PAIN ASSESSMENT

ACUPUNCTURE COV-19 SYM NOV 2020

IN THE
UNCONSCIOUS
PATIENTS R Besthadi Sukmono, SpAn-KAR
Regional Anesthesia and Pain Medicine Division
Department of Anesthesiology and Intensive Care
RSUPN Cipto Mangunkusumo
Fakultas Kedokteran Universitas Indonesia
PAIN (2020)
AN UNPLEASANT SENSORY AND EMOTIONAL
EXPERIENCE ASSOCIATED WITH, OR
RESEMBLING THAT ASSOCIATED WITH, ACTUAL
OR POTENTIAL TISSUE DAMAGE
INTERNATIONAL ASSOCIATION FOR THE STUDY OF PAIN (IASP) 2020
PAIN ASSESSMENT
- Pain is a highly subjective and personal
experience.
- Self-reported pain
- Most reliable source of information on an
individual’s pain experience
- Gold standard in most populations
- VAS, NRS, NRS-V, Faces Pain
Thermometer (FPT)
- Routinely monitored, assessed,
reassessed, and documented
- Facilitate management
- Communication among healthcare
providers
Clin Geriatr Med 24 (2008) 237–262
 WHAT ARE
PAIN ASSESSMENT THE
CHALLENGES
CLINICAL CONDITIONS SIMILARITI
- Dementias
ES
- Delirium
-
- BETWEEN
Cerebrovascular accident

ALL OF
State of unconsciousness, advanced life support,
intubation
-
THEM IN
Severe depression
- Psychosis
-
PAIN
Mental disability
- Coma, persistent vegetative state
- Encephalopathy
- Terminal illness ASSESS
Clin Geriatr Med 24 (2008) 237–262
PAIN ASSESSMENT
CHALLENGES
- Older adults with severe cognitive

-
impairment
- Lack of pain assessment

-
Unconscious patients
Intubated patients/Critically ill patient
- Problematic barriers to
achieving good pain
management.
- Inability to use verbal

-
language

-- Behavioral Assessment Tools

Proxy Reporters - Language impairment
(eg, aphasia, dysphasia)

-
Physiological Measures
Vital signs (VS): (heart rate [HR], BP, respiratory rate [RR],
- No single physiologic
parameter or score has

- oxygen saturation [SpO2], and end-tidal CO2)

Administration of analgesics
been found to reflect states
of acute pain accurately
Clin Geriatr Med 24 (2008) 237–262
THE AMERICAN SOCIETY FOR PAIN
MANAGEMENT
-
RECOMMENDATIONS FOR PAIN ASSESSMENT IN
Obtain a self-report of pain if at all possible
-
NONVERBAL INDIVIDUALS
Search for potential causes of pain
-pathologic conditions
-common procedures known to cause pain
-Observe behaviors that may indicate pain;
-Solicit surrogate reporting from significant others familiar with the patient’s response
to pain
-Use analgesics to evaluate if pain management reduces behaviors believed to be
related to pain.

Clin Geriatr Med 24 (2008) 237–262

PAIN WHEN
YOU’RE NOT
AWAKE?
OR WILL YOU REMEMBER IT?
 PAIN
PHYSIOLOGY
PERCEPTION

PAIN

MODULATION
Descending
modulation Dorsal Horn

Ascending
input
Dorsal root ganglion
TRANSMISSION

TRANSDUCTION
Spinothalamic
Peripheral
tract
nerve

Peripheral
TRAUMA
nociceptors

Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.
Brain Inj, 2014; 28(9): 1202–1208

NORMAL - The cortical nociceptive network

PATHWAY - Primary (S1) and secondary somatosensory
(S2) cortices
- The stimulation of nociceptors - Posterior insula (lateral network)
- (A∂ and C fibres) - Sensory–discriminative aspects of pain
- The transmission of information via the
processing
- Conscious experience of pain
- Activation of Pain matrix
spinothalamic and spinoreticular
pathways to the midbrain (i.e. periaqueductal
matter) and thalamus
- Transmission to the cortex. - Cingulate, anterior insula and prefrontal
cortices (medial network)
- Motivational–affective and cognitive–
evaluative aspects of pain processing
PAIN IN PATIENTS WITH
SEVERE
- BRAIN INJURY
A minority of persons with severe brain injuries remain in a state of severely
disordered consciousness (DOC) beyond the acute phase
- Vegetative state (unresponsive wakefulness syndrome [UWS])
- patients will show only reflexive movements
- Minimally conscious state (MCS)
- patients demonstrate reproducible but fluctuating voluntary behaviors without
functional communication
- Both UWS and MCS may last for weeks or months or become chronic
- Physical or psychological pain in DOC

