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Behavioral changes in brain-injured critical care adults with different levels of consciousness during nociceptive stimulation: an observational study

Marie-José Roulin| Anne-Sylvie Ramelet
Original
Volume 40, Issue 8 / August , 2014

Pages 1115 - 1123

Abstract

Purpose

The primary objective of this study was to describe the frequency of behaviors observed during rest, a non-nociceptive procedure, and a nociceptive procedure in brain-injured intensive care unit (ICU) patients with different levels of consciousness (LOC). Second, it examined the inter-rater reliability and discriminant and concurrent validity of the behavioral checklist used.

Methods

The non-nociceptive procedure involved calling the patient and shaking his/her shoulder. The nociceptive procedure involved turning the patient. The frequency of behaviors was recorded using a behavioral checklist.

Results

Patients with absence of movement, or stereotyped flexion or extension responses to a nociceptive stimulus displayed more behaviors during turning (median 5.5, range 0–14) than patients with localized responses (median 4, range 0–10) or able to self-report their pain (median 4, range 0–10). Face flushing, clenched teeth, clenched fist, and tremor were more frequent in patients with absence of movement, or stereotyped responses to a nociceptive stimulus. The reliability of the checklist was supported by a high intra-class correlation coefficient (0.77–0.92), and the internal consistency was acceptable in all three groups (KR 20, 0.71–0.85). Discriminant validity was supported as significantly more behaviors were observed during nociceptive stimulation than at rest. Concurrent validity was confirmed as checklist scores were correlated to the patients’ self-reports of pain (rs = 0.53; 95 % CI 0.21–0.75).

Conclusion

Brain-injured patients reacted significantly more during a nociceptive stimulus and the number of observed behaviors was higher in patients with a stereotyped response.

