ORIGINAL ARTICLE

Psychometric Analysis of Behavioral Pain Scale Brazilian Version in Sedated and Mechanically Ventilated Adult Patients: A Preliminary Study Isabela F. Azevedo-Santos, PT*; Iura G.N. Alves, PT, MSc*; Daniel Badau^e-Passos, DVM, PhD*; Valter J. Santana-Filho, PT, PhD*,†; Josimari M. DeSantana, PT, PhD*,† *Federal University of Sergipe, Aracaju, SE; †Department of Physical Therapy, Federal University of Sergipe, Aracaju, SE, Brazil

& Abstract Background and Purpose: Pain assessment in Intensive Care Units (ICU) can be performed based on validated instruments as the Behavioral Pain Scale (BPS). Despite the existence of this clinical score, there is no Brazilian version of it to assess critically ill patients. This study aimed to translate the BPS into Brazilian Portuguese, verify its psychometric properties (reliability, validity, and responsiveness) and the correlation between pain measured and heart rate (HR), blood pressure (BP), Ramsay, and RASS scores. Methods: Pain intensity by using Brazilian BPS version, HR, and BP were observed by 2 investigators during 3 different moments: at rest; during eye cleaning (EC); and tracheal suctioning (TS) in 15 adult subjects sedated and mechanically ventilated. Sedation level, severity of disease, and use of sedatives and analgesic drugs were also recorded. Results: There was a high responsiveness coefficient (coefficient = 1.72) and pain was significantly higher during tracheal suctioning (P ≤ 0.003) and eye cleaning (P ≤ 0.04)

Address correspondence and reprint requests to: Josimari Melo DeSantana, PT, PhD, Departamento de Fisioterapia, Hospital Univerrio/UFS, Rua Cla udio Batista, s/n CEP: 49060-100 Aracaju (SE), Brazil. sita E-mail: [email protected]. I.F. Azevedo-Santos & I.G.N. Alves equally contributed to this work. Submitted: July 30, 2014; Revised: October 29, 2014; Revision accepted: December 6, 2014 DOI. 10.1111/papr.12287

© 2015 World Institute of Pain, 1530-7085/15/$15.00 Pain Practice, Volume

, Issue
, 2015

–



than at rest. It was evidenced a low reliability and no significant correlation between translated BPS scores and physiological parameters during tracheal suctioning, sedation scales, flow of the sedatives drugs, or with the general health status (P > 0.07). Conclusion: Brazilian BPS has high responsiveness and capacity to detect pain intensity in different situations in the ICU routine. This preliminary study proved the feasibility and importance of valid this scale in Brazil in order to improve critically ill patients care. & Key Words: Intensive Care Units, pain measurement, validation studies, Brazilian BPS, Portuguese, Behavioral Pain Scale, psychometrics

BACKGROUND Pain is defined by the International Association for the Study of Pain (IASP) as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.1 The Intensive Care Units (ICUs) were developed to care for patients with serious or decompensated health conditions. In these centers, the critically ill patients are subjected to various routine procedures that can promote discomfort and/or pain.2–4 Pain assessment and management in ICU patients has received more notoriety in recent times.5 Many studies

2


AZEVEDO-SANTOS ET AL.

suggest that mechanical ventilation is stressful, noxious, and harmful for those patients and usually associated with acute pain, which affects the quality of life even after discharge from the ICU.3,4,6–9 Therefore, pain assessment is considered as a vital activity performed by different health care providers for patients in the ICU environment. Specialists indicate that the most effective method to assess pain is the self-report,10 whereas a large number of ICU patients are unable to self-report their pain experience as being blocked by the placement of artificial airways or sedative treatment.10–12 In cases when patients are unable to verbally report pain, studies show that assessment can be performed by observing and recording physiological parameters such as heart rate (HR), blood pressure (BP), breathing, and sweating in response to a noxious action, which are not considered the best way to assess pain as many factors can influence those parameters, irrespective of the pain sensation.2 Recommended strategies for pain measurement in critically ill subjects are the objective instruments, represented by the behavior scales. For example, the Behavioral Pain Scale (BPS), validated in English in 2001 by Payen et al.,3 is a specific instrument for assessing pain in mechanically ventilated patients. The sum of 3 subscales: (1. facial expression; 2. movements of upper limbs; and 3. compliance with mechanical ventilation) results in the final score of this tool. Each one of these subscales is scored from 1 (without pain) to 4 (maximum pain), hence, the final score of BPS is from 3 (without pain) to 12 (maximum pain).13 Behavioral Pain Scale, when was used to assess pain in critically ill and mechanically ventilated patients, showed high interrater reliability and satisfactory internal consistency to differentiate responses to noxious stimulus. Additionally, a significant variance (65%) in pain expression during painful procedures demonstrated appropriate validity and responsiveness, suggesting that this is a powerful tool to detect pain in ICU patients.13 Based on that, it is possible to observe that pain assessment in ICUs is important because patients in these units are exposed to painful procedures. Despite the existence of verbal and nonverbal clinical scores to quantify pain, the application of this tool becomes infeasible in Brazil, since there is no Brazilian version of these scales to assess ICU patients.14,15 Thus, pain assessment in patients using artificial airway remains a challenge to the Brazilian health professionals.2 After being validated in the other 2 countries (China and Portugal), and reproducible in other stud-

