Intensive and Critical Care Nursing (2016) 34, 111

Available online at www.sciencedirect.com

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journal homepage: www.elsevier.com/iccn

REVIEW

Pain assessment in the critically ill adult:

Recent evidence and new trends
Cline Glinas
Ingram School of Nursing, McGill University, Montreal, QC H3A 2A7, Canada
Accepted 3 March 2016

KEYWORDS
Pain;
Pain assessment;
Behaviours;
Vital signs;
Pupillometry;
Critically ill;
Intensive care

Summary Pain assessment in the critically ill adult remains a daily clinical challenge. Position statements and practice guidelines exist to guide the ICU care team in the pain assessment
process. The patients self-report of pain remains the gold standard measure for pain and
should be obtained as often as possible. When self-report is impossible to obtain, observational
pain scales including the Behavioural Pain Scale (BPS) and the Critical-Care Pain Observation
Tool (CPOT) have been recommended for clinical use in the critically ill adult. However, their
adaptation and validation in brain-injured and burn ICU patients is required. Family caregivers
may help in the identication of pain-related behaviours and should be more involved in the
ICU pain assessment process. Fluctuations in vital signs should only be considered as cues for
further assessment of pain with appropriate tools, and may better represent adverse events of
severe pain. Other physiologic measures of pain should be explored in the ICU, and pupillometry
appears as a promising technique to further study. Implementation of systematic pain assessment approaches using tools adapted to the patients ability to communicate and condition
has shown positive effects on ICU pain practices and patient outcomes, but randomised control
trials are needed to conrm these conclusions.
2016 Elsevier Ltd. All rights reserved.

Implications for Clinical Practice

Pain measures must be selected according to the patients ability to communicate.
Behavioural pain scales remain alternative measures in the ICU patient unable to self-report.
Fluctuations in vital signs could be considered as adverse events of severe pain rather than indicators for pain
assessment.
Pain management initiatives must involve the ICU inter-professional team for better practices and patient outcomes.

Tel.: +514 398 6157; fax: +514 398 8455.

E-mail address: celine.gelinas@mcgill.ca

http://dx.doi.org/10.1016/j.iccn.2016.03.001
0964-3397/ 2016 Elsevier Ltd. All rights reserved.

Introduction
Pain is an enduring concern and a common symptom in
critically ill adults. Indeed, pain has been shown to be experienced at rest by more than 30% of patients (Chanques
et al., 2007), and this percentage exceeds 50% during
common care procedures in the intensive care unit (ICU)
(Glinas, 2007a; Puntillo et al., 2001, 2014). Turning, endotracheal suctioning, tube or drain removal, wound care
and arterial line insertion are procedures described as the
most painful by ICU patients in large international studies
(Puntillo et al., 2001, 2014). Nurses are facing numerous
challenges with pain assessment in the ICU as many patients
are unable to self-report because of various factors such as
altered level of consciousness (LOC), sedation and mechanical ventilation. Under-assessment of pain represents one
of the primary barriers to the adequate treatment of pain
in critically ill patients (Pasero et al., 2009). The evidence
demonstrating absent or incomplete assessment of pain is
associated with negative patient outcomes such as longer
duration of mechanical ventilation and ICU length of stay,
and increased mortality (Kastrup et al., 2009; Payen et al.,
2009), is a particular concern for nurses. This paper might
help nurses in reversing this situation through the review of
steps for proper pain assessment, recent evidence and new
trends in measures and indicators for the assessment of pain
in the critically ill adult.

Denition of pain and its gold standard

measure
As per the universal denition by the International Association for the Study on Pain (IASP, 1979), pain is described as
an unpleasant sensory and emotional experience associated
with actual or potential tissue damage or described in terms
of such damage. This denition has remained unchanged in
the Kyoto protocol of IASP Basic Pain Terminology (Loeser
and Treede, 2008). In other words, pain is recognised as a
multidimensional subjective experience which implies that
pain has to be reported by the person who is experiencing
it. Such a denition of pain highlights that the patients selfreport is the gold standard measure of pain and should be
obtained as often as possible. However, the IASP Task Force
on Taxonomy (1994) has acknowledged that The inability to self-report does not negate the possibility that an
individual is experiencing pain and is in need of appropriate pain-relieving treatment. Therefore, pain assessment
methods must be adapted to the patients cognitive capacity
and condition (Herr et al., 2011).

