Intensive and Critical Care Nursing 42 (2017) 75–79

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Intensive and Critical Care Nursing

journal homepage: www.elsevier.com/iccn

Research article

Factors affecting pain assessment scores in patients on mechanical

ventilation
Yumi Ito a,∗ , Koji Teruya b , Hiroshi Kubota c , Tomoko Yorozu d , Emiko Nakajima a
a
Department of Nursing, Faculty of Health Sciences, Kyorin University, Tokyo, Japan
b
Department of Public Health, Faculty of Health Sciences, Kyorin University, Tokyo, Japan
c
Department of Cardiovascular Surgery, School of Medicine, Kyorin University, Tokyo, Japan
d
Department of Anesthesiology, School of Medicine, Kyorin University, Tokyo, Japan

a r t i c l e i n f o a b s t r a c t

Keywords: Objective: To determine how respiratory status and other aspects of the patients’ condition affect pain
Behavioral pain scale assessments.
Critically ill Methods: Pain was assessed in 20 patients aged ≥20 years who underwent cardiovascular surgery, and
Intensive care
required postoperative mechanical ventilation in an intensive care unit using the Behavioral Pain Scale
Pain assessment
(BPS). A BPS score of ≥6 (pain) versus <6 (no pain) was the dependent variable for determining the effect
on pain.
Results: Multiple logistic regression analysis showed that in 99 observations made at rest, pre- and post-
turning and pre- and post-tracheal suctioning, the BPS score was significantly affected by gender, the
Acute Physiology and Chronic Health Evaluation (APACHE) II score, Richmond Agitation–Sedation Scale
score, PaCO2 , and HCO3 − .
The associations between BPS scores and APACHE II scores and HCO3 − demonstrated that pain results
from biological responses to invasion. Increases in PaCO2 affecting only the total BPS score suggests that
PaCO2 is associated with other pain responses, regardless of respiratory status.
Conclusion: The BPS score was significantly associated with disease severity and ventilatory capacity,
demonstrating a need to examine pain assessment methods tailored to the severity of underlying dis-
ease, degree of respiratory failure and other aspects of individual patient’s condition for effective pain
management.
© 2017 Elsevier Ltd. All rights reserved.

Implications for clinical practice

• The Behavioral Pain Scale (BPS) score is significantly affected by gender Acute Physiology and Chronic Health Evaluation II score,
Richmond Agitation–Sedation Scale score, and PaCO2 , and HCO3 − values.
• Given that the severity and degree of respiratory insufficiency were significantly related to the BPS score, the necessity of considering
a pain assessment method that takes into account the patient’s condition during mechanical ventilation was suggested.
• By clarifying the pain assessment method based on the patients’ condition, we could administer analgesia more appropriately and
contribute to early withdrawal from mechanical ventilation among critically ill patients.

Introduction

For patients with a severe disease who require mechanical ven-

tilation, it has recently been recommended that in order to reduce
∗ Corresponding author at: Department of Nursing, Faculty of Health Sciences, the duration of ventilation, excessive administration of sedatives
Kyorin University 6-20-2 Sinkawa Mitaka−shi, Tokyo 181-8611, Japan. should be avoided and sedation should be maintained at a level
E-mail address: yumito@ks.kyorin-u.ac.jp (Y. Ito). that is light enough to enable patients awakening during the day-

