Critical-Care Pain Observation Tool Research Articles

Effects of Foot Massage on Pain Severity during Change Position in Critically Ill Trauma Patients; A Randomized Clinical Trial.

Objective:To determine the effects of foot massage on pain severity during in unconscious trauma patients admitted to the intensive care unit (ICU). Methods: In this randomized clinical trial (RCT), 80 unconscious trauma patients admitted in the ICU of a hospital in an urban area of Iran were included using the convenience sampling method. They were randomly assigned to the intervention and control groups (n=40 in each group). In both groups, the intensity of pain was measured immediately, 10 minutes after the first change position and without any intervention before the change of position using the Critical Care Pain Observation Tool (CCPOT). In the intervention group, before the second position change, classic foot massage was performed for 20 minutes, but the control group received routine care. Pain was re-evaluated after the change position at desired times. The pain intensity was compared between the two study groups. Results:The baseline characteristics were comparable between the two study groups and no difference was found. There was no statistically significant difference between the mean scores of pain after the change of position (immediately and ten minutes later) before the intervention in the groups (p=0.915 and 0.660, respectively). However, after the intervention, the pain intensity was significantly lower in the intervention groups compared to the control group (p<0.001).Conclusion:Foot massage decreases the pain intensity related to the change of position in unconscious trauma patients admitted in the ICU. Due to its simplicity and low cost, this method can be used along with analgesic drugs to reduce pain in patients.

Using a clinical judgement model to understand the impact of validated pain assessment tools for burn clinicians and adult patients in the ICU: A multi-methods study

BackgroundIntensive care (ICU) patients’ burn pain is difficult to assess, communicate and address, risking chronic pain syndromes and psychological morbidity. AimsTo understand how the introduction of validated pain tools (Critical Care Pain Observation Tool [CPOT], Numerical Rating Scale [NRS], Pain Assessment in Advanced Dementia [PAINAD]) affected clinical judgement processes, analgesia/sedation administration and the experience of burn-injured patients. MethodsConsecutive chart review compared type and amount of analgesia/sedation administered, ventilation time and length of ICU/hospital stay between consecutive burn patients pre- and 6-months post-intervention (n=70). Analysis of 36 qualitative interviews with ICU clinicians (n=12) and burn-injured adults (n=12) pre- and post-intervention was guided by Tanner's (2006) Clinical Judgement Model. ResultsOverall, there was a significant increase in morphine (P=0.04) and propofol (P=0.04) use and a trend towards increased paracetamol (P=0.06) use post-intervention. There was a trend towards greater Midazolam use for TBSA<20% (P=0.06), and significantly increased propofol use for TBSA≥20% (P=0.03). Ventilation time and ICU/hospital length of stay were unchanged.Qualitative analysis revealed complex clinical judgement dependent on the context of the patient's situation, unit culture, background beliefs of clinicians and in knowing the patient. Whilst the CPOT and NRS enhanced analytic reasoning and pain advocacy, the PAINAD appeared redundant. ConclusionsEffective pain assessment, management and advocacy are assisted by evidence-based assessment practices.

Authorized Agent-Controlled Analgesia for Pain Management in Critically Ill Adult Patients.

Patient-controlled analgesia is commonly used for adult patients requiring parenteral opioid analgesia in the postoperative setting. However, many patients are unable to use patient-controlled analgesia because of physical or cognitive limitations. Authorized agent-controlled analgesia, in which a nurse or family member activates the patient-controlled analgesia device, has been studied in the pediatric population but has received little attention in adults. To evaluate the efficacy of authorized agent-controlled analgesia in critically ill adult patients. A retrospective pilot study was conducted involving 46 patients who were placed on an authorized agent-controlled analgesia protocol in a mixed medical/surgical adult intensive care unit. Critical-Care Pain Observation Tool scores were abstracted for the 24 hours before and after initiation of authorized agent-controlled analgesia. Authorized agent-controlled analgesia was administered by nurses only. The mean (SD) change in pain score was -3.4 (2.0) (95% CI, -4.0 to -2.7), representing a 69% decrease in the mean (SD) pain score from before to after initiation of authorized agent-controlled analgesia (4.8 [1.8] vs 1.5 [1.6]; P < .001). When the results were controlled for time, sedative administration, and opioid medication administration, the effect of authorized agent-controlled analgesia initiation on pain scores remained significant (P < .001). Use of authorized agent-controlled analgesia is associated with a reduction in pain in critically ill patients. Larger studies are warranted to confirm these findings.

