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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The incidence of pain in adult critical care patients is higher than 50&#37; and it can be experienced at rest or during routine clinical care procedures<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">1&#8211;5</span></a>&#46; Inadequate management of pain is associated with a stress response that includes changes in physiological parameters&#44; neuro-endocrine secretion and immunomodulation<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">6&#44;7</span></a>&#46; It is also associated with agitation<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">8</span></a> and sleep pattern alterations<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">9</span></a>&#44; and it can be a contributing risk factor for delirium<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">10</span></a> and post-traumatic stress disorder in critical care patients<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">11</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The systematic evaluation of pain integrated in the pain-agitation-delirium &#40;PAD&#41; management protocols has been associated with reductions in the incidence of pain&#44; use of analgesics&#44; duration of mechanical ventilation &#40;MV&#41; and length of stay &#40;LOS&#41; in the Intensive Care Unit &#40;ICU&#41; <a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">1&#44;12&#8211;15</span></a>&#46; Adequate pain treatment necessarily requires the use of reliable tools that aid in its detection and measurement<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">16&#44;17</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Recent international guidelines recommend the use of scales based on behavioral indicators of pain for patients who are unable to self-report&#44; provided that their motor function is preserved and behaviors are observable<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">18&#44;19</span></a>&#46; For these patients&#44; the behavioral pain scale &#40;BPS&#41;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">20</span></a> and the critical care pain observation tool &#40;CPOT&#41;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">21&#44;22</span></a> are recommended due to their psychometric properties<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">17&#44;23</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In 2011&#44; Latorre et al&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">24</span></a> validated a new tool&#44; the behavioral indicators of pain scale or ESCID from its acronym in Spanish&#44; as a useful tool for assessing pain in mechanically ventilated and unable to self-report critically ill adult patients&#46; The ESCID scale was developed after the original Campbell scale&#44; proposed by The Analgesia and Sedation Working Group of the Spanish Society of Intensive Care Medicine and Coronary Units&#44; taking in to account that the Campbell scale could be an appropriate instrument to assess pain and quantify its intensity in non-communicative&#44; critically ill patients<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">25</span></a>&#46; However&#44; the Campbell scale has two limitations&#58; it is not been subjected to validation studies in critically ill patients and it is not applicable to patients with mechanical ventilation because it does not include it as an indicator&#46; In the validated version of the ESCID scale&#44; the indicator &#8216;vocalization&#8217; from the original Campbell scale was replaced by &#8216;compliance with mechanical ventilation&#8217;&#46; Additionally&#44; each indicator of the scale was more precisely defined and quantified to minimize subjectivity of the observer&#46; The ESCID scale provides a greater number of behavioral indicators&#44; which can help decrease the artifacts produced by causes unrelated to pain&#44; considering the positive correlation between the number of behavioral indicators exhibited by the patient and pain shown<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">26</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The ESCID scale has shown good psychometric properties&#58; the internal consistency measured with the Cronbach&#39;s Alpha Coefficient was 0&#46;70&#8211;0&#46;80&#59; a high correlation between ESCID and BPS scales&#59; and good interrater and intrarater reliability&#46; However&#44; the ESCID scale validation study has some limitations that affect its external validity&#44; as is the fact that it was conducted in a single ICU with a sample of 42 critical care patients with exclusively medical pathologies<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">24</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The interest of the current study is to determine the psychometric properties of the ESCID scale when applied to a wide range of medical and surgical critical care patients in various ICUs of different hospitals<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">27</span></a>&#46; Our primary hypothesis is that the ESCID scale is a valid and reliable tool for measuring pain in mechanically ventilated and unable to self-report critical care patients&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">This study pretends to validate the ESCID scale by addressing the following research objectives&#58; &#40;a&#41; to assess interrater agreement when using pain scales&#59; &#40;b&#41; to assess intrarater agreement when using pain scales in repeated measures for the same patient&#59; &#40;c&#41; to examine the correlation between the ESCID scale and the BPS while using them simultaneously in the same patient and at the same time&#44; when patients are exposed to a non-nociceptive procedure and two nociceptive procedures&#59; &#40;d&#41; to examine the relationship between applying a painful routine care procedure and the changes in physiological indicators of pain&#59; &#40;e&#41; to evaluate the possible differences in the application of the scales for measuring pain in patients with medical and surgical pathologies&#59; and &#40;f&#41; to evaluate the possible differences in the application of scales to measure pain in patients with different levels of sedation&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Patients and methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">Multicenter&#44; prospective and observational study to validate a scale-measuring instrument was conducted in 20 Intensive Care Units of 14 Spanish National Health System hospitals with different types of patients admitted for medical and surgical pathologies&#46; The study was initiated in January 2012 and finalized in January 2014<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">27</span></a>&#46; The protocol was approved by the Clinical Investigation Ethics Committee of <span class="elsevierStyleItalic">Puerta de Hierro Majadahonda University Hospital</span> &#40;Spain&#41;&#44; the coordinating center &#40;University Hospital Ethics Committee&#44; record n&#176; 273&#44; January 23&#44; 2012&#41;&#44; and all corresponding Ethics Committees in each hospital participating in the study&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Written informed consent was obtained from the next of kin or the patient&#39;s legal guardian&#44; and was ratified afterwards by the patient itself&#46; To maintain anonymity and guarantee confidentiality&#44; all participants were identified by a code number that was maintained throughout the study&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Study population</span><p id="par0050" class="elsevierStylePara elsevierViewall">Inclusion criteria were&#58; age &#8805;18 years&#59; receiving MV&#59; showing no motor or verbal communication&#59; ability to understand the Spanish language&#59; and the presence of a legal guardian with the authority to give consent to the patient&#39;s participation in the study if the patient was unable to do so&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Exclusion criteria were&#58; quadriplegia&#59; severe polyneuropathy&#59; treatment with neuromuscular blocking agents&#59; neurological disease that resulted in a score &#60;4 in the motor section of the Glasgow Coma Scale &#40;GCS&#41;&#59; and the suspicion or presence of delirium assessed using the Confusion Assessment Method for the ICU&#46; All these conditions resulted in study exclusion as they had the potential to