A Comparison of Scales in Patients with Disorders of Consciousness Following Craniotomy Suwannee Suraseranivongse MD*, Pensook Yuvapoositanont BN**, Paphatsorn Srisakkrapikoop BN**, Ruetaichanok Pommul BN**, Waraporn Phaka BN**, Parunut Itthimathin MD***

* Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand ** Division of Nursing, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand *** Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

Objective: Evaluate the validity, reliability, and practicality of pain assessment tools in patients with disorders of consciousness who underwent craniotomy. Material and Method: This prospective observational study cross-validated three pain scales, FLACC (Face, Legs, Activity, Cry, Consolability), rFLACC (Revised FLACC), and NCS ( Coma Scale), based on validity, reliability, and practicality. After translation, the three pain scales were tested for concurrent validity, construct validity, and interrater reliability in patients who experienced disorders of consciousness within 24 hours following craniotomy. Opinions regarding practicality were elicited via questionnaire from nurses who have used and are familiar with these pain scales. Results: Fifty-eight patients were enrolled in the present study. Concurrent validity was supported by positive correlations among all scales, which ranged from r = 0.638 to r = 0.978. All scales yielded fair to moderate agreement (K = 0.380-0.626) with routine clinical decision to treat postoperative pain. Concurrent validity was much improved in the assessment of intubated patients. Construct validity was demonstrated by high scores (3-5) in higher pain situations before was given and low pain scores (0) in pain-free situations after analgesic was given. All scales had good interrater reliability (intraclass correlation = 0.7506-0.8810). Conclusion: All pain scales were found to be valid and reliable, especially in intubated patients. In terms of practicality, NCS was found to be the most acceptable by practitioners.

Keywords: Craniotomy, Pain, Postoperative, Pain scales, Validity

J Med Assoc Thai 2015; 98 (7): 684-92 Full text. e-Journal: http://www.jmatonline.com Post-craniotomy pain has been demonstrated pain in patients with disorders of consciousness to be moderate to severe in nature(1-4). Appropriate pain following craniotomy. Several pain scales validated assessment and adequate pain relief are extremely in other patient populations who were unable to important in reducing restlessness, high blood pressure, communicate have been used for this purpose. shivering, and vomiting, any or all of which may Examples of these scales include Faces, Legs, Activity, increase intracranial pressure and subsequently lead to Cry, Consolability pain assessment tool (FLACC)(6,7), intracranial hemorrhage(3). Although the recognition Nociception Coma Scale (NCS)(8), Neonatal Infant of analgesic need following craniotomy has been (NIPS)(9), Pain Assessment in Advanced increasing, evidence of suitable Dementia Scale (PAINAD)(10), and Checklist of protocols in this group of patients is still lacking(5). As Non-Verbal Pain Indicator (CNPI)(11). a result, the prevalence of inadequate pain relief has FLACC was validated for pain assessment in remained high in the range of about 60 to 70%(1,4). small children(6) and critically ill patients, including Postoperative patients with disorders of two cases in which the patient underwent intracranial consciousness are not able to communicate or surgery(7) (Appendix 1). FLACC has become popular appropriately report their pain. There is currently no for pain assessment in neurosurgical patients. There is specific pain scale that is validated for assessment of a revised version of FLACC (rFLACC), which includes Correspondence to: added detail that improves reliability and validity in Suraseranivongse S, Department of Anesthesiology, Faculty of children with cognitive impairment(12,13) (Appendix 2). Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, NCS was introduced for pain assessment in Thailand. Phone: +66-2-419-7990, Fax: +66-2-4113256 48 post-comatose patients from acute care, neurology, E-mail: [email protected] neurorehabilitation, and nursing home center