The Effect of the Open and Closed System Suctions on Pain Severity and Physiological Indicators in Mechanically Ventilated Patients with Traumatic Brain Injury: A Randomised Controlled Trial.

ObjectiveTracheal suctioning can cause pain and physiological indicator variations in patients with traumatic brain injury (TBI). The aim of the present study was to compare pain severity and physiological indicator variations during the closed tracheal suction system (CTSS) and open tracheal suction system (OTSS) in patients with TBI.MethodsThis study was a clinical trial. Samples included all ventilated patients with TBI. The patients were randomly divided into the OTSS and CTSS groups. In both groups, the Critical Care Pain Observation Tool (CPOT) and physiological indicators were recorded by three nurses prior to suctioning, the end of suctioning and 5 min after suction completion. Data were analysed using the independent t-test and repeated measurement tests.ResultsA total of 112 patients participated in the present study. Before the interventions, the mean value of the Glasgow Coma Scale was 6.45±1.13, blood pressure 128.33±20.54, saturated oxygen in arterial blood (SpO2) 96.74±2.76, respiratory rate (RR) 15.06±3.98, end-tidal CO2 (EtCO2) 36.2±21.98, heart rate 82.18±42.33 and CPOT-based pain 0.43±0.94 in the patients. Independent t-test was used to compare CTSS and OTSS, suggesting significant differences with respect to the mean values of SpO2, RR and EtCO2 immediately after suctioning. This test showed significant differences between the two groups with respect to pain intensity at all three points of measurement. The two groups were also found to be significantly different with respect to RR measured 5 min after suctioning (p<0.05).ConclusionCompared to OTSS, CTSS can cause higher reductions in pain levels during and after suctioning in patients with head traumas and can also cause higher improvements in physiological indicators, such as RR, O2 saturation and EtCO2.

Comparison of the Zurich Observation Pain Assessment with the Behavioural Pain Scale and the Critical Care Pain Observation Tool in nonverbal patients in the intensive care unit: A prospective observational study

ObjectivesTo determine the concordance of Zurich Observation Pain Assessment (ZOPA) with the behavioural Pain Scale (BPS) and the Critical Care Pain Observation Tool (CPOT) to detect pain in nonverbal ICU patients. DesignProspective observational study [BASEC-Nr. PB_2016-02324]. SettingA total of 49 ICU patients from cardiovascular, visceral and thoracic surgery and neurology and neurosurgery were recruited. Data from 24 patients were analyzed. Main Outcome MeasurementsThree independent observers assessed pain with the BPS, the CPOT or ZOPA prior, during and after a potential painful nursing intervention. Tools were randomized concerning the pain management after each pain assessment. Frequency of nine additional pain indicating items from a previous qualitative, explorative study was calculated. ResultsZOPA was positive in 32 of 33 measuring cycles (97.0%; 95%CI: 84.2-99.9%), followed by the CPOT (28/33 cycles, 84.8%; 95%CI: 68.1–94.9%) and the BPS (23/33 cycles, 67.0%; 95%CI: 51.3–84.4%). In 22/33 cycles all tools were concordant (66.7%; 95%CI: 48.2-82.0%). Analgesics were provided in 29 out of 33 cycles (87.9%; 95%CI: 71.8–96.6%). Additional pain indicating items were inconsistently reported. ConclusionZOPA is concordant with the BPS and the CPOT to indicate pain but detects pain earlier due to the low threshold value. Inclusion of further items does not improve pain assessment.

