title: An exploratory study of the bilateral bispectral index for pain detection in traumatic-brain-injured patients with altered level of consciousness.
abstract: BACKGROUND
  Many patients with a traumatic brain injury (TBI) cannot communicate because of altered level of consciousness. Although observation of pain behaviors (e.g., frowning) is recommended for pain assessment in nonverbal populations, they are attenuated and sometimes even suppressed in patients with TBI receiving high doses of sedatives. This study explored the potential utility of the bilateral bispectral index system (BIS) for pain detection in critically ill adults with TBI and altered level of consciousness.
  
  
  METHODS
  Using a repeated measure within-subject design, participants (N = 25) were observed for 1 minute before (baseline), during, and 15 minutes after two procedures: (a) noninvasive blood pressure (nonnociceptive) and (b) turning (nociceptive). At each assessment, BIS indexes (0-100) of the right (R) and left (L) hemispheres and pain behaviors were documented.
  
  
  RESULTS
  Compared with baseline, significant median increases (p ≤ .05) in BIS-R (+4.93%) and BIS-L (+8.43%) and in the frequency of pain behaviors (+3.00) were observed during turning but not noninvasive blood pressure. Interestingly, increases in BIS-R were more pronounced in participants with left-sided TBI (+17.23%, p = .021) than those with right-sided TBI (+3.01%). BIS-R fluctuations in participants with left-sided TBI were also positively correlated (r(s) = .986, p ≤ .001) with the frequency of pain behaviors observed during turning.
  
  
  CONCLUSIONS
  Overall, only increases in BIS-R were correlated with participants' pain behaviors and in those with left-sided TBI exclusively. Although further research is needed, our findings support the potential use of the bilateral BIS for pain detection in nonverbal patients with TBI who cannot behaviorally respond to pain, but only when they have a left-sided injury.
authors.affiliation: Questions or comments about this article may be directed to Caroline Arbour, RN PhD, at caroline.arbour@mail.mcgill.ca. She is a Postdoctoral Trainee, Department of Psychology, Université de Montréal; Centre for Advanced Research in Sleep Medicine, Sacré-Coeur Hospital, Montreal, Quebec, Canada. Céline Gélinas, RN PhD, is an Associate Professor and Nurse Scientist, Ingram School of Nursing, McGill University; Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital; Quebec Nursing Intervention Research Network (RRISIQ); and The Alan Edwards Center for Research on Pain, McGill University, Montreal, Quebec, Canada. Carmen G. Loiselle, RN PhD, is an Associate Professor and Program Director, Ingram School of Nursing, McGill University; Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital; and Quebec Nursing Intervention Research Network (RRISIQ), Montreal, Quebec, Canada. Patricia Bourgault, RN PhD, is Vice Dean and Nurse Scientist, School of Nursing, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke; Quebec Nursing Intervention Research Network (RRISIQ), Montreal, Quebec, Canada.
authors.forename: Caroline
authors.initials: C
authors.lastname: Arbour
authors.forename: Céline
authors.initials: C
authors.lastname: Gélinas
authors.forename: Carmen G
authors.initials: CG
authors.lastname: Loiselle
authors.forename: Patricia
authors.initials: P
authors.lastname: Bourgault
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001930:Brain Injuries / Q000451:nursing* / Q000503:physiopathology*; D016292:Procedural Sedation; D003244:Consciousness Disorders / Q000451:nursing* / Q000503:physiopathology*; D056805:Consciousness Monitors; D064648:Critical Care Nursing / Q000379:methods*; D004292:Dominance, Cerebral / Q000502:physiology; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D008297:Male; D008875:Middle Aged; D059225:Nociception / Q000502:physiology; D010147:Pain Measurement / Q000379:methods*; D011237:Predictive Value of Tests; D055815:Young Adult