684 J Med Assoc Thai Vol. 98 No. 7 2015 environments (Appendix 3). The authors validated Exclusion criteria included patients who received NCS, as compared with NIPS, FLACC, PAINAD, and sedation or neuromuscular blocking drugs three days CNPI. They found that NCS showed high correlations prior and patients with documented history of brain with other validated assessment tools. NCS and CNPI injury, delayed development, psychiatric illness, demonstrated higher levels of effectiveness than other and inability to move extremities from fracture or pain assessment tools in vegetative state patients, as paralysis. Patients who were diagnosed with thalamic compared to patients that were minimally conscious. hemorrhage were also excluded due to an inability to In a comparison of the two, NCS was found to be more express feelings. sensitive than CNPI in measuring pain(9). Patient demographic data, operation details, The objective of the present study was to test and analgesic prescribed were all recorded. All the validity (concurrent and construct validity), nurses in this unit were trained in how to score pain reliability, and practicality of FLACC, rFLACC, and using FLACC, rFLACC, and NCS. Ten patient NCS in post-craniotomy patients who experienced behaviors demonstrated during painful procedures disorders of consciousness and who were unable to (e.g., suctioning, blood sampling) were shown on communicate or accurately and effectively report videotape to train nurses until the intraclass correlation their pain within 24 hours following surgery. reached 0.8 or more. Three nurses assessed each patient every 1 or 2 hours until 24 hours postoperation Material and Method or until patients were able to rate their severity of pain. Language translated FLACC, rFLACC, During each assessment, two nurses independently and NCS were cross-validated to test validity evaluated the same patient using three pain scales. The (concurrent validity and construct validity), reliability, third nurse assessed patients and made routine and practicality. The comparison of these same clinical decisions to treat pain based on increased three criteria was also performed among the three pain blood pressure of more than 20% from baseline plus assessment scales. at least one pain related behavior, such as facial This prospective observational study was grimace, crying, vocal complaints (both verbal and approved by the Siriraj Institutional Review Board nonverbal), restlessness, arching, rigidity, or jerking. (SiRB) (Ref: 461/2554EC2) and registered in the Other etiologies of increased blood pressure, such as ClinicalTrials.gov website (NCT01547663). After full bladder or increased intracranial pressure, were obtaining written informed consent from the ruled out before analgesic was given. relatives of patients who were admitted to the Siriraj Concurrent validity: Correlations were tested neurosurgical intensive care unit, the study was between FLACC, rFLACC, and NCS at the same time conducted in four phases. point for all patients. Construct validity: The ability of each pain Phase 1: Translation scale to differentiate high pain scores before analgesic First, a bilingual (English-Thai) physician was given and low pain scores after analgesic was translated the three pain scales from English into Thai. given. A second translator who was not involved in the By using the average high scores of FLACC, translation phase then translated the Thai version back rFLACC, and NCS before analgesic was given to into English. Finally, a third translator, whose mother determine the cut-off point, the agreement kappa (k) tongue is English, rechecked the back translated scales between the three pain scales assessed by the first and with the original scales. The third translator made final second nurses and the routine clinical decisions by the determinations regarding corrections to ensure accurate third nurse were tested. translation of the original English language scales. Interrater reliability: Consistencies in scoring from each of the pain scales as evaluated by the Phase 2: Testing of concurrent validity, construct first and second nurse were identified by interrater validity, and interrater reliability in post-craniotomy reliability. pain Adult patients, aged 18 years or more, who Phase 3: Practicality of measures and testing content were admitted to the neurosurgical intensive care unit validity with a post-craniotomy Glasgow coma score (GCS) Practicality of measures: Questionnaires of less than 15 were enrolled in the present study. asking for opinion when using the three pain scales

