Accuracy of Critical Care Pain Observation Tool and Behavioral Pain Scale to assess pain in critically ill conscious and unconscious patients: prospective, observational study

Paolo Severgnini, Paolo Pelosi, Elena Contino, Elisa Serafinelli, Raffaele Novario, Maurizio Chiaranda, Paolo Severgnini, Paolo Pelosi, Elena Contino, Elisa Serafinelli, Raffaele Novario, Maurizio Chiaranda

Abstract

Background: Critically ill patients admitted to intensive care unit (ICU) may suffer from different painful stimuli, but the assessment of pain is difficult because most of them are almost sedated and unable to self-report. Thus, it is important to optimize evaluation of pain in these patients. The main aim of this study was to compare two commonly used scales for pain evaluation: Critical Care Pain Observation Tool (CPOT) and Behavioral Pain Scale (BPS), in both conscious and unconscious patients. Secondary aims were (1) to identifying the most relevant parameters to determine pain scales changes during nursing procedures, (2) to compare both pain scales with visual analog scale (VAS), and (3) to identify the best combination of scales for evaluation of pain in patients unable to communicate.

Methods: In this observational study, 101 patients were evaluated for a total of 303 consecutive observations during 3 days after ICU admission. Measurements with both scales were obtained 1 min before, during, and 20 min after nursing procedures in both conscious (n.41) and unconscious (n.60) patients; furthermore, VAS was recorded when possible in conscious patients only. We calculated criterion and discriminant validity to both scales (Wilcoxon, Spearman rank correlation coefficients). The accuracy of individual scales was evaluated. The sensitivity and the specificity of CPOT and BPS scores were assessed. Kappa coefficients with the quadratic weight were used to reflect agreement between the two scales, and we calculated the effect size to identify the strength of a phenomenon.

Results: CPOT and BPS showed a good criterion and discriminant validity (p < 0.0001). BPS was found to be more specific (91.7 %) than CPOT (70.8 %), but less sensitive (BPS 62.7 %, CPOT 76.5 %). COPT and BPS scores were significantly correlated with VAS (p < 0.0001). The combination of BPS and CPOT resulted in better sensitivity 80.4 %. Facial expression was the main parameter to determine pain scales changes effect size = 1.4.

Conclusions: In critically ill mechanically ventilated patients, both CPOT and BPS can be used for assessment of pain intensity with different sensitivity and specificity. The combination of both BPS and CPOT might result in improved accuracy to detect pain compared to scales alone.

Trial registration: NCT01669486.

Keywords: Behavioral Pain Scale; Critical Care Pain Observation Tool; Critical ill patients; Intensive care unit; Pain; Pain management.

Figures

Fig. 1
Fig. 1
Consort flow diagram. Flow diagram summarizing inclusion, allocation, and analysis
Fig. 2
Fig. 2
Variations BPS and CPOT values during the nursing. Variations Behavioral Pain Scale (BPS) and Critical Care Pain Observation Tool (CPOT) values in overall conscious and unconscious patients before, during, and after nursing procedures. White column identifies the box and whisker graph; the vertical line bar identifies results in three different moments. Empty circles and triangles show the maximum, minimum, and percentile values
Fig. 3
Fig. 3
ROC curve of BPS and CPOT combination score. The curve identifies Behavioral Pain Scale (BPS) and Critical Care Pain Observation Tool (CPOT) combination score sensitivity and specificity compared with the gold standard Visual Analog Scale

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