Pain assessment in the critically ill ventilated adult: validation of the Critical-Care Pain Observation Tool and physiologic indicators

OBJECTIVES: Use of a valid behavioral measure for pain is highly recommended for critically ill, uncommunicative adults. The aim of this study was to validate the English version of the Critical-Care Pain Observation Tool (CPOT) and physiologic indicators [mean arterial pressure, heart rate, respiratory rate, and transcutaneous oxygen saturation (SpO(2))] in critically ill ventilated adults. METHODS: A total of 30 conscious and 25 unconscious patients in the intensive care unit participated in the study. Patients were assessed by staff nurses and research team members before, during, and 20 minutes after the 2 following procedures: (1) nociceptive procedure: turning, and (2) non-nociceptive procedure: taking noninvasive blood pressure (NIBP). Conscious ventilated patients provided self-report level of pain. RESULTS: Interrater reliability of the CPOT was supported with high intraclass correlation coefficients (0.80 to 0.93). Discriminant validity was supported with increases of the CPOT and physiologic indicators, and a decrease in SpO(2) during turning, but remaining stable during NIBP. Conscious patients had higher CPOT scores during turning compared with unconscious patients. For criterion validity, the CPOT scores were correlated to the patients' self-reports of pain, whereas physiologic measures were not. Using a CPOT cutoff score of >3 yielded a sensitivity of 66.7% and a specificity of 83.3%. DISCUSSION: The CPOT is a reliable and valid tool to assess pain in critically ill adults. Behavioral indicators represent more valid information in pain assessment than physiologic indicators. Further research is needed to explore how specific critically ill populations (eg, head injury) react to a painful procedure.     

Item selection and content validity of the Critical-Care Pain Observation Tool for non-verbal adults

Title. Item selection and content validity of the Critical‐Care Pain Observation Tool for non‐verbal adults. Aim. This paper is a report of the item selection process and evaluation of the content validity of the Critical‐Care Pain Observation Tool for non‐verbal critically ill adults. Background. Critically ill patients experience moderate to severe pain in the intensive care unit. While critical care clinicians strive to obtain the patient’s self‐report of pain, many factors compromise the patient’s ability to communicate verbally. Pain assessment methods often need to match the communication capabilities of the patient. In non‐verbal patients, observable behavioural and physiological indicators become important indices for pain assessment. Method. A mixed method study design was used for the development of the Critical‐Care Pain Observation Tool in 2002–2003. More specifically, a four‐step process was undertaken: (1) literature review, (2) review of 52 patients’ medical files, (3) focus groups with 48 critical care nurses, and interviews with 12 physicians, and (4) evaluation of content validity with 17 clinicians using a self‐administered questionnaire. Results. Item selection was derived from different sources of information which were convergent and complementary in their content. An initial version of the Critical‐Care Pain Observation Tool was developed including both behavioural and physiological indicators. Because physiological indicators received more criticism than support, only the four behaviours with content validity indices >0·80 were included in the Critical‐Care Pain Observation Tool: facial expression, body movements, muscle tension and compliance with the ventilator. Conclusion. Item selection and expert opinions are relevant aspects of tool development. While further evaluation is planned, the Critical‐Care Pain Observation Tool appears as a useful instrument to assess pain in critically ill patients.     

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

BackgroundCritically 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.AimsThis 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.DesignSecondary analysis of observational pilot study and case report.ParticipantsMethodsWe 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.ResultsWe 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.ConclusionsThe 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.     

