Patricia Bourgault

Exploring the validity of the bispectral index, the Critical-Care Pain Observation Tool and vital signs for the detection of pain in sedated and mechanically ventilated critically ill adults: A pilot study

This pilot study aimed to explore the validity of the bispectral (BIS) index, the Critical-Care Pain Observation Tool (CPOT) score, and vital signs (mean arterial pressure, heart rate) during rest and painful procedures in sedated and mechanically ventilated ICU adults. A convenience sample of nine patients with various diagnoses participated in this observational repeated measures study. Patients were observed during 2 minute periods at rest (baseline), and during procedures known to be painful: turning and endotracheal suctioning. Both the BIS index and the CPOT score were found to increase when patients were exposed to procedures compared with rest, and were found to be more sensitive to procedures compared with vital signs. Indeed, vital signs remained quite stable during procedures in this sample. Results from this study support the recommendation that behavioural indicators (i.e. in this case, the use of a behavioural pain scale called the CPOT) be used for the detection of pain in nonverbal ICU patients. However, in some situations (e.g. deep sedation, use of blocking agents), behavioural indicators may no longer be observable, and all that is left are physiologic signs. The BIS seems to be an interesting technique and further research is required in order to establish if it could be used to guide clinicians for the detection of pain in this vulnerable population.

Different autonomic responses to experimental pain in IBS patients and healthy controls.

Background Pain perception ratings in irritable bowel syndrome (IBS) patients suggest that they present either hypoalgesia or hyperalgesia. However, little is known about the physiologic responses these patients present to a somatic painful stimulus. Goals The main goal of this project was to study autonomic nervous system responses and the cardiac response to experimental pain in IBS patients. Study This was addressed by exposing 27 women, 14 IBS, and 13 healthy controls (HCs), to a cold water (7°C) immersion test of the forefoot for 2 minutes. Pain perception, galvanic skin responses (GSR), and heart rate (HR) were monitored during and after the immersion. Results For comparable pain perception, a significant group difference (P<0.02) in the cardiac response was observed during the immersion where the peak rise in HR was much higher for HCs, reaching 22%, whereas it only reached 8% for IBS patients. Moreover, HR variability analysis demonstrated that IBS and HCs had opposite autonomic cardiac reactivity to pain, where IBS had increased parasympathetic/decreased sympathetic reactivity. Conclusions For comparable pain perception, IBS subject demonstrated different autonomic nervous system response to pain, which supports the view of autonomic dysregulation in IBS.

Pain in the emergency department with one-week follow-up of pain resolution.

OBJECTIVES To determine the intensity of pain in the emergency department (ED), the use of analgesics in relation to pain intensity, which patients are at risk for unresolved pain at one week post-discharge, and the postdischarge treatment of pain. METHODS Patients (n=871) admitted to two urban, university-affiliated EDs who were experiencing any pain were recruited on different shifts over the summer months of 1997. Pain intensity was self-reported, and chart reviews of the assessment, immediate treatment and follow-up prescriptions were conducted. Patients (n=699) were contacted one week later, and reports of pain intensity, activity, resuming normal functions and patient attitudes toward pain were documented. Descriptive and regression analyses were performed on the results of patients with complete data (n=585). RESULTS Mean pain intensity on admission was 6.0 (SD=2.5) on a zero to 10 visual analogue scale, and 5.0 (SD=2.9) at discharge (n=871). One-quarter (23%) of patients were given analgesics while in the ED; their mean pain intensity was 7.0 (95% CI 6.7 to 7.3) versus 5.7 (95% CI 5.5 to 5.9) for those who were not given analgesics (P<0.001). At one week, the mean intensity for worst pain in the past 24 h was 5.2 (SD=2.9) and the usual pain intensity was 3.7 (SD=2.6). Using a cutoff point of pain greater than three on the zero to 10 visual analogue scale as residual pain at one week, 35% (n=207) remained in pain, with musculoskeletal pain accounting for half (n=102) of those cases. Logistic regression showed that the following patients were most likely to have pain at one week: women; those with pain present longer than 48 h before ED visit; those with a high discharge pain rating; those who were taking analgesics; and those who had pain of musculoskeletal origin. Both the attitudes and beliefs about pain and the treatment of pain while in the ED or on discharge were unrelated to the presence of residual pain at one week. An examination of the same factors in relation to the return to normal activities found that they were similar, with the exception that admission and not discharge pain intensity was predictive of not returning to normal activities. CONCLUSIONS More than one-third of patients presenting to the ED with pain do not experience resolution of their pain. Women presenting with severe musculoskeletal pain of more than a week in duration are less likely to have resolution of their pain and to return to normal activities within a week of the ED visit.

Comparing pain modulation and autonomic responses in fibromyalgia and irritable bowel syndrome patients.