http://dx.doi.org/10.1016/j.iccn.2017.03.001
0964-3397/© 2017 Elsevier Ltd. All rights reserved.
76 Y. Ito et al. / Intensive and Critical Care Nursing 42 (2017) 75–79
Table 1
Behavioral Pain Scale.
Item Description
Facial expression Relaxed
Partially tightened (e.g., brow lowering)
Fully tightened (e.g., eyelid closing)
Grimacing
Upper limbs No movement
Partially bent
Fully bent with finger flexion
Permanently retracted
Compliance with ventilation Tolerating movement
Coughing but tolerating ventilation for
most of the time
Fighting ventilator
Unable to control ventilation
Payen et al. (2001).
time (Girard et al., 2008). These recommendations have made it
more important to appropriately assess patients’ levels of pain and
plan pain management. However, in patients whose general condi-
tion is unstable, such as severe respiratory failure, sedation needs
be prioritised (Reade and Finfer, 2014) and the maintenance of a
light sedation level is difficult. In such cases, an objective evalua-
tion of the patient’s pain is necessary. In order to do so, the Clinical
Practice Guidelines for the Management of Pain, Agitation, and
Delirium in Adult Patients in the Intensive Care Unit (“PAD Guide-
lines”), published by the American College of Critical Care Medicine
in 2013, recommend the use of the Behavioral Pain Scale (BPS) or
Critical-Care Pain Observation Tool (CPOT) (Barr et al., 2013). In
light of the publication of the PAD Guidelines, the Japanese Society
of Intensive Care Medicine published the Japanese Clinical Practice
Guidelines for the Management of Pain, Agitation, and Delirium
in Adult Patients in the Intensive Care Unit (“J-PAD Guidelines”) in
2014 (Japanese Society of Intensive Care Medicine J-PAD Guidelines
Production Committee, 2014). These guidelines recommend the
application of the BPS and CPOT for the assessing pain in critically
ill patients. Although a complete Japanese version of the CPOT does
not exist, a Japanese version of the BPS was introduced as a scale
for assessing pain during mechanical ventilation (Table 1) (Japanese
Society of Respiratory Care Medicine, 2007).
The BPS assesses pain based on facial expression, upper limb
movements and compliance with mechanical ventilation. Payen,
who developed the BPS, compared BPS scores during tracheal suc-
tioning and mobilization with BPS scores at rest, thus verifying the
scale’s reliability (Payen et al., 2001).
Studies have been conducted to verify the reliability and validity
of the BPS since its development (Al Darwish et al., 2016). However,
considering that pain is one of the important signs of a biological
response in a critically ill patient subjected to particularly inva-
sive surgery or trauma (D’Arcy and Burns, 2014), no study has been
conducted on the BPS that incorporate the relevance of treatment
factors, such as disease state and mechanical ventilation.
Therefore, this study was conducted to clarify how the disease
state and severity, including the respiratory state of the patient,
affect the BPS.
Methods
Participants and setting
The subjects were patients who were hospitalised in the inten-
sive care unit (ICU) of a university hospital in Tokyo Prefecture
between May 30 and September 15, 2013. These subjects, who were
aged ≥20 years, underwent cardiovascular surgery and required
postoperative mechanical ventilation in the ICU. As burn and
trauma patients are not accommodated in this ICU, they were not
included as subjects. Owing to the possibility of quadriplegia, we
excluded one patient with a diagnosis of cranial nerve disease as a
Score subject to avoid potential differences in behavior expression related
1 to pain (Payen et al., 2001). We ended our observation once patients
2 were able to verbally communicate with us.
3
4 Ethical considerations
1
2
3 The present study was approved by the Institutional Review
4 Board of the Faculty of Health Sciences at Kyorin University
1 (Approval No: 25-1) and the Institutional Review Board of the Fac-
2
ulty of Medicine and Clinical Epidemiology at Kyorin University
3
(Approval No: 374). Potential subjects and their families received
4 an explanation of the study from the surgeon prior to surgery.
Patients who provided consent were included in this study.
Consent was obtained by presenting a written document detail-
ing the voluntary nature of participation, right to withdraw from
the study at any time, and protection of privacy. All patient names
were coded to preserve anonymity.
Data collection
Pain was assessed with the BPS at rest as well as pre- and post-
turning, and pre- and post-tracheal suctioning. Assessments at rest
were conducted at times during which the arterial blood gas analy-
sis results could be obtained. In addition to basic information, such
as gender, clinical diagnosis, underlying disease and operative pro-
cedure; evaluation items obtained from medical records consisted
of the following: Acute Physiology and Chronic Health Evaluation
(APACHE) II, Sequential Organ Failure Assessment (SOFA) severity
and Richmond Agitation–Sedation Scale (RASS) scores; mechanical
ventilation mode; patient information obtained from the mechan-
ical ventilator (minute ventilation, airway pressure, respiratory
rate); arterial blood gas analysis values (pH, PaO2 , PaCO2 , HCO3 − ,
SaO2 ); haemodynamics (blood pressure, heart rate); types and
dosages of analgesics and sedatives used and type of artificial air-
way.
Data analysis
We performed multiple logistic regression analysis to deter-
mine how factors obtained from patient data affect BPS scores. A
BPS score of ≥6 versus <6, which represents the presence versus
absence of unbearable pain in the PAD Guidelines (Barr et al., 2013),
was used as the dependent variable. Independent variables con-
sisted of gender (male vs. female); APACHE II, SOFA, and RASS
scores; minute ventilation, airway pressure, and respiratory rate;
pH, PaO2 , PaCO2 , HCO3 − , and SaO2 values; and blood pressure and
heart rate. Variables were selected using backward elimination per-
formed with a likelihood ratio test. The goodness of fit of the model
was assessed with the Hosmer–Lemeshow test. Statistics were ana-
lysed using SPSS Statistics 19, with the level of significance set at
5%.
Results
Subject characteristics
All 20 subjects underwent cardiovascular surgery. Three
patients were diagnosed with diabetes as an underlying disease,
whereas one patient was undergoing renal dialysis treatment for
chronic renal failure. The 20 subjects comprised 14 men and 6
women aged 72.8 ± 10.2 years (mean ± standard deviation), with a
duration of mechanical ventilation of 6.5 ± 8.2 days, and an APACHE
II score of 18.9 ± 6.1; only one subject underwent tracheostomy
(Tables 2 and 3). The mode of mechanical ventilation upon BPS
 Y. Ito et al. / Intensive and Critical Care Nursing 42 (2017) 75–79 77