A stepwise approach for pain assessment and

the Communication Model of Pain
Pain should be monitored routinely in all adult ICU patients
(Barr et al., 2013). In their position statement, the American
Society for Pain Management Nursing (ASPMN) has proposed
a 4-step approach for the assessment of pain which can be
summarised as follows: (1) always attempt to obtain the
patients self-report of pain; (2) use a validated behavioural
pain scale or look for behavioural changes; (3) ask the

C. Glinas
family or caregiver about the patients pain behaviours; and
(4) attempt an analgesic trial when pain is suspected, and
reassess for pain (Herr et al., 2011).
The 010 Numeric Rating Scale (NRS) is commonly used
in clinical practice, and an enlarged visual format of the
NRS was found to be the most feasible and discriminative
self-report scale in comparison to other scales (i.e., visual
analogue scale, verbal descriptor scale) and formats (i.e.,
oral versus visual) for measuring pain intensity in critically
ill adult patients (Chanques et al., 2010). The vertical thermometer format has also been found to be easier to use by
critically ill adults and older adults (Glinas, 2007b; Herr,
2011). When a self-report of pain intensity is not possible,
a simple yes or no indicating the presence versus the
absence of pain should be considered as a valid self-report
(Herr et al., 2011). When self-report of pain is impossible
to obtain, validated behavioural pain scales should be used
as alternative measures for pain assessment. The family can
also provide the care team with relevant information on the
patients pain behaviours to enhance the detection of pain.
However, not much is known about the family members
perception of patients pain-related behaviours in the ICU
context. To our knowledge, only one qualitative study has
been conducted with seven family members of ICU patients
with a traumatic brain injury (TBI) (Vanderbyl and Glinas,
2014). Interestingly, family members identied behaviours
indicative of pain similar to those included in most scales
recommended for clinical use such as facial expressions,
body movements and muscle rigidity. More specically, they
described movements of the eyes and the mouth, tears or
eye weeping, touching or trying to touch the pain site and
visible muscle tension. They also provided meaningful explanations of their perception in relation to their knowledge
of the patient. Another study examined the interrater reliability of proxy reporters of pain (Puntillo et al., 2012).
Family proxy reporters were found to be closer to ICU
patients self-reports when compared to nurses and physicians. Specically in regards to pain, moderate intraclass
correlation coefcient (ICC) of 0.43 and 0.45 were found
between patient-family member reports of pain intensity
and pain distress, respectively. Lower ICCs of 0.190.40
were obtained between patient-nurse and patient-physician
pain reports (Puntillo et al., 2012). Unfortunately, little evidence exists about proxy reporters reliability in the pain
assessment process and further research is necessary.
The Communication Model of Pain (Hadjistavropoulos and
Craig, 2002; Hadjistavropoulos et al., 2011) also offers an
interesting conceptual foundation for the assessment of pain
(Fig. 1). This A B C model conceptualises pain as an internal state (A) that may be encoded in particular features of
expressive behaviours (B), allowing observers or raters to
draw inferences (C) about the nature of the patients experience. More specically, the processing of the pain stimulus
is modulated by intrapersonal and/or contextual factors (A)
inuencing the way pain is experienced in each individual.
Gender, age, ethnicity, health condition and the context in
which this individual is evolving are examples of these factors. The use of mechanical ventilation and the administration of analgesic and sedative agents are more specic to the
critical care context and add challenges to pain assessment.
The pain stimulus is encoded in self-report (for patients able
to communicate) and behaviours (B) which are decoded by

Pain assessment in the critically ill adult

Figure 1

Adapted from the Communication Model of Pain (Hadjistavropoulos and Craig, 2002).

observers (C). Self-report depends on higher mental processing while behaviours are less subject to voluntary control
and are more automatic. Behaviours may be more difcult
to decode by observers, and educational training is of great
importance to support them in developing the competence
of adequately assessing pain behaviours using observational
measures. For example, standardised training for the use
of BPS and CPOT has led to appropriate tool utilisation into
practice and consistent scoring among ICU nurses and physicians (Chanques et al., 2006; Glinas et al., 2011a,b).
Such a conceptual framework may guide nurses in considering different aspects of the patients situation and the
context in which he/she is evolving in the pain assessment
process. It also provides a strong scientic basis for the
most appropriate methods to assess pain i.e., self-report and
behavioural observation to be interpreted by decoders (e.g.,
nurses and family caregivers). Furthermore, it ts nicely
with the current recommendations and guidelines for pain
assessment (Barr et al., 2013; Herr et al., 2011).

called BPS-NI for non-intubated patients (Chanques et al.,

2009) includes an item related to vocalisation in place of
compliance with the ventilator for non-mechanically ventilated patients. Both the BPS and CPOT were shown to
discriminate between nociceptive procedures known to be
painful and non-nociceptive procedures (i.e. discriminant
validation), to be related to the patients self-report of pain
(i.e. criterion validation) and to lead to consistent scores
when used independently by different raters (i.e. interrater
reliability). In the Society of Critical Care Medicine (SCCM)
practice guidelines (Barr et al., 2013), the BPS and the CPOT
are the two suggested scales for clinical use in ICU patients
unable to self-report and whose motor function is intact and
behaviours are observable. Therefore, these scales are of
limited use in patients with a Glasgow Coma Scale (GCS)
(Teasdale and Jennett, 1974) score of three or a Richmond
Agitation Sedation Scale (RASS) score of 5 (Sessler et al.,
2002) as such scores indicate that the patient is unresponsive or unarousable. Some questions pertaining to their use
are discussed.

Challenges with the use of behavioural pain

scales

How should we interpret behavioural pain scores?

