Detecting pain in traumatic brain-injured patients with different levels of consciousness during common procedures in the ICU: typical or atypical behaviors?
OBJECTIVE
Pain behaviors such as grimacing and muscle rigidity are recommended for pain assessment in nonverbal populations. However, these behaviors may not be appropriate for critically ill patients with a traumatic brain injury (TBI) depending on their level of consciousness (LOC). This study aimed to validate the use of behaviors for assessing pain of critically ill TBI adults with different LOC.


METHODS
Using a repeated measure within subject design, participants (N=45) were observed for 1 minute before (baseline), during, and 15 minutes after 2 procedures: (1) noninvasive blood pressure: NIBP (non-nociceptive); and (2) turning (nociceptive). A behavioral checklist combining 50 items from existing pain assessment tools and video recording were used to describe participants' behaviors. Intrarater and interrater agreements of observed behaviors were also examined.


RESULTS
Overall, pain behaviors were observed more frequently during turning (median=4; T=-5.336; P≤0.001) than at baseline (median=1), or during noninvasive blood pressure (median=0). TBI patients' pain behaviors were mostly "atypical" and included uncommon responses such as flushing, sudden eye opening, eye weeping, and flexion of limbs. These behaviors were observed in ≥25.0% of TBI participants during turning independent of their LOC, and in 22.2% to 66.7% of conscious participants who reported the presence of pain. Agreements were >92% among and between the 2 raters.


CONCLUSIONS
This study support previous findings that critically ill TBI patients could exhibit atypical behaviors when exposed to nociceptive procedures. As such, use of current recommended pain behaviors as part of standardized scales may not be optimal for assessing the analgesic needs of this vulnerable group.
*Ingram School of Nursing, McGill University †Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, Montreal, Qc, Canada ‡Quebec Nursing Intervention Research Network (RRISIQ), Montreal, Qc, Canada §The Alan Edwards Center for Research on Pain, McGill University ∥Centre de recherche de Centre hospitalier de l'Université de Montréal (CRCHUM), Université de Montréal, Montreal, Qc ¶Trauma and Neurosurgery Program, Keenan Research Center of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada #Department of Physiological Nursing, School of Nursing, University of California San Francisco, San Francisco, CA.
Caroline
C
Arbour
Manon
M
Choinière
Jane
J
Topolovec-Vranic
Carmen G
CG
Loiselle
Kathleen
K
Puntillo
Céline
C
Gélinas
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001795:Blood Pressure Determination; D001930:Brain Injuries / Q000150:complications / Q000503:physiopathology* / Q000628:therapy; D003243:Consciousness; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D055805:Moving and Lifting Patients / Q000009:adverse effects*; D059225:Nociception; D010146:Pain / Q000175:diagnosis* / Q000209:etiology / Q000503:physiopathology*; D010147:Pain Measurement / Q000379:methods*; D015203:Reproducibility of Results; D057566:Self Report; D014474:Unconsciousness / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology; D014741:Video Recording; D055815:Young Adult