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Maintaining optimum analgesia in anesthetized patients is challenging due to the inability to self-report pain or exhibit pain-related behaviours. The Analgesia Nociception Index (ANI) (based on heart rate variability [HRV]) and the Nociception Level Index (NOL) (based on HRV, photoplethysmography, skin conductance, and temperature) both include HRV and provide continuous index monitoring for nociception assessment. The research question was: “What are the validation strategies of the NOL and ANI for nociception assessment in anesthetized patients?”. The objectives were to describe and analyze the validation strategies and results. A systematized review was conducted using a comprehensive search with keywords under three concepts (nociception/pain, ANI/NOL, and validity) in four databases. A quality assessment using an adapted GRADE approach for measurement tools, and a risk of bias assessment using QUADAS-2 tool were performed by two reviewers. Out of 525 results, 15 validation studies were included. Strategies included hypothesis testing, discriminative, and criterion validation. Significant changes in ANI/NOL values were found in response to nociceptive stimuli at different opioid concentrations (hypothesis testing). Higher ANI/NOL values were observed during nociceptive stimuli (discriminative). AUCs ranging from 0.83 to 0.99 were obtained to detect nociceptive stimuli (criterion). Both technologies performed superiorly in detecting nociceptive stimuli compared to individual monitoring of HR and blood pressure. Although the aforementioned validation strategies are deemed appropriate, in the absence of a gold standard, criterion validation findings should be interpreted with caution. Moreover, reliability could be examined using test–retest with consistent ANI/NOL values during a stable time-interval.

The aim of this study was to explore the use of a multi-parameter technology, the Nociception Level (NOL) index (Medasense Biometrics Ltd, Ramat Gan, Israel), for pain assessment in postoperative awake patients after cardiac surgery during non-nociceptive and nociceptive procedures in the intensive care unit (ICU). A prospective cohort repeated-measures design was used. Patients were included if they were in the ICU after undergoing cardiac surgery and if they could self-report their pain. A non-invasive probe was placed on the patient's finger for the continuous monitoring of the NOL index. Patients' self-reports of pain and anxiety (0-10 Numeric Rating Scale or NRS), and behavioral scores with the Critical-Care Pain Observation Tool (CPOT) were obtained before and during a non-nociceptive procedure (ie, non-invasive blood pressure [NIBP] using cuff inflation), and before, during and after a nociceptive procedure (ie, chest tube removal [CTR]) for a total of five time points. Non-parametric tests were used to compare scores at different time points, and receiver operating characteristic curve analysis was performed. Fifty-four patients were included in the analysis. The NOL index, pain and anxiety scores were significantly higher during CTR compared to rest and NIBP (p < 0.001). During CTR, the NOL was associated with self-reported pain intensity and unpleasantness but not with anxiety and CPOT scores. The NOL showed a modest performance in detecting pain (NRS ≥1 and ≥5) in this sample with sensitivity and specificity ranging from 61% to 85%. The NOL index was able to discriminate between a non-nociceptive and a nociceptive procedure and was associated with self-reported pain. Further validation testing of the NOL is necessary in a heterogeneous sample of ICU patients.

Background Pain assessment in brain-injured patients in the intensive care unit (ICU) is challenging and existing scales may not be representative of behavioral reactions expressed by this specific group. This study aimed to validate the French-Canadian and English revised versions of the Critical-Care Pain Observation Tool (CPOT-Neuro) for brain-injured ICU patients. Methods A prospective cohort study was conducted in three Canadian and one American sites. Patients with a traumatic or a non-traumatic brain injury were assessed with the CPOT-Neuro by trained raters (i.e., research staff and ICU nurses) before, during, and after nociceptive procedures (i.e., turning and other) and non-nociceptive procedures (i.e., non-invasive blood pressure, soft touch). Patients who were conscious and delirium-free were asked to provide their self-report of pain intensity (0–10). A first data set was completed for all participants ( n  = 226), and a second data set ( n  = 87) was obtained when a change in the level of consciousness (LOC) was observed after study enrollment. Three LOC groups were included: (a) unconscious (Glasgow Coma Scale or GCS 4–8); (b) altered LOC (GCS 9–12); and (c) conscious (GCS 13–15). Results Higher CPOT-Neuro scores were found during nociceptive procedures compared to rest and non-nociceptive procedures in both data sets ( p  < 0.001). CPOT-Neuro scores were not different across LOC groups. Moderate correlations between CPOT-Neuro and self-reported pain intensity scores were found at rest and during nociceptive procedures (Spearman rho > 0.40 and > 0.60, respectively). CPOT-Neuro cut-off scores ≥ 2 and ≥ 3 were found to adequately classify mild to severe self-reported pain ≥ 1 and moderate to severe self-reported pain ≥ 5, respectively. Interrater reliability of raters’ CPOT-Neuro scores was supported with intraclass correlation coefficients > 0.69. Conclusions The CPOT-Neuro was found to be valid in this multi-site sample of brain-injured ICU patients at various LOC. Implementation studies are necessary to evaluate the tool’s performance in clinical practice.

