Evaluation of pain during mobilization and endotracheal aspiration in critical patients

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La línea discontinua marca el 10%, que es el valor que se consideró a priori como clínicamente relevante. Tan solo los valores del BIS fueron clínicamente relevantes. Los valores se expresan como mediana y rango intercuartil. BIS: índice biespectral; FC: frecuencia cardiaca; FR: frecuencia respiratoria; PAM: presión arterial media; PAS: presión arterial sistólica." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "G. Robleda, F. Roche-Campo, L. Membrilla-Martínez, A. Fernández-Lucio, M. Villamor-Vázquez, A. Merten, I. Gich, J. Mancebo, E. Català-Puigbó, J.E. Baños" "autores" => array:10 [ 0 => array:2 [ "nombre" => "G." "apellidos" => "Robleda" ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Roche-Campo" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Membrilla-Martínez" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Fernández-Lucio" ] 4 => array:2 [ "nombre" => "M." "apellidos" => "Villamor-Vázquez" ] 5 => array:2 [ "nombre" => "A." 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"apellidos" => "Baños" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "h" "identificador" => "aff0040" ] ] ] ] "afiliaciones" => array:8 [ 0 => array:3 [ "entidad" => "Department of Intensive Care Medicine, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Doctorate Program in Medicine of the University of Barcelona (UB), Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Intensive Care Medicine, Hospital de Tortosa Verge de la Cinta, Tortosa, Tarragona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Postsurgery Critical Care Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Department of Anesthesiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Department of Clinical Epidemiology and Public Health, Institut d’Investigació Biomèdica (IIB), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Consorcio de Investigación Biomédica de Epidemiología y Salud Pública (CIBERESP), Universitat Autònoma de Barcelona, Barcelona, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Evaluación del dolor durante la movilización y la aspiración endotraqueal en pacientes críticos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1087 "Ancho" => 1662 "Tamanyo" => 59705 ] ] "descripcion" => array:1 [ "en" => "Percentage variation of the different vital signs and BIS between the pre-procedure timepoint (T1) and the procedure (T2). The broken line marks 10%, which is the value a priori considered to be clinically relevant. Only the BIS values were clinically relevant. Values expressed as the median and interquartile range. BIS: bispectral index; HR: heart rate; RF: respiratory frequency; MBP: mean blood pressure; SBP: systolic blood pressure." ] ] ] "textoCompleto" => "IntroductionBetween 50 and 70% of all patients admitted to the Department of Intensive Care Medicine (DICM) experience pain.<a class="elsevierStyleCrossRefs" href="#bib0185">1,2</a> Furthermore, pain has relevant consequences in the critical patient. Apart from ethical considerations, pain is the most unpleasant memory patients describe upon discharge from the DICM.<a class="elsevierStyleCrossRef" href="#bib0195">3</a> On the other hand, the presence of pain during admission to the DICM is associated to an increased incidence of chronic pain<a class="elsevierStyleCrossRef" href="#bib0200">4</a>, posttraumatic stress syndrome<a class="elsevierStyleCrossRef" href="#bib0205">5</a> and, in general, poorer quality of life<a class="elsevierStyleCrossRef" href="#bib0210">6</a>.Pain may be due to a number of causes, such as the background disease process or monitoring techniques and/or nursing care procedures, which are frequent and unavoidable. Puntillo et al.<a class="elsevierStyleCrossRef" href="#bib0215">7</a> evaluated the perception of pain in over 6000 conscious critical patients subjected to 6 procedures: mobilization with turning, the placement of central venous catheters, the removal of chest drains, wound cures, endotracheal aspiration, and the removal of femoral arterial catheters. The authors concluded that all these procedures were painful, and that mobilization was the most painful procedure of all.The main reason for not diagnosing–and therefore not treating–pain is failure to detect the problem.<a class="elsevierStyleCrossRefs" href="#bib0185">1,2</a> Self-evaluation is the best way to assess pain in the conscious patient.<a class="elsevierStyleCrossRef" href="#bib0220">8</a> However, many patients admitted to the DICM are unable to communicate for different reasons: altered level of consciousness, mechanical ventilation (MV) and/or the use of sedatives or neuromuscular blockers. In these patients, the self-evaluation of pain is not viable, and other instruments must be used. In this regard, a number of validated scales are currently available.<a class="elsevierStyleCrossRefs" href="#bib0225">9–14</a> The systemic use of these scales has been shown to improve pain management, with a lesser need for sedating analgesics, and better clinical outcomes.<a class="elsevierStyleCrossRefs" href="#bib0255">15,16</a> However, in patients subjected to deep sedation or neuromuscular block, pain is not easy to evaluate. The monitoring of different vital signs has therefore been proposed, such as arterial pressure and heart rate (HR), for evaluating pain. The results obtained by the different studies are contradictory,<a class="elsevierStyleCrossRefs" href="#bib0265">17,18</a> however, and this approach is therefore presently not recommended.<a class="elsevierStyleCrossRefs" href="#bib0185">1,2</a>The bispectral index (BIS) has recently been proposed as an objective method for evaluating pain in non-communicative patients. This parameter is derived from the electroencephalographic (EEG) tracing, and reflects brain reactivity.<a class="elsevierStyleCrossRef" href="#bib0275">19</a> Some studies have found the BIS to fluctuate in response to pain, even in deeply sedated patients–thus supporting its potential usefulness for the detection of pain in non-communicative patients.<a class="elsevierStyleCrossRef" href="#bib0280">20</a>There has been only limited research on pain during nursing procedures in sedated critical patients, and the usefulness of vital signs and of the BIS as indicators of pain has not been well established. Considering the above, the present study was carried out with the following objectives: (1) to evaluate the prevalence of pain in the course of two common nursing procedures; and (2) to evaluate the usefulness of vital signs and of the BIS in detecting pain during such procedures.Patients and methodsA prospective, repeated-measures analytical observational study was carried out in a series of medical-surgical patients. The study was conducted between September 2010 and April 2011 in the DICM of Santa Creu i Sant Pau Hospital in Barcelona (Spain), and was approved by the Clinical Research Ethics Committee of the hospital, with adherence to the ethical principles of the Declaration of Helsinki (2013).<a class="elsevierStyleCrossRef" href="#bib0285">21</a> Since the patients were unable to communicate, a member of the research team obtained written informed consent to participation from their legal representatives.PatientsThe following inclusion criteria were established: (1) patients over 18 years of age; (2) admission to the DICM; (3) a need for mechanical ventilation and pharmacological sedation; and (4) a need for endotracheal aspiration and/or mobilization with turning.The following exclusion criteria were established: (1) patients with acute brain damage; (2) confirmed cognitive defects or decompensated psychiatric disease; (3) treatment with neuromuscular blockers; (4) limitation of therapeutic effort or brain death; and (5) deep sedation (Richmond Agitation Sedation Scale [RASS] score −5).<a class="elsevierStyleCrossRef" href="#bib0290">22</a>ProceduresThe two procedures evaluated were endotracheal aspiration and mobilization with turning. The choice of these procedures was based on the results of earlier studies,<a class="elsevierStyleCrossRefs" href="#bib0215">7,9</a> which showed them to be potentially painful for patients.Variables and instrumentsThe presence of pain was evaluated using the Behavioral Pain Scale (BPS)<a class="elsevierStyleCrossRef" href="#bib0225">9</a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), which contemplates three behavioral indicators: facial expression, movement of the upper extremities, and adaptation to mechanical ventilation. Each indicator is scored from 1 to 4, and the total score ranges from 3 (absence of pain) to 12 (maximum pain). A BPS score of >3 indicates pain, and a BPS score of ≥5 indicates significant pain.<a class="elsevierStyleCrossRef" href="#bib0295">23</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The following vital signs were evaluated: systolic blood pressure (SBP), mean blood pressure (MBP), heart rate (HR) and respiratory frequency (RF). These signs were obtained through continuous monitoring at the patient bedside (General Electric MD 15T®, Finland; General Electric Company, Solar TM 8000M/i, Spain), with recordings once every minute.The BIS is a noninvasive monitoring tool that measures different cortical electrical parameters by means of electrodes positioned on the forehead of the patient. The index can range from 0 (total suppression of the EEG tracing) to 100 (fully awake), according to the level of consciousness of the patient. Specifically, a BIS of 90–100 is correlated to a good waking state, while an index of 70–80 indicates mild sedation, 60–70 reflects moderate sedation, and 30–60 corresponds to deep sedation similar to that observed during general anesthesia.<a class="elsevierStyleCrossRef" href="#bib0275">19</a> The BIS numerical values were obtained using a BIS VISTA™ monitor (Aspect Medical Systems Inc., Newton, MA, USA), which converts the data into numerical values at 5-s intervals.The level of sedation was evaluated using the RASS,<a class="elsevierStyleCrossRef" href="#bib0290">22</a> which has been validated for measuring the depth of sedation and agitation in adult patients subjected to mechanical ventilation. The RASS score ranges from −5 (patients unresponsive to stimuli) to +4 (combative patients).ProtocolPatient inclusion was made conditioned to the availability of the principal investigator (PI). All the evaluations were made by the PI of the study–a nurse previously trained in the use of the BPS in over 100 patients. The nurses in charge of patient care carried out the procedures in accordance with the needs of the patient and following the interventional protocols of the DICM. In certain cases, and depending on the clinical condition of the patients, analgesia and sedation were provided before carrying out the procedures.A maximum of four procedures per patient were evaluated, establishing a minimum period of 30min between two successive evaluable procedures carried out in the same patient.The patients were evaluated at three timepoints. A resting baseline evaluation was made at least 30min before starting the nursing procedure (T0); a second evaluation was made 5min before starting the procedure (pre-procedure, T1); and a third evaluation was made during the procedure (T2).The PI recorded the exact time at which the evaluation corresponding to each timepoint was made.At T0 the demographic data (age, gender) and variables related to treatment were recorded–including the level of sedation (RASS) and the analgesic and sedating drugs administered in continuous perfusion and/or as intermittent bolus doses during the four hours before data collection. This period was considered to correspond to the mean elimination half-life of the drugs included in the analgesia and sedation protocol of the DICM. The PI prepared the skin of the forehead of the patient with isopropyl alcohol and positioned the BIS sensors according to the instructions of the manufacturer. After checking the impedance of the electrodes and confirming good signal quality, the BIS monitor was turned on to compile the data.For evaluating pain based on the BPS, the patient was previously observed by the PI for one minute at T0 and T1, and pain assessment was then made at T2 during the procedure.At the end of the procedure, the means of the absolute values corresponding to systolic blood pressure, mean blood pressure, HR and RF were calculated from the continuous monitoring data obtained, and the BIS information was entered in electronic format. The BIS data were selected from the registry of the evaluation time, calculating a delay of one minute between the point of stimulation and the BIS value.Data analysisThe normality of the distribution of the variables was confirmed using the Kolmogorov–Smirnov test.The categorical variables (gender, diagnosis, type of analgesia and sedation, and preventive analgesia and sedation) were expressed as percentages and number of cases. The quantitative variables (BPS score, systolic blood pressure, mean blood pressure, HR, RF and BIS) were expressed as medians and interquartile range (IQR1-IQR3).In order to determine whether the existence of pain can be predicted from the observation of pain behavior and the physiological indicators, comparisons were made of the BPS scores, the absolute values of the vital signs and the BIS values before (T1) and during (T2) the procedures, using the Mann–Whitney U-test.The effect of pain present before the procedures upon pain during the procedures was evaluated by creating a new variable: the mean difference in the BPS scores between T1 and T2. The values were expressed as the median and IQR.The clinical relevance of the differences was assessed by analyzing the variations in vital signs and BIS values as percentage changes. The data were reported as the median and IQR. In accordance with the results of earlier studies,<a class="elsevierStyleCrossRef" href="#bib0300">24</a> we a priori defined clinical relevance as corresponding to a percentage change of ≥10%.Comparison of the vital signs and BIS values between T1 and T2 was carried out using the Wilcoxon test.Lastly, a subgroups analysis was used to compare the effects of administration or non-administration of preventive analgesia and sedation. Specifically, comparisons were made of the BPS scores and the percentage changes in BIS between the patients who had received preventive analgesia and sedation and those who had not received such treatment, based on the Mann–Whitney U-test.A two-tailed approach was used, establishing a level of statistical significance of 5% (α=0.05). The SPSS® version 21.0 statistical package was used throughout.ResultsBaseline characteristics of the patientsThe baseline characteristics of the patients are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. A total of 146 procedures (84 endotracheal aspirations and 62 mobilizations) were evaluated in 70 patients. There were no statistically significant differences between endotracheal aspiration and mobilization. The mean duration of the aspiration procedure was 8s, while the mean duration of mobilization was four minutes.