Objectives:Past studies confirm that patients with fibromyalgia (FM) and irritable bowel syndrome (IBS) show similar pain processing dysfunctions, such as reduced pain inhibition and aberrant autonomic nervous system (ANS) responses. However, patients with FM and IBS have rarely been investigated in the same study. The aim of the present study, therefore, was to compare descending pain inhibition, pain sensitivity, and ANS reactivity to pain in FM, IBS, and healthy controls (HC). Methods:Female patients with FM (n=10), IBS (n=13), and HCs (n=10) were exposed to multiple cold water (12°C) immersions to study pain sensitivity and descending pain inhibition. Heart rate variability was also assessed during immersions. Results:Pain intensity scores were highest in FM, intermediate in IBS, and smallest in HCs. In contrast, pain inhibition was absent in FM, intermediate in IBS, and strongest in HCs. Importantly, controlling for differences in pain inhibition abolished group differences in pain sensitivity. Heart rate variability analyses confirmed that, in response to mild levels of pain, patients with FM showed greater sympathetic activity whereas HCs showed greater parasympathetic activity. Patients with IBS showed intermediate ANS responses. Discussion:Our results confirm the presence of graded levels of somatic hyperalgesia across patients with IBS and FM. A similar pattern of result was observed for pain inhibitory dysfunctions. These pain processing changes were accompanied by abnormal autonomic responses, which maintained patients (principally patients with FM) in a state of sympathetic hyperactivity. Results suggest that patients with IBS and FM may present common, but graded, pain processing and autonomic dysfunctions.

Self-reported Pain intensity and associated distress in children aged 4-18 years on admission, discharge, and one-week follow up to Emergency Department

Objectives: Pain is the most common complaint among children presenting to the Emergency Department (ED), yet it is poorly managed. Although the poor management of pain has been documented, no studies have simultaneously determined the distress caused by the presenting pain nor have children been followed after the ED visit to determine whether the pain and distress have resolved. The purpose of this study was to describe pain intensity, distress from pain, and treatment of pain in children presenting to the ED and to follow them 1 week later to describe resolution of their pain. Methods: A survey design with follow up of patients identified with pain in 2 urban university-affiliated pediatric EDs with children between ages 4 and 18 (N = 533). Measures used included the Coloured Analogue Scale (CAS) for both pain and distress related to pain, mobility problems related to pain, and interference with activities of daily living due to pain. Chart reviews were conducted for documentation of pain assessment and analgesic administration and prescription at discharge. Results: Half of the children presenting were experiencing pain due to musculoskeletal injury and two-thirds of the pain problems had an onset within 48 hours of presentation to the ED. Mean pain intensity on admission was 5.2 (SD 2.3) and at discharge was 4.1 (SD 2.7), however, 22% had worsening of pain and for 26%, the pain remained the same. On admission, 12.8% reported pain intensity 8/10 or more but 23% reported distress levels 8/10 or more. Only 39% received analgesics during the visit and 11% were given a prescription for analgesics at discharge. Children (n = 104) were reached 1 week following discharge from ED and only 5% were reporting pain of 4/10 or more but, of those reporting any pain at all, 34% reported distress from their pain of 4/10 or more. Conclusions: A greater proportion of children report high intensity of distress from pain than of pain intensity itself when in the ED. Only a small proportion of children received analgesics during the visit to the ED and only slightly more on discharge. Although pain seems to resolve by 1 week, distress is less likely to have resolved. More attention needs to be paid both to pain children are experiencing in the ED and equally to the accompanying distress.

Is the Deficit in Pain Inhibition in Fibromyalgia Influenced by Sleep Impairments

It has been proposed that a deficit in inhibitory conditioned pain modulation (ICPM) underlies the pathophysiology of fibromyalgia (FM), but there is high variability in ICPM efficacy in this syndrome that remains poorly understood. Based on emerging data showing that age, anxiety, depression and sleep can modulate ICPM efficacy, the main objective of this study was to determine the clinical correlates of experimentally-induced pain perception in FM. Fifty FM patients and 39 healthy controls (HC) were tested. Anxiety, depression, sleep and FM symptoms were measured with questionnaires or interview-type scales. Experimental pain testing consisted of two tonic heat pain stimulations separated by a 2-minute cold pressor test (CPT). Thermal pain thresholds and tolerance were higher in HC compared to FM patients. Pain ratings during the CPT were lower in HC relative to FM patients. ICPM efficacy was stronger in HC compared to FM patients. Finally, sleep quality was the only factor significantly related to ICPM efficacy. To our knowledge, this is the first study to report this association in FM. Future studies will need to replicate this finding, to determine whether impaired sleep is primary or secondary to deficient pain inhibition, and to characterize the neurobiological mechanisms underlying this association.