ies,2,13,16,17 the BPS can be considered an interesting and useful instrument to be used for a validation study in Brazil. From that, this preliminary study aimed to translate the BPS to Brazilian Portuguese, analyze the reliability, validity, and responsiveness of the translated BPS in a small sample, observe the correlation between pain, and the measures of BP and HR, level of sedation (Ramsay and Richmond Sedation-Agitation Scale [RASS]-scores), severity of disease (Severity Disease Classification System—APACHE II), and sedative drug flow rate in critically ill patients.

METHOD Sample This cross-sectional study was conducted at the ICU of a public hospital in Aracaju (Sergipe/Brazil), Hospital de Urg^encias de Sergipe (HUSE). The university and hospital ethical committees approved the study protocol. The term of consent was signed by the subject’s legal conservator, once they were unconscious or in use of sedative medicines. The sample consisted of adult subjects suffering from neurological disease (mainly traumatic brain injury, because it is a referral hospital in trauma) using mechanical ventilation (controlled mode). Exclusion criteria for this study: (1) age less than 18 years old; (2) quadriplegia; (3) diagnosed with peripheral neuropathy; (4) stiffness due to decortication or decerebration; (5) cardiac dysfunction; or (6) use of neuromuscular blockers. Those clinical conditions could change pain expression and/or hemodynamic parameters. Procedures First, an authorization by the author who validated BPS in English (Ph.D. Jean-Francßois Payen—Grenoble/ France) was obtained to use the BPS in our study. The translation to Portuguese was done by a health professional (physical therapist) who mastered the English language and by an English teacher who do not work in health sciences, thus obtaining the same translations. After this first procedure, the back translation (Portuguese to English) was done by another health professional who had not read this scale before.18 Expert analysis was done by a physical therapists and nurses’ committee when the first version of BPS in

Psychometric Analysis of BPS Brazilian Version
3

Item

Descrição

Pontuação

Relaxada

1

Parcialmente contraída (ex. abaixamento palpebral)

2

Completamente contraída (olhos fechados)

3

Contorção facial

4

Sem movimento

1

Movimentação parcial

2

Movimentação completa com flexão dos dedos

3

Permanentemente contraídos

4

Tolerante

1

Tosse mas tolerante à ventilação mecânica a maior parte do tempo

2

“Brigando” com o ventilador

3

Sem controle da ventilação

4

Expressão Facial

Movimento dos membros superiores

Conforto com o ventilador mecânico

Figure 1. Brazilian version of Behavioral Pain Scale (Escala Comportamental de Dor para Pacientes Crıticos Ventilados Mecanicamente).

Brazilian Portuguese (Figure 1) was created and applied on the sample recruited for this preliminary validation study.18 This Brazilian BPS version was applied in sedated and mechanically ventilated patients during 3 different moments: at rest (stable subject in bed); during eye cleaning with cotton soaked in saline 0.9% (considered nonpainful procedure2); and during the catheter insertion on the airway at tracheal suctioning (considered painful2,3,13,19–21). Three investigators (1 physical therapist and 2 nurses) participated in the study and before the beginning of the assessment, they were exposed to the new version of the scale (they were trained to apply the scale, but the meaning of the items was not explained to verify the interpretation of this first Brazilian BPS version). During pain measurement with BPS, because of the ICU professionals’ routine, just 2 of them who were available did the measurement with the scale. In other words, both simultaneously observed the subject0 s behavior during the 3 preset moments. The investigators were not responsible for the stimulation of the patients and they could not keep any kind of communication during the procedures.