Translation into Spanish and Cultural Adaptation of the Critical-Care Pain Observation Tool.

The Critical-Care Pain Observation Tool (CPOT) is recommended for evaluating pain behaviors in patients in the intensive care unit who are unable to report pain. The source of the only published Spanish version of the CPOT does not verify that it underwent a formal translation process. To describe the translation into Spanish and cultural adaptation of the original French version of the CPOT. Key persons in the translation process included one with a master's degree in translation, a critical care physician, nurse faculty members with vast experience in intensive care units, and the instrument's developer. This team followed the Principles of Good Practice for the Translation and Cultural Adaptation Process for Patient-Reported Outcomes Measures as a guide to translate and culturally adapt the CPOT. The first Spanish-language version was back translated to French and was also compared with the English version. Revisions necessitated a second version, which was submitted to experts in critical care. Their modifications required a third version, which was back translated to French and discussed with the CPOT developer, after which a fourth version was created. Finally, a linguistic expert proofread the tool, and the translation leaders incorporated the recommendations, thereby obtaining a final Spanish version. The Spanish version is ready to undergo validation with patients in the intensive care unit, which is the next step toward its use in assessing pain behaviors among patients in intensive care units where Spanish is spoken.

Pain Assessment, Using the Critical Care Pain Observational Tool in Intensive Care Unit. An Observational Study, Lahore, Pakistan

Aim: Aim this study is to determine impact of enforcement of the critical Care Pain Observation Tool (CPOT) on the quantity and frequency of ICU’s management of analgesic. Background: Severely critically admitted patients to the Intensive care unit may also experience from specific painful stimuli, but the evaluation of pain is difficult due to the fact that the maximum number of patients are almost sedated and also unable to self report. Thus, optimizing pain assessment in those sufferers is far-reaching. Pain control or management of the pain is one of furthermost important obligations of staff nurses in an extensive care unit. The Critical Care Pain Observational Tool (CPOT) is the one of important behavioral pain scale that have been developed and tested to detect pain in significantly ill nonverbal adults. Methods: A observational quantitative study is done in a tertiary care hospital in Lahore. Study duration is 4 months, from January 2020 to May 2020. The target population of study is nurses who are working in different type of (Icu) units. Sample size is 200. An observational checklist consisted of 22 items is used as research instrument. Result: No any pain assessment or used any pain tool or intervention done by any staff nurse. Pain assessment checked through direct observation in first phase, In this phase observe nurses pain assessment in 24 hours, physician pain assessment in 24 hours, After direct observation there was held a educational session about pain assessment and pain management according pain observation tool, And then We then carried out this empirical analysis in order to verify the CPOT validity and feasibility through questioners and make it accessible around the staff nurses. Mostly nurses believed that there was sufficient helpful in assessing patients pain by using of CPOT in nursing practice. Conclusion: lThe results of this research indicate that the Critical Care Pain Monitoring Method may be used as a reliable method for pain appraisal in chronically ill adult intubated patients. This method is effective and efficient in patients who are chronically ill with a regimen of analgo-sedation focused on no-hypnotic, opioid-infusion. CPOT ratings were well associated with the self-reported pain experience of patients, and demonstrated outstanding reliability amongst raters. That makes the CPOT’s a powerful method for pain evaluation.

Exploration of the Nociception Level (NOL™) Index for Pain Assessment during Endotracheal Suctioning in Mechanically Ventilated Patients in the Intensive Care Unit: An Observational and Feasibility Study

