Validation of the Critical-Care Pain Observation Tool in Adult Patients

Céline Gélinas, Lise Fillion, Kathleen A. Puntillo, Chantal Viens and Martine Fortier
Am J Crit Care 2006;15:420-427
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AJCC, the American Journal of Critical Care, is the official peer-reviewed research journal of the American Association of Critical-Care Nurses (AACN), published bimonthly by The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright © 2006 by AACN. All rights reserved.

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15:420-427) ain is an important stressor for many patients in critical care. and Martine Fortier. an important goal in patients’ care. Limitations include small sample sizes (<40 patients). during a nociceptive procedure (positioning).14 Several pain scales have been used to document self-reporting of pain in intubated patients.13.7-9.18-20 lack of validation in intubated http://ajcc. Chantal Viens. Volume 15. significant associations were found between the patients’ self-reports of pain and the scores on the Critical-Care Pain Observation Tool. and changes in the level of consciousness. PhD. contact The InnoVision Group. University of California. 4 Downloaded from ajcc. MPs. • RESULTS The reliability and validity of the Critical-Care Pain Observation Tool were acceptable. Kathleen A. reprints@aacn. McGill University. Faculty of Nursing. Each patient’s self-report of pain was obtained while the patient was conscious and intubated and after extubation. Quebec (CG). RN. Aliso Viejo. Although critical care clinicians strive to obtain each patient’s self-report of pain. Quebec (LF. for a total of 9 assessments. MF). July 2006. From School of Nursing. fax. Canada. P 420 sedative agents. Interrater reliability was supported by moderate to high weighted κ coefficients. Quebec City. Discriminant validity was supported by higher scores during positioning (a nociceptive procedure) versus at rest. many factors compromise patients’ ability to communicate verbally. 101 Columbia. Use of these instruments in critical care practice is restricted because of the limitations of the studies.VALIDATION OF THE CRITICAL-CARE PAIN OBSERVATION TOOL IN ADULT PATIENTS By Céline Gélinas. Lise Fillion. RN. PhD. • OBJECTIVE To validate the Critical-Care Pain Observation Tool. Following surgery. patients were evaluated by using the Critical-Care Pain Observation Tool at rest.12 In the absence of a patient’s self-report. critically ill adult patients react to a noxious stimulus by expressing different behaviors that may be associated with pain.4-12 Pain assessment is the first step in proper pain relief. CA 92656. (949) 362-2049. and 20 minutes after the procedure.1-3 and it is not unusual for the intensity of the pain to be described as moderate to severe. Montreal. recruited in a cardiology health center in Quebec. Puntillo. the tool could be used to assess the effect of various measures for the management of pain. mechanical ventilation. RN. Therefore. and Department of Physiological Nursing.org by guest on December 2. CV.org AMERICAN JOURNAL OF CRITICAL CARE. participated in the study. PhD. 2006. including the use of To purchase electronic or print reprints. RN. especially for patients who cannot communicate verbally. For criterion validity. observable behavioral and physiological indicators become important indices for the assessment of pain. Laval University. For each of the 3 testing periods. DNSc. San Francisco. Phone. e-mail. 2011 . Calif (KP).org. (800) 809-2273 or (949) 362-2050 (ext 532). all 105 were evaluated after extubation. (American Journal of Critical Care. 33 of the 105 were evaluated while unconscious and intubated and 99 while conscious and intubated. • BACKGROUND Little research has been conducted to validate pain assessment tools in critical care.aacnjournals. • METHODS A total of 105 cardiac surgery patients in the intensive care unit. No.13.15-17 Preliminary research18-20 has been conducted to validate instruments that include behavioral and/or physiological indicators.aacnjournals. • CONCLUSIONS The Critical-Care Pain Observation Tool showed that no matter their level of consciousness.