Archives of Physical Medicine and Rehabilitation 2018;99:1755-62

PAIN IN PATIENTS WITH
-SEVERE BRAIN INJURY
Spasticity, contractures, pressure ulcers, soft tissue ischemia, peripheral nerve injuries, and

-
premorbid painful conditions

-
Painful condition related to disturbances in the network involved in pain perception
Malfunctions of the sensory processing of physical stimuli (eg, allodynia, central post stroke
pain)

UWS emotional perception.

MCS
- severe corticosubcortical
disconnection in response to noxious - preserved cortical responses similar to
stimulation participants without brain injury,
- complex cortical responses to
nociceptive and emotional stimuli
- higher probability of subjectively
experiencing pain in MCS
- subgroup that behaviorally unresponsive
could retain cortical abilities for pain and

Archives of Physical Medicine and Rehabilitation 2018;99:1755-62

-
Laureys S et al, 2002
Increase of metabolism from pain
stimuli in VS/UWS in midbrain,

- contralateral thalamus and S1

Severely impaired functional
connectivity in cortico-cortical

- pathways
Activation of the primary cortex
isolated from higher-order
associative cortices
- Painful stimuli are not experienced
in an integrated and conscious
manner.

--
Boly et al, 2008
MCS patients
Brain activation similar to controls

-in response to noxious stimuli

Perceive the unpleasant aspect of

-painful stimuli
Intact connectivity between

-primary and associative cortices

existence of conscious pain
perception
Brain Inj, 2014; 28(9): 1202–1208
 PAIN IN THE
CRITICALLY-ILL-
-
Journal of Critical Care 49 (2019) 14–20

>50% of critically ill patients MECHANICALLY-

- Increased release of catecholamine,
experience moderate to severe
unrelieved pain VENTILATED
cortisol, and antidiuretic
- Psychosocial effects
hormones

- -
-
Source of pain in ICU
Depression, anxiety, delirium, and
Procedures performed during care posttraumatic stress disorder
- Underlying health condition or disease - INCREASED MORBIDITY AND
- -
MORTALITY

-
Insertion of catheters or tubes
Assessment

-
Unable to change position
- Behavioral

-
Physiological response to pain
- Scores

-
Fatal unstable hemodynamic status,
-
-
Physiological
Alterations in immune system
functioning BPs and HRs
- Hyperglycemia
 PAIN IN THE
CRITICALLY-ILL-
- 33.2%
Journal of Critical Care 49 (2019) 14–20
MECHANICALLY-
- of patients suffered pain at rest, with a BPS > 3;
VENTILATEDICU
- Variables that correspondingly predicted resting pain
10% presented significant pain levels (BPS ≥ 5).

-- Age (β = −0.010, p b 0.001) PROCEDUR

- Method of ventilation (β = −0.281, p = 0.021)
- 90%
Sedation score (β = −0.153, p b 0.01)
ES
of patients suffered pain during the procedures, with a
- Nociceptive procedures
-
median BPS of 6 (IQR: 4–8)

- Significant predictors of procedural pain

83% of patients experienced significant pain levels. - repositioning, endotracheal
suctioning and vascular

-- Age (β = −0.022, p = 0.001), -

puncture
Non-nociceptive

- Receiving
Sedation score (β = −0.355, p b 0.001), procedures
sedation and/or analgesia in last hour (β = - mouth care, eye care and

-- Resting
0.483, p = 0. 01), chest tube dressing change
pain levels (β = −0.742, p b 0.001)
Type of painful procedure (β = −0.906, p b 0.001) were
BEHAVIORAL
ASSESSMENT TOOLS
FOR THE UNCONSCIOUS
SCALES IN PATIENTS WITH
LANGUAGE
- IMPAIRMENT
The Checklist of Nonverbal Pain Indicators (CNPI)
- The Doloplus 2
- The Pain Assessment Checklist for Seniors with Severe Dementia (PAC- SLAC)
- The Pain Assessment Checklist for Seniors with Severe Dementia–Dutch-
Revised (PACSLAC-D- Revised)
- The Pain Assessment in Advanced Dementia (PAINAD)
- Behavioral Pain Scale (BPS)
- Critical Care Pain Observation Tool (CPOT)