BackgroundMany patients in the intensive care unit (ICU) suffer from pain and are non-communicative. Therefore, alternative pain measures are necessary. Although behavioral pain measures are available, physiological measures are lacking. The Nociception Level index (NOL™) provides a value from combination of multiple physiological parameters to measure pain and its use in the ICU is new. AimTo explore the use of a multiple physiological parameter measure for pain assessment, the NOL™ index, in mechanically ventilated patients able to self-report pain in the ICU. MethodsA prospective cohort study was performed. Data were collected before, during, and 15 minutes after a non-nociceptive procedure (noninvasive blood pressure using cuff inflation) and a nociceptive procedure (endotracheal suctioning). NOL index, 0 to 10 pain intensity, and Critical-Care Pain Observation Tool (CPOT) scores were also obtained. Data were analyzed using Friedman and Mann-Whitney tests. Feasibility of study procedures was described. ResultsOut of 28 patients who consented, 17 remained eligible and data were analyzed for 15. Technical issues prevented obtaining a NOL signal in 2 patients. NOL values were higher during endotracheal suctioning (median = 41.6) compared with before (median = 11.2) and after the procedure (median = 11.8) and compared with cuff inflation (median = 15.1; Friedman test, p < .001). NOL values were associated with pain intensity and CPOT scores (Mann-Whitney tests, p < .05). ConclusionsThe study procedures with the NOL were found feasible; NOL values could discriminate between nociceptive and non-nociceptive procedures, and values were associated with reference pain measures. Further NOL testing is required in other ICU patient groups and procedures.

Implementing the ABCDE Bundle, Critical-Care Pain Observation Tool, and Richmond Agitation-Sedation Scale to Reduce Ventilation Time.

Prolonged mechanical ventilation of patients in intensive care units across the United States consumes billions of health care dollars every year. Using the awakening and breathing coordination, delirium monitoring/management, and early mobility (ABCDE) bundle along with the Critical-Care Pain Observation Tool and the Richmond Agitation-Sedation Scale combines the best available evidence to optimize outcomes for critically ill patients. This study is the first to examine the effects of implementing the ABCDE bundle, the Critical-Care Pain Observation Tool, and the Richmond Agitation-Sedation Scale together in a coordinated effort across multiple disciplines. The aim of using this combination of evidence-based tools is to reduce ventilation time by reducing oversedation, decreasing the incidence of delirium, and improving pain management.

Effects of the Enhanced Recovery Program on the Recovery and Stress Response in Patients With Cancer Undergoing Pancreatoduodenectomy.

Aim the study was the comparison of enhanced recovery after surgery (ERAS) versus conventional care (CON) protocols in patients undergoing pancreatoduodenectomy with regard to pain intensity, emotional response (optimism/sadness/stress), and stress biomarker levels (adrenocorticotropopic hormone, cortisol). We conducted a prospective two-group randomized controlled study with repeated measures in 85 patients with cancer pancreatoduodenectomy. In the ERAS group (N = 44), the ERAS protocol was followed, compared with the CON group (N = 41). We assessed pain with the numeric rating scale and a behavioral scale (Critical Care Pain Observation Tool), emotional responses (numeric rating scale), and serum adrenocorticotropopic hormone and cortisol levels at three time points: T1, admission day; T2, day of surgery; and T3, discharge day (ERAS) or the fifth day of stay (CON). Data were analyzed by linear mixed modeling to account for repeated measurements. We observed decreased postoperative pain in ERAS patients after adjusting for confounders (p = .002) and a trend for less complications. No significant associations with stress/emotional responses were noted. Only age, but not protocol, appeared to have a significant effect on adrenocorticotropopic hormone levels despite a significant interaction with time toward increased adrenocorticotropopic hormone levels in the ERAS group. In conclusion, despite its fast track nature, ERAS is not associated with increased stress in patients undergoing pancreatoduodenectomy and is associated with decreased pain.

Validation of the Critical Care Pain Observational Tool in Palliative Care

PurposePain assessment at the end of life remains a problem for patients who are unable to self-report their pain when transitioning across care settings. This study therefore tested the internal consistency and discriminant, concurrent, and convergent validity of the Critical-Care Pain Observational Tool (French version) when used with end-of-life patients in a palliative care setting. DesignThis was a descriptive correlational study that used a repeated-measures within-subjects prospective design. MethodsThe pain of 13 patients was assessed when at rest and during turning. ResultsThe internal consistency reliability coefficient alphas were .64 at rest and .70 during turning. Discriminant validity was shown by a decrease in the total Critical-Care Pain Observation Tool score. Concurrent validity was demonstrated by the association between the patients' self-report of pain and the Critical-Care Pain Observation Tool score at rest (0.65, p < .016) and during turning (0.77, p = .002). Finally, the convergent validity between the Critical-Care Pain Observation Tool score and the Algoplus scale score was demonstrated with a Spearman's correlation coefficient of 0.76 at rest and 0.84 during turning. ConclusionsThe results suggest that the Critical-Care Pain Observation Tool can be used with end-of-life patients in French-speaking countries.