As previously mentioned, when the patients self-report is

impossible to obtain, behavioural pain scales should be used.
To date, a total of eight behavioural pain scales have been
developed and/or validated for use with nonverbal critically
ill ICU adults (Glinas et al., 2013). From this recent critical review and a previous one (Pudas-Thk et al., 2009),
both the 512 Behavioural Pain Scale (BPS: Payen et al.,
2001) and the 08 Critical-Care Pain Observation Tool (CPOT:
Glinas et al., 2006) were identied as the scales with the
most robust psychometric properties (i.e., validity and reliability) for detecting pain in medical, surgical and trauma
ICU patients. Briey, the content of these two scales is
similar to three items related to facial expression, body
movements, and compliance with the ventilator. The CPOT
has a fourth item assessing muscle rigidity, and compliance
with the ventilator can be replaced with vocalisation in nonmechanically ventilated patients. An adaptation of the BPS,

Cut-off scores for the presence of pain have been established for the BPS (>5) (Payen et al., 2007) and CPOT (>2)
(Glinas et al., 2009) which both represent more than two
points from their respective minimal score. Behavioural pain
scores based on the nurses observation of the patient should
be interpreted differently from the patients self-report pain
intensity scores. In fact, although they both represent pain
scores, they are not measuring the same dimension of pain.
More specically, the patients self-report of pain intensity
relates to the sensory dimension of pain which refers to
the perception of pain by the person who is experiencing
it (Melzack and Casey, 1968). On the other hand, the nurses
observational scores are associated with the behavioural
component of pain i.e., behavioural responses exhibited by
patients to express their pain (McGuire, 1992) and decoded
by an external observer (as illustrated in the C component of
Fig. 1). Self-reported pain intensity scores and behavioural

Figure 2

C. Glinas

Pain Intervention Algorithm Glinas C (2016). NRS, Numeric Rating Scale; CPOT, Critical-Care Pain Observation Tool.

pain scores move in the same direction (i.e., when one score
increases, the other score increases as well) (Herr et al.,
2011; Glinas et al., 2013), but are not equal scores. Moreover, while it is useful to classify the intensity of pain as mild,
moderate and severe for the development of pain management protocols, it is important to know that behavioural
pain scales only allow the detection of the presence versus
absence of pain. Indeed, in most studies, this criterion of
presence versus absence of pain was used to establish BPS
(Chen et al., 2014) and CPOT (Echegaray-Benites et al.,
2014; Glinas and Johnston, 2007; Li et al., 2014) cut-off
scores. However, in a previous study with postoperative
ICU patients, it was found that the CPOT cut-off score >2
could better classify patients who self-reported moderate
to severe pain (Glinas et al., 2009). Knowing this, opioid and/or non-opioid analgesic agents could be trialled
when cut-off scores of behavioural pain scales are reached.
An intervention algorithm with the CPOT was created to
help guide the ICU care team in their decision for pain
management (Fig. 2), and its implementation still needs to
be trialled in clinical practice. Nevertheless, pain management protocols must be adapted to take into account that
behavioural pain scores cannot discriminate between mild,
moderate and severe levels of pain.

Can behavioural pain scales be used in any

critically ill adult patient population?
Although behavioural pain scales have been developed for
use in critically ill adults, some challenges remain in specic patient groups. These include ICU patients with a brain
injury, burns, delirium and a cognitive decit. Evidence and
challenges with the use of behavioural pain scales in these
groups are discussed.

The study of pain in ICU patients with a brain injury

from a traumatic and a non-traumatic source has received
some attention from research teams around the world.
In a rst Canadian study by Glinas and Arbour (2009),
unconscious ICU patients with a TBI (n = 43) exhibited different behaviours such as a relaxed face (70%), eye weeping
(14%), eye opening (16%) and relaxed muscles (72%) during turning. Not surprisingly, their CPOT score was lower
(mean = 2.05) in comparison with surgical ICU patients
(mean = 3.30) (p < 0.001). Similar ndings were found in
a study by a research team from Iran (Dehghani et al.,
2014) who found higher BPS scores during endotracheal
suctioning (mean = 7.75) compared with a non-nociceptive
procedure (i.e., eye care) (mean = 3.28) in 50 critically ill
TBI patients (p < 0.001). Unfortunately, the authors did not
provide details regarding item scores so it is difcult to
draw conclusions on their specic behavioural responses
to the nociceptive procedure. Description of behavioural
responses in critically ill TBI patients (n = 45) was further
explored by the same Canadian research group (Arbour
et al., 2014a). During turning, a high proportion of TBI
patients showed neutral behaviours (i.e., relaxed face
48.9%, absence of body movements 44.4%, and relaxed muscles 88.9%) and this was inuenced by their LOC. In fact,
87.5% of unconscious TBI patients (n = 8) were more likely
to exhibit a relaxed face and to remain immobile. However, signicant proportions of altered LOC and conscious
TBI patients exhibited pain-related behaviours or autonomic
responses including moaning (>50%), brow lowering (>38%),
face ushing (>33%), eye opening (>25%), eye weeping
(>25%) and limb exion (>23%). A positive high correlation
(rs = 0.82; p < 0.001) was found between the number of painrelated behaviours/autonomic responses and the patients
self-reported 010 pain intensity. Only four conscious TBI