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Sixty-one percent of the patients suffered pain under resting conditions (T0), with a median BPS score of 4 (IQR: 3–5). Thirty-three percent of the patients presented significant pain (BPS≥5).Pain during the proceduresPain behavior was noted in 94% of the procedures evaluated, with a median BPS score of 6 (IQR: 5–8). In 86% of the procedures, the pain was scored as significant (BPS≥5). There were no significant differences in BPS score between mobilization with turning and endotracheal aspiration (6 [5–8] vs. 7 [6–8]; p=0.146, respectively).The comparisons of the pain scores before (T1) and during (T2) the procedures are shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. Both the global comparisons (4 [3–5] vs. 6 [5–8]; p<0.001, respectively) and the partial comparisons referred to facial expression (2 [1–2] vs. 2 [2–3]; p<0.001, respectively), movement of the extremities (1 [1–2] vs. 2 [2–2]; p<0.001, respectively) and adaptation to mechanical ventilation (1 [1–2] vs. 2 [2–3]; p<0.001, respectively) were statistically significant.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The patients with pain (BPS>3) under resting conditions (T0) experienced more pain during the procedures (T2) than those without resting pain (BPS=3) (7 [6–8] vs. 6 [5–8]; p=0.012, respectively).Vital signs and bispectral index during the proceduresThe vital signs (systolic blood pressure, mean blood pressure, HR and RF) and the BIS increased significantly from T1 to T2 (108 [94–121] vs. 118 [102–132]; p<0.001, 73 [62–80] vs. 76 [67–85]; p<0.001, 88 [76–108] vs. 90 [80–108]; p=0.002, 16 [12–20] vs. 17 [13–22]; p<0.001, 58.5 [47–72] vs. 71 [59–80]; p<0.001, respectively). However, the percentage change was only clinically relevant (≥10%) for the BIS values (13% [IQR: 2–26%]) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The variation in BIS was ≥10% in 72% of the pain behavior observations.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Effect of preventive analgesia and sedation upon pain and the bispectral index values during the procedures. Subgroups analysisBefore the procedures, and based on the criterion of the nurse and/or physician in charge, preventive analgesia was administered in 7% of the procedures and preventive sedation in 21% (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>With regard to analgesia, the patients who received a preventive analgesic bolus dose before the procedures showed a significant decrease in pain between T1 and T2 versus those who did not receive preventive analgesia (−2 [IQR: {−5}–0] vs. 3 [IQR: 1–4]; p<0.01, respectively).Likewise, the patients who received a preventive analgesic bolus dose before the procedures showed a statistically smaller and clinically non-relevant change in BIS versus those who did not receive preventive analgesia (5% [IQR: {−40}–18%] vs. 16% [IQR: 3–37%]; p=0.021, respectively).With regard to sedation, the patients who received an additional sedation dose before the procedures experienced an increase in pain between T1 and T2, though the increase was smaller than in those who did not receive preventive sedation (1 [IQR: {−3}–3] vs. 3 [IQR: 1–4]; p<0.001, respectively).Likewise, the patients who received an additional sedation bolus dose before the procedures also presented a statistically smaller and clinically non-relevant change in BIS versus those who did not receive sedation (−5% [IQR: {−40}–7%]) vs. 20% [IQR: 9–37%]; p<0.001, respectively.DiscussionThe main result of our study can be summarized as follows: (1) the patients in our DICM suffer resting pain; (2) mobilization with turning and endotracheal aspiration are painful procedures; (3) the physiological signs are not useful for evaluating pain; (4) the variation in BIS could be useful for evaluating pain; and (5) preventive analgesia may decrease pain during the procedures.Resting painIn our series, 61% of the patients experienced pain (BPS>3) under resting conditions, and 33% suffered significant pain (BPS≥5). This high percentage is not surprising and is consistent with the data found in the literature on the prevalence of resting pain in critical patients who are unable to communicate. Chanques et al., in a series of surgical cases,<a class="elsevierStyleCrossRef" href="#bib0255">15</a> found 63% of their patients to have significant pain under resting conditions. This figure dropped to 42% following a training initiative targeted to nurses and physicians, in which improvements were made in the detection of pain and the administration of analgesic treatment. Other studies have shown the objective control of analgesia, sedation and delirium to improve detection and treatment of the problem.<a class="elsevierStyleCrossRef" href="#bib0305">25</a>Although these scales are simple to apply, they are little used in routine clinical practice,<a class="elsevierStyleCrossRef" href="#bib0295">23</a> and the incidence of resting pain remains high. The studies published to date show important discrepancies between actual clinical practice and the current recommendations.<a class="elsevierStyleCrossRefs" href="#bib0185">1,2</a> On the other hand, we should ask ourselves whether health professionals are well instructed on how to assess pain behavior. In a recent study,<a class="elsevierStyleCrossRef" href="#bib0310">26</a> the authors evaluated interobserver reliability of the BPS scale under resting conditions and during a painful procedure. The facial expression subscale was seen to show poor concordance and low correlation. These results reflect a need for sufficient prior training and a minimum level of experience in order to guarantee adequate pain evaluation through behavioral indicators.This approach therefore could be useful in developing appropriate educational programs and future guidelines for the management of sedation and analgesia in the DICM. Emphasis should be placed on the need to evaluate pain using the validated scales at our disposal, in order to identify and treat the problem correctly.<a class="elsevierStyleCrossRefs" href="#bib0225">9–14</a>Pain during the nursing proceduresCritical patients undergo multiple diagnostic and therapeutic procedures carried out by nurses, and most of them describe having experienced pain during the procedures even several years later.<a class="elsevierStyleCrossRef" href="#bib0315">27</a> Our results indicate that the procedures we have studied are painful for most patients. The percentages obtained are consistent with the results recently published by the Europain® study.<a class="elsevierStyleCrossRef" href="#bib0320">28</a> The authors evaluated pain in 3850 conscious patients in 192 Intensive Care Units from 28 countries. The results showed a significant increase in pain from the start to the time of performing the 12 procedures evaluated–including mobilization and endotracheal aspiration. Furthermore, the study found pre-procedure pain to be a risk factor for greater pain intensity during the procedures. The authors concluded that good control of resting pain can lessen pain during the procedures.Usefulness of vital signs and the bispectral index in the evaluation of painIn patients unable to communicate with the health professionals, several vital signs have been postulated for evaluating pain. However, vital signs are not specific of pain and can be influenced by the administration of drugs (e.g., vasopressors, betablockers, antiarrhythmic agents) or the underlying disease condition itself (sepsis). In fact, several studies have shown that these parameters increase during both painful and non-painful procedures,<a class="elsevierStyleCrossRef" href="#bib0325">29</a> and/or remain without change during procedures shown to be painful by validated scales.<a class="elsevierStyleCrossRef" href="#bib0330">30</a> Our results reveal significant changes in all the vital signs and in the BIS values, though only the latter were clinically relevant. Our findings therefore reinforce the evidence suggesting that vital signs should not be used isolatedly for assessing pain behavior in patients who are unable to communicate verbally.<a class="elsevierStyleCrossRefs" href="#bib0185">1,2</a>The BIS has been used to monitor levels of consciousness in patients under sedation and anesthesia.<a class="elsevierStyleCrossRef" href="#bib0275">19</a> Earlier studies in critical patients have shown that transient increments of between 5 and 20% in the BIS values can be associated to pain.<a class="elsevierStyleCrossRefs" href="#bib0265">17,18</a> However, multiple factors (e.g., tactile or hearing stimuli) can interfere with these variations. Some authors support the idea the BIS could be useful provided these factors are adequately controlled.<a class="elsevierStyleCrossRef" href="#bib0270">18</a> In any case, our results coincide with those already found in the literature, and support the idea that variations in BIS can be useful for the evaluation of pain–though further studies are needed to confirm this possibility.Additional analgesics and sedatives before the proceduresMost patients admitted to the DICM receive some kind of analgesic treatment. According to a French study,<a class="elsevierStyleCrossRef" href="#bib0295">23</a> on the second day of admission 72% of the patients were receiving some analgesic medication. On day four this percentage was found to be 55%, versus 50% on day 6 of admission. In our series, practically all patients received some type of analgesia. However, the administered medication doses do not seem to suffice to alleviate resting pain, and are clearly insufficient in avoiding pain during the nursing procedures.For this reason, preventive analgesia before performing a procedure could be a good strategy. In our series, the nurse or physician decided to provide preventive analgesia in only 7% of the procedures. Such limited use of preventive analgesia in our setting is consistent with the different multicenter and multinational observational studies found in the literature.<a class="elsevierStyleCrossRefs" href="#bib0215">7,28</a>To our knowledge, the efficacy of preventive analgesia has only been evaluated in three procedures: femoral catheter removal,<a class="elsevierStyleCrossRef" href="#bib0335">31</a> the aspiration of secretions,<a class="elsevierStyleCrossRef" href="#bib0340">32</a> and chest drain removal.<a class="elsevierStyleCrossRefs" href="#bib0345">33–36</a> The results of these studies are moreover inconclusive.Fulton et al.<a class="elsevierStyleCrossRef" href="#bib0335">31</a> evaluated the efficacy of morphine, fentanyl, subcutaneous lidocaine or placebo administered before femoral artery catheter removal in 130 patients subjected to cardiac catheterization. They recorded no differences in relation to pain perception. The authors concluded that the procedure was not sufficiently painful for preventive analgesia to be able to demonstrate its benefits.Brocas et al.<a class="elsevierStyleCrossRef" href="#bib0340">32</a> evaluated the effect of the preventive administration of alfentanyl before endotracheal tube aspiration upon the BIS value in 10 critical patients subjected to mechanical ventilation. The BIS increased significantly in aspiration performed without preventive analgesia versus aspiration performed after preventive alfentanyl administration. The authors concluded that preventive analgesia was effective in reducing pain evaluated by the BIS.Puntillo and Ley<a class="elsevierStyleCrossRef" href="#bib0345">33</a> evaluated the efficacy of morphine, ketorolac or patient information on the procedure before chest drain removal in 75 heart surgery patients. These authors likewise found no differences between the groups in relation to the perception of pain, and also concluded that the process was probably not painful enough for preventive analgesia to be able to demonstrate its benefits. However, in other studies, significantly lower pain scores were recorded in patients who before chest drain removal had received intravenous morphine plus relaxation exercises<a class="elsevierStyleCrossRef" href="#bib0350">34</a>, sufentanil or fentanyl35 or topical valdecoxib.<a class="elsevierStyleCrossRef" href="#bib0360">36</a>It is easy to imagine that patients admitted to the DICM would wish to have pain treated on a preventive basis with drugs or other means before undergoing painful procedures. Consequently, preventive analgesia and/or non-pharmacological interventions are currently recommended for alleviating pain in adult patients before chest drain removal is carried out, and similar measures are also advised in other potentially painful procedures.<a class="elsevierStyleCrossRef" href="#bib0185">1</a> On the other hand, it must be taken into account that the administration of analgesic medication–mainly opioids and nonsteroidal antiinflammatory drugs–can produce side effects.On the basis of the above, different authors have proposed the concept of dynamic analgesia, which could allow a lowering of the analgesia dose under resting conditions and an increase before potentially painful procedures are performed. The idea would be similar to that used for avoiding the accumulation of sedative agents. Strategies such as “sequential sedation”, “dynamic sedation” or “daily sedation interruption” have demonstrated their efficacy in preventing the complications associated to prolonged sedation.<a class="elsevierStyleCrossRefs" href="#bib0185">1,2</a>Regarding sedating drug use before the procedures, our results show that it is not as effective as analgesia in avoiding pain. In this regard, pain can cause agitation or restlessness in the critical patient, and its management should be based on analgesia rather than on sedation.Study limitationsOur study has a number of limitations. Firstly, it is a single-center study in sedated patients subjected to mechanical ventilation and mostly subjected to surgery. As a result, the findings cannot be extrapolated to other types of patients. Secondly, no non-painful procedure was used as control. In this regard, a control group would have helped to discriminate between the effects inherent to the procedure and the simple effect of interacting with the patient. On the other hand, evaluation after completing the procedures was not made, but would have helped clarify the evolution of pain associated to the procedures. Finally, the number of patients who received preventive analgesia was small; as a result, we are unable to draw firm conclusions on these partial results.ConclusionsCritical patients who are unable to communicate continue to experience resting pain. Furthermore, mobilization with turning and endotracheal aspiration are both painful procedures. The detection and treatment of baseline pain, enhanced by routine maneuvers, confirms the usefulness of the clinical scales and advises the administration of preventive analgesia and the expanded use of the BIS.Financial supportThis study has received no financial support.