SYMPTOMS OF PATIENTS & FAMILIES

Pain without words:

Are reactions comparable among patients?

Tuesday, November 12th, 2013

By Céline Gélinas, RN, PhD Assistant Professor

Ingram School of Nursing, McGill University Researcher and Nurse Scientist

Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital

Montréal, Canada celine.gelinas@mcgill.ca

Acknowledgements Research team

Darina Tsoller (coordinator) Caroline Arbour, RN, PhD Stephanie Avery, BScN(student) Mélanie Bérubé, RN, NP, PhD(student) Madalina Boitor, RN, PhD(student) Christian Drouin, MScA(student) Christine Echegaray-Benites, RN, MScA(N) Esther Garceau, BScN(student) Oxana Kapoustina, RN, MScA(N) Jade Remy, CEPI, BScN Melody Ross, CEPI, MScA(student) Brandy Vanderbyl, MScA(student)

Funding agencies

Key collaborators

Jane Topolovec-Vranic, PhD (co-PI) Kathleen Puntillo, RN, DNSc, FAAN Manon Choinière, PhD Andrew Baker, MD Michael Cusimano, MD, PhD Anne-Sylvie Ramelet, RN, PhD David Streiner, PhD

What is pain?

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (IASP, 1979)

Alternative definition for non-verbal patients:

«Behavioral alterations caused by pain are valuable forms of self-report and should be considered as alternative measures of pain» (Anand & Craig, 1996)

“The inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment” (IASP, 2011)

The picture of pain in the ICU Pain is a major stressor for critically ill patients (Rotondi et al., 2002)

Pain is experienced by ICU patients either at rest (Chanques et al., 2007) or during nociceptive procedures (Puntillo et al., 2001)

Incomplete or absence of pain assessments have been associated with longer ICU stay, longer MV duration, and increased mortality in the ICU (Kastrup et al., 2009; Payen et al., 2009)

Many ICU patients are unable to self-report…

In such situations, the use of a valid behavioral pain scale is recommended by the ASPMN (Herr et al., 2011) and SCCM (Barr et al., 2013)

BPS (Payen et al., 2001) or CPOT (Gélinas et al., 2006)

Chanques et al., ICM 2009;35:2060-7

Critical-Care Pain Observation Tool

(CPOT; Gélinas et al., AJCC 2006; 15:420-7)

© Gélinas, 2013

Facial Expressions

Relaxed

0

Tense

1

Grimacing

2

Body Movements

Absence of movements or

normal position

0

Protection

1

Agitation

2

Muscle Tension Relaxed

0

Tense, rigid

1

Very tense/rigid

2

Compliance with the

Ventilator (intubated)

Tolerating ventilator or movements

0

Coughing but tolerating

1

Fighting ventilator

2

Vocalization (extubated)

Normal or silent

0

Sighing or moaning

1

Crying out or sobbing

2

CPOT - Facial expressions of pain

© Gélinas, 2013 * A score of 1 may be attributed when a change in the patient’s facial expression is observed compared with rest (e.g. eye opening or weeping).

Cut-off scores for significant pain

CPOT>2 (see ROC: Gélinas et al., 2009)

BPS>5 (Payen et al., 2007)

Impact of their use in ICU practice

CPOT (Gélinas et al., 2011; Rose et al., 2013) ↑ documentation of pain assessments

Changes in analgesic and sedative use

ICU nurses reported that it helped them assess pain more effectively, but inter-professional communication of pain assessment findings was identified as an area for improvement

BPS (Chanques et al., 2006; Radtke et al., 2012) ↑ documentation of pain assessments

↓ incidence of pain

Changes in analgesic and sedative use

↓ MV duration and nosocomial infections

Training: To plan carefully

See CPOT teaching video at

http://pointers.audiovideoweb.com/stcasx/il83win10115/CPOT2011-

WMV.wmv/play.asx

Funded and created by

Kaiser Permanente Northern California Nursing Research

Clinical Practice Recommendations Concerning Pain

Assessment in the Patient Unable to Self-Report American Society for Pain Management Nursing (Herr et al., PMN 2011; 12:230-50)

Attempt to obtain the patient’s self-report of pain – Gold standard A simple yes or no = valid self-report

Look for behavioral changes Use a standardized and valid behavioral pain scale

The family can help to identify pain behaviors

Sources of pain = “Assume pain is present”

Attempt an intervention for pain relief

1

2

3

4

Clinical Practice Recommendations Concerning Pain

Assessment in the Patient Unable to Self-Report American Society for Pain Management Nursing (Herr et al., PMN 2011; 12:230-50)

Be cautious when interpreting a behavioral score!

self-report score

Allows the detection of the presence/absence of pain

Allows the assessment of intervention effectiveness

Related to changes observed in behaviors

Clinical Practice Recommendations Concerning Pain

Assessment in the Patient Unable to Self-Report American Society for Pain Management Nursing (Herr et al., PMN 2011; 12:230-50)

Be cautious with vital signs!

