The effectiveness of systematic pain assessment on critically ill patient outcomes: A randomised controlled trial

BackgroundEvidence suggests that critically ill patients’ pain may still be underestimated. Systematic approaches to pain assessment are of paramount importance for improving patients’ outcomes.ObjectivesTo investigate the effectiveness of a systematic approach to pain assessment on the incidence and intensity of pain and related clinical outcomes in critically ill patients.MethodsRandomized controlled study with consecutive critically ill patients allocated to either a standard care only or a systematic pain assessment group. The Behavioral Pain Scale (BPS) and the Critical Pain Observation Tool (C-POT) were completed twice daily for all participants. In the intervention group, clinicians were notified of pain scores. Linear Mixed Models (LMM) for the longitudinal effect of the intervention were employed.ResultsA total of 117 patients were included (control: n=61; intervention: n2=56). The incidence of pain (C-POT >2) in the intervention group was significantly lower compared to the control group (p < .001). The intervention had a statistically significant effect on pain intensity (BPS, p = 0.01). The average total morphine equivalent dose in the intervention group was higher than in the control group (p = 0.045), as well as the average total dose of propofol (p = 0.027). There were no statistically significant differences in ICU mortality (23.4% vs 19.3%, p=0.38, odds ratio 0.82 [0.337-1.997]) and length of ICU stay (13.5, SD 11.1 vs 13.9, SD 9.5 days, p= 0.47).ConclusionSystematic pain assessment may be associated with a decrease in the intensity and incidence of pain and influence the pharmacological management of pain and sedation of critically ill patients.     

Validation and properties of the verbal numeric scale in children with acute pain

Although the verbal numeric scale (VNS) is used frequently at patients’ bedsides, it has never been formally validated in children with acute pain. In order to validate this scale, a prospective cohort study was performed in children between 8 and 17 years presenting to a pediatric emergency department (ED) with acute pain. Pain was graded using the VNS, the visual analogue scale (VAS), and the verbal rating scale (VRS). A second assessment was done before discharge. We determined a priori that in order to be valid, the VNS would need to: correlate with the VAS (concurrent validity); decrease after intervention to reduce pain (construct validity); and be associated with the VRS categories (content validity). The VNS interchangeability with the VAS, its minimal clinically significant difference, and test–retest reliability were also determined. A total of 202 patients (mean age: 12.2 ± 2.6 years) were enrolled. The VNS correlated with the VAS: r_ic = 0.93, p < 0.001. There were differences in the VNS before versus after interventions (p < 0.001), and between VRS categories (mild versus moderate, p < 0.001; moderate versus severe, p < 0.001). The 95% limits of agreement (interchangeability) between VNS/VAS were outside the a priori set limit of ±2.0: −1.8, 2.5. The VNS minimal clinically significant difference was 1. The VNS had good test–retest reliability with 95% limits of agreement of −0.9 and 1.2. In conclusion, the VNS provides a valid and reliable scale to evaluate acute pain in children aged 8–17 years but is not interchangeable with the VAS.     

Prevalence and predictors of difficulty accessing the mouths of intubated critically ill adults to deliver oral care: An observational study

BackgroundOral care of intubated patients is essential to the prevention of infection and patient discomfort. However, barriers to oral access and delivery of oral care have received little attention.ObjectiveTo determine prevalence and predictors of oral access difficulty.DesignA prospective, observational, multi-center study.SettingsFour intensive care units in Toronto, Canada.ParticipantsAdult patients orally intubated for ≥48 h.MethodsWe screened consecutive admissions once a week to identify eligible participants. We observed each patient and asked the patient’s nurse about presence or absence of difficulty accessing the mouth to deliver oral care across three categories: (1) visualizing inside the mouth; (2) obtaining patient cooperation, or (3) inserting instruments for delivery of oral care. We asked nurses to identify presence of patient behaviors contributing to oral access difficulty and perceived level of difficulty on a Likert response scale. We examined patient and treatment characteristics associated with extreme difficulty (i.e., difficulty in all 3 categories) using a generalized estimating equation regression model.ResultsA total of 428 patients were observed, 58% admitted with a medical diagnosis. More than half (57%) had ≥2 oral devices up to maximum of 4. Oral care difficulty was identified in 83% of patients and rated as moderate to high for 217 (51%). Difficulty concerned visibility (74%), patient cooperation (55%), and space to insert instruments (53%). Patient behaviors contributing difficulty included coughing/gagging (60%), mouth closing (49%), biting (45%) and localizing (27%) during care. Variables associated with extreme difficulty included neurological (OR 1.92, 95% CI 1.42–2.60) or trauma admission (OR 1.83, 95% CI 1.16–2.89), lack of pain assessment or treatment in the 4 h prior to oral care (OR 1.43, 95% CI 1.14–1.80), more oral devices (OR 1.40, 95% CI 1.05–1.87), and duration of intubation (OR 1.05, 95% CI 1.01–1.10). Absence of documented agitation in the 4 h prior to oral care was associated with less difficulty (OR 0.68, 95% CI 0.54–0.86).ConclusionsOral care is complex and difficulties are experienced in a vast majority of intubated patients. Some difficulties are amenable to correction such as pain management.     