This study aimed to examine the interrater agreement of Critical-Care Pain Observation Tool-Neuro (CPOT-Neuro) scores as a newly developed tool for pain assessment in patients with critical illness and brain injury between raters using two methods of rating (bedside versus video) during standard care procedures (i.e., non-invasive blood pressure and turning). The bedside raters were research staff, and the two video raters had different backgrounds (health and non-health disciplines). Raters received standardized 45 min training by the principal investigator. Video recordings of 56 patient participants with a brain injury at different levels of consciousness were included. Interrater agreement was supported with an Intraclass Correlation Coefficient (ICC) > 0.65 for all pairs of raters and for each procedure. Interrater agreement was highest during turning in the conscious group, with ICCs ranging from 0.79 to 0.90. The use of video recordings was challenging for the observation of some behaviors (i.e., tearing, face flushing), which were influenced by factors such as lighting and the angle of the camera. Ventilator alarms were also challenging to distinguish from other sources for the video rater from a non-health discipline. Following standardized training, video technology was useful in achieving an acceptable interrater agreement of CPOT-Neuro scores between bedside and video raters for research purposes.

Many patients experience pain in the intensive care unit (ICU) despite receiving pain medication. Research has shown that music can help reduce pain. Music interventions studied so far have not used music streaming to generate playlists based on patient preferences while incorporating recommended tempo and duration. Previous research has focused on postoperative ICU patients able to self-report, which is underrepresentative of the ICU population that might benefit from a music intervention for pain management. We developed a new patient-oriented music intervention (POMI) that incorporates features based on theoretical, empirical, and experiential data intended to be used in the ICU. Such a music intervention should consider the expertise of ICU patients, family members, and nursing staff, as well as the practicality of the intervention when used in practice. The primary objectives of this study are to (1) evaluate the acceptability and feasibility of the POMI to reduce pain in ICU patients and (2) evaluate the feasibility of conducting a crossover pilot randomized controlled trial (RCT) for intervention testing in the ICU. A secondary objective is to examine the preliminary efficacy of the POMI to reduce pain in ICU patients. A single-blind 2×2 crossover pilot RCT will be conducted. Patients will undergo 1 sequence of 2 interventions: the POMI which delivers music based on patients' preferences via headphones or music pillow for 20-30 minutes and the control intervention (headphones or pillow without music). The sequence of the interventions will be inverted with a 4-hour washout period. Timing of the interventions will be before a planned bed turning procedure. Each patient will undergo 1 session of music. Twenty-four patients will be recruited. Patients able to self-report (n=12), family members of patients unable to self-report (n=12), and nursing staff (n=12) involved in the bed turning procedure will be invited to complete a short questionnaire on the POMI acceptability. Data will be collected on the feasibility of the intervention delivery (ie, time spent creating a playlist, any issue related to headphones/pillow or music delivery, environmental noises, and intervention interruptions) and research methods (ie, number of patients screened, recruited, randomized, and included in the analysis). Pain scores will be obtained before and after intervention delivery. Recruitment and data collection began in March 2022. As of July 5, 2022, in total, 22 patients, 12 family members, and 11 nurses were recruited. Methodological limitations and strengths are discussed. Study limitations include the lack of blinding for patients able to self-report. Strengths include collecting data from various sources, getting a comprehensive evaluation of the intervention, and using a crossover pilot RCT design, where participants act as their own control, thus reducing confounding factors. ClinicalTrials.gov NCT05320224; https://clinicaltrials.gov/ct2/show/NCT05320224. DERR1-10.2196/40760.

