In this episode, I’ll discuss three different pain assessments to use in ICU patients who are unable to verbally communicate pain.
The use of pain assessments for patients who are unable to verbally communicate are recommended in the SCCM Pain, Agitation & Delirium Guidelines.
There are 3 main pain assessments that can be used in patients who are unable to verbally communicate pain.
- The Behavioral Pain Scale (BPS)
- The Critical Care Pain Observation Tool (CPOT)
- The Behavioral Pain Assessment Tool (BPAT)
The Behavioral Pain Scale (BPS)
The Behavioral Pain Scale (BPS) examines 3 domains giving 1 to 4 points on each domain for a range in score of 3 to 12. The 3 domains are:
Facial expression
Movements of upper limbs
Compliance with mechanical ventilation
The Critical Care Pain Observation Tool (CPOT)
The Critical Care Pain Observation Tool (CPOT) examines 4 domains giving 0 to 2 points on each domain for a range in score of 0 to 8. The 4 domains are:
Facial expression
Body movements
Compliance with the ventilator or vocalization if extubated
Muscle tension
The Behavioral Pain Assessment Tool (BPAT)
The Behavioral Pain Assessment Tool (BPAT) examines 8 domains giving 0 or 1 point on each domain for a range in score of 0 to 8. The 8 domains are:
Absence of a neutral expression
Grimace
Wince
Eyes closed
Moaning
Verbal complaints of pain
Rigid muscles
Clenched fist
Comparison
The Behavioral Pain Scale (BPS) is the oldest of these 3 pain scales. It is designed for use in intubated patients.
The Critical Care Pain Observation Tool (CPOT) swaps out the “compliance with the ventilator” domain for the “vocalization” domain if a patient is extubated. The CPOT is the only one of these 3 pain scales to be validated for use in patients with ICU delirium. This gives the CPOT a high degree of flexibility in that it can be used whether the patient is intubated, extubated, or delirious. Be aware when applying the CPOT to extubated patients who are also delirious that only 10% of patients in the validation study were extubated.
The Behavioral Pain Assessment Tool (BPAT) is the easiest to administer out of these 3 pain scales. The BPS and CPOT require knowledge of a range of possible behaviors in each domain. The BPAT is a simple yes/no assessment based on the presence or absence of each domain item. The majority of patients in the BPAT validation group were not intubated.
Neither the BPS nor the BPAT make any adjustment for the patient being intubated or not. The maximum score on the BPS is reduced from 12 to 8 in any patient who is not intubated, and the maximum score on the BPAT is reduced from 8 to 6 in any patient who is intubated.
If I had to choose just one of these 3 assessments to use, it would be the CPOT. The CPOT has the most flexibility in that it can be used regardless of the presence or absence of delirium or mechanical ventilation.
Analgesic dosing
In the original BPS trial, there was a non-statistically significant trend between the dose of analgesic and the BPS score in patients who had pain behaviors from nociceptive pain such as suctioning or mobilization. However, I am unable to find data to support using a severity-based dose of analgesic dependant on how high any of these 3 pain scale scores are. Instead, I use a fixed dose of analgesic if any of these pain scales suggest the patient is in pain.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
It is my understanding that the CPOT is not designed to QUANTIFY the level of pain, but only to determine whether it is present or not. A score of 2 or more on the CPOT indicates the presence of “significant” pain and should prompt administration of an analgesic.
I think we often get confused because the common alternative scale used in patients able to communicate is the NRS, which requires the patient to QUANTIFY pain on a scale of 0 to 10 – because we are much more familiar with this scale, it is hard to remember sometimes that with the CPOT a higher number does not necessarily indicate MORE pain.
I agree – I use a fixed analgesic dose rather than a range based on how high any of these scores get.