J Med Assoc Thai Vol. 98 No. 7 2015 685 were sent to nurses who had used these scales in a Results neurosurgical intensive care unit. All three pain Fifty-eight neurosurgical patients who assessment scales were ranked from “0 = least” to underwent craniotomy were enrolled in the present “10 = most” in terms of simplicity of use, time study. There were 26 males (44.8%) with a mean age consumed, feasibility in routine clinical use, ability of 58.03 years (SD 12.86 years, range 24-88 years) and to differentiate pain severity, assistance in decision median GCS of 11 (range 3-14). Fourteen patients to give analgesic, and overall satisfaction with the (24.1%) had GCS less than or equal to 8 and 44 patients scales. (75.9%) had GCS greater than 8. Diagnoses were Testing content validity: Language translated tumor (n = 44), aneurysm (n = 10), and other (n = 4). FLACC, rFLACC, and NCS were assessed in Seven hundred sixty observations were performed. terms of content by eight experts who were Thirty-two percent of patients were intubated and senior nurses with at least 5-years experience in a ventilated following operation. Twenty-five patients neurosurgical intensive care unit. Content assessment (43%) were able to ultimately provide their own scoring was coded, as follows: 1 = agree, 0 = no idea, assessment of pain. -1 = disagree. Concurrent validity was evaluated in terms of correlation between pain scales in all patients (Table 1). Statistical data analysis The correlation between FLACC and rFLACC was The sample size calculation was based on an excellent (r>0.9), whereas the correlations between estimated correlation of 0.5, alpha of 0.01, and power NCS and FLACC or rFLACC were good (0.702-0.711). of 0.9. Using the StatsToDo statistics website, the All correlations between pain scales for nurse A and B sample size was estimated to be 48. With the addition were much higher for intubated patients than for non- of dropout rate of 20%, the minimum sample size was intubated patients. Interrater reliability between nurse increased to 58 cases. A and B for all pain scales was good (FLACC = 0.8810, Patient demographic data were described rFLACC = 0.8786, and NCS = 0.7506). as mean (SD), median (range), and percentage. Construct validity was determined in all Correlations among FLACC, rFLACC, and NCS patients who underwent craniotomy. Median pain were analyzed using Spearman’s rank correlation scores before analgesic was given were higher than coefficient. Interrater reliability was analyzed by after analgesic was given (Table 2). intraclass correlation using a two-way random effect The cut-off points derived from median scores model. An intraclass correlation of 0.8 or more was of FLACC, rFLACC, and NCS before analgesic was considered acceptable. given were 3, 3, and 4, respectively. Kappa agreements Differences in pain scores before and after between the third nurse’s clinical decision to treat analgesic given (used to determine construct validity) pain and the three pain scales were fair to moderate were compared using the Wilcoxon matched-pairs (Table 3). signed-rank test. Agreement of all pain scales from Regarding practicality, NCS was rated the independent evaluations of the first and second superior to FLACC and rFLACC for all criteria nurse at the cut-off points (corresponding to high pain (Table 4). The content of FLACC, rFLACC, and before analgesic given) with the third nurse’s routine NCS was accepted by all nurses, except the ‘visual decisions to treat pain were analyzed using Cohen’s response’ identifier in NCS. kappa statistic (k). Values of k were interpreted, as follows: ≤2 poor agreement, 0.21 to 0.4 fair Discussion agreement, 0.41 to 0.6 moderate agreement, 0.61 to The present study demonstrated good 0.8 good agreement, and 0.81 to 1.0 very good concurrent validity among FLACC, rFLACC, and NCS, agreement(14). The practicality of the three pain scales especially in intubated patients. All pain assessment was analyzed using descriptive statistics. Content scales showed construct validity, good interrater validity, in terms of behavioral items and scoring items, reliability, and fair to moderate agreement with routine was analyzed by summation of scores divided by clinical decisions to treat pain. Based on comments number of experts. If the results were ≥0.5, content and opinions elicited from nurses, NCS was the most validity for those items was accepted. SPSS for practical scale. The categories of all pain scales were Windows v.11.5 (SPSS, Chicago, IL, USA) was used accepted by nurses, except for the ‘visual response’ for all analyses. component of NCS.

686 J Med Assoc Thai Vol. 98 No. 7 2015 Table 1. Spearman’s rank correlation among FLACC, rFLACC, and NCS in patients following craniotomy, all p-value were less than 0.001 Nurse A Nurse B FLACC rFLACC NCS FLACC rFLACC NCS All patients (760 observations) FLACC 1 1 rFLACC 0.939 1 0.956 1 NCS 0.704 0.711 1 0.703 0.702 1 Intubated patients (249 observations) FLACC 1 1 rFLACC 0.950 1 0.978 1 NCS 0.795 0.769 1 0.847 0.837 1 Non-intubated patients (511 observations) FLACC 1 1 rFLACC 0.933 1 0.944 1 NCS 0.662 0.687 1 0.638 0.642 1 FLACC = face, legs, activity, cry, consolability; rFLACC = revised FLACC; NCS = nociception coma scale

Table 2. Construct validity of pain scores from nurse A and B before and after giving analgesic, Wilcoxon matched-pair signed-rank test; all p-value were less than 0.001 Pain scales Observer Pain scores, median (IQR) Before analgesic given After analgesic given FLACC A 3 (1, 5) 0 (0, 1) B 3 (1, 5) 0 (0, 1) rFLACC A 3 (1, 5.25) 0 (0, 1) B 3 (1, 5) 0 (0, 1) NCS A 5 (2.75, 6.25) 0 (0, 2) B 4 (2, 6) 0 (0, 3)

