Madalina Boitor

Validation of the Critical-Care Pain Observation Tool and Vital Signs in Relation to the Sensory and Affective Components of Pain During Mediastinal Tube Removal in Postoperative Cardiac Surgery Intensive Care Unit Adults.

Background:The Critical-Care Pain Observation Tool (CPOT) is a behavioral scale recommended in clinical practice guidelines for the assessment of pain in nonverbal intensive care unit (ICU) adults. Although the CPOT has been validated in various ICU patient groups, its association with the affective component of pain has not yet been explored, and in most studies, turning was the used nociceptive procedure. Aim:In this study, we aim to validate the use of the CPOT and vital signs in association with the sensory and affective components of pain during mediastinal tube removal (MTR) in postoperative cardiac surgery ICU adults. Methods:A sample of 125 patients participated in this prospective repeated-measures, within-subject study. A total of 6 assessments of the main study variables (CPOT scores and patients’ self-reports of pain intensity and unpleasantness) were completed by trained research assistants while patients were in the ICU. Assessments were done before, during, and 15 minutes after the nonnociceptive procedure (ie, noninvasive blood pressure taking [NIBP]) and nociceptive procedure (ie, MTR). Results:Discriminant validation of the scale use was supported as higher CPOT scores were obtained during MTR (mean [SD], 2.74 [1.61]) compared with NIBP (mean [SD], 0.50 [0.747]) (t124 = 14.33, P < .001). Similarly, higher values were recorded for mean arterial pressure and heart and respiratory rates during MTR compared with NIBP (P < .01). During MTR, CPOT scores correlated significantly with self-report of pain intensity (r = 0.419, P < .01) and unpleasantness (r = 0.313, P < .01), supporting criterion and convergent validation. Conversely, vital signs did not correlate with either self-report. Conclusions:Study findings confirmed the validity of the CPOT for the assessment of the sensory and affective components of pain in the postcardiac surgery ICU adults. Vital signs were not specific to pain and should be used only as cues to begin further assessment of pain using validated instruments for this purpose.

The Effect of Massage on Acute Postoperative Pain in Critically and Acutely Ill Adults Post-thoracic Surgery: Systematic Review and Meta-analysis of Randomized Controlled Trials

Abstract Critical care practice guidelines identify a lack of clear evidence on the effectiveness of massage for pain control. To assess the effect of massage on acute pain in critically and acutely ill adults post‐thoracic surgery. Medline, Embase, CINAHL, PsychInfo, Web of Science, Scopus and Cochrane Library databases were searched. Eligible studies were randomized controlled trials (RCTs) evaluating the effect of massage compared to attention control/sham massage or standard care alone on acute pain intensity post‐thoracic surgery. Twelve RCTs were included. Of these, nine evaluated massage in addition to standard analgesia, including 2 that compared massage to attention control/sham massage in the intensive care unit (ICU), 6 that compared massage to standard analgesia alone early post‐ICU discharge, and 1 that compared massage to both attention control and standard care in the ICU. Patients receiving massage with analgesia reported less pain (0–10 scale) compared to attention control/sham massage (3 RCTs; N = 462; mean difference −0.80, 95% confidence interval [CI] −1.25 to −0.35; p < 0.001; I2 = 13%) and standard care (7 RCTs; N = 1087; mean difference −0.85, 95% CI −1.28 to −0.42; p < 0.001; I2 = 70%). Massage, in addition to pharmacological analgesia, reduces acute post‐cardiac surgery pain intensity.