alter a patient&#39;s behavioral responses to pain&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Protocol</span><p id="par0060" class="elsevierStylePara elsevierViewall">A group of nurses from each of the ICU were responsible for collecting data&#46; All the ICU nurses implicated in the study received a 90<span class="elsevierStyleHsp" style=""></span>min debrief where the principal investigator discussed the recruitment of patients&#44; the Informed Consent form&#44; the study procedures&#44; correct use of the ESCID and BPS scales<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">27</span></a>&#44; and the data collection&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Prior to commencing the study&#44; a pilot trial was carried out in each ICU &#40;5 patients per unit&#41; to detect any possible difficulties that might arise so that they could be remedied beforehand&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Pain was assessed using two scales&#44; BPS<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">20</span></a> and ESCID &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; simultaneously applied by two independent observers who were blinded to each other&#39;s assessments&#46; Observations coincided with the application of two routine care procedures previously documented as painful<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">26</span></a>&#58; turning&#47;repositioning and endotracheal suctioning&#46; Furthermore&#44; to achieve greater consistency and establish a comparative element&#44; as proposed in other studies<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">20&#44;28&#44;29</span></a>&#44; the same pain assessment was carried out by applying a non-painful procedure that consisted on gently rubbing a gauze cloth over a portion of the patient&#39;s healthy skin tissue&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">To avoid any possible bias&#44; pain measurement was performed once for each patient and procedure&#46; All the patients were free of physical restraints during the pain assessments&#44; in order to avoid bias in the evaluation of the body movements as behaviors of pain&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Pain assessment was carried out at 3 time points as follows&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall">First measurement &#40;at rest&#41;&#58; 5<span class="elsevierStyleHsp" style=""></span>min before starting the procedure&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Second measurement&#58; during the procedure &#40;turning&#47;repositioning and non-painful procedure&#41; or 10&#8211;30<span class="elsevierStyleHsp" style=""></span>s after completing the procedure &#40;endotracheal suctioning&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Third measurement&#58; 15<span class="elsevierStyleHsp" style=""></span>min after the procedure was completed&#46;</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Measures and data collection</span><p id="par0100" class="elsevierStylePara elsevierViewall">The following independent variables were obtained from each participant through continuous hemodynamic monitoring&#44; the patient&#39;s clinical history and direct observation&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Demographic data&#58; age&#44; gender&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Clinical data&#58; heart rate&#44; invasive blood pressure&#44; and respiratory rate&#46; Sedation and analgesic medication administered during the previous 24<span class="elsevierStyleHsp" style=""></span>h by both continuous infusion and bolus were recorded as well as the scores from the Richmond sedation agitation scale &#40;RASS&#41;&#46; For patients with neurological disorders&#44; the GCS was applied before the procedure&#46; In addition&#44; the following clinical data were collected&#58; current pathology&#44; reason for ICU admission&#44; medical history &#40;comorbidities&#44; history of chronic pain&#44; chronic use of analgesics&#41; and severity index determined by simplified acute physiology score &#40;SAPS II&#41;&#46;</p></li></ul></p><p id="par0115" class="elsevierStylePara elsevierViewall">The ESCID and BPS scales were used to measure the pain level as dependent variables&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Statistical analysis</span><p id="par0120" class="elsevierStylePara elsevierViewall">The sample size was calculated by assuming several criteria&#58; &#40;1&#41; taking into account that multivariable techniques&#44; such as factor analysis&#44; usually require at least 10 participants per variable to achieve replicable findings<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">30</span></a>&#59; &#40;2&#41; given the heterogeneity of critical care medical and surgical patients&#44; the aim was to ensure sufficient participation to obtain a representative sample&#59; &#40;3&#41; to guarantee the accuracy of the measurements by reducing any possible bias&#59; and &#40;4&#41; more than 50 participants as a quality criterion for testing scale&#58; construct validity<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">17</span></a>&#46;</p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Measurement of psychometric properties</span><p id="par0125" class="elsevierStylePara elsevierViewall">Psychometric properties related to the use of the pain assessment tools were determined using the recommendations made by G&#233;linas et al&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">17</span></a>&#44; which proposed the use of established scales as published in recent guidelines<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">18&#44;19</span></a>&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Internal consistency</span><p id="par0130" class="elsevierStylePara elsevierViewall">ESCID reliability was measured by the internal consistency of each item using Cronbach&#39;s Alpha Coefficient&#46; A Cronbach-&#945; value higher than 0&#46;7 reflects a satisfactory internal consistency&#44; which is a high inter-relation between each domain of the tool&#46; For greater consistency&#44; the calculation considered the mean of the assessments of each item at the three time points in which the scale was used &#40;before&#44; during and after the procedure&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Interrater and intrarater reliability</span><p id="par0135" class="elsevierStylePara elsevierViewall">Repeated measures analysis of variance &#40;ANOVA&#41; was used to analyze interrater and intrarater agreement through comparing the components of the ESCID and BPS scales&#44; to measure the changes between the results obtained according to the time&#44; observer and procedure&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Discriminant validation</span><p id="par0140" class="elsevierStylePara elsevierViewall">Discriminant validation was determined by comparing total scores obtained during different situations and stimuli&#44; i&#46;e&#46;&#44; at rest and during a procedure &#40;turning&#47;repositioning&#44; endotracheal suctioning or non-painful procedure&#41;&#46; The main effects of the three original variables &#40;procedure&#44; time and observer&#41; were compared as were the three first-order interactions &#40;time<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>procedure&#44; time<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>observer and procedure<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>observer&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Convergent validation</span><p id="par0145" class="elsevierStylePara elsevierViewall">Convergent validation is another strategy for verifying reliability and validity of the use of pain assessment tools&#46; Refers to the ability of the assessment tool to correlate with another tool&#44; ideally using a different method&#44; measuring the same construct &#40;i&#46;e&#46;&#44; pain&#41;&#46; The BPS is considered one of the most valid and reliable scales available to evaluate pain in non-communicative ICU patients &#40;Cronbach-&#945; 0&#46;63&#8211;0&#46;72&#44; Kappa coefficients 0&#46;67&#8211;0&#46;83&#41;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">17&#44;18</span></a>&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Spearman&#39;s correlation coefficient was used to evaluate the correlation between the ESCID and BPS scales in terms of the measurements taken before&#44; during and after each