Development and psychometric validation of the Behavioral Indicators of Pain Scale-Brain Injury (ESCID-DC) for pain assessment in critically ill patients with acquired brain injury, unable to self-report and with artificial airway

Abstract

Introduction: The aim of this study was to develop and validate the adaptation of the behavioural indicators of pain scale (ESCID) for patients with acquired brain injury (ESCID-DC), unable to self-report and with artificial airway.

Methods: Multicenter study conducted in 2 phases: scale development and evaluation of psychometric properties. Two blinded observers simultaneously assessed pain behaviours with two scales: ESCID-DC and Nociception Coma Scale-Revised version-adapted for Intubated patients (NCS-R-I). Assessments were performed at 3 time points: 5 min before, during and 15 min after the application of the painfull procedures (tracheal suction and application of pressure to the right and left nail bed) and a non-painful procedure (rubbing with gauze). On the day of measurement, the Glasgow Coma Score (GCS) and the Richmond Agitation Sedation Scale (RASS) were evaluated. A descriptive and psychometric analysis was performed.

Results: A total of 4152 pain evaluations were performed in 346 patients, 70% men with a mean age of 56 years (SD = 16.4). The most frequent etiologies of brain damage were vascular 155 (44.8%) and traumatic 144 (41.6%). The median GCS and RASS on the day of evaluation were 8.50 (IQR = 7 to 9) and -2 (RIQ = -3 to -2) respectively. In ESCID-DC the median score was 6 (IQR = 4 to 7) during suction, 3 (RIQ = 1 to 4) for right pressure and 3 (RIQ = 1 to 5) for left pressure. During the non-painful procedure it was 0. The ESCID-DC showed a high discrimination capacity between painful and non-painful procedures (AUC > 0.83) and is sensitive to change depending on the time of application of the scale. High interobserver agreement (Kappa > 0.87), good internal consistency during procedures (α-Cronbach≥0.80) and a high correlation between the ESCID-DC and the NCS-R-I (r ≥ 0.75) were obtained.

Conclusions: The results of this study demonstrate that the ESCID-DC is a valid and reliable tool for assessing pain in patients with acquired brain injury, unable to self-report and with artificial airway.

Keywords: Artificial airway; Behaviour; Brain injuries; Comportamiento; Evaluación del dolor; Intensive care units; Lesión cerebral; Pain assessment; Reproducibilidad de los resultados; Reproducibility of results; Unidad de cuidados intensivos; Vía aérea artificial.