Behavioral Pain Scale Research Articles

Pain assessment of traumatic brain injury victims using the Brazilian version of the Behavioral Pain Scale.

ObjectiveTo evaluate the validity and reliability of the Brazilian version of the Behavioral Pain Scale (BPS-Br) in victims of traumatic brain injury.MethodsObservational prospective study with paired and repeated measures conducted at two intensive care units (clinical and surgical) of a large general hospital. The convenience sample consisted of adult victims of moderate or severe penetrating or blunt craniocerebral trauma who were sedated and mechanically ventilated. A total of 432 paired observations were performed by independent evaluators simultaneously, prior to eye cleaning, during eye cleaning, during tracheal aspiration and after tracheal aspiration. Sociodemographic, clinical, trauma-related, sedoanalgesia and physiological parameter data (heart rate, systolic and diastolic blood pressure) were collected. The discriminant validity was tested using the Friedman and Wilcoxon paired tests. The intraclass correlation coefficient and Cohen's Kappa coefficient were used to evaluate the reliability. The Spearman correlation test was used to test the association between clinical variables and BPS-Br scores during tracheal aspiration.ResultsThere was a significant increase in the physiological parameters during tracheal aspiration, but without correlation with the BPS-Br scores. Pain was significantly more intense during tracheal aspiration (p < 0.005). Satisfactory interobserver agreement was found, with an intraclass correlation coefficient of 0.95 (0.90 - 0.98) and Kappa coefficient of 0.70.ConclusionBrazilian version of the Behavioral Pain Scale scores increased during tracheal aspiration. The Brazilian version of the scale was valid and reliable for pain assessment of traumatic brain injury victims undergoing tracheal aspiration.

Correction to: Terminal weaning or immediate extubation for withdrawing mechanical ventilation in critically ill patients (the ARREVE observational study).

Correction to: Intensive Care Med (2017) DOI 10.1007/s00134-017-4891-0.

Featured Article: The ABCDs of Pain Management: A Double-Blind Randomized Controlled Trial Examining the Impact of a Brief Educational Video on Infants' and Toddlers' Pain Scores and Parent Soothing Behavior.

To test the efficacy of a brief behavioral pain management strategy (The ABCDs of Needle Pain Management), delivered via video, on infants' and toddlers' pain scores and on parental soothing behavior. This was a double-blind, parallel trial design. Parent-child dyads (N = 128) were recruited before their child's 6-month (infant) or 18-month (toddler) vaccination in a pediatric clinic and randomly assigned to watch a 5-min treatment video or a placebo video. The primary outcome was the Modified Behavior Pain Scale (Taddio et al., Journal of Pain and Symptom Management, 10, pp. 456-463, 1995), coded during four epochs (Pain Reactivity, Pain Regulation 1 min, Pain Regulation 2 min, and Pain Regulation 3 min) after the last vaccination needle. Secondary analyses examined parental use of distraction, rocking, and physical comforting over this same time period. Results demonstrated a treatment effect for toddlers (18-month-olds) for the Pain Regulation 1 (d = 0.84) and Pain Regulation 2 (d = 0.76) postvaccination scores. Secondary analyses found differences in parental rocking and physical comforting between treatment conditions and between age-groups (d's = 0.37-0.54). The ABCD pain management strategy delivered via video was an effective way to reduce toddler pain after vaccination and increase parental use of rocking and physical comforting. The treatment effect was not demonstrated with infants.