Table 2 were found to decrease as HCO3 − increased. Regarding the asso-

Subject characteristics (n = 20).
ciation between respiratory status and BPS scores, the analysis
Gender (n) Male/Female 14/6 results demonstrated that BPS scores increased as PaCO2 increased.
Clinical diagnosis (n) Ischemic heart disease 9 However, increased PaCO2 was associated only with the overall
Valvular heart disease 9 BPS score. Ventilation, the BPS subscale that assesses the patient’s
Aortic disease 2 compliance with mechanical ventilation, was not independently
Artificial airway type (n) Intubation/tracheostomy 19/1 correlated with PaCO2 (rho = −0.153, p = 0.160).
Age (years, mean ± SD) 72.8 ± 10.2
Duration of mechanical ventilation (days, mean ± SD) 6.5 ± 8.2
APACHE II score (points, mean ± SD) 18.9 ± 6.1
Discussion

Table 3
One reason for the necessity to assess pain in critically ill
Subject attributes (n = 99).
patients on mechanical ventilation is that pain has been demon-
Outcome Mean ± SD strated to elicit delirium and agitation (Lynch et al., 1998; Reade
RASS score (points) −1.43 ± 2.1 and Finfer, 2014), thus making pain assessment an essential factor
Minute ventilation (L/min) 8.72 ± 2.18 in sedation.
Peak inspiratory pressure (cm H2 O) 23.47 ± 3.47 The BPS used in the present study is the assessment scale recom-
Respiratory rate (breaths/min) 21.9 ± 6.13
mended by the PAD Guidelines and J-PAD Guidelines for patients
pH 7.466 ± 0.042
PaO2 (torr) 124.57 ± 27.4 on mechanical ventilation. The reliability of BPS has been validated
PaCO2 (torr) 35.54 ± 4.18 several times since its development. However, the reliability of the
HCO3 − (mmol/L) 25.38 ± 3.10 BPS has only been examined by comparing pain assessment scores
SaO2 (%) 98.27 ± 0.84
at rest with scores during painful procedures or with patients’
PaO2 /FI O2 ratio 277.28 ± 67.7
Mean blood pressure (mmHg) 70.17 ± 16.15
self-reported pain (Ahlers et al., 2010; Aïssaoui et al., 2005). An
Heart rate (beats/min) 95.12 ± 19.73 examination on whether or not the BPS is capable of reflecting the
pain exhibited by patients as biological responses or if the BPS is
RASS; Richmond Agitation–Sedation Scale, SD; standard deviation.
associated with the patient’s disease severity remains to be con-
ducted.
Table 4
This study was performed to clarify the reliability of the BPS
Factors affecting Behavioral Pain Scale score.
as a scale for evaluating pain among critically ill patients dur-
Factor ␤ OR (95% CI) p-value ing mechanical ventilation. In addition, we aimed to investigate
Gender 4.693 109.213 (3.607–3307.112) 0.007 the influence of patient’s disease condition and severity on BPS
APACHE II 0.345 1.412 (1.020–1.957) 0.038 to obtain suggestions for more precise pain assessment using the
RASS 1.503 4.495 (1.900–10.635) 0.001
scale. When the results were subjected to multiple logistic regres-
PaCO2 0.340 1.404 (1.037–1.901) 0.028
HCO3 − −0.703 0.495 (0.274–0.893) 0.020
sion analysis, APACHE II scores and HCO3 − and PaCO2 values, which
are used to judge the patient’s disease condition and severity, were
Hosmer–Lemeshow test: ␹2 = 1.267, p = 0.996.
found to be associated with the BPS, demonstrating that the BPS
␤; beta coefficient, CI; confidence interval, OR; odds ratio.
score is affected by the disease state.
Although the APACHE II was not specifically designed for
assessment was synchronized intermittent mandatory ventilation patients following surgery using cardiopulmonary bypass (Marino
in two observations only. In all other observations, the mode and Sutein, 2007), a severity scoring system specifically for post-
of mechanical ventilation was biphasic positive airway pressure cardiopulmonary bypass patients has not yet been developed and
(BIPAP) or continuous positive airway pressure (CPAP). a previous study has stated that the APACHE II is applicable to
patients following cardiovascular surgery (Turner et al., 1991).
Analysis of factors affecting BPS assessment Therefore, we used APACHE II in the present study. The associa-
tion between APACHE II and BPS scores has not been previously
We administered the BPS in a total of 99 observations. Of these, examined. However, the results of the present study demonstrate
eight observations were conducted following tracheal suctioning, that BPS score also increases as the APACHE II score increases, that