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres613064" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec626847" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres613065" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec626846" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and methods" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patients" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Procedures" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Variables and instruments" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Protocol" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Data analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0040" "titulo" => "Results" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Baseline characteristics of the patients" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Pain during the procedures" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Vital signs and bispectral index during the procedures" ] 3 => array:2 [ "identificador" => "sec0060" "titulo" => "Effect of preventive analgesia and sedation upon pain and the bispectral index values during the procedures. Subgroups analysis" ] ] ] 7 => array:3 [ "identificador" => "sec0065" "titulo" => "Discussion" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0070" "titulo" => "Resting pain" ] 1 => array:2 [ "identificador" => "sec0075" "titulo" => "Pain during the nursing procedures" ] 2 => array:2 [ "identificador" => "sec0080" "titulo" => "Usefulness of vital signs and the bispectral index in the evaluation of pain" ] 3 => array:2 [ "identificador" => "sec0085" "titulo" => "Additional analgesics and sedatives before the procedures" ] 4 => array:2 [ "identificador" => "sec0090" "titulo" => "Study limitations" ] ] ] 8 => array:2 [ "identificador" => "sec0095" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0100" "titulo" => "Financial support" ] 10 => array:2 [ "identificador" => "sec0105" "titulo" => "Conflicts of interest" ] 11 => array:2 [ "identificador" => "xack206659" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-12-27" "fechaAceptado" => "2015-03-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec626847" "palabras" => array:6 [ 0 => "Critically-ill patients" 1 => "Pain assessment" 2 => "Procedural pain" 3 => "Tracheal aspiration" 4 => "Mobilization with turning" 5 => "Bispectral index" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec626846" "palabras" => array:6 [ 0 => "Pacientes críticos" 1 => "Dolor" 2 => "Dolor procedimientos" 3 => "Aspiración endotraqueal" 4 => "Movilización con giro" 5 => "Índice biespectral" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "Objectives(1) To assess the prevalence of pain during nursing care procedures, and (2) to evaluate the usefulness of certain vital signs and the bispectral index (BIS) in detecting pain. MethodsA prospective, observational analytical study was made of procedures (endotracheal aspiration and mobilization with turning) in critically ill sedated patients on mechanical ventilation. The Behavioral Pain Scale was used to assess pain, with scores of ≥3 indicating pain. Various physiological signs and BIS values were recorded, with changes of >10% being considered clinically relevant. ResultsA total of 146 procedures in 70 patients were analyzed. Pain prevalence during the procedures was 94%. Vital signs and BIS values increased significantly during the procedures compared to resting conditions, but only the changes in BIS were considered clinically relevant. In the subgroup of patients receiving preemptive analgesia prior to the procedure, pain decreased significantly compared to the group of patients who received no such analgesia (−2 [IQR: {−5}–0] vs. 3 [IQR: 1–4]; P<.001, respectively). ConclusionsThe procedures evaluated in this study are painful. Changes in vital signs are not good indicators of pain. Changes in BIS may provide useful information about pain, but more research is needed. The administration of preemptive analgesia decreases pain during the procedures." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "Objetivos1) Evaluar la prevalencia de dolor durante 2 procedimientos de enfermería, y 2) analizar la utilidad de ciertos signos vitales y del índice biespectral (BIS) para detectar dolor. MétodosEstudio prospectivo, observacional y analítico de medidas repetidas en pacientes con ventilación mecánica y sedación. Los procedimientos evaluados fueron la aspiración endotraqueal y la movilización con giro. El dolor se evaluó mediante la Behavioral Pain Scale. Valores≥3 se consideraron dolorosos. Se registraron distintos signos fisiológicos y los valores del BIS. Una variación porcentual>10% se consideró clínicamente relevante. ResultadosSe analizaron 146 procedimientos en 70 pacientes. La prevalencia de dolor durante los procedimientos fue del 94%. Los signos vitales y los valores del BIS aumentaron significativamente durante los procedimientos respecto el reposo, pero solo la variación del BIS alcanzó relevancia clínica. En un subgrupo de pacientes que recibieron analgesia preventiva antes de los procedimientos, el dolor disminuyó significativamente respecto a los pacientes que no recibieron analgesia preventiva (−2 [RIQ: {−5}-0] vs. 3 [RIQ: 1–4]; p<0,001, respectivamente). ConclusionesLos procedimientos evaluados son dolorosos. La variación de los signos vitales no es un buen indicador de dolor. La variación del BIS podría ser útil, pero precisa nuevas investigaciones. La administración de analgesia preventiva disminuye la prevalencia de dolor durante los procedimientos." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Robleda G, Roche-Campo F, Membrilla-Martínez L, Fernández-Lucio A, Villamor-Vázquez M, Merten A, et al. Evaluación del dolor durante la movilización y la aspiración endotraqueal en pacientes críticos. Med Intensiva. 2016;40:96–104." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2663 "Ancho" => 2413 "Tamanyo" => 183404 ] ] "descripcion" => array:1 [ "en" => "Pain behavior during the nursing procedures. All comparisons between the pre-procedure timepoint (T1) and the procedure (T2) were statistically significant (p<0.01). Values expressed as the median and interquartile range." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1087 "Ancho" => 1662 "Tamanyo" => 59705 ] ] "descripcion" => array:1 [ "en" => "Percentage variation of the different vital signs and BIS between the pre-procedure timepoint (T1) and the procedure (T2). The broken line marks 10%, which is the value a priori considered to be clinically relevant. Only the BIS values were clinically relevant. Values expressed as the median and interquartile range. BIS: bispectral index; HR: heart rate; RF: respiratory frequency; MBP: mean blood pressure; SBP: systolic blood pressure." ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Presence of pain with BPS >3. Presence of significant pain with BPS ≥5." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Facial expression</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Relaxed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Partially tightened \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Fully tightened \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Grimacing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Movements of the upper extremities</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">No movement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Partially bent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Fully bent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Permanently retracted \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Adaptation to mechanical ventilation</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Adapted movements \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Good adaptation most of the time \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Struggling with respirator \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Impossible to ventilate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1004294.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Behavioral Pain Scale." ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "NSAIDs: nonsteroidal antiinflammatory drugs; BIS: bispectral index; BPS: Behavioral Pain Scale; cp: continuous perfusion; RASS: Richmond Agitation Sedation Scale; IQR: interquartile range." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Age in years, median (IQR) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">71 (62–79) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Gender, n (%)</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Females \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 (36) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Males \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45 (64) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Reason for admission, n (%)</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Medical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (10) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Surgical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">63 (90) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">BPS score, n (%)</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">=3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 (39) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">>3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43 (61) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">≥5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (33) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">RASS score, n (%)</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">≥+1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (15) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">0 to −2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 (32) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">−3 to −4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 (53) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">BIS, median (IQR) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62 (50–72) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Analgesia, n (%)</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Without analgesia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Morphine cp \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42 (60) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Remifentanil cp \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Bolus dose analgesia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (16) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Paracetamol or NSAIDs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (20) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Others \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Sedation, n (%)</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Propofol cp \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 (53) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Midazolam cp \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 (44) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Bolus dose sedation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 (40) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Combination of several drugs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (3) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1004293.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Baseline characteristics of the study population (n=70)." ] ] 4 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "BPS: Behavioral Pain Scale.Values expressed as the median (interquartile range)." "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Analgesia n=10 (7%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Without analgesia n=136 (93%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p-value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Baseline BPS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (3–6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (3–5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.179 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Pre-procedure BPS (T1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (5–9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (3–5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Procedure BPS (T2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (4–6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (6–8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">T1–T2 difference \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−2 ([−5]–0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (1–4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">% variation BIS T1–T2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 ([−40]–18) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (3–37) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.021 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1004295.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sedation n=31 (21%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Without sedation n=115 (79%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p-value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Baseline BPS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (3–5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (3–5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.086 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Pre-procedure BPS (T1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (4–7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (3–5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Procedure BPS (T2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (4–7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (6–8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.82 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">T1–T2 difference \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 ([−3]–3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (1–4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">% variation BIS T1–T2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−5 ([−40]–7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (9–37) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1004296.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Effects of preventive analgesia and sedation upon pain and the bispectral index." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:36 [ 0 => array:3 [ "identificador" => "bib0185" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. 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Evaluation of pain during mobilization and endotracheal aspiration in critical patients