Besides pain assessment with the translated BPS, the systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP), and HR were measured through noninvasive methods in the 3 phases of evaluation (rest, eye cleaning, and tracheal suctioning). These hemodynamic parameters were cataloged based on previous studies showing that higher HR and BP indicate presence of pain evidenced by the nursing staff.22 Patient0 s level of sedation was assessed by using Ramsay scale23 and Richmond Agitation-Sedation Scale (RASS).24,25 Sample characteristics such as age, gender, disease, use of sedative and/or analgesics (name, flow and administration form), and score on Severity Disease Classification System (APACHE II)26 were also recorded mainly by the investigator before the pain measurement. Statistical Analysis Data normality was verified with the Kolmogorov– Smirnov test. The reliability of the translated BPS, which includes internal consistency and interrater reliability, was analyzed by calculating Cronbach a and Intraclass

4


AZEVEDO-SANTOS ET AL.

Correlation Coefficient (ICC), respectively. Internal consistency acceptable value was Cronbach a higher than 0.7.27 As for interrater, reliability values should be higher than 0.7528 to be considered satisfactory. For validity, Friedman0 s test, followed by post-hoc Tukey0 s test, was used to compare Brazilian BPS scores at rest, eye cleaning, and tracheal suctioning. Spearman0 s correlation was performed to confront the BPS scores with hemodynamic parameters, sedative drug flow rate, and Ramsay, RASS, and APACHE II scores. Responsiveness coefficient was calculated, dividing the difference between the mean scores of the translated BPS in individuals at rest and during painful procedures by the standard deviation (SD) of the mean scores of the individual at rest. A coefficient value higher than 0.8 was considered satisfactory for responsiveness.29 P value less than 0.05 was considered significant. Data were represented as mean and standard error of mean.

RESULTS Fifteen subjects with mean age 35 years old, sedated and mechanically ventilated, were assessed during rest, eye cleaning, and tracheal suctioning, totaling 90 behavior observations with translated BPS (15 subjects 9 2 investigators at the same time 9 3 different moments). Demographic data are represented in Table 1. Subjects were sedated with midazolam, fentanyl, remifentanila, or dexmedetomidine hydrochloride, in continuous infusion (16.0  2.48 mL/hour). Ramsay scale had mean value of 5.07  0.33 (sluggish response to light glabellar tap or loud auditory stimulus) and RASS a mean of 3.8  0.52 (moderate sedation). For analgesia, the drug most commonly used was metamizole (87% of the subjects), administered accord-

Table 1. Demographic Data (n = 15 subjects) Variable

Specification

Age (years) Gender Male (n) Female (n) Disease (n)

35.47  3.45*

APACHE II score

12 3 Traumatic Brain Injury (11) Central abscess (1) Brain Vascular Disease (1) Cerebral Aneurysm (1) Hepatic Encephalopaty (1) 19.67  1.73*

*Data were represented as mean  standard error of mean or absolute frequency (n), when relevant.

ing to the prescribed hour interval (6/6 or 8/8 hour) or in emergency cases (SOS), but not at the assessment moment. Thirteen percent of the subjects had no analgesic prescription at the assessment moment. Hemodynamic parameters along 3 assessment moments (rest, eye cleaning and tracheal suctioning) were listed on Table 2. Heart rate was significantly higher during painful procedure when compared with rest and eye cleaning (P = 0.001). The same result was not observed when the HR values at rest were compared with the values at eye cleaning (P > 0.05). No changes were observed at the others physiological parameters (SBP, DBP, MBP) over time (P > 0.1). Reliability The Cronbach a coefficient values related to the scale subitems were analyzed at the 3 assessment moments: rest (Cronbach a = 0.42); eye cleaning (Cronbach a = 0.53); and tracheal suctioning (Cronbach a = 0.57). In relation to the ICC, the values obtained were 0.65 (at rest and tracheal suctioning) and 0.53 (during eye cleaning) when the total translated BPS scores were compared between the investigators. Additionally, when the partial subitems scores were compared, the coefficients were between 0.27 and 0.49. Validity It was observed that no significant correlation between the translated BPS scores and the hemodynamic parameters (SBP, DBP, MBP, and HR) during tracheal aspiration was assessed by both investigators. It was evidenced that there was no significant correlation between sedation scores (Ramsay scale and RASS) with translated BPS, and neither between pain measured and sedative flow rate or APACHE II scores (Table 3). In the other hand, comparing BPS translated results assessed by both investigators at rest and during tracheal suctioning, scores during painful procedure were higher than during the assessment at rest (P ≤ 0.003). However, when rest scores were compared with nonpainful procedure scores (eye cleaning), just the result of investigator 2 was significantly higher during eye care (P ≤ 0.04). In the analysis of BPS results, comparing the eye cleaning values and tracheal suctioning of both investigators, the result was higher during the painful procedure than at eye care moment (P ≤ 0.05), according to Figure 2.