中文版晚期老年痴呆症疼痛评估量表在老年精神科护理应用中的信效度研究

目的测试中文版晚期老年痴呆症疼痛评估量表对老年精神障碍患者疼痛评估的信度和效度。方法使用中文版晚期老年痴呆症疼痛评估量表对79例老年精神科住院患者进行疼痛评估,分析该量表的信度和效度。结果中文版晚期老年痴呆症疼痛评估量表的Cronbach’sα系数为0.748,分半信度为0.610,量表得分与语言描述量表、面部表情疼痛量表评分相关性系数为0.366、0.569,因子分析的贡献率是53.11%,显示具有较好的信度和效度。结论晚期老年痴呆症疼痛评估量表能用于评估老年精神障碍患者的疼痛程度。     

修订版归因问卷-27中文版在医学生中应用的信效度分析

目的 修订、引进归因问卷-27,并评价其在医学生群体中应用的信度和效度.方法 采用标准翻译/回译的方法将归因问卷-27英文版翻译成中文版,整群抽取在广州市某医科大学5个班的学生共230人,用归因问卷-27中文版进行测评,间隔1周后,选取30人进行重测,对量表的因子结构、信度和效度进行检验.结果 中文版归因问卷-27总Cronbach α系数是0.82,各个因子的Cronbachα系数是0.55 ～0.84,量表总的重测信度为0.77,各因子的重测信度为0.61～0.81.由6个因素构成责任归因模型的各项拟合指数分别为x2/df=3,GFI=0.925,NFI=0.880,CFI=0.856,IFI=0.761,RMSEA=0.094,由3个因素组成的危险归因模型的各项拟合指数为x2/df=1.773,GFI=0.959,NFI=0.941,CFI=0.973,IFI=0.973,RMSEA=0.058.路径分析结果支持原有的理论假设.结论 修订版归因问卷-27中文版在医学生中具有较好的信效度,可用于测评医学生对精神分裂症患者的态度.     

Reproducibility of physiological track-and-trigger warning systems for identifying at-risk patients on the ward

OBJECTIVE: Physiological track-and-trigger warning systems are used to identify patients on acute wards at risk of deterioration, as early as possible. The objective of this study was to assess the inter-rater and intra-rater reliability of the physiological measurements, aggregate scores and triggering events of three such systems. DESIGN: Prospective cohort study. SETTING: General medical and surgical wards in one non-university acute hospital. PATIENTS AND PARTICIPANTS: Unselected ward patients: 114 patients in the inter-rater study and 45 patients in the intra-rater study were examined by four raters. MEASUREMENTS AND RESULTS: Physiological observations obtained at the bedside were evaluated using three systems: the medical emergency team call-out criteria (MET); the modified early warning score (MEWS); and the assessment score of sick-patient identification and step-up in treatment (ASSIST). Inter-rater and intra-rater reliability were assessed by intra-class correlation coefficients, kappa statistics and percentage agreement. There was fair to moderate agreement on most physiological parameters, and fair agreement on the scores, but better levels of agreement on triggers. Reliability was partially a function of simplicity: MET achieved a higher percentage of agreement than ASSIST, and ASSIST higher than MEWS. Intra-rater reliability was better then inter-rater reliability. Using corrected calculations improved the level of inter-rater agreement but not intra-rater agreement. CONCLUSION: There was significant variation in the reproducibility of different track-and-trigger warning systems. The systems examined showed better levels of agreement on triggers than on aggregate scores. Simpler systems had better reliability. Inter-rater agreement might improve by using electronic calculations of scores.     

