DISCUSSIONIn the present study, pai

DISCUSSION
In the present study, pain assessments were conducted in critical care patients with brain injury throughout the first 14 days of ICU admission with the use of the CPOT to provide descriptive data on patterns of temporal change in pain during this critical period. Regarding overall pain intensity, subjects in the present study exhibited a relatively low level of pain, which is consistent with the findings reported by Gelinas et al. (2006), who found that unconscious intubated and conscious extubated brain injury patients had CPOT scores of 0.55-0.67 and 0.69-0.87, respectively.
Temporal changes in pain intensities displayed a consistent pattern in the present study. For the 31 study subjects, mean pain score was highest on day 1, decreased rapidly to reach a minimum on day 3 or 6, then increased on day 9 and, in most cases, reduced slightly on day 14. Furthermore, these changes in pain intensity were significant. Because few studies have been conducted on the temporal pattern of pain in brain injury patients during the critical period, direct comparisons between our results and those of others are difficult. However, after general surgery, such as an abdominal operation, pain has been reported to decrease continuously with time.

The nature of the ICU environment often leads physicians and nurses to underestimate pain. The finding that pain intensity scores were highest on day 1 should be noted by those involved in critical nursing practice in cases of acute brain injury. Importantly, it should be remembered that although ICU patients may not be able to self-report pain, they may still have pain. Therefore, ICU patients need to be continuously assessed for the presence and level of pain to ensure that pain control is adequate, as well as monitored for other vital physiologic variables, such as respiration rate, heart rate, ICP, and blood pressure. In addition, the present findings suggest a need for more aggressive pain management during critical period, particularly on day 1.However, more detailed studies are required to confirm this issue.
We also examined the relationship between pain intensity and analgesics use and consciousness level. The proportions of subjects that required analgesics on days 1, 3, 6, 9, and 14 after ICU admission were 80.6%, 74.2%, 71.0%, 74.2%, and 51.6%, respectively. This temporal pattern differs from the temporal pattern of pain intensity and indicates that pain changes observed in this study are unlikely to have been related to analgesics use.
On the other hand, temporal pain changes could be associated with consciousness levels. Findings of the present study show that GCS scores varied during the first 6 days after ICU admission, but then consistently improved, which was in line with pain perception. It has been reported that secondary brain insults (brain edema and intracranial hypertension) can occur immediately after primary brain injury and produce further neurologic deterioration and reduced levels of consciousness. Therefore, it could be inferred that the decreases in CPOT scores observed over day 3 to day 6 were caused by a diminished level of consciousness due to secondary neuronal injuries.
In the present study, the mean CPOT scores of those that did not undergo surgery were significantly higher than the scores of those that did. This may have been due to analgesic use, because a higher proportion of subjects in the surgery group were administered analgesics (55%-91% vs. 44%-65%). Furthermore, most of those that underwent brain surgery were given barbiturate or midazolam for ICP control, and these agents may have affected pain perception.
In terms of brain injury severity, overall CPOT scores in patient with moderate injury tended to be higher than in patients with severe injury, though this was without significance. A similar finding was obtained in patients with severe traumatic brain injury, who were found to complain of pain less frequently than those with a mild-moderate brain injury also reported that 70% of their subjects with a mild brain injury complained of pain, whereas only 40% of those with a mild-moderate brain injury did so. A further detailed study on pain at different severity levels is needed.
Throughout the 14-day ICU admission period, CPOT scores immediately after suctioning were significantly higher than those before suctioning, without exception. However, CPOT scores at 20 minutes after suctioning did not differ significantly from those before suctioning. This finding is in accordance with that found by Gelinas and Johnson (2007), who found that significant increments in pain level occur after endotracheal suctioning in intubated brain injury patients with diverse disease types. In addition, endotracheal suctioning has been repeatedly reported to induce hypoxia, and it is generally accepted that oxygen should be provided to prevent endotracheal suctioning-induced hypoxia. Similarly, our finding of higher CPOT scores immediately after suctioning suggests the need for routine pain relief before suctioning.
The present study is meaningful because it presents valid clinical information about patterns and characteristics of acute pain in brain injury patients who are often unable to self-report on the presence and intensity of pain. In addition, the study provides useful evidence on the need for acute pain management and raises clinical concerns regarding pain control in critically ill brain injury patients.