Table 3. Agreement between clinical decision to treat postoperative pain and FLACC, rFLACC, and NCS in all patients, intubated patients, and non-intubated patients Patients Pain scales Cut-off point Kappa with clinical decision to treat pain (Nurse 3) Nurse 1 Nurse 2 All patients FLACC 3 0.456 0.505 rFLACC 3 0.480 0.506 NCS 4 0.5 0.465 Intubated patients FLACC 3 0.513 0.552 rFLACC 3 0.519 0.558 NCS 4 0.626 0.5 Non-intubated patients FLACC 3 0.434 0.487 rFLACC 3 0.465 0.485 NCS 4 0.444 0.380

FLACC was originally validated for acute except that rFLACC contained more detail in each pain assessment in small children(6), whereas rFLACC assessment component. The NCS contained some was revised and validated for children with cognitive different assessment behaviors and was validated in impairment(12,13). The rFLACC was highly correlated severely brain injured patients recovering from coma(8). with FLACC because they assessed similar behaviors, Nevertheless, the correlation between NCS and both

J Med Assoc Thai Vol. 98 No. 7 2015 687 Table 4. Practicality aspect as evaluated by 26 nurses with mean experience of 11.19 years (SD 5.86, range 1-20 years); rating score: 0 (least likely) to 10 (most likely); presented as mean (SD) Items of practicality FLACC rFLACC NCS Simple to use 4.62 (2.32) 4.58 (2.30) 6.12 (2.53) Time wasting 6.88 (1.86) 7.04 (2.11) 5.38 (1.88) Difficulty in assessing 6.50 (1.66) 6.54 (1.88) 5.04 (1.73) Assisting in decision to give analgesic 4.62 (2.12) 4.69 (2.17) 5.38 (2.84) Appropriate for routine practice 4.65 (1.76) 4.58 (1.75) 5.35 (2.64) Able to differentiate pain severity 4.73 (1.99) 4.65 (1.92) 5.31 (2.48) Global rating 5.20 (1.79) 5.20 (1.77) 6.01 (1.98)

Table 5. Content validity: item correlation (IC) = sum of points of rFLACC and NCS were not reported in rating scores/number of raters; IC should be ≥0.5 previous studies. Our results demonstrate a cut-off Description FLACC rFLACC NCS point of 3 for rFLACC and 4 for NCS; scores that are appropriate to and consistent with their content. We Facial response 0.63 0.88 0.75 also found better agreement among all pain scales in Leg 0.63 0.88 - intubated patients with routine clinical decisions to Activity/motor response 0.63 1.0 0.63 treat pain, which indicated that they were appropriate Cry 0.5 0.88 - to be generally applied in post-craniotomy patients Consolability 0.63 0.63 - with severe disorders of consciousness. Construct validity of all pain scales was Verbal response - - 0.5 proved from higher pain behavior scores before Visual response - - 0 analgesic was given and lower scores in pain-free or lower pain behaviors after analgesic was given. Good FLACC and rFLACC were also positive. Common interrater reliability demonstrated that the scales behaviors between NCS with other pain scales yielded reproducible and consistent findings across included facial response, motor response (FLACC assessors. & rFLACC: Leg & Activity), and verbal response Concerning practicality, NCS was the most (FLACC & rFLACC: Cry). Different behaviors were acceptable pain scale in all items, most notably for its “consolability” from FLACC and rFLACC and “visual simplicity, being less time-consuming, and its ability response” from NCS. The correlation between NCS to differentiate pain severity. Based on pain assessment and the other pain scales in intubated patients was much tool content reviewed and evaluated by 8 senior nurses better. The reason may be that most of the intubated from the neurosurgical intensive care unit, all agreed neurosurgical patients were non-communicative and with all categories from FLACC, rFLACC, and usually had more severe disorders of consciousness. NCS, except for the ‘visual response’ component of Discordance of assessment between different categories NCS. This behavior was originally validated in of each scale, such as consolability and visual response, severely brain-injured patients who did not receive may be minimal. In addition, there was no verbal any neuromuscular blocking drugs or sedation within response in intubated patients. Consequently, rest 24 hours of enrollment and who had preserved the behaviors to be assessed were only “facial response” sleep-wake cycle, which was indicated by the presence and “motor response”, which are recommended for of an eye opening period(8). However, this visual patients who cannot communicate their pain(15,16). response was not relevant in the 24-hour postoperative Cut-off points for the three pain scales were period following craniotomy, because the retention of identified from average high pain scores before anesthetics combined with some degree of brain injury analgesic was given for purposes of implementing all usually induced drowsiness and eyelid closure. As a pain scales in clinical practice for post-craniotomy result, this category was likely rated as “0 = none”. patients. FLACC has a cut-off point of 3, similar to the There were some limitations in the present study in small children(17), which meant that the FLACC study. First, patients who were enrolled in the present score in patients with pain was 3 or higher. The cut-off study that met the criteria of post-craniotomy and