Content validation of behaviours and autonomic responses for the assessment of pain in critically ill adults with a brain injury

BackgroundThe evidence shows that brain-injured patients express behaviours that are related to their level of consciousness (LOC), and different from other patients in the intensive care unit (ICU). Therefore, existing behavioural scales should be revised to enhance their content and validity for use in these patients. ObjectivesThe aim was to evaluate the content relevance of behaviours and autonomic responses for pain assessment of brain-injured ICU patients from the perspective of critical care clinicians. MethodsA total of 77 clinicians from four adult neuroscience ICUs (three from Canada and one from the United States) participated in this descriptive study. A physician/nurse ratio of 21% (13/61) was reached in this quota sample, and three physiotherapists also participated. They completed a content validation questionnaire of 19 items rated on clarity and relevance based on the patient’s LOC. Item Content Validity Index (I-CVI), and modified kappa (κ*) were calculated. Values higher than 0.78 and 0.75 respectively were considered excellent. ResultsRegardless of the patient’s LOC, brow lowering, grimacing, and trying to reach the pain site were rated as the most relevant behaviours by clinicians, with excellent values of I-CVI>0.78 and κ*>0.75. Eyes tightly closed, moaning and verbal complaints of pain also obtained excellent values in altered LOC and conscious patients. Eye weeping obtained excellent values only in conscious patients. Other items showed fair (0.40–0.59) to good (0.60–0.74) values, while blinking and coughing showed poor values (<0.40) at various LOC. ConclusionsFacial expressions, movements towards the pain site, and vocalisation of pain were the most relevant pain-related behaviours rated by critical care clinicians. The relevance of some behaviours (e.g., moaning and verbal complaints of pain) varied across LOCs, thereby calling forth adaptations of behavioural pain scales to allow for interpretation in the context of a patient’s LOC and ability to express specific behaviours.

Validation of two Chinese-version pain observation tools in conscious and unconscious critically ill patients

ObjectivesTo compare the construct validities of the Chinese-versions Critical-Care Pain Observation Tool and Behavioural Pain Scale as measures of critically ill patients’ pain by (a) discriminant validation of behavioural scales and vital signs (e.g. heart rate and mean arterial pressure) during a non-nociceptive procedure (noninvasive blood pressure] assessment) and a nociceptive procedure (endotracheal suctioning), (b) criterion validation of behavioural scales and vital signs with patients’ self-reported pain and (c) testing the interrater reliability of both scores. Research methodology/designIn this crossover, observational study, pain responses of 316 critically ill patients (213 conscious; 103 unconscious) were measured by both the Critical Care Pain Observation Tool and the Behavioural Pain Scale scores, vital signs and self-report (if conscious) during noninvasive blood pressure assessment and endotracheal suctioning procedures. Interrater reliability was tested in nociceptive procedures of a pilot study on 20 critically ill patients. Data were analysed by descriptive statistics, multiple logistic regression analysis and receiver-operating characteristic curves. SettingA medical intensive care unit in a regional teaching hospital in northern Taiwan. ResultsPatients’ self-reported pain was predicted by total Critical Care Pain Observation Toolscores (odds ratio=1.93, p<0.01) and total Behavioural Pain scores (odds ratio=1.83, p<0.01) but not by vital signs after controlling for patients’ demographic and clinical characteristics. Moreover, Chinese-versions had areas under the receiver-operating characteristic curve of 76.4% and 73.1%, respectively, indicating good ability to detect pain. ConclusionsThe Chinese-versions of the Critical care Pain Observation Toll and Behavioural Pain Score have good construct validity and can sensitively discriminate when critically ill patients experience pain or no pain.

Analgesia nociception index for the assessment of pain in critically ill patients: a diagnostic accuracy study

