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Pain is a common and distressing symptom in ICU patients. Only two pain behavior instruments have been tested for their reliability, validity, and feasibility of use in ICUs. Alternative methods of augmenting a pain evaluation should be considered.
Pain is a common and distressing symptom in ICU patients. Only two pain behavior instruments have been tested for their reliability, validity, and feasibility of use in ICUs. Alternative methods of augmenting a pain evaluation should be considered.
Pain is a common and distressing symptom in ICU patients. Only two pain behavior instruments have been tested for their reliability, validity, and feasibility of use in ICUs. Alternative methods of augmenting a pain evaluation should be considered.
Kathleen Puntillo, RN, CNS, DNSc; Chris Pasero, MS, RN-BC;
Denise Li, PhD, RN, CNS; Richard A. Mularski, MD, MSHS, MCR, FCCP; Mary Jo Grap, PhD, RN; Brian L. Erstad, PharmD; Basil Varkey, MD, FCCP; Hugh C. Gilbert, MD; Justine Medina, RN, MS; and Curtis N. Sessler, MD, FCCP Pain is a common and distressing symptom in ICU patients. Yet a major challenge exists in assessing and evaluating the pain. Although the patients self-report of pain is the gold standard for pain assessment, other methods must be considered when patients are unable to self-report. Currently only two pain behavior instruments have been tested for their reliability, validity, and feasibility of use in ICUs: the pain behavior scale and the Critical-Care Pain Observation Tool. Other tools, albeit with less validity testing, include the pain assessment, intervention, and notation (PAIN) algorithm and a pain behaviors checklist. When established tools are insufficient to evaluate a patients pain, alternative methods of augmenting a pain evaluation should be considered. These can include the completion of a pain risk profile, use of surrogates, or performance of an analgesic trial. Meticulous attention to the evaluation of a critically ill patients pain provides the basis for selection of pain interventions and the subsequent assessment of the interventions effectiveness. (CHEST 2009; 135:10691074) Key words: ICU pain; pain assessment; pain evaluation; pain tools Abbreviations: BPS behavior pain scale; CAM confusion assessment method; CPOT Critical-Care Pain Observation Tool; NRS numeric rating scale; PAIN pain assessment, intervention, and notation T he relief of pain and improvement of patient outcomes provide the rationale for conducting systematic evaluations of pain experienced by ICU patients. Choice of methods used for these evalua- tions are predicated on our knowledge of what pain is and how we can convert pain from an individual, private experience to words or expressions perceived by others. This article, part of a series of articles being published in CHEST on the topic of pain in ICU patients, focuses on pain evaluation. For some time now, we have known and accepted various definitions of pain. The International Asso- ciation for the Study of Pain 1 defines pain as un- pleasant sensory and emotional experience associ- ated with actual or potential tissue damage or described in terms of such damage. A more clini- cally applicable definition is that pain is whatever the experiencing person says it is, existing whenever he/she says it does. 2 Both of these definitions can provide the foundation for pain assessment of ICU patients who can speak or who can self-report infor- mation about their pain in other ways such as pointing to numbers or words. Although the system- atic evaluation of pain is of prime importance, methods by which to evaluate pain require thought- ful consideration within the context of the ICU patients ability to participate in a pain evaluation. It is also important to conduct pain assessments regularly, For editorial comment see page 894 For related article see page 1075 particularly if the patient has undergone an event that could be painful. The regularity of pain assess- ments should be standardized according to an indi- vidual ICUs pain assessment policy but be increased in circumstances of difficult-to-treat pain. Anticipa- tory pain such as that associated with some proce- dures should be considered. Self-Report The patients self-report is considered the most reliable method of evaluating pain. Providing patients with methods to help them report their pain should be CHEST Postgraduate Education Corner CONTEMPORARY REVIEWS IN CRITICAL CARE MEDICINE www.chestjournal.org CHEST / 135 / 4 / APRIL, 2009 1069 Downloaded From: http://journal.publications.chestnet.org/ on 07/16/2014 attempted, and the intensity of their pain determined whenever feasible. The most commonly used 0-to-10 numeric rating scale (NRS) should be offered to pa- tients who seem able to communicate. This scales validity, when used with ICU surgical patients, was established several years ago by Puntillo and Weiss. 