Evaluación del dolor durante la movilización y la aspiración endotraqueal en pacientes críticos

G. Robledaa,b,

Corresponding author

grobleda@santpau.cat

Corresponding author.

, F. Roche-Campoa,c, L. Membrilla-Martínezd, A. Fernández-Luciod, M. Villamor-Vázqueze, A. Mertene, I. Gichf,g, J. Manceboa, E. Català-Puigbóe, J.E. Bañosh

a Department of Intensive Care Medicine, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

b Doctorate Program in Medicine of the University of Barcelona (UB), Barcelona, Spain

c Department of Intensive Care Medicine, Hospital de Tortosa Verge de la Cinta, Tortosa, Tarragona, Spain

d Postsurgery Critical Care Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

e Department of Anesthesiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

f Department of Clinical Epidemiology and Public Health, Institut d’Investigació Biomèdica (IIB), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

g Consorcio de Investigación Biomédica de Epidemiología y Salud Pública (CIBERESP), Universitat Autònoma de Barcelona, Barcelona, Spain

h Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain

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posttraumatic stress syndrome<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">5</span></a> and&#44; in general&#44; poorer quality of life<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">6</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Pain may be due to a number of causes&#44; such as the background disease process or monitoring techniques and&#47;or nursing care procedures&#44; which are frequent and unavoidable&#46; Puntillo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">7</span></a> evaluated the perception of pain in over 6000 conscious critical patients subjected to 6 procedures&#58; mobilization with turning&#44; the placement of central venous catheters&#44; the removal of chest drains&#44; wound cures&#44; endotracheal aspiration&#44; and the removal of femoral arterial catheters&#46; The authors concluded that all these procedures were painful&#44; and that mobilization was the most painful procedure of all&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The main reason for not diagnosing&#8211;and therefore not treating&#8211;pain is failure to detect the problem&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">1&#44;2</span></a> Self-evaluation is the best way to assess pain in the conscious patient&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">8</span></a> However&#44; many patients admitted to the DICM are unable to communicate for different reasons&#58; altered level of consciousness&#44; mechanical ventilation &#40;MV&#41; and&#47;or the use of sedatives or neuromuscular blockers&#46; In these patients&#44; the self-evaluation of pain is not viable&#44; and other instruments must be used&#46; In this regard&#44; a number of validated scales are currently available&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">9&#8211;14</span></a> The systemic use of these scales has been shown to improve pain management&#44; 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tracing&#44; and reflects brain reactivity&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">19</span></a> Some studies have found the BIS to fluctuate in response to pain&#44; even in deeply sedated patients&#8211;thus supporting its potential usefulness for the detection of pain in non-communicative patients&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">20</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">There has been only limited research on pain during nursing procedures in sedated critical patients&#44; and the usefulness of vital signs and of the BIS as indicators of pain has not been well established&#46; Considering the above&#44; the present study was carried out with the following objectives&#58; &#40;1&#41; to evaluate the prevalence of pain in the course of two common nursing procedures&#59; and &#40;2&#41; to evaluate the usefulness of vital signs and of the BIS in detecting pain during such procedures&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">A prospective&#44; repeated-measures analytical observational study was carried out in a series of medical-surgical patients&#46; The study was conducted between September 2010 and April 2011 in the DICM of Santa Creu i Sant Pau Hospital in Barcelona &#40;Spain&#41;&#44; and was approved by the Clinical Research Ethics Committee of the hospital&#44; with adherence to the ethical principles of the Declaration of Helsinki &#40;2013&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">21</span></a> Since the patients were unable to communicate&#44; a member of the research team obtained written informed consent to participation from their legal representatives&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0035" class="elsevierStylePara elsevierViewall">The following inclusion criteria were established&#58; &#40;1&#41; patients over 18 years of age&#59; &#40;2&#41; admission to the DICM&#59; &#40;3&#41; a need for mechanical ventilation and pharmacological sedation&#59; and &#40;4&#41; a need for endotracheal aspiration and&#47;or mobilization with turning&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The following exclusion criteria were established&#58; &#40;1&#41; patients with acute brain damage&#59; &#40;2&#41; confirmed cognitive defects or decompensated psychiatric disease&#59; &#40;3&#41; treatment with neuromuscular blockers&#59; &#40;4&#41; limitation of therapeutic effort or brain death&#59; and &#40;5&#41; deep sedation &#40;Richmond Agitation Sedation Scale &#91;RASS&#93; score &#8722;5&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Procedures</span><p id="par0045" class="elsevierStylePara elsevierViewall">The two procedures evaluated were endotracheal aspiration and mobilization with turning&#46; The choice of these procedures was based on the results of earlier studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">7&#44;9</span></a> which showed them to be potentially painful for patients&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Variables and instruments</span><p id="par0050" class="elsevierStylePara elsevierViewall">The presence of pain was evaluated using the Behavioral Pain Scale &#40;BPS&#41;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">9</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; which contemplates three behavioral indicators&#58; facial expression&#44; movement of the upper extremities&#44; and adaptation to mechanical ventilation&#46; Each indicator is scored from 1 to 4&#44; and the total score ranges from 3 &#40;absence of pain&#41; to 12 &#40;maximum pain&#41;&#46; A BPS score of &#62;3 indicates pain&#44; and a BPS score of &#8805;5 indicates significant pain&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">23</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The following vital signs were evaluated&#58; systolic blood pressure &#40;SBP&#41;&#44; mean blood pressure &#40;MBP&#41;&#44; heart rate &#40;HR&#41; and respiratory frequency &#40;RF&#41;&#46; These signs were obtained through continuous monitoring at the patient bedside &#40;General Electric MD 15T<span class="elsevierStyleSup">&#174;</span>&#44; Finland&#59; General Electric Company&#44; Solar TM 8000<span class="elsevierStyleHsp" style=""></span>M&#47;i&#44; Spain&#41;&#44; with recordings once every minute&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The BIS is a noninvasive monitoring tool that measures different cortical electrical parameters by means of electrodes positioned on the forehead of the patient&#46; The index can range from 0 &#40;total suppression of the EEG tracing&#41; to 100 &#40;fully awake&#41;&#44; according to the level of consciousness of the patient&#46; Specifically&#44; a BIS of 90&#8211;100 is correlated to a good waking state&#44; while an index of 70&#8211;80 indicates mild sedation&#44; 60&#8211;70 reflects moderate sedation&#44; and 30&#8211;60 corresponds to deep sedation similar to that observed during general anesthesia&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">19</span></a> The BIS numerical values were obtained using a BIS VISTA&#8482; monitor &#40;Aspect Medical Systems Inc&#46;&#44; Newton&#44; MA&#44; USA&#41;&#44; which converts the data into numerical values at 5-s intervals&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The level of sedation was evaluated using the RASS&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">22</span></a> which has been validated for measuring the depth of sedation and agitation in adult patients subjected to mechanical ventilation&#46; The RASS score ranges from &#8722;5 &#40;patients unresponsive to stimuli&#41; to &#43;4 &#40;combative patients&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Protocol</span><p id="par0070" class="elsevierStylePara elsevierViewall">Patient inclusion was made conditioned to the availability of the principal investigator &#40;PI&#41;&#46; All the evaluations were made by the PI of the study&#8211;a nurse previously trained in the use of the BPS in over 100 patients&#46; The nurses in charge of patient care carried out the procedures in accordance with the needs of the patient and following the interventional protocols of the DICM&#46; In certain cases&#44; and depending on the clinical condition of the patients&#44; analgesia and sedation were provided before carrying out the procedures&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">A maximum of four procedures per patient were evaluated&#44; establishing a minimum period of 30<span class="elsevierStyleHsp" style=""></span>min between two successive evaluable procedures carried out in the same patient&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The patients were evaluated at three timepoints&#46; A resting baseline evaluation was made at least 30<span class="elsevierStyleHsp" style=""></span>min before starting the nursing procedure &#40;T0&#41;&#59; a second evaluation was made 5<span class="elsevierStyleHsp" style=""></span>min before starting the procedure &#40;pre-procedure&#44; T1&#41;&#59; and a third evaluation was made during the procedure &#40;T2&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The PI recorded the exact time at which the evaluation corresponding to each timepoint was made&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">At T0 the demographic data &#40;age&#44; gender&#41; and variables related to treatment were recorded&#8211;including the level of sedation &#40;RASS&#41; and the analgesic and sedating drugs administered in continuous perfusion and&#47;or as intermittent bolus doses during the four hours before data collection&#46; This period was considered to correspond to the mean elimination half-life of the drugs included in the analgesia and sedation protocol of the DICM&#46; The PI prepared the skin of the forehead of the patient with isopropyl alcohol and positioned the BIS sensors according to the instructions of the manufacturer&#46; After checking the impedance of the electrodes and confirming good signal quality&#44; the BIS monitor was turned on to compile the data&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">For evaluating pain based on the BPS&#44; the patient was previously observed by the PI for one minute at T0 and T1&#44; and pain assessment was then made at T2 during the procedure&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">At the end of the procedure&#44; the means of the absolute values corresponding to systolic blood pressure&#44; mean blood pressure&#44; HR and RF were calculated from the continuous monitoring data obtained&#44; and the BIS information was entered in electronic format&#46; The BIS data were selected from the registry of the evaluation time&#44; calculating a delay of one minute between the point of stimulation and the BIS value&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Data analysis</span><p id="par0105" class="elsevierStylePara elsevierViewall">The normality of the distribution of the variables was confirmed using the Kolmogorov&#8211;Smirnov test&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The categorical variables &#40;gender&#44; diagnosis&#44; type of analgesia and sedation&#44; and preventive analgesia and sedation&#41; were expressed as percentages and number of cases&#46; The quantitative variables &#40;BPS score&#44; systolic blood pressure&#44; mean blood pressure&#44; HR&#44; RF and BIS&#41; were expressed as medians and interquartile range &#40;IQR1-IQR3&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In order to determine whether the existence of pain can be predicted from the observation of pain behavior and the physiological indicators&#44; comparisons were made of the BPS scores&#44; the absolute values of the vital signs and the BIS values before &#40;T1&#41; and during &#40;T2&#41; the procedures&#44; using the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span>-test&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The effect of pain present before the procedures upon pain during the procedures was evaluated by creating a new variable&#58; the mean difference in the BPS scores between T1 and T2&#46; The values were expressed as the median and IQR&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The clinical relevance of the differences was assessed by analyzing the variations in vital signs and BIS values as percentage changes&#46; The data were reported as the median and IQR&#46; In accordance with the results of earlier studies&#44;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">24</span></a> we a priori defined clinical relevance as corresponding to a percentage change of &#8805;10&#37;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Comparison of the vital signs and BIS values between T1 and T2 was carried out using the Wilcoxon test&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Lastly&#44; a subgroups analysis was used to compare the effects of administration or non-administration of preventive analgesia and sedation&#46; Specifically&#44; comparisons were made of the BPS scores and the percentage changes in BIS between the patients who had received preventive analgesia and sedation and those who had not received such treatment&#44; based on the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span>-test&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">A two-tailed approach was used&#44; establishing a level of statistical significance of 5&#37; &#40;<span class="elsevierStyleItalic">&#945;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; The SPSS<span class="elsevierStyleSup">&#174;</span> version 21&#46;0 statistical package was used throughout&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Baseline characteristics of the patients</span><p id="par0145" class="elsevierStylePara elsevierViewall">The baseline characteristics of the patients are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; A total of 146 procedures &#40;84 endotracheal aspirations and 62 mobilizations&#41; were evaluated in 70 patients&#46; There were no statistically significant differences between endotracheal aspiration and mobilization&#46; The mean duration of the aspiration procedure was 8<span class="elsevierStyleHsp" style=""></span>s&#44; while the mean duration of mobilization was four minutes&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">Sixty-one percent of the patients suffered pain under resting conditions &#40;T0&#41;&#44; with a median BPS score of 4 &#40;IQR&#58; 3&#8211;5&#41;&#46; Thirty-three percent of the patients presented significant pain &#40;BPS<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>5&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Pain during the procedures</span><p id="par0155" class="elsevierStylePara elsevierViewall">Pain behavior was noted in 94&#37; of the procedures evaluated&#44; with a median BPS score of 6 &#40;IQR&#58; 5&#8211;8&#41;&#46; In 86&#37; of the procedures&#44; the pain was scored as significant &#40;BPS<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>5&#41;&#46; There were no significant differences in BPS score between mobilization with turning and endotracheal aspiration &#40;6 &#91;5&#8211;8&#93; vs&#46; 7 &#91;6&#8211;8&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;146&#44; respectively&#41;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The comparisons of the pain scores before &#40;T1&#41; and during &#40;T2&#41; the procedures are shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; Both the global comparisons &#40;4 &#91;3&#8211;5&#93; vs&#46; 6 &#91;5&#8211;8&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#44; respectively&#41; and the partial comparisons referred to facial expression &#40;2 &#91;1&#8211;2&#93; vs&#46; 2 &#91;2&#8211;3&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#44; respectively&#41;&#44; movement of the extremities &#40;1 &#91;1&#8211;2&#93; vs&#46; 2 &#91;2&#8211;2&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#44; respectively&#41; and adaptation to mechanical ventilation &#40;1 &#91;1&#8211;2&#93; vs&#46; 2 &#91;2&#8211;3&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#44; respectively&#41; were statistically significant&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">The patients with pain &#40;BPS<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>3&#41; under resting conditions &#40;T0&#41; experienced more pain during the procedures &#40;T2&#41; than those without resting pain &#40;BPS<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#41; &#40;7 &#91;6&#8211;8&#93; vs&#46; 6 &#91;5&#8211;8&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;012&#44; respectively&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Vital signs and bispectral index during the procedures</span><p id="par0170" class="elsevierStylePara elsevierViewall">The vital signs &#40;systolic blood pressure&#44; mean blood pressure&#44; HR and RF&#41; and the BIS increased significantly from T1 to T2 &#40;108 &#91;94&#8211;121&#93; vs&#46; 118 &#91;102&#8211;132&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#44; 73 &#91;62&#8211;80&#93; vs&#46; 76 &#91;67&#8211;85&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#44; 88 &#91;76&#8211;108&#93; vs&#46; 90 &#91;80&#8211;108&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#44; 16 &#91;12&#8211;20&#93; vs&#46; 17 &#91;13&#8211;22&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#44; 58&#46;5 &#91;47&#8211;72&#93; vs&#46; 71 &#91;59&#8211;80&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#44; respectively&#41;&#46; However&#44; the percentage change was only clinically relevant &#40;&#8805;10&#37;&#41; for the BIS values &#40;13&#37; &#91;IQR&#58; 2&#8211;26&#37;&#93;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The variation in BIS was &#8805;10&#37; in 72&#37; of the pain behavior observations&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Effect of preventive analgesia and sedation upon pain and the bispectral index values during the procedures&#46; Subgroups analysis</span><p id="par0175" class="elsevierStylePara elsevierViewall">Before the procedures&#44; and based on the criterion of the nurse and&#47;or physician in charge&#44; preventive analgesia was administered in 7&#37; of the procedures and preventive sedation in 21&#37; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">With regard to analgesia&#44; the patients who received a preventive analgesic bolus dose before the procedures showed a significant decrease in pain between T1 and T2 versus those who did not receive preventive analgesia &#40;&#8722;2 &#91;IQR&#58; &#123;&#8722;5&#125;&#8211;0&#93; vs&#46; 3 &#91;IQR&#58; 1&#8211;4&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#44; respectively&#41;&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Likewise&#44; the patients who received a preventive analgesic bolus dose before the procedures showed a statistically smaller and clinically non-relevant change in BIS versus those who did not receive preventive analgesia &#40;5&#37; &#91;IQR&#58; &#123;&#8722;40&#125;&#8211;18&#37;&#93; vs&#46; 16&#37; &#91;IQR&#58; 3&#8211;37&#37;&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;021&#44; respectively&#41;&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">With regard to sedation&#44; the patients who received an additional sedation dose before the procedures experienced an increase in pain between T1 and T2&#44; though the increase was smaller than in those who did not receive preventive sedation &#40;1 &#91;IQR&#58; &#123;&#8722;3&#125;&#8211;3&#93; vs&#46; 3 &#91;IQR&#58; 1&#8211;4&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#44; respectively&#41;&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Likewise&#44; the patients who received an additional sedation bolus dose before the procedures also presented a statistically smaller and clinically non-relevant change in BIS versus those who did not receive sedation &#40;&#8722;5&#37; &#91;IQR&#58; &#123;&#8722;40&#125;&#8211;7&#37;&#93;&#41; vs&#46; 20&#37; &#91;IQR&#58; 9&#8211;37&#37;&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#44; respectively&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><p id="par0200" class="elsevierStylePara elsevierViewall">The main result of our study can be summarized as follows&#58; &#40;1&#41; the patients in our DICM suffer resting pain&#59; &#40;2&#41; mobilization with turning and endotracheal aspiration are painful procedures&#59; &#40;3&#41; the physiological signs are not useful for evaluating pain&#59; &#40;4&#41; the variation in BIS could be useful for evaluating pain&#59; and &#40;5&#41; preventive analgesia may decrease pain during the procedures&#46;</p><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Resting pain</span><p id="par0205" class="elsevierStylePara elsevierViewall">In our series&#44; 61&#37; of the patients experienced pain &#40;BPS<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>3&#41; under resting conditions&#44; and 33&#37; suffered significant pain &#40;BPS<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>5&#41;&#46; This high percentage is not surprising and is consistent with the data found in the literature on the prevalence of resting pain in critical patients who are unable to communicate&#46; Chanques et al&#46;&#44; in a series of surgical cases&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">15</span></a> found 63&#37; of their patients to have significant pain under resting conditions&#46; This figure dropped to 42&#37; following a training initiative targeted to nurses and physicians&#44; in which improvements were made in the detection of pain and the administration of analgesic treatment&#46; Other studies have shown the objective control of analgesia&#44; sedation and delirium to improve detection and treatment of the problem&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">25</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Although these scales are simple to apply&#44; they are little used in routine clinical practice&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">23</span></a> and the incidence of resting pain remains high&#46; The studies published to date show important discrepancies between actual clinical practice and the current recommendations&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">1&#44;2</span></a> On the other hand&#44; we should ask ourselves whether health professionals are well instructed on how to assess pain behavior&#46; In a recent study&#44;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">26</span></a> the authors evaluated interobserver reliability of the BPS scale under resting conditions and during a painful procedure&#46; The facial expression subscale was seen to show poor concordance and low correlation&#46; These results reflect a need for sufficient prior training and a minimum level of experience in order to guarantee adequate pain evaluation through behavioral indicators&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">This approach therefore could be useful in developing appropriate educational programs and future guidelines for the management of sedation and analgesia in the DICM&#46; Emphasis should be placed on the need to evaluate pain using the validated scales at our disposal&#44; in order to identify and treat the problem correctly&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">9&#8211;14</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Pain during the nursing procedures</span><p id="par0220" class="elsevierStylePara elsevierViewall">Critical patients undergo multiple diagnostic and therapeutic procedures carried out by nurses&#44; and most of them describe having experienced pain during the procedures even several years later&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">27</span></a> Our results indicate that the procedures we have studied are painful for most patients&#46; The percentages obtained are consistent with the results recently published by the Europain<span