BackgroundBehavioural pain tools are used in Intensive Care Unit (ICU) patients unable to self-report their pain-intensity but need sustained efforts to educate and train the ICU team because of the subjective nature of these clinical tools. This study measured the validity and performance of an electrophysiological monitoring tool based on the spectral analysis of heart rate variability, the Analgesia Nociception Index (ANI) which varies from 0 (minimal parasympathetic tone, maximal stress-response and pain) to 100 (maximal parasympathetic tone, minimal stress-response and pain). MethodsMean-ANI (ANIm) and Instant-ANI (ANIi) were continuously recorded then compared with the Behavioral Pain Scale (BPS) before, during and after routine care procedures in critically-ill non-comatose patients. Results969 assessments were performed in 110 patients. ANIi was the most discriminative pain tool. It was significantly correlated with BPS (r=–0.30; 95%CI –0.37 to –0.25; P<0.001). For an ANIi threshold of 42.5, the sensitivity, specificity, positive and negative predictive values were respectively 61.4%, 77.4%, 37.0%, and 90.4%. Compared with the BPS, ANIi had no significantly different ability to change during turning and tracheal-suctioning but changed significantly more during dressing change. ANIi increased independently with age, obesity and severity of illness, and controlled mechanical-ventilation, vasopressors use and analgesia. ANIi decreased independently when vigilance status and respiratory rate increased. ANIm demonstrated poor psychometric properties to detect pain. ConclusionsDespite low sensitivity/specificity, ANIi≥43 had a Negative-Predictive-Value of 90%. Hence ANIi may be of highest benefit for excluding significant pain. A randomized controlled trial should compare sedation-analgesia protocols based on ANIi to presently recommended behavioural-pain-tools.

Pain Assessment in Newborns, Infants, and Children.

Pain in children is underestimated and undertreated because of lack of pain assessment tools. Pain assessment depends on the cognitive development of the child being tested, clinical context, and pain typology. For children older than age 6 years, pain assessment is based on a self-report. For children younger than age 6 years, behavioral pain scales are needed to assess pain. Numerous pain scales exist. Many are reliable and some are recommended, but all have specific conditions for their use. In this article, we review the available pain scales for children from birth to adolescence. We provide the validity criteria of each pain scale to help caregivers use the adapted tools. We then propose a synthesis of the reliable tools to use based on the pain context. [Pediatr Ann. 2017;46(10):e387-e395.].

Procedural Pain Scale Evaluation (PROPoSE) study: protocol for an evaluation of the psychometric properties of behavioural pain scales for the assessment of procedural pain in infants and children aged 6–42 months

IntroductionInfants and children are frequently exposed to painful medical procedures such as immunisation, blood sampling and intravenous access. Over 40 scales for pain assessment are available, many designed for neonatal...

Progress of pain assessment and analgesia strategy for mechanical ventilation patients

Standardized pain assessment is a precondition of appropriate analgesia for mechanical ventilation patients. However, routine pain assessment rates remain very low in intensive care unit (ICU). Behavioral pain scale (BPS) and critical-care pain observation tool (CPOT) can be used to assess pain in mechanical ventilation patients who are unable to report pain by themselves. No matter what strategy we taken, analgesia-first sedation should be used in priority. Meanwhile, patient-centered and goal-directed sedation strategy should be adopted based on the individual condition.If condition permits, patients should be maintained in light states of sedation as long as possible, because this is associated with improved clinical outcomes. Humanistic care, multidisciplinary cooperation and comprehensive training are also important components of a perfect analgesia strategy.

Analgosedation of adult patients with elevated intracranial pressure : Survey of current clinical practice in Austria.

