Gélinas C, Arbour C. Behavioral and physiologic indicators during a nociceptive procedure in conscious and unconscious mechanically ventilated adults: Similar or different? J Crit Care.24:628.e7-628.17

School of Nursing, McGill University, Montreal, Quebec, Canada.
Journal of critical care (Impact Factor: 2). 04/2009; 24(4):628.e7-17. DOI: 10.1016/j.jcrc.2009.01.013
Source: PubMed


The purpose of this study was to describe behavioral and physiologic indicators to a nociceptive procedure in conscious and unconscious mechanically ventilated adults and to examine their association with the patients' self-reports of pain.
A total of 257 intensive care unit patients (144 conscious and 113 unconscious) from 4 clinical settings in Canada participated. Patients were observed at rest, during a nociceptive procedure, and 20 minutes postprocedure. Behavioral indicators were measured with the Critical Care Pain Observation Tool (CPOT), and physiologic indicators were documented from the available monitoring.
Conscious patients showed more intense behaviors and a more elevated mean arterial pressure compared with unconscious patients at all measurements. Conscious patients who self-reported being in pain during the procedure showed more intense behaviors compared with patients without pain. Only the CPOT score could predict the presence or the absence of pain on the basis of the patient's self-report during the procedure.
The use of behaviors is strongly recommended for pain assessment in unconscious patients, and results from this study support this clinical guideline. Vital signs should be used with caution for the detection of pain as they can be influenced by other factors besides pain.


Available from: Caroline Arbour
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    • "When patients are unable to self-report, assessment is based on behavioural and physical signs. Unfortunately physiological variables are not predictive of the presence or absence of pain [2], and recommended behavioural tools (Critical Care Pain Observation Tool and Behavioural Pain Scale) [3] only identify patients who are experiencing pain. "
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    • "More recently, a vocalization domain was added to the BPS, demonstrating good psychometric properties in ICU nonintubated patients [34]. Vital signs, such as heart rate and blood pressure, are unreliable as pain assessment surrogates in ICU patients compared with behavioral parameters [33-35]; the guidelines make this point and emphasize the need for systematic and rigorous pain assessment, particularly because ICU patients’ pain is consistently underrated by ICU caregivers [36-38]. Behavioral pain tools should not be used in communicative patients, because correlation coefficients between BPS and self-reported pain scales are low [24]. "
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    • "Regarding the CPOT, a cut-off score (> 2) for the presence of pain was empirically determined using ROC curve analysis in verbal critically ill patients (Gé linas et al., 2009a). This can allow the detection of the presence of pain as well as the evaluation of the effectiveness of pain management interventions. "
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