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Evaluation of Pain in ICU Patients*

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
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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
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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-
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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
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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.
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