Pain assessment in the critically ill adult

patients (n = 16; 25%) exhibited a full grimace and tried
to reach their pain site during turning. Interestingly, in
those able to self-report their pain (n = 13/16), nine of them
reported pain during turning but only one exhibited a grimace and muscle rigidity; such ndings are opposite to the
Thunder Project in which these two behaviours were the
most frequent in ICU patients who reported pain (Puntillo
et al., 2004).
To our knowledge, only three studies addressed painrelated behaviours in ICU patients with a non-traumatic
brain injury. In a rst study by a research team from
Korea (Lee et al., 2013), pain was assessed at rest and
during endotracheal suctioning using the CPOT on ve specic days (i.e., 1, 3, 6, 9 and 14) after ICU admission
in 31 brain-injured patients most of them with a cerebral haemorrhage and two with a brain tumour. None had
a GCS of 1315 and patients were unable to self-report.
Mean CPOT scores decreased over time, and were higher
in ICU patients who did not undergo brain surgery (n = 9)
after including analgesic use as a covariate which was
common in the surgery group (n = 22). Consistent with previous validation studies, mean CPOT scores were higher
ranging from 2.58 to 3.26 during endotracheal suctioning.
Therefore, the CPOT cut-off score of >2 for the presence
of pain was reached during a painful procedure in this
patient group. In another study by a research team from
Switzerland (Roulin and Ramelet, 2014), pain behaviours
were described in 116 ICU patients with a non-traumatic
brain injury (i.e., 66% with intracranial haemorrhage, 30.2%
with anoxic or ischaemic origin and others). Patients were
clustered into three groups according to their LOC: (a)
stereotyped responses i.e., limb exion/extension or no
response to a nociceptive stimulus (n = 37); (b) localised
responses to a nociceptive stimulus (n = 33); and (c) those
able to self-report and to follow commands (n = 46). Some
differences in pain behaviours were observed during turning
across the three groups. For instance, brow lowering, eye
closure and touching the pain site were observed more often
in the self-report group (63%, 73% and 29% respectively) than
in the localised group (29%, 65% and 7%) and the stereotyped group (51%, 35% and 4%) (p < 0.05). Interestingly, face
ushing was more frequently identied in the stereotyped
group (43%) than in the localised (19%) and the self-report
groups (21%) (p < 0.05). Opposite to what was found in TBI
patients (Arbour et al., 2014a; Glinas and Arbour, 2009),
muscle rigidity was observed in similar proportions (3248%)
in all three groups. Overall, median number of behaviours
was higher during turning than at rest (p < 0.01). In addition,
a moderate positive correlation was found between number
of behaviours and the patients self-report of pain intensity using the 010 NRS (rs = 0.53) in the self-report group
(n = 30/46) during turning. However, the grimace which is a
key facial expression of pain was not described.
The last study conducted in non-traumatic brain injury
ICU patients was led by a Canadian team (Echegaray-Benites
et al., 2014) with elective brain surgery ICU patients (n = 43)
who underwent either a craniotomy (79%) or a craniectomy (21%). Pain was assessed with the CPOT before, during
and after two procedures: (a) non-nociceptive: non-invasive
blood pressure (NIBP) and (b) nociceptive: turning. CPOT
scores were higher during turning (median = 2; range 06)
in comparison with rest (median = 0; range 03) and NIBP

5
(median = 0; range 06) (p < 0.001). Patients who reported
pain during turning had higher CPOT scores than those
who reported no pain (p < 0.001), and a moderate positive
correlation was obtained with their 010 NRS self-report
(rs = 0.57; p < 0.001). A CPOT cut-off score 2 showed sensitivity and specicity ndings of 76.9% and 73.3% respectively
and the ability to discriminate (Area Under the Curve or AUC)
between those with or without pain was high at 86.4%.
Only one American study was conducted in a burn population (Wibbenmeyer et al., 2011) and evaluated two pain
scales including the CPOT (Glinas et al., 2006) and the NonVerbal Pain Scale (NVPS: Odhner et al., 2003). The NVPS
includes three behavioural items (i.e., facial expression,
activity and muscle guarding) and two physiologic ones in
relation to changes in vital signs (i.e., blood pressure and
heart rate) and others (i.e., skin temperature, diaphoresis,
dilated pupils and ushing) for a possible total score ranging
from 0 to 10 (Odhner et al., 2003). A total of 225 paired
assessments were performed in 38 burn patients at rest,
before and after daily activities (either wound cleansing or
physical/occupational therapy). Flame or ash burn was the
most common aetiology (76.3%) and the average burn size
was 10.4% (SD = 12.1%) of body surface area. CPOT and NVPS
scores were shown to discriminate between pain at rest and
during activity but remained low with mean scores <1. In this
sample, patients were able to self-report and mild positive
correlations were obtained between behavioural scores and
the 010 NRS scores with Pearson coefcients of 0.36 (for
CPOT) and 0.38 (for NVPS) (p < 0.01). It is worth mentioning
that means of 4.27 and 5.41 of self-reported 010 NRS scores
were described at rest and during activity respectively showing moderate perceived pain in this sample. Again, the item
scores were not presented making it impossible to identify the behavioural responses exhibited by these patients.
Moreover, the body area was not specied which would have
been useful in better understanding the pain scores. For
example, we could expect that patients with burns located
on the face would have altered facial expressions in relation
with pain.
Finally, behavioural pain scales were validated in delirious ICU patients in only two studies. A research team
from France validated the use of the BPS-NI in 30 medical or surgical ICU patients with 84% being positive for
delirium (Chanques et al., 2009) as per the Confusion Assessment Method (CAM)-ICU (Ely et al., 2001). Patients were
assessed for pain during a non-nociceptive procedure (i.e.,
catheter dressing change) and a nociceptive procedure (i.e.,
turning). Higher BPS-NI scores were found during turning
(median = 6) compared with rest (median = 3) and the nonnociceptive procedure (median = 3) (p < 0.001). The effect
size for responsiveness was large for the three items of the
BPS-NI with 3.64 for vocalisation, 2.82 for facial expression,
1.47 for upper limb movements and 3.46 for the total BPSNI scores. Recently, the use of the CPOT was validated in 40
delirious ICU patients (i.e., as per screening with CAM-ICU)
by a Canadian research team (Kanji et al., 2016). Similarly, higher CPOT scores during painful procedures (i.e.,
turning, endotracheal suctioning or dressing change) compared with baseline and a non-painful procedure (mean
difference = 3.13; p < 0.001, and effect size Cohen D = 2.0).
These study ndings suggest that the BPS-NI and the CPOT
are valid tools for the assessment of pain in ICU patients with