To evaluate the use of vital signs for pain detection in brain-injured patients in the intensive care unit. A repeated-measures descriptive-correlational study. Two neurological intensive care units in Montréal, Canada. A total of 101 brain-injured patients were included. This study examined the fluctuations in systolic and diastolic blood pressure, heart and respiratory rates, and oxygen saturation in brain-injured critically ill patients before, during, and 15 minutes after turning and soft touch using a data collection computer. When possible, patients’ pain self-reports were obtained using a 0–10 Faces Pain Thermometer. The heart and respiratory rates were higher during turning than soft touch and higher during the procedure compared to prior (p < 0.05), but their fluctuation was modest. The systolic blood pressure increased during both turning and soft touch by 2 mmHg, but was 26.6 mmHg higher for those who reported pain versus no pain (Mann-Whitney = 25.00, p = 0.008, n = 28). A moderate correlation was observed between the systolic blood pressure (Spearman’s rho = 0.617, p = 0.004, n = 24) and self-reported pain intensity during turning. No significant effects were observed for diastolic blood pressure and oxygen saturation. Only increases in systolic blood pressure were positively associated with pain in this sample and replication studies with larger samples is needed.

Introduction: The aim of this study was to explore the use of a multi-parameter technology, the Nociception Level (NOL) index (Medasense Biometrics Ltd, Ramat Gan, Israel), for pain assessment in postoperative awake patients after cardiac surgery during non-nociceptive and nociceptive procedures in the intensive care unit (ICU). Materials and Methods: A prospective cohort repeated-measures design was used. Patients were included if they were in the ICU after undergoing cardiac surgery and if they could self-report their pain. A non-invasive probe was placed on the patient's finger for the continuous monitoring of the NOL index. Patients' self-reports of pain and anxiety (0-10 Numeric Rating Scale or NRS), and behavioral scores with the Critical-Care Pain Observation Tool (CPOT) were obtained before and during a non-nociceptive procedure (ie, non-invasive blood pressure [NIBP] using cuff inflation), and before, during and after a nociceptive procedure (ie, chest tube removal [CTR]) for a total of five time points. Non-parametric tests were used to compare scores at different time points, and receiver operating characteristic curve analysis was performed. Results: Fifty-four patients were included in the analysis. The NOL index, pain and anxiety scores were significantly higher during CTR compared to rest and NIBP (p < 0.001). During CTR, the NOL was associated with self-reported pain intensity and unpleasantness but not with anxiety and CPOT scores. The NOL showed a modest performance in detecting pain (NRS [greater than or equal to]1 and [greater than or equal to]5) in this sample with sensitivity and specificity ranging from 61% to 85%. Conclusion: The NOL index was able to discriminate between a non-nociceptive and a nociceptive procedure and was associated with self-reported pain. Further validation testing of the NOL is necessary in a heterogeneous sample of ICU patients. Keywords: nociception, pain, pain assessment, adult, cardiac surgery, intensive care unit