Incidence of pain at rest and during nursing procedures in ICU patients: a longitudinal observational study.

To evaluate pain monitoring in surgical and no-surgical ICU patients and to observe the presence of pain at rest and during nursing procedures. A longitudinal, observational study was conducted at an intensive care unit in Italy. Based on the specific conditions of the patient the best rating scale was used (Numerical Rating Scale or the Critical-Care Pain Observation Tool). Two ICU nurses performed pain assessments before and during some nursing procedures that are considered nociceptive. The pain incidence rate in 1,602 days of observation was 0.06 patient/day (59/1000 days of observation). The incidence rate of intense pain was 0.012 patient/day (12/1000 days of observation). Pain at rest was detected in 67 (27.6%) patients. Pain during procedures was found 134 (36.1%) times. In the 96 patients who were in pain the ICU stay (15.4 days + 7.8 vs 11.4 days + 5.6) and the days of mechanical ventilation (13.4 + 7.9 vs 9.7 + 4.9) was increased. Surgical patients had an increased pain risk than non-surgical patients (RR = 2.7, CI = 2.0-3.6; p<.001). The incidence of pain was recorded in 39.5% of ICU patients. However further studies of larger patient samples are needed.

Movements and trends in intensive care pain treatment and sedation: What matters to the patient?

Oversedation, delirium and immobilisation in the intensive care unit are associated with increased length of stay in the unit. Routines of systematic pain and sedation assessment and the use of valid tools are highly stressed in international guidelines. For improving the quality of pain treatment and sedation in a Norwegian intensive care unit, in 2009-2015, we compared supplementation with an analgosedation approach and the existing systematic approach, measured by the adherence to current international pain, sedation and delirium guidelines. In a longitudinal study following the Standards for Reporting Implementation Studies, pain, sedation, delirium and mobilisation data from patients' complete intensive care unit stays, encompassing three separate periods of 4-6months, were compared. The primary outcome was adherence to current protocol including assessment and documentation of patients' level of pain, sedation and prevalence of delirium at least every 8hr, early mobilisation and titration towards a light level of sedation. We included 205 patients, corresponding to 1,607 patient intensive care unit days. The patient sedation levels, measured by the Richmond Agitation and Sedation Scale, decreased significantly, from -2.2 in 2009--1.7 in 2015, so did the amount of administrated propofol. Mean pain scores measured by the numeric rating scale during activity were maximum 3.1 in 2014, decreasing to 2.2 in 2015. In patients not able to self-report, pain mean scores were 1.7 in 2014 and 1.6 in 2015, measured by the Critical Care Pain Observational Tool. The number of patients unable to assess for delirium decreased significantly. By discounting the group of patients unable to assess, the prevalence of delirium varied from 32%, 25% and 33%. The goal of having an awake patient able to cooperate, with acceptable levels of pain, was gradually achieved during a 6-year period. The results showed that pain treatment and sedation in the intensive care unit primarily succeeded in the setting of an established routine of systematic assessment and documentation. The results of the study draw attention to pain treatment, sedation and delirium in intensive care patients, as well as implementation strategies aimed at achieving healthcare personnel's adherence to international guidelines in clinical practice.

A Psychometric Analysis Update of Behavioral Pain Assessment Tools for Noncommunicative, Critically Ill Adults.