procedure&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Presentation of data</span><p id="par0155" class="elsevierStylePara elsevierViewall">Quantitative data are shown as frequencies&#44; percentages&#44; means&#44; medians&#44; standard deviations and 25th and 75th percentiles &#40;p25 and p75&#41;&#46; Inference using the <span class="elsevierStyleItalic">t</span>-test and Spearman&#39;s correlation were applied to explore the association between the level of pain and the independent variables&#46; Analysis of variance &#40;ANOVA&#41; was used to compare the means of more than two groups&#46; All the multiple comparison tests were adjusted by means of Bonferroni correction&#46; A <span class="elsevierStyleItalic">p</span> value of &#60;0&#46;05 was considered statistically significant&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Graphic representation of the pain variable according to the ESCID scale &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; is shown using a box-plot approach&#46; Each box shows p25&#44; median and p75&#46; Each whisker covers values 1&#46;5 times the interquartile range and the circles represent the extreme values &#40;outliers&#41;&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Data were analyzed using SPSS software &#40;v&#46;19&#46;0&#46; SPSS Inc&#46; Chicago&#44; IL&#44; USA&#41;&#46;</p></span></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Results</span><p id="par0170" class="elsevierStylePara elsevierViewall">Two hundred eighty-six patients from 20 ICUs were included during the recruitment period&#46; During the study period&#44; 4386 observations were recorded by 150 observers&#46; A consort flow chart of patient enrolment is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; The patients&#8217; characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">Finally&#44; 190 patients completed the pain assessments in all of three procedures proposed in the study&#44; resulting in 3420 observations being recorded and included in the analysis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; These patients had similar characteristics to those defined for the study population &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Internal consistency</span><p id="par0180" class="elsevierStylePara elsevierViewall">ESCID presented a high reliability with a Cronbach-&#945; coefficient of 0&#46;85 &#91;95&#37; confidence interval &#40;CI&#41;&#44; 0&#46;81&#8211;0&#46;88&#93;&#46; The facial expression &#91;0&#46;87 &#40;95&#37;CI 0&#46;84&#8211;0&#46;89&#41;&#93;&#44; calmness &#91;0&#46;84 &#40;95&#37;CI 0&#46;81&#8211;0&#46;87&#41;&#93;&#44; muscle tone &#91;0&#46;80 &#40;95&#37;CI 0&#46;75&#8211;0&#46;84&#41;&#93; and consolability &#91;0&#46;85 &#40;95&#37;CI 0&#46;81&#8211;0&#46;88&#41;&#93; domains presented a high internal consistency with a Cronbach-&#945; coefficients &#8805;0&#46;80&#46; The compliance with mechanical ventilation domain presented good internal consistency &#91;0&#46;70 &#40;95&#37;CI 0&#46;63&#8211;0&#46;75&#41;&#93;&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">On evaluating the reliability of the ESCID scale with respect to the type of ICU admittance&#44; it was observed that the internal consistency of the scale was greater in medical patients&#58; the Cronbach-&#945; coefficient was 0&#46;85 &#40;95&#37;CI 0&#46;81&#8211;0&#46;89&#41; for medical patients and 0&#46;80 &#40;95&#37;CI 0&#46;73&#8211;0&#46;86&#41; for surgical patients&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">When evaluating the reliability of the ESCID scale with respect to the sedation level &#40;measured by RASS&#41;&#44; it was observed that the internal consistency of the scale was reduced in patients with the highest level of sedation &#40;RASS score &#8722;5&#44; unarousable patients&#41; with a Cronbach-&#945; coefficient of 0&#46;63 &#40;95&#37;CI 0&#46;55&#8211;0&#46;71&#41;&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Interrater and intrarater reliability</span><p id="par0195" class="elsevierStylePara elsevierViewall">There was a high interrater and intrarater conformity when the ESCID scale was applied at the three moments of each procedure &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; There were no statistically significant intrarater differences &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;241&#41;&#44; however differences were observed between procedures &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; given that the values were similar for painful procedure but differed for non-painful ones&#46; The values show evaluation of increased pain during the application of painful procedures which normalized in the measurement taken 15<span class="elsevierStyleHsp" style=""></span>min after&#46; However&#44; there were no changes in the pain levels at the three moments during non-painful procedures&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0200" class="elsevierStylePara elsevierViewall">The median punctuation of the ESCID and BPS scales &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41; demonstrate a difference of 0&#46;0 or 0&#46;1 points between the two observers at the three measuring time points&#46; These results demonstrate a high intrarater and interrater conformity&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Discriminant validation</span><p id="par0205" class="elsevierStylePara elsevierViewall">The response to pain as measured by the ESCID and BPS scales differs over time &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; When performing Bonferroni&#39;s multiple comparison test&#44; it can be seen that this difference is due to increased mean pain scores during the painful procedures with respect to the measurements taken before and after&#44; with no statistically significantly differences between the latter two&#46; On the other hand&#44; there were no variations during the non-painful procedure &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#44; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; which establishes that there were differences in the procedure factor &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; but no differences in the observer factor &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;5&#41;&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Convergent validation</span><p id="par0210" class="elsevierStylePara elsevierViewall">There was a good correlation between the ESCID and BPS scales when applied at the three moments during each procedure&#46; Spearman&#39;s correlation between the ESCID and BPS scales was <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;94&#8211;0&#46;99 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Taking time changes into consideration&#44; Spearman&#39;s correlation between the two scales prior to the procedure was <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;96&#44; during <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;95&#44; and after <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;96&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Other relevant results</span><p id="par0215" class="elsevierStylePara elsevierViewall">There were no statistically significant differences between pain measured with the ESCID and BPS scales and the type of patient &#40;medical or surgical&#41; during the three procedures at the three moments&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">There were no statistically significant differences between the level of sedation &#40;RASS &#62;&#8722;4&#44; &#8722;4 and &#8722;5&#41; and patient type &#40;medical or surgical&#41;&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">With respect to physiological indicators &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#44; it was observed that the parameters remained stable with a slight variation during the application of painful procedures&#44; which normalized with respect to measurements taken at rest&#46; These changes were not observed during non-painful procedures&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0205">Discussion</span><p id="par0230" class="elsevierStylePara elsevierViewall">The main finding of this study is that the ESCID scale has good psychometric properties&#46; Considering the results obtained in relation to the internal consistency&#44; interrater and intrarater reliability as well as the discriminant validation of the ESCID scale&#44; it can be concluded that this tool is a valid and reliable tool for measuring