Can fluctuations in vital signs be used for pain assessment in critically ill patients with a traumatic brain injury?

Caroline Arbour,Carmen G Loiselle,Jane Topolovec-Vranic,Céline Gélinas,Manon Choinière

doi:10.1155/2014/175794

Abstract

Background. Many critically ill patients with a traumatic brain injury (TBI) are unable to communicate. While observation of behaviors is recommended for pain assessment in nonverbal populations, they are undetectable in TBI patients who are under the effects of neuroblocking agents. Aim. This study aimed to validate the use of vital signs for pain detection in critically ill TBI patients. Methods. Using a repeated measure within subject design, participants (N = 45) were observed for 1 minute before (baseline), during, and 15 minutes after two procedures: noninvasive blood pressure: NIBP (nonnociceptive) and turning (nociceptive). At each assessment, vital signs (e.g., systolic, diastolic, mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), capillary saturation (SpO2), end-tidal CO2, and intracranial pressure (ICP)) were recorded. Results. Significant fluctuations (P < 0.05) in diastolic (F = 6.087), HR (F = 3.566), SpO2 (F = 5.740), and ICP (F = 3.776) were found across assessments, but they were similar during both procedures. In contrast, RR was found to increase exclusively during turning (t = 3.933; P < 0.001) and was correlated to participants' self-report. Conclusions. Findings from this study support previous ones that vital signs are not specific for pain detection. While RR could be a potential pain indicator in critical care, further research is warranted to support its validity in TBI patients with different LOC.

Highlights

Many patients with a traumatic brain injury (TBI) are unable to self-report their pain in the intensive care unit (ICU) because of altered levels of consciousness (LOC), mechanical ventilation, and/or aphasia [1]
Use of behaviors suggestive of pain (a.k.a pain behaviors) such as grimacing, increased muscle tension, protective movements, and noncompliance with the ventilator is recommended for pain assessment [2, 3]
According to our research objectives, an initial data collection was completed in all participants and a second data collection was completed in a subsample of n = 13 participants who changed LOC category within the first month of ICU stay, for a total of 58 data collections

Summary

Introduction

Many patients with a traumatic brain injury (TBI) are unable to self-report their pain in the intensive care unit (ICU) because of altered levels of consciousness (LOC), mechanical ventilation, and/or aphasia [1]. Critically ill TBI patients are commonly under the effects of high doses of sedatives or neuroblocking agents to prevent deleterious elevation of intracranial pressure (ICP). While high doses of sedatives have the potential to attenuate patients’ reactivity to sensorial stimuli (including painful ones), neuroblocking agents induce complete paralysis [2]. As such, these drugs make it challenging to use behaviors for pain assessment. Sedatives (i.e., hypnotic agents and benzodiazepines) and neuroblocking agents have no analgesic properties [4] For this reason, clinicians cannot rule out the presence of pain in TBI patients receiving them and must rely on signs other than behaviors to perform pain assessment. While RR could be a potential pain indicator in critical care, further research is warranted to support its validity in TBI patients with different LOC

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Discussion

Conclusion