Utilization of the Critical-Care Pain

Observation Tool to assess the

appropriateness of pain management during
spontaneous awakening trials
Rowena Tang, PharmD
PGY-1 Pharmacy Resident
Indiana University Health Ball Memorial Hospital
Muncie, IN
The speaker has no actual or potential conflict
of interest in relation to this presentation.

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Indiana University Health Ball Memorial Hospital

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Background
Pain and discomfort during ICU stay
~50% of patients reported moderate to severe pain
Untreated pain can lead to short and long-term consequences
Insufficient sleep
Developing post-traumatic stress disorder
Acute pain can lead to poor outcomes in critically ill patients

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Rijkenberg S, Stilma W, Endeman H, Bosman RJ, Oudemans-van Straaten HM. Pain measurement in mechanically ventilated critically ill patients:
Behavioral Pain Scale vs Critical-Care Pain Observation Tool. J Crit Care. 2015 Feb;30(1):167-72.
Pain Assessment
Limitations to traditional pain assessment is inability to self-report
Can be due to severity of illness, pharmacotherapy, or inability to speak
Pain assessment tool must take into account the patient’s ability to report pain
If self-report is not possible, valid behavioral pain score should be used
Behavioral Pain Scale
Critical-Care Pain Observation Tool

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Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive
care unit. Crit Care Med. 2013 Jan;41(1):263-306.
Critical-Care Pain Observation Tool (CPOT)
Most valid and reliable behavioral pain scale for monitoring pain in medical,
postoperative, or trauma (except brain injury) in adult ICU patients
Originally developed in French
Includes four behavioral categories
Scored from 0 to 8 (no pain to extreme pain)

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Gélinas C, Fillion L, Puntillo KA, Viens C, Fortier M. Validation of the Critical-Care Pain Observation Tool in adult patients. Am J Crit Care. 2006
Jul;15(4):420-7.
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Gélinas C, Fillion L, Puntillo KA, Viens C, Fortier M. Validation of the Critical-Care Pain Observation Tool in adult patients. Am J Crit Care. 2006
Jul;15(4):420-7.
Need for Study

CPOT was implemented in Dec 2017

Evaluate proper reporting of CPOT score in ICU and CIC
Assess whether pain medication is given appropriately based on the CPOT score
Determine if sedation was decreased when pain controlled

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Methods
Determined by IRB that approval not required
Study period: December 13, 2017 to February 28, 2018
Retrospective chart review of patients that are sedated and scored with the CPOT
Statistics used: Mantel-Haenszel Chi-square statistics using SAS 9.4 software
Inclusion Exclusion

• Patients ≥ 18 years old • Received a neuromuscular blocker within

• Hospitalized and sedated in the ICU and 48 hours
CIC • Glasgow Coma scale score < 4 at the
• Undergoing a spontaneous awakening time of assessment
trial (SAT)
• Recorded CPOT score during SAT 9
Data Collection
CPOT score before and during SAT
RASS score before and during SAT
Glasgow Coma Scale
History of opioid use
Pain medication given
Presence of continuous analgesic drip
Type of sedation used
Outcome of SAT

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Results
CPOT Score Before SAT During SAT Total of 103 SAT from 36 patients
n (%) n (%) met inclusion criteria
0 71 (68.9) 55 (53.4) 29 trials (28.2%) had increase in
1 1 (0.97) 1 (0.97) CPOT score from before to during SAT
2 5 (4.85) 6 (5.83)
3 11 (10.6) 19 (18.5)
4 5 (4.85) 8 (7.77)
5 4 (3.88) 6 (5.83)
6 3 (2.91) 5 (4.85)
7 2 (1.94) 2 (1.94)
8 1 (0.97) 1 (0.97)
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Results
CPOT scores divided into 2 categories
Low = 0–3
High = 4–8

CPOT Score Before SAT During SAT Pain Med Given

During SAT
n (%) n (%) n (%)
Low (0–3) 88 (85.4) 81 (78.6) 14 (17.3)
High (4–8) 15 (14.6) 22 (21.4) 12 (54.5)

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Results – Continuous Analgesic Drip
Pain Control Low CPOT During SAT High CPOT During SAT
n (%) n (%)
No continuous 67 (78.8) 18 (21.2)
analgesic
Continuous analgesic 14 (77.8) 4 (22.2)