pain in unable to self-report mechanically ventilated critically ill patients&#46; These results are consistent with those reported in the first validation of the ESCID scale performed with a small sample of patients in a single medical ICU<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">24</span></a>&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">The psychometric properties of the ESCID scale are similar to those shown by the BPS<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">20&#44;23&#44;28&#44;29</span></a> and the CPOT<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">21&#8211;23</span></a> scales&#44; which is why the use of such behavioral scales has been recommended in recent guidelines<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">18&#44;19</span></a>&#46; The internal consistency of the ESCID scale had a Cronbach-&#945; coefficient of 0&#46;85&#44; similar to other studies such as that of Chanques et al&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">23</span></a>&#44; which reported a Cronbach-&#945; coefficient of 0&#46;80 for the BPS and 0&#46;81 for the CPOT&#46; On the other hand&#44; the ESCID scale demonstrated a high internal consistency in its five domains with Cronbach-&#945; coefficients of 0&#46;70&#8211;0&#46;87&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">In both painful and painless procedures&#44; ESCID shows a high degree of correlation with the BPS&#44; the tool of reference which has been used in different studies<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">1&#44;20&#44;23&#44;28&#44;29</span></a>&#44; in addition to demonstrating a high degree of interrater and intrarater conformity in the measurements performed&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">The ESCID scale has two additional domains with respect to the BPS and is also innovative with respect to other scales&#44; such as the BPS and the CPOT<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">16&#44;17&#44;23</span></a>&#44; with the introduction of the &#8220;consolability&#8221; domain which reflects the patient&#39;s reaction to interaction with the observer through verbal and&#47;or tactile stimuli&#46; The &#8220;Consolability&#8221; domain has proven useful and reliable in other pain behavioral scales&#44; such as FLACC in pediatric patients<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">31</span></a> and PAINAD in patients with advanced dementia<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">32</span></a>&#44; but has not previously been tested in scales to measure pain in critically ill patients&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">The fact that the &#8220;consolability&#8221; domain had a high Cronbach-&#945; coefficient reinforces the internal consistency of the ESCID scale&#44; especially knowing that 150 different observers participated in the study with high interrater and intrarater concordance&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">To avoid bias&#44; as in several previous studies<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">28&#44;29</span></a>&#44; a single measurement was performed per patient and procedure&#46; In addition&#44; all observations were made by 2 observers who were blinded to each other&#39;s evaluation&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">The reliability of the ESCID scale according to the type of ICU admission was high in both cases&#44; although Cronbach-&#945; coefficient was better in patients with medical compared to surgical pathologies&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">The internal consistency of the ESCID scale displayed a significant decrease in very profoundly sedated patients &#40;RASS score -5&#41; with a Cronbach-&#945; coefficient of 0&#46;63&#44; due to bias or abolition of behavioral indicators&#44; therefore its use may be limited in these patients&#46; This finding was consistent with the literature where other studies have established the existence of some limitations in the use of the BPS and the CPOT&#44; which make them inapplicable in cases of deep sedation&#44; neuromuscular block&#44; tetraplegia or polyneuropathy&#46; This concurs with the guidelines published by Barr et al&#46; <a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">18</span></a>&#44; which established that behavioral scales should be used in patients whose motor functions are intact and in whom behavioral indicators are observable&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">The ESCID scale is the only scale which has been subjected to a psychometric validation process in the Spanish language&#46; This is relevant because it increases the possibility of integrating it into PAD management protocols when implementing these in Spanish-speaking countries&#46; The use of a tool which is validated and adapted to the language is crucial<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">18</span></a> because this can produce improvements in the outcomes of critical care patients<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">1&#44;3&#44;12&#8211;15</span></a>&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">The nurses responsible for data collection were previously trained in the use of the ESCID and BPS scales&#46; While some reliability studies have shown lower interrater conformity values in the use of the BPS&#44; in which the subjective interpretation of the included items has been established as its main limitation<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">17&#44;33</span></a>&#44; prior knowledge of behavioral scale use could promote correct application<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">23</span></a>&#44; as demonstrated in the good interrater conformity obtained using the ESCID and BPS scales in the present study&#46; The ESCID scale also features a user guide that furthers the knowledge and application of this scale aiming to minimize observer bias<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">27</span></a>&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">As in previous studies&#44; the presence of procedural pain is evident&#46; Major studies&#44; such as the Thunder Project II<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">26</span></a> and the Europain<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">5</span></a>&#44; demonstrated the presence of pain during turning&#47;repositioning and tracheal suctioning procedures&#46; In this study&#44; the patients presented increased pain scores when the procedures were carried out&#58; 1&#46;6 &#40;BPS&#41; and 2&#46;4 &#40;ESCID&#41; during turning&#47;repositioning&#44; and 2&#46;2 &#40;BPS&#41; and 3&#46;1 &#40;ESCID&#41; during tracheal suctioning&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">This result could justify the conclusion that the analgesia used prior to performing such procedures was insufficient&#46; In fact&#44; in our study&#44; only 9&#37; of patients received a bolus of analgesia prior to painful procedures&#46; It is important to establish pre-emptive analgesia<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">34&#8211;36</span></a> for improved pain control and&#44; consequently&#44; decrease adverse events related to pain and increase the adequate administration of analgesics and sedatives<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">37</span></a>&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">An effort is required to implement validated tools for the detection of pain&#44; which are currently underused<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">38&#8211;40</span></a>&#44; to avoid pain going undetected and untreated as has been demonstrated in some studies<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">3&#44;41&#44;42</span></a>&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">In our sample&#44; no significant differences were observed between the level of pain and the type of admission &#40;medical or surgical&#41;&#46; Similarly&#44; no significant differences were found between the level of sedation and the type of admission&#46; This confirms the findings of studies into procedural pain in both medical and surgical patients&#44; regardless of the reason for admittance<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">2&#44;3&#44;5&#44;26</span></a>&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">This study has several limitations&#44; such as the exclusion of