Analgesia and sedation are key items in intensive care. Recently published S3 guidelines specifically address treatment of patients with elevated intracranial pressure. The Austrian Society of Anesthesiology, Resuscitation and Intensive Care Medicine carried out an online survey of neurointensive care units in Austria in order to evaluate the current state of practice in the areas of analgosedation and delirium management in this high-risk patient group. The response rate was 88%. Induction of anesthesia in patients with elevated intracranial pressure is carried out with propofol/fentanyl/rocuronium in >80% of the intensive care units (ICU), 60% use midazolam, 33.3% use esketamine, 13.3% use barbiturates and 6.7% use etomidate. For maintenance of analgosedation up to 72 h, propofol is used by 80% of the ICUs, followed by remifentanil (46.7%), sufentanil (40%) and fentanyl (6.7%). For long-term sedation, 86.7% of ICUs use midazolam, 73.3% sufentanil and 73.3% esketamine. For sedation periods longer than 7 days, 21.4% of ICUs use propofol. Reasons for discontinuing propofol are signs of rhabdomyolysis (92.9%), green urine, elevated liver enzymes (71.4% each) and elevated triglycerides (57.1%). Muscle relaxants are only used during invasive procedures. Inducing abarbiturate coma is rated as alast resort by 53.3% of respondents. The monitoring methods used are bispectral index (BIS™, 61.5% of ICUs), somatosensory-evoked potentials (SSEP, 53.8%), processed electroencephalography (EEG, 38.5%), intraparenchymal partial pressure of oxygen (pO2, 38.5%) and microdialysis (23.1%). Sedation and analgesia are scored using the Richmond agitation and sedation score (RASS, 86.7%), sedation agitation scale (SAS, 6.7%) or numeric rating scale (NRS, 50%) and behavioral pain scale (BPS, 42.9%), visual analogue scale (VAS), critical care pain observation tool (CCPOT, each 14.3%) and verbal rating scale (VRS, 7.1%). Delirium monitoring is done using the confusion assessment method for intensive care units (CAM-ICU, 46.2%) and intensive care delirium screening checklist (ICDSC, 7.7%). Of the ICUs 46.2% do not carry out delirium monitoring. We found good general compliance with the recommendations of the current S3 guidelines. Room for improvement exists in monitoring and the use of scores to detect delirium.

Somatoform Dissociation, Fatigue Severity and Pain Behavior Compared in Patients with Migraine Headache and in Healthy Individuals.

The prevalence of migraine in the world is about 15 and 7% among women and men, respectively. The purpose of this study was comparison of somatoform dissociation, fatigue severity and pain behavior in patients with migraine headache and its relationship with coping strategies. This descriptive analytical study has been done on 120 patients with migraine headache and 120 healthy subjects were selected randomly. Data collected by somatoform dissociation questionnaire (SDQ-20), fatigue severity scale, pain behavior scale and coping strategies scale. For data analysis we used SPSS.19. The means of the somatoform dissociation, pain behavior scale, help searching subscale and pain compliant in migraine and healthy subjects were statistically significant. There was not significant difference in avoidance subscales between the two groups. Comparison of fatigue severity in patients with migraine and control group was meaningful. There was significant positive correlation between all four scales and coping strategies. It seems that these symptoms can play an important role in this disease; thus, their careful evaluation in the treatment of migraine headache is essential.

Avaliação dos níveis álgicos de pacientes críticos em terapia intensiva, antes, durante e após sessão de fisioterapia respiratória: um estudo piloto

*** Evaluation of pain levels of critically ill intensive care unit patients, before, during and after a session of chest physical therapy: a pilot study ***AIMS: To evaluate pain levels of critically ill patients before, during, and after a chest physical therapy intervention.METHODS: Pilot study conducted at the intensive care unit (ICU) of a teaching hospital. Sedated and mechanically ventilated adult patients aged 18 to 60 years were selected. Sociodemographic, clinical, and hemodynamic data were analyzed, and the Behavioral Pain Scale (BPS) scale was used to assess pain in patients unable to be evaluated by self-report questionnaires.The physical therapy protocol consisted of manual vibrocompression maneuvers in both hemithoraces and of intratracheal aspiration. The hemodynamic variables and the BPS were analyzed in three periods: immediately before, in the fifth minute of intervention, and immediately after physical therapy. The Shapiro-Wilk test and ANOVA were used for the statistical analyses. The level of significance was p ≤0.05.RESULTS: The sample consisted of 22 patients, most of them male, aged 55±23.8 years. Nosocomial pneumonia the most prevalent pathology. There were no significant differences in hemodynamic variables and in pain assessment (p = 0.78) of the critically ill patients in any of the evaluated periods.CONCLUSIONS: In this sample of critically ill and mechanically ventilated ICU patients , no alterations in pain levels were detected during or after chest physical therapy.