This is an updated, comprehensive review of the psychometric properties of behavioral pain assessment tools for use with noncommunicative, critically ill adults. Articles were searched in 5 health databases. A total of 106 articles were analyzed, including 54 recently published papers. Nine behavioral pain assessment tools developed for noncommunicative critically ill adults and 4 tools developed for other non-communicative populations were included. The scale development process, reliability, validity, feasibility, and clinical utility were analyzed using a 0 to 20 scoring system, and quality of evidence was also evaluated. The Behavioral Pain Scale, the Behavioral Pain Scale-Nonintubated, and the Critical-Care Pain Observation Tool remain the tools with the strongest psychometric properties, with validation testing having been conducted in multiple countries and various languages. Other tools may be good alternatives, but additional research on them is necessary.

The German version of the Critical-Care Pain Observation Tool for critically ill adults : Aprospective validation study.

The implementation of the Critical-Care Pain Observation tool (CPOT) in intensive care units (ICU) has been associated with more frequent pain assessments, areduced number of complications, and improved administration of analgesics and sedatives. So far no German translation exists. Translating this tool into foreign languages requires further validation testing. The aim of this prospective observational validation study was to translate the original version of the CPOT according to scientific principles for translation and to establish the validity and reliability of the German translation of CPOT for critically ill adult patients. A total of 292 cardiac surgery patients from 2 ICUs of 2 German university teaching hospitals were included (114 patients at center1 and 178 patients at center2). Of the included patients 22.6% were female and 76.4% were male with amean age of 68.5 years ±9.3SD. Pain was evaluated with the CPOT, the Bhavioral Pain Scale (BPS) and with the Numeric Rating scale (NRS) at three time points (1.intubated + sedated, 2.intubated + awake, 3.extubated + awake) at rest and during nociceptive stimulus (positioning). Assessments were made separately by trained physicians and nursing staff. Good results for interrater reliability and internal consistency could be demonstrated (weighted Cohen's kappa of 0.73, Cronbach's coefficient alpha of 0.8). Spearman correlation between CPOT and NRS was moderate but significant. The receiver operating characteristic (ROC) analysis to obtain optimal thresholds of CPOT to detect pain revealed different results during rest and stimulus and in intubated and extubated patients. The validated German CPOT translation is areliable tool for pain assessment in cardiac ICU patients in the absence of patients' ability for self-reporting. The use of this German version of CPOT now allows abetter international comparability of corresponding data in future studies.

Analgesic sparing effects of Dexmedetomidine in surgical intensive care patients

Background: Dexmedetomidine (Dex) is a sedative agent with analgesic property.1,2 A recent review of the literature has shown clear advantages over the traditional sedation namely lesser respiratory depression, less delirium, better sedation, analgesia, organ protection and anti-shivering effect.3,4 Optimal sedation in critically ill patients is of vital importance, under sedation will raise work of breathing and causes adverse hemodynamic effects. Whereas over sedation will lead to increased number of imaging studies and higher morbidity and mortality.4,5 The aim of our study was to investigate the efficacy of dexmedetomidine (Dex), its use in intubated patients and post-extubation period, rescue sedation, safety and analgesic sparing effect in critically ill surgical patients. Patients and Methods: All patients sedated with dexmedetomidine (Dex) in the surgical intensive unit of a tertiary healthcare facility were included prospectively in the study. Patients' demographic data, diagnosis, surgical interventions, traditional sedation, Dex dosage and days, post-extubation Dex use, general adverse effects, adverse effects associated with lower or higher Dex doses, analgesic, and rescue sedation requirements were recorded. Patients were intubated and ventilated, the initial dose of Dex infusion was 0.5 mcg/kg/hr along with either fentanyl or remifentanil infusion. Dex infusion was titrated to keep the Ramsay sedation score of 3 to 4. Analgesia was titrated according to the NRS (numeric rating scale) in extubated patients and the Critical-Care Pain Observation Tool (CPOT) score in intubated patients. The infusion of fentanyl and remifentanil were titrated and decreased according to the CPOT score. Some of the patients extubated required continuation of the Dex infusion in the post-extubation period to maintain analgesia and to keep them calm.Chi-square test was performed to compare among the groups. P-value ≤ 0.05 was considered as statistically significant. Results: A total of 428 patients were enrolled in the study. The majority of patients were male (73.3%). The most common diagnosis was acute abdomen and frequently the performed surgery was laparotomy (28.9%) (Figure 1a). The duration of Dex treatment ranged from 2 to 28 days; the most commonly used dose was 0.5 to 1.4 μg/kg/hours (Figure 1b). Seventy-eight percent (78%) of patients required Dex in the post-extubation period at a dose of 0.2 μg /kg/hours. There was significant reduction in the analgesic requirements in the post-Dex period (p < 0.001) (Table 1(a)). Adverse effects such as bradycardia 6.1%, hypertension 4% and hypotension 1.6% were observed (Figure 2) and there was no significant difference in lower and higher dose of Dex and occurrence of adverse effects (p < 0.82). Patients administered a higher dose of Dex required significantly higher rescue traditional sedation (p < 0.01) (Table 1(b)). Conclusion: We used dexmedetomidine in different surgical critical patients. The occurrence of adverse effects such as bradycardia, hypotension and hypertension were comparable to that mentioned in the literature. There was a significant analgesia sparing effect of dexmedetomidine. We continued Dex in the post-extubation period and the effective dose used was 0.2 mcg/kg/hour. There was no significant difference in occurrence of adverse effects with lower and higher range of Dex. The patients on a higher dose of Dex needed more rescue traditional sedation.