patients with suspicion or diagnosis of delirium&#46; Moreover&#44; the diagnosis of delirium is not possible in deeply sedated patients &#40;RASS score &#8722;4 or &#8722;5&#41;&#44; in whom the CAM-ICU tool is not applicable&#44; so it is impossible to determine whether these patients had delirium during the measurements of pain&#46; Although the presence of delirium was considerer an exclusion criteria&#44; delirium screening was not routinely done in all of the patients so the possibility exists that delirious patients might have been included&#46; Consequently&#44; subsequent studies should be performed to determine the influence of delirium on the ESCID scale domains&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">The ESCID scale has been validated in the Spanish language in non-communicative medical and surgical patients&#46; Using the ESCID scale in other ICU patient populations and translating the same into foreign languages will require further validation testing&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0210">Conclusions</span><p id="par0310" class="elsevierStylePara elsevierViewall">The ESCID scale offers good psychometric characteristics for pain assessment in non-communicative&#44; mechanically ventilated critical care patients&#46; As shown in our study&#44; which included a large sample of patients with different types of admission&#44; the ESCID scale is a valid&#44; reliable and reproducible tool&#44; and its integration into PAD management protocols could help to prevent significant adverse events resulting from poor pain management&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">Pain monitoring should be performed routinely&#44; especially in potentially painful procedures that are performed on critical care patients in routine clinical practice&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0215">Funding disclosures</span><p id="par0320" class="elsevierStylePara elsevierViewall">This study was financed by the <span class="elsevierStyleGrantSponsor" id="gs1">Spanish Health Research Fund</span> &#40;<span class="elsevierStyleGrantNumber" refid="gs1">PI11&#47;00766</span>&#44; Health Ministry&#46; Spanish National Research&#44; Development and Innovation Plan 2008&#8211;2001&#46; Spanish title&#58; &#8220;Estudio multic&#233;ntrico de validez y fiabilidad de la Escala de Conductas Indicadoras de Dolor ESCID para medir el dolor en pacientes cr&#237;ticos&#44; no comunicativos y sometidos a ventilaci&#243;n mec&#225;nica&#8221;&#41; after a peer-reviewed funding process&#46; Also co-financed by <span class="elsevierStyleGrantSponsor" id="gs2">FEDER Fund and Economy and Competitiveness Ministry</span>&#46;</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0220">Author&#39;s contributions</span><p id="par0325" class="elsevierStylePara elsevierViewall">I&#46;L&#46;&#44; M&#46;S&#46;&#44; M&#46;A&#46;&#44; L&#46;H&#46;&#44; study concept and design&#46; I&#46;L&#46;&#44; M&#46;S&#46;&#44; data analysis and interpretation&#46; I&#46;L&#46;&#44; M&#46;S&#46;&#44; M&#46;A&#46;&#44; L&#46;H&#46;&#44; manuscript preparation and drafting&#46; I&#46;L&#46;&#44; M&#46;S&#46;&#44; statistical methods&#44; statistical data analysis&#46; C&#46;L&#46;&#44; M&#46;M&#46;S&#46;&#44; M&#46;W&#46;&#44; J&#46;d&#46;P&#46;&#44; G&#46;R&#46;&#44; R&#46;d&#46;B&#46;&#44; M&#46;J&#46;F&#46;&#44; C&#46;G&#46;&#44; J&#46;d&#46;F&#46;&#44; C&#46;C&#46;&#44; acquisition of the data and manuscript critique and review&#46; All authors approved the manuscript submitted&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0225">Conflicts of interest</span><p id="par0330" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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    "fechaRecibido" => "2016-04-16"
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            0 => "Critically ill patients"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To assess the psychometric properties of the behavioral indicators of pain scale &#40;ESCID&#41; when applied to a wide range of medical and surgical critical patients&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A multicentre&#44; prospective observational study was designed to validate a scale measuring instrument&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Setting</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Twenty Intensive Care Units of 14 hospitals belonging to the Spanish National Health System&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Participants</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A total of 286 mechanically ventilated&#44; unable to self-report critically ill medical and surgical adult patients&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Procedure</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Pain levels were measured by two independent evaluators simultaneously&#44; using two scales&#58; ESCID and the behavioral pain scale &#40;BPS&#41;&#46; Pain was observed before&#44; during&#44; and after two painful procedures &#40;turning&#44; tracheal suctioning&#41; and one non-painful procedure&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Main variables</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">ESCID reliability was measured on the basis of internal consistency using the Cronbach-&#945; coefficient&#46; Inter-rater and intra-rater agreement were measured&#46; The Spearman correlation coefficient was used to assess the correlation between ESCID and BPS&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 4386 observations were made in 286 patients &#40;62&#37; medical and 38&#37; surgical&#41;&#46; High correlation was found between ESCID and BPS &#40;r&#61;0&#46;94&#8211;0&#46;99&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; together with high intra-rater and inter-rater concordance&#46; ESCID was internally reliable&#44; with a Cronbach-&#945; value of 0&#46;85 &#40;95&#37;CI 0&#46;81&#8211;0&#46;88&#41;&#46; Cronbach-&#945; coefficients for ESCID domains were high&#58; facial expression 0&#46;87 &#40;95&#37;CI 0&#46;84&#8211;0&#46;89&#41;&#44; calmness 0&#46;84 &#40;95&#37;CI 0&#46;81&#8211;0&#46;87&#41;&#44; muscle tone 0&#46;80 &#40;95&#37;CI 0&#46;75&#8211;0&#46;84&#41;&#44; compliance with mechanical ventilation 0&#46;70 &#40;95&#37;CI 0&#46;63&#8211;0&#46;75&#41; and consolability 0&#46;85 &#40;95&#37;CI 0&#46;81&#8211;0&#46;88&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">ESCID is valid and reliable for measuring pain in mechanically ventilated unable to self-report medical and surgical critical care patients&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Clinicaltrials&#46;gov</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall"><a class="elsevierStyleInterRef" id="intr0005" href="ctgov:NCT01744717">NCT01744717</a>&#46;</p></span>"
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        "resumen" => "<span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Objetivo</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Evaluar las propiedades psicom&#233;tricas de la Escala de Conductas Indicadoras de Dolor &#40;ESCID&#41;&#44; aplicada a una muestra amplia de pacientes cr&#237;ticos de patolog&#237;a m&#233;dica y posquir&#250;rgica&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Dise&#241;o</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Estudio multic&#233;ntrico&#44; observacional&#44; prospectivo de validaci&#243;n de una escala como instrumento de medida&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">&#193;mbito</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Veinte Unidades de Cuidados Intensivos de 14 hospitales del Sistema Nacional de Salud espa&#241;ol&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Participantes</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Doscientos ochenta y seis pacientes cr&#237;ticos adultos&#44; sometidos a ventilaci&#243;n mec&#225;nica&#44; sin capacidad de comunicaci&#243;n&#44; de patolog&#237;a m&#233;dica y posquir&#250;rgica&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Intervenci&#243;n</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Se midi&#243; el nivel de dolor de los pacientes por 2 observadores de manera simult&#225;nea y utilizando dos escalas&#58; ESCID y la <span class="elsevierStyleItalic">Behavoiral Pain Scale</span>&#46; El dolor fue medido antes&#44; durante y despu&#233;s de la aplicaci&#243;n de dos procedimientos dolorosos &#40;movilizaci&#243;n y aspiraci&#243;n endotraqueal&#41; y