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J Pain Symptom Manage. 2018 Dec 26. pii: S0885-3924(18)31481-7. doi: 10.1016/j.jpainsymman.2018.12.333. [Epub ahead of print]

Behaviors indicative of pain in brain-injured adult patients with different levels of consciousness in the intensive care unit.

Author information

1
Ingram School of Nursing, McGill University, 680 Sherbrooke West, Montreal, QC, Canada H3A 2M7; Centre for Nursing Research and Lady Davis Institute, CIUSSS Centre-Ouest-Ile-de-Montréal - Jewish General Hospital, 3755 Côte-Sainte-Catherine Road, Montréal, Qc, Canada H3T 1E2. Electronic address: celine.gelinas@mcgill.ca.
2
Ingram School of Nursing, McGill University, 680 Sherbrooke West, Montreal, QC, Canada H3A 2M7; Centre for Nursing Research and Lady Davis Institute, CIUSSS Centre-Ouest-Ile-de-Montréal - Jewish General Hospital, 3755 Côte-Sainte-Catherine Road, Montréal, Qc, Canada H3T 1E2.
3
Physiological Nursing, University of California San Francisco, 2 Koret Way, San Francisco CA. United States, 94143.
4
Faculty of Nursing, Pavillon Marguerite d'Youville, Université de Montréal, C.P. 6128 succ. Centre-ville, Montréal, Qc, Canada, H3C 3J7; Centre de recherche Hôpital du Sacré-Cœur de Montréal du CIUSSS du Nord-de-l'Île-de-Montréal, 5400 boul. Gouin Ouest, Montreal, Qc, Canada, H4J 1C5.
5
Trauma and Neurosurgery Program, St Michael's, 30 Bond Street, Bond 4-016, Toronto, ON, Canada, M5B 1W8.
6
Injury Prevention Research Office and Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Canada.
7
Centre de recherche du Centre hospitalier de l'Université de Montréal; Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal; Montreal Heart Institute Research Centre, Montréal, Quebec, Canada.
8
Department of Psychiatry & Behavioural Neurosciences, St. Joseph's Healthcare, Mountain Site; McMaster University, 1280 Main Street West, Hamilton, Ontario, Canada, L8S4L8; Department of Psychiatry, University of Toronto, 33 Russell Street, Toronto, Ontario, M5S 2S1.

Abstract

CONTEXT:

Many brain-injured patients are unable to self-report their pain during their hospitalization in the intensive care unit (ICU), and existing behavioral pain scales may not be well suited.

OBJECTIVES:

To describe and compare behaviors in brain-injured patients with different levels of consciousness (LOC) during nociceptive and non-nociceptive care procedures in the ICU, and to examine interrater agreement of individual behaviors as well as discriminative and criterion validation of putative pain behaviors.

METHODS:

Brain-injured ICU patients were observed using a 40-item behavioral checklist before and during: soft touch (i.e., non-nociceptive procedure), turning and other care procedures (nociceptive) by pairs of trained raters. When possible, patients self-reported their pain on a 0-10 numeric rating scale. Patients were classified into unconscious (Glasgow Coma Scale, 3<GCS<8), altered consciousness (9<GCS<12) or conscious (13<GCS<15).

RESULTS:

A sample of 147 patients participated (65 conscious, 56 altered consciousness, 26 unconscious). Active behaviors (e.g., face expressions and body movements) were more frequent in conscious patients. High percentage interrater agreement (80-98%) was obtained for most behaviors. The total number of active behaviors was significantly higher during turning and other nociceptive procedures compared to rest (Wilcoxon = 9.873, p<0.001) and soft touch (Wilcoxon = 9.486, p<0.001) regardless of LOC. The strongest predictors of pain intensity (n=33) were grimace, mouth opening, orbit tightening, eye weeping, and eyes tightly closed; these behaviors were moderately correlated to self-reported pain intensity (Spearman rho=0.47).

CONCLUSION:

These findings may guide the revision of existing pain scales to make their content more suited for this population.

KEYWORDS:

assessment; behaviors; brain-injured; critical care; pain

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