Controlled sedation with midazolam and analgesia with nalbuphine to alleviate pain in patients undergoing subcutaneous implantable cardioverter defibrillator implantation.

Subcutaneous implantable cardioverter defibrillator (S-ICD) is an alternative to transvenous ICD to prevent sudden cardiac death. Subcutaneous ICD implantation frequently requires general anesthesia because of procedure nociceptive steps during creation of a large device pocket and lead tunneling. This study aims to determine if a strategy of operator-guided controlled sedation with midazolam and analgesia with nalbuphine is effective in alleviating pain during S-ICD implantation. This prospective study included consecutive patients undergoing S-ICD implantation under controlled sedation with midazolam and combined analgesia with nalbuphine. The Critical-Care Pain Observation Tool (CPOT), a behavioral pain scale, was used for pain assessment during S-ICD placement and the Numeric Rate Scale (NRS) was used for evaluation of pain recollection after patient recovery. CPOT score of 3 or above and NRS score of 4 or above are considered to be associated with significant pain. Sixteen patients were included in this study: Ten men (62.5%) and six women with a mean age of 54±11years. Indication for S-ICD implantation was primary prevention in 11 patients (68.8%). Mean dose of administrated midazolam and nalbuphine was 0.11±0.03 and 0.27±0.05mg/kg, respectively. Mean CPOT during the whole procedure was 1.4±1.6. No patient presented procedural pain recollection as all 16 patients had NRS score less than 4. No serious adverse event related to sedation occurred during S-ICD implantation. This study suggests that operator-guided controlled sedation with midazolam and analgesia with nalbuphine is effective to alleviate procedural pain in patients undergoing S-ICD implantation and may constitute an alternative to general anesthesia.

Validação da versão Brasileira da Escala Comportamental de Dor ( Behavioral Pain Scale ) em adultos sedados e sob ventilação mecânica

The Behavioral Pain Scale is a pain assessment tool for uncommunicative and sedated Intensive Care Unit patients. The lack of a Brazilian scale for pain assessment in adults mechanically ventilated justifies the relevance of this study that aimed to validate the Brazilian version of Behavioral Pain Scale as well as to correlate its scores with the records of physiological parameters, sedation level and severity of disease.Twenty-five Intensive Care Unit adult patients were included in this study. The Brazilian Behavioral Pain Scale version (previously translated and culturally adapted) and the recording of physiological parameters were performed by two investigators simultaneously during rest, during eye cleaning (non-painful stimulus) and during endotracheal suctioning (painful stimulus).High values of responsiveness coefficient (coefficient=3.22) were observed. The Cronbach's alpha of total Behavioral Pain Scale score at eye cleaning and endotracheal suctioning was 0.8. The intraclass correlation coefficient of total Behavioral Pain Scale score was ≥ 0.8 at eye cleaning and endotracheal suctioning. There was a significant highest Behavioral Pain Scale score during application of painful procedure when compared with rest period (p≤0.0001). However, no correlations were observed between pain and hemodynamic parameters, sedation level, and severity of disease.This pioneer validation study of Brazilian Behavioral Pain Scale exhibits satisfactory index of internal consistency, interrater reliability, responsiveness and validity. Therefore, the Brazilian Behavioral Pain Scale version was considered a valid instrument for being used in adult sedated and mechanically ventilated patients in Brazil.

Pain, Agitation, and Delirium Guidelines: Interprofessional Perspectives to Translate the Evidence.