un procedimiento no doloroso&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Variables de inter&#233;s</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">La fiabilidad de ESCID se midi&#243; mediante la consistencia interna determinada con el coeficiente alfa de Cronbach&#46; Se midi&#243; la concordancia inter- e intraobservadores&#46; Se determin&#243; la correlaci&#243;n entre las escalas ESCID y <span class="elsevierStyleItalic">Behavoiral Pain Scale</span> mediante el coeficiente de Spearman&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Resultados</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Se realizaron 4&#46;386 observaciones de dolor en 286 pacientes &#40;62&#37; patolog&#237;a m&#233;dica y 38&#37; posquir&#250;rgica&#41;&#46; Se evidencia una alta correlaci&#243;n entre ESCID y <span class="elsevierStyleItalic">Behavoiral Pain Scale</span> &#40;r&#61;0&#44;94-0&#44;99&#59; p&#60;0&#44;001&#41; as&#237; como una alta concordancia inter- e intraobservador&#46; La escala ESCID presenta buena consistencia interna&#44; con un valor de &#945;-Cronbach de 0&#44;85 &#40;IC 95&#37; 0&#44;81-0&#44;88&#41;&#46; Los 5 dominios de ESCID presentan alta consistencia interna con &#945;-Cronbach&#58; musculatura facial 0&#44;87 &#40;IC 95&#37; 0&#44;84-0&#44;89&#41;&#44; tranquilidad 0&#44;84 &#40;IC 95&#37; 0&#44;81-0&#44;87&#41;&#44; tono muscular 0&#44;80 &#40;IC 95&#37; 0&#44;75&#8211;0&#44;84&#41;&#44; adaptaci&#243;n a ventilaci&#243;n mec&#225;nica 0&#44;70 &#40;IC 95&#37; 0&#44;63&#8211;0&#44;75&#41; y confortabilidad 0&#44;85 &#40;IC 95&#37; 0&#44;81&#8211;0&#44;88&#41;&#46;</p></span> <span id="abst0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusi&#243;n</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">ESCID es v&#225;lida y fiable para medir el dolor en pacientes cr&#237;ticos m&#233;dicos y posquir&#250;rgicos&#44; no comunicativos y sometidos a ventilaci&#243;n mec&#225;nica&#46;</p></span> <span id="abst0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Clinicaltrials gov</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall"><a class="elsevierStyleInterRef" id="intr0010" href="ctgov:NCT01744717">NCT01744717</a>&#46;</p></span>"
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            "identificador" => "abst0050"
            "titulo" => "Objetivo"
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          1 => array:2 [
            "identificador" => "abst0055"
            "titulo" => "Dise&#241;o"
          ]
          2 => array:2 [
            "identificador" => "abst0060"
            "titulo" => "&#193;mbito"
          ]
          3 => array:2 [
            "identificador" => "abst0065"
            "titulo" => "Participantes"
          ]
          4 => array:2 [
            "identificador" => "abst0070"
            "titulo" => "Intervenci&#243;n"
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          5 => array:2 [
            "identificador" => "abst0075"
            "titulo" => "Variables de inter&#233;s"
          ]
          6 => array:2 [
            "identificador" => "abst0080"
            "titulo" => "Resultados"
          ]
          7 => array:2 [
            "identificador" => "abst0085"
            "titulo" => "Conclusi&#243;n"
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          8 => array:2 [
            "identificador" => "abst0090"
            "titulo" => "Clinicaltrials gov"
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            "apendice" => "<p id="par0355" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0125"
          ]
        ]
      ]
    ]
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          "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Study flow chart&#46;</p>"
        ]
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      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Pain measured with ESCID scale in mechanically ventilated&#44; unable to self-report critically ill patients&#44; by two independent observers before&#44; during and after three different procedures&#46; This figure shows the median scores of the ESCID scale evaluated by two observers according to different situations&#58; before&#44; during and after turning&#47;repositioning&#44; tracheal suctioning and non-painful procedure &#40;rub with a gauze cloth over a portion of healthy skin tissue of the patient&#41;&#46; The numbers show a significant increasing of the level of pain during the two painful procedures&#44; that normalized in the assessment after 15<span class="elsevierStyleHsp" style=""></span>min finishing this procedure&#46; However&#44; there were no modifications in the pain level in the three assessment times during the non-painful procedure&#46; There is a good inter-observer concordance&#46; The points are outliers or values outside these limits&#46; <span class="elsevierStyleItalic">Note</span>&#58; Proced&#58; procedure&#59; Obs&#58; observer&#46;</p>"
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                  <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"><span class="elsevierStyleItalic">Behavioral indicators of pain scale &#40;ESCID&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Number of observation domains&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Number of descriptors per domain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Rated per descriptor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#8211;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Total score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#8211;10&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-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Facial expression</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Score</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Relaxed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Tense&#44; frowning&#47;grimacing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Regularly frowning&#47;clenched jaw&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" 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  " 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">Calmness</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Calm&#44; relaxed&#44; normal movements&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Occasional restless movement&#44; shifting position&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Frequent movement&#44; including head or limbs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" 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  " 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">Muscle tone</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Increased&#46; Flexion of fingers and&#47;or toes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Rigid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" 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  " 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">Compliance with mechanical ventilation &#40;MV&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Tolerates MV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Coughs&#44; however&#44; tolerates MV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Fights with the respirator&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" 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  " 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">Consolability</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Comfortable&#44; quiet&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Reassured by touch or talk&#46; Distractible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Difficult to comfort by touch or talking&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  <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-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age &#40;years&#41;&#44; median &#91;25th to 75th percentiles&#93;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">61 &#91;50&#8211;73&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Sex &#40;F&#47;M&#41; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55 &#40;29&#41;&#47;135 &#40;71&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Type of admission to the ICU &#40;medical&#47;surgical&#41; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">120 &#40;63&#41;&#47;70 &#40;37&#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-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Chronic pain