Discriminative ability of the Behavioural Indicators of Pain Scale-Brain Injury (Escala de Conductas Indicadoras de Dolor-Daño Cerebral) according to level of sedation in critically ill patients with acquired brain injury and disorders of consciousness: A multicentre observational study.

BACKGROUND

Appropriate assessment of pain is essential to ensure effective treatment.

OBJECTIVES

The objective of this study was to determine the discriminative ability of the Behavioural Indicators of Pain Scale-Brain Injury (Escala de Conductas Indicadoras de Dolor-Daño Cerebral [ESCID-DC]) under different sedation levels (deep vs. light-to-moderate) and procedures in critically ill patients with acquired brain injury and disorders of consciousness.

METHODS

A multicentre, observational study was conducted involving critically ill patients with acquired brain injury and an artificial airway unable to self-report. Patients with prior brain injuries, cognitive impairment, or any condition (clinical or pharmacological) affecting motor response were excluded. The ESCID-DC was administered 5 min before, during, and 15 min after performing painful procedures (tracheal suctioning, right/left nail bed pressure) and a nonpainful procedure (gauze pad rubbing). All assessments were repeated under deep and light-to-moderate sedation.

RESULTS

A total of 418 patients (284 men; 68%) were enrolled. The mean (standard deviation) age was 56.2 (16.3) years. Pain was assessed in 369 patients under deep sedation and in 346 under light-to-moderate sedation. Median (interquartile range) Glasgow Coma Scale scores were 6 (4-7) and 8.5 (7-9) in the deep and light-to-moderate sedation groups, respectively. Under deep sedation, median pain scores during the suctioning and pressure procedures were, respectively, 3 (2-5) and 0 (0-2). Median ESCID-DC scores under light-to-moderate sedation during suctioning and right and left nail bed pressure were 6 (4-7), 3 (1-4), and 3 (1-5), respectively. The ESCID-DC score during the nonpainful procedure was 0. During tracheal suctioning, the discriminative ability of the ESCID-DC was adequate (area under the curve = 0.88; 95% confidence interval: 0.84-0.93), even in patients with very low levels of consciousness. For the pressure procedures, discriminative ability was adequate only when the Glasgow Coma Scale score was ≥5.

CONCLUSIONS

The discriminative ability of the ESCID-DC depends on the level of consciousness and type of procedure. In patients with a low level of consciousness, the scale has a limited capacity to detect pain during less painful procedures.