Assessing Pain Behaviors in Healthy Subjects Using the Critical-Care Pain Observation Tool (CPOT): A Pilot Study

The Critical-Care Pain Observation Tool (CPOT) is a behavioral scale recommended by experts for pain assessment in critically ill patients unable to verbally communicate. The main goal of this study was to determine the relationship between self-reports of pain intensity and the CPOT score, and establish the sensibility and the specificity of the CPOT to different levels of pain intensity in healthy subjects. A total of 18 healthy subjects participated in the study (mean age = 37.8 years). All subjects underwent a 2 minutes noxious cold pressor test (CPT) at 7°C. Verbal pain ratings were obtained with a visual analog scale (0-100) while pain behaviors were videotaped. Afterwards, 2 independent evaluators quantified pain behaviors using the CPOT. Interrater reliability was supported with an ICC of 0.963 (95%CI [0.904-0.986]). A moderate positive correlation between the CPOT scores and self-reports of pain intensity during the CPT was found (r = 0.52, p = 0.028). Such result indicates that subjects reporting high level of pain showed a higher number or more intense pain behaviors. A cut-off score >2.5/8 on the CPOT led to a sensibility of 64% and a specificity of 86%. Results from this pilot study support that an increase of CPOT score is correlated with moderate to high levels of pain intensity and further support the clinical use of the CPOT.     

P-CPOT: An Adaptation of the Critical-Care Pain Observation Tool for Pediatric Intensive Care Unit Patients

BackgroundThe Pediatric Critical-Care Observation Tool (P-CPOT) is an adaption of the Critical-Care Pain Observation Tool (CPOT) originally designed to assess pain in nonverbal critically-ill adults.AimThe study validated the P-CPOT in assessing nociceptive procedure pain in pediatric intensive care unit (PICU) children who are unable to verbalize pain.MethodsContent validity was tested using a two-round expert panel review with 8 experts. With a sample of 78 PICU patients, prospective repeated measures were designed to detect the change over time at pre- (T1), during (T2), and post- (T3) for routinely scheduled nociceptive procedures. Each measure was independently completed by two raters using two scales, the P-CPOT and the FLACC (Faces, Legs, Activity, Cry and Consolability).ResultsAll categories had Item-level content validity indices of 0.88 to 1.00. A one-factor structure containing 5 items was established and accounted for 85% variance in P-CPOT scores. Inter-rater reliability was substantial with correlation coefficient of 0.996 and Kappa value of 0.90. A threshold value of 4 resulted in excellent balance between sensitivity (98.6%) and specificity (97.6%). Both tools detected the score changes over time (p = .025). P-CPOT had a larger effect size (Cohen’s d = 4.1) as well as a higher score than FLACC at T2 (p = .039). Linear regression revealed that patients being ventilated tended to have a P-CPOT score of 1.1 higher than the FLACC score while controlling for heart rates (p < .001), meaning that P-CPOT is more sensitive than FLACC for detecting pain increase during nociceptive procedures in ventilated patients.ConclusionThe P-CPOT is a valid scale for assessing pain in PICU patients with very good psychometric performance. It is especially adept in detecting pain in ventilated patients.     

Transport of critically ill adults

Interhospital transport can be hazardous because of rapid changes in a patient's physiologic status and the use of monitoring systems. A retrospective study evaluated the first 204 critically ill adult patients transported from community hospitals to Stanford Medical Center by a special transport team. To relate the risk of transport to severity of illness, a retrospective scoring system was devised. Sixty-one percent (n = 125) of the patients were at high risk for transport. The patients were stabilized at the referring hospital, and invasive monitoring was used as mandated by the patient's condition. The average transport distance was 133 km, and the average duration of transport was 4.38 h. One hundred and five patients (51.5%) were transported by air, and the remaining patients were transported by surface ambulance. All patients survived the transport, and 71.6% were eventually discharged from the hospital. Hospital mortality correlated with the risk-scoring system (p less than .01) and increased five-fold as severity of illness increased. This study demonstrates that, with appropriate hemodynamic stabilization and monitoring, severely ill patients can be transported safely.     

