Arbour Caroline, Choinière Manon, Topolovec-Vranic Jane, Loiselle Carmen G, Puntillo Kathleen, Gélinas Céline
*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.
Clin J Pain. 2014 Nov;30(11):960-9. doi: 10.1097/AJP.0000000000000061.
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.
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.
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.
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.
对于无法言语的人群，建议采用诸如 grimacing（面部扭曲）和肌肉僵硬等疼痛行为来进行疼痛评估。然而，对于患有创伤性脑损伤（TBI）的重症患者，这些行为可能并不适用，这取决于他们的意识水平（LOC）。本研究旨在验证使用这些行为来评估不同意识水平的成年重症 TBI 患者疼痛的有效性。
采用受试者内重复测量设计，在两种操作之前（基线）、操作期间以及操作后 15 分钟对参与者（N = 45）进行 1 分钟的观察：（1）无创血压测量：NIBP（非伤害性）；（2）翻身（伤害性）。使用结合了现有疼痛评估工具中 50 项内容的行为清单和视频记录来描述参与者的行为。还检查了观察者内部和观察者之间对观察到的行为的一致性。
总体而言，与基线（中位数 = 1）或无创血压测量期间（中位数 = 0）相比，翻身期间观察到的疼痛行为更频繁（中位数 = 4；T = -5.336；P≤0.001）。TBI 患者的疼痛行为大多为“非典型”，包括脸红、突然睁眼、流泪和肢体屈曲等不常见反应。在翻身期间，≥25.0%的 TBI 参与者无论其意识水平如何都出现了这些行为，在报告有疼痛的意识清醒参与者中，这一比例为 22.2%至 66.7%。两位评估者之间以及评估者内部的一致性均>92%。
本研究支持先前的研究结果，即重症 TBI 患者在接受伤害性操作时可能表现出非典型行为。因此，将当前推荐的疼痛行为作为标准化量表的一部分用于评估这一弱势群体的镇痛需求可能并非最佳选择。