Keywords

References

  1. Gelinas C, Harel F, Fillion L, Puntillo KA, Johnston CC (2009) Sensitivity and specificity of the critical-care pain observation tool for the detection of pain in intubated adults after cardiac surgery. J Pain Symptom Manage 37(1):58–67. doi:10.1016/j.jpainsymman.2007.12.022
    • View reference on PubMed
    • View reference on publisher's website
  2. Payen JF, Francony G, Canet C, Coppo F, Fauvage B (2009) Sedation in neurointensive care unit. [Neurosédation en réanimation]. Ann FR Anesth 28(12):1015–1019
    • View reference on publisher's website
  3. Gottschalk A, Yaster M (2008) The perioperative management of pain from intracranial surgery. Neurocrit Care 10(3):387–402. doi:10.1007/s12028-008-9150-3
    • View reference on PubMed
    • View reference on publisher's website
  4. Payen JF, Bru O, Bosson JL, Lagrasta A, Novel E, Deschaux I et al (2001) Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med 29(12):2258–2263
    • View reference on PubMed
    • View reference on publisher's website
  5. Chanques G, Payen JF, Mercier G, de Lattre S, Viel E, Jung B et al (2009) Assessing pain in non-intubated critically ill patients unable to self report: an adaptation of the behavioral pain scale. Intens Care Med 35(12):2060–2067. doi:10.1007/s00134-009-1590-5
    • View reference on publisher's website
  6. Gelinas C, Fillion L, Puntillo KA, Viens C, Fortier M (2006) Validation of the critical-care pain observation tool in adult patients. Am J Crit Care 15(4):420–427
    • View reference on PubMed
  7. Gelinas C, Johnston C (2007) Pain assessment in the critically ill ventilated adult: validation of the critical-care pain observation tool and physiologic indicators. Clin J Pain 23(6):497–505. doi:10.1097/AJP.0b013e31806a23fb
    • View reference on PubMed
    • View reference on publisher's website
  8. Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF et al (2013) Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 41(1):263–306. doi:10.1097/CCM.0b013e3182783b72
    • View reference on PubMed
    • View reference on publisher's website
  9. Radtke FM, Heymann A, Franck M, Maechler F, Drews T, Luetz A et al (2012) How to implement monitoring tools for sedation, pain and delirium in the intensive care unit: an experimental cohort study. Intensive Care Med 38:1974–1981. doi:10.1007/s00134-012-2678-x
  10. Chanques G, Sebbane M, Barbotte E, Viel E, Eledjam JJ, Jaber S (2007) A prospective study of pain at rest: incidence and characteristics of an unrecognized symptom in surgical and trauma versus medical intensive care unit patients. Anesthesiology 107(5):858–860. doi:10.1097/01.anes.0000287211.98642.51
    • View reference on PubMed
    • View reference on publisher's website
  11. Topolovec-Vranic J, Gelinas C, Li Y, Pollman-Mudryj MA, Innis J, McFarlan A et al (2013) Validation and evaluation of two observational pain assessment tools in a trauma and neurosurgical intensive care unit. Pain Res Manag 18(6):e107–e114
    • View reference on PubMed
  12. Roulin MJ, Goulet C, Ramelet AS (2011) Critical review of instruments to assess pain in the non communicative brain injured persons in intensive care (Revue critique d’instruments pour évaluer la douleur chez les personnes cérébrolesées non communicantes aux soins intensifs). Rech Soins Infirm 104:64–85
    • View reference on PubMed
  13. Gelinas C, Arbour C (2009) Behavioral and physiologic indicators during a nociceptive procedure in conscious and unconscious mechanically ventilated adults: similar or different? J Crit Care 24(4):628. doi:10.1016/j.jcrc.2009.01.013
    • View reference on PubMed
    • View reference on publisher's website
  14. Arbour C, Choiniere M, Topolovec-Vranic J, Loiselle CG, Puntillo KA, Gelinas C (2014) Detecting pain in traumatic brain injured patients with different levels of consciousness during common procedures in the ICU: typical or atypical behaviors? Clin J Pain. doi:10.1097/AJP.0000000000000061
    • View reference on PubMed
  15. Chatelle C, Majerus S, Whyte J, Laureys S, Schnakers C (2012) A sensitive scale to assess nociceptive pain in patients with disorders of consciousness. J Neurol Neurosurg Psychiatry 83(12):1233–1237. doi:10.1136/jnnp-2012-302987
    • View reference on PubMed
    • View reference on publisher's website
  16. Schnakers C, Zasler ND (2007) Pain assessment and management in disorders of consciousness. Curr Opin Neurol 20(6):620–626. doi:10.1097/WCO.0b013e3282f169d9
    • View reference on PubMed
    • View reference on publisher's website
  17. Roulin MJ, Ramelet AS (2012) Pain indicators in brain-injured critical care adults: an integrative review. Aust Crit Care 25(2):110–118. doi:10.1016/j.aucc.2011.10.002
    • View reference on PubMed
    • View reference on publisher's website
  18. Roulin MJ, Ramelet AS (2011) Indicators used by clinicians to assess pain in the brain injured. Intensive Care Med 37(Suppl 1):S182
  19. Puntillo KA, Pasero C, Li D, Mularski RA, Grap MJ, Erstad BL et al (2009) Evaluation of pain in ICU patients. Chest 135(4):1069–1074. doi:10.1378/chest.08-2369
    • View reference on PubMed
    • View reference on publisher's website
  20. Wijdicks EF, Bamlet WR, Maramattom BV, Manno EM, McClelland RL (2005) Validation of a new coma scale: the FOUR score. Ann Neurol 58(4):585–593. doi:10.1002/ana.20611
    • View reference on PubMed
    • View reference on publisher's website
  21. Fischer M, Ruegg S, Czaplinski A, Strohmeier M, Lehmann A, Tschan F et al (2010) Inter-rater reliability of the full outline of unresponsiveness score and the Glasgow coma scale in critically ill patients: a prospective observational study. Crit Care 14(2):r64. doi:10.1186/cc8963
    • View reference on PubMed
    • View reference on publisher's website
  22. Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O’Neal PV, Keane KA et al (2002) The Richmond agitation-sedation scale: validity and reliability in adult intensive care unit patients. Am J Resp Crit Care Med 166(10):1338–1344. doi:10.1164/rccm.2107138
    • View reference on PubMed
    • View reference on publisher's website
  23. Le Gall J-R, Lemeshow S, Saulnier F (1993) A new simplified acute physiology score (SAPS II) based on a European/North American multicenter study. JAMA 270(24):2957–2963. doi:10.1001/jama.1993.03510240069035
    • View reference on PubMed
    • View reference on publisher's website
  24. Puntillo KA, Morris AB, Thompson CL, Stanik-Hutt J, White CA, Wild LR (2004) Pain behaviors observed during six common procedures: results from thunder project II. Crit Care Med 32(2):421–427. doi:10.1097/01.CCM.0000108875.35298.D2
    • View reference on PubMed
    • View reference on publisher's website
  25. Streiner DL, Norman GR (2008) Health measurement scales: a practical guide to their development and use, 4th edn. Oxford University Press, Oxford
  26. Gelinas C, Loiselle CG, LeMay S, Ranger M, Bouchard E, McCormack D (2008) Theoretical, psychometric, and pragmatic issues in pain measurement. Pain Manage Nurs 9(3):120–130. doi:10.1016/j.pmn.2007.12.001
    • View reference on publisher's website
  27. Hadjistavropoulos T, Craig KD, Duck S, Cano A, Goubert L, Jackson P et al (2011) A biopsychosocial formulation of pain communication. Psychol Bull 137(6):910–939. doi:10.1037/a0023876
    • View reference on PubMed
    • View reference on publisher's website
  28. Ramelet AS, Rees NW, McDonald S, Bulsara MK, Huijer Abu-Saad H (2007) Clinical validation of the multidimensional assessment of pain scale. Paediatr Anaesth 17(12):1156–1165. doi:10.1111/j.1460-9592.2007.02325.x
    • View reference on PubMed
    • View reference on publisher's website

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