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VOLUME 21 , ISSUE 9 ( 2017 ) > List of Articles


Pain measurement in mechanically ventilated patients with traumatic brain injury: Behavioral pain tools versus analgesia nociception index

Ali Jendoubi, Ahmed Abbes, Salma Ghedira, Mohamed Houissa

Keywords : Behavioral pain scale, Intensive Care Unit, pain assessment, traumatic brain injury

Citation Information : Jendoubi A, Abbes A, Ghedira S, Houissa M. Pain measurement in mechanically ventilated patients with traumatic brain injury: Behavioral pain tools versus analgesia nociception index. Indian J Crit Care Med 2017; 21 (9):585-588.

DOI: 10.4103/ijccm.IJCCM_419_16

License: CC BY-ND 3.0

Published Online: 01-12-2015

Copyright Statement:  Copyright © 2017; The Author(s).


Introduction: Pain is highly prevalent in critically ill trauma patients, especially those with a traumatic brain injury (TBI). Behavioral pain tools such as the behavioral pain scale (BPS) and critical-care pain observation tool are recommended for sedated noncommunicative patients. Analysis of heart rate variability (HRV) is a noninvasive method to evaluate autonomic nervous system activity. The analgesia nociception index (ANI) device (Physiodoloris®, MDoloris Medical Systems, Loos, France) allows noninvasive HRV analysis. The ANI assesses the relative parasympathetic tone as a surrogate for antinociception/nociception balance in sedated patients. The primary aim of our study was to evaluate the effectiveness of ANI in detecting pain in TBI patients. The secondary aim was to evaluate the impact of norepinephrine use on ANI effectiveness and to determine the correlation between ANI and BPS. Methods: We performed a prospective observational study in 21 deeply sedated TBI patients. Exclusion criteria were nonsinus cardiac rhythm; presence of pacemaker; atropine or isoprenaline treatment; neuromuscular blocking agents; and major cognitive impairment. Heart rate, blood pressure, and ANI were continuously recorded using the Physiodoloris® device at rest (T1), during (T2), and after the end (T3) of the painful stimulus (tracheal suctioning). Results: In total, 100 observations were scored. ANI was significantly lower at T2 (Median [min – max] 54.5 [22–100]) compared with T1 (90.5 [50–100], P < 0.0001) and T3 (82 [36–100], P < 0.0001). Similar results were found in the subgroups of patients with (65 measurements) or without (35) norepinephrine. During procedure, a negative linear relationship was observed between ANI and BPS (r2 = −0.469, P < 0.001). At the threshold of 50, the sensitivity and specificity of ANI to detect patients with BPS ≥ 5 were 73% and 62%, respectively, with a negative predictive value of 86%. Discussion: Our results suggest that ANI is effective in detecting pain in ventilated sedated TBI patients, including those patients treated with norepinephrine.

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  1. Berben SA, Meijs TH, van Dongen RT, van Vugt AB, Vloet LC, Mintjes-de Groot JJ, et al. Pain prevalence and pain relief in trauma patients in the accident and emergency department. Injury 2008;39:578-85.
  2. Payen JF, Bru O, Bosson JL, Lagrasta A, Novel E, Deschaux I, et al. Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med 2001;29:2258-63.
  3. Gélinas C, Fillion L, Puntillo KA, Viens C, Fortier M. Validation of the critical-care pain observation tool in adult patients. Am J Crit Care 2006;15:420-7.
  4. Logier R, Jeanne M, De Jonckheere J, Dassonneville A, Delecroix M, Tavernier B, et al. PhysioDoloris: A monitoring device for analgesia/nociception balance evaluation using heart rate variability analysis. Conf Proc IEEE Eng Med Biol Soc 2010;2010:1194-7.
  5. Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the Intensive Care Unit. Crit Care Med 2013;41:263-306.
  6. Skrobik Y, Chanques G. The pain, agitation, and delirium practice guidelines for adult critically ill patients: A post-publication perspective. Ann Intensive Care 2013;3:9.
  7. Aïssaoui Y, Zeggwagh AA, Zekraoui A, Abidi K, Abouqal R. Validation of a behavioral pain scale in critically ill, sedated, and mechanically ventilated patients. Anesth Analg 2005;101:1470-6.
  8. Herr K, Coyne PJ, Key T, Manworren R, McCaffery M, Merkel S, et al. Pain assessment in the nonverbal patient: Position statement with clinical practice recommendations. Pain Manag Nurs 2006;7:44-52.
  9. Ledowski T, Tiong WS, Lee C, Wong B, Fiori T, Parker N, et al. Analgesia nociception index: Evaluation as a new parameter for acute postoperative pain. Br J Anaesth 2013;111:627-9.
  10. Boselli E, Bouvet L, Bégou G, Dabouz R, Davidson J, Deloste JY, et al. Prediction of immediate postoperative pain using the analgesia/nociception index: A prospective observational study. Br J Anaesth 2014;112:715-21.
  11. Broucqsault-Dédrie C, De Jonckheere J, Jeanne M, Nseir S. Measurement of heart rate variability to assess pain in sedated critically ill patients: A Prospective observational study. PLoS One 2016;11:e0147720.
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