3 Recently, Ahlers and colleagues 4 tested the validity and reliability of the NRS in critically ill patients, with similar findings as Puntillo and Weiss. Yet even use of the NRS can offer challenges for ICU patients. Suffi- cient time should be given to offering the patient an opportunity to use the NRS. Table 1 5 offers some simple tips for increasing the likelihood that a patient will be able to use a self-report tool like the NRS. Even patients with diminished cognitive capacity can report their pain. In a sample of 152 ICU patients who were tested for delirium with the Confusion Assessment Method-ICU (CAM-ICU), there was an almost equal percent of CAM-positive surveys (n 39.3%) and CAM-negative surveys (40.7%) from patients able to report the presence of pain (n 324 surveys) [K. Puntillo, RN, CNS, DNSc; unpublished data; March 2009]. A laminated pain assessment tool that includes a number of methods that can help critical care nurses assess their patients pain can be placed at patients bedsides. The 0-to-10 NRS and a body outline diagram can be held up to the patient so that the patient can point to the appropriate number on the NRS and to the body location(s) where pain is being felt. 6 The laminated form can include words that may describe the qualitative nature of the pain. The words may be read to patients as suggestions, with patients responding with yes or no depending on the qualitative nature of their pain. Critically ill patients may be able to report pain in many different ways. Ventilated patients who are unable to point to a scale may be able to blink or squeeze their eyes tightly to communicate the pres- ence of pain. 7 It may also be possible to obtain the intensity of this pain by pointing to each number on the NRS and asking the patient to blink when the number reflects the severity of their pain. Many patients who can speak prefer to use words rather than numbers to report their pain 8 and may be able to report the general intensity of their pain using descriptions such as mild, moderate, or severe. Patients can also be asked to use quality descriptors instead, such as sharp, aching, or burning. However, the arbitrary assignment of a particular pain intensity rating to specific words or behaviors should be avoided in patients who cannot rate pain intensity. In general, there is no demonstrated cor- relation between pain intensity and specific words or behaviors or the number of words or behaviors. 9 Yet, in patients reporting procedural pain, researchers found a moderate (r 0.54) and significant (p 0.001) correlation between patients pain inten- sity scores on a 0-to-10 NRS and the total number of pain behaviors. 10 *From the Department of Physiological Nursing (Dr. Puntillo), University of California, San Francisco, San Francisco, CA; Pain Management Educator and Clinical Consultant (Ms. Pasero), El Dorado Hills, CA; Department of Nursing & Health Sciences (Dr. Li), College of Science, California State University, East Bay, Hayward, CA; Oregon Health & Science University (Dr. Mularski), Portland, OR; Adult Health and Nursing Systems Department (Dr. Grap), School of Nursing, Virginia Common- wealth University, Richmond, VA; University of Arizona College of Pharmacy (Mr. Erstad), Department of Pharmacy Practice & Science, Tucson, AZ; Department of Medicine (Dr. Varkey), Medical College of Wisconsin, Milwaukee, WI; NorthShore University Health System (Dr. Gilbert), Northwestern Univer- sity, Chicago, IL; Virginia Commonwealth University Health System (Dr. Sessler), Richmond, VA; and American Association of Critical Care Nurses (Ms. Medina), Aliso Viejo, CA. Dr. Puntillo has no relationships with industry, but she does make formal presentations at professional societies that are sometimes sponsored by industry. She has no personal contact with industry personnel or others that make those arrangements. Ms. Pasero discloses that her lectures, which cover general pain management, do not promote any products or equipment and are occasionally supported by industry (Baxter Healthcare Corporation, Ortho Mc- Neil, and Johnson & Johnson). She is paid as a consultant to critique pain management products in development (eg, Alpharma, Johnson & Johnson); answer general pain management questions of industry customers, such as nurses, pharmacists, and physicians (Baxter Healthcare Corporation, Cardinal Health); and develop patient education materials (Endo Pharmaceutical). Drs. Li, Mularski, Grap, and Gilbert, and Mr. Erstad and Ms. Medina have no conflicts of interest to disclose. Dr. Varkey served as a speaker and in an advisory board meeting for Astra Zeneca in August 2008. Dr. Sessler received a grant from Physiometrix and served as a consultant and on the advisory committee for Hospira. Manuscript received October 1, 2008; revision accepted Decem- ber 16, 2008. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Kathleen Puntillo, RN, CNS, DNSc, Professor of Nursing and Co-Director, Critical Care/Trauma Program, Department of Physiological Nursing, 2 Koret Way, Box 0610, University of California, San Francisco, CA 94143-0610; e-mail: kathleen.puntillo@nursing.ucsf.edu DOI: 10.1378/chest.08-2369 Table 1Suggestions for Assisting the ICU Patient to Use a Self-Report Pain Assessment Instrument Enlarge the font of the tool Include descriptive words below ranges of pain intensities (eg, 0 no pain; 14 mild pain; 56 moderate pain; 7 10 severe pain) 5 Show the tool to the patient, explain its purpose, and correct its use each time pain is assessed Provide reading glasses and hearing aids to patients who require them Ask questions slowly and more than once if necessary Allow the patient ample time to process instructions and respond Ask ventilated patients to point to a number on the NRS if they are able to do so 1070 Postgraduate Education Corner Downloaded From: http://journal.publications.chestnet.org/ on 07/16/2014 Patients may also be able to respond to the finger span scale, a simple assessment tool that has been used for years in children who are critically ill or unable to comprehend more sophisticated scales. 