Fifteen (71%) observers from among the 21 who participated in the study sent back the questionnaire. Regarding the proportion of ratings that were moderately to very positive, the BPS, NCS-I, and NCS-R-I were believed to be precise by 80%, 93%, and 93% of users, respectively. The usefulness of the scales was 87% for the BPS and 100% for the NCS-I/NCS-R-I. The easiness of learning was 67% for the BPS and 80% for the NCS-I/NCS-R-I. The scale that was found the most frequently easy or very easy to learn was the NCS-R-I (57%), compared with the others (NCS-I = 47%; BPS = 27%).
Our study has several limitations. First, we were not able to perform a convergent validation of the pain scales (correlation coefficients) because, contrary to previous reports in non–brain-injured ICU patients,27,28 videopupillometry poorly performed in our patient population, even if injuries potentially associated with pupillary response were considered as exclusion criteria (brain-stem injuries and clinical anisocoria). This is a major finding of this study. Recently, the electrophysiology of pain based on heart rate variability has shown promising results in ICU patients, regardless of brain injury status.11,22 Also, due to the study purpose, the patients were unable to self-report their pain intensity, and thus, the correlation between self-reported pain intensity and the behavioral pain scales could not be measured. However, this is also part of the reason why behavioral pain scales have been developed as surrogate markers of pain in the first place. When patients are able to self-report their pain intensity, even if significant, the correlation between self-reported pain scales and behaviors is poor, making the use of behavioral pain tools possibly inappropriate.12 Second, the item selection and content validation of the pain scales were not performed before this study. Rather, this study deals with pre-existing pain scales adapted to a more-specific type of population (brain-injured patients). However, the modification of the NCS(-R) for intubated patients was made by expert clinicians in intensive and neurointensive care. Moreover, the content validation is supported by recent data in brain-injured patients, as previously discussed.37 Finally, the psychometric properties of the pain scales assessed in this study can be quoted within the range of well-validated pain scales in the general ICU population, following the method used in the recent guidelines regarding pain management in ICU patients18 (see eTable 1 in the electronical supplementary material, available at http://links.lww.com/PAIN/A834). However, the principal component analysis of the pain scales highlighted that some items could be modified to better fit with this specific population, contrary to what has been reported for non–brain-injured patients (for the BPS).9,10 In the same way, a greater proportion of neurocritical caregivers preferred the NCS-I/NCS-R-I over the BPS in this study. This may be because the NCS was specifically constructed for brain-injured patients. Recent data on brain-injured patients reported several different and new types of behavior when assessed by video recording.20 New pain tools specifically designed for CIBI patients will be developed in the future. These tools will need to be assessed for psychometric validity and feasibility in regards to pre-existing, routinely used tools such as the BPS, NCS, and CPOT. Finally, the next step in pain research will be to assess the impact of analgesia protocols using specifically validated pain scales for improving the pain management and related outcomes in CIBI patients, as demonstrated in non–brain-injured patients.8,18
In contrast to videopupillometry, the BPS, NCS-I, and NCS-R-I are valid, reliable, and acceptable pain tools for use in mechanically ventilated brain-injured patients. In ICU settings where the BPS is commonly used for assessing pain in nonverbal patients, the BPS can also be used in the specific subgroup of brain-injured patients. In neurological settings where the NCS or NCS-R are commonly used for assessing pain in brain-injured patients, the NCS-I or NCS-R-I can now also be used in the specific subgroup of intubated patients. Future pain scales that will be constructed specifically for brain-injured ICU patients should be tested against these widely used tools.
In contexts unrelated to the present work, G. Chanques has consulted for and received honorarium from Orion Pharma and Aspen Medical France. S. Jaber has consulted for and received honorarium from the following companies: Dräger, Hamilton, Maquet, and Fisher Paykel. C. Bernard and G. Chanques report a National Grant from the Direction Générale de la Santé (DGOS): Projet Hospitalier de Recherche Infirmière et Paramédicale. The remaining authors declare that they have no conflicts of interest or financial supports to disclose.
The authors are grateful for the participation of nurses, assistant nurses, physicians, and physiotherapists of the ICU at Gui de Chauliac Montpellier University Hospital and for the support and guidance of the hospital pain management committee (Comité de LUtte contre la Douleur, CLUD, Montpellier University Hospitals). The authors are also grateful to Delegation for Clinical Research and Innovation at the Montpellier University Hospitals for their help and guidance with administrative and regulatory concerns. But first and foremost, the authors thank all patients who participated in the study and their families who gave their consent for participation. The authors also specifically thank Julie Carr, MD, and Carey M Suehs, BA, BS, PhD, for having substantially edited the manuscript as native English-American speakers.
National Grant from the Direction Générale de la Santé (DGOS): Projet Hospitalier de Recherche Infirmière et Paramédicale PHRIP-15-0080 (France); ClinicalTrial: NCT02830256.
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