The Effectiveness of Hand Massage on Pain in Critically Ill Patients After Cardiac Surgery: A Randomized Controlled Trial Protocol

Background Postoperative pain is common in the intensive care unit despite the administration of analgesia. Some trials suggest that massage can be effective at reducing postoperative pain in acute care units; however, its effects on pain relief in the intensive care unit and when pain severity is highest remain unknown. Objective The objective is to evaluate the effectiveness of hand massage on the pain intensity (primary outcome), unpleasantness and interference, muscle tension, anxiety, and vital signs of critically ill patients after cardiac surgery. Methods A 3-arm randomized controlled trial will be conducted. A total of 79 patients who are 18 years or older, able to speak French or English and self-report symptoms, have undergone elective cardiac surgery, and do not have a high risk of postoperative complications and contraindications to hand massage will be recruited. They will be randomly allocated (1:1:1) to standard care plus either 3 20-minute hand massages (experimental), 3 20-minute hand holdings (active control), or 3 20-minute rest periods (passive control). Pain intensity, unpleasantness, anxiety, muscle tension, and vital signs will be evaluated before, immediately after, and 30 minutes later for each intervention administered within 24 hours postoperatively. Peer-reviewed competitive funding was received from the Quebec Nursing Intervention Research Network and McGill University in December 2015, and research ethics approval was obtained February 2016. Results Recruitment started in April 2016, and data collection is expected to be complete by January 2017. To date, 24 patients were randomized and had data collection done. Conclusions This study will be one of the first randomized controlled trials to examine the effect of hand massage on the pain levels of critically ill patients after cardiac surgery and to provide empirical evidence for the use of massage among this population. ClinicalTrial ClinicalTrials.gov NCT02679534; https://clinicaltrials.gov/ct2/show/NCT02679534 (Archived by WebCite at http://www.webcitation.org/6l8Ly5eHS)

Effects of Massage in Reducing the Pain and Anxiety of the Cardiac Surgery Critically Ill—a Randomized Controlled Trial

Objective To evaluate the effectiveness of hand massage on the pain and anxiety of the cardiac surgery critically ill. Design A three-arm randomized controlled trial. Setting This study was conducted in a medical-surgical intensive care unit in Canada. Subjects Adult patients who underwent elective cardiac surgery, who were able to speak French/English and to self-report symptoms, without a high risk of postoperative complications were eligible. Methods Patients were randomly allocated to standard care plus either two 20-minute hand massages (experimental), two 20-minute hand holdings (active control), or two 20-minute rest periods (passive control/standard care). Pain intensity, pain unpleasantness, anxiety, muscle tension, and vital signs were evaluated before, after, and 30 minutes later for each intervention. Results From the 83 patients recruited, 60 were randomized (20 massage, 19 hand holding, 21 standard care). After controlling for baseline scores, the massage group reported significantly lower pain intensity, pain unpleasantness, and anxiety for the first data collection set compared with both hand holding and standard care (analysis of covariance, P < 0.02), with an average decrease of two points on a 0-10 scale. No statistically significant differences were noted between hand holding and standard care for any of the symptoms. Similar results were observed for the second data collection set (N = 43). Patients had decreased muscle tension post massage. Vital signs did not differ significantly between groups. Conclusions Findings suggest that a 20-minute hand massage in addition to routine postoperative pain management can concomitantly reduce pain intensity, pain unpleasantness, and anxiety by two points on average on a 0-10 scale.

Acceptability and feasibility of an interprofessional end-of-life/palliative care educational intervention in the intensive care unit: A mixed-methods study

OBJECTIVES This study aimed to describe a seven hour End-of-Life/Palliative Care educational intervention including online content related to symptom management, communication and decision-making capacity and an in-person group integration activity, from the perspective of the interprofessional team in terms of its acceptability and feasibility. RESEARCH DESIGN A mixed-methods study design was used. SETTING AND SAMPLE The study was conducted in a medical-surgical Intensive Care Unit in Montreal, Canada. The sample consisted of 27 clinicians of the Intensive Care Unit interprofessional team who completed the End-of-Life/Palliative Care educational intervention, and participated in focus groups and completed a self-administered questionnaire. MAIN OUTCOME MEASURES The main outcomes were the acceptability and feasibility of the educational intervention. FINDINGS The intervention was perceived to be appropriate and suitable in providing clinicians with knowledge and skills in symptom management and communication through self-reflection and self-evaluation, provision of assessment tools and promotion of interprofessional teamwork. The online format was more feasible, but the in-person group activity was key for the integration of knowledge and the promotion of interprofessional discussions. CONCLUSION Findings suggest that an interprofessional educational intervention integrating on-line content with in-person training has the potential to support clinicians in providing quality End-of-Life/Palliative Care in the Intensive Care Unit.

