Critical Care Pain Observation Tool (CPOT)

Why Use

It is estimated that up to 71% of ICU patients experience untreated pain. ( Gélinas 2007 ) The Society of Intensive Care Medicine recommends routine monitoring of pain in ICU patients. Treatment of pain is associated with fewer days on mechanical ventilation, decreased infections and increased satisfaction. The CPOT is an innovative pain assessment tool that is based on 2 preliminary studies with expert selected variables, prior research of behavioral indicators for pain and vigorously compared scores at varying levels of consciousness.

When to Use

The CPOT can be used to assess intubated or sedated patients pain based on facial expressions, muscle tension and movement as well as compliance with ventilated breaths for intubated patients or vocalized pain for non-intubated patients.

Formula

Pearls / Pitfalls

The Critical Care Pain Observation Tool (CPOT) was designed to assess the pain of critically ill patients who are incapable of reporting their pain. The gold standard of pain assessment is patient’s self-reported pain. The CPOT was created from retrospective reviews of common pain characteristics and vetted by ICU nurses and physicians. Physiologic finding were removed after initial evaluation. The original study included cardiac patients who were relatively healthy, only 2 data collectors performed the analysis, and one evaluation only included 33 patients out of 105. CPOT scores were higher when conscious and intubated than when unconscious or extubated, which is thought to be due to endotracheal tube discomfort or positive pressure causing incision site pain. CPOT scores were similar for unconscious and conscious extubated patients which may be due to lingering anesthesia or pain resolution from extubation. Further analyses have validated the score in multiple post-surgical and medical ICU settings.

Management

For those patients with a CPOT score of ≤ 2: There is likely minimal to no pain present. Consider re-evaluation in the future. For those patients with a CPOT score of >2: There is an unacceptable level of pain. Consider further or alternative analgesia and sedation.

Critical Actions

Regular re-evaluation is crucial to appropriate pain management.

Advice

The CPOT is designed to scale the pain of patients who are unable to report it themselves through objective findings. The CPOT has good interrater reliability in multiple studies and high sensitivity when patients are in pain.

More Information

Scoring system and definitions of criteria: Criteria Score Definition Facial expression Relaxed, neutral 0 No muscular tension observed Tense 1 Presence of frowning, brow lowering, orbit tightening Grimacing 2 All of the above facial movements plus eyelids tightly closed Body movements Absence of movements 0 Does not move at all (does not necessarily mean absence of pain) Protection 1 Slow cautious movements, touching or rubbing the pain site, seeking attention through movements Restlessness 2 Pulling tube, attempting to sit up, moving limbs/thrashing, not following commands Muscle tension (Evaluation by passive flexion and extension of upper extremities) Relaxed 0 No resistance to passive movements Tense, rigid 1 Resistance to passive movements Very tense or rigid 2 Strong resistance to passive movements; inability to complete them EITHER Compliance with the ventilator (Intubated patients only) Tolerating ventilator or movement 0 Alarms not activated, easy ventilation Coughing but tolerating 1 Alarms stop spontaneously Fighting ventilator 2 Asynchrony: blocking ventilation, alarms frequently activated OR Vocalization (Extubated patients only) Talking in normal tone or no sound 0 Talking in normal tone or no sound Sighing, moaning 1 Sighing, moaning Crying out, sobbing 2 Crying out, sobbing