Psychometric Analysis of BPS Brazilian Version
5

Table 2. Hemodynamic Parameters at the 3 Assessment Moments with Translated BPS Variable

Rest

Eye Cleaning

SBP (mm Hg) DBP (mm Hg) MBP (mm Hg) HR (bpm)

135.2 79.2 97.6 84.9

   

5.83 3.62 3.84 5.53

132.2 78.4 96.7 88.7

   

3.61 3.82 5.07 3.93*

Tracheal Suctioning 136.8 82.0 99.9 106.7

   

3.88 6.23 5.53 5.05†

P value 0.18 1.00 0.66 0.001

*P ≤ 0.001 compared to tracheal suctioning. † P ≤ 0.001 compared to the rest and eye cleaning (Friedman0 s test with post-hoc Tukey0 s test). Data were represented as meanstandard error of mean. SBP, systolic blood pressure; DBP, dyastolic blood pressure; MBP, mean arterial pressure; HR, heart rate.

Table 3. Correlations Between Translated BPS Scores of Both Investigators During Tracheal Suctioning and Hemodynamic Parameters, Ramsay Score, RASS Score, APACHE II Score, and Sedative Drug Flow

SBP (mm Hg) DBP (mm Hg) MBP(mm Hg) HR (bpm) RAMSAY RASS APACHE II Sedative flow

BPS Score TS (INV 1)

BPS Score TS (INV 2)

CC*

P**

CC*

P**

0.33 0.36 0.41 0.40 0.13 0.08 0.26 0.07

0.22 0.18 0.12 0.07 0.64 0.76 0.34 0.79

0.40 0.30 0.46 0.30 0.08 0.08 0.10 0.40

0.07 0.23 0.08 0.27 0.75 0.75 0.50 0.10

*Spearman0 s Correlation Coefficient (CC). **P values were not considered significant (P ≥ 0.05). TS, tracheal suctioning; I, investigator; SBP, systolic blood pressure; DBP, dyastolic blood pressure; MBP, mean blood pressure; HR, heart rate.

Figure 2. Translated BPS scores during rest, eye cleaning and tracheal suctioning of both investigators (INV). The values represent mean and standard error of mean. *P ≤ 0.04 compared to rest; †P ≤ 0.05 compared to rest and eye cleaning (Friedman0 s test with post-hoc Tukey0 s test).

Responsiveness Responsiveness coefficient value was 1.72, which represents Brazilian BPS’s ability to detect significant changes over time, even with small changes.

DISCUSSION Many studies show the relevance of pain assessment in sedated and mechanically ventilated patients in ICUs

using internationally validated instruments, as BPS, developed specifically to assess pain in that population. This preliminary study aimed to translate and verify the psychometric properties of this scale and adapt a pain measurement instrument to critically ill patients in Brazil. Testing the validity of the new translated scale in this sample, it was observed a significant increase on the final score both during nonpainful and painful procedures when they were compared with the final score at rest. It means that at these moments of higher pain intensity, the behavioral expression and consequently the final Brazilian BPS scores were higher too. This score variation over time shows the Brazilian scale0 s capacity for detecting and discriminating pain in this population. Similarly, study performed by Payen et al.,3 where pain was measured by 46 nurses and nurses’ aides, used English BPS in 30 patients allocated in 2 groups, submitted to, respectively, painful procedures (tracheal aspiration and mobilization) and nonpainful procedures (compression stockings application and central venous catheter dressing change). In this study,3 high total final scores in the nociceptive group were observed, reflecting the achievement of precise results with this scale. It was not observed, in our study, significant correlation between the hemodynamic parameters and BPS translated total scores in any of the 3 assessment moments, that contradicts the hypothesis that higher pain intensity causes higher hemodynamic values, as pointed out by Puntillo et al.,3 based on nurse staff reports. As our findings in a previous study13 suggested, their was a lack of significant correlation between the BP and HR values with BPS: evidence that these parameters can be influenced by drug administration (vasopressors, b blockers, antiarrhythmic, sedatives, among others) and pathological conditions (sepsis, shock, hypoxia, fear).10 Other studies confirm the low specificity of pain assessment by using hemodynamic parameters. Physiological