688 J Med Assoc Thai Vol. 98 No. 7 2015 Glasgow coma score of less than 15 may have had intracranial surgery. The revised version of FLACC different degrees of consciousness disorder relating to (rFLACC) includes detail that improves reliability brain injury. Most of the patients (68%) were not and validity in children with cognitive impairment. intubated. Some of these patients may have experienced The NCS was introduced for pain assessment in only minimal consciousness impairment and, as such, 48 post-comatose patients from acute care, neurology, may have been able to verbally communicate their pain. neurorehabilitation, and nursing home center As a result, their pain behaviors may have been environments. discordant with their feelings, similar to the result of The authors found that FLACC, rFLACC, using self-report pain scales, compared with pain and NCS were valid and reliable for assessing pain behaviors in children aged 3 to 7 years(18). However, in patients with disorders of consciousness within all pain scales demonstrated higher levels of validity 24 hours following craniotomy, especially in intubated and reliability in intubated patients, the group that patients. NCS was rated as being the most practical most accurately characterized severe consciousness assessment in a busy routine clinical practice. disorder. Second, brain abnormality may induce some behaviors, such as abnormal movement of extremities Acknowledgements and verbal responses, which may interfere with The authors wish to thank the Siriraj Research observable pain behaviors. Development Fund for financial support, Dr. Chulaluk In conclusion, FLACC, rFLACC, and NCS Komoltri for her invaluable suggestions in statistical were found to be valid and reliable for assessing pain analysis, and Ms. Nichapat Sooksri for her kind in patients with disorders of consciousness within assistance. 24 hours following craniotomy, most notably in intubated patients. The NCS was rated to be the most Funding practical assessment tool for busy routine clinical This study was funded by a grant from the practice. Siriraj Research Development Fund (grant number R015432063). What is already known on this topic? Post-craniotomy pain has been demonstrated Potential conflicts of interest to be moderate to severe in nature and the prevalence None. of inadequate pain relief remains high in the range of about 60 to 70%. Appropriate pain assessment References and adequate pain relief are extremely important in 1. Gottschalk A, Berkow LC, Stevens RD, Mirski reducing restlessness, high blood pressure, shivering, M, Thompson RE, White ED, et al. Prospective and vomiting, any or all of which may increase evaluation of pain and analgesic use following intracranial pressure and subsequently lead to major elective intracranial surgery. J Neurosurg intracranial hemorrhage. 2007; 106: 210-6. Postoperative patients with disorders of 2. Klimek M, Ubben JF, Ammann J, Borner U, consciousness are not able to communicate or Klein J, Verbrugge SJ. Pain in neurosurgically appropriately report or describe their pain. To date, treated patients: a prospective observational there is no specific pain scale that has been validated study. J Neurosurg 2006; 104: 350-9. for the assessment of pain in patients with disorders 3. Flexman AM, Ng JL, Gelb AW. Acute and chronic of consciousness following craniotomy. pain following craniotomy. Curr Opin Anaesthesiol 2010; 23: 551-7. What this study adds? 4. Nair S, Rajshekhar V. Evaluation of pain following This study cross-validated three pain scales, supratentorial craniotomy. Br J Neurosurg 2011; including Faces, Legs, Activity, Cry, Consolability pain 25: 100-3. assessment tool (FLACC), revised FLACC (rFLACC), 5. Hansen MS, Brennum J, Moltke FB, Dahl JB. and Nociception Coma Scale (NCS). These pain scales Pain treatment after craniotomy: where is the were validated in populations who were unable to (procedure-specific) evidence? A qualitative communicate. The FLACC was validated for pain systematic review. Eur J Anaesthesiol 2011; 28: assessment in small children and critically ill patients, 821-9. including two cases in which the patient underwent 6. Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya

J Med Assoc Thai Vol. 98 No. 7 2015 689 S. The FLACC: a behavioral scale for scoring 13. Voepel-Lewis T, Malviya S, Tait AR, Merkel S, postoperative pain in young children. Pediatr Nurs Foster R, Krane EJ, et al. A comparison of the 1997; 23: 293-7. clinical utility of pain assessment tools for children 7. Voepel-Lewis T, Zanotti J, Dammeyer JA, Merkel with cognitive impairment. Anesth Analg 2008; S. Reliability and validity of the face, legs, activity, 106: 72-8. cry, consolability behavioral tool in assessing 14. Altman DG. Some common problems in medical acute pain in critically ill patients. Am J Crit Care research. In: Altman DG, editor. Practical statistics 2010; 19: 55-61. for medical research. London: Chapman and Hall, 8. Schnakers C, Chatelle C, Vanhaudenhuyse A, 1991: 404-8. Majerus S, Ledoux D, Boly M, et al. The 15. Kapoustina O, Echegaray-Benites C, Gelinas C. Nociception Coma Scale: a new tool to assess Fluctuations in vital signs and behavioural nociception in disorders of consciousness. Pain responses of brain surgery patients in the Intensive 2010; 148: 215-9. Care Unit: are they valid indicators of pain? J Adv 9. Lawrence J, Alcock D, McGrath P, Kay J, Nurs 2014; 70: 2562-76. MacMurray SB, Dulberg C. The development of 16. Arbour C, Choiniere M, Topolovec-Vranic J, a tool to assess neonatal pain. Neonatal Netw Loiselle CG, Gelinas C. Can fluctuations in vital 1993; 12: 59-66. signs be used for pain assessment in critically ill 10. Warden V, Hurley AC, Volicer L. Development and patients with a traumatic brain injury? Pain Res psychometric evaluation of the Pain Assessment Treat 2014; 2014: 175794. in Advanced Dementia (PAINAD) scale. J Am 17. Suraseranivongse S, Santawat U, Kraiprasit K, Med Dir Assoc 2003; 4: 9-15. Petcharatana S, Prakkamodom S, Muntraporn N. 11. Feldt KS. The checklist of nonverbal pain indicators Cross-validation of a composite pain scale for (CNPI). Pain Manag Nurs 2000; 1: 13-21. preschool children within 24 hours of surgery. 12. Malviya S, Voepel-Lewis T, Burke C, Merkel S, Br J Anaesth 2001; 87: 400-5. Tait AR. The revised FLACC observational pain 18. Beyer JE, McGrath PJ, Berde CB. Discordance tool: improved reliability and validity for pain between self-report and behavioral pain measures assessment in children with cognitive impairment. in children aged 3-7 years after surgery. J Pain Paediatr Anaesth 2006; 16: 258-65. Symptom Manage 1990; 5: 350-6.

690 J Med Assoc Thai Vol. 98 No. 7 2015 Appendix 1. Face, Legs, Activity, Cry, Consolability (FLACC) Scale Categories Score 012 Face No particular expression or smile Occasional grimace, frown, Frequent to constant frown, withdrawn or disinterested clenched jaw, quivering chin Legs Normal position or relaxed Uneasy, restless or tense Kicking, or legs drawn up Activity Lying quietly, normal position, Squirming, shifting back and Arched, rigidity or jerking moves easily forth, or tense Cry No cry Moans, whimpers, or occasional Crying steadily, screams or sobs, complaint frequent complaints Consolability Content, relaxed Reassured by occasional touching, Difficult to console or comfort hugging, or being talked to; distractable