Assessment and management of pain in the terminally ill

Regular assessment for the presence of pain and response to pain management strategies should be high priority in terminally ill patients. Pain management interventions are most effective when treatments are individualized based on the various physical and nonphysical components of pain at the end of life, and patients and family are educated and involved in the decision making. Opioids remain the cornerstone of pain management, and adjuvant analgesics and nonpharmacologic options are usually considered after relative stabilization of pain. This article describes the various issues that are pertinent to the assessment and treatment of pain in terminally ill patients.     

Selenium supplementation in critically ill patients: A systematic review and meta-analysis

Purpose

The oxidative stress is recognized as a constant feature in critical illness. Nevertheless, the use of antioxidant therapy remains controversial. We tried to demonstrate that intravenous selenium supplementation could promote antioxidant status and help protect against infection and organ failure, improving outcome in critically ill patients.

Materials and Methods

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the exogenous supplementation of selenium versus standard therapy without any adjuvant in critically ill adults.

Results

Nine RCTs met inclusion criteria. Selenium supplementation was associated with a reduction in 28-day mortality of borderline statistical significance (risk ratio = 0.84, 95% confidence interval 0.71–0.99, P = .04). The analysis of pre-defined subgroups detected no significant effects regarding the supplementation with doses of selenium ≤ 500 μg/d, administration of a load dose with a bolus and duration of treatment. Only 2 studies analyzed 6-month mortality and could not show a difference. No effects could be demonstrated on hospital length of stay, pulmonary infections, or renal failure.

Conclusions

The use of high-dose selenium might be associated with a beneficial effect on 28-day mortality in critically ill patients. Nevertheless, the use of selenium as adjuvant therapy needs further evaluations.     

氟哌啶醇预防危重症患者谵妄发生的Meta分析

目的系统评价氟哌啶醇预防危重患者发生谵妄的疗效和安全性。 方法计算机检索Medline、EMbase、The Cochrane Library、维普数据库、中国知网、中国生物医学文献数据库数据库从建库至2018年9月的关于氟哌啶醇预防危重症患者谵妄疗效的随机对照试验（RCT）。由2位研究者按照纳入与排除标准独立筛选文献、提取资料和评价质量后,采用RevMan 5.2软件进行Meta分析。 结果共纳入4个RCT,2 455例患者。Meta分析结果显示,试验组与对照组危重症患者间28 d谵妄发病率[相对危险度（RR） = 0.96,95%置信区间（CI）（0.65,1.43）,Z = 0.19,P = 0.85]、28 d无谵妄及无昏迷时间[均数差（MD） = 0.05,95%CI（-0.06,0.15）,Z = 0.88,P = 0.38]、28 d存活率[RR = 1.00,95%CI（0.97,1.04）,Z = 0.23,P = 0.82]、ICU住院时间[MD = -0.18,95%CI（-2.00,1.64）,Z = 0.20,P = 0.84]的比较,差异均无统计学意义。且在严重不良反应方面,两组患者间QTc间期延长[RR = 1.18,95%CI（0.83,1.67）,Z = 0.92,P = 0.36]、锥体外系症状[RR = 1.07,95%CI（0.69,1.67）,Z = 0.31,P = 0.76]、过度镇静[RR = 1.90,95%CI（0.77,4.66）,Z = 1.40,P = 0.16]发生的比较,差异也均无统计学意义。 结论氟哌啶醇不能预防危重症患者谵妄的发生,且对预后也没有明显改善作用。     

危重病患者并发弥散性血管内凝血的诊治

目的探讨危重病患者并发弥散性血管内凝血(DIC)的最早临床线索及有效治疗措施。方法对本科2002年1月至2004年12月危重病患者并发DIC的最早临床线索及治疗措施进行回顾性分析和总结。结果本组26例,治愈11例,死亡10例,自动出院5例。结论危重病患者DIC发生率高,死亡率高,ICU医生对DIC一定要保持高度警惕,及早发现线索,及时抓住线索,及时诊断,及时综合治疗,才能提高对危重病患者的抢救成功率。     