6


AZEVEDO-SANTOS ET AL.

values were recommended for assessing pain only as an aid, when the observation of behavioral indicators is not available, because it was concluded that in unconscious mechanically ventilated post cardiac surgery patients, an increase in MBP and HR occured both in painful and in nonpainful procedures.30 Correspondingly, other studies31–33 demonstrate inconsistency of this parameters for pain assessment, once they are kept stable, even during painful procedures. Among the hemodynamic parameters recorded (SBP, DBP, MBP, HR) analyzed alone over time, just the HR significantly increased between rest, eye cleaning, and painful procedure. Differently, previous studies show that when pain was assessed by using BPS during eye cleaning and mobilization (nonpainful and painful events, respectively), it resulted in an increase of BP and HR during painful stimuli.2,3,13 The fact that BP does not have a significant increase can be attributed to compensatory mechanisms of the organism with the increase of HR at the painful procedure caused by decrease of peripheral vascular resistance, maintenance of systolic volume, etc. Similarly, Jeitziner33 found that the SBP increased during the painful procedure, which reinforces the idea that it is not just pain that causes change in hemodynamic parameters, but lots of factories can contribute with that event. In the same context of validation property, no correlation was evidenced between sedation level (scores obtained with Ramsay scale and RASS), sedative drug flow rate, and pain intensity (assessed with BPS). This contradicts the expectation that a relation exists between sedation level and pain, justifying once more, the need for using different scales to assess these 2 variables, because they are distinct and need independent measurement. In contrast, other studies2,3,13 evidenced a significant inverse correlation between Ramsay scores and BPS during painful procedures. In other words, the higher the sedation level, the lower the BPS score, because lower was the capacity of expressing pain. Another factor involved is the administration of analgesics as fentanyl and remifentanil (opioids) with the anxiolytics, resulting in lower pain intensities with high sedation level. In addition to this, the analgesic drug metamizole was indicated to a large number of these ICU patients, however, this agent is not available in the majority of countries where BPS was validated, which means that the Brazilian pain management routine should be considered for pain assessment and consequently cultural adaptation of this scale to this country.

Regarding the relation between RASS and pain level, a study was developed by Jeitziner et al.,33 which observed that the agitation-sedation score of ICU patients increased when intratracheal suctioning was done under and without sedation, but not after fentanyl administration. This means that when the pain level (measured by a set of behavioral parameters, not a validated scale) was higher, the patient was more alert and/or agitated, which can induce a correlation between these 2 variables, although it could not be concluded in our study. The Severity Disease Classification System Score (APACHE II) was used in previous studies only for characterization of the sample, with no association with pain intensity, as done in this preliminary study. The relation between these 2 variables could not be observed likely because of the severity of the disease, according to APACHE II involving hematologic, gasometrical, and physiological data26 that are not directly associated with pain sensation. The Brazilian version of BPS presented good responsiveness (coefficient ≥ 0.8), demonstrating that this tool is precise to detect important changes on pain intensity over time. In a similar way, Assaoui et al.13 performed a study with 30 critically ill ventilated subjects with a similar method as 1 of our studies applied by 28 health professionals, evidencing a high responsiveness coefficient and showing the applicability of this scale at clinical practice. Another psychometric property analyzed was the reliability. Cronbach a and ICC were not statistically satisfactory in this study,27,28,34 which can indicate both low internal consistency and low capacity for similar measures among different investigators. This probably occurred due to the reduced number of subjects and investigators in the sample and the difficulty investigators had in understanding each item of the translated scale as a function of the literal translation that is not adapted for our language, as reported by Batalha et al.16 When a BPS version was applied in an ICU in Portugal in a study after first translation, back translation, and cultural adaptation of the scale, acceptable but not high reliability values were observed in all items. There are discrepant data in other studies2,13,35 where high values of internal consistency and interrater reliability were found. Chen et al.17 demonstrated this evidence in a study where the Chinese BPS version was applied by 2 investigators during (1) rest, (2) before and during body temperature measurement (nonpainful), and (3) before and during endotracheal suctioning with