seven were performed following turning and all others were carried is, as the patient’s disease severity increases. Owing to the disease
out at rest. The number of measurements for each patient ranged itself as well as surgery and other treatments, critically ill patients
from 1 to 24 with a median of 2.5. are subjected to major invasion. The observed association between
Analysis revealed that the following selected variables signifi- the APACHE II and BPS scores suggests that the BPS reflects pain
cantly affected the BPS score: gender (odds ratio [OR] = 109.21; 95% that manifests as a biological response to invasion. In this analy-
confidence interval [CI], 3.61–3307.1; p = 0.007), APACHE II score sis, increased APACHE II scores were related to higher BPS scores,
(OR = 1.41; 95% CI, 1.02–1.96; p = 0.038), RASS score (OR = 4.50; but the SOFA scores did not affect the BPS scores. Both APACHE II
95% CI, 1.90–10.64; p = 0.001), PaCO2 (OR = 1.41; 95% CI, 1.04–1.91; and SOFA scores are indicators of prognostic prediction; however,
p = 0.028), and HCO3 − (OR = 0.50; 95% CI, 0.27–0.89; p = 0.020). The the SOFA score is based on the impairment extent of important
Hosmer–Lemeshow test yielded a p-value of 0.996 (Table 4). organs (Minne et al., 2008), whereas the APACHE II score uses
No significant changes were observed from the results described many criteria to evaluate respiratory function. The severity of res-
above in the analysis conducted only with observations at rest or in piratory insufficiency was speculated to be related to higher BPS
the analysis in which individual differences between patients was scores.
accounted for. Furthermore, the BPS score was found to decrease as HCO3 −
Women demonstrated a BPS score of ≥6 than men significantly. increased. Metabolic acidosis manifests in severe circulatory dis-
In terms of the association between the RASS and BPS scores, BPS turbance or nephropathy resulting from excessive shock or other
scores were found to be significantly higher when the sedation lev- stress responses. Similar to the APACHE II score, the severity of
els were light. In the present study, APACHE II scores were found metabolic acidosis is also associated with the BPS score. Although
to significantly affect BPS assessment. Furthermore, BPS scores the subjects in the present study did not present with acidosis,
78 Y. Ito et al. / Intensive and Critical Care Nursing 42 (2017) 75–79
a tendency toward acidic metabolism has been demonstrated to
potentially intensify pain. To determine whether or not severe aci-
dosis intensifies pain, further study must be conducted in patients
whose conditions are more severe.
In addition, PaCO2 increased as the BPS score increased, high-
lighting the correlation between the BPS score and the respiratory
status of the patient. In thoracic and upper abdominal surgeries,
postoperative pain is known to restrict respiratory movement and
cough reflex, thereby diminishing respiratory function (Fujimoto
et al., 2005). All subjects in the present study underwent cardio-
vascular surgery in which the incisions reached the thorax. The
observed association between increased PaCO2 and BPS score may
be attributed to ventilation changes caused by the pain resulting
from these surgical incisions.
The correlation between PaCO2 increase and BPS score was only
found when PaCO2 was compared with the total BPS score, but
not with ventilation (V) alone. One potential factor in this lack of
correlation is that the modes of mechanical ventilation for nearly
all subjects were biphasic positive airway pressure (BIPAP) and
continuous positive airway pressure (CPAP), which prioritise spon-
taneous breathing. In these modes, pain-induced PaCO2 increases
do not inhibit the patient’s compliance with mechanical ventilation.
Moreover, despite the oxygenation reduction in our analysis, other
items reflecting ventilation function (minute ventilation and respi-
ratory rate) were unaffected. Thus, we can infer that the subjects’
respiratory statuses were not so poor as to elicit changes in res-
piratory movement. One conceivable reason for this result is that
the subjects tended toward hyperventilation based on the mean
PaCO2 and minute ventilation. Another reason is that the subjects
were able to avoid long-term postoperative mechanical ventilation
(mean duration: 6.5 days SD) and thus did not experience dimin-
ished respiratory muscle reserve.
The fact that PaCO2 affected the overall BPS score but not the BPS