Archives of Physical Medicine and Rehabilitation 2018;99:1755-62

Gregory J (2019) Use of pain scales
and observational pain assessment

OBSERVA
tools in hospital settings. Nursing
Standard. doi:
10.7748/ns.2019.e11308

TIONAL
PAIN
ASSESSM
ENT
TOOLS
SCALES IN PATIENTS WITH
SEVERE
- BRAIN INJURY
Behavioral Pain Scale (BPS)
- Critical Care Pain Observation Tool (CPOT)
- noncommunicative and sedated adult patients in intensive care.
- Behavior Indicators of Pain (Escala de Conductas Indicadoras de Dolor)
- ventilated critically ill patients
- Zurich Observation Pain Assessment
- patients with major cognitive impairments or DOC
- Nociception Coma Scale–Revised (NCS-R)

Archives of Physical Medicine and Rehabilitation 2018;99:1755-62

SCALES IN PATIENTS IN
INTENSIVE
- CARE UNIT
The PACU Behavioral Pain Rating Scale
- Pain Assessment and Intervention Notation (P.A.I.N.) algorithm
- Nonverbal Pain Assessment Tool (NPAT)
- Harris Scale
- Adult Nonverbal Pain Scale (A-NVPS)/Adult Non Verbal Pain Score-Revised
(NVPS-R)
- The Pain Assessment and Intervention Notation (PAIN)
- The Faces Pain Thermometer (FPT)
- Behavioral Pain Scale (BPS)/Behavioral Pain Scale-Non Intubated (BPS-NI)
- Critical Care Pain Observation Tool (CPOT)
- Behavioral Pain Assessment Tools (BPAT)
Archives of Physical Medicine and Rehabilitation 2018;99:1755-62
THE NOCICEPTION COMA
SCALE-REVISED - demonstrated high sensitivity
in assessing responses to acute

-
nociceptive pain
cut-off score of 4 (with a
sensitivity of 73% and
specificity of 97%) for
detecting and, potentially,
treating pain

Clin J Pain 2016;32:321–326

ADULT NON VERBAL PAIN
SCORE-REVISED (NVPS-R)
-
-
Odher, 2003 in burn patients
Autonomic indicator does not
have a good correlation with

-
the other dimensions

-
Wegman, 2005.
autonomic indicators were
replaced by “respiratory”

-
assessment
“respiration” (R-NVPS) had a
higher sensitivity than
“physiology II” (O-NVPS) in
assessing pain

-
-
Mild (0 - 3)

-
Moderate (4 - 6)
Severe (7 - 10)

Indian J Crit Care Med. 2017 Jul; 21(7): 429–435.

NONVERBAL PAIN
ASSESSMENT TOOL
- similiar to CPOT
- 3 domains: facial expressions/facial cues,
movements, and muscle tension/positioning
guarding
- moderately strong validity and strong interrater
reliability.
- easy to use, and provides a standard approach to
assessing pain in the adult patient unable to
verbalize a pain score.
CRITICAL-CARE PAIN
OBSERVATION TOOL (CPOT)
Directives to use the CPOT
- The patient must be observed at rest for one minute to

-
obtain a baseline value of the CPOT.
Then, the patient should be observed during nociceptive
procedures (e.g. turning, wound dressing) to detect any

-
changes in the patient’s behaviours to pain.
The patient should be evaluated before and at the peak
effect of an analgesic agent to assess if the treatment was
effective

-
in relieving pain.
For the rating of the CPOT, the patient should be attributed

-
the highest score observed during the assessment period.
The patient should be attributed a score for each behavior
included in the CPOT and muscle tension should be
evaluated the last, especially when the patient is at rest
because just the stimulation of touch (passive flexion and

- painless (0)
extension of the arm) may lead to behavioural reactions.