Pain assessment in critically ill patients in low resource countries

We attempted to review the published literature to find out the status of pain assessment in critically ill patients (CIPs) managing in ICUs of low resource countries. We used broad electronic database (2004-2018) from common search engines. Evidence showed that 33%-61% of the patients in ICU experienced pain at rest and among them 10%-33% of patients experienced moderate to severe pain in developed countries. Prevalence of pain is expected to be high in low resource countries due to huge disease burden of CIPs. The gold standard of pain assessment is self-reporting; however, this is not possible when patients in ICU are unable to communicate. Alternatively, Behavioral Pain Scale (BPS) and Critical Care Pain Observation Tool (CPOT) can be used in this population. These methods/tools are being used in developed countries, however, no evidence is available in low resource countries. The dynamic nature of pain in ICU patients justifies regular pain assessment in all ICU settings. Authors strongly recommend that pain should be objectively assessed in all ICU patients regardless of age and gender using reliable and validated tools like BPS or CPOT.Citation: Afshan G, Siddiqui S. Pain assessment in critically ill patients in low resource countries. Anaesth Pain &amp; Intensive Care 2018;22 Suppl 1:S83-S87

Non-cardio respiratory monitoring of mechanically ventilated critically ill patients

Critically ill patients often require multiple organ supports; respiratory support in terms of mechanical ventilation (MV) is one of the commonest. But, only providing an organ support contributes less to the complete well being of the patients. Moreover, MV itself can affect various physiological systems, metabolic response, and cause side effects. A very close temporal relationship exists between patients, monitoring and management decision too, and therefore, appropriate information from monitoring can lead to better outcomes. The present review is intended to briefly highlight the current opinions and strategies for non cardio-respiratory monitoring in such critically ill patients.Abbreviations: AKI-Acute Kidney Injury; APACHE-Acute Physiology and Chronic Health Evaluation; BPS-Behavioral Pain Scale; CAM-ICU-Confusion Assessment Method for the Intensive Care Unit; CPOT–Critical Care Pain Observation Tool; EVLWI-Extra vascular lung water index; FDA-Food and Drug Administration; ISO-International Organization for Standardization; ICU-Intensive Care Unit; LOS-Length of stay; MODS-Multiple Organ Dysfunction Score; MV-Mechanical Ventilation; PaO2-Partial pressure of arterial oxygen; FiO2-Fraction of inspired oxygen; SAPS-Simplified Acute Physiologic Score; RASS-Richmond Agitation Sedation Scale; SOFA-Sequential Organ Failure Assessment; SAS-Sedation Agitation Scale; UO-Urine outputCitation: Panda CK, Karim HMR, Singha SK. Non-cardio respiratory monitoring of mechanically ventilated critically ill patients. Anaesth Pain &amp; Intensive Care 2018;22 Suppl 1:S150-S159Received: 9 Jul 2018 Reviewed: 1 Oct 2018 Corrected &amp; Accepted: 9 Oct 2018