11 Although the scale has not been tested in critically ill adults, it has been used successfully in adults who were asked to measure dental pain 12 and may be a reasonable alternative when other approaches for obtaining self-report are unsuccessful. The scale requires the clinician to demonstrate by holding the thumb and forefinger of one hand together and telling the patient that this signifies no pain. Next, the clinician should spread the thumb and forefinger a small distance apart to indicate tiny or mild pain, a bit more distance for medium or moder- ate pain, and as far apart as possible for most possible or severe pain. In selecting self-report measures of pain, it is essential to consider that cultural and language differences can also affect the patients communica- tion of pain. Languages differ in the types and numbers of words used to express pain. For example, Hebrew, Chinese, and Japanese have very few pain expressions, whereas the English language has 16 categories of pain with 64 words. 13 When differences in language and culture exist between patients and their caregivers, pain assessment and management can be significantly affected. As clinicians perform an evaluation of their patients pain, it is important that they recognize and respect these culture/language differences and offer their patients the use of language-appropriate pain assessment tools. Finally, pain assessments should be regularly repeated to promote better pain management. Objective Measures of Pain There are multiple instances in ICUs when the definitions of pain we presented earlier that rely on reports from patients are not helpful (ie, when patients are not able to communicate with ICU clinicians). Unfortunately, little is known about the presence or degree of pain intensity in these criti- cally ill patients. We do know that, although con- scious perception of pain may be altered in patients with decreased neurologic function, noxious stimuli induce reflexive responses despite the absence of self-reports of pain. 14 Use of a valid, objective, and structured tool to assess these patients responses to noxious events is an essential approach. 15 Within the past decade, we have achieved major improvements in our understanding of critically ill adult patients observable pain responses. A growing body of research has examined certain structured tools used for pain assessment in ICU patients. In a recent critical review 16 of six published objective pain measures, three instruments were presented that are used to identify the presence of pain in noncommunicative ICU patients. Each measure has received certain degrees of validation. 16 The first, the pain assessment, intervention, and notation (PAIN) algorithm, 17,18 is a tool to guide clinicians systematically through the pain assessment and management decision-making process. This tool prompts clinicians through the following three steps: (1) assessment of pain-related behavioral and physi- ologic indicators (eg, facial expressions, body move- ment and posture, vocalizations, changes in vital signs); (2) identification of potential risks that could influence opioid administration; and (3) implemen- tation and documentation of analgesic treatment. Using the PAIN algorithm, ICU and post-anesthesia care unit nurses (n 14) were able to identify facial expressions, body movements, and vocalization as the most frequently observed pain-related behaviors in their patients. Increased heart rate and BP were the most commonly noted physiologic responses to pain. 18 These pain behaviors and vital signs were shown to have convergent validity with nurses rat- ings of their patients pain intensity (p 0.05). The use of a structured guide such as the PAIN algorithm may be used to help coach clinicians through the pain assessment and management processes. 17 How- ever, because this type of approach does not stan- dardize observations, one cannot ensure interrater reliability. The PAIN algorithm in its research-tested form is too detailed for day-to-day use in an ICU; however, it could be tailored to meet the needs of a busy ICU environment. The validation of certain pain-related behaviors was confirmed in a 2004 study 10 that included a large sample of acutely and critically ill patients undergo- ing noxious procedures. Certain pain behaviors on a pain behaviors checklist, such as grimacing, rigidity, wincing, closing of eyes, verbal complaints, moaning, and clenched fists, were identified by a large propor- tion of observers as associated with the procedural pain. Although the use of assessment tools such as the PAIN algorithm 17,18 or a behavior checklist 10 shows promise of clinical utility, two other objective pain behavior instruments for use with noncommunica- tive ICU patients during mechanical ventilation have been tested for validity and reliability: the behavioral pain scale (BPS) 19 and the Critical-Care Pain Obser- vation Tool (CPOT). 