Societal guidelines exist for the management of pain, agitation, and delirium (PAD) in critically ill patients. This contemporary practice aims for a more awake and interactive patient. Institutions are challenged to translate the interrelated multivariable concepts of PAD into daily clinical practice and to demonstrate improvement in quality outcomes. An interdisciplinary goal-directed approach shows outcomes in high-acuity surgical critical care during the early stages of implementation. This study was a prospective preintervention and postintervention design. A formal PAD clinical practice guideline targeting standardized assessment and "light" levels of sedation was instituted. All mechanically ventilated patients admitted to a 24-bed surgical intensive care unit (ICU) at an academic medical center during a 6-month period were included (3 months before and 3 months after implementation). Sedation and agitation were measured using the Richmond Agitation Sedation Scale (RASS), pain measured using a Behavioral or Numeric Pain Scale (NPS/BPS), and delirium using the Confusion Assessment Method for the Intensive Care Unit. Total ventilator days with exposure to continuous opioid or sedative infusions and total ICU days where the patient received a physical activity session exercising out of bed were recorded. There were 106 patients (54 at preintervention and 52 at postintervention). Mean percentage of RASS scores between 0 to -1 increased from 38% to 50% postintervention (P < .02). Mean percentage of NPS/BPS scores within the goal range (<5 for BPS and <3 for NPS) remained stable, 86% to 83% (P = .16). There was a decrease in use of continuous narcotic infusions for mechanically ventilated patients. This was reported as mean percentage of total ventilator days with a continuous opioid infusing: 65% before implementation versus 47% after implementation (P < .01). Mean percentage of ICU days with physical activity sessions increased from 24% to 41% (P < .001). Overall mean ventilator-free days and ICU length of stay were 5.4 to 4.5 days (P = .29) and 11.75 to 9.5 days (P = .20), respectively. Measureable patient outcomes are achievable in the early stages of PAD guideline initiatives and can inform future systems-level organizational change. Pain, agitation, and delirium assessment tools form the foundation for clinical implementation and evaluation. High-acuity surgical critical care patients can achieve more time at goal RASS, decreased ventilator days, and less exposure to continuous opioid infusions, all while maintaining stable analgesia.

A Longitudinal Randomized Trial of the Effect of Consistent Pain Management for Infant Vaccinations on Future Vaccination Distress.

This randomized controlled trial did not find a long-term benefit of consistent pain management during infant vaccinations on future infant pain responsivity at 15months. The results are relevant to clinicians and researchers studying and evaluating pain interventions in children undergoing medical procedures.

Development and validation of the self-reported PROMIS pediatric pain behavior item bank and short form scale.

Pain behaviors are important indicators of functioning in chronic pain; however, no self-reported pain behavior instrument has been developed for pediatric populations. The purpose of this study was to create a brief pediatric measure of patient-reported pain behaviors as part of the Patient-Reported Outcome Measurement Information System (PROMIS). A pool of 47 candidate items for this measure had been previously developed through qualitative research. In this study, youth with chronic pain associated with juvenile fibromyalgia, juvenile idiopathic arthritis, or sickle cell disease (ages 8-18 years) from 3 pediatric centers completed all 47 candidate items for development of the pain behavior item bank along with established measures of pain interference, depressive symptoms, fatigue, average pain intensity, and pain catastrophizing. Caregivers reported on sociodemographic information and health history. Psychometric properties of the pain behavior items were examined using an item response theory framework with confirmatory factor analysis and examination of differential item functioning, internal consistency, and test information curves. Results were used along with expert consensus and alignment with the adult PROMIS pain behavior items to arrive at an 8-item pediatric pain behavior short form, and all 47 items were retained in a calibrated item bank. Confirmatory factor analysis and correlations with validated measures of pain, pain interference, and psychosocial functioning provided support for the short form's reliability and validity. The new PROMIS pediatric pain behavior scale provides a reliable, precise, and valid measure for future research on pain behavior in school-aged children with chronic pain.

Methods of pain assessment in adult intensive care unit patients - Polish version of the CPOT (Critical Care Pain Observation Tool) and BPS (Behavioral Pain Scale).

