Ingram School of Nursing, McGill University, Montréal, Québec, Canada; Centre for Nursing Research and Lady Davis Institute, CIUSSS Centre-Ouest-Ile-de-Montréal - Jewish General Hospital, Montréal, Québec, Canada.
Faculty of Dentistry, McGill University, Montréal, Québec, Canada; Centre for Nursing Research and Lady Davis Institute, CIUSSS Centre-Ouest-Ile-de-Montréal - Jewish General Hospital, Montréal, Québec, Canada.
J Pain Symptom Manage. 2019 Apr;57(4):761-773. doi: 10.1016/j.jpainsymman.2018.12.333. Epub 2018 Dec 27.
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.
The objectives of this study were to describe and compare behaviors in brain-injured patients with different levels of consciousness during nociceptive and nonnociceptive care procedures in the ICU and to examine interrater agreement of individual behaviors as well as discriminative and criterion validation of putative pain behaviors.
Brain-injured ICU patients were observed using a 40-item behavioral checklist before and during soft touch (i.e., nonnociceptive procedure), turning, and other care procedures (nociceptive) by pairs of trained raters. When possible, patients self-reported their pain on a 0-10 visual thermometer. Patients were classified into unconscious (Glasgow Coma Scale, 3<GCS≤8), altered consciousness (9≤GCS≤12), or conscious (13≤GCS≤15).
A sample of 147 patients participated (65 conscious, 56 altered consciousness, and 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 with rest (Wilcoxon = 9.873, P < 0.001) and soft touch (Wilcoxon = 9.486, P < 0.001) regardless of levels of consciousness. 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 with self-reported pain intensity (Spearman rho = 0.47).
These findings may guide the revision of existing pain scales to make their content more suited for this population.
许多脑损伤患者在重症监护病房（ICU）住院期间无法自行报告疼痛，而现有的行为疼痛量表可能不太适用。
本研究旨在描述和比较不同意识水平的脑损伤患者在 ICU 接受伤害性和非伤害性护理过程中的行为，并检验个体行为的评分者间一致性，以及潜在疼痛行为的判别和标准验证。
使用 40 项行为检查表，由经过培训的两名评分者在脑损伤 ICU 患者接受轻柔触摸（即非伤害性操作）、翻身和其他护理操作（伤害性操作）前后进行观察。在可能的情况下，患者使用 0-10 视觉温度计报告自己的疼痛。患者被分为无意识（格拉斯哥昏迷量表，3<GCS≤8）、意识改变（9≤GCS≤12）或意识清醒（13≤GCS≤15）。
共有 147 例患者参与（65 例意识清醒，56 例意识改变，26 例无意识）。有意识的患者更频繁地表现出主动行为（如面部表情和身体运动）。大多数行为的评分者间高度一致（80%-98%）。与休息（Wilcoxon=9.873，P<0.001）和轻柔触摸（Wilcoxon=9.486，P<0.001）相比，无论意识水平如何，翻身和其他伤害性操作期间主动行为的总数显著更高。疼痛强度（n=33）的最强预测因子是面部扭曲、张口、眼眶紧绷、流泪和紧闭双眼；这些行为与自我报告的疼痛强度中度相关（Spearman rho=0.47）。
这些发现可能指导对现有疼痛量表的修订，使其内容更适合该人群。