A convenience sample of 105 cardiac surgery patients in the intensive care unit (ICU) at a cardiology health center in Quebec. moaning Crying out. and were able to hear and to see. body movements. the study was explained to eligible patients.aacnjournals. and levator contraction All of the above facial movements plus eyelid tightly closed Does not move at all (does not necessarily mean absence of pain) Slow. and use of dependent observations (ie. Items in each section are 421 AMERICAN JOURNAL OF CRITICAL CARE. not following commands. range 0 1 2 0-8 patients. body movements and muscle rigidity). developed in French.19 The aim of our study was to examine the reliability and validity of a newly developed instrument for pain assessment: the Critical-Care Pain Observation Tool (CPOT).25. sobbing Total. had a dependence on alcohol or drugs. At this time. 18 use of a subjective scale (eg. rigid Very tense or rigid Tolerating ventilator or movement Coughing but tolerating Fighting ventilator Talking in normal tone or no sound Sighing. moaning Crying out. and Ethics A repeated measures design was chosen for this quantitative study.18 confusion in the definition of behaviors (eg.org Critical-Care Pain Observation Tool. orbit tightening. has 4 sections. death). Volume 15. seeking attention through movements Pulling tube. and extreme intensity of behaviors). trying to climb out of bed Score Relaxed. Sample. Canada. hemorrhage. had an ejection fraction less than 0. alarms frequently activated Relaxed Tense. slight.aacnjournals. This study was approved by the human research committee of the health center. had been admitted for cardiac surgery. touching or rubbing the pain site. Instruments Method Design. they were 18 years or older. attempting to sit up. No. inability to complete them Compliance with the ventilator (intubated patients) Alarms not activated. and informed consent was obtained. moderate. received medical treatment for chronic pain. 2011 . 4 Downloaded from ajcc. statistical analysis of the observations rather than of the sample of patients). delirium. Behavioral and physiological indicators are important indices for assessment of pain in patients unable to self-report.org by guest on December 2. patients were taught how to use the pain intensity descriptive scale. understood French. absence. received neuromuscular blockers following surgery. cautious movements. sobbing 0 1 2 0 1 2 OR Vocalization (extubated patients) Talking in normal tone or no sound Sighing. neutral Tense Grimacing Absence of movements Protection Restlessness 0 1 2 0 1 2 Body movements Muscle tension No resistance to passive movements Evaluation by passive flexion and Resistance to passive movements extension of upper extremities Strong resistance to passive movements. muscle tension. striking at staff. Patients were considered for inclusion if http://ajcc. easy ventilation Alarms stop spontaneously Asynchrony: blocking ventilation.Table 1 Description of the Critical-Care Pain Observation Tool Indicator Facial expression Description No muscular tension observed Presence of frowning. brow lowering. July 2006. was recruited for the study. Patients were excluded if they had been admitted for a heart transplant or thoracic aortal aneurysm repair. Recruitment was done the day before the surgery. were in the ICU after surgery. each with different behavioral categories: facial expression. The CPOT. and compliance with the ventilator for intubated patients or vocalization for extubated patients (Table 1). moving limbs/ thrashing. had preexisting psychiatric or neurological problems. or had complications after surgery (eg.

were calculated. 1 = mild.27 Two modifications were made in the CAM-ICU to adapt it to the sedation scale used in our study and to facilitate assessment of patients’ inattention. 3.26. with a possible total score ranging from 0 to 8. 20 minutes after the positioning procedure. R. Procedure Three testing periods. each including 3 assessments for a total of 9 pain assessments (T1-T9) with the CPOT. Patients were considered conscious if they had a score of 2. approximately 2 hours after the end of surgery. 2 = a little. intubated patients communicated the presence or absence of pain by nodding their heads (yes or no) to the 422 AMERICAN JOURNAL OF CRITICAL CARE. approximately 5 hours after the second testing period. scored from 0 to 2. The instrument has good sensitivity and specificity for assessing delirium in critically ill patients. assessments T4-T6). Second. 2011 . which were part of the postoperative care protocol.org by guest on December 2. Confusion Assessment Method for the Intensive Care Unit. recovery (20 minutes after the positioning procedure). Upon completion of the CPOT during the second testing period (ie. T1 was done with the patient at rest. were completed during each patient’s early postoperative course (Figure 1).18-21 In addition. 3 = severe. No. Content validity indices. The CPOT was developed as follows.25 in acute and critical care. First. This scale has been used in previous studies18. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) was used to assess delirium. pain indicators were described by using findings from a chart review of the medical files of 52 critically ill patients22 and from 9 focus groups with 48 critical care nurses and interviews of 12 physicians. Volume 15.N. T3 was done at recovery. For each of the 3 testing periods. During this time. the patient was still intubated but conscious. REC.9 One of us (C. the third testing period (assessments T7T9) was after the patient was extubated. rest. or 4 on the Ramsay Scale.aacnjournals. Finally. positioning procedure.) and a critical care nurse (G. Pain Intensity Descriptive Scale.aacnjournals. Content validity indices greater than 0. Finally.80 were sufficiently satisfactory24 to consider including all these indicators in the CPOT. The positioning procedure at T8 sometimes occurred with ambulation and/or respiratory exercises. patients’ inattention was verified by assessing their capacity to concentrate on the pain intensity descriptive scale used in our study. A previously validated pain intensity descriptive scale (0 = none. endotracheal suctioning often was performed at the same time as positioning. T2 was completed a few minutes after T1 during positioning of the patient. 3 = moderately. For each patient. All indicators had indices of 0.Intensive care unit First testing period Unconscious intubated patients Consent day before surgery Operating room T1 R T2 P T3 REC T4 R T5 P T6 REC T7 R T8 P T9 REC Second testing period Third testing period Conscious intubated Conscious extubated patients patients Figure 1 Illustration of the time of consent and the 3 testing periods. the f irst 3 assessments (T1-T3) were done while the patient was intubated and still unconscious (ie.org Downloaded from ajcc. patients were evaluated with the CPOT for 1 minute at rest both before and after positioning and for the duration of the positioning procedure. The second testing period (assessments T4-T6) was 3 hours after the first testing period.) evaluated the patients.88 to 1. 2 = moderate. with a sedation score of 5 or 6 on the Ramsay Scale). 4 = unbearable) was used. July 2006.23 Content validity of the CPOT was established with 4 physicians and 13 critical care nurses. which are the proportion of participants who answered 3 or 4 on the Likert scale. the Ramsay Scale28 was used to assess the level of sedation. This standardization of procedures was based on the work of Puntillo et al. Some items and their operational definitions were derived from previously described instruments for pain assessment.00. The physicians and nurses completed a questionnaire on the relevance of the inclusion of these indicators in the CPOT by using a Likert scale (1 = not at all. Positioning represented a previously confirmed nociceptive procedure. and 4 = very much). 4 http://ajcc.9 On the basis of the patient’s needs. Abbreviations: P.G.

the patient’s self-report) Extubated patients (T7-T9): In this study. Volume 15. For each patient.org by guest on December 2. assessments T7T9) after completion of the CPOT. Table 3 gives the demographic characteristics of the patients. this medication was tapered off and stopped 1 to 3 hours after the patient’s arrival in the ICU. Spearman correlations31 were calculated between the A total of 131 patients were approached for consent the day before surgery. we examined whether the CPOT could be used to discriminate between pain during positioning and lack of pain at rest Rest time compared with positioning for all three testing periods: paired t test Discriminant validity P ≤ . Weighted κ coefficients were calculated for all assessments (T1T9).Table 2 Description of reliability and validity methods examined in this study Psychometric property Interrater reliability Description Interrater reliability is the consistency with which 2 raters agree on their measurement/observation (ie. death).41-0. delirium.01 Abbreviation: CPOT. During the third testing period (ie. and T7 with T8). 2011 . 4 423 Downloaded from ajcc.29 To test validity of the CPOT. During the course of the study. Finally. discriminant validity 31 was examined by performing paired t tests between assessments with the CPOT taken at rest and during positioning (T1 with T2. The final sample size was 105 patients enrolled during a 3-month period. * Levels of acceptability for interrater reliability scores from Landis and Koch.aacnjournals. Interrater reliability was examined. patients were evaluated by using the CAM-ICU to determine the presence of delirium.61-0. Do you have pain? This procedure was selected because many intubated patients during this phase of their recovery were unable to use the pain intensity descriptive scale. Three patients were excluded because of delirium. yes/no and pain intensity Spearman correlation were used as the gold standard self-report measures Discriminant validity refers to evidence that instruments measuring 2 different constructs should not correlate In this study. Criterion validity was examined by measuring the relationship between the CPOT scores and the patients’ selfreports.01 Poor Slight Fair Moderate Substantial Almost perfect Criterion validity Criterion