Many patients treated in the intensive care unit (ICU) experience pain that is a source of suffering and leaves a longterm imprint (chronic pain, post-traumatic stress disorder). Nearly 30% of patients experience pain at rest, while the percentage increases to 50% during nursing procedures. Pain in ICU patients can be divided into four categories: continuous ICU treatment-related pain/discomfort, acute illness-related pain, intermittent procedural pain and pre-existing chronic pain present before ICU admission. As daily nursing procedures and interventions performed in the ICU may be a potential source of pain, it is crucial to use simple pain monitoring tools. The assessment of pain intensity in ICU patients remains an everyday challenge for clinicians, especially in sedated, intubated and mechanically ventilated patients. Regular assessment of pain intensity leads to improved outcome and better quality of life of patients in the ICU and after discharge from ICU. The gold standard in pain evaluation is patient self-reporting, which is not always possible. Current research shows that the two tools best validated for patients unable to self-report pain are the Behavioral Pain Scale (BPS) and the Critical Care Pain Observation Tool (CPOT). Although international guidelines recommend the use of validated tools for pain evaluation, they underline the need for translation into a given language. The authors of this publication obtained an official agreement from the authors of the two behavioral scales - CPOT and BPS - for translation into Polish. Validation of these tools in the Polish population will aid their wider use in pain assessment in ICUs in Poland.

Factors affecting pain assessment scores in patients on mechanical ventilation

ObjectiveTo determine how respiratory status and other aspects of the patients’ condition affect pain assessments. Methods Pain was assessed in 20 patients aged ≥20 years who underwent cardiovascular surgery, and required postoperative mechanical ventilation in an intensive care unit using the Behavioral Pain Scale (BPS). A BPS score of ≥6 (pain) versus <6 (no pain) was the dependent variable for determining the effect on pain. Results Multiple logistic regression analysis showed that in 99 observations made at rest, pre- and post-turning and pre- and post-tracheal suctioning, the BPS score was significantly affected by gender, the Acute Physiology and Chronic Health Evaluation (APACHE) II score, Richmond Agitation–Sedation Scale score, PaCO2, and HCO3−.The associations between BPS scores and APACHE II scores and HCO3− demonstrated that pain results from biological responses to invasion. Increases in PaCO2 affecting only the total BPS score suggests that PaCO2 is associated with other pain responses, regardless of respiratory status. Conclusion The BPS score was significantly associated with disease severity and ventilatory capacity, demonstrating a need to examine pain assessment methods tailored to the severity of underlying disease, degree of respiratory failure and other aspects of individual patient’s condition for effective pain management.

Pain Measurement in Mechanically Ventilated Patients After Cardiac Surgery: Comparison of the Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT)

The Behavioral Pain Scale (BPS) and Critical-Care Pain Observation Tool (CPOT) are behavioral pain assessment tools for sedated and unconscious critically ill patients. The aim of this study was to compare the reliability, internal consistency, and discriminant validation of the BPS and the CPOT simultaneously in mechanically ventilated patients after cardiac surgery. A prospective, observational cohort study. A 20-bed closed-format intensive care unit with mixed medical, surgical, and cardiac surgery patients in a teaching hospital in Amsterdam, The Netherlands. The study comprised 72 consecutive intubated and mechanically ventilated patients after cardiac surgery who were not able to self-report pain. Two nurses assessed the BPS and CPOT simultaneously and independently at the following 4 moments: rest, a nonpainful procedure (oral care), rest, and a painful procedure (turning). Both scores showed a significant increase of 2 points between rest and turning. The median BPS score of nurse 1 showed a significant increase of 1 point between rest and the nonpainful procedure (oral care), whereas both median CPOT scores did not change. The interrater reliability of the BPS and CPOT showed fair-to-good agreement of 0.74 overall. During the periods of rest 1 and rest 2, values ranged from 0.24 to 0.46. Cronbach's alpha values for the BPS were 0.62 (nurse 1) and 0.59 (nurse 2) compared with 0.65 and 0.58, respectively, for the CPOT. The BPS and CPOT are reliable and valid pain assessment tools in a daily clinical setting. However, the discriminant validation of both scores seems less satisfactory in sedated or agitated patients and this topic requires further investigation.