class="elsevierStyleSup">&#174;</span> study&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">28</span></a> The authors evaluated pain in 3850 conscious patients in 192 Intensive Care Units from 28 countries&#46; The results showed a significant increase in pain from the start to the time of performing the 12 procedures evaluated&#8211;including mobilization and endotracheal aspiration&#46; Furthermore&#44; the study found pre-procedure pain to be a risk factor for greater pain intensity during the procedures&#46; The authors concluded that good control of resting pain can lessen pain during the procedures&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Usefulness of vital signs and the bispectral index in the evaluation of pain</span><p id="par0225" class="elsevierStylePara elsevierViewall">In patients unable to communicate with the health professionals&#44; several vital signs have been postulated for evaluating pain&#46; However&#44; vital signs are not specific of pain and can be influenced by the administration of drugs &#40;e&#46;g&#46;&#44; vasopressors&#44; betablockers&#44; antiarrhythmic agents&#41; or the underlying disease condition itself &#40;sepsis&#41;&#46; In fact&#44; several studies have shown that these parameters increase during both painful and non-painful procedures&#44;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">29</span></a> and&#47;or remain without change during procedures shown to be painful by validated scales&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">30</span></a> Our results reveal significant changes in all the vital signs and in the BIS values&#44; though only the latter were clinically relevant&#46; Our findings therefore reinforce the evidence suggesting that vital signs should not be used isolatedly for assessing pain behavior in patients who are unable to communicate verbally&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">The BIS has been used to monitor levels of consciousness in patients under sedation and anesthesia&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">19</span></a> Earlier studies in critical patients have shown that transient increments of between 5 and 20&#37; in the BIS values can be associated to pain&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">17&#44;18</span></a> However&#44; multiple factors &#40;e&#46;g&#46;&#44; tactile or hearing stimuli&#41; can interfere with these variations&#46; Some authors support the idea the BIS could be useful provided these factors are adequately controlled&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">18</span></a> In any case&#44; our results coincide with those already found in the literature&#44; and support the idea that variations in BIS can be useful for the evaluation of pain&#8211;though further studies are needed to confirm this possibility&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Additional analgesics and sedatives before the procedures</span><p id="par0235" class="elsevierStylePara elsevierViewall">Most patients admitted to the DICM receive some kind of analgesic treatment&#46; According to a French study&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">23</span></a> on the second day of admission 72&#37; of the patients were receiving some analgesic medication&#46; On day four this percentage was found to be 55&#37;&#44; versus 50&#37; on day 6 of admission&#46; In our series&#44; practically all patients received some type of analgesia&#46; However&#44; the administered medication doses do not seem to suffice to alleviate resting pain&#44; and are clearly insufficient in avoiding pain during the nursing procedures&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">For this reason&#44; preventive analgesia before performing a procedure could be a good strategy&#46; In our series&#44; the nurse or physician decided to provide preventive analgesia in only 7&#37; of the procedures&#46; Such limited use of preventive analgesia in our setting is consistent with the different multicenter and multinational observational studies found in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">7&#44;28</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">To our knowledge&#44; the efficacy of preventive analgesia has only been evaluated in three procedures&#58; femoral catheter removal&#44;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">31</span></a> the aspiration of secretions&#44;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">32</span></a> and chest drain removal&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">33&#8211;36</span></a> The results of these studies are moreover inconclusive&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Fulton et al&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">31</span></a> evaluated the efficacy of morphine&#44; fentanyl&#44; subcutaneous lidocaine or placebo administered before femoral artery catheter removal in 130 patients subjected to cardiac catheterization&#46; They recorded no differences in relation to pain perception&#46; The authors concluded that the procedure was not sufficiently painful for preventive analgesia to be able to demonstrate its benefits&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Brocas et al&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">32</span></a> evaluated the effect of the preventive administration of alfentanyl before endotracheal tube aspiration upon the BIS value in 10 critical patients subjected to mechanical ventilation&#46; The BIS increased significantly in aspiration performed without preventive analgesia versus aspiration performed after preventive alfentanyl administration&#46; The authors concluded that preventive analgesia was effective in reducing pain evaluated by the BIS&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Puntillo and Ley<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">33</span></a> evaluated the efficacy of morphine&#44; ketorolac or patient information on the procedure before chest drain removal in 75 heart surgery patients&#46; These authors likewise found no differences between the groups in relation to the perception of pain&#44; and also concluded that the process was probably not painful enough for preventive analgesia to be able to demonstrate its benefits&#46; However&#44; in other studies&#44; significantly lower pain scores were recorded in patients who before chest drain removal had received intravenous morphine plus relaxation exercises<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">34</span></a>&#44; sufentanil or fentanyl35 or topical valdecoxib&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">36</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">It is easy to imagine that patients admitted to the DICM would wish to have pain treated on a preventive basis with drugs or other means before undergoing painful procedures&#46; Consequently&#44; preventive analgesia and&#47;or non-pharmacological interventions are currently recommended for alleviating pain in adult patients before chest drain removal is carried out&#44; and similar measures are also advised in other potentially painful procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">1</span></a> On the other hand&#44; it must be taken into account that the administration of analgesic medication&#8211;mainly opioids and nonsteroidal antiinflammatory drugs&#8211;can produce side effects&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">On the basis of the above&#44; different authors have proposed the concept of dynamic analgesia&#44; which could allow a lowering of the analgesia dose under resting conditions and an increase before potentially painful procedures are performed&#46; The idea would be similar to that used for avoiding the accumulation of sedative agents&#46; Strategies such as &#8220;sequential sedation&#8221;&#44; &#8220;dynamic sedation&#8221; or &#8220;daily sedation interruption&#8221; have demonstrated their efficacy in preventing the complications associated to prolonged sedation&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">Regarding sedating drug use before the procedures&#44; our results show that it is not as effective as analgesia in avoiding pain&#46; In this regard&#44; pain can cause agitation or restlessness in the critical patient&#44; and its management should be based on analgesia rather than on sedation&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Study limitations</span><p id="par0280" class="elsevierStylePara elsevierViewall">Our study has a number of limitations&#46; Firstly&#44; it is a single-center study in sedated patients subjected to mechanical ventilation and mostly subjected to surgery&#46; As a result&#44; the findings cannot be extrapolated to other types of patients&#46; Secondly&#44; no non-painful procedure was used as control&#46; In this regard&#44; a control group would have helped to discriminate between the effects inherent to the procedure and the simple effect of interacting with the patient&#46; On the other hand&#44; evaluation after completing the procedures was not made&#44; but would have helped clarify the evolution of pain associated to the procedures&#46; Finally&#44; the number of patients who received preventive analgesia was small&#59; as a result&#44; we are unable to draw firm conclusions on these partial results&#46;</p></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conclusions</span><p id="par0285" class="elsevierStylePara elsevierViewall">Critical patients who are unable to communicate continue to experience resting pain&#46; Furthermore&#44; mobilization with turning and endotracheal aspiration are both painful procedures&#46; The detection and treatment of baseline pain&#44; enhanced by routine maneuvers&#44; confirms the usefulness of the clinical scales and advises the administration of preventive analgesia and the expanded use of the BIS&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Financial support</span><p id="par0290" class="elsevierStylePara elsevierViewall">This study has received no financial support&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Conflicts of interest</span><p id="par0295" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Abstract"
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          "titulo" => "Introduction"
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          "titulo" => "Patients and methods"
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              "titulo" => "Baseline characteristics of the patients"
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              "titulo" => "Pain during the procedures"
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              "identificador" => "sec0055"
              "titulo" => "Vital signs and bispectral index during the procedures"
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              "titulo" => "Effect of preventive analgesia and sedation upon pain and the bispectral index values during the procedures&#46; Subgroups analysis"
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          "titulo" => "Discussion"
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            0 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "Resting pain"
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            1 => array:2 [
              "identificador" => "sec0075"
              "titulo" => "Pain during the nursing procedures"
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            2 => array:2 [
              "identificador" => "sec0080"
              "titulo" => "Usefulness of vital signs and the bispectral index in the evaluation of pain"
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              "titulo" => "Additional analgesics and sedatives before the procedures"
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              "titulo" => "Study limitations"
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          "titulo" => "Conflicts of interest"
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          "titulo" => "Acknowledgements"
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          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2014-12-27"
    "fechaAceptado" => "2015-03-14"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec626847"
          "palabras" => array:6 [
            0 => "Critically-ill patients"
            1 => "Pain assessment"
            2 => "Procedural pain"
            3 => "Tracheal aspiration"
            4 => "Mobilization with turning"
            5 => "Bispectral index"
          ]
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:6 [