Background.Adults admitted to the intensive care unit (ICU) often experience pain. A multimodal approach to pain management is recommended, including nonpharmacological interventions such as music. To determine the effect of music interventions for ICU pain management, our systematic review of randomized controlled trials supported that 20-30 minutes of music with a tempo of 60-80 bpm was efficacious to reduce pain in ICU patients able to self-report. However, music efficacy in patients unable to self-report remains unknown. Gaps in acceptability and feasibility of music interventions tested in the ICU setting were also highlighted.Objectives. This study included two phases. Phase I aimed to describe the acceptability of a newly developed patient-oriented music intervention (POMI) and to guide its refinement. Phase II aimed to evaluate the acceptability and feasibility of POMI, and the feasibility of research methods. A secondary objective was to examine the preliminary efficacy of POMI to reduce pain. Methods.I. A descriptive design was used to inform the acceptability of a preliminary POMI developed based on theoretical and empirical knowledge, which uses a music streaming service to generate playlists based on patient preferences, the recommended tempo and duration. Critical care experts were recruited using purposive and snowball sampling and completed a questionnaire and a semi-structured interview via video conference. Participants rated acceptability items from 0-4 and provided feedback on POMI acceptability and features. Their experiential knowledge guided the POMI refinements. II. Three samples of participants were recruited: ICU patients (2 groups: able and unable to self-report); family members; and nurses. Patients were randomized to either sequence 1 (POMI period, then control period), or sequence 2 (control period, then POMI period), with a 4-hour washout period. POMI was administered for at least 20 minutes before a turning procedure. No music was played during the control period. Outcomes included acceptability and feasibility of POMI (e.g., delivery, fidelity), feasibility of research methods (e.g., eligibility and retention rates) and pain scores (i.e., 0-8 behavioral scores in all patients; 0-10 pain intensity and pain distress in patients able to self-report). Pain was measured at four timepoints (pre-intervention; post-intervention; during turning; 30 minutes post-turning).Results.I. The POMI was developed based on theoretical and empirical knowledge and refined according to experiential knowledge. Participants (i.e., 9 ICU clinicians and 3 music therapists) had 4-36 years of experience in critical care. Acceptability was very good with items having high median scores (≥3/4). Participants emphasized the importance of considering the patient’s music preferences and found the use of streaming services convenient. They rated the acceptability of POMI delivery higher before a painful procedure (e.g., turning) than after. II. Samples of 23 ICU patients, 11 family members, and 12 nurses were included in data analysis. POMI was found acceptable with median scores >3/4. The POMI was feasible for most patients; however, timing of turning was sometimes unpredictable, and interruptions were frequent. Eligibility rate was low (15%), but retention rate was high (96%). The POMI showed preliminary efficacy in reducing pain during turning in both ICU patients able and unable to self-report.

Nursing staff have been at the forefront of the pandemic, reporting high traumatic stress and anxiety levels related to high fear of COVID-19. Recommendations from previous studies include using the Fear of COVID-19 Scale (FCV-19S) as a screening tool to identify any individuals who may benefit from targeted psychological support. Thus far, the accuracy of the Canadian English and French versions of FCV-19S to detect high levels of traumatic stress and anxiety symptoms has not been examined. The objectives of this methodological psychometric study were to examine among nursing staff: (a) the structure and internal consistency of the Canadian versions of the FCV-19S and (b) its ability in detecting high levels of traumatic stress and anxiety symptoms. An anonymous online survey was distributed among nursing staff (n = 387) in the province of Quebec (Canada). This survey included the FCV-19S and scales measuring their traumatic stress (PCL-5) and anxiety symptoms (GAD-7). Exploratory factor analysis and receiver operating characteristic (ROC) analyses were performed. The one-factor structure of the FCV-19S was supported (Cronbach alpha = 0.87). The FCV-19S showed better accuracy for the detection of traumatic stress (area under the curve (AUC) 0.75 [95% CI 0.68, 0.82]) in comparison to anxiety symptoms (AUC 0.65 [95% CI 0.60, 0.74]). The FCV-19S may benefit from adaptation for its use in nursing staff and in a future pandemic context.

Current guidelines suggest that family members be consulted in the pain assessment process of patients unable to self-report. However, little is known regarding family members' perceptions of their loved one's pain behaviors and pain management. This qualitative descriptive study aimed to describe family members' perceptions of pain behaviors and pain management in critically ill hospitalized patients admitted to an intensive care unit and unable to self-report. A qualitative descriptive design was used. This study was conducted in a medical-surgical intensive care unit in Canada. Family members of nonverbal adult patients participated in a semistructured interview regarding their perceptions of pain behaviors and pain management in the intensive care unit. Ten family members with a nonverbal loved one admitted to the intensive care unit participated. Family members agreed on the presence of pain in the intensive care unit and reported being proactive and applying nonpharmacological interventions to help palliate pain of their loved one. Although family members identified behavioral indicators such as grimace, limb movement, and verbal complaints to assess pain in their loved one, the majority were unsure of their ability to detect pain. Family members have intimate knowledge of their loved one and could be invited to share their perceptions of their loved one's pain when they feel confident to do so.