Have not been found to be valid for assessing pain

No change No pain

Behavioral responses in the critically ill

Pain Behavioral Pain Tool (PBAT)

AACN Thunder Project II; Puntillo et al., CCM 2004; 32:421-7

Pain behaviors during procedure

N=5,957; Puntillo et al., CCM 2004; 32:421-7

Moderate correlation between number of behaviors and pain intensity (r=0.54; p<0.001)

CPOT item Conscious (n=144) Unconscious (n=113) Test

FE – Relaxed, neutral 16 (11.1%) 35 (31%) Chi-Square, p<0.001

Tense (frowning) 90 (62.5%) 65 (57.5%)

Grimacing 38 (26.4%) 13 (11.5%)

MT - Relaxed 40 (27.8%) 74 (65.5%) Chi-Square, p<0.001

Tense or rigid 92 (63.9%) 33 (29.2%)

Very tense or rigid 12 (8.3%) 6 (5.3%)

CPOT score 3.47 (1.51) 2.23 (1.48) F, p<0.001

In press in PMN, available online

N=10 moderate to severe critically ill TBI patients with altered LOC

New behaviors observed in 5 or more TBI patients during turning

Frowning Levator contraction Eye opening Eye weeping Eyebrow raising

CPOT developments

Adaptation of the CPOT content for brain-injured ICU patients with altered LOC (Funded by CIHR and FRQ-S; Gélinas, Topolovec-Vranic et al. with Dr. Kathleen Puntillo)

Phase 1 – Item generation

Phase 2 – Content validation

Phase 3 – Validation of CPOT-Neuro at the ICU bedside

Phase 1: Different brain-injured patient groups under observation

Elective brain surgery group (N=43)

Mainly conscious, awake, and stable

Use of original CPOT was found to be valid (Echegaray-Benites, Kapoustina & Gélinas, under review)

Neuro medical group (N=53)

TBI group (target N=95, now at 91)

Gélinas, Topolovec-Vranic et al.

Nociceptive and non-nociceptive procedures

Conscious post-op brain surgery

Video used with permission

Phase 1: TBI group

Some findings from 84 critically ill TBI patients

Mostly men (76.2%)

Mean age of 54 years (SD=22.7)

Mild (23.7%), moderate (33.8%) and severe (42.5%) TBI

Frontal region (51.8%), fall as a main cause (51.2%)

Conscious – GCS >13 (n=14, 16.7%)

Reduced LOC – GCS 9-12 (n=35, 41.7%)

Unconscious – GCS <8 (n=35, 41.7%)

Conscious TBI exhibited more behaviors (mean=5.8) compared to those with reduced LOC (mean=4.0) and unconsciousness (mean=2.0) (p<0.001)

Gélinas, Topolovec-Vranic et al. Picture reproduced with permission

New behaviors observed during turning

Frowning (39.3%) Eye opening (36.9%) Mouth opening (21.4%) Limb movements (21.4%) Eye weeping (13.1%)

Were mainly absent Grimacing (84.5%) Muscle rigidity (86.9%)

Severe TBI patient with altered LOC

Video used with permission

Severe TBI patient with altered LOC

Video used with permission

Cerebral stroke with altered LOC

Video used with permission

What to remember

Brain-injured ICU patients with altered LOC seem to present atypical behavioral responses to pain which would necessitate some modification of the content of existing scales

By the mean time, we should follow clinical recommendations and guidelines and look for behavioral changes when a patient is exposed to procedures known to be painful and intervene accordingly

“ “ “ “

SCCM Pain Care Bundle

Assess

•Assess pain 4x/shift & PRN

•Suggested pain assessment tools:

•Patient able to self-report 0-10 NRS

•Patient unable to self-report BPS (3-12) or CPOT (0-8)

•Significant pain with NRS >3, BPS >5, or CPOT >2

Treat

•Treat pain within 30 minutes of detecting significant pain and REASSESS:

•Non-pharmacological treatment (e.g. relaxation)

•Pharmacological treatment

•Nociceptive pain IV opioids non-opioid analgesics

•Neuropathic pain gabapentin or cabamazepine, + IV opioids

•AAA repair, rib fractures thoracic epidural

Prevent

• Administer pre-procedural analgesia and/or non-pharmacological interventions

• Treat pain first, then sedate

Barr et al., CCM 2013;41:263-306

A source of inspiration

The most practical lesson that can be given to nurses is to teach them what to observe and how to observe

Florence Nightingale

THANK YOU!

celine.gelinas@mcgill.ca