ventilation score suggests that PaCO2 is associated with other pain
responses regardless of the patient’s respiratory status and can be
considered as verification of the BPS reliability. However, arterial
blood gas values cannot be continuously assessed and are there-
fore unsuitable for continuous comprehension of signs exhibited
by patients.
Only one of the subjects in the present study underwent tra-
cheostomy. Thus, our analysis did not cover how different types
of artificial airways or the backgrounds of patients using artificial
airways affect pain assessment scores. Going forward, investi-
gating other pain responses and developing an assessment scale
tailored to the respiratory failure severity are necessary, in addition
to examining BPS scores in patients with diminished ventilatory
capacity who suffer from severe respiratory failure or are on long-
term mechanical ventilation.
Patients experiencing severe respiratory failure and with other
poor general condition might be sedated deeply. Hence, BPS scores
may be affected by the sedation level. BPS scores were found to be
significantly higher when sedation levels were light. We could not
find any previous reports that directly discussed the association
between the RASS and BPS scores or the association between the
sedation levels and BPS scores. The mean sedation level, as repre-
sented by the RASS score, among the subjects in the present study
was −1.43 (± 2.1), which is a light sedation level that correspond
to a score of 2–3 on the Ramsay scale. When other factors were
adjusted, an association was observed between the sedation level
and BPS score. This result is taken as confirmation of the importance
of pain assessment in the management of patients in intensive care
medicine, which are currently recommended to be subjected to
light sedation. It is necessary to consider the influence of sedation
level when using the BPS.
With regard to gender and pain assessment, previous studies
have demonstrated that women are more sensitive to pain than
men and that gender differences in response to pain management
exist (Bartley and Fillingim, 2013; Yorke et al., 2004). Although the
mechanism of gender differences in pain sensitivity remains poorly
understood, the results of the present study are consistent with the
findings regarding gender differences in previous studies.
In the present study, we determined that the BPS scores were
significantly associated with APACHE II scores, HCO3 − and PaCO2
values among patients during mechanical ventilation, even after
adjusting for gender and sedation status. BPS scores were signifi-
cantly associated with severity and ventilatory ability. This finding
suggests that considering a pain assessment method based on the
disease condition is necessary to provide a more effective pain
management.
By clarifying the pain assessment methods based on patient
condition and educating nurses regarding to these recommenda-
tions, appropriate assessment of patients’ pain during mechanical
ventilation is possible, thus preventing related complications and
shortening the duration of ICU stay among critically ill patients.
Limitations
Some limitations of the study should be considered. The present
study was conducted only with patients who had undergone car-
diovascular surgery at a single university hospital in a restricted
period. Thus, the number of subjects was insufficient. Therefore, the
generalisability of the results must be judged carefully. However,
the present study is the first to examine the association between
BPS scores and disease severity and respiratory status, thus making
the results highly meaningful.
We would like to continue investigating the effects of disease
severity on BPS scores in patients with a wide variety of underly-
ing diseases. We would also like to examine the BPS assessment
methods tailored to the patient’s condition.
Conclusion
Multiple logistic regression analysis involving 99 observations
of BPS assessment among 20 patients on mechanical ventilation
following cardiovascular surgery at a university hospital in Tokyo
Prefecture revealed that BPS scores were significantly affected by
gender, RASS and APACHE II scores, as well as PaCO2 and HCO3 −
values. The finding that the BPS score is significantly associated
with disease severity and ventilatory capacity, even after adjust-