syndrome&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Time of chronic pain &#40;months&#41;&#44; median &#91;25th to 75th percentiles&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 &#91;9&#8211;24&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Time of analgesics &#40;months&#41;&#44; median &#91;25th to 75th percentiles&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 &#91;12&#8211;24&#93;&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 to the ICU</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Respiratory&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44 &#40;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cardiac surgery&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">40 &#40;21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Trauma&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Gastrointestinal&#44; abdominal surgery&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Neuro&#47;neurosurgery&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Infection&#47;sepsis&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cardiac&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Miscellaneous<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;5&#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-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Time between admission to ICU and enrolment &#40;days&#41;&#44; median &#91;25th to 75th percentiles&#93;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#91;1&#8211;7&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">SAPS II score within 24 h after admission to ICU&#44; median &#91;25th to 75th percentiles&#93;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44 &#91;34&#8211;57&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Mechanical ventilation upon enrolment&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">190 &#40;100&#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">For procedure &#40;n</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">570&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sedation &#40;continuous intravenous infusion&#41;&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">485 &#40;85&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sedation &#40;intravenous boluses&#41;&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Analgesia &#40;continuous intravenous infusion&#41;&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">450 &#40;79&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Analgesia &#40;intravenous boluses&#41;&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">51 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>RASS level&#44; median &#91;25th to 75th percentiles&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8722;4 &#91;&#8722;5&#59; &#8722;2&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>RASS level &#62;&#8722;4&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">256 &#40;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>RASS level &#8722;4&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">160 &#40;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>RASS level &#8722;5&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">154 &#40;27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  <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">&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">Turning&#47;repositioning&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">Tracheal suctioning&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">Non-painful procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&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"><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>190&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"><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>190&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"><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>190&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><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">Mean &#40;SD&#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">Mean &#40;SD&#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">Mean &#40;SD&#41;&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  " colspan="4" align="left" valign="top"><span class="elsevierStyleBold">BPS scale</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Before</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Observer 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;1 &#40;0&#46;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">3&#46;2 &#40;0&#46;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">3&#46;2 &#40;0&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Observer 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;2 &#40;0&#46;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">3&#46;2 &#40;0&#46;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">3&#46;2 &#40;0&#46;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="4" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">During procedure</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Observer 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;7 &#40;1&#46;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">5&#46;4 &#40;1&#46;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">3&#46;2 &#40;0&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Observer 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;8 &#40;1&#46;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">5&#46;3 &#40;1&#46;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">3&#46;3 &#40;0&#46;7&#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="4" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">After</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Observer 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;2 &#40;0&#46;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">3&#46;2 &#40;0&#46;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">3&#46;1 &#40;0&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Observer 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;3 &#40;0&#46;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">3&#46;2 &#40;0&#46;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">3&#46;2 &#40;0&#46;5&#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="4" 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="4" align="left" valign="top"><span class="elsevierStyleBold">ESCID scale</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Before</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Observer 1&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;2 &#40;0&#46;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">0&#46;3 &#40;0&#46;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">0&#46;2 &#40;0&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Observer 2&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;3 &#40;0&#46;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">0&#46;3 &#40;0&#46;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">0&#46;3 &#40;0&#46;9&#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="4" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">During procedure</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Observer 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;6 &#40;2&#46;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">3&#46;4 &#40;2&#46;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;3 &#40;0&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Observer 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;7 &#40;2&#46;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">3&#46;3 &#40;2&#46;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">0&#46;4 &#40;1&#46;0&#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="4" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">After</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Observer 1&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;3 &#40;1&#46;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">0&#46;3 &#40;0&#46;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">0&#46;2 &#40;0&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Observer 2&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;4 &#40;1&#46;1&#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;3 &#40;0&#46;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">0&#46;3 &#40;0&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Analysis of variance for repeated measures &#40;ANOVA&#41; for BPS and ESCID&#46;</p>"
