INTRODUCTION. The assessment of pain in critically ill brain-injured patients is challenging
for health professionals. In addition to be unable to self-report, the confused and
stereotyped behaviors of these patients are likely to alter their ''normal'' pain responses.
Therefore, the pain indicators observed in the general critically ill population may not be
appropriate.
OBJECTIVES. To identify behavioral and physiological indicators used by clinicians to
assess pain in critically ill brain-injured patients who are unable to self-report.
METHODS.Amixed-method design was used with the first step being the combination of the
results of an integrative literature review with the results of nominal groups of 12 nurses and
four physicians. The second step involved a web-based survey to establish content validity.
Fourteen experts (clinicians and academics) from three French speaking European countries
rated the relevance of each indicator. A content validity index (CVI) was computed for each
indicator (I-CVI) and for each category (S-CVI).
RESULTS. The first step generated 52 indicators. These indicators were classified into six
categories: facial expressions, position/movement, muscle tension, vocalization, compliance
with ventilator, and physiological indicators. In the second step, the agreement between raters
was high with an Intraclass Correlation Coefficient of 0.88 (95% CI 0.83-0.92). The I-CVIs
ranged from 0.07 to 1. Indicators with an I-CVI below 0.5 (n = 12) were not retained, resulting
in a final list of 30 indicators. The CVI for this final list was 0.75 with categories ranging from
0.67 (compliance with ventilation) to 0.87 (vocalization).
CONCLUSIONS. This process identified specific pain indicators for critically ill braininjured
patients. Further evaluation is in progress to test the validity and relevance of these
indicators in the clinical setting.