Physical antipyresis in critically ill adults

Nurses use a variety of methods to cool critically ill patients, even though there are no guidelines for the treatment of temperature elevation in this population. In order to determine whether physical methods of antipyresis, such as the application of cooling blankets, are appropriate for use in the ICU, and if so which methods are best, the authors conducted a literature review. Their findings raise concerns about whether external cooling methods should be used at all in the absence of hyperthermia or cerebral damage. In addition, the authors give an overview of the causes and effects of temperature elevation, focusing mostly on fever.A literature review examines external cooling methods for use in the ICU. The findings raise some doubts.     

Benzodiazepine-associated delirium in critically ill adults

Purpose

The association between benzodiazepine use and delirium risk in the ICU remains unclear. Prior investigations have failed to account for disease severity prior to delirium onset, competing events that may preclude delirium detection, other important delirium risk factors, and an adequate number of patients receiving continuous midazolam. The aim of this study was to address these limitations and evaluate the association between benzodiazepine exposure and ICU delirium occurrence.

Methods

In a cohort of consecutive critically ill adults, daily mental status was classified as either awake without delirium, delirium, or coma. In a first-order Markov model, multinomial logistic regression analysis was used, which considered five possible outcomes the next day (i.e., awake without delirium, delirium, coma, ICU discharge, and death) and 16 delirium-related covariables, to quantify the association between benzodiazepine use and delirium occurrence the following day.

Results

Among 1112 patients, 9867 daily transitions occurred. Benzodiazepine administration in an awake patient without delirium was associated with increased risk of delirium the next day [OR 1.04 (per 5 mg of midazolam equivalent administered) 95 % CI 1.02–1.05). When the method of benzodiazepine administration was incorporated in the model, the odds of transitioning to delirium was higher with benzodiazepines given continuously (OR 1.04, 95 % CI 1.03–1.06) compared to benzodiazepines given intermittently (OR 0.97, 95 % CI 0.88–1.05).

Conclusions

After addressing potential methodological limitations of prior studies, we confirm that benzodiazepine administration increases the risk for delirium in critically ill adults but this association seems to be limited to continuous infusion use only.

     

Sedation assessment in critically ill adults.

OBJECTIVE: To review methods for assessing sedation in critically ill adults, discuss their impact on patient outcomes, and provide recommendations for implementing these methods into clinical practice in the intensive care unit (ICU). DATA SOURCES: A computerized search of MEDLINE from 1980 through June 2000 and a manual search of abstracts presented at recent critical care meetings were performed. STUDY SELECTION AND DATA EXTRACTION: Sedation assessment tools that have been used to titrate therapy in adult, critically ill patients were identified. Special emphasis was placed on sedation assessment instruments that have been prospectively validated. Objective methods that have been used to assess sedation therapy were also identified. DATA SYNTHESIS: Twenty-three adult sedation assessment instruments were identified. Few scales have been prospectively evaluated for validity (n = 6) or reliability (n = 7). Other methods of sedation assessment were identified (e.g., bispectral index monitor); however, most of these methods have only been studied in small subsets of critically ill patients. CONCLUSIONS: Incorporation of sedation assessment into ICU clinical practice may improve patient care. These sedation assessment instruments must be further evaluated to determine their impact on quality of care and ICU length of stay.     

Management of delirium in critically ill older adults

Delirium in older adults in critical care is associated with poor outcomes, including longer stays, higher costs, increased mortality, greater use of continuous sedation and physical restraints, increased unintended removal of catheters and self-extubation, functional decline, new institutionalization, and new onset of cognitive impairment. Diagnosing delirium is complicated because many critically ill older adults cannot communicate their needs effectively. Manifestations include reduced ability to focus attention, disorientation, memory impairment, and perceptual disturbances. Nurses often have primary responsibility for detecting and treating delirium, which can be extraordinarily complicated because patients are often voiceless, extremely ill, and require high levels of sedatives to facilitate mechanical ventilation. An aggressive, appropriate, and compassionate management strategy may reduce the suffering and adverse outcomes associated with delirium and improve relationships between nurses, patients, and patients' family members.