20 The BPS assesses three behavioral domains (ie, facial expression, movements of upper limbs, and compliance with ventilation). Its 12 items (4 per domain) are rated on a 1 to 4 scale, with a total score range from 3 (which suggests no pain-related behav- www.chestjournal.org CHEST / 135 / 4 / APRIL, 2009 1071 Downloaded From: http://journal.publications.chestnet.org/ on 07/16/2014 ioral response) to 12 (which suggests the greatest pain-related behavioral response). The BPS domains were modified from two previously published pain and sedation scales. 21,22 The discriminant validity of the BPS was demonstrated by the finding of a significantly higher BPS score during noxious proce- dures performed on ICU patients compared to patients undergoing nonnoxious procedures and sig- nificantly lower BPS scores in patients who received sedation/analgesia compared to those who did not (p 0.05). 19,23 The interrater reliability of the BPS is satisfactory. 19,23 However, as has been recently confirmed, BPS scores can be skewed to the lower end of the range of the scale of 3 to 12, suggesting the lack of the BPSs sensitivity in patients with higher pain (as noted by high nurse-obtained NRS scores in patients whose BPS scores were 3). 4 Another objective pain measure, the CPOT, was designed for use with both verbal patients and nonverbal mechanically ventilated patients. The CPOT assesses four behavioral domains (ie, facial expressions, movements, muscle tension, and vocal sound or ventilator compliance). The number of pain behaviors that can be identified when using the CPOT range from 0 (indicating no pain) to 8 (indi- cating the most pain). Similar to the recent evalu- ation of the BPS, 4 evaluation studies have been conducted on the CPOT. This tool possesses discriminant validity in that significantly higher CPOT scores were recorded during noxious pro- cedures compared to lower scores during baseline (p 0.001). The CPOT also has satisfactory interra- ter reliability 20,24 and specificity and sensitivity. 25 Criterion validity was demonstrated by higher CPOT scores in patients who self-reported pain to be present than in patients who self-reported pain to be absent. 20 In comparing the clinical usefulness of the BPS and the CPOT, both were designed for use in ICU patients receiving mechanical ventilation, and both incorporate similar behavioral domains. With the BPS there is potential for external devices to hinder a patients ability to exhibit upper limb movement, one of the behaviors on the scale. Furthermore, the BPS descriptors of ventilator compliance are not measurable parameters, which may affect the reli- ability of observer response. In contrast, the CPOT contains operationally defined descriptors and has a more logical scoring system than the BPS. In the CPOT, a score of 0 reflects no pain response; the BPS uses a score of 3 to indicate no pain response. Neither the BPS nor CPOT has been evaluated for analgesic responsiveness, which refers to the scales ability to differentiate pain responses before and after pharmacologic interventions. This differentia- tion is a critical attribute for establishing the clinical usefulness of a pain assessment tool. Moreover, because both tools are behavioral scales, they are not applicable for use when deeply sedated patients become unresponsive to external stimuli. Further research is needed to provide additional evidence to support the use of these two tools in heterogeneous ICU populations. Yet, in general, literature to date suggests that the BPS and the CPOT are valid and reliable for use in assessing pain in ICU patients. Although none of these objective measures em- braces all criteria of a well-established pain mea- surement instrument, they have emerged as useful tools for pain assessment in noncommunicative ICU patients. Pain Risk Profile There are no available structured tools that iden- tify potential risks for pain. Yet many personal, illness, and environmental factors impose important potential sources of pain in critically ill patients. Early recognition of a patients risk for pain may lead to effective preemptive pain management. Sug- gested methods for this aspect of pain assessment may include a risk appraisal of the nature and severity of illness, chronic pain conditions, coexisting symptoms, and frequency and invasiveness of thera- pies. As noted in an accompanying article regarding pain approaches at the end of life in the ICU, these assessment tools have particular importance in the sickest of patients who experience shifts in the goals of care from life restoring to an emphasis on comfort. Surrogate Reporting Family members may be able to offer their per- spectives about the patients current pain status and to provide a description of behaviors that might be indicative of pain based on their history together. The evidence regarding the reliability of surrogates reports is equivocal, however. As noted in an accom- panying article regarding pain approaches at the end of life in the ICU, certain factors can increase surrogates levels of accuracy: (1) when patients levels of pain are at the lowest and highest ex- tremes (9.1 and 3.2 times greater odds for accu- racy, respectively; 89% accuracy when patients reported severe pain); and (2) when surrogates estimates are within one level of the patients pain (increase from 73.5 to 82% accuracy). 