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The Use of the Behavioral Pain Scale to Assess Pain in Conscious Sedated Patients

Sabine J. G. M. Ahlers, MSc^*, Aletta M. van der Veen, MScN, Monique van Dijk, PhD, Dick Tibboel, MD, PhD, and Catherijne A. J. Knibbe, Pharm D, PhD^*,

From the Departments of *Clinical Pharmacy, and Anaesthesiology and Intensive Care, St. Antonius Hospital, Nieuwegein; and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands.

Address correspondence and reprint requests to Sabine J.G.M. Ahlers, MSc, Department of Clinical Pharmacy, St. Antonius Hospital, PO Box 2500, 3440 EM Nieuwegein, The Netherlands. Address e-mail to s.ahlers{at}antoniusziekenhuis.nl.

Abstract

Background: Assessing pain in mechanically ventilated critically ill patients is a great challenge. There is a need for an adequate pain measurement tool for use in conscious sedated patients because of their questionable communicative abilities. In this study, we evaluated the use of the Behavioral Pain Scale (BPS) in conscious sedated patients in comparison with its use in deeply sedated patients, for whom the BPS was developed. Additionally, in conscious sedated patients, the combination of the BPS and the patient-rated Verbal Rating Scale (VRS-4) was evaluated.

Methods: We performed a prospective evaluation study in 80 nonparalyzed critically ill adult intensive care unit patients. Over 2 mo, nurses performed 175 observation series: 126 in deeply sedated patients and 49 in conscious sedated patients. Each observation series consisted of BPS ratings (range 3–12) at 4 points: at rest, during a nonpainful procedure, at retest rest, and during a routine painful procedure. Patients in the conscious sedated state also self-reported their pain using the 4-point VRS-4.

Results: BPS scores during painful procedures were significantly higher than those at rest, both in deeply sedated patients (5.1 [4.8–5.5] vs 3.4 [3.3–3.5], respectively) and conscious sedated patients (5.4 [4.9–5.9] vs 3.8 [3.5–4.1], respectively) (mean [95% confidence interval]). For both groups, scores obtained during the nonpainful procedure and at rest did not significantly differ. There was a strong correlation between nurses' BPS ratings and conscious sedated patients' VRS-4 ratings during the painful procedure (r_s = 0.67, P < 0.001). At rest and during nonpainful procedures, 98% of the observations were rated as acceptable pain (VRS 1 or 2) by both nurses and patients. During painful procedures, nurses rated the pain higher than patients did in 16% of the observations and lower in 12% of the observations.

Conclusion: The BPS is a valid tool for measuring pain in conscious sedated patients during painful procedures. Thus, for noncommunicative and mechanically ventilated patients, it may be regarded as a bridge between the observational scale used by nurses and the VRS-4 used by patients who are able to self-report pain.