Is near infrared spectroscopy valid for the detection of procedural pain in postoperative cardiac surgery intensive care unit adults

This study aimed to examine the validity of the regional cerebral oxygenation using the near infrared spectroscopy technique for pain assessment in postoperative cardiac surgery adults in the intensive care unit. The near infrared spectroscopy for the assessment of pain has been studied in pediatric population, but its use in adult population especially in the critically ill is new. A total of 125 cardiac surgery intensive care unit patients from a Canadian university-affiliated hospital participated in this prospective repeated-measures study. Six assessments were completed at rest before, during, and 15 min after two procedures: (1) non-nociceptive (blood pressure measurement using cuff inflation) and (2) nociceptive (mediastinal tube removal). Regional cerebral oxygenation (%) was measured using the INVOS 5100 device (Somanetics, Troy, MI, USA). The Critical-Care Pain Observation Tool was employed to assess behavioral responses to pain. Self-reports of pain intensity and unpleasantness using 0–10 scales were also obtained. Participants were mostly males (89%) and averaged 65 of age. Regional cerebral oxygenation showed significant mild bilateral decreases (<1%; p<0.01) while higher mean Critical-Care Pain Observation Tool scores, pain intensity, and unpleasantness self-reports were obtained during mediastinal tube removal (p < 0.001). Only the Critical-Care Pain Observation Tool score was mildly correlated to the right side regional cerebral oxygenation (r −0.23; p < 0.01). Changes in regional cerebral oxygenation were mild and in the opposite direction. Unfortunately, the findings do not support the clinical use of the INVOS 5100 (Somanetics, Troy, MI, USA) and its regional cerebral oxygenation hemodynamic parameter for the assessment of pain in the cardiac surgery critically ill patients.

Content validation of behaviours and autonomic responses for the assessment of pain in critically ill adults with a brain injury.

BACKGROUND The evidence shows that brain-injured patients express behaviours that are related to their level of consciousness (LOC), and different from other patients in the intensive care unit (ICU). Therefore, existing behavioural scales should be revised to enhance their content and validity for use in these patients. OBJECTIVES The aim was to evaluate the content relevance of behaviours and autonomic responses for pain assessment of brain-injured ICU patients from the perspective of critical care clinicians. METHODS A total of 77 clinicians from four adult neuroscience ICUs (three from Canada and one from the United States) participated in this descriptive study. A physician/nurse ratio of 21% (13/61) was reached in this quota sample, and three physiotherapists also participated. They completed a content validation questionnaire of 19 items rated on clarity and relevance based on the patients LOC. Item Content Validity Index (I-CVI), and modified kappa (κ*) were calculated. Values higher than 0.78 and 0.75 respectively were considered excellent. RESULTS Regardless of the patients LOC, brow lowering, grimacing, and trying to reach the pain site were rated as the most relevant behaviours by clinicians, with excellent values of I-CVI>0.78 and κ*>0.75. Eyes tightly closed, moaning and verbal complaints of pain also obtained excellent values in altered LOC and conscious patients. Eye weeping obtained excellent values only in conscious patients. Other items showed fair (0.40-0.59) to good (0.60-0.74) values, while blinking and coughing showed poor values (<0.40) at various LOC. CONCLUSIONS Facial expressions, movements towards the pain site, and vocalisation of pain were the most relevant pain-related behaviours rated by critical care clinicians. The relevance of some behaviours (e.g., moaning and verbal complaints of pain) varied across LOCs, thereby calling forth adaptations of behavioural pain scales to allow for interpretation in the context of a patients LOC and ability to express specific behaviours.