of the literature individual scale indicators included in the categories of Face and Synchronization with the ventilator and the scheme of their scoring were re-defined. The result of the study is modified Polish version of BPS. Conclusions: The validation process of the research tool is not a one-time process. The implementation of the scale into clinical practice is required as well as further monitoring of its reliability and validity indicators. It is necessary to implement the system of personnel training in BPS application

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Comparison between Dexmedetomidine and Midazolam for Sedation in Patients with Intubation after Oral and Maxillofacial Surgery

BioMed Research International ◽

10.1155/2020/7082597 ◽

2020 ◽

Vol 2020 ◽

pp. 1-6

Author(s):

Li Wang ◽

Tiejun Zhang ◽

Lili Huang ◽

Wei Peng

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Maxillofacial Surgery ◽

Pain Scale ◽

Oral And Maxillofacial Surgery ◽

Midazolam Group ◽

Significant Difference ◽

Behavioral Pain Scale ◽

Random Number Table ◽

The Difference

The aim of the investigation is to clarify the beneficial sedative effects for patients with postoperative intubation in the intensive care unit (ICU) after oral and maxillofacial surgery. Forty patients with postoperative intubation were divided into two groups in method of random number table: midazolam group and dexmedetomidine group. The Ramsay score, the behavioral pain scale (BPS) score, SpO2, HR, MAP, and RR were recorded before sedation (T0), 30 minutes (T1), 1 hour (T2), 2 hours (T3), 6 hours (T4), and 12 hours (T5) after dexmedetomidine or midazolam initiation in intensive care unit, and 10 minutes after extubation (T6). The rate of incidences of side effects was calculated. Sedation with midazolam was as good as standard sedation with dexmedetomidine in maintaining target sedation level. The BPS score in the midazolam group was higher than that in the dexmedetomidine group. The time of tracheal catheter extraction in the dexmedetomidine group was shorter than that in the midazolam group (p≤0.001). The incidence of bradycardia in the dexmedetomidine group was higher than that in the midazolam group (p=0.028). There was no statistically significant difference in the incidence of hypotension between the two groups (p=0.732). The incidence of respiratory depression of group midazolam was higher than that of group dexmedetomidine (p=0.018). The incidence of delirium in the dexmedetomidine group was significantly lower than that in the midazolam group, and the difference was statistically significant (p=0.003). Dexmedetomidine and midazolam can meet the needs for sedation in ICU patients. And dexmedetomidine can improve patients’ ability to communicate pain compared with midazolam.

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Comparison of Self-Reported and Behavioral Pain Assessment Tools in Critically Ill Patients

Journal of Intensive Care Medicine ◽

10.1177/0885066618757450 ◽

2018 ◽

Vol 35 (5) ◽

pp. 453-460 ◽

Cited By ~ 6

Author(s):

Rima H. Bouajram ◽

Christian M. Sebat ◽

Dawn Love ◽

Erin L. Louie ◽

Machelle D. Wilson ◽

...

Keyword(s):

Critically Ill ◽

Pain Assessment ◽

Critically Ill Patients ◽

Strong Correlation ◽

Rating Scale ◽

Assessment Method ◽

Pain Scale ◽

Assessment Tools ◽

Pain Scales ◽

Behavioral Pain Scale

Background:Self-reported and behavioral pain assessment scales are often used interchangeably in critically ill patients due to fluctuations in mental status. The correlation between scales is not well elucidated. The purpose of this study was to describe the correlation between self-reported and behavioral pain scores in critically ill patients.Methods:Pain was assessed using behavioral and self-reported pain assessment tools. Behavioral pain tools included Critical Care Pain Observation Tool (CPOT) and Behavioral Pain Scale (BPS). Self-reported pain tools included Numeric Rating Scale (NRS) and Wong-Baker Faces Pain Scales. Delirium was assessed using the confusion assessment method for the intensive care unit. Patient preference regarding pain assessment method was queried. Correlation between scores was evaluated.Results:A total of 115 patients were included: 67 patients were nondelirious and 48 patients were delirious. The overall correlation between self-reported (NRS) and behavioral (CPOT) pain scales was poor (0.30, P = .018). In patients without delirium, a strong correlation was found between the 2 behavioral pain scales (0.94, P < .0001) and 2 self-reported pain scales (0.77, P < .0001). Self-reported pain scale (NRS) and behavioral pain scale (CPOT) were poorly correlated with each other (0.28, P = .021). In patients with delirium, there was a strong correlation between behavioral pain scales (0.86, P < .0001) and a moderate correlation between self-reported pain scales (0.69, P < .0001). There was no apparent correlation between self-reported (NRS) and behavioral pain scales (CPOT) in patients with delirium (0.23, P = .12). Most participants preferred self-reported pain assessment.Conclusion:Self-reported pain scales and behavioral pain scales cannot be used interchangeably. Current validated behavioral pain scales may not accurately reflect self-reported pain in critically ill patients.

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