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Further Assessment
of
a Behavioural Pain Scale
or
DOLOUSI Pain Scale
for patients who are unable to communicate
M. De Val Intensive Care Unit Charleroi BELGIUM
In ICU
Adequate assessment and management of pain
are of particular importance.
The recognition of pain is a medical and ethical
challenge for every physician and nurse
In particular, the evaluation of pain in patients who
cannot communicate, and more specifically :
sedated and ventilated patients.
• Postoperative pain is well know for communicating patients.(1)
• Non Communicating Patients (NCP) ,intubated and ventilated form a special group.(2)
• Few scales devoted to critically ill NCP staying in an ICU
(1) BARDIAU F. Contribution à l’élaboration d’un programme d’amélioration continue de la qualité de la
prise en charge de la douleur postopératoire. Thèse de doctorat en santé publique. ULB 1999-2000
(2) Sedation in the mechanically ventilated patient. Critical Care Med. – Volume 34, n° 10
• Elaboration of a behavioral pain scale for Non Communicating Patients (NCP)
2000
LAGRASTA (3)
• Improvement of Lagrasta’s scale 2001
PAYEN et al. (4)
• Validation of Payen’s scale 2005
AISSAOUI (5)
(3) LAGRASTA A. , DESCHAUX I. Enseignement supérieur en soins infirmiers adultes et pédiatriques 2000,
Elsevier : pp 66-72
(4) PAYEN JF et al. Critical Care Med. 2001: 29 : 225-263
(5) ASSAOUI Y et al. Anesth. Anal 2005: 101 : pp1470-176
• Elaboration of Dolousi Pain Scale (DPS) based on behavioral pain scales such as FLACC(6), CHEOPS(7) and Doloplus 2(8)…
2005
DE VAL et al.
• Elaboration of Nociception Coma Scale (NCS) to detect pain in minimally conscious and vegetative patients
2010 SCHNAKERS C. et al. (9)
(6) MERKEL et al. The FLACC (Face, Legs, Cry, Consolability) . Pediatric Nursing 1997: 23 : pp 293-297
(7) Mc GRATH et al. CHEOPS (Children’s Hospital of Eastern Ontario Pain Scale) : a behavioral scale for
rating postoperative pain in children. Advances in Pain Research and Therapy. 1985 , vol 9 : pp 395-402
(8) Doloplus 2 BMC Geriatrics 2007, 7 :29 doi : 10.1186/1471-2318-7-29. A valid tool for behavioral pain assessment?
(9) SCHNAKERS C. et al. Pain 2010 : 148(2) : pp215-219
- Elaborated and used in our ICU since 2005
- A behavioral, one-dimensional scale based upon hetero-evaluations of 4
items:
Adaptation to
ventilation
1 Compliant to ventilation settings
2 Occasional cough, triggers ventilator
3 In conflict with ventilator, coughing, ventilator overpressures
4 Incompatible with controlled ventilation
Facial expression
1 Relaxed
2 Mild tension or occasional grimaces (frown, pursing lips, trembling chin)
3 Severe tension on the face, frequent, persistent and marked grimacing
4 Permanently strained and exhausted expression
Motricity 1
Quiet, relaxed, comfortable
No defensive movements during nursing and investigations
2 Restless, intentional moving without strength or aggression, easily calmed
by verbal or tactile mediation
3 Agitated: frequent uncontrolled movements intended to escape nursing and
investigations; requiring bonds
4 Severely agitated: brutal flexion and stiff crispation of extremities to escape
nursing, fists clenched, pulls out catheters and bites tube
5 Combative: violent retractions, stiff defensive movements immediately
dangerous for the environment and for himself, risks falling out of bed
Tears
1 No tears
2 Presence of tears
Minimum score: 4 – Maximum score: 15
Prospective study:
110 consecutive Non Communicating Patients
Inclusion criteria
- intubated and mechanically ventilated for at least
24 h.
- GCS ≤ 10 (E4, M5, V1)
- Ramsay ≥ 4 for sedated patients
Exclusion criteria
- quadriplegic
- neuromuscular blocking or barbiturate coma
- Guillain Barré or peripheral neuropathies
- < 15 years old
196 observations of 24 hours each
3 evaluations at rest
588 evaluations non painful stimulus
1 evaluation during eye care
196 evaluations with slightly painful stimulus
1 evaluation during complete toilet with lateral
decubitus shifting
196 evaluations with more painful stimulus
Statistical analysis were performed with Wilcoxon or Friedman tests for non parametric data :
a P value < 0,001 is accepted as significant.
The Cronbach coefficient was also evaluated :
0 0.5 : insufficient values ; 0.5 0.7 : acceptable values ; 0.70 0.99 : significant values
For each observation of 24 hours, several parameters
were also recorded
Medication: dose of sedatives and/or analgesics.