P-CPOT: An Adaptation of the Critical-Care Pain Observation Tool for Pediatric Intensive Care Unit Patients

BackgroundThe Pediatric Critical-Care Observation Tool (P-CPOT) is an adaption of the Critical-Care Pain Observation Tool (CPOT) originally designed to assess pain in nonverbal critically-ill adults. AimThe study validated the P-CPOT in assessing nociceptive procedure pain in pediatric intensive care unit (PICU) children who are unable to verbalize pain. MethodsContent validity was tested using a two-round expert panel review with 8 experts. With a sample of 78 PICU patients, prospective repeated measures were designed to detect the change over time at pre- (T1), during (T2), and post- (T3) for routinely scheduled nociceptive procedures. Each measure was independently completed by two raters using two scales, the P-CPOT and the FLACC (Faces, Legs, Activity, Cry and Consolability). ResultsAll categories had Item-level content validity indices of 0.88 to 1.00. A one-factor structure containing 5 items was established and accounted for 85% variance in P-CPOT scores. Inter-rater reliability was substantial with correlation coefficient of 0.996 and Kappa value of 0.90. A threshold value of 4 resulted in excellent balance between sensitivity (98.6%) and specificity (97.6%). Both tools detected the score changes over time (p = .025). P-CPOT had a larger effect size (Cohen’s d = 4.1) as well as a higher score than FLACC at T2 (p = .039). Linear regression revealed that patients being ventilated tended to have a P-CPOT score of 1.1 higher than the FLACC score while controlling for heart rates (p < .001), meaning that P-CPOT is more sensitive than FLACC for detecting pain increase during nociceptive procedures in ventilated patients. ConclusionThe P-CPOT is a valid scale for assessing pain in PICU patients with very good psychometric performance. It is especially adept in detecting pain in ventilated patients.

Pain Screening in the Older Adult With Delirium

BackgroundIn patients with cognitive impairments who are unable to self-report pain, nurses must rely on behavioral observation tools to assess and manage pain. Although frequently employed in medical-surgical units, evidence supporting the psychometric efficacy of the Pain in Advanced Dementia (PAINAD) for pain screening in older adults with delirium is lacking. AimTo examine the psychometrics of the PAINAD for older adults with delirium in medical-surgical settings. DesignA descriptive repeated measures design. SettingMedical-surgical units in an urban tertiary care hospital. ParticipantsSixty-eight older adults with delirium. MethodsPatients with delirium unable to self-report pain were screened by two data collectors with the PAINAD and the Critical Care Pain Observation Tool (CPOT). Patients with a PAINAD score ≥3 or a CPOT score ≥2 received a pain intervention. Pain assessments were repeated 30 minutes post baseline or pain intervention. ResultsPatients were predominately female (58.8%) with dementia (71%). Thirty-nine patients screened positive for pain and received a pain intervention. PAINAD reliability was strong (Cronbach's α = 0.81-0.87; interrater intraclass coefficients [ICC] = 0.91-0.94; test-retest ICC = 0.76-0.77). Construct validity was supported by a statistically significant interaction effect between time (baseline versus follow-up) and condition (pain intervention versus no pain group; Rater 1: F(1,66) = 8.31, p = 0.005, ηp2 = 0.11; Rater 2: F(1,66) = 8.22, p = 0.006, ηp2 = 0.11. ConclusionsThe PAINAD is a reliable and valid tool for pain screening for older adults with delirium in medical-surgical settings. Clinical ImplicationsPain and delirium frequently co-occur in the older adult population. Best practices require a holistic assessment for contributing pain and non-pain factors in patients exhibiting distress.