Psychometric Analysis of BPS Brazilian Version
7

a closed system (painful procedure). The pain scale had the inter-rater and test–retest reliability confirmed by high scores at Pearson’s correlation (r = 0.65 to 1.00) and inter-rater agreement (88.6% to 100%) which is relevant considering the necessity of using the instrument at critical care centers. Physical therapists and nurses were chosen to apply this first version of Brazilian BPS because in Brazil, these 2 professional categories are responsible for ICU care. In this country, physical therapists act on mechanical ventilation and motor improvement of critically ill patients in association to physicians, nurses, phycologists, nutritionists, and other health professionals. The difficulty of these investigators to comprehend the meaning of each translated item was a limitation of this study. They reported the occurrence of doubts when it was necessary to observe the subjects and correlate the terms with the behaviors presented. Two items were related to the subscale “Compliance with mechanical ventilation,” which included: “Fighting ventilator” and “Unable to control ventilation.” These items can be referred to different conditions and generate different interpretation of the real subject0 s behavior because their ventilatory control can be changed for a lot of causes and not just pain. The group of researchers from Portugal who translated BPS to their language exposed the same problem in their study, where there was investigators discordance in “Compliance with mechanical ventilator” subscale,16 as in our sample. This evidence reinforces the need of standardization of the Brazilian BPS items to improve the comprehension and applicability of this tool. This can be obtained with the cultural adaptation, a step that follows translation and incorporates the concepts and interpretations used in the country, resulting in a clear and concise instrument. The sample composed by subjects with neurological diseases (mainly traumatic brain injury) was another limitation of this preliminary study. This clinical condition can deregulate physiological parameters as HR, BP, and RR, which were important variables for our data analysis. It is encouraged that future studies involve a larger sample of critically ill sedated and intubated patients with different clinical conditions to avoid bias in data collection and BPS validation. This preliminary study proved the feasibility to translate and apply BPS in Brazil. However, the necessity of cross-cultural adaptation of this scale and validation of other instruments with the same purpose stimulates future studies in order to improve routine care, pain assessment, and manage-

ment of mechanically ventilated adult patients in Brazilian ICUs.

REFERENCES 1. Merskey H. Classification of chronic pain syndromes and definitions of pain terms. Pain. 1986; (suppl 3):226. 2. Young J, Siffleet J, Nikoletti S, Shaw T. Use of a Behavioral Pain Scale to assess pain in ventilated, unconscious and/or sedated patients. Intensive Crit Care Nurs. 2006;22:32–39. 3. Payen J, Bru O, Bosson J, et al. Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med. 2001;29:2258–2263. 4. Stanik-Hutt JA, Soeken KL, Belcher AE, Fontaine DK, Gift AG. Pain experiences of traumatically injured patients in a critical care setting. Am J Crit Care. 2001;10:252–259. 5. Rotondi AJ, Chelluri L, Sirio C, et al. Patients’ recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit. Crit Care Med. 2002;30:746–752. 6. Schelling G, Stoll C, Haller M, et al. Health-related quality of life and posttraumatic stress disorder in survivors of the acute respiratory distress syndrome. Crit Care Med. 1998;26:651–659. 7. Jones C, B€ ackman C, Capuzzo M, et al. Precipitants of post-traumatic stress disorder following intensive care: a hypothesis generating study of diversity in care. Int Care Med. 2007;33:978–985. 8. Puntillo KA, Wild LR, Morris AB, et al. Practices and predictors of analgesic interventions for adults undergoing painful procedures. Am J Crit Care. 2002;11:415–429. 9. Chanques G, Sebbane M, Barbotte E, et al. A prospective study of pain at rest: incidence and characteristics of an unrecognized symptom in surgical and trauma versus medical intensive care unit patients. Anesthesiology. 2007;107:858–860. 10. Hamill-Ruth RJ, Marohn ML. Evaluation of pain in the critically ill patient. Crit Care Clin. 1999;15:35–54. 11. Puntillo KA. The phenomenon of pain and critical care nursing. Heart Lung. 1988;17:262–270. 12. Shannon K, Bucknall T. Pain assessment in critical care: what have we learnt from research. Intensive Crit Care Nurs. 2003;19:154–162. 13. A€ıssaoui Y, Zeggwagh AA, Zekraoui A, Abidi K, Abouqal R. Validation of a Behavioral Pain Scale in Critically Ill, Sedated, and Mechanically Ventilated Patients. Anesth Analg. 2005;101:1470–1476. 14. Egerod I, Christensen BV, Johansen L. Trends in sedation practices in Danish intensive care units in 2003: a national survey. Intensive Care Med. 2006;32:60–66. 15. Martin J, Franck M, Sigel S, Weiss M, Spies C. Changes in sedation management in German intensive care units between 2002 and 2006: a national follow up survey. Crit Care. 2007;11:R124. 16. Batalha L, Figueiredo AM, Marques M, et al. Adaptacß~ ao cultural e propriedades psicometricas da vers~ ao

