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
Adequate assessment and management of pain
are of particular importance.
In ICU
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
2000
LAGRASTA (3)
• Elaboration of a behavioral pain scale
for Non Communicating Patients (NCP)
2001
PAYEN et al. (4)
• Improvement of Lagrasta’s scale
2005
AISSAOUI (5)
• Validation of Payen’s scale
(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
2005
DE VAL et al.
2010
SCHNAKERS C. et al. (9)
• Elaboration of Dolousi Pain Scale (DPS)
based on behavioral pain scales such as
FLACC(6), CHEOPS(7) and Doloplus 2(8)…
• Elaboration of Nociception Coma Scale
(NCS) to detect pain in minimally
conscious and vegetative patients
(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
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
Facial 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
1
No tears
2
Presence of tears
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)
N = 196 observations of 24 hours each
DPS : SCORE = 4
DPS : SCORE ≥5
100%
90%
80%
51,17%
70%
60%
81,12%
87,23%
18,88%
12,76%
50%
40%
30%
48,83%
20%
10%
0%
At rest
Eye Care
P < O,OO1
P < O,OO1
P < O,OO1
Mann-Whitney and Wilcoxon test
Complete toilet
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
two independent examiners
Same inclusion and exclusion criteria
n = 45
Examiner 1
Score = 4
Examiner 2
Score ≥ 5
Score = 4
100%
100%
90%
90%
80%
80%
70%
65,72%
68,57%
70%
60%
60%
100%
50%
40%
30%
30%
34,28%
31,43%
20%
10%
10%
0%
0%
Without
nociception
100%
50%
40%
20%
Score ≥ 5
Nociception
P < O,OO1
Without
nociception
Mann-Whitney and Wilcoxon test
Nociception
P < O,OO1
Boîtes à Moustaches de plusieurs v ariables
Feuille de données4 2v *35c
Médiane; Boîte: 25%-75%; Moustaches: Etendue horsatypiques
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)
Box-plots of several variables
16
Histogram of several variables
Médiane
25%-75%
Etendue hors-atypiques
Points atypiques
Extrêmes
14
14
12
12
10
medians
8
6
Nbre d'obs.
10
8
6
4
4
2
2
Var1
Var2
Var1
Var2
0
4
5
6
7
8
9
10
Significantly different scores between the two situations
– at rest / nociception
Mann-Whitney and Wilcoxon test : p < 0,001
11
12
13
14
 MédianeMédiane
 2525%-75%
% - 75 % Min-Max
  Min - Max
Feuille de données9 2v*35c
Var1 = 35*1*normal(x; 5,2;
Curves of distribution
of1,2078)
several variables
Var2 = 35*1*normal(x; 5,2286; 1,2623)
11
14
10
12
9
10
Nbre d'obs.
8
8
7
6
6
4
5
4
2
Var1
Var2
0
4
5
6
7
8
9
10
3
Var1
Var2
Coefficients of Correlations of ranks of Spearman = 0,949063
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)
Curves of distribution of several variables
Boîtes à Moustaches de plusieurs variables
données7
2v*35c
Médiane Feuille de25
% - 75
%
Médiane; Boîte: 20%-80%; Moustaches: 1%-99%

  Min -
15 Max
8
14
7
13
6
Nbre d'obs.
12
5
11
4
10
9
3
8
2
7
1
6
0
Var1
Var2 5
6
7
8
9
10
11
12
13
14
Médiane
20%-80%
1%-99%
Var1
Var2
Coefficients of Correlations of ranks of Spearman = 0,899677
Significant correlations marked in p <0,00100
The DPS yielded a Cronbach alpha that varied
between
0,739565 to 0,729985
according to the situation
this fulfils the criterion of significant
internal consistency
Cronbach alpha : 0,70 – 0,99 = significant values
accurate
Easy to use
Dolousi Pain Scale
Good inter-rater reliability
Good internal consistency
Threshold
7?
Importance of adequate tools to evaluate pain by the nursing staff
Quality
Patients
Safety
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
588 at rest evaluations
196 eye care evaluations
196 shifting evaluations
196 observations of 24 hours
From 2006 to March 2008
2 nd study
110 patients
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
at rest
Eye care
194 patients
1453 evaluations
295 observations
shifting
nociception
@ : [email protected] ; [email protected]