Appendix 2. Revised FLACC Categories Scoring 012 F No particular expression or smile Occasional grimace or frown, Frequent to constant frown, Face withdrawn, disinterested clenched jaw, quivering chin Appears sad or worried Distressedlooking face: expression of fright or panic L Normal position or relaxed Uneasy, restless, tense Kicking or legs drawn up Legs Occasional tremors Marked increase in spasticity, constant tremors, or jerking A Lying quietly, normal position, Squirming, shifting back and Arched, rigid, or jerking Activity moves easily forth, tense Severe agitation, head banging, Mildly agitated (e.g., head back shivering (not rigors); breath- and forth, aggression); holding, gasping or sharp intake shallow, splinting respirations, of breath; severe splinting intermittent sighs C No cry (awake or asleep) Moans or whimpers, occasional Crying steadily, screams or sobs, Cry complaint frequent complaints Occasional verbal outburst or Repeated outbursts, constant grunt grunting C Content, relaxed Reassured by occasional touching, Difficult to console or comfort Consolability hugging, or being talked to, Pushing away caregiver, resisting distractable care or comfort measures

Appendix 3. Nociception Coma Scale (NCS) Categories Score 01 2 3 Motor response None/flaccid Abnormal posturing Flexion withdrawal Localization to noxious stimulation Verbal response None Groaning Vocalisation Verbalisation (intelligible) Visual response None Startle Eye movements Fixation Facial expression None Oral reflex movement/ Grimace Cry startle response

J Med Assoc Thai Vol. 98 No. 7 2015 691 การเปรียบเทียบมาตรวัดความปวดในผูปวยที่มีความรูสึกตัวไมปกติหลังผาตัดสมอง

สุวรรณี สุรเศรณีวงศ, เพ็ญสุข ยุวภูษิตานนท, พภัสสรณ ศรีศักราภิคุปต, ฤทัยชนก พุมมูล, วราภรณ ผากา, ปฤณัต อิทธิเมธินทร

วตถั ประสงคุ : การศกษานึ ตี้ องการประเม นิ ความเทยงตรงและความสะดวกในการใชี่ งานของเคร องมื่ อประเมื นความปวดในผิ ปู วย ที่มีความรูสึกตัวไมปกติหลังผาตัดสมอง วัสดุและวิธีการ: เปนการศึกษาแบบสังเกตการณไปขางหนา โดยแปลเครื่องมือวัดระดับความปวด 3 ชนิด เปนภาษาไทย ไดแก FLACC (Faces, Legs, Activity, Cry, Consolability), rFLACC (Revised FLACC) และ NCS (Nociceptive Coma Scale) แลวตรวจสอบความตรงดวย concurrent validity และ construct validity ตรวจสอบความเที่ยงดวย interrater reliability ในผปู วยท มี่ ความรี สู กตึ วไมั ปกต ิ ภายใน 24 ชวโมงั่ หลงการผั าต ดสมองั และตรวจสอบการใชงานง ายโดยใช แบบสอบถาม พยาบาลที่เคยใชเครื่องมือดังกลาว ผลการศึกษา: ทําการศึกษาในผูปวย 58 ราย พบวาเครื่องมือวัดระดับความปวดทั้ง 3 ชนิด มี concurrent validity คือมี positive correlation ระหวางกัน (คา r อยูระหวาง 0.638 ถึง 0.978) เครื่องมือทั้ง 3 ชนิด มี fair to moderate agreement กบการตั ดสั นใจใหิ ยาแก ปวดโดยการประเม นอาการและอาการแสดงทางคลิ นิ กทิ ี่ใชอย เปู นประจ าํ (kappa = 0.380-0.626) สาหรํ บั คา concurrent validity พบสูงขึ้นในการประเมินผูปวยที่ใสทอชวยหายใจ การทดสอบ construct validity พบวา คะแนน ความปวดในชวงที่มีความปวดมาก กอนไดรับยาแกปวด (3-5) มีคาสูงกวาคะแนนความปวดในชวงที่มีความปวดนอย หลังไดรับ ยาแกปวด (0) เครองมื่ อทื กชนุ ดมิ ความเที ยงระหวี่ างผ วู ดั หรอื คา interrater reliability อยูในเกณฑด ี(intraclass correlation = 0.756-0.8810) สรุป: เครื่องมือวัดระดับความปวดทั้ง 3 ชนิด มีความเที่ยงตรง โดยเฉพาะในกลุมผูปวยที่ใสทอชวยหายใจ ดานการใชงาน NCS เปนที่ยอมรับในกลุมพยาบาลผูใชวาใชงานงายที่สุด

692 J Med Assoc Thai Vol. 98 No. 7 2015