Abstract
BackgroundPain assessment in brain-injured patients in the intensive care unit (ICU) is challenging and existing scales may not be representative of behavioral reactions expressed by this specific group. This study aimed to validate the French-Canadian and English revised versions of the Critical-Care Pain Observation Tool (CPOT-Neuro) for brain-injured ICU patients.MethodsA prospective cohort study was conducted in three Canadian and one American sites. Patients with a traumatic or a non-traumatic brain injury were assessed with the CPOT-Neuro by trained raters (i.e., research staff and ICU nurses) before, during, and after nociceptive procedures (i.e., turning and other) and non-nociceptive procedures (i.e., non-invasive blood pressure, soft touch). Patients who were conscious and delirium-free were asked to provide their self-report of pain intensity (0–10). A first data set was completed for all participants (n = 226), and a second data set (n = 87) was obtained when a change in the level of consciousness (LOC) was observed after study enrollment. Three LOC groups were included: (a) unconscious (Glasgow Coma Scale or GCS 4–8); (b) altered LOC (GCS 9–12); and (c) conscious (GCS 13–15).ResultsHigher CPOT-Neuro scores were found during nociceptive procedures compared to rest and non-nociceptive procedures in both data sets (p < 0.001). CPOT-Neuro scores were not different across LOC groups. Moderate correlations between CPOT-Neuro and self-reported pain intensity scores were found at rest and during nociceptive procedures (Spearman rho > 0.40 and > 0.60, respectively). CPOT-Neuro cut-off scores ≥ 2 and ≥ 3 were found to adequately classify mild to severe self-reported pain ≥ 1 and moderate to severe self-reported pain ≥ 5, respectively. Interrater reliability of raters’ CPOT-Neuro scores was supported with intraclass correlation coefficients > 0.69.ConclusionsThe CPOT-Neuro was found to be valid in this multi-site sample of brain-injured ICU patients at various LOC. Implementation studies are necessary to evaluate the tool’s performance in clinical practice.
Highlights
Pain assessment in brain-injured patients in the intensive care unit (ICU) is challenging and existing scales may not be representative of behavioral reactions expressed by this specific group
Grimace was the best predictor of self-reported pain intensity in brain-injured ICU patients who were conscious and able to communicate in a reliable manner, i.e., not delirious [17]
Similar results were obtained for the second data set, where 54% and 44% of patients did not receive analgesia/sedation, 37% and 40% received continuous analgesia and/or sedation, and only 9% and 15% had a bolus of analgesia within one hour before turning and other procedures, respectively
Summary
Pain assessment in brain-injured patients in the intensive care unit (ICU) is challenging and existing scales may not be representative of behavioral reactions expressed by this specific group. This study aimed to validate the French-Canadian and English revised versions of the Critical-Care Pain Observation Tool (CPOT-Neuro) for braininjured ICU patients. Several studies have tested the two recommended scales, i.e., the Behavioral Pain Scale (BPS: [2]) and the Critical-Care Pain Observation Tool (CPOT: [3]) for pain assessment purposes in this specific ICU patient group; six studies used the BPS [4,5,6,7,8,9], six the CPOT [10,11,12,13,14,15], and one used both tools [16]. Other tools are available for brain-injured patients with disorders of consciousness such as the Nociception Coma Scale [21] and its revised version [22], these were not developed for use in the ICU context and are not applicable to mechanically ventilated patients [23]
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