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          "leyenda" => "<p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">SAP&#58; systolic arterial pressure&#59; DAP&#58; diastolic arterial pressure&#59; HR&#58; heart rate&#59; RR&#58; respiratory rate&#59; SD&#58; standard deviation&#46;</p>"
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                  <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">&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">Turning&#47;repositioning&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">Tracheal suctioning&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">Non-painful procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&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"><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>190&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"><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>190&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"><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>190&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><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">Mean &#40;SD&#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">Mean &#40;SD&#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">Mean &#40;SD&#41;&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  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Before</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>SAP &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">125 &#40;21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">126 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">120 &#40;21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>DAP &#40;mmHg&#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 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>HR &#40;beats per minute&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84 &#40;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">86 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84 &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>RR &#40;breaths per minute&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19 &#40;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">19 &#40;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">18 &#40;5&#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="4" 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="4" align="left" valign="top"><span class="elsevierStyleItalic">During</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>SAP &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">132 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">133 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">123 &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>DAP &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65 &#40;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65 &#40;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>HR &#40;beats per minute&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">88 &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">85 &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>RR &#40;breaths per minute&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21 &#40;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">23 &#40;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">18 &#40;5&#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="4" 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="4" align="left" valign="top"><span class="elsevierStyleItalic">After</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>SAP &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">125 &#40;21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">125 &#40;21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">122 &#40;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>DAP &#40;mmHg&#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 &#40;12&#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 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>HR &#40;beats per minute&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">85 &#40;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">86 &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84 &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>RR &#40;breaths per minute&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18 &#40;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">19 &#40;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">19 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:42 [
            0 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Impact of systematic evaluation of pain and agitation in an intensive care unit"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "G&#46; Chanques"
                            1 => "S&#46; Jaber"
                            2 => "E&#46; Barbotte"
                            3 => "S&#46; Violet"
                            4 => "M&#46; Sebbane"
                            5 => "P&#46; Perrigault"
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                    0 => array:2 [
                      "doi" => "10.1097/01.CCM.0000218416.62457.56"
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2006"
                        "volumen" => "34"
                        "paginaInicial" => "1691"
                        "paginaFinal" => "1699"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16625136"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
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              "identificador" => "bib0220"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A prospective study of pain at rest&#58; incidence and characteristics of an unrecognized symptom in surgical and trauma versus medical intensive care unit patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "G&#46; Chanques"
                            1 => "M&#46; Sebbane"
                            2 => "E&#46; Barbotte"
                            3 => "E&#46; Viel"
                            4 => "J&#46;J&#46; Eledjam"
                            5 => "S&#46; Jaber"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1097/01.anes.0000287211.98642.51"
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesthesiology"
                        "fecha" => "2007"
                        "volumen" => "107"
                        "paginaInicial" => "858"
                        "paginaFinal" => "860"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18073576"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0225"
              "etiqueta" => "3"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Current practices in sedation and analgesia for mechanically ventilated critically ill patients&#58; a prospective multicenter patient-based study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;F&#46; Payen"
                            1 => "G&#46; Chanques"
                            2 => "J&#46; Mantz"
                            3 => "C&#46; Hercule"
                            4 => "I&#46; Auriant"
                            5 => "J&#46;L&#46; Leguillou"
                          ]
                        ]
                      ]
                    ]
                  ]
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        "identificador" => "xack250224"
        "titulo" => "Acknowledgements"
        "texto" => "<p id="par0335" class="elsevierStylePara elsevierViewall">The authors want to express a special recognition to the nurses who have participated in the data collection of this study&#46; The authors want also to thank to patients and relatives who participated in the study&#44; without whom the study could not be possible&#46;</p> <p id="par0340" class="elsevierStylePara elsevierViewall">The authors would like to express the collaboration of Isabel Mill&#225;n and Ana Royuela&#44; Biostadisticians of the Instituto de Investigaci&#243;n Puerta de Hierro Majadahonda &#40;Madrid&#41;&#46;</p> <p id="par0345" class="elsevierStylePara elsevierViewall">In addition to the authors of this paper&#44; the ESCID research group includes the following investigators&#58; Arias S&#44; Cuenca M&#44; Molano M&#44; Zaragoza I&#44; De la Vera E&#44; Lospitao S&#44; Sabell S&#44; Samper M&#44; Bajo R&#44; Merch&#225;n R&#44; Roqueiro MJ&#44; Prieto MJ&#44; Bonilla G and Castillo AM&#46;</p>"
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