            0 => "Pacientes cr&#237;ticos"
            1 => "Dolor"
            2 => "Dolor procedimientos"
            3 => "Aspiraci&#243;n endotraqueal"
            4 => "Movilizaci&#243;n con giro"
            5 => "&#205;ndice biespectral"
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#40;1&#41; To assess the prevalence of pain during nursing care procedures&#44; and &#40;2&#41; to evaluate the usefulness of certain vital signs and the bispectral index &#40;BIS&#41; in detecting pain&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A prospective&#44; observational analytical study was made of procedures &#40;endotracheal aspiration and mobilization with turning&#41; in critically ill sedated patients on mechanical ventilation&#46; The Behavioral Pain Scale was used to assess pain&#44; with scores of &#8805;3 indicating pain&#46; Various physiological signs and BIS values were recorded&#44; with changes of &#62;10&#37; being considered clinically relevant&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 146 procedures in 70 patients were analyzed&#46; Pain prevalence during the procedures was 94&#37;&#46; Vital signs and BIS values increased significantly during the procedures compared to resting conditions&#44; but only the changes in BIS were considered clinically relevant&#46; In the subgroup of patients receiving preemptive analgesia prior to the procedure&#44; pain decreased significantly compared to the group of patients who received no such analgesia &#40;&#8722;2 &#91;IQR&#58; &#123;&#8722;5&#125;&#8211;0&#93; vs&#46; 3 &#91;IQR&#58; 1&#8211;4&#93;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#44; respectively&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The procedures evaluated in this study are painful&#46; Changes in vital signs are not good indicators of pain&#46; Changes in BIS may provide useful information about pain&#44; but more research is needed&#46; The administration of preemptive analgesia decreases pain during the procedures&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objectives"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">1&#41; Evaluar la prevalencia de dolor durante 2 procedimientos de enfermer&#237;a&#44; y 2&#41; analizar la utilidad de ciertos signos vitales y del &#237;ndice biespectral &#40;BIS&#41; para detectar dolor&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo&#44; observacional y anal&#237;tico de medidas repetidas en pacientes con ventilaci&#243;n mec&#225;nica y sedaci&#243;n&#46; Los procedimientos evaluados fueron la aspiraci&#243;n endotraqueal y la movilizaci&#243;n con giro&#46; El dolor se evalu&#243; mediante la Behavioral Pain Scale&#46; Valores<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>3 se consideraron dolorosos&#46; Se registraron distintos signos fisiol&#243;gicos y los valores del BIS&#46; Una variaci&#243;n porcentual<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>10&#37; se consider&#243; cl&#237;nicamente relevante&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se analizaron 146 procedimientos en 70 pacientes&#46; La prevalencia de dolor durante los procedimientos fue del 94&#37;&#46; Los signos vitales y los valores del BIS aumentaron significativamente durante los procedimientos respecto el reposo&#44; pero solo la variaci&#243;n del BIS alcanz&#243; relevancia cl&#237;nica&#46; En un subgrupo de pacientes que recibieron analgesia preventiva antes de los procedimientos&#44; el dolor disminuy&#243; significativamente respecto a los pacientes que no recibieron analgesia preventiva &#40;&#8722;2 &#91;RIQ&#58; &#123;&#8722;5&#125;-0&#93; vs&#46; 3 &#91;RIQ&#58; 1&#8211;4&#93;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#44; respectivamente&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Los procedimientos evaluados son dolorosos&#46; La variaci&#243;n de los signos vitales no es un buen indicador de dolor&#46; La variaci&#243;n del BIS podr&#237;a ser &#250;til&#44; pero precisa nuevas investigaciones&#46; La administraci&#243;n de analgesia preventiva disminuye la prevalencia de dolor durante los procedimientos&#46;</p></span>"
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          2 => array:2 [
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Robleda G&#44; Roche-Campo F&#44; Membrilla-Mart&#237;nez L&#44; Fern&#225;ndez-Lucio A&#44; Villamor-V&#225;zquez M&#44; Merten A&#44; et al&#46; Evaluaci&#243;n del dolor durante la movilizaci&#243;n y la aspiraci&#243;n endotraqueal en pacientes cr&#237;ticos&#46; Med Intensiva&#46; 2016&#59;40&#58;96&#8211;104&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Pain behavior during the nursing procedures&#46; All comparisons between the pre-procedure timepoint &#40;T1&#41; and the procedure &#40;T2&#41; were statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46; Values expressed as the median and interquartile range&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Percentage variation of the different vital signs and BIS between the pre-procedure timepoint &#40;T1&#41; and the procedure &#40;T2&#41;&#46; The broken line marks 10&#37;&#44; which is the value a priori considered to be clinically relevant&#46; Only the BIS values were clinically relevant&#46; Values expressed as the median and interquartile range&#46; BIS&#58; bispectral index&#59; HR&#58; heart rate&#59; RF&#58; respiratory frequency&#59; MBP&#58; mean blood pressure&#59; SBP&#58; systolic blood pressure&#46;</p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Presence of pain with BPS &#62;3&#46; Presence of significant pain with BPS &#8805;5&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Fully tightened&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Partially bent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Fully bent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Permanently retracted&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Adaptation to mechanical ventilation</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Adapted movements&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Good adaptation most of the time&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Struggling with respirator&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Impossible to ventilate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1004294.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Behavioral Pain Scale&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">NSAIDs&#58; nonsteroidal antiinflammatory drugs&#59; BIS&#58; bispectral index&#59; BPS&#58; Behavioral Pain Scale&#59; cp&#58; continuous perfusion&#59; RASS&#58; Richmond Agitation Sedation Scale&#59; IQR&#58; interquartile range&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Age in years&#44; median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71 &#40;62&#8211;79&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Gender&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Females&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25 &#40;36&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Males&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45 &#40;64&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Reason for admission&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Medical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Surgical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63 &#40;90&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">BPS score&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#61;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27 &#40;39&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#62;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43 &#40;61&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8805;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23 &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">RASS score&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8805;&#43;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>0 to &#8722;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22 &#40;32&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8722;3 to &#8722;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37 &#40;53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">BIS&#44; median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">62 &#40;50&#8211;72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Analgesia&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Without analgesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Morphine cp&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42 &#40;60&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Remifentanil cp&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bolus dose analgesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Paracetamol or NSAIDs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Others&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Sedation&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Propofol cp&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37 &#40;53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Midazolam cp&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31 &#40;44&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bolus dose sedation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28 &#40;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Combination of several drugs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1004293.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Baseline characteristics of the study population &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>70&#41;&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">BPS&#58; Behavioral Pain Scale&#46;</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Values expressed as the median &#40;interquartile range&#41;&#46;</p>"
          "tablatextoimagen" => array:2 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Analgesia<br>n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10 &#40;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Without analgesia<br>n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>136 &#40;93&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Baseline BPS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;3&#8211;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;3&#8211;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;179&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pre-procedure BPS &#40;T1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;5&#8211;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;3&#8211;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Procedure BPS &#40;T2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;4&#8211;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;6&#8211;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">T1&#8211;T2 difference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;2 &#40;&#91;&#8722;5&#93;&#8211;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;1&#8211;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#37; variation BIS T1&#8211;T2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;&#91;&#8722;40&#93;&#8211;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16 &#40;3&#8211;37&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;021&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sedation<br>n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>31 &#40;21&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Without sedation<br>n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>115 &#40;79&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Baseline BPS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;3&#8211;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;3&#8211;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;086&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pre-procedure BPS &#40;T1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;4&#8211;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;3&#8211;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Procedure BPS &#40;T2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;4&#8211;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;6&#8211;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">T1&#8211;T2 difference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;&#91;&#8722;3&#93;&#8211;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;5 &#40;&#91;&#8722;40&#93;&#8211;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 21735727
Original language: English

