Use of a Behavioural Pain Scale to assess pain in ventilated, unconscious and/or sedated patients.

UNLABELLED: Current empirical evidence supports claims that pain in sedated, unconscious Intensive Care Unit (ICU) patients is underrated and under-treated. Given the severity of ICU patients' illness pain management, whilst important, may not be considered a priority and therefore can be easily overlooked. The aim of this study was to validate the Behavioural Pain Scale (BPS) for the assessment of pain in critically ill patients by evaluating facial expressions, upper limb movements and compliance with mechanical ventilation. METHODS: A prospective, descriptive repeated measures study design was used to assess the validity and reliability of the BPS for assessing pain in critically ill patients undergoing routine painful (repositioning) and non-painful (eye care) procedures. RESULTS: An average of 73% of BPS scores increased (indicating pain) after patients were repositioned, as opposed to 14% after eye care. This increase was statistically significant for repositioning (p < 0.003) but not for eye care (p > 0.3). The odds of an increase in BPS between pre- and post-procedure assessments was more than 25 times higher for repositioning compared with eye care (p < 0.0001), after controlling for analgesics and sedatives. CONCLUSION: The BPS was found to be a valid and reliable tool in the assessment of pain in the unconscious sedated patient. Results also highlighted that traditional pain indicators, such as fluctuations in haemodynamic parameters, are not always an accurate measure for the assessment of pain in unconscious patients and as such more objective pain assessment measures are essential. Finally, further validation of the BPS and identification of other painful routine procedures is needed to enhance pain management delivery for unconscious patients.

Patients' self-report of procedural pain in the intensive care unit.

AIM: To determine which routine nursing procedures performed on conscious intensive care unit (ICU) patients were painful and which routine procedures were not painful. BACKGROUND: Current empirical evidence supports that routine procedures are often not viewed in the context of causing pain to the critically ill patient. Given the complexity of illness and the need to prioritize care in ICU patients, clinicians may not consider routine procedures as causing pain. With patients in intensive care undergoing frequent routine procedures, greater understanding of which procedures inflict pain is warranted to improve patient care and inform and shape nursing practice. DESIGN: A prospective, descriptive study using a convenience sample of ICU patients was used. METHODS: Sixty-one patients were asked to rate pain intensity experienced prior to and during a routine nursing procedure using a verbal numeric rating scale. The procedures observed were turning, tracheal suctioning, line removal, deep breathing and coughing exercises, simple dressings and drain removal. RESULTS: Results showed that certain routine procedures cause pain with significant differences observed between pre- and postprocedure pain scores for drain removal (p = 0.042), deep breathing and coughing exercises (p = 0.003), suctioning (p = 0.025), positional change (p = 0.000) and line removal (p = 0.010). A higher proportion of morphine was administered to those patients undergoing drain removal (50%), deep breathing and coughing exercises (38.5%) and turns (32.6%) but results show that <50% of patients actually received analgesia. Heart rate, systolic and diastolic blood pressure all increased slightly postprocedure but were not found to be statistically significant. CONCLUSION: Haemodynamic measures are not suitable indicators for the presence of pain. Nurses need to recognise that certain routine procedures can cause pain and should therefore plan patient care with this in mind. RELEVANCE TO CLINICAL PRACTICE: Nurses need to recognise of the fact that routine procedures can cause pain and to use analgesia appropriately to minimize this pain. Practice guidelines should recommend that pain relieving measures be considered as part of routine procedural instructions. Analgesic prescription and administration could be improved for this patient group.

Review of analgesia use in the intensive care unit after heart surgery.

OBJECTIVE: To investigate analgesic prescription patterns and administration in postoperative cardiac surgery patients in the ICU in a tertiary hospital. METHOD: The audit was registered with the institutional Quality Improvement Committee. A sample of 73 postcardiac surgery patients who were admitted to the ICU during a 12-month period in 2003-2004 were reviewed. RESULTS: All patients received opioid analgesia in the ICU. On the first postoperative day, patients received a mean of 1.27 mg morphine equivalents per hour, while the 25 patients present in the ICU for a second day received a mean of 0.84 mg morphine equivalents per hour. No relationship was seen between Day 1 administration of analgesia and age, sex or use of an internal mammary artery (IMA) graft or Day 2 administration and sex or use of IMA. A slight negative relationship existed between morphine administered on Day 2 and age (r = ?0.38, P = 0.06). Paracetamol or paracetamol plus codeine (8 mg or 30 mg) was administered to 70 patients (96%), but was prescribed 6-hourly in 24 patients (33%) and actually administered 6- hourly in 32 (44%). No analgesia was administered in 23% of patients before removal of chest drains. The average time to extubation was 15.7 h (SD, 12.1 h). A moderate correlation between time to extubation and morphine equivalents per hour on Day 1 was demonstrated (r=0.43, P < 0.001). The average duration of ICU stay was 28.1 h. A routine pain assessment score was not charted for any the 73 patients. CONCLUSION: We recommend introducing scoring of patient pain in the ICU, both at rest and with movement, and provision of a designated area on the ICU flow chart for these scores. Paracetamol or other simple analgesics could be prescribed regularly, and staff need education about premedication of patients before removal of chest drains.