8


AZEVEDO-SANTOS ET AL.

Portuguesa da escala Behavioral Pain Scale: intubated Patient (BPS-IP/PT). Rev Enf Ref. 2013;9:7–16. 17. Chen YY, Lai YH, Shun SC, et al. The Chinese Behavior Pain Scale for critically ill patients: translation and psychometric testing. Int J Nurs Stud. 2011;48:438–448. 18. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of selfreport measures. Spine. 2000;25:3186–3191. 19. Puntillo KA. Dimensions of procedural pain and its analgesic management in critically ill surgical patients. Am J Crit Care. 1994;3:116–122. 20. Puntillo KA, White C, Morris AB, et al. Patients perceptions and responses to procedural pain: results from Thunder Project II. Am J Crit Care. 2001;10:238–251. 21. Vaghadia H, Al-Ahdal OA, Nevin K. EMLAâ patch for venous cannulation in adult surgical outpatients. Can J Anaesth. 1997;44:798–802. 22. Puntillo KA, Miaskowski C, Kehrle K, Stannard D, Gleeson S, Nye P. Relationship between behavioral and physiological indicators of pain, critical care patients’ selfreports of pain, and opioid administration. Crit Care Med. 1997;25:1159–1166. 23. Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxolone-alphadolone. Br Med J. 1974;2:656–659. 24. Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care patients. Am J Respir Crit Care Med. 2002;166:1338–1344. 25. Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med. 1999;27:325–329.

26. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:18–29. 27. George D, Mallery P. SPSS for Windows Step by Step: A Simple Guide and Reference. 11.0 update. 4th ed. Boston, MA: Allyn & Bacon; 2003:231. 28. Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bull. 1979;86:420–428. 29. Wright JG, Young NL. A comparison of different indices of responsiveness. J Clin Epidemiol. 1997;50:239–246. 30. Arbour C, Gelinas C. Are vital signs valid indicators for the assessment of pain in postoperative cardiac surgery ICU adults? Intensive Crit Care Nurs. 2010;26:83–90. 31. Gelinas C, Tousignant-Laflamme Y, Tanguay A, Bourgault P. Exploring the validity of the bispectral index, the Critical-Care Pain Observation Tool and vital signs for the detection of pain in sedated and mechanically ventilated critically ill adults: a pilot study. Intensive Crit Care Nurs. 2011;27:46–52. 32. Kabes AM, Graves JK, Norris J. Further validation of the nonverbal pain scale in intensive care patients. Crit Care Nurse. 2009;29:59–66. 33. Jeitziner MM, Schwendimann R, Hamers JP, et al. Assessment of pain in sedated and mechanically ventilated patients: an observational study. Acta Anaesthesiol Scand. 2012;56:645–654. 34. Nunally J, Bernstein I. Psychometric Theory. 3rd ed. New York: McGraw-Hill; 1994:83–113. 35. Ahlers SJ, van der Veen AM, van Dijk M, Tibboel D, Knibbe CA. The use of the behavioral pain scale to assess pain in conscious sedated patients. Anesth Analg. 2010;110:127– 133.