American Society of Regional Anesthesia and Pain Medicine November 2017 - 32

Table 2: Behavioral pain score.

Table 1: Critical care pain observation tool.
Behavior

Patient response
Tolerating ventilator

Compliance with
ventilator

Coughing but tolerating
Fighting ventilator
Relaxed, neutral

Facial expression

Muscle tension

+1
+2

Grimacing

+2
0

Protection

+1

Restlessness

+2

Facial expression

0

Tense/rigid

+1

Very tense/rigid

+2

ventilation and ICU length of stay when compared to sedation-free
protocols.
Less sedative medication allows for early mobilization, which in
turn results in improved outcomes. In studies designed to compare
standard of care versus early mobilization of ventilated patients,
patients who were randomized to early mobilization had shorter
ICU and hospital lengths of stay and were less likely to die or be
rehospitalized in the year following their critical illness.12,13
Other potential acute negative effects of untreated pain include
delirium, self-harm from accidental removal of lines or tubes,
sympathetic activation with increased catecholamine release
leading to tachycardia and increased systemic vascular resistance,
increased cardiac workload leading to oxygen supply demand
mismatch, and myocardial ischemia.14,15 In addition to acute
negative health effects, untreated and undertreated pain has
been associated with the development of chronic medical issues,
including chronic pain, long-term psychological illness, and lower
quality of life.16,17
HOW SHOULD WE ASSESS PAIN IN THE ICU?
Two sensitive and validated measures are used to assess pain in
patients unable to communicate their pain: the Critical Care Pain
Observation Tool (CPOT) and the Behavioral Pain Score (BPS).

32

Compliance with
ventilator

0
+1

Relaxed

Behavior

0

Tense

No movements
Body movements

Score

Upper limb
movements

Patient response

Score

Tolerating ventilator

+1

Coughing but tolerating
most of the time

+2

Fighting ventilator

+3

Unable to control
ventilation

+4

Relaxed, neutral

+1

Partially tightened

+2

Fully tightened

+3

Grimacing

+4

No movement

+1

Partially bent

+2

Fully bent with finger
flexion

+3

Permanently retracted

+4

CPOT evaluates four behaviors-facial expressions, body
movements, muscle tension, and compliance with the ventilator for
mechanically ventilated patients or vocalization for nonintubated
patients-rated on a scale of 0-2 with a total score ranging from
0-8 (see Table 1).18
BPS evaluates three behaviors-facial expressions, upper limb
movements, and ventilator compliance-rated on a scale of 1-4
with a total score ranging from 3-12 (see Table 2).19
The SCCM makes numerous recommendations about treating
pain in the ICU. They acknowledge the presence of pain at rest
and in routine care, and they make recommendations that pain
be routinely monitored using BPS or CPOT for patients who are
unable to self-report.20 They emphasize that validated scoring
systems should be used to assess pain and state that changes in
blood pressure and tachycardia should not be routinely used as
measures for assessment of pain.21 For more information regarding
the SCCM recommendations, refer to the SCCM pain, agitation, and
delirium guidelines as well as the ABCDEF bundle for prevention of
postintensive care syndrome.

American Society of Regional Anesthesia and Pain Medicine
2017



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