CONCLUSIONS AND STUDY LIMITATIONS
Temporal changes in pain in critical care patients with a brain injury were found to display a consistent pattern during the first 14 days of ICU admission. Mean pain score was highest on day 1, decreased rapidly to reach a nadir on day 3 or 6, and then increased on day 9. In most cases, pain reduced slightly between days 9 and 14. Furthermore, these temporal changes in pain intensity were found to be significant. It can be speculated that these temporal changes are probably associated with level of consciousness and that they are unlikely to be related to analgesics use. In addition, mean CPOT scores in the nonsurgery group were significantly higher than in the surgery group, and the mean CPOT scores of those with moderate brain injury were nonsignificantly higher than the scores of those with severe injury. Finally, CPOT scores immediately after endotracheal suctioning were significantly higher than before endotracheal suctioning, but scores 20 minutes after suctioning were similar to those before suctioning.
Pain is a stressor in critical care patients and exerts a negative influence on patient recovery. Therefore, the assessment and management of pain requires priority in critical care practice. In particular, acute pain causes sympathetic stimulation and thus affects ICP in brain injury patients. Unfortunately, estimates of acute pain are often inaccurate, and therefore the relief of pain is inadequate in these patients. For this reason, more precise measurement tools are required to determine pain severities in these patients, and they should be repeatedly tested for validity and reliability. Most importantly, the first step toward providing adequate pain relief is the collection of valid clinical information about patterns and characteristics of pain in defined patient groups. For this reason, the present study was conducted to provide descriptive information about pain patterns after brain injury during the critical period as well as present evidence that COPT provides a useful measure of pain in brain injury patients during this period.
However, it should be borne in mind that this study is limited by the small number of patients recruited and by a lack of empirical evidence confirming the sensitivity of CPOT in nonverbal patients. To confirm the findings of this study, it is suggested that a large-scale study be conducted with other verified behavioral pain scales, such as the Behavioral Pain Rating Scale, the Behavioral Pain Scale, and the Pain Behavior Assessment Tool, in nonverbal patients

Hasil (Bahasa Indonesia) 1:

DISKUSIDalam penelitian ini, sakit penilaian yang dilakukan dalam perawatan kritis pasien dengan cedera otak sepanjang hari pertama dalam masuk ICU dengan menggunakan CPOT untuk menyediakan data yang deskriptif pada pola perubahan sementara rasa sakit selama periode Genting ini. Mengenai keseluruhan Intensitas nyeri, subyek dalam penelitian ini menunjukkan tingkat relatif rendah sakit, yang konsisten dengan temuan-temuan yang dilaporkan oleh Gelinas et al. (2006), yang menemukan bahwa bawah sadar yang intubated dan pasien trauma otak sadar extubated telah CPOT puluhan 0,55-0,67 dan 0,69-0,87, masing-masing.Sementara perubahan dalam intensitas nyeri ditampilkan pola yang konsisten dalam penelitian ini. Untuk subjek studi 31, sakit berarti Skor adalah tertinggi pada hari 1, menurun dengan cepat untuk mencapai minimum pada hari 3 atau 6, kemudian meningkat pada hari 9 dan, dalam banyak kasus, sedikit berkurang pada hari 14. Selain itu, perubahan-perubahan dalam intensitas nyeri yang signifikan. Karena beberapa penelitian telah dilakukan pada pola temporal nyeri pada pasien trauma otak selama periode kritis, perbandingan langsung antara hasil kami dan orang lain sulit. Namun, setelah bedah umum, seperti operasi perut, sakit telah dilaporkan untuk mengurangi terus-menerus dengan waktu.Sifat lingkungan ICU sering menyebabkan dokter dan perawat meremehkan sakit. Menemukan bahwa rasa sakit intensitas nilai yang tertinggi pada hari 1 harus dicatat oleh mereka yang terlibat dalam praktik perawatan kritis dalam kasus-kasus cedera akut otak. Penting, harus diingat bahwa meskipun ICU pasien tidak dapat Self-laporan sakit, mereka mungkin masih memiliki sakit. Oleh karena itu, pasien ICU perlu terus dinilai untuk tingkat rasa sakit untuk memastikan bahwa kontrol nyeri memadai, serta dipantau untuk variabel fisiologis penting lainnya, seperti tingkat pernapasan, detak jantung, ICP, dan tekanan darah dan kehadiran. Selain itu, hadir temuan menunjukkan kebutuhan untuk lebih agresif manajemen nyeri selama masa-masa kritis, terutama pada hari 1.However, studi lebih lanjut diperlukan untuk mengkonfirmasi masalah ini. Kita juga akan meneliti hubungan antara intensitas nyeri dengan tingkat penggunaan dan kesadaran analgesik. Proporsi mata pelajaran yang diperlukan analgesik pada hari 1, 3, 6, 9, dan 14 setelah masuk ICU adalah 80.6%, 74,2%, 71.0%, 74,2% dan 51,6%, masing-masing. Pola fosil ini berbeda dari pola temporal intensitas nyeri dan menunjukkan bahwa perubahan rasa sakit yang diamati dalam studi ini tidak mungkin telah berhubungan dengan penggunaan analgesik. Di sisi lain, sementara sakit perubahan dapat dikaitkan dengan tingkat kesadaran. Temuan-temuan dari penelitian ini menunjukkan bahwa nilai GCS bervariasi selama 6 hari pertama setelah masuk ICU, tapi kemudian secara konsisten membaik, yang sejalan dengan persepsi nyeri. Telah dilaporkan bahwa penghinaan sekunder otak (edema otak dan hipertensi intrakranial) dapat terjadi segera setelah cedera otak primer dan menghasilkan lebih lanjut kerusakan neurologis dan mengurangi tingkat kesadaran. Oleh karena itu, dapat disimpulkan bahwa penurunan nilai CPOT diamati selama hari 3 hari 6 disebabkan oleh tingkat kesadaran karena cedera saraf sekunder yang berkurang. Dalam penelitian ini, rata-rata nilai CPOT dari mereka yang tidak menjalani operasi secara signifikan lebih tinggi daripada nilai mereka yang melakukannya. Ini mungkin karena penggunaan analgesik, karena proporsi yang lebih tinggi dari mata pelajaran dalam kelompok operasi dikelola analgesik (55% - 91% vs 44% - 65%). Selain itu, kebanyakan dari mereka yang menjalani operasi otak diberi barbiturate atau midazolam pengendalian ICP, dan agen ini telah mempengaruhi persepsi nyeri. In terms of brain injury severity, overall CPOT scores in patient with moderate injury tended to be higher than in patients with severe injury, though this was without significance. A similar finding was obtained in patients with severe traumatic brain injury, who were found to complain of pain less frequently than those with a mild-moderate brain injury also reported that 70% of their subjects with a mild brain injury complained of pain, whereas only 40% of those with a mild-moderate brain injury did so. A further detailed study on pain at different severity levels is needed. Throughout the 14-day ICU admission period, CPOT scores immediately after suctioning were significantly higher than those before suctioning, without exception. However, CPOT scores at 20 minutes after suctioning did not differ significantly from those before suctioning. This finding is in accordance with that found by Gelinas and Johnson (2007), who found that significant increments in pain level occur after endotracheal suctioning in intubated brain injury patients with diverse disease types. In addition, endotracheal suctioning has been repeatedly reported to induce hypoxia, and it is generally accepted that oxygen should be provided to prevent endotracheal suctioning-induced hypoxia. Similarly, our finding of higher CPOT scores immediately after suctioning suggests the need for routine pain relief before suctioning. The present study is meaningful because it presents valid clinical information about patterns and characteristics of acute pain in brain injury patients who are often unable to self-report on the presence and intensity of pain. In addition, the study provides useful evidence on the need for acute pain management and raises clinical concerns regarding pain control in critically ill brain injury patients.CONCLUSIONS AND STUDY LIMITATIONSTemporal changes in pain in critical care patients with a brain injury were found to display a consistent pattern during the first 14 days of ICU admission. Mean pain score was highest on day 1, decreased rapidly to reach a nadir on day 3 or 6, and then increased on day 9. In most cases, pain reduced slightly between days 9 and 14. Furthermore, these temporal changes in pain intensity were found to be significant. It can be speculated that these temporal changes are probably associated with level of consciousness and that they are unlikely to be related to analgesics use. In addition, mean CPOT scores in the nonsurgery group were significantly higher than in the surgery group, and the mean CPOT scores of those with moderate brain injury were nonsignificantly higher than the scores of those with severe injury. Finally, CPOT scores immediately after endotracheal suctioning were significantly higher than before endotracheal suctioning, but scores 20 minutes after suctioning were similar to those before suctioning.Pain is a stressor in critical care patients and exerts a negative influence on patient recovery. Therefore, the assessment and management of pain requires priority in critical care practice. In particular, acute pain causes sympathetic stimulation and thus affects ICP in brain injury patients. Unfortunately, estimates of acute pain are often inaccurate, and therefore the relief of pain is inadequate in these patients. For this reason, more precise measurement tools are required to determine pain severities in these patients, and they should be repeatedly tested for validity and reliability. Most importantly, the first step toward providing adequate pain relief is the collection of valid clinical information about patterns and characteristics of pain in defined patient groups. For this reason, the present study was conducted to provide descriptive information about pain patterns after brain injury during the critical period as well as present evidence that COPT provides a useful measure of pain in brain injury patients during this period.However, it should be borne in mind that this study is limited by the small number of patients recruited and by a lack of empirical evidence confirming the sensitivity of CPOT in nonverbal patients. To confirm the findings of this study, it is suggested that a large-scale study be conducted with other verified behavioral pain scales, such as the Behavioral Pain Rating Scale, the Behavioral Pain Scale, and the Pain Behavior Assessment Tool, in nonverbal patients