- mild (0–3)
- moderate
6)
(3–

- severe (6–8)
International Journal of Nursing Studies 48 (2011) 1495–1504
BEHAVIORAL PAIN BPS-NON
SCALE (BPS) Anesth Analg 2005;101:1470 –6

INTUBATED (BPS-
NI)

-
-
painless (3) - BPS ≥ 6 moderate to severe
pain
- -
mild (4–6)
Intensive Care Med (2009) 35:2060–2067
moderate (7–9)
- severe (10–12)
requires treatment
 Intensive Care Med (2009) 35:2060–2067

BEHAVIORAL
PAIN SCALE-
NON
INTUBATED
(BPS-NI)
- Adapted for non-mechanically
ventilated critically ill patients
- Unable to self-report their pain
- impaired vigilance status
and/or delirium
- Valid, reliable and responsive
instrument to measure pain in
ICU patients.
- Could be used by caregivers
several times a day to
assess pain for usual clinical
 CPOT IN BRAIN
-
Journal of Critical Care 36 (2016) 76–80
INJURED ICU PTS
To test the reliability and validity of the CPOT use with brain-injured ICU adults.
- scored the CPOT before and during a nonpainful (ie, gentle touch) and at least 1
painful (eg, turning) procedure
- Intraclass correlation coefficient between trained raters was 0.73 (95% confidence
interval, 0.57-0.83)
- CPOT scores were significantly higher during turning compared with gentle
touch (P< .001) and correlated significantly with self-reports of pain intensity
during turning (0.64, P< .01).
- CPOT reliable and valid in this patient group
 BPS VS CPOT
-
Journal of Critical Care 30 (2015) 167–172

Prospective observational cohort study in 68 mechanically ventilated medical adult

mixed. ICU patients who were unable to report pain.
- compares the discriminant validation and reliability of the CPOT and the BPS
simultaneously
- The BPS and CPOT scores showed a significant increase of 2 points between rest
and the painful procedure (turning).
- The median BPS scores between rest and the nonpainful procedure (oral care)
showed a significant increase of 1 point, whereas the median CPOT score remained
unchanged.
- The interrater reliability of the BPS and CPOT scores showed a fair to good
agreement
- BPS use was less supported because it increased during a nonpainful stimulus
BEHAVIORAL
PAIN CHECKLIST
--
J Pain Symptom Manage 2019;57:761-773

Proposed Behavioral checklist

derived from CPOT, the Behavior

- Observation Tool, and others

Active behaviors was significantly
higher during turning and other
nociceptive procedures compared

- with rest and soft touch

The strongest predictors of pain

-
intensity
Grimace, mouth opening, orbit
tightening, eye weeping, and
eyes tightly closed
THE BEHAVIOR PAIN
ASSESSMENT TOOL
PAIN 158 (2017) 811–821

- BPAT
- Classify
cut-point score >3.5
patients with or without severe

- sensitivity
levels (≥8) of pain intensity and distress
and specificity that ranged

- during
from 61.8 to 75.1%
the procedure, look at patient for 1
minute when you expect the patient to
have the most pain. Pay special attention
to the patient’s face. Mark ALL behaviors

--
that are ‘present’ or ‘absent.
most common pain behavior
Grimacing, wincing, verbal complaints,
and clenching of fist
BPS > 5
CPOT > 2
CUT-OFF SCORES FOR SIGNIFICANT PAIN
THE PAIN
MANAGE
MENT
ALGORITH
M

Heart & Lung 44 (2015) 521-527

ANALGESIA-FIRST VERSUS
ANALGESIA-BASED
- SEDATION
Analgesia-first sedation
- An analgesic (usually an opioid) is used before a sedative to reach the sedative goal
-Analgesia-based sedation
- An analgesic (usually an opioid) is used instead of a sedative to reach the sedative
goal
Iranian J Nursing Midwifery Res 2015;20:502-7.

3.2 ± 1.4 days in the study group vs. 7.4 ±

4.8 days in the control group (P < 0.001)
CONCLUSION
- Pain is subjective and multidimensional
-
-
The Gold standard of pain assessment is self report
Disorders of consciousness (DOC) made assessment of pain difficult
- Other means to assess pain are:
- Proxy reporting, Behavioral Assessment Tool, Physiological Measure, and Administration of
analgesia
-
-
Patients with DOC experienced pain
Behavioral Assessment Tools:
- NVPS
-
-
CPOT
BPS/BPS-NI
- BPAT
- After applying the right tools for your patients, use appropriate algorithm to manage the pain
- After good pain management comes good sedation
 y

CAN’T SLEEP THE PAIN A