validity refers to the relationship Intubated patients (T4-T6): analysis of variance between the instrument (ie.60 0.org AMERICAN JOURNAL OF CRITICAL CARE. the gold standard measure of pain.40 0.00 P ≤ . No. and all were receiving continuous infusions of propofol after surgery (mean dose 85. the CPOT) and the gold standard measure of pain (ie. the CPOT) of a phenomenon (ie. not interested (n = 3). T4 with T5. Chicago.21-0.aacnjournals. Before the third testing period. all patients were receiving propofol during http://ajcc.81-1. Descriptive statistics were computed for all variables. Reasons for refusal were as follows: anxious about the surgery (n = 9 patients). and 117 (89%) agreed to participate in the study. Thus.80 0. and 1 because of extubation right after surgery. Critical-Care Pain Observation Tool.30 question. Ill). Results Characteristics of the Sample Statistical analyses were completed by using version 11.7 mg/h). Analysis of variance was used to examine the differences between the intubated patients’ self-reports of pain (yes or no) and the CPOT scores (assessments T4-T6). Data Analysis extubated patients’ self-reports of pain intensity (ordinal descriptive scale) and the CPOT scores (assessments T7-T9). the extubated patients used the pain intensity descriptive scale to grade their pain.20 0. 8 patients were excluded because of postoperative complications (hemorrhage.5 of SPSS for Windows (SPSS Inc.4 mg/h. SD 39. Also. and bad experience with research (n = 1). 3 because their surgery was canceled. at T7. pain) Two raters assessed the patients in this study: the principal investigator and 1 critical care nurse Coefficient or analysis κ coefficient (proportion of responses in which the 2 raters agreed) Level of acceptability* <0 0-0. we determined criterion and discriminant validity (Table 2). July 2006. Anesthesia was similar for all patients. undecided (n = 1).

of patients 12 12 14 29 33 33 34 33 34 Weighted κ coefficient 0.38 1. For assessments T1 to T3. July 2006. patients had the highest scores on the CPOT (Figure 2). 424 AMERICAN JOURNAL OF CRITICAL CARE.0 Rest T4 T7 T1 83 (79) 11 (10) 9 (9) 2 (2) T6 T9 T3 Procedure Time Recovery the first testing period (ie.71 Together.04 First Testing Period.7 µg/h (SD 31.87 1. Sample at the 3 Testing Periods Testing period 1 Unconscious intubated patients (n = 33) 2 Conscious intubated patients (n = 99) 3 Conscious extubated patients (n = 105) Assessment T1 Rest T2 Procedure T3 Recovery T4 Rest T5 Procedure T6 Recovery T7 Rest T8 Procedure T9 Recovery Mean 0.aacnjournals. assessments T1-T3). Conscious intubated T5 T8 T2 Conscious extubated Unconscious intubated Value 60 83 22 (8) 3. 2011 . data were collected on 33 of the 105 intubated patients who were unconscious.88 0.77 0. *Assessments made by using the Critical-Care Pain Observation Tool were independently completed by the principal investigator and the critical care nurse when both were present. patients (n = 4) received an intravenous bolus of fentanyl before positioning.42 0. the principal investigator and the critical care nurse (C.70 0.87 SD 1.03 1. Volume 15.aacnjournals. No.0 1.52 0. Rarely.79 0.G. a criterion for testing during this period.) completed the CPOT at all 9 assessments and were blinded to each other’s scores.67 1. No.85 0.5 0.63 0.Table 3 Description of the study sample (n = 105)* 4.0 0.23 1. The sample sizes for interrater reliability differed for each time.N.36 0. 4 http://ajcc.83 0.21 3.5 1.5 3. Second Testing Period. Finally. for assessments T7 to T9.0 Mean score (79) (21) 2. All patients also were receiving continuous infusions of fentanyl when they were admitted to the ICU from surgery.1) at the third testing period.55 2.85 0. and G. all 105 patients were assessed after they were extubated.7 µg/h (SD 21. of patients (%) Coronary artery bypass graft Valvular repair or replacement Coronary artery bypass graft and valvular surgery Interauricular/interventricular communication repair *All patients had sternal incisions.38 1.org by guest on December 2. mean (SD) Sex. CPOT scores were higher during the positioning procedure (T5) than during rest (T4) or recovery (T6). Again. For assessments T4 to T6.89 1.35 0.5 2.8) at the first testing period to 50.0 Variable Age. Moreover. reflecting the times when both were present. The mean dosage of fentanyl decreased from 73.62 0. Third Testing Period. CPOT scores were higher during the positioning procedure (T2) than during rest (T1) or recovery (T3. Figure 2). (%) of patients Male Female Type of cardiac surgery.69 2. data were collected on 99 of the awake 105 intubated patients.31 1. Table 4 Weighted κ coefficients for each assessment from T1 to T9* Assessment T1 T2 T3 T4 T5 T6 T7 T8 T9 No. The scores can range from 0 to 8.org Downloaded from ajcc. The remaining 6 patients were extubated before the completion of this testing period. in this testing period. The CPOT scores were similar to those of the 2 previous testing periods (Figure 2). Interrater Reliability Figure 2 Mean scores and standard deviations of the CriticalCare Pain Observation Tool for the 3 testing periods (N = 105 patients). No.