Étude Descriptive du Processus D’ÉValuation et de Documentation de la Douleur Postopératoire dans un Hôpital Universitaire

Plusieurs etudes demontrent que les patients recoivent souvent un traitement insatisfaisant de la douleur en contexte postoperatoire. Le but de la presente etude descriptive etait d’examiner et d’analyser diverses donnees ayant trait au soulagement de 40 patients apres une intervention chirurgicale non urgente. Les patients ont rempli un journal de douleur afin d’evaluer le niveau d’intensite et de desagrement engendre par la douleur durant les trois premieres journees postoperatoires. Une analyse du dossier a permis de verifier la documentation de l’evaluation de la douleur par le personnel infirmier. Les resultats indiquent que la douleur en contexte postoperatoire est peu et inadequatement evaluee et peu documentee par le personnel infirmier. Lorsque la douleur est evaluee selon une echelle numerique, les infirmieres ont tendance a la sous-evaluer en comparaison avec l’evaluation notee par les patients. Pour la premiere journee postoperatoire, l’intensite moyenne de la douleur documentee par les infirmieres est de 1,57 (±0,23) sur une echelle numerique de 0 a 10, alors que l’intensite moyenne documentee par les patients est de 3,82 (±0,41). Cette etude fait ainsi ressortir qu’il n’y a pas de correlation significative entre l’intensite de la douleur documentee par l’infirmiere et celle notee par le patient, ce qui peut expliquer en partie un soulagement non optimal.

The use of the bispectral index in the detection of pain in mechanically ventilated adults in the intensive care unit: A review of the literature

The bispectral index is a technique that involves assessing brain activity (through electroencephalography as well as electromyography), and has been proposed to be useful for the detection of pain among patients who are unable to communicate verbally. This review aimed to clarify whether the bispectral index is an appropriate tool to assess pain in the intensive care unit.

Intervention Focused on the Patient and Family for Better Postoperative Pain Relief

Hip arthroplasty results in high-intensity postoperative pain. To counter this, a multimodal approach (combining pharmacologic and nonpharmacologic strategies) is recommended. The involvement of the patient and family is also suggested, but there are few examples. The purpose of this study was to measure the effects of a patient and family-centered educational intervention (accompanying family member), promoting nonpharmacologic strategies, about pain relief, anxiety, and the pain-coping strategies used. The intervention took the family into consideration by recognizing its expertise, existence, experience, and need for hope. Thirty-three patients took part in this quasiexperimental study, all being accompanied by a significant other (control group [CG]: n = 17; experimental group [EG]: n = 16). The control group received conventional treatment and the experimental group received the intervention. The results show that EG members experienced less intense pain on postoperative days 2 (2.75 vs. 5.14; p = .001) and 4 (2.17 vs. 4.00; p = .01). EG members reported less anxiety (29.50 vs. 37.00; p = .041). EG members used significantly fewer negative pain-coping strategies, such as ignorance and dramatization. The results suggest that a patient and family-centered educational intervention (accompanying family member), promoting nonpharmacologic strategies, should be routinely used in combination with the multimodal approach. This combination improves pain management, lowers anxiety, and facilitates the use of positive postoperative coping strategies.

Accuracy of Self-reported Prescribed Analgesic Medication Use: Linkage Between the Quebec Pain Registry and the Quebec Administrative Prescription Claims Databases.

Objectives:The validity of studies conducted with patient registries depends on the accuracy of the self-reported clinical data. As of now, studies about the validity of self-reported use of analgesics among chronic pain (CP) populations are scarce. The objective of this study was to assess the accuracy of self-reported prescribed analgesic medication use. This was attained by comparing the data collected in the Quebec Pain Registry (QPR) database to those contained in the Quebec administrative prescription claims database (Régie de l’assurance maladie du Québec [RAMQ]). Methods:To achieve the linkage between the QPR and the RAMQ databases, the first 1285 patients who were consecutively enrolled in the QPR between October 31, 2008 and January 27, 2010 were contacted by mail and invited to participate in a study in which they had to provide their unique RAMQ health insurance number. Using RAMQ prescription claims as the reference standard, &kgr; coefficients, sensitivity, specificity, and their respective 95% confidence intervals were calculated for each therapeutic class of prescribed analgesic drugs that the participants reported taking currently and in the past 12 months. Results:A total of 569 QPR patients responded to the postal mailing, provided their unique health insurance number, and gave informed consent for the linkage (response proportion=44%). Complete RAMQ prescription claims over the 12 months before patient enrollment into the QPR were available for 272 patients, who constituted our validated study population. Regarding current self-reported prescribed analgesic use, &kgr; coefficients measuring agreement between the 2 sources of information ranged from 0.66 to 0.78 for COX-2-selective nonsteroidal anti-inflammatory drugs, anticonvulsants, antidepressants, skeletal muscle relaxants, synthetic cannabinoids, opiate agonists/partial agonists/antagonists, and antimigraine agents therapeutic classes. For the past 12-month self-reported prescribed analgesic use, QPR patients were less accurate regarding anticonvulsants (&kgr;=0.59), opiate agonists/partial agonists/antagonists (&kgr;=0.57), and antimigraine agents use (&kgr;=0.39). Discussion:Information about current prescribed analgesic medication use as reported by CP patients was accurate for the main therapeutic drug classes used in CP management. Accuracy of the past year self-reported prescribed analgesic use was somewhat lower but only for certain classes of medication, the concordance being good on all the others.