GCS score
Ramsay score
Dolousi (DPS) score
All medical and nursing staff received training in these observations
Each assessment was performed by nurses belonging to the normal
daily nursing staff
The study protocol was approved by the ethical committee of the
CHU Charleroi.(Belgium)
P < O,OO1 P < O,OO1
P < O,OO1
N = 196 observations of 24 hours each
12
Mann-Whitney and Wilcoxon test
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
At rest Eye Care Complete toilet
48,83%
18,88% 12,76%
51,17%
81,12% 87,23%
DPS : SCORE = 4 DPS : SCORE ≥5
N = 196 observations of 24 hours each
45 Non Communicating Patients (NCP)
Intubated ventilated for at least 24 hours
With or without analgo-sedation
DPS score
- at rest
- during a pressure on the thumbnail during 5 seconds
Same inclusion and exclusion criteria
two independent examiners
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Without
nociception
Nociception
34,28%
65,72%
100%
Score = 4 Score ≥ 5
Examiner 1 Examiner 2 n = 45
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Without
nociception
Nociception
31,43%
68,57%
100%
Score = 4 Score ≥ 5
P < O,OO1 P < O,OO1 Mann-Whitney and Wilcoxon test
Histogramme de plusieurs v ariables
Feuille de données4 2v *35c
Var1 = 35*1*normal(x; 5,2; 1,2078)Var2 = 35*1*normal(x; 9,5714; 2,1867)
Var1 Var2
4 5 6 7 8 9 10 11 12 13 140
2
4
6
8
10
12
14
Nb
re d
'ob
s.
Boîtes à Moustaches de plusieurs v ariables
Feuille de données4 2v *35c
Médiane; Boîte: 25%-75%; Moustaches: Etendue hors-atypiques
Médiane 25%-75% Etendue hors-atypiques Points atypiques Extrêmes
Var1 Var22
4
6
8
10
12
14
16
Mann-Whitney and Wilcoxon test : p < 0,001
Significantly different scores between the two situations
– at rest / nociception
Histogram of several variables Box-plots of several variables
medians
Médiane 25%-75% Min-Max
Var1 Var23
4
5
6
7
8
9
10
11
Feuille de données9 2v*35c
Var1 = 35*1*normal(x; 5,2; 1,2078)Var2 = 35*1*normal(x; 5,2286; 1,2623)
Var1 Var2
4 5 6 7 8 9 100
2
4
6
8
10
12
14
Nb
re d
'ob
s.
Curves of distribution of several variables
Coefficients of Correlations of ranks of Spearman = 0,949063 Significant correlations marked in p <0,00100
Médiane 25 % - 75 % Min - Max
Coefficients of Correlations of ranks of Spearman = 0,899677 Significant correlations marked in p <0,00100
Feuille de données7 2v*35c
Var1 = 35*1*normal(x; 9,5714; 2,1867)Var2 = 35*1*normal(x; 9,9143; 2,1195)
Var1 Var2
6 7 8 9 10 11 12 13 140
1
2
3
4
5
6
7
8
Nb
re d
'ob
s.
Boîtes à Moustaches de plusieurs variables
Feuille de données7 2v*35c
Médiane; Boîte: 20%-80%; Moustaches: 1%-99%
Médiane 20%-80% 1%-99%
Var1 Var25
6
7
8
9
10
11
12
13
14
15
Curves of distribution of several variables Médiane 25 % - 75 % Min -
Max
The DPS yielded a Cronbach alpha that varied
between
according to the situation
this fulfils the criterion of significant
internal consistency
0,739565 to 0,729985
Cronbach alpha : 0,70 – 0,99 = significant values
Dolousi Pain Scale
accurate
Easy to use
Good inter-rater reliability
Good internal consistency
Threshold 7 ?
Importance of adequate tools to evaluate pain by the nursing staff
Quality
Safety Patients
From 2004 to 2005
1 st pretest 4 patients 24 evaluations 4 specific observations
2 nd pretest 11 patients 74 evaluations 11 specific observations
1 st study 24 patients 117 at rest evaluations
39 eye care evaluations
39 shifting evaluations
39 Observations of 24 hours
From 2006 to March 2008
2 nd study 110 patients 588 at rest evaluations
196 eye care evaluations
196 shifting evaluations
196 observations of 24 hours
From April 2009 to April 2010 - 2 periods of 4 months each - 2 examiners in the same time
3 rd study 45 patients 90 at rest evaluations
90 Nociception evaluations
45 specific observations
194 patients 1453 evaluations
at rest
Eye care
shifting
nociception
295 observations