CPOT scores were significantly higher for intubated patients reporting pain than for those who had no pain. 95) (1. and T6) Assessment T4 T5 T6 Patients’ self-reports of pain: pain present or absent* Yes. present (n = 53) No.19 In our study. 5 patients at T4. Discussion Our f indings validated the CPOT. Our study. and then awake and extubated. Spearman correlations of 0. Payen et al19 obtained a weighted κ coefficient of 0.18† 38.83† 22.01) than during rest at T7 (1. Alpha is adjusted to 0. lending support to its validity. absent (n = 41) Yes. when patients were extubated during the third testing period. http://ajcc.89† ANOVA df (1.90 1.62 0. July 2006. the higher was the patient’s score on the CPOT. however. No.40 (P ≤ .40 0. Payen et al19 also found higher behavioral scores during positioning than at rest in unconscious critically ill patients.aacnjournals. 0.07 0. Volume 15. T5. and 1 physician participated in that study. Discriminant Validity At the 3 testing periods.74 when they compared behavioral pain scores between pairs of evaluators.01 because 3 comparisons were made on the same subjects. assessments T4-T6) and the analysis of variance are presented in Table 5.65 2. and 0.71) and recovery at T9 (1. Our results support the criterion validity of the CPOT because the indicators were tested against the most valid measurement of pain. When patients were intubated during the second testing period. and results cannot be generalized to other ICU nurses. *Because of intermittent drowsiness postoperatively. At each assessment in this testing period.38 0. CPOT scores were significantly higher during positioning than during the rest periods. the higher a patient’s selfreport of pain was. conscious and intubated.11 2. absent (n = 18) Yes. which was developed specifically to assess pain in ICU patients. that is. 4 Downloaded from ajcc.001) at T7 to T9 showed that the patients’ selfreported pain intensity scores were moderately correlated with the CPOT scores.40). present (n = 79) No. 2 at T5. mean pain intensity scores were significantly higher during the positioning procedure at T8 (2. the patients’ self-reports. A total of 46 nurses and nurse’s aides.88 F 11.59. These results 425 AMERICAN JOURNAL OF CRITICAL CARE. 1 physical therapist. These results are consistent with those of previous studies18. †P ≤ . and 6 at T6 were unable to give their self-reports of pain by nodding their heads. which is a limitation to the examination of interrater reliability. During the third testing period (ie. 92) (1. 91) Abbreviation: ANOVA.001. CPOT scores were higher during painful procedures. Interrater reliability was high for most assessments and moderate at T4.32 in which self-reports of pain of patients in a postanesthesia care unit were moderately related to pain behaviors. Mean CPOT scores according to patients’ selfreports of the presence or absence of pain during the second testing period (ie. CPOT scores differed significantly between those who reported pain and those who did not.31 0.Table 5 Differences in scores on the Critical-Care Pain Observation Tool according to patients’ self-reports of pain in the second testing period (T4. Criterion Validity CPOT scores were associated with patients’ self-reports of pain.49 SD 1.85 1. Weighted κ coefficients were moderate to high at all assessments (Table 4). Table 6 gives the results of the paired t tests.78 3. present (n = 54) No.org by guest on December 2. absent (n = 39) Scores Mean 1. Moreover. analysis of variance. assessments T7-T9). is the first to document differences in pain behavior scores according to levels of activity during different states of consciousness and intubation: unconscious and intubated.aacnjournals. 2011 . Such results emphasize that pain behaviors are observable even if a patient cannot report pain.49.org Discriminant validity was supported by the finding that CPOT scores were higher during positioning than at rest in the 3 testing periods. only 2 evaluators used the instrument.