P-value = 0.922

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Results – Pain Medication

Pain Control Low CPOT During SAT High CPOT During SAT P-Value
n (%) n (%)
No fentanyl inj. given 73 (90.1) 15 (68.2)
Fentanyl inj. given 8 (9.88) 7 (31.8) 0.01

No morphine inj. given 76 (93.8) 17 (77.3)

Morphine inj. given 5 (6.17) 5 (22.7) 0.021
92 trials (89.3%) had pain medication ordered
9 trials (8.74%) had pain medication with PRN indication for CPOT ordered

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Results – SAT Outcome
Successful SAT defined as holding sedation or reducing rate of sedation after trial
Total SAT: 161 trials
SAT using CPOT: 103 trials
Successful SAT using CPOT: 70 trials (67.9%)
20 trials (28.6%) had pain medication given
Passed SAT using CPOT: 14 trials (13.6%)

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Summary
No statistical significance between continuous analgesic drip and CPOT score
during SAT
Statistical association between the CPOT score and whether the pain medication
(fentanyl or morphine) was given
67.9% of SATs that used the CPOT were successful

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Limitations
Small sample size (total 36 patients)
Not adequately powered
Based on individual SAT as opposed to controlled for each patient
36% of SAT did not meet inclusion due to use of non-verbal pain score
Delay in implementation of CPOT score
Retrospective study
Data is based on what is reported in the electronic medical record

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Conclusion and Future Plans
Re-education of nursing staff assessing pain using the CPOT due to extended
period of time between training and implementation of CPOT
Opportunity to educate medical staff on ordering PRN medications indicated for
CPOT score while patient is sedated and ventilated undergoing SAT

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Self Assessment
Which of the following statements regarding the Critical-Care Pain Observation Tool
(CPOT) is correct?

A.The CPOT is not a valid and reliable behavioral pain scale for non-verbal patients in
the ICU
B.There are 5 total sections of the CPOT score with each section scored from 0 to 2

C.The CPOT is used for both intubated and extubated patients

D.The total possible score for the CPOT ranges from 0 to 10

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Self Assessment
Which of the following statements regarding the Critical-Care Pain Observation Tool
(CPOT) is correct?

A.The CPOT is not a valid and reliable behavioral pain scale for non-verbal patients in
the ICU
B.There are 5 total sections of the CPOT score with each section scored from 0 to 2
C.The CPOT is used for both intubated and extubated patients

D.The total possible score for the CPOT ranges from 0 to 10

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Self Assessment
What are the sections of the Critical-Care Pain Observation Tool (CPOT)?

A.Facial expression, body movements, muscle tension, compliance with ventilator

or vocalization
B.Facial expression, upper limb movement, compliance with mechanical
ventilation
C.Facial expression, body movements, vital signs, respiratory rate
D.Facial expression, upper limb movements, vital signs, compliance with ventilator
or vocalization

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Self Assessment
What are the sections of the Critical-Care Pain Observation Tool (CPOT)?

A.Facial expression, body movements, muscle tension, compliance with ventilator

or vocalization
B.Facial expression, upper limb movement, compliance with mechanical
ventilation
C.Facial expression, body movements, vital signs, respiratory rate
D.Facial expression, upper limb movements, vital signs, compliance with ventilator
or vocalization

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Acknowledgement
Statistical support:

Dr. Munni Begum

Professor
Mathematical Sciences
Ball State University

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References
Rijkenberg S, Stilma W, Endeman H, Bosman RJ, Oudemans-van Straaten HM. Pain measurement in
mechanically ventilated critically ill patients: Behavioral Pain Scale vs Critical-Care Pain Observation Tool. J
Crit Care. 2015 Feb;30(1):167-72.

Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and
delirium in adult patients in the intensive care unit. Crit Care Med. 2013 Jan;41(1):263-306.

Gélinas C, Fillion L, Puntillo KA, Viens C, Fortier M. Validation of the Critical-Care Pain Observation Tool in
adult patients. Am J Crit Care. 2006 Jul;15(4):420-7.

Gélinas C, Arbour C, Michaud C, et al. Implementation of the critical-care pain observation tool on pain
assessment/management nursing practices in an intensive care unit with nonverbal critically ill adults: a
before and after study. Int J Nurs Stud. 2011 Dec;48(12):1495-504.

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Utilization of the Critical-Care Pain
Observation Tool to assess the
appropriateness of pain management during
spontaneous awakening trials
Rowena Tang, PharmD
PGY-1 Pharmacy Resident
Indiana University Health Ball Memorial Hospital
Muncie, IN
rtang@iuhealth.org