26 As Des- biens and colleagues 27 pointed out, the sensitivity and specificity of surrogate reports in the large multisite Study to Understand Prognoses and Pref- erences for Outcomes and Risks of Treatments (or 1072 Postgraduate Education Corner Downloaded From: http://journal.publications.chestnet.org/ on 07/16/2014 SUPPORT), although not exact, were 79.7% and 67.6%, respectively, figures comparable to stress tests to detect coronary artery disease. Thus, when the self-report capability of the patient deteriorates, others can be useful sources of proxy information. 28 If proxy information is inflated, this error would most likely be on the side of overtreating rather than undertreating distressing symptoms such as pain. Erring on the side of pain control may help reduce patient and family suffering. One factor that may influence the accuracy of a family members rating of a patients pain is how the family member is coached before providing their estimate of the patients pain. In a sample of cancer patients, family members who were coached to put themselves in the patients symptom situation were more accurate about the patients symptom than were family members who were coached to imagine how they themselves would feel in the patients situation. 29 Thus, critical care clinicians who are seeking family members estimate of the patients pain can instruct them to consider specifically what the patient might be feeling. This instruction, along with a prompt to identify any behaviors that are indicative of pain based on their past experiences with the patient, may increase the accuracy of re- sults. Certainly, further research of this assessment intervention with ICU patients and their families is warranted. It is also important to note that, although we might invite family members to help with pain assessments, titration of pain medications based on these assessments must remain the responsibility of health-care professionals. Use of an Analgesic Trial to Evaluate Pain An empirical analgesic trial is recommended as another assessment approach for ICU patients who are unable to report pain and in whom pain is suspected. 30,31 The primary goal of an analgesic trial is to verify the presence of pain. It also serves as the foundation for the ongoing pain treatment plan if pain is thought to be present. Although the intensity of pain may be unknown at the time of an analgesic trial, an assumption can be made that many critically ill patients are likely to experience moderate-to- severe pain. 32 An analgesic trial involves administra- tion of a low dose of a first-line analgesic followed by observation of the patients pain-related behaviors after the administration. It is appropriate to initiate the analgesic trial with a low dose of an opioid (eg, 2 to 5 mg of IV morphine or equivalent). If no changes in behaviors are evident after the analgesic is given, the initial dose can be increased by percentages, based on the patients tolerance of the previous dose. For example, the dose can be increased by 100% if the previous dose produced no or minimal side effects. 33 If the patients pain-related behaviors seem to decrease in response to the analgesic, further interventions can be planned, such as around-the- clock analgesic dosing. If there is no change in behaviors despite administration of optimal analgesic doses, alternative causes of the patients behaviors, such as hypoxia, sepsis, or metabolic disorders, should be considered. Conclusions Clearly, evaluation of pain in ICU patients is usually not a simple task. Yet, although not simple, it is essential. ICU clinicians are encouraged to select pain evaluation methods using a hierarchical ap- proach. 31 First, attempt to gain the patients self- report using instruments and methods we have suggested here. Second, select and evaluate the usefulness of various objective measures of pain in the clinicians particular setting. Finally, consider less conventional pain evaluation processes such as developing a pain risk profile, recruiting surrogates, and/or performing an analgesic trial. The appropriate treatment of pain is based on a clinician-performed pain evaluation process that is as accurate and detailed as possible. Key Points Patients who seem to be able to communicate should be offered methods to self-report their pain. There now exist tools to evaluate pain behaviors in patients who cannot self-report. Each ICU should evaluate the tool most relevant to their patient population and implement its use. When established tools are insufficient to evaluate a patients pain, the following methods of augmenting a pain evaluation should be considered: a pain risk profile; reports from surrogates; and an analgesic trial. References 1 International Association for Study of Pain. Pain terms: a list with definitions and notes on usage. Pain 1979; 6:249252 2 McCaffery M. Nursing management of the patient with pain. Philadelphia, PA: Lippincott, 1979; 3 3 Puntillo K, Weiss SJ. Pain: its mediators and associated morbidity in critically ill cardiovascular surgical patients. Nurs Res 1994; 43:3137 4 Ahlers SJ, van Gulik L, van der Veen AM, et al. 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