tioned.8 may help to explain these findings.17 This pressure may cause stretching of the sternal incision. Second.01* -12. in a study by Lawrence.01 because 3 comparisons were made on the same subjects.org Downloaded from ajcc. Finally. data could be collected for only 33 of the 105 patients while the patients were unconscious. Those patients might have had more time to recuperate from the residual effects of anesthesia than our patients did. Limitations This study was not without limitations. may demonstrate pain behaviors in response to a nociceptive procedure. perhaps the CPOT can be used to assess pain in other populations of critical care patients.12. 18 of them who did not report pain had high CPOT scores (mean 2. Moreover. and respond emotionally to what was being said while they were unconscious. of patients 33 99 105 t -9. cardiac surgery patients are a relatively healthy ICU group and may not represent most ICU patients. Previous studies7-9. when conscious intubated patients were positioned during assessment T5. leading to higher CPOT scores in the absence of reported pain.001. No. Data collection in this study was completed in the 8 hours after surgery. understand.35 formerly unconscious patients revealed that they could hear.19 Once extubated. Also. This result may have occurred because the patients were highly sedated while unconscious and may have been experiencing the residual effects of anesthesia.11.34 recommend that these patients be treated the same way as conscious patients when the patients are exposed to sources of pain. and T7) and during the procedure (T2. T4.aacnjournals. 4 http://ajcc. whatever their levels of consciousness. Indeed. 2011 . 65 conscious intubated patients had endotracheal suctioning while they were being posi426 We also found that CPOT scores were similarly low for both unconscious and conscious extubated patients. in addition to the sternal incision.37 rather than a painful one. patients seemed to have higher CPOT scores when they were conscious and intubated than they did when they were unconscious or extubated. More raters should be used in tests of interrater reliability in subsequent evaluations of the CPOT. especially if behavioral responses to noxious stimuli occur.5. T5.aacnjournals.07* -15. experts recommend that healthcare providers assume that unconscious patients may have pain. and which can be painful to some patients. First. mechanical ventilation modes provided a positive inspiratory pressure to allow distribution of oxygen throughout the lungs. Interestingly. Experts recommend we assume that unconscious patients have pain. However. especially if behavioral responses to a known noxious stimulus occur. and 9 (21%) of 43 patients were unable to communicate their self-report of pain because of drowsiness. Behaviors observed by using the CPOT may indicate more than pain. suggest that patients. data were collected by only 2 persons. In the study by Ferguson et al.5 patients’ self-reports of pain after coronary artery bypass graft surgery were collected more than 8 hours after the end of surgery. The presence of the endotracheal tube as a potential source of pain6. SD 0. This finding suggests that behaviors observed by using the CPOT may be an indicator of more than pain. In light of this finding.90). Until there is evidence to the contrary. Third.org by guest on December 2.9. July 2006.20 in which intubated patients provided self-reports of pain were conducted in periods varying from 12 to 72 hours after the end of surgery. they could have experienced less severe pain than they did when they were intubated. postoperative drowsiness led to missing data for some patients. Further research is warranted to determine the sensitivity and specificity of the CPOT as a measure of pain. a period when intermittent drowsiness can be expected. Perhaps for these patients the positioning was a distressful or an uncomfortable experience1. Alpha is adjusted to 0. who are AMERICAN JOURNAL OF CRITICAL CARE.Table 6 Differences in scores on the Critical-Care Pain Observation Tool measured at rest before the procedure (T1. In our study. Volume 15. This hypothesis requires confirmation in future studies. the endotracheal tube may have caused coughing during the positioning procedure.36 for cardiac surgery patients.96* df 32 98 104 *P < . Whether a behavioral response to a noxious procedure is accompanied by perception of pain in an unconscious patient is unknown. The occurrence of the same inability to communicate in the patients in our study is not surprising. The experts33. which does not occur in nonsurgical patients. and T8) Assessments T1-T2 T4-T5 T7-T8 No.

