Indian Journal of Critical Care Medicine

Register      Login

SEARCH WITHIN CONTENT

FIND ARTICLE

Volume / Issue

Online First

Archive
Related articles

VOLUME 24 , ISSUE 8 ( August, 2020 ) > List of Articles

EDITORIAL

Behavioral Pain Assessment Tool: Yet Another Attempt to Measure Pain in Sedated and Ventilated Patients!

Keywords : Behavior, Pain assessment, Sedation, Ventilation

Citation Information : Behavioral Pain Assessment Tool: Yet Another Attempt to Measure Pain in Sedated and Ventilated Patients!. Indian J Crit Care Med 2020; 24 (8):617-618.

DOI: 10.5005/jp-journals-10071-23536

License: CC BY-NC 4.0

Published Online: 21-09-2020

Copyright Statement:  Copyright © 2020; Jaypee Brothers Medical Publishers (P) Ltd.


Abstract

The interesting study by Mitra et al. in this issue explores this newly developed pain assessment tool— Behavior pain assessment tool (BPAT) for critical patients who cannot communicate. The authors explored the tool in a prospective survey in 400 adults, noncomatose intensive care unit (ICU) patients. BPAT scoring was done within 2–3 hours of admission in ICU, followed by every day in the morning, and also before and after ICU procedures associated with pain. The BPAT scoring was done by untrained senior residents independent of each other. Majority of the patients had BPAT score of ≤3 (initial score in 83.5% and baseline score in 74.5% patients). In all, 56.5% patients had a postprocedure pain score of ≤3, highlighting the role of institutional sedation–analgesia protocol, as all patients received either morphine or fentanyl infusion along with midazolam infusion. Grimace was the most liked behavior (67%) by the observers, whereas closed eyes was the least liked (59%). Closed eyes behavior was felt to have poor utility in paralyzed, ventilated patients. Authors feel that as verbal and bodily responses could not be assessed in these patients, the BPAT can be further modified to observe pain in such patients. The behaviors like verbal complaints, muscle rigidity, and clenched fist were also liked less. For most behavior patterns liked by observers, the κ coefficient was quite high (>0.9). The BPAT tool was found easy to understand (93.3%) and apply (91.8%) by untrained observers. Most observers (59.25%) considered that the time spent on calculating BPAT was short, although the timelines have not been defined. The study again confirms that sedated, paralyzed, and ventilated patients are the most difficult group for assessment of pain. Interobserver variability may lead to subjective bias. The study has not looked at the impact of BPAT scoring on reduction or adjustment of opioid needs of these patients. Further studies may throw more light on the practical applications of BPAT score, and comparative studies between BPAT, behavioral pain scale (BPS), and critical-care pain observation tool (CPOT) would be very interesting.


  1. Li D, Puntillo K, Miaskowski C. A review of objective pain measures for use with critical care adult patients unable to self-report. J Pain 2008;9(1):2–10. DOI: 10.1016/j.jpain.2007.08.009.
  2. Chanques G, Payen JF, Mercier G, De attre S, Viel E, Jung B, et al. Assessing pain in Non-intubated critically ill patients unable to self report: an adaptation of the Behavioral pain scale. Intensive Care Med 2009;35(12):2060. DOI: 10.1007/s00134-009-1590-5.
  3. Puntillo KA, White C, Morris AB, Perdue ST. Patients’ perceptions and responses to Procedural pain: results from thunder Project II. Am J Crit Care 2001;10(4):238–251. DOI: 10.4037/ajcc2001.10.4.238.
  4. Payen JF, Chanques G, Mantz J, Hercule C, Auriant I, Leguillou JL, et al. Current practices in sedation and analgesia for mechanically ventilated critically ill patients: a prospective multicenter patient based study. Anesthesiology 2007;106(4):687–695. DOI: 10.1097/01.anes.0000264747.09017.da.
  5. Oliveira LS, Macedo MP, Martins da Silva SA, Oliveira APF, Santos VS. Pain assessment in critical patients using the Behavioral pain scale. Br J Pain São Paulo 2019;2(2):112–116. DOI: 10.5935/2595-0118.20190021.
  6. Rose L, Haslam L, Dale C, Knechtel L, McGillion M. Behavioral pain assessment tool for critically ill adults unable to self-report pain. Am J Crit Care 2013;22(3):246–255. DOI: 10.4037/ajcc2013200.
  7. Gélinas C, Tousignant-Laflamme Y, Tanguay A, Bourgault P. Exploring the validity of the bispectral index, the critical-care pain observation tool and vital signs for the detection of pain in sedated and mechanically ventilated critically ill adults: a pilot study. Intensive Crit Care Nurs 2011;27(1):46–52. DOI: 10.1016/j.iccn.2010.11.002.
  8. Faritous Z, Barzanji A, Azarfarin R, Ghadrdoost B, Ziyaeifard M, Aghdaei N, et al. Comparison of bispectral index monitoring with the critical-care pain observation tool in the pain assessment of intubated adult patients after cardiac surgery. Anesth Pain Med 2016;6(4):e38334. DOI: 10.5812/aapm.38334.
  9. Ahlers SJ, van Gulik L, van der Veen AM, van Dongen HP, Bruins P, Belitser SV, et al. Comparison of different pain scoring systems in critically ill patients in a general ICU. Crit Care 2008;12(1):R15. DOI: 10.1186/cc6789.
  10. Gélinas C, Puntillo KA, Levin P, Azoulay E. The behavior pain assessment tool for critically ill adults: a validation study in 28 countries. Pain 2017;158(5):811–821. DOI: 10.1097/j.pain.0000000000000834.
  11. Mitra S, Jain K, Singh J, Saxena P, Nyima T, Selvam SR, et al. Clinical utility of the behavioral pain assessment tool in patients admitted in the intensive care unit. Indian J Crit Care Med 2020;24(8): 695–700.
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.