Pupillary dilation reflex and behavioural pain scale: Study of diagnostic test

BackgroundThe objective of this study was to assess the value of the pupillary dilation reflex as an assessment pain tool in critically ill patients. It is important to continue working for the well-being and security of critically ill patients.MethodsWe studied the diagnostic accuracy of the pupillary dilation reflex against the Behavioral Pain Scale. Inclusion criteria were: age greater than 18, receiving mechanical ventilation, with a basal score of the Behavioural Pain Scale of three and a Richmond Agitation and Sedation score between −1 and −4. We studied the responses to a non-painful stimulus, four calibrated stimuli, after a tracheal aspiration and with and without pain. The receiver operating curve was plotted and we calculated the area under the curve. We identified the cut-off points showing the highest sensitivity and specificity and studied diagnostic performance based on negative predictive value, positive predictive value, and accuracy. These were reported with their 95% confidence intervals.Results183 measurements were performed. An AUC of 0.88(95% CI 0.83–0.94) was obtained. The pupillary dilation reflex of 11.5% had a sensitivity of 89.8%(95% CI 78.2–95.6) and a specificity of 78.4%(95% CI 70.6–84.5) with an accuracy of 81.4(75.2–86.4). The pupillary dilation reflex detected nociceptive pain response in 15.8% of the measurements that did not show pain according to the Behavioural Pain Scale.ConclusionsPupillometry may be a valid alternative for identifying pain in critically ill patients.     

Validation of the multiple organ dysfunction (MOD) score in critically ill medical and surgical patients

Objective To validate the Multiple Organ Dysfunction (MOD) score externally.Design Prospective observational cohort study.Setting Mixed medical/surgical ICU in a tertiary referral university hospital.Patients and participants Thousand eight hundred and nine patients admitted to ICU for more than 24 h over a 3-year period.Interventions None.Measurements and results The MOD score was calculated daily for all patients. The criterion validity of the individual organ scores, the maximal MOD score and the change in MOD score were assessed by examining the relationship between increasing scores and ICU mortality. Increased maximal MOD scores and each of the six individual organ scores, and change in MOD scores were associated with increased mortality.Conclusions Maximal and individual organ scores have criterion validity when tested in a different ICU from that in which the scores were derived, indicating that the scoring systems are reproducible. The association of change in MOD score with mortality indicates that the score is responsive. These data, combined with previous data establishing concept and content validity, indicate that the MOD score is a valid measure of multi-organ dysfunction.     

Reliability assessment and approaches to determining agreement between measurements: Classic methods paper

This classic methods paper (Bland and Altman, 2010) considers the assessment of agreement between measures, an often overlooked aspect of assessing measurements taken for use in research and practice and (re) introduces the ubiquitous ‘Bland Altman’ procedures for assessing agreement. The importance of these procedures is high and they address issues that are not always considered in research which uses measurement scales or describes the characteristics of scales developed for use in clinical practice. Many widely used approaches for reliability assessment can fail to consider the agreement between measures at all and can give an entirely misleading impression of an instrument's suitability for use in research or practice.     

A pain assessment scale for population-based studies: development and validation of the pain module of the Standard Evaluation Questionnaire

The objectives of this study were to develop and validate a tool for assessing pain in population-based observational studies and to develop three subscales for back/neck, upper extremity and lower extremity pain. Based on a literature review, items were extracted from validated questionnaires and reviewed by an expert panel. The initial questionnaire consisted of a pain manikin and 34 items relating to (i) intensity of pain in different body regions (7 items), (ii) pain during activities of daily living (18 items) and (iii) various pain modalities (9 items). Psychometric validation of the initial questionnaire was performed in a random sample of the German-speaking Swiss population. Analyses included tests for reliability, correlation analysis, principal components factor analysis, tests for internal consistency and validity. Overall, 16,634 of 23,763 eligible individuals participated (70%). Test–retest reliability coefficients ranged from 0.32 to 0.97, but only three coefficients were below 0.60. Subscales were constructed combining four items for each of the subscales. Item-total coefficients ranged from 0.76 to 0.86 and Cronbach’s were 0.75 or higher for all subscales. Correlation coefficients between subscales and three validated instruments (WOMAC, SPADI and Oswestry) ranged from 0.62 to 0.79. The final Pain Standard Evaluation Questionnaire (SEQ Pain) included 28 items and the pain manikin and accounted for the multidimensionality of pain by assessing pain location and intensity, pain during activity, triggers and time of onset of pain and frequency of pain medication. It was found to be reliable and valid for the assessment of pain in population-based observational studies.