13. thanks to Celeste Johnston. Relationship between behavioral and physiological indicators of pain. Christoph SB. and opioid administration. Evaluation of pain in the critically ill patient. Patients’ perceptions and responses to procedural pain: results from Thunder Project II.2:656-659. critical care patients’ self-reports of pain. 22. Haljamäe H. Lenz ER. Pain assessment in critical care: what have we learnt from research? Intensive Crit Care Nurs. and useful tool for measuring pain in critically ill patients who are unable to self-report. 18. Br Med J. 2005. Pain and satisfaction with pain control in seriously ill hospitalized adults: findings from the SUPPORT research investigations. Future research should be conducted to determine if CPOT scores can be used to differentiate pain from other conditions.25:1159-1166. Laval University. Crit Care Nurs Clin North Am. Girard N. Controlled sedation with alphaxalone-alphadolone. Springhorn HE.15:592-599. 29. 8.34:557-562. 4.10:238-251. Morris AB. The unconscious experience. Pa: Lippincott. Analysis of pain management in critically ill patients. Pharmacotherapy. 1991.7:15-21. Bosson JL. Puntillo KA. A pilot study to assess the relationship between behavioral manifestations and self-report of pain in postanaesthesia care unit patients. 32. Soeken KL.1:167. Miaskowski C. 36. Potgieter PD. Webb MR.29:2258-2263. Ely EW. 9.24:1953-1961. Quebec City. 3rd ed. development of the CPOT was based on previous research of others as well as on descriptive data from 2 preliminary studies that led to selection of the behavioral indicators. Puntillo KA. 33. 1994. Savege T. 1990. Crit Care Nurs Clin North Am. et al.org AMERICAN JOURNAL OF CRITICAL CARE. New York. Bergbom-Engberg I. 19. First. Ely EW. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). ACKNOWLEDGMENTS Special thanks to Gaëlle Napert. 1999. Assessment of pain in the critically ill. Health Measurement Scales: A Practical Guide to Their Development and Use. Wilson VS. Melzack R. Nursing Research: Principles and Methods. Dimensions of procedural pain and its analgesic management in critically ill surgical patients. Marohn L. Philadelphia. Pain. Am J Crit Care. Gélinas C. 10. Patients’ experiences of postoperative respirator treatment: influence of anaesthetic and pain treatment regimens. JAMA. Landis RJ. Ambuel B. Assessing pain in critically ill sedated patients by using a behavioral pain scale. Heart Lung. Gilroy D. Ferguson J. 2011 . Am J Crit Care. Viens C. Nye P. This study was supported by a nursing fellowship research grant from the Heart and Stroke Foundation of Canada and a doctorate research grant from the Fondation de Recherche en Sciences Infirmières du Québec. 16-20.19:526-533. DEd. Delirium in mechanically ventilated patients: validity and reliability of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). 1990. 15. the statistician who reviewed the analyses. 6th ed. 2001. Crit Care Med. 14. Crit Care Med. 24. Am J Crit Care. this study was innovative in several aspects. 2003. 1992. Haljamäe H. 2001. 4 427 Downloaded from ajcc. Thanks to all intensive care unit nurses and physicians for their support and collaboration in the performance of this study. Summer 1995. 1992. the critical care nurse who contributed to data collection.33:159-174. et al. Puntillo KA. 17. 2nd ed. 12. Hamlett KW. Puntillo KA.13:126-135. 1996. Kwekkeboom KL. Polit DF. 2001.26:1065-1072. Volume 15. Puntillo KA.17:95-109. Fernsler J. 1994. thanks to all the patients who participated in this study. Assessment of patients’ experience of discomforts during respirator therapy. Bru O.43:31-36.16:267-273. 1974. 30. Hungler BP. 1994.4:227-232. Streiner DL. pain relief and accuracy of their recall after cardiac surgery. the tool needs to be further validated in different populations of critically ill patients.much sicker.3:11-16. Simpson B.15:35-53. Crit Care Med. Crit Care Med. However. Viens C. Special thanks to Drs Jean Bussières and Mathieu Simon for their valuable collaboration in the conception and the conduction of this study. The measurement of observer agreement for categorical data. Puntillo KA. 1995. Am J Crit Care. Finally. Waltz CF. Fontaine DK. 6. Herr KA. Broste SK. 2001. Focus Crit Care. Bushnell MC. Patients’ recollection of intensive care unit experience. Hamill-Ruth RJ. Also. 7. Canada. Kehrle K. receiver operating characteristic curve analysis could be performed to examine the specificity and the sensitivity of the CPOT as a measure of pain. Les indicateurs de douleur en soins critiques [Pain indicators in critical care]. Crit Care Med. 31. 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