DOI:10.1016/j.medine.2015.03.008

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Year/Month	Html	Pdf	Total

2024 November	9	14	23
2024 October	57	70	127
2024 September	53	33	86
2024 August	55	54	109
2024 July	55	37	92
2024 June	67	52	119
2024 May	49	58	107
2024 April	41	39	80
2024 March	46	28	74
2024 February	34	38	72
2024 January	46	42	88
2023 December	29	44	73
2023 November	48	38	86
2023 October	47	35	82
2023 September	38	37	75
2023 August	34	16	50
2023 July	38	29	67
2023 June	38	26	64
2023 May	39	35	74
2023 April	29	24	53
2023 March	43	35	78
2023 February	69	40	109
2023 January	66	30	96
2022 December	63	43	106
2022 November	78	33	111
2022 October	48	44	92
2022 September	44	36	80
2022 August	37	36	73
2022 July	32	33	65
2022 June	38	29	67
2022 May	37	42	79
2022 April	31	33	64
2022 March	44	48	92
2022 February	40	31	71
2022 January	60	42	102
2021 December	44	40	84
2021 November	39	51	90
2021 October	53	82	135
2021 September	65	35	100
2021 August	48	60	108
2021 July	32	56	88
2021 June	40	40	80
2021 May	48	49	97
2021 April	128	109	237
2021 March	51	31	82
2021 February	52	31	83
2021 January	50	37	87
2020 December	54	38	92
2020 November	44	31	75
2020 October	47	34	81
2020 September	45	16	61
2020 August	30	17	47
2020 July	38	20	58
2020 June	61	22	83
2020 May	62	26	88
2020 April	91	15	106
2020 March	58	16	74
2020 February	127	24	151
2020 January	116	33	149
2019 December	74	29	103
2019 November	76	27	103
2019 October	81	27	108
2019 September	92	25	117
2019 August	80	24	104
2019 July	80	29	109
2019 June	29	18	47
2019 May	108	36	144
2019 April	28	27	55
2019 March	39	25	64
2019 February	37	37	74
2019 January	38	34	72
2018 December	64	54	118
2018 November	80	86	166
2018 October	52	26	78
2018 September	27	6	33
2018 August	28	5	33
2018 July	32	7	39
2018 June	36	9	45
2018 May	20	3	23
2018 April	26	9	35
2018 March	23	4	27
2018 February	21	6	27
2018 January	26	7	33
2017 December	33	7	40
2017 November	32	12	44
2017 October	26	6	32
2017 September	16	8	24
2017 August	24	7	31
2017 July	21	5	26
2017 June	35	6	41
2017 May	33	7	40
2017 April	31	9	40
2017 March	8	10	18
2017 February	9	7	16
2017 January	14	4	18
2016 December	29	24	53
2016 November	48	26	74
2016 October	46	28	74
2016 September	35	11	46
2016 August	55	3	58
2016 July	34	15	49

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