ing for gender and sedation status, indicates that the BPS is a valid
scale for pain assessment. Moreover, the finding that disease sever-
ity and degree of respiratory failure affect BPS scores suggests the
need for a pain assessment method that is tailored to the individual
patients’ condition to manage pain more effectively. Appropriate
pain assessment of critically ill patients during mechanical ventila-
tion might prevent related complications and shorten the duration
of their ICU stay.
Funding
The authors have no sources of funding to declare.
Conflict of interest
The authors have no conflict of interest to declare.
Acknowledgements
We would like to express our deep respect and gratitude to the
subjects of the present study for their pleasant cooperation and
the valuable information they provided us. We would also like to
 Y. Ito et al. / Intensive and Critical Care Nursing 42 (2017) 75–79
extend our sincere thanks to the physicians, the chief nurse and all
the nurses at the university hospital for their considerable under-
standing and tremendous effort during the performance of our
study.
References
Aïssaoui, Y., Zeggwagh, A.A., Zekraoui, A., Abidi, K., Abouqal, R., 2005. Validation
of a behavioral pain scale in critically ill, sedated, and mechanically ventilated
patients. Anesth. Analg. 101, 1470–1476.
Ahlers, S.J., van der Veen, A.M., van Dijk, M., Tibboel, D., Knibbe, C.A., 2010. The use
of the behavioral pain scale to assess pain in conscious sedated patients. Anesth.
Analg. 110, 127–133.
Al Darwish, Z.Q., Hamdi, R., Fallatah, S., 2016. Evaluation of pain assessment tools in
patients receiving mechanical ventilation. AACN Adv. Crit. Care 27, 162–172.
Barr, J., Fraser, G.L., Puntillo, K., Ely, E.W., Gélinas, C., Dasta, J.F., et al., 2013. Clinical
practice guidelines for the management of pain, agitation, and delirium in adult
patients in the intensive care unit. Crit. Care Med. 41, 263–306.
Bartley, E.J., Fillingim, R.B., 2013. Sex differences in pain: a brief review of clinical
and experimental findings. Br. J. Anaesth. 11, 52–58.
D’Arcy, Y., Burns, S.M., 2014. Pain sedation, and neuromuscular blockade manage-
ment. In: Burns, S.M. (Ed.), AACN Essentials of Critical Care Nursing, third edition.
McGraw-Hill Education, USA, pp. 159–181.
Fujimoto, Y., Hayashida, M., Hanaoka, K., 2005. Effects of post-operative pain on the
living body. Pain Clin. 26, 9–13.
79
Girard, T.D., Kress, J.P., Fuchs, B.D., Thomason, J.W., Schweickert, W.D., Pun, B.T., et al.,
2008. Efficacy and safety of a paired sedation and ventilator weaning protocol
for mechanically ventilated patients in intensive care (Awakening and Breathing
Controlled trial): a randomised controlled trial. Lancet 371, 126–134.
Japanese Society of Intensive Care Medicine J-PAD Guidelines Production Commit-
tee, 2014. Japanese clinical practice guidelines for the management of pain,
agitation, and delirium in adult patients in the intensive care unit [in japanese].
J. Jpn. Soc. Intensive Care Med. 21, 539–579.
Japanese Society of Respiratory Care Medicine, 2007. Guidelines for sedation during
mechanical ventilation production committee. guidelines for sedation during
mechanical ventilation [in Japanese]. Jpn. J. Respir. Care 24, 146–167.
Lynch, E.P., Lazor, M.A., Gellis, J.E., Orav, J., Goldman, L., Marcantonio, E.R., 1998. The
impact of postoperative pain on the development of postoperative delirium.
Anesth. Analg. 86, 775–781.
Marino, P.L., Sutein, K.M., 2007. Clinical scoring systems. In: The ICU Book, third
edition. Lippincott Williams & Wilkins, USA, pp. 997–1000.
Minne, L., Abu-Hanna, A., de Jonge, E., 2008. Evaluation of SOFA-based models for
predicting mortality in the ICU: a systematic review. Crit. Care 12, R161.
Payen, J.F., Bru, O., Bosson, J.L., Lagrasta, A., Novel, E., Deschaux, I., et al., 2001. Assess-
ing pain in critically ill sedated patients by using a behavioral pain scale. Crit.
Care Med. 29, 2258–2263.
Reade, M.C., Finfer, S., 2014. Sedation and delirium in the intensive care unit. N. Engl.
J. Med. 370, 444–454.
Turner, J.S., Mudaliar, Y.M., Chang, R.W., Morgan, C.J., 1991. Acute physiology and
chronic health evaluation (APACHE II) scoring in a cardiothoracic intensive care
unit. Crit. Care Med. 19, 1266–1269.
Yorke, J., Wallis, M., McLean, B., 2004. Patients’ perceptions of pain management
after cardiac surgery in an Australian critical care unit. Heart Lung 33, 33–41.