6
delirium; however, further testing by other research teams
is required to support such conclusions.
Assessment tools can only be shown to be valid for a specic purpose, in a determined group of respondents and in a
given context (Streiner et al., 2014). As specied in the recommendation related to BPS and CPOT in the PAD guidelines
(Barr et al., 2013), their use should be considered with caution in brain-injured ICU patients. Indeed, recent evidence
has shown that ICU patients with a brain injury affecting
their LOC appear to have different behavioural reactions to
pain, such as the absence of grimace and muscle rigidity in
most of them. Therefore, existing behavioural pain scales
may not be applicable to those patients and further adaptation of these scales may be necessary. Insufcient evidence
is available in burn patients (Wibbenmeyer et al., 2011).
However, we may anticipate that burns on the face and limbs
may affect facial expressions and limb movements which
would necessitate adaptation of existing pain scales. The
BPS-NI and CPOT appear to be valid for use in ICU patients
with delirium but this has to be replicated by other research
teams to support external validity. Yet no evidence on the
validity of the use of behavioural pain scales in ICU patients
with cognitive decit is available and research is denitely
needed.

Impact of the implementation of pain

assessment tools on ICU practices and patient
outcomes
A recent systematic review described the impact of pain
assessment on critically ill patients outcomes (Georgiou
et al., 2015). A total of 10 eligible studies were identied.
Overall, there was evidence of positive effects on the detection and management of pain, and on patient outcomes
including duration of mechanical ventilation, ICU length of
stay, adverse events and mortality. However, an observational pre-experimental design was used in all studies, and a
higher level of evidence research (i.e., experimental design)
is necessary to draw rm conclusions. Some key studies for
which methodological quality was evaluated as moderate
to strong in the systematic review were selected for further discussion of implementation strategies and outcomes.
These studies targeted the implementation of systematic
pain assessment approaches using the BPS, CPOT and NRS.
Although its methodology quality was considered weak by
Georgiou et al. (2015), the implementation study of the
NVPS by Topolovec-Vranic et al. (2010) is also discussed as
it described patient satisfaction which was rarely addressed
previously.
The rst study to evaluate the impact of a systematic pain and sedation assessment approach was conducted
by a research team from France led by Chanques et al.
(2006) who implemented the NRS and BPS (Payen et al.,
2001) along with RASS (Sessler et al., 2002) in a medicosurgical ICU. Using a pre/post prospective controlled
design (n = 100 in control group and n = 130 in intervention group), they documented decreased incidence of pain
(63% versus 42%, p = 0.002) and agitation events (29% versus
12%, p = 0.002), and increased therapeutic changes (escalation and de-escalation) of analgesics and psychoactive
drugs post-implementation. Verbal information and written

C. Glinas
support tools on the evaluation of pain were provided to
ICU nurses, physicians and residents; pocket cards were
distributed to nurses, and posters were placed in every
patients room. After patients were assessed for pain with
the NRS or the BPS by ICU nurses, physicians were notied of a pain event (NRS > 3 or BPS > 5) or an agitation
event (RASS > 2) and could intervene accordingly. Decreases
in mechanical ventilation duration and nosocomial infection
rate were demonstrated in the intervention group (p < 0.05)
but no differences in ICU length of stay and mortality
were found. Another research team from Australia implemented the BPS along with RASS in a general ICU (Williams
et al., 2008) using a pre/post-test study design. Education on the tool use was provided to all staff. Outcomes
were documented in 369 and 400 mechanically ventilated
patients before and after the tool implementation, respectively. The proportion of ICU patients who received sedatives
with or without analgesics was greater after tool implementation (88%) than before (57%) (p < 0.001). No difference
in duration of mechanical ventilation was found between
the two groups (Williams et al., 2008). In a pre/post
prospective study from a German research team (Radtke
et al., 2012), the NRS and BPS were also implemented
along with a sedation (RASS: Sessler et al., 2002) and
delirium (Delirium Detection Score: Otter et al., 2005)
scales in three ICUs. A total of 619 ICU patients were
included i.e., 241 in the pre-training period, 228 in the
post-training period and 150 in the follow-up period. This
latter period representing the extended training (with three
consecutive educational sessions, and an ICU support team
available during the implementation phase) was compared
with standard training (one educational session of 45-minute
duration) in the post-training period and was found to
lead to more signicant changes in ICU practices (i.e.,
more frequent documentations of pain assessments) and
to their sustainability at 1-year follow-up (p < 0.01). Tool
implementation had no impact on mechanical ventilation
duration and ICU length of stay. Pain monitoring was associated with a decrease in mortality (OR = 0.35 with 95% CI:
0.140.86).
More recently, in a quality improvement project led by
Chanques team, systematic pain assessments with NRS or
BPS were completed by ICU nurses during the rst turning of
the day (De Jong et al., 2013), and appropriate pain management interventions were provided in collaboration with
physicians. Similar educational strategies (i.e., training in
small group sessions, posters) from the rst study (Chanques
et al., 2006) were used, and the clinical information system
software was updated. A total of 630 care procedures were
analysed in 193 ICU patients i.e., 53 at baseline (n = 184 procedures), 90 during implementation (n = 299 procedures) and
50 post-implementation (n = 149 procedures). The incidence
of severe pain as dened by NRS > 6 or BPS > 5 decreased
signicantly from 16% at baseline to 6% during the implementation phase, and 2% post-implementation (p < 0.05).
Incidence of at least one severe adverse event (i.e., cardiac
arrest, arrhythmias, tachycardia, bradycardia, hypertension, hypotension, desaturation, bradypnoea or ventilator
distress) also signicantly decreased from 37% at baseline to
17% during implementation, and 21% post-implementation
(p < 0.05). Patients who had severe pain were more likely to
experience a severe adverse event (OR = 2.74 (1.54; 4.89),

Pain assessment in the critically ill adult

p < 0.001). The administration of at least one analgesic drug
was higher at post-implementation compared with baseline
(33% versus 53%, p < 0.01).
Regarding the implementation of the CPOT (Glinas
et al., 2006), two before-after prospective studies led by
two Canadian research teams were published (Glinas et al.,
2011a; Rose et al., 2013). In the rst study in a medical/surgical/trauma ICU, a 90-minute standardised training
for the use of the CPOT which also included practice with
patient videos, and the creation of a support ICU champion
team to provide feedback and answer ICU nurses questions were used (Glinas et al., 2011a). The CPOT was
also incorporated into the ICU nursing ow sheet prior to
conducting the study. Findings showed an increase in the frequency of documented pain assessments per patient per day
between pre and post-implementation groups (n = 30/group)
(median of 3 at pre, and 10.5 at 3-month post) which was
maintained at 12-month post (median of 12). Pain reassessments following the administration of an analgesic and/or
sedative agents were also higher post-implementation of
the CPOT (10% at pre versus 43% and 59% at 3 and 12month post respectively), and a decrease in the use of
sedative agents was also observed (p < 0.05). At 12 month
post-implementation, 92100% of ICU nurses (n = 38) agreed
that the CPOT was quick and easy to use, and 87% mentioned that it helped them to adequately evaluate pain.
However, less than 50% of ICU nurses mentioned that the
tool helped them to effectively communicate pain assessment results with physicians, and this was identied as
an area for improvement (Glinas et al., 2014). Regarding clinical outcomes, only a signicant decrease in the
number of complications was found in a small subsample of trauma ICU patients (n = 15) at post-implementation
(p < 0.05) (Arbour et al., 2011). Using the same standardised training (Glinas et al., 2011a) in addition to other
strategies (i.e., incorporating the CPOT in protocols, bedside and web portal tools), another study was conducted
by Rose and colleagues in two ICUs (i.e. cardiovascular
and medical/surgical/trauma) with 189 and 184 patients
before and after CPOT implementation, respectively. Similar ndings were found in both settings with frequencies
of documented pain assessments being four times higher at
post-implementation than at pre (p < 0.001). Interestingly,
decreases in the use of analgesic (5 mg to 4 mg; p = 0.02) and
sedative (12 mg to 2 mg; p < 0.001) medication were found
in the cardiovascular ICU. However, mixed ndings were
obtained in the two ICUs according to length of stay and
mechanical ventilation duration.
In another prospective pre/post study, the use of the
Non-Verbal Pain Scale (NVPS: Odhner et al., 2003) was implemented in a trauma/neurosurgery ICU (Topolovec-Vranic
et al., 2010). In-service small group training sessions of
1520 minutes were offered by the study investigator who
reached 90% of the ICU nurses. Pocket cards were distributed to nurses, and a poster was placed in the ICU
for staff reference. Nurses documented pain assessments
on a NVPS documentation tool created for this study. Similar to other studies, the number of documented pain
assessments increased per day in the ICU after the implementation of the tool (2.2 pre versus 3.4 post, p = 0.02).
A total of 64 patients (25 pre and 39 post-implementation
of NVPS) were approached and of these, 20 (80%) patients

7
before and 32 (82%) patients after tool implementation had
recollection of their ICU stay and completed the patient
satisfaction survey. Patients reported decreased retrospective pain ratings (8.5 pre versus 7.2 post, p = 0.04) and
were satised with pain control before and after the pain
tool implementation. Fifty-three surveys (89% of all distributed) and 32 (50%) were completed by ICU nurses pre
and post-implementation of NVPS, respectively. Most nurses
(78%) ranked the tool as easy to use. Implementation of
the tool increased nurses condence in assessing pain
in nonverbal, sedated patients (57% pre versus 81% postimplementation, p = 0.02). However, no differences were
found in nurses condence in managing patients pain
before and after the tool implementation. The main barriers
described by nurses included the physicians pain management practices, personal beliefs and attitudes towards
pain, and characteristics that limit the patients ability to
self-report.
Although these study results are promising, further
research is clearly needed to evaluate the uptake of an
ICU pain management initiative by the inter-professional
team, and to measure its impact on sustainability of practice
changes and patients outcomes. Indeed, earlier studies primarily focused on the effects of clinicians training on the
use of pain assessment tools. Whether this really translates
into the day-to-day use of such tools by the ICU interprofessional team, changes in clinical practices that are
sustained over time, improved inter-professional collaboration and better patient outcomes needs to be investigated
more closely. In addition, very little is known about the
impact of such initiatives on the patients experience of pain
in the ICU and many initiatives were led by nursing teams
only (Glinas et al., 2011a; Rose et al., 2013; TopolovecVranic et al., 2010). Involving the ICU inter-professional
team in the implementation process is necessary to ensure
their collaboration and support in the pain management
process. Indeed, inter-professional collaboration is a key
component in health care delivery and can lead to better
patient outcomes (Rose, 2011). Finally, pain and sedation
assessments should be performed concomitantly as it has
been found to guide clinicians in their decision making process and to lead to better use of analgesic and sedative
agents (Chanques et al., 2006).

Caution with vital signs

In comparison to pain related-behaviours, vital signs have
received less attention in research in critically ill adults,
and inconsistent ndings were reported. In most studies,
heart rate (HR) or blood pressure (BP) indicators were found
to increase when ICU patients were exposed to painful
procedures such as endotracheal suctioning, mediastinal
tube removal, turning and wound care (Aissaoui et al.,
2005; Arbour and Glinas, 2010; Arroyo-Novoa et al., 2008;
Boitor et al., 2015; Chanques et al., 2009; Chen and Chen,
2015; Glinas and Arbour, 2009; Glinas and Johnston, 2007;
Kapoustina et al., 2014; Li et al., 2009; Payen et al., 2001;
Stotts et al., 2004). However, these increases (<20%) were
not considered to be clinically signicant by the authors.
Conversely, these vital signs could either be found to uctuate both during painful and non-painful procedures (Arbour

8
et al., 2014b; Young et al., 2006) or to remain stable during
painful ones (Glinas et al., 2011b; Sifeet et al., 2007). In
other studies, respiratory rate (RR) (Chanques et al., 2009;
Kapoustina et al., 2014) and end-tidal CO2 were found to
increase during a painful procedure (Arbour and Glinas,
2010; Glinas and Arbour, 2009), while SpO2 (oxygen saturation) was found to decrease (Boitor et al., 2015; Glinas
and Johnston, 2007). Except for associations found between
vital signs (i.e., HR, RR and SpO2 ) and the self-report of
pain in cardiac surgery ICU patients (Arbour and Glinas,
2010) and critically ill TBI patients (Arbour et al., 2014b);
vital signs failed to be related to the patients self-report of
pain (Arbour and Glinas, 2010; Boitor et al., 2015; Chen and
Chen, 2015; Glinas and Arbour, 2009; Glinas and Johnston,
2007; Kapoustina et al., 2014). Such ndings are not surprising as many other sources of distress besides pain can make
them uctuate (Herr et al., 2011).
However, as described in a wide Canadian survey, most
ICU nurses (n = 733/796, 92%) consider vital signs moderately
to extremely important for the assessment of pain (Rose
et al., 2012). Nurses need to be more aware of the evidence
showing the lack of validity related to the use of vital signs
in the ICU pain assessment process. Indeed, the recommendation in both ASPMN (Herr et al., 2011) and SCCM (Barr
et al., 2013) calls for caution with their use, and that they
should only be used as cues for further assessment of pain
with appropriate validated tools i.e., self-report measures
or behavioural pain scales.

New trends in pain-related indicators

Besides vital signs, other indicators have been studied in
relation to the detection of pain in the ICU. From those,
the BISpectral Index (BIS), and pupillary reexes have been
examined. These indicators were mainly studied in the context of anaesthesia or sedation, and their interest of use
in the ICU pain assessment process is relatively new. The
BIS index is a single number computed from complex algorithmic equation based on the electroencephalogram (EEG)
data obtained from healthy subjects undergoing general
anaesthesia (Johansen and Sebel, 2000). The BIS index value
can vary from 0 (complete EEG suppression) to 100 (fully
awake) and its primary purpose is for the titration of anaesthetic agents during surgery. In three studies with small
samples of medical, surgical and trauma ICU patients (overall n of 82 in 3 studies), the BIS index value was found to
signicantly increase (>5%) during nociceptive procedures
such endotracheal suctioning and turning (Arbour et al.,
2015; Glinas et al., 2011b; Li et al., 2009). Interestingly
in Arbour and colleagues study (2015), the bilateral BIS
monitor was utilised in 25 critically ill TBI patients, and the
increases in the BIS index values were contralateral to the
brain lesion. More specically, increases in BIS-Right were
more pronounced in left-sided TBI patients than those with
right-sided injury. Also, BIS-Right uctuations in left-sided
TBI patients were highly positively correlated (rs = 0.99,
p < 0.001) with the number of pain behaviours observed during turning. Although these ndings appear promising, the
primary purpose of the BIS index is not to measure pain, and
further research in larger samples is needed to conrm its
utility in the ICU pain assessment process. Moreover, the BIS

C. Glinas
index can only be utilised in sedated patients and it would
not be applicable to patients who are awake, conscious and
unable to self-report.
Regarding pupillary reexes, pupil size signicantly
increased by 16% during a noxious procedure (i.e., endotracheal suctioning or repositioning) and returned to baseline
ve minutes after the procedure (p < 0.001) in 48 sedated
and mechanically ventilated cardiac surgery ICU patients (Li
et al., 2009). Interestingly, in a sample of 100 postoperative patients who awoke from general anaesthesia (Aissou
et al., 2012), a high positive correlation of 0.88 (p < 0.001)
was found between pain scores (5-item verbal rating scale
or VRS) and pupil dilatation reex (PDR). In patients (n = 39)
who reported a VRS > 1, PDR before and after morphine titration was 35% and 12% respectively (p < 0.001). Moreover, the
PDR threshold value of 23% was associated with a sensitivity of 91% and a specicity of 94% (Aissou et al., 2012). In a
recent study by Lukaszewicz et al. (2015), a percentage of
pupil size variation >19% was found to predict the presence
of pain by a BPS score >3 with a sensitivity of 100% and a
specicity of 77% before surgical dressing changes in 37 ICU
patients with cellulitis. Similar ndings were obtained in a
previous study by Paulus et al. (2014) in which a threshold
value of PDR >5% during a 20 mA tetanic stimulation could
predict with an AUC of 0.78 or 78% (95%CI: 0.610.91) insufcient analgesia (dened by an increase 1 point score on
the BPS) before endotracheal suctioning in 34 sedated ICU
patients. Overall, these results suggest that pupillometry
may potentially guide clinicians to adjust analgesia before
nociceptive procedures in critically ill patients.

Future avenues in research

Behavioural pain scales have undergone numerous validation
studies, but adaptation in their content is required in braininjured or burn ICU patient populations. Also, not much
is known on the validity of the use of these scales in ICU
patients with delirium or cognitive decit. Although an
effort was made to include items relevant to the patients
condition (i.e., those who are mechanically ventilated or
those able to vocalise), those items are not representative
of patients with a tracheostomy who are not on a ventilator and unable to vocalise (Bambi and Solaro, 2012). An
alternative item could be considered for this patient subgroup. There is also need for valid physiologic measures of
pain especially in ICU patients too heavily sedated or paralysed as behavioural responses cannot be observed in such
situations. Research on ICU proxy reporters of pain is scarce
and experimental design is needed to evaluate the effects
of the implementation of pain assessment and management
approaches on patient outcomes, ICU practices and their
sustainability over time.

Conclusion
Despite major discoveries in relation to pain assessment in
the critically ill adult in the last three decades, pain remains
a problem. Pain practice guidelines exist (Barr et al.,
2013; Herr et al., 2011), and their implementation into ICU
practice is urgently needed. Inter-professional ICU teams
must adjust their pain management protocols to available

Pain assessment in the critically ill adult

pain measures (i.e., self-report scores versus behavioural
scores) so they adequately represent score interpretation
of pain levels or presence versus absence of pain. Family caregivers should be systematically consulted to better
understand the patients behavioural responses to pain (Herr
et al., 2011). A change in nursing ICU practice in relation to
the use of vital signs in the ICU pain assessment process
must happen. Fluctuations in vital signs should be considered as adverse events to severe pain (De Jong et al., 2013)
rather than indicators for pain assessment as they are not
valid for this purpose (Barr et al., 2013; Herr et al., 2011).
Finally, pain assessment and management is a collaborative
effort and pain management initiatives must involve the ICU
inter-professional team for better outcomes.

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