Appropriateness of behavioural scales in the monitoring of pain in the critically ill patient unable to self-report.

Appropriateness is a dimension of quality that evaluates the effective use of technologies, resources or interventions in specific situations or populations, assessing whether our interventions do more benefit than harm. The evidence regarding pain monitoring in the critically ill patient points to the periodic assessment of pain using appropriate tools, with the aim of improving pain management and more efficient use of analgesics in the intensive care unit. The first step would be to assess the patient's ability to communicate or self-report and, based on this, to select the most appropriate pain assessment tool. In patients who are unable to self-report, behavioural pain assessment tools are recommended. When we talk about the suitability of behavioural scales for pain monitoring in critically ill patients unable to self-report, we refer to their use with a clear clinical benefit, i.e. using the right tool for pain assessment to be effective, efficient and consistent with bioethical principles. To our knowledge, there are no published data on the suitability of pain assessment tools in unable to self-report critically ill patients, so, in the framework of continuous quality improvement in pain care, new research should incorporate this approach by integrating the best scientific evidence with current clinical practice.

Assessment of analgesia, sedation, physical restraint and delirium in patients admitted to Spanish intensive care units. Proyecto ASCyD. / Valoración de la analgesia, sedación, contenciones y delirio en los pacientes ingresados en unidades de cuidados intensivos españolas. Proyecto ASCyD.

AIMS: Main aim: To determine the Spanish intensive care units (ICU) that assess and record pain levels, sedation/agitation, delirium and the use of physical restraint (PR) as standard practice. Secondary aims: To determine the use of validated assessment tools and to explore patients' levels of pain and sedation/agitation, the prevalence of delirium, and the use of PR. METHOD: An observational, descriptive, cross-sectional, prospective and multicentre study using an ad hoc survey with online access that consisted of 2 blocks. Block I: with questions on the unit's characteristics and routine practice; Block II: aspects of direct care and direct assessments of patients admitted to participating units. RESULTS: One hundred and fifty-eight units and 1574 patients participated. The pain of communicative patients (CP) was assessed and recorded as standard in 109 units (69%), the pain of non-communicative patients (NCP) in 84 (53%), sedation/agitation in 111 (70%), and delirium in 39 units (25%). There was recorded use of PR in 39 units (25%). Validated scales were used to assess the pain of CP in 139 units (88%), of NCP in 102 (65%), sedation/agitation in 145 (92%), delirium in 53 units (34%). In 33 units (21%) pain, sedation/agitation and delirium of PC and NPC was assessed, and in 8 of these units there was a specific PR protocol and register. Among the patients who could be assessed, an absence of pain was reported in 57%, moderate pain in 27%; 48% were calm and collaborative, and 10% agitated; 21% had PR, and 12.6% of the patients had delirium. CONCLUSIONS: The assessment of pain, sedation and delirium is demonstrated, and low percentages of agitation and delirium achieved. We observed a high percentage of patients with pain, and moderate use of PC. We should generalise the use of protocols to assess, prevent and treat pain and delirium by appropriately managing analgesia, sedation, and individual and well-considered use of PC. (ClinicalTrials.gov Identifier: NCT03773874).

Psychometric validation of the behavioral indicators of pain scale for the assessment of pain in mechanically ventilated and unable to self-report critical care patients.

OBJECTIVE: To assess the psychometric properties of the behavioral indicators of pain scale (ESCID) when applied to a wide range of medical and surgical critical patients. DESIGN: A multicentre, prospective observational study was designed to validate a scale measuring instrument. SETTING: Twenty Intensive Care Units of 14 hospitals belonging to the Spanish National Health System. PARTICIPANTS: A total of 286 mechanically ventilated, unable to self-report critically ill medical and surgical adult patients. PROCEDURE: Pain levels were measured by two independent evaluators simultaneously, using two scales: ESCID and the behavioral pain scale (BPS). Pain was observed before, during, and after two painful procedures (turning, tracheal suctioning) and one non-painful procedure. MAIN VARIABLES: ESCID reliability was measured on the basis of internal consistency using the Cronbach-α coefficient. Inter-rater and intra-rater agreement were measured. The Spearman correlation coefficient was used to assess the correlation between ESCID and BPS. RESULTS: A total of 4386 observations were made in 286 patients (62% medical and 38% surgical). High correlation was found between ESCID and BPS (r=0.94-0.99; p<0.001), together with high intra-rater and inter-rater concordance. ESCID was internally reliable, with a Cronbach-α value of 0.85 (95%CI 0.81-0.88). Cronbach-α coefficients for ESCID domains were high: facial expression 0.87 (95%CI 0.84-0.89), calmness 0.84 (95%CI 0.81-0.87), muscle tone 0.80 (95%CI 0.75-0.84), compliance with mechanical ventilation 0.70 (95%CI 0.63-0.75) and consolability 0.85 (95%CI 0.81-0.88). CONCLUSION: ESCID is valid and reliable for measuring pain in mechanically ventilated unable to self-report medical and surgical critical care patients. CLINICALTRIALS.GOV: NCT01744717.

[Evaluation of immediate post-operative pain in heart surgery using the Behavioural Pain Scale]. / Valoración del dolor durante el postoperatorio inmediato de cirugía cardiaca mediante la Behavioural Pain Scale.

INTRODUCTION: Patients in the immediate postoperative period of cardiac surgery have abolished communication skills and therefore can not express pain. Pain produces significant adverse effects that alter the patients' course. Therefore, identifying and controlling them will lead to increased quality of care for the critical patient. OBJECTIVE: To measure the degree of pain in patients in the immediate postoperative period of cardiac surgery by scaling Behavioural Pain Scale. MATERIAL AND METHOD: An observational, prospective and longitudinal. Patients over 18 years in the first 24 hours of admission with no communication problems who were under sedation and subjected to mechanical ventilation were included. Twenty patients were enrolled in the study. The Behavioural Pain Scale (BPS) was used during two procedures usually considered as a painful practice in the literature, that is, mobilization and/or postural changes and aspiration of secretions. RESULTS: Twenty-seven measurements were made of procedures considered as painful. The results obtained by applying the scale BPS showed that 70.4% of patients had no pain, 22.2% had mild to moderate pain and 7.4% had unacceptable pain. CONCLUSION: This study has identified that the patients suffer pain during the postoperative period. Within these patients, there is a small, but not insignificant number whose pain is unacceptable during this period. This finding serves as a beginning for a line of research to improve the handling of the postoperative pain during immediate post-operative cardiac surgery.

[Validation of the Scale of Behavior Indicators of Pain (ESCID) in critically ill, non-communicative patients under mechanical ventilation: results of the ESCID scale]. / Validación de la Escala de Conductas Indicadoras de Dolor para valorar el dolor en pacientes críticos, no comunicativos y sometidos a ventilación mecánica: resultados del proyecto ESCID.

OBJECTIVE: To determine the reliability and validity of the "Scale of Behavior Indicators of Pain" (Escala de Conductas Indicadoras de Dolor: ESCID) as a tool to assess pain in the critically ill, non-communicative patients with mechanical ventilation. METHODS: An observational study of development and validation of this scale as an instrument for pain measurement in ICU patients over 18 years of age, who are uncommunicative and under mechanical ventilation. Their pain was assessed with the Behavioral Pain Scale (BPS) and the ESCID simultaneously, by two independent observers, when the painful maneuvers (PM), secretion aspiration and mobilization, were applied. Measurements were obtained before, during and after the PM. A descriptive analysis of the general characteristics of the population was carried out. The reliability of the ESCID was measured through the internal consistency of each item using Cronbach's alpha. Intraobserver and interobserver concordance was measured with the repeated measurements analysis of variance test. The components of the two pain scales were compared to obtain the change between the results obtained based on time, observer and procedure. The correlation between the scales was measured with the Pearson's correlation. RESULTS: A total of 480 observations were obtained in 42 patients, 62% were males; age 57.33 ± 16.35 years. The most frequent ICU admission was due to infectious disease (36%) and neurological disease (35%). Glasgow Coma Scale 8.45±1.2 and Richmond Agitation-Sedation Scale -2.55±1.5. Arterial blood pressure, heart rate and respiratory rate remained stable. Cronbach's s Alpha Coefficient for ESCID ranged from 0.70-0.80. There is a good correlation between the ESCID and BPS in the three measurement points in time: Pearson's correlation: before 0.97, during 0.94 and after 0.95. CONCLUSIONS: ESCID is